GOP On Attack On Questionable CMS Part D Demonstration
The GOP is on the attack over the Centers for Medicare and Medicaid Services’ (CMS) announcement of a demonstration project to stabilize 2025 Part D premiums. CMS hurriedly put together the demo after it saw huge increases in Part D premiums come in during the 2025 bid cycle. This was due to the Inflation Reduction Act’s (IRA) shifting of huge costs from the government to health plans and out-of-pocket cost reductions. CVS, the biggest standalone Part D plan, apparently recommended that CMS create the program, although one already exists in law covering just a piece of the benefit.
The conservative Paragon Health Institute says the program could cost $10 billion over three years to limit premiums by bailing out insurers. The IRA approach on Part D was flawed and the public will be hurt by high premiums, but I continue to feel the demo is extra-regulatory and extra-legal.
(Article may require a subscription.)
#partd #pdp #medicareadvantage #premiums #medicare #drugpricing
Is The Two-Midnight Rule Driving Medicare Advantage Costs
Most Medicare Advantage (MA) plans say inpatient costs are increasing, but there is a mixed review on whether the two-midnight rule, which was dictated by the Centers for Medicare and Medicaid Services as of January 1, is the main reason. I tend to go with Humana, the MA-dominant insurer, who would know the most on MA issues.
#medicareadvantage #priorauthorization
Provider-Favorable Report On Claim Denials
A provider-friendly report claims providers have huge administrative costs due to health plans’ claims denials.
One complaint is that plans deny or delay claims by arguing more information is needed. The reports says:
- Payers initially denied 3.8% of billed charges in the first five months of 2024 and asked for more information.
- Providers spent $1.9 billion in the first five months of 2024 fulfilling requests. This is up from prior years.
- The report says provider claims are not sloppy.
- Inpatient denials are larger.
- Medicaid and commercial products have higher denials.
Call me biased, but I do not see denial rates of 3.8% or scrutinizing inpatient claims as unreasonable. Nonetheless, with Congress (both sides of the aisle) in the hip pocket of providers, the report will resonate.
(Article may require a subscription.)
#claimsdenials #priorauthorization #providers #healthplans
https://www.modernhealthcare.com/providers/inpatient-claim-denials-kodiak-solutions-2023
Great KFF Analysis Of Medicare Advantage Enrollment
Two great analyses from the Kaiser Family Foundation (KFF) on Medicare Advantage (KFF). A few key facts:
- MA enrolls a disproportionate share of people of color and dual eligibles.
- The average MA enrollee has access to forty-three plan choices.
- I disagree with the estimate, but KFF cites MedPAC saying MA is over-reimbursed by $83 billion annually.
- KFF notes that the largest plans in the nation dominate MA.
- MA plans receive an additional $2,329 per enrollee above their estimated costs of providing Medicare-covered services to provide additional benefits.
- Premiums in MA have been on the downturn since 2105. But I say that could change when 2025 plans are announced due to the fiscal pressures plans see.
Additional article: https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-premiums-out-of-pocket-limits-supplemental-benefits-and-prior-authorization/
#kff #medicareadvantage
https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-enrollment-update-and-key-trends
States With Healthcare Spending Targets May Work To Some Degree
Eight states have established various forms of healthcare spending targets and there is some evidence it works. Data from five states across all lines of business found that spending growth moderated in 2022, compared to 2021, but still exceeded targets in four out of the five states.
(Article may require a subscription.)
#healthcare #spending
Three Lawmakers Want March-In Rights Undertaken
Rep. Llyod Doggett (D-Texas), Sen. Angus King (I-Maine), and Elizabeth Warren (D-Mass.) want the Biden administration to finalize a federal rule allowing for the government to seize taxpayer-funded patents in order to combat the high price of drugs.
#drugpricing #branddrugmakers
https://thehill.com/policy/healthcare/4818596-warren-king-doggett-high-drug-prices
Walgreens Saga Continues
Financially-ailing Walgreens is saying that it might sell all of its interest in VillageMD, a provider investment. VillageMD’s expansion plans have failed spectacularly.
Additional article: https://www.modernhealthcare.com/providers/walgreens-villagemd-stake-sale-tim-wentworth
(Some articles may require a subscription.)
#walgreens #retailmeetshealthcare #primarycare
https://www.healthcaredive.com/news/walgreens-considers-villagemd-full-sale/723682
— Marc S. Ryan
