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MA Issues Trickle Down To Providers And Vendors

This article focuses on Medicare Advantage (MA) troubles – rates, utilization, medical expense, and punitive regulatory requirements – and how they impact insurers, value-based-care providers, and vendors. My intel suggests that the traditionally flush global and partial risk funds that insurers have with providers around the country (providers share in profits when they help reduce costs and improve quality) have dried up or are drying up. Providers are already attacking insurers on numerous issues and this development will only make such relationships even worse.

Note as well the reference to MA plans emphasizing profitability by reining in market growth and benefits.  I say just this in my blog on the topic here: https://www.healthcarelabyrinth.com/with-boom-over-will-medicare-advantage-collapse-or-adjust/ . As well, see my just published blog on the 2025 MA payment proposal: https://www.healthcarelabyrinth.com/2025-rates-for-medicare-advantage-plans-look-tight/

(Article may require a subscription.)

#medicareadvantage #vbc #providers

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Another Flat Year For Medicare Advantage Before Risk Score Trends

The Centers for Medicare and Medicaid Services (CMS) announced the 2025 rate hike for Medicare Advantage will be relatively flat. This is similar to what happened in 2024 after big increases in 2022 and 2023.  The effective growth rate was up, but the phase-in of a new risk adjustment model basically offsets those gains. The final notice may push these numbers up a bit. If you include risk score trends, MA revenue could increase by about 3.7%. So real revenue should be up, but health plans don’t like thinking of it that way as they think risk score trends tie to increased medical exposure. 

I include all these articles here but read with caution as many reporters interpret things differently. In the end, this is not the worst news, but it is bad in the face of some major medical expense and utilization increases.  See my recent blog here for where MA is headed: https://www.healthcarelabyrinth.com/with-boom-over-will-medicare-advantage-collapse-or-adjust/

The CMS Fact Sheet is at the link.  Additional government releases and fact sheets here: https://www.cms.gov/newsroom/press-releases/cms-releases-proposed-payment-updates-2025-medicare-advantage-and-part-d-programs and https://www.hhs.gov/about/news/2024/01/31/cms-releases-proposed-payment-updates-2025-medicare-advantage-part-d-programs.html and https://www.hhs.gov/about/news/2024/01/31/biden-harris-administration-strengthening-medicare-protecting-and-serving-americas-seniors.html

Additional articles here: https://www.fiercehealthcare.com/payers/cms-proposes-37-pay-rate-increase-ma-plans-redesigning-part-d-program and https://www.modernhealthcare.com/politics-policy/cms-proposes-medicare-advantage-pay-cuts-2025-ahip and https://insidehealthpolicy.com/daily-news/cms-expects-37-ma-pay-bump-after-2024-s-advance-notice-tumult and https://www.statnews.com/2024/01/31/medicare-advantage-2025-proposed-payment/ .

(Some articles may require a subscription.)

#medicareadvantage #rates #payments

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Health Policies To Watch In 2024

The Peterson-Kaiser Family Foundation Health Tracker has a good briefer on expected healthcare policy issues to watch in 2024.  Among the many include site-neutral policies, price transparency, drug pricing and trends, PBM reform, drug price differences around the developed world for weight-loss drugs, value-based care and payments, and anti-trust activity.  A great primer!

#peterson #kff #healthcare #healthcarereform

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Elevance Health Sues CMS Over Medicare Advantage Star Rating

Interesting article on Elevance Health’s lawsuit against the Centers for Medicare and Medicaid Services (CMS) on Stars.  If this is anything close to true, CMS needs to relook at how it ensure fairness in calculations. How many others may have been impacted?

#elevancehealth #stars #medicareadvantage

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2023 Bankruptcies Highest In Five Years

As was reported earlier, another report also shows that bankruptcies were very high in the healthcare arena in 2023.  Hospitals, pharmaceutical and senior care companies were on the list.

Additional articles here: https://www.modernhealthcare.com/finance/healthcare-bankruptcies-2023-gibbins-advisors and https://www.healthcaredive.com/news/healthcare-bankruptcies-spike-2023-gibbins-advisors/705738/

(Some articles may require a subscription.)

#hospitals #healthcare #bankruptcies

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Humana Reconfirms Bad News On Utilization In MA

After an earlier filing, Humana reconfirmed bad news on the medical expense front. Because it is a predominant Medicare Advantage (MA) insurer, it has seen a major and unexpected rise in utilization, which impacted the company’s 2023 numbers and prospects for 2024 and beyond.  Broussard is one of the smartest healthcare leaders out there and he is someone I listen to closely. Given the medical expense rise, rate compression, and regulatory changes (such as the new prior authorization rule), Broussard said he expects similar pricing adjustments from other payers, as the spike in utilization along with ongoing regulatory changes will have major impacts in 2025 and potentially beyond. Broussard says this could very well be industrywide. Humana reduced benefits for 2024 and this could be a continued trend into the future. Humana plans on cutting about $700 million in administrative costs.

It doesn’t mean MA is not a good place to be, but it does show the shortsightedness of the Centers for Medicare and Medicaid Services (CMS) and Capitol Hill as they seek to bind the hands of MA plans too much.

Additional articles: https://www.modernhealthcare.com/finance/humana-cuts-medicare-advantage-changes-earnings and https://www.healthcaredive.com/news/humana-dour-2024-profit-forecast/705537/

(Some articles may require a subscription.)

#medicareadvantage #humana #medicalexpense

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Record Enrollment In Exchanges Nationwide

The Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services (HHS) announced something to celebrate.  Driven in part by Medicaid redetermination enrollment losses and enhanced premium subsidies, state and federal exchange enrollment reached a projected 21.3 million for 2024. An amazing achievement. Over 5 million new enrollees joined over 16 million existing members. Nearly 4.2 million people with incomes of less than 250% of the federal poverty level signed up for 2024 coverage.  They receive both premium subsidies and cost-sharing reductions. About 15% of those enrollment previously had Medicaid.  That translates to a little over 3 million – a small amount of those who lost Medicaid coverage. Over 16 million are in the federal Exchange and about 5 million in various state Exchanges.

CMS press release here: https://www.cms.gov/newsroom/press-releases/historic-213-million-people-choose-aca-marketplace-coverage . CMS Snapshot here: https://www.cms.gov/newsroom/fact-sheets/marketplace-2024-open-enrollment-period-report-final-national-snapshot . HHS press release here: https://www.hhs.gov/about/news/2024/01/24/historic-21-million-people-choose-aca-marketplace-coverage.html

Kaiser Family Foundation analysis here: https://www.kff.org/policy-watch/another-year-of-record-aca-marketplace-signups-driven-in-part-by-medicaid-unwinding-and-enhanced-subsidies/

Other articles here: https://www.modernhealthcare.com/insurance/open-enrollment-breaks-21m-2024 and https://thehill.com/homenews/4426408-obamacare-marks-record-enrollment-5-million/ and https://insidehealthpolicy.com/daily-news/cms-touts-medicaid-marketplace-transitions-enrollments-hit-record-213m

(Some articles may require a subscription.)

#exchanges #aca #obamabcare #enrollment #coverage #medicaid #redeterminations

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Rural Hospitals In Distress

A good measure of the distress rural hospitals: most no longer deliver babies. Over half of the country’s rural hospitals aren’t offering labor and delivery services and more could end such services.

Some would argue that the rural hospitals’ plight could be solved by more money for hospitals overall.  The truth is the abominable hospital price system we have in this country along with the gross inefficiency of most hospitals drains overall healthcare resources and means we do not have enough to respond to true crises, such as those in rural communities.

#ruralhealthcare #hospitals

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Elevance Health All In On AI

Elevance Health CEO Gail Boudreaux gave a keynote speech that shows the second-largest insurer will be all in on AI. She wants her company to use the technology to make healthcare more proactive, predictive and personalized. She wants AI to help people navigate the system and simplify it.

#elevancehealth #ai #digitalhealth

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Weight Loss Drugs Take Nation By Storm

Ozempic and other new drugs are all the rage for weight loss.  These new drugs have both great promise and the potential to be abused and drive up healthcare costs phenomenally.  See some of the trends here.

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#weightlossdrugs #healthcare

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