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Some Hope For Medicaid Hikes

Medicaid managed care plans have argued that risk in the program has gone up with the Medicaid unwinding (redeterminations) and rates have become inadequate to serve remaining enrollees. A number of state Medicaid directors are now saying mid-year rate hikes could address the financial woes of plans.

The Alliance of Community Health Plans is urging the current administration to urge states to re-evaluate current rates.

Notwithstanding the positive signs, states will have a hard time affording major hikes given the drying up of extraordinary federal revenue given to states during the COVID pandemic.

(Article may require a subscription.)

#medicaid #redeterminations #rates #healthplans #managedcare

https://insidehealthpolicy.com/daily-news/states-promote-mid-year-rate-adjustments-mcos-struggling-post-covid

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HHS Issues Cybersecurity Rule

The U.S. Department of Health and Human Services (HHS), through its Office for Civil Rights (OCR), issued a proposed rule to improve cybersecurity and better protect the healthcare system from cyberattacks.

The proposed rule modifies the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule. It requires health plans, healthcare clearinghouses, most healthcare providers, and most business associates, to strengthen cybersecurity protections against external and internal threats. It requires updates to existing cybersecurity safeguards, using modern best practices, to reflect advances in technology and cybersecurity. It provides greater detail on what covered entities and business associates need to do to protect the security of electronic protected health information (PHI). Policies and procedures would have to be in writing, reviewed, tested, and updated on a regular basis.

Specifically, HHS says the rule reacts to:

  • Changes in the environment in which healthcare is provided.
  • Significant increases in breaches and cyberattacks.
  • Common deficiencies OCR has observed in investigations into Security Rule compliance by covered entities and their business associates.
  • Other cybersecurity guidelines, best practices, methodologies, procedures, and processes.
  • Court decisions that affect enforcement of the Security Rule.

The rule is in response to growing cybersecurity incidents, including the Change Healthcare attack earlier this year that made much of healthcare come to a standstill.

Th fact sheet is well written and explains many of the details of the rule.  I am surprisingly impressed with the proposal and its details. I think it is a good start to protecting the nation from emerging cyberattacks.  The problem, though is the readiness of health plans and providers, especially many who have limited expertise and knowledge. They do not have the dollars or know-how to implement protections.  As such, I think we need a true national cyber plan with a strong budget and implementation strategy.  The rule is a start but is not enough.

Rule at Federal Register: https://www.federalregister.gov/public-inspection/2024-30983/health-insurance-portability-and-accountability-act-security-rule-to-strengthen-the-cybersecurity-of .

Fact Sheet: https://www.hhs.gov/hipaa/for-professionals/security/hipaa-security-rule-nprm/factsheet .

#cybersecurity #healthplans #providers #cms #hhs

https://www.hhs.gov/about/news/2024/12/27/hhs-office-civil-rights-proposes-measures-strengthen-cybersecurity-health-care-under-hipaa.html

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Wakely Finds VBID Sunset Could Impact Medication Adherence Rates

Many Medicare Advantage (MA) proponents have said that the sunset of the Value Based Insurance Design (VBID) in Medicare Advantage (MA) as of 2026 could have impact on outcomes and complicate affordability of healthcare for beneficiaries. Wakely Consulting, an actuarial and consulting firm, has found that this could be true in the area of medication adherence.

Plans have used the VBID program to target waiver of pharmacy cost-sharing for low-income (LI) beneficiaries. These are the same targeted individuals in the new Health Equity Index (HEI) rolling out in Star Year 2027. Wakely found that medication adherence for diabetes, hypertension, and hyperlipidemia could be impacted if the cost-sharing waivers disappear. The analysis found that removing copays on maintenance medications improved beneficiary adherence, which is tied to improved quality of care and health outcomes. These are three key star measures in the Part D program. Wakely argues eliminating copays for this LI group needs to remain a focus after the VBID sunset.

Wakely found that in the first year of waiving LI cost sharing, every plan demonstrated improvement in at least one medication adherence measure. Five out of the eight plans observed improvements in all three adherence measures. Two others showed progress in two of the measures, while the remaining plan improved in just one measure. Wakley says that eliminating copay barriers for LI individuals enhances their ability and willingness to consistently fill their prescribed medications.

The normalized improvement observed in medication adherence was significant in all three measures: 2.2% improvement for diabetes, 2.5% improvement for hypertension, and 1.2% for cholesterol.

#cms #stars #vbid #medicationadherence #quality

https://www.wakely.com/blog/advancing-medication-adherence-does-waiving-drug-copays-improve-medication-accessibility-for-medicare-advantage-members/

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What More Could The CMS Actuary Do For Its Annual Healthcare Spending Report?

Interesting Health Affairs Forefront Blog on what more the Centers for Medicare and Medicaid Services (CMS) Actuary could do in terms of analysis of National Healthcare Expenditures Data (NHED) each year. As the author notes, there are some crucial missing pieces that could aid analysis and reform.

  • The NHED do not report prices by payer sector. We know that the commercial world is saddled with huge prices compared with the government sector. Interestingly, the author does note that healthcare inflation declined in a real sense. As I noted in a reent blog, the surge in overall spending was tied to utilization. That blog is here: https://www.healthcarelabyrinth.com/national-healthcare-expenditure-data-issued-for-2023-what-does-it-all-mean/ .
  • The NHED do include estimates of the change in volume and intensity — overall and by provider sector. The author opines that: “What matters is the specifics of which prices could be reduced with little decline in access or quality and which care is not improving health. … Identifying opportunities for more efficient care delivery, and payment systems/delivery models that encourage those efficiencies to be realized, is crucial.”
  • The NHED do not capture costs that are not funneled through providers or insurers. The commercial sector has vast costs in this area. Also, many activities directed toward studying and managing the complexity of the healthcare system are not counted.

(Article may require a subscription.)

#nhed #cms #healthcare #spending

https://www.healthaffairs.org/content/forefront/beyond-national-health-expenditure-data-three-things-wish-were-better-measured

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CMS Pushing Streamlining Of Quality Measurement

Interesting article on the Centers for Medicare and Medicaid Services’ (CMS) push to streamline quality metrics across programs. Its approach, called the Universal Foundation, is meant to ease complexity, burden, and the administrative costs on providers and health plans by establishing standardized metrics and financial incentives. Right now, CMS has about 20 measure sets that encompass hundreds of discrete measures.

I certainly endorse standardization and streamlining, but migrating to the Universal Foundation will take years. Further, given differences in demographics, we will always have some unique measures in each program. But standardizing Accountable Care Organization (ACO) and Medicare Advantage (MA) measures would be a great place to start.

(Article may require a subscription.)

#quality #stars #acos #medicareadvantage #cms 

https://www.modernhealthcare.com/policy/cms-universal-foundation-quality-data-reporting-measurement

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House Passes Stop Gap; On To Senate To Avoid Shutdown

The House passed a continuing resolution (CR) to fund the government late Friday. This should avert a midnight shutdown. The CR funded government through March 14, 2025. Far-reaching healthcare provisions once going to pass as part of a free-standing bill or within the CR became a closely tailored list of must-haves for healthcare.

The funding bill extends Medicare telehealth flexibilities and CMS’ acute hospital at home program for 90 days, through March 31, 2025. The CR postpones scheduled cuts to Medicaid disproportionate share payments for safety-net hospitals and extends special Medicare reimbursements for low-volume hospitals and Medicare-dependent hospitals until April 1. It sustains funding for community health centers and pandemic preparedness programs until March 31. No relief for Medicare physicians, who now will see a 2.8% rate reduction as of January 1. ACOs did not see an extension of critical funding. Pharmacy benefit manager (PBM) reforms and steps toward site-neutral payments were axed.

Democrats reversed course and supported the bill after refusing to support a similar bill yesterday. One big change: no debt ceiling extension, which Democrats opposed as they wanted a GOP Congress to own the issue in 2025. Hardline Republicans came around too as they did not want the debt ceiling extension in the bill either, which they believe would erode their leverage to obtain spending guts in the future. Instead, Republicans entered into a gentlemen’s agreement with leadership where the borrowing limit will be increased by $1.5 trillion in exchange for $2.5 trillion in net cuts to spending. This will be done through a reconciliation package in the next Congress.

The Senate will undoubtedly adopt the bill later tonight or tomorrow.

12/21 Update: The Senate passed the bill early Saturday morning.

Additional articles: https://www.modernhealthcare.com/politics-policy/spending-bill-house-healthcare-package and https://insidehealthpolicy.com/inside-drug-pricing-daily-news/house-passes-cr-without-key-health-care-reforms-setting-stage-march and https://thehill.com/homenews/house/5051634-government-funding-shutdown-house-bill/

(Some articles may require a subscription.)

#crs #governmentshutdown #congress #healthcare

https://www.fiercehealthcare.com/payers/how-healthcare-orgs-are-reacting-proposed-government-funding-bill

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Government Shutdown Looms with Stop Gap Failure In House

A government shutdown now looms as the budget funding saga plays out. This week President-elect Donald Trump, a number of his incoming aides, and a set of rightist House Republicans came out against a bipartisan stop gap that would have funded the government through March 14 and extended the debt limit until January 2027.

The House GOP has just attempted to pass a skinny continuing resolution (CR), which stripped out a number of things on the healthcare front and still funded disaster aid. The House Democrats opposed the refinements and fewer spending initiatives. The bill needed two-thirds to pass due to the inability to put the bill through the rules committee. At about 7:00 PM tonight the bill failed, with all but two Democrats opposing. The bill would not have passed under regular order, either. About three dozen conservatives opposed the bill as too rich because $100 billion in disaster was not offset with spending cuts.

We will learn tomorrow what will be done if anything to avoid a government shutdown set to begin at 11:59 PM Friday. Trump did urge the House GOP to support the skinny CR given the debt extension.

The skinny CR eliminated PBM reforms and pulled back on a number of healthcare issues previously included. It extends Medicare telehealth flexibilities and hospital at home waivers until March 31, 2025. A temporary Medicare physician rate increase for doctors was eliminated too, which means the 2.8% reduction would go into effect.

Additional article: https://thehill.com/policy/healthcare/5049676-house-republicans-drop-pbm-reform/

#congress #crs #governmentshutdown #healthcare #pbms

https://www.fiercehealthcare.com/payers/how-healthcare-orgs-are-reacting-proposed-government-funding-bill

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Passage Of Stop Gap Measure In Limbo

The passage of a government shutdown bill is now in limbo after a group of House Republicans as well as President-elect Donald Trump, VP-elect JD Vance, Elon Musk, and Vivek Ramaswamy came out against the measure, arguing it is irresponsible and not a straight government-funding extension.

The bill includes provisions to bolster the accuracy and reliability of Medicare Advantage (MA) provider directories and cost-sharing protections for those who receive care from out-of-network providers due to inaccuracies in those directories.

The bill also includes reform of pharmacy benefit managers’ practices in Medicare, Medicaid and the commercial market and reforming so-called patent thickets to delay generic competition.

Trump and Vance also argue the debt ceiling should be raised under Biden’s watch to avoid issues with Democratic support in 2025.

In other news, the final health piece of the bill left out site-neutral payments and prior authorization reforms.

House Democrats have said they will not support a clean CR to keep government operating.

Additional articles: https://www.fiercehealthcare.com/payers/how-healthcare-orgs-are-reacting-proposed-government-funding-bill and https://www.modernhealthcare.com/politics-policy/donald-trump-government-spending-bill-debt-ceiling and https://insidehealthpolicy.com/daily-news/congress-moves-forward-25-physician-pay-fix-omits-site-neutral-prior-auth-reforms and https://insidehealthpolicy.com/daily-news/trump-jeopardizes-two-year-telehealth-extension-broader-health-deal and https://insidehealthpolicy.com/daily-news/medicare-advantage-ghost-network-reforms-risk-trump-urges-lawmakers-oppose-cr and https://insidehealthpolicy.com/inside-drug-pricing-daily-news/cr-flux-pbm-generic-drug-transparency-drug-patent-reforms-uncertain and https://thehill.com/homenews/administration/5047382-trump-government-spending-deal/ and https://thehill.com/homenews/house/5047510-hakeem-jeffries-democrats-government-funding/

(Some articles may require a subscription.)

#governmentshutdown #crs #healthcare

https://thehill.com/homenews/house/5047285-mike-johnson-spending-plan-b

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PBMs Took Payments From Drug Makers During Opioid Crisis

A New York Times multi-part expose continues its attacks on the pharmacy benefits manager (PBM) industry. In its latest investigation, the newspaper tells us that PBMs took payments from opioid manufacturers in return for not restricting the flow of pills. PBMs collected billions while tens of thousands overdosed and died from the prescription painkillers. Among the drug manufacturer payors was Purdue Pharma and the disgraced Sackler Family.

Slowly but surely the roles of various drug channel stakeholders have come to light, from drug makers to wholesalers to PBMs to pharmacies. It is a national tragedy stoked by greed. All of the corruption needs to come to light and violators civilly and criminally held to account.

The report is sure to turn up the heat even more on PBMs on Capitol Hill.

(Article may require a subscription.)

#nyt #opioids #branddrugmakers #pbms

https://www.nytimes.com/2024/12/17/business/pharmacy-benefit-managers-opioids.html

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CR and Healthcare Policy Bill Updates

Capitol Hill lawmakers are inching toward a continuing resolution (CR) that needs to be adopted by the end of the week. At the same time, Congress looks like it has agreed to a critical bill to extend certain healthcare programs set to expire at year’s end. Telehealth extensions will be for two years, while the hospital at home program will get a five-year extension. Medicare docs will get a 2.5% hike in 2025 vs. a 2.8% cut. At least a dozen other healthcare areas get fixes or increases under the bill.

In a bombshell, there are major offsets to pay for increases, including major pharmacy benefits manager (PBM) reforms.

  • A “delinking” policy to require that Part D Plan sponsors delink PBM compensation from the price of the drug.
  • Prohibition on PBM “spread pricing” in Medicaid.
  • Medicare Part D transparency requirements for PBMs and Medicare Part D.
  • Private Insurance PBM reforms.

Reports also suggest that Medicare Advantage (MA) prior authorization reforms are or may be included. These could include some or all of the provisions in the Improving Seniors’ Timely Access to Care Act.

The PBM trade lobby, the Pharmaceutical Care Management Association (PCMA), issued a vociferous response to reports, arguing the changes will increase costs to the government, employers, and consumers. Specifically, it says the delinking reform would increase premiums in Part D by $13 billion and will benefit drug companies.

In other news, an interesting article on the state of traditional PBMs and those dedicated to transparency. President-elect Trump declared last week he would support reform of PBMs. Major companies with PBMs saw their stocks drop on the declaration.

Additional articles: https://thehill.com/business/budget/5042654-government-funding-deal-progress/ and https://insidehealthpolicy.com/daily-news/lawmakers-close-health-package-includes-two-year-telehealth-extension and https://www.fiercehealthcare.com/payers/pbm-lobby-punches-back-end-year-package and https://insidehealthpolicy.com/daily-news/pbm-lobby-blasts-reported-inclusion-delinking-private-market-transparency-policies and https://www.fiercehealthcare.com/payers/2025-outlook-alternative-pbms-look-heap-pressure-industry-titans and https://www.modernhealthcare.com/politics-policy/cvs-unitedhealth-cigna-shares-pbms-donald-trump-middlemen

(Some articles may require a subscription.)

#crs #governmentshutdown #healthcare #pbms #drugpricing #hospitalathome #telehealth #medicareadvantage #partd #pdp #medicaid #physicians #rates #trump

https://www.fiercehealthcare.com/regulatory/two-year-extension-telehealth-likely-negotiations-crest-congress

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