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March 28, 2024

Change Cyberattack Could Open Americans Up To Multiple Notifications Of Breach We don’t know yet if Change’s breach will be a record.  But based on the 6 terabyte report of compromise as well as the breadth of the Change system, it very well could be. United is reporting that it may be hard to tell who was impacted by the breach.  Further, because of Change’s tentacles in the market with providers and payers, it could be that people are notified multiple times from different providers and a payer that their data was impacted.  There could be hundreds of millions (even billions) of notifications.  This will cause mass confusion. In other events, United seems to be complaining that some insurers and providers are slow to reconnect to Change systems, which is needed to get the flow of information and claims.  Some complain that they do not know yet if Change is

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Surprise! Surprise! No Surprises Act Favors Providers And Is Driving Up Costs

Since the No Surprises Act (NSA) was passed in late 2020, I have argued that the baseball-style arbitration process is heavily stacked against health plans and favors providers.  The law went into effect on January 1, 2022, with some portions still forestalled by the federal government.  But the main components  that stop surprise billing to patients and the process to settle what is paid by plans to providers has been in force now for about 2 years.  The implementation of the arbitration has been rocky.  The number of cases is demonstrably above what was expected.  That said, more and more data is now available that shows how well providers are doing from the process. In commercial coverage, the main component of the law disallows providers from billing patients for out-of-network services beyond plan outlined in-network cost-sharing for emergency situations, post-emergency stabilization, and non-emergency in-network facility-based procedures where non-network services may

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March 27, 2024

Improper Payments Huge In Federal Programs A new Government Accountability Office analysis finds that the federal government made nearly $236 billion in improper payments in 2023. The payments were largely in Medicare, Medicaid, Pandemic Unemployment Assistance, the Earned Income Tax Credit and Paycheck Protection Program loan forgiveness. Medicare had the largest improper payments at $51.1 billion.  Medicaid had $50.3 billion. GAO Report here: https://www.gao.gov/products/gao-24-106927 #fwa #medicare #medicaid Link to Article New Rule Simplifies Medicaid and Children’s Insurance Enrollment A new Centers for Medicare & Medicaid Services (CMS) final rule will help enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) coverage. Among changes include transfer from Medicaid and CHIP if Medicaid is lost, renewals no sooner than every 12 months, no waiting periods, and sufficient time to respond to state inquiries on coverage. Federal press release and fact sheet: https://www.cms.gov/newsroom/press-releases/biden-harris-administration-builds-success-affordable-care-act-streamlining-enrollment-medicaid-and and https://www.cms.gov/newsroom/fact-sheets/streamlining-medicaid-childrens-health-insurance-program-and-basic-health-program-application Additional articles: https://www.modernhealthcare.com/government/cms-medicaid-chip-enrollment-renewal-rule and https://insidehealthpolicy.com/daily-news/cms-finalizes-rule-overhauling-medicaid-enrollment-eligibility-processes (Some articles may

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March 26, 2024

The Looming Election Year Debate Over The Affordable Care Act This article captures the big divide between advocates and detractors of the Affordable Care Act (ACA). Good links to various studies. Proponents say that over 21 million are enrolled in the Exchanges and a total of about 45 million gained coverage including Medicaid expansion.  Opponents argue costs have been huge — 36,798 per additional private insurance enrollee and 20,739 per additional non-group enrollee.  This is well above original estimates. Further, critics say insurers have benefited disproportionately. Here is my Republican defense of the ACA – as strange as that sounds. I also am dubious of the study that says 3 in 4 (73%) U.S. adults “report that in one way or another the healthcare system is failing to meeting their needs.”  Other surveys would suggest general contentment with their coverage and insurer. #healthcare #healthcarereform #aca #obamacare #exchanges #medicaid  Link to

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March 25, 2024

Biden Signs Funding Bill President Joe Biden signed a $1.2 trillion spending package on Saturday, avoiding a government shutdown. The package includes funding for the Department of Health and Human Services (HHS). The Senate passed the measure 74-24, technically after the deadline. Additional article: https://www.modernhealthcare.com/politics-policy/spending-bill-passes-hhs-funding (Some articles may require a subscription.) #governmentshutdown #spending #healthcare Link to Article Change Ready To Turn On Last Major Products Involving Claims UnitedHealth Group said that its largest clearinghouse, called Relay Exchange, will be back online this weekend.  Further, after testing by clients, $14 billion in medical claims will be processed through a system. It also unveiled a timeline for remaining products to come online – roughly through mid-April. Another article speaks to a new bill that would open up funding during cyberattacks if providers have met certain cyber standards. As well, the American Hospital Association (AHA) is opposing proposals that would tie cyber standards

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The Audacity of Mark Cuban

Mark Cuban is known as a bold entrepreneur — a smart-thinking guy who cuts through all the nonsense to come up with the right solution. But how audacious was he at a recent White House forum when he suggested that federal and state programs as well as employers essentially cut the top three pharmacy benefits managers (PBMs) out of the pharmacy spending equation altogether in favor of a transparent model? However difficult in the short term, I believe the provocative Cuban has the right answer and wants to aggressively go after it. The entrepreneur is a recent entrant into the world of healthcare. His Cost Plus Drug Company (CPD or Cost Plus) is taking the nation by storm by showing how going direct to the manufacturer — and then to the consumer — can make money and lower costs. He would argue it is not a new model in free

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March 22, 2024

Senate Has Funding Bill After House Passage The Senate will need to pass a huge funding bill before midnight Friday to avert a government shutdown.  The House passed the bill, which includes healthcare funding, on a vote of  286-to-134 (112 Republicans and 22 Democrats voted against the bill). One conservative House member has called for the ouster of House Speaker Mike Johnson, R-LA, who hails from the Freedom Caucus.  She says she has support from folks, but the caucus and some Democrats do not want to see more chaos. The GOP hold on the House will be razor-thin with two early retirements. #governmentshutdown Link to Article After Win On Prior Authorization, Providers Now To Focus On Denied Claims Medicare Advantage (MA) and other health plans watch out. Providers will now want strict rules from the Centers for Medicare and Medicaid Services (CMS), Medicaid agencies, and state legislatures regarding claims denials. 

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15. What Does King Charles’ Cancer Diagnosis Tell Us About Access To Treatment Around The World?

Episode Teaser: King Charles has been diagnosed with cancer.  It has led to a debate within the U.K. about access to cancer and other treatment.  What does his cancer tell us about access around the world, including the United States?  Listen in to learn more on the latest Healthcare Labyrinth Podcast. About the Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through the Healthcare Labyrinth website and his book of the

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March 21, 2024

Medicare To Cover GLP-1s For Specific Conditions Medicare Part D will cover obesity drugs if they are approved for specific medical conditions. For example, Novo Nordisk’s Wegovy, just received approval from the Food and Drug Administration (FDA) to reduce risk of stroke or heart attack in people with cardiovascular disease and who are obese/overweight. The same rule will apply to Medicaid. The decision does not make these weight-loss drugs available more broadly. Additional article on trials showing GLP-1s slowing kidney disease progress and cardiovascular events: https://www.managedhealthcareexecutive.com/view/ozempic-reduces-kidney-disease-progression-cardiovascular-events-by-24- Additional articles: https://www.fiercehealthcare.com/payers/wsj-cms-broadens-part-d-coverage-obesity-drugs and https://www.medpagetoday.com/publichealthpolicy/medicare/109305 #weightlossdrugs #medicare #medicaid Link to Article GOP Senators Want HHS To Explain Delay In Responding To Cyberattack Senate HELP Committee Ranking Member Bill Cassidy, R-LA, and member Tommy Tuberville, R-AL, have asked why it took the Department of Health and Humans Services (HHS) almost two weeks to respond to the Change Healthcare cyberattack. Check out my blog here on

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The Change Healthcare Cyberattack:  What It Is and Its Implications

A number of Healthcare Labyrinth blog readers asked me if I would write on the Change Healthcare cyberattack and its implications. Below is what I have culled together over the past month and my thoughts about what happened and repercussions. I will attempt to write at a high level and not get too technical – in part because details are still scarce. Overview of what happened We are a month into the Change Healthcare cyberattack. On February 21, 2024, Change Healthcare reported that it was a victim of a cyberattack. It appears that the attack was a ransomware attack by the BlackCat organization and affiliates. It is known to target the healthcare industry. Change Healthcare may have paid a ransom of as much as $22 million, but this has not been confirmed. The attackers claimed about six terabytes of PHI and PII data were stolen (this could be tens of

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