Another Devastating Piece From The Wall Street Journal On Medicare Advantage
Yet another piece from The Wall Street Journal (WSJ) is bound to generate huge attention on Capitol Hill and among regulators. In its latest expose on Medicare Advantage (MA) finances, WSJ finds that MA home visits’ diagnoses for risk adjustment generated $15 billion in extra pay from 2019 to 2021. WSJ says nurses are pushed to make diagnoses the patient does not have and such diagnoses are never treated by hospitals or physicians. A July article found that $50 billion in overpayments occurred from 2019 to 2021 tied to risk adjustment submissions not treated by healthcare providers.
I am a supporter of MA, but I have made the case that a small number of bad actors are generating a huge amount of overpayments and giving all plans a bad name. I have told plans to expect that the Centers for Medicare and Medicaid Services (CMS) will eventually bar health risk assessment visits as well as manual chart review submissions for encounter data. I think this is fair and reasonable. See my blog on the subject here: https://www.healthcarelabyrinth.com/will-cms-rein-in-risk-adjustment-submissions/. And my related podcast here: https://www.healthcarelabyrinth.com/25-ma-plans-should-ready-for-changes-to-risk-adjustment-submissions/ .
WSJ article (needs subscription): https://www.wsj.com/health/healthcare/medicare-extra-payments-home-visits-diagnosis-057dca8b
Additional article: https://www.beckershospitalreview.com/care-coordination/insurers-push-diagnoses-during-at-home-visits-bringing-in-billions-wsj.html
(Some articles may require a subscription.)
#medicareadvantage #riskadjustment #radv #overpayments
KFF Analyzes Medicare Advantage Prior Authorizations
The Kaiser Family Foundation (KFF) has analyzed the rate of prior authorizations in the Medicare Advantage (MA) program. It finds the following, which should lead to more scrutiny on Capitol Hill and from the Centers for Medicare and Medicaid Services (CMS):
- 99% of MA enrollees are required to obtain prior authorization (PA) for some services, such as inpatient hospital stays, skilled nursing facility stays, and chemotherapy.
- More than 46 million PA requests were submitted to MA plans in 2022, up from 37 million in 2019. In 2022, there were 1.7 prior authorization requests per Medicare Advantage enrollee, similar to the amount in 2019. So, the growth is largely tied to enrollment growth in the program.
- In 2022, MA plans fully or partially denied 3.4 million (7.4%) prior authorization requests. The share of all prior authorization requests that were denied was 5.7% in 2019, 5.6% in 2020, 5.8% in 2021, and 7.4% in 2022.
- Less than 10% of denials were appealed. The vast majority of appeals (83.2%) resulted in overturning the initial prior authorization denial.
The analysis also discusses rates by MA plan as well as recent PA rules.
#medicareadvantage #kff #priorauthorization
Healthcare Politics: Where Do The Candidates Stand
A number of healthcare politics articles were in the news this week. Socialist magazine Jacobin discusses Kamala Harris’ move from full supporter of Medicare for All to her modified version that would preserve private plans at least for some time. The Kaiser Family Foundation (KFF) has updated its healthcare comparison site from Biden vs. Trump to Harris vs. Trump. The Healthcare Blog discusses what a second Trump term would look like for healthcare. An Axios article predicts major Medicaid cuts under Trump 47 based on various conservative think tank proposals. MedPage today recounts Harris’ antitrust record in California, which could spell doom for hospital mergers.
I have a blog on the healthcare pros and cons of each candidate coming on Thursday.
Additional articles: https://www.kff.org/compare-2024-candidates-health-care-policy/ and https://thehealthcareblog.com/blog/2024/08/05/what-the-health-system-can-expect-from-a-second-trump-term/ and https://jacobin.com/2024/08/kamala-harris-medicare-for-all and https://www.axios.com/2024/08/05/medicaid-trump-republican-cuts
#election2024 #harris #trump #healthcare #coverage
https://www.medpagetoday.com/washington-watch/electioncoverage/111368
Retail Healthcare Not Dead
Despite some high-profile failures, retail healthcare is not dead yet. The article goes into some high-profile failures as well as those still in it. CVS Health continues to make investments via its new subsidiary Oak Street. Oak Street has opened ten clinics in CVS stores and six independent locations. Eighteen in-store and twenty stand-alone more are planned. Humana just announced it will take space in Walmart superstores in twenty-three locations across three states after Walmart Health shuttered.
It seems clear to me that to make a go of retail healthcare a clear understanding of primary care is needed as well as the right financial incentives and a connection to other healthcare assets be in place. Focusing on Medicare is also important.
(Article may require a subscription.)
#retailmeetshealthcare #primarycare #cvshealth #humana
Senate Committee Urges CMS To Further Biosimilars
The Senate Appropriations Committee wants the Centers for Medicare and Medicaid Services (CMS) to eliminate more obstacles to biosimilar access and adoption. This will help Medicare enrollees and the system save money. The committee raises issues such as education, formulary design, and exclusion from utilization management edits. CMS and the Food and Drug Administration (FDA) have taken some steps to promote biosimilar use.
(Articles may require a subscription.)
#drugpricing #biosimilars #branddrugmakers #medicare #partd
Milliman Projects Major Drug Price Trends
A great white paper on drug trends in the commercial world from actuary Milliman. Based on drug mix through 2023, Milliman projects an overall average wholesale price (AWP) increase between 13% and 17% annually among commercial plans from 2023 to 2025.
#drugpricing #healthcare #employercoverage
ACA Premiums To Increase For Third Straight Year
After several years of relatively stable rates under the Biden administration, Exchange rates appear on a consistent upward trajectory again. The Kaiser Family Foundation (KFF) says that its analysis of rate proposals finds that the median premium increase is 7% for 2025, similar to the 6% premium increase filed for 2024. Insurers cite growing healthcare prices, in particular the return of hospital inflation and utilization as well as growing use of weight loss and other specialty drugs.
The average Silver benchmark premium nationwide from 2019 to 2022 actually fell each year, driven by growing membership and lower risk. The same benchmark rate increased by 4.1% in 2023 and 4.6% in 2024.
KFF press release: https://www.kff.org/affordable-care-act/press-release/marketplace-insurers-are-proposing-a-7-average-premium-hike-for-2025/ and https://www.kff.org/affordable-care-act/issue-brief/how-much-and-why-2024-premiums-are-expected-to-grow-in-affordable-care-act-marketplaces/
#kff #aca #exchanges #obamacare #coverage
— Marc S. Ryan
