April 4, 2024

CVS Executive Pushes Back On Cuban And PBM Transparency Narrative

CVS Caremark President David Joyner wrote and op-ed for Fortune to explain the innovation and transparency his pharmacy benefits manager (PBM) is engaged in.  It seeks to counter some of the press Mark Cuban is getting.  I will note that leadership at CVS Health overall is on a path of reform and innovation.

#cvshealth #pbms #transparency

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Good Wall Street Journal Article On Why We Need Site-Neutral Payments

This Wall Street Journal article tells how hospitals and health systems are buying up physician practices.  In so doing, they are changing practice patterns and forcing their now doctor-employees to practice at hospital-owned settings.  This increases costs for sometimes low professional fees into gigantic bills because facility fees are added on.  The hospital lobby was successful stopping the start of site-neutral payments in Medicare, but I doubt they can hold it off forever with these ugly headlines. As Marty Makary notes, this has huge impacts on patients, especially those with high-deductible policies. Some states are trying to stop these outrageous facility fees.

(Article may require a subscription.)

#siteneutral #hospitals #physicians

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PCP Treatment Does Not Appear To Be Very Different Between MA and Traditional Program

Interesting Commonwealth Fund analysis that concludes that primary care physicians do not have very different approaches to a traditional Medicare enrollee versus a Medicare Advantage (MA) plan member. Most have a mix of MA and traditional lives.

#medicare #medicareadvantage #primarycare

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Final MA 2025 Rule Reforms Marketing And Other Aspects of MA

The Centers for Medicare and Medicaid Services (CMS) finalized the 2025 Medicare Advantage and Part D rule largely as proposed.  Rule changes include:

  • Fixing marketing agent compensation
  • Bringing more transparency to prior authorization
  • Making network requirement changes
  • Changing dual eligibles and low income subsidy (LIS) member special enrollment period rules
  • Expanding external review rights to MA enrollees for certain outpatient services
  • Mandating reporting on supplemental benefits
  • Facilitating biosimilar adoption

CMS press release and fact sheet: https://www.cms.gov/newsroom/fact-sheets/contract-year-2025-medicare-advantage-and-part-d-final-rule-cms-4205-f and https://www.cms.gov/newsroom/press-releases/biden-harris-administration-finalizes-rule-expanding-access-care-and-increasing-protections-people

(Some articles may require a subscription.)

#medicareadvantage #partd #cms

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Change HealthCare Seeks To Consolidate Lawsuits

Faced with mounting lawsuits, Change Healthcare is seeking to consolidate various lawsuits filed by both patients and providers. In addition, there is rising awareness on the vulnerable status of the nation’s healthcare infrastructure.  Risk analysis and ensuring redundancy is recommended.  Smaller providers may be especially vulnerable. The Senate Finance Committee will hold a hearing on the Change cyberattack.

Additional articles: https://www.healthcaredive.com/news/change-healthcare-cyberattack-cybersecurity-resilience-planning/711650/ and https://insidehealthpolicy.com/daily-news/senate-finance-hold-hearing-change-cyberattack

(Some articles may require a subscription.)

#changehealthcare #cyberattack #providers

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Higher Hospital Fines Have Worked To Drive Price Transparency Compliance

The federal government significantly increased fines for non-compliance with the hospital price transparency rule and it seems to have driven much higher compliance. At least three-quarters of hospitals have posted prices they negotiated with commercial insurers. That is a three-fold increase since 2021. New rules will also make it easier to access and review the data.

(Article may require a subscription.)

#pricetransparency #hospitals

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Healthcare M And A Will Remain Strong But Face Greater Scrutiny

Lawyers win.  M and A in the healthcare world is expected to remain strong but deals will face more regulatory scrutiny on the antitrust front and mean much more due diligence.  The scrutiny could lead some to look at joint ventures as well as cross-market mergers to escape the antitrust rules.

(Article may require a subscription.)

#manda #mergers #acquisitions #providers #hospitals #privateequityfirms #antitrust

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Trump Could Attack Big Pharma By Bringing Back His Own Drug Pricing Plan

As I often say, President Biden and former President Trump have more in common on drug pricing than one would think.  Biden is fighting Big Pharma in court over his Medicare drug price negotiations.  In part to counter Biden’s attacks on healthcare issues, Trump has said he could resurrect his dead proposal to use international reference pricing to cap the prices of the top 50 Medicare Part B drugs. Trump laid out the plan in the twilight of his administration.  It was stopped in court and eventually retired by Biden.  In large measure this was because Trump did not follow rule-making and the initial price-setting for drugs was a twisted negotiation process saddled on providers.

Big Pharma is in for a long and treacherous ride no matter who wins (smile!). In my book The Healthcare Labyrinth (available at this site), I dedicate a full chapter to how we tackle drug prices.

(Article may require a subscription.)

#ira #drugpricing #medicare #biden #trump

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— Marc S. Ryan

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