December 1, 2023

Cigna-Humana Deal Could Pass Muster

While federal and state regulators will look closely and potentially oppose a combination, experts seem to think that the Cigna-Humana merger could eventually go through.  As I have indicated as well, the company profiles are quite different than earlier deals that fell through.

#cigna #humana #mergers #acquisitions

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November 30, 2023

Walgreen’s Launches Drug Tool

Similar to others, Walgreen’s has launched a drug price transparency and saver tool for its customers. No monthly fee applies.

#drugpricing #walgreens

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November 29, 2023

Cigna and Humana Exploring A Merger

Stunning news on the health plan front with speculation that Cigna and Humana are entertaining a merger.  This explains reports not too long ago that Cigna was thinking about giving up its Medicare Advantage (MA) line of business.  The merger seems like a match made in heaven.  Cigna is a commercial powerhouse, but its MA line is much smaller than Humana’s. Its MA line is struggling from a Star perspective. It sold its only Medicaid assets a few years ago. Humana is second only to United in MA and has a growing Medicaid line. Both plans have some provider assets as well. And Express Scripts, Cigna’s PBM and one of the nation’s big three, would be a huge asset for Humana. Humana has a subscale PBM asset.

Earlier mega mergers (Aetna-Humana and Cigna-Anthem) fell apart due to federal and state pushback and footprint overlaps.  Cigna would have to sell its MA line in some states, but otherwise this merger is much cleaner than the earlier ones. The feds may still attempt to stop it given the political climate on Capitol Hill.

One story at the Article link and two more here. (Some may require a subscription.):



#medicare advantage #commercial #medicaid #managedcare #mergers #healthplans

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November 28, 2023

Innovation In State And Federal ACA Exchange Programs

Interesting article on policy brief from the Commonwealth Fund on various innovations occurring in the state-based and federal Exchange programs.  As of 2023, 20 states operate a state-based marketplace and 30 rely on Healthcare.gov for sign-ups. Some state-based exchanges use the federal website for enrollment.

States are experimenting with enrollment campaigns, simplified enrollment, auto-enrollment programs, health-equity requirements, and more. 

Article at link.  The actual study is here: https://www.commonwealthfund.org/publications/issue-briefs/2023/nov/policy-innovations-affordable-care-act-marketplaces

#aca #obamacare #exchanges #commonwealthfund

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November 27, 2023

Pro Publica Article on Health Plans Not Covering Mandated Services

Pro Publica article recounts where health plans have not covered mandated services in state laws.  It is easy to sensationalize mistakes, but health plans every day are approving treatments timely. (May require subscription.)

#plandenials #healthplans

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November 23 and 24, 2023

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!

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November 22, 2023

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

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November 21, 2023

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 should hospitals be able to set ridiculously high fees for services that could be done around the corner at a free-standing lab for sometimes pennies on the dollar? Another outrage here — the provider’s behavior. The provider appears to be a hospital-owned (or at least aligned) provider referring to hospital-owned entities (in this case, a lab). This is without regard to the patient’s best interests. The provider knows they will get a surprise bill. Today, over half of all doctors are owned by hospital systems and help further drive up costs by practicing at or referring to costly hospital-owned places of services.

#pricetransparency #hospitals #healthcarereform #siteneutral

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November 20, 2023

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

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November 17, 2023

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

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