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The Importance of Price Transparency In Healthcare Reform

November 27, 2023 No Comments

While website postings of hospital and health plan negotiated prices may not seem of particular importance, the nation’s modest move toward price transparency should bear fruit over time. It is one of the more important initiatives we have seen in healthcare reform as of late. With interoperability of data, price transparency will finally give us some useful information on the inner workings (even machinations) of negotiations between health plans and providers. What are the price transparency requirements? Both health plans (effective July 1, 2022) and hospitals (effective January 1, 2021) have been required to post various pricing information on their websites. Hospitals must report all their gross and net charges in a machine-readable format as well as at least 300 shoppable services (cash and payer prices) in a consumer-friendly format. Health plans must report allowed amounts and contracted rates for hospitals and other provider services for all in-network covered services

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CMS’ Medicare Advantage Utilization Management Rule Sets A Terrible Precedent

November 22, 2023 No Comments

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

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Medicare Advantage Will Have Huge Challenges Ahead

November 20, 2023 No Comments

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

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2024 Star Ratings Turmoil Creates Huge Vulnerability for Medicare Advantage Plans

November 16, 2023 No Comments

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,

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Major Changes in Medicare Advantage Oversight

November 13, 2023 No Comments

The Centers for Medicare and Medicaid Services (CMS) have been active this year proposing major new restrictions on Medicare Advantage (MA) plans. Many of the changes are in reaction to provider lobbying efforts on Capitol Hill as well as public outcry over misleading tactics by third-party entities who enroll individuals in the popular senior and disabled plans. Let’s start out with the changes effective January 1, 2024, from the 2024 MA and Part D rule finalized earlier this year.  It is important to note that CMS issued a memo that states that it will enforce the 2024 rule beginning January 1, 2024.  Usually, such rules are enforced through the regular program audit process and it takes a number of years before regulatory changes are rolled into the audit protocols.  That seemed fair as major changes take time for plans to implement.  But in the October 24, 2023, memo issued through

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Welcome To The Healthcare Labyrinth Blog!

November 13, 2023 No Comments

Welcome and thanks for coming to the website and reading my blog.  Some of you may know me from MHK and the Strategic Insights Blog.  I have established my own independent healthcare website and will have a newsfeed, blog and podcast.  You can read more about me on this website.  While I am a Republican, I can be characterized as an unconventional one on healthcare. While I am a fiscal conservative, I believe in prudent investments in healthcare as it ultimately will save dollars and improve quality.  I believe we need to remake healthcare and have identified three key aspects to reform – conquer price/cost; pivot to wellness, prevention and care management; and ensure affordable access to healthcare for all.  I am a believer in reasonable government regulation, but in a private delivery system as this will ensure innovation along the way. Today, November 13, is the premiere of the

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