Blog Archives - Page 17 of 18 - The Healthcare Labyrinth

Inflation Reduction Act’s Medicare Price Negotiations Should Have Small Impact On Innovation But Positive Impact On American Lives And What We Pay

January 8, 2024 No Comments

If you have read my book, The Healthcare Labyrinth (available at this website), you know I am a proponent of negotiating drug prices nationally as well as the Medicare drug price provisions of the Inflation Reduction Act (IRA) more specifically. In my book, I argue a few fundamentals about drug prices in America: I am a Republican and I hold atypical views on drug pricing for my party – at least compared with most House and Senate GOP lawmakers. But the truth is, the last president and current president have proposed similar reforms on drug pricing. Respected think tanks with bipartisan representation support change, too. Polls also show support across parties for drastic changes to lower drug prices. I also don’t believe that if you support drug price negotiations and other reforms that somehow you are anti-free market. Negotiations and contractual agreements are a cornerstone of the free market. But

Risk Adjustment Basics and The Controversy Over Medicare RADV

January 4, 2024 No Comments

A few readers have sent me messages and asked me to detail some basics of risk adjustment (RA) — how it works, its benefits, and its challenges — and the controversy surrounding risk adjustment data validation (RADV) in Medicare Advantage (MA) specifically. RA is a complex world, but here is my best effort to keep the overview simple and then move to the coming RADV conflagration. While not practiced in the employer world because of the penetration of self-insured funds under the Employee Retirement Income Security Act (ERISA, where the employer shoulders the entire burden of costs and insurers are not at risk), risk adjustment has become an important and common practice in MA, Medicaid managed care, and Exchange managed care. Quite simply, risk adjustment is critical to ensuring that health plans are compensated fairly to cover the costs of a given individual as well as the population as a

Channeling Nostradamus: The Healthcare Labyrinth’s 2024 Predictions

January 2, 2024 No Comments

In my last blog, I gave you my healthcare year-in-review for 2023. After that, as I always do each year, I play Nostradamus to prognosticate about what will happen in the next twelve months in the world of healthcare. Despite my Irish last name, I do have French blood (well, 50% French Canadien, so I count it). But I don’t claim to be an oracle or seer like our 16th century physician, apothecary, and astrologer friend. I do take a page from Nostradamus, though, in that my healthcare predictions for 2023 (not really prophecies) will be sometimes deliberately vague (they include a lot of mays, coulds, shoulds, and possibles) so as to amass a reasonable record for those tracking and putting together my forecasting report card for the history books. Here is hoping my crystal ball is clear and not cloudy, but don’t hold me to any of this; I am simply

The Healthcare Labyrinth 2023 Year-In-Review

December 28, 2023 No Comments

As I have done for many years, I write a healthcare year-in-review blog to tell you about all the major health stories and trends of the last twelve months. It is meant to be a general assessment and you can check this website’s Newsfeeds and Blogs as well as my LinkedIn posts ( https://www.linkedin.com/in/marc-s-ryan-%F0%9F%87%BA%F0%9F%87%A6-1a99529/ ) for more information. I break the stories and trends into categories to help your understanding. It is clear that 2023 was a busy year for healthcare, so this blog will be a long one! Here we go! Healthcare, Insurers, and Providers In General In general, 2023 was a continuing year of recovery from the COVID pandemic (2020 to 2022). Healthcare utilization was up again and costs/inflation are returning to normal. We shall see this continue into 2024. We saw moderate inflation in the healthcare sector in 2023 with similar projections for next year (5% to

The Insanity of Drug Pricing and Shortages: A Christmas Story

December 26, 2023 No Comments

After what I went through, I asked Santa to bring me a rational drug pricing system for Christmas . But not even the great St. Nick can sort this mess out. Drug shortages or supply disruptions are in the news of late, with serious concerns over the availability of critical cancer and other life-saving drugs. While my drug supply story is not nearly as serious, I write about it today as I have been dealing with it over the Christmas holiday and it shows the pure insanity of our drug supply and pricing system in America. I am withholding the names of the pharmacies and the pharmacy benefits manager (PBM) as not doing so would be unfair to an individual drug chain or PBM. What we see here occurs across the drug supply chain. I am disclosing the drug manufacturers as this helps make clear the complexity of drug pricing.

Are Health Plans’ Relationships With Owned Entities Fair? Will They Open Up More Regulatory Scrutiny?

December 21, 2023 No Comments

A late November bipartisan letter from Sens. Elizabeth Warren, D-MA, and Mike Braun, R-IN, to the Health and Human Services (HHS) Office of Inspector General (OIG) has many wondering if lawmakers and policymakers will open up a new regulatory front that will bring heightened scrutiny of health insurers’ finances and internal contractual relationships. Let’s give some history first before diving deeper into the issue. With this set up, what does the letter say? Warren and Braun want the HHS OIG to open an investigation on MLR gaming. They are reacting to a recent Brookings Institution analysis and Wall Street Journal (WSJ) report showing the extent of contracting by major insurers with their own subsidiaries and the impact that could have on costs in the healthcare marketplace, especially for consumers. The letter alleges that certain insurers are using these arrangements to evade the minimum MLR rule. In effect, they say insurers

National Healthcare Expenditure Data Issued for 2022: What Does It All Mean?

December 18, 2023 No Comments

One of my Christmas traditions is to write about the release of the Centers for Medicare and Medicaid Services (CMS) Actuary’s National Healthcare Expenditure Data (NHED) for a given calendar year. This usually is released in the first half of December each year for the prior year. It literally takes CMS about a year to capture, calculate and categorize all the data for a year given the size and labyrinthine complexity of our healthcare system. Each year as well, usually in the first half of June, the CMS Actuary updates healthcare spending projections for ten outyears. Why is this so important? First, it is the main comprehensive source of data for calculating the history and future of healthcare spending. Most other studies rely on the CMS Actuary’s NHED reports in some way. Second, it is a treasure trove of data that helps explain the inner workings of the healthcare system.

PBM Transparency And Reform Is A Big Trend In The American Healthcare System

December 14, 2023 No Comments

The push for lower drug prices in general and reform of America’s Pharmacy Benefit Management (PBM) industry specifically are major focuses of Capitol Hill and state and federal regulators. With these trends taking center stage, I thought it would be interesting to lay out where the impetus for reform is coming from and what the future likely holds. I don’t pretend this is an exhaustive piece, but it is meant to set the table for future discussions and blogs. It is clear to me that the push for reform substantially is coming from outside the industry, but there are clear trends even within the drug and PBM industry toward change. What is the current status? It is critical to recognize that PBMs alone do not set prices in American healthcare. We have a tremendously opaque drug supply channel that begins with drug makers. The below walk-through is simplified and does

New Poll Shows Americans Want To Work To Improve The Current Healthcare System Not Replace It

December 11, 2023 No Comments

In my last blog on December 7, I argued that former President Donald Trump gave Democrats an issue to run on in 2024 when he stated on two occasions that he wanted to repeal the Affordable Care Act (ACA). I argued that the Republican party has a “compassion gap” and Trump signaling he would repeal the ACA widens that gap and gives a leg up to the Democrats. A recent Kaiser Family Foundation (KFF) poll showed that the ACA was a very important issue for about half of those surveyed and that about a third of Republican voters felt that way. In general, on healthcare issues, the poll underscored that voters may trust the Democrats more. As I noted, my blog was published on December 7 and later that day a new poll was published that underscores my views. The poll had 2,000 respondents and was conducted by the Partnership

Republicans Have a Compassion Gap But Trump Gives Democrats Momentum on Healthcare Anyway

December 7, 2023 No Comments

Former President Donald Trump recently brought up the possible repeal of the Affordable Care Act (ACA) and has put his (and my) party in a bind. Republicans suffered at the polls on the very issue Trump has resurrected. Why is he raising the status of the landmark act again? In a post on Truth Social on November 25, Trump declared: “The cost of Obamacare is out of control, plus, it’s not good Healthcare. I’m seriously looking at alternatives.” He clearly caught his party by surprise. You could hear the collective signs and groans coming from Capitol Hill Republicans who survived the issue in the past. After some criticism, Trump sought to clarify his remarks but actually reiterated his stand. On November 29 on Truth Social, Trump stated: “I don’t want to terminate Obamacare, I want to REPLACE IT with MUCH BETTER HEALTHCARE. Obamacare Sucks!!!” Fellow candidate and FL Gov. Ron

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