The Healthcare Labyrinth Newsfeed will be off on November 23 and 24 for the Thanksgiving holiday. We will be back on November 27. Happy Thanksgiving to all! Stay safe! — Marc S. Ryan
CMS’ UM Rule for Medicare Advantage Already Being Debated The new CMS 2024 Medicare Advantage (MA) rule prohibiting the use of most evidence-based criteria by MA plans is already being debated. Hospital lobbies are saying plans are out of compliance and January 1 has not even hit yet. Read my new companion blog at the blog tab on this site. I tell you why this rule is a terrible idea. Additional article here: https://www.modernhealthcare.com/politics-policy/health-plans-2024-medicare-advantage-rule-aha-cms-unitedhealthcare #hospitals #medicareadvantage #medicare #ncd #lcd #priorauthorization Link to Article Interesting Article on Cancer Care Between MA and FFS Interesting study on cancer care differences between MA and FFS. Touches on prior authorization and networks. Something for MA plans to think about as the PA debate heats up and the new UM rule comes unto effect. #medicare #medicareadvantage #cancercare #priorauthorization #networkadequacy Link to Article FL Blue Using AI to Speed Authorizations While many plans are being criticized
I have mentioned the new 2024 Medicare Advantage (MA) Utilization Management (UM) rule in two of my blogs recently. But here is a relatively short one to drive home the idea that the rule sets a terrible precedent. What does the rule do? It takes external evidence-based criteria off the table in favor of the policies used in the traditional Medicare program. Unless a FFS policy is not fully established, an MA plan must rely strictly on the traditional FFS program criteria instead of outside evidence-based clinical criteria. “Fully established” is not well defined, but CMS likely will argue that the NCDs and LCDs are fully established except in some small and extreme circumstances. Let’s set my argument up with three points. First, the rule was a direct result of the aggressive lobbying by provider groups opposed to the growth of managed care in Medicare. The Biden administration is sympathetic
Out For Blood Is Right: Great Example of Outrageous Prices And The Need For Reform Kaiser Health News, the healthcare news aggregator, also does tremendous original news stories. One of its series is “Bill of the Month,” where it features one person’s heartache related to a recent healthcare bill. In this article, KFF intervened to get the patient’s bill cancelled, but she is among the lucky ones. It is also important to remember that not all surprise bills you receive will suddenly go away under the No Surprises Act. This surprise bill was from an in-network provider (hospital), which was charging outrageous lab fees on everyday tests. The health plan negotiated a poor discount and the patient’s plan had the insured covering a percentage of allowable costs. The article touches upon the need for site neutral payments to lower costs in the system and protect consumer’s from high costs. Why
Improper Payments Detailed By CMS CMS touts that improper payments were under 10% in traditional Medicare and in Medicaid, but it is nothing to be proud of. The traditional estimator of 10% for fraud, waste, and abuse (FWA) is a misnomer. Recent studies suggest that true FWA is perhaps 25% of all healthcare expenditures. In 2021, healthcare expenditures were $4.3 trillion. That means almost $1.1 trillion is true FWA. #fwa #medicare #medicaid Link to Article Providers Impacted As Well When Star Ratings Fall Good article describing how providers suffer too when Star ratings fall in Medicare Advantage. Many have entered into partial or global risk-sharing arrangements with health plans and share in bonus revenue. (May require subscription.) #medicareadvantage #providers #stars Link to Article New Speaker’s Healthcare Advisor Named New House Speaker Mike Johnson (R-LA) has named Drew Keyes, a former Republican Study Committee staffer, as his senior health policy advisor.
Medicare Advantage (MA) has been known as the most profitable sector of any health plan. With high premiums, a lucrative Star quality bonus, and chance to reduce medical expenses compared to the traditional fee-for-service program, plans have been able to register higher percentage and overall dollar margins in MA as compared with commercial and Medicaid. But as we have seen throughout the last few years, MA is not without its challenges and that will continue into the future. Surprisingly, at least one major player could be shopping its Medicare Advantage portfolio and getting out of the business. Here are the top challenges I see and areas MA plans need to keep an eye on. The collapse of the insurtechs Just a few years ago, the insurtechs were the darlings of investors. Investors believed that the insurtechs would leverage technology to transform healthcare, reduce costs, and drive quality. The investors also
Civil Rights Groups Issuing Report Cards On State Medicaid Redetermination Processes With a large proportion of the 10M Medicaid disenrollees cut from the program for procedural reasons, a group of civil rights entities are issuing report cards to states. The report cards seek to call out whether each state has done the necessary due diligence during unwinding to ensure those who remain eligible retain coverage. While states and the Centers for Medicare and Medicaid Services (CMS) are at some fault, Congress is really to blame for not passing legislation that allowed for a longer transition time. #medicaid #redterminations Link to Article FTC Moves To Stop Hospital Merger in California Kudos to the Federal Trade Commission (FTC) on taking action to stop the merger of two California hospitals. The Biden Administration, including the FTC, Justice and Health and Human Services, have been active in calling attention to the massive consolidation occurring
CMS Changes Network Adequacy And Open Enrollment For State Exchanges The Centers for Medicare and Medicaid Services (CMS) is mandating that State Exchanges follow federal network adequacy as well as open enrollment periods, among other changes. #networkadequacy #cms #aca #exchanges #obamacare Link to Article Commonwealth Fund Study Shows Impact of High Cost Healthcare System In The U.S. Must read report from the Commonwealth Fund on the impact of our high costs in America on citizens’ access to healthcare. Commonwealth compares us to eight other countries and finds that Americans skipped medical care more often and had more problems handling or paying a bill. American adults face wider income-related disparities in healthcare affordability compared to adults in other high-income countries. This all links back to the fact that America is the only developed nation without affordable universal access to healthcare. It should be noted that other developed nations do much better than
While the Medicare Advantage (MA) Star Program has always made it difficult for plans to achieve and maintain high Star scores, the Star roller coaster ride has been much more profound over the past several years. We now have had two years of pretty bad news, which puts a blemish on the program (fair or not). What’s more, the percentage of high-scoring contracts and the percentage of enrollment in them are now below pre-COVID years. To refresh a bit on this, during the COVID pandemic, the Centers for Medicare and Medicaid Services (CMS) created fairly major calculation allowances for both Star 2021 (2019 and 2020 data) and 2022 (2020 and 2021 data). These allowances had the effect of boosting Star scores. We saw a surge in Star scores in 2022, including for plans that historically did not have a great track record of consistently hitting 4 Stars and above. However,
Great Series on America’s Long-Term Care Problem Congratulations to the Kaiser Family Foundation and The New York Times on the first in a series of articles on America’s long-term care crisis. America needs an aging policy. The series shows real-life examples of the impact of not having a national agenda on aging. It clearly shows that the lack of adequate supports for the elderly also impacts other generations, including children’s loss of income to take care of an elderly loved one. In my book (available for purchase on this website), I devote a chapter to aging and recommend ways to make services available to all in an income-based buy-in strategy. Not addressing aging will only drive long-term care and medical costs even higher in the future. In addition to the NYT story and press release at the link below, here is a link to the KFF summary of a survey
