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End-Of-Year Stop Gap Funding In Flux

With the House staying Republican, some are saying the stop gap measure to fund government by the end of the calendar year is now in flux. Some Republicans want to punt any substantive legislative action to the new Congress when the GOP is fully in control. Others want to pass substantive legislation, including several healthcare initiatives. They could include pharmacy benefit manager reform, hospital transparency, and site-neutral payments.

One of the top issues that many aim to pass in the lame-duck session is instituting site-neutral payment rules for outpatient care. This is heavily opposed by the hospital lobby, but it is gaining bipartisan momentum. It is unknown how expansive any proposal would be (some or all outpatient services) and whether it would apply just to Medicare or include commercial. The Congressional Budget Office (CBO) projects that the most robust site-neutral legislation would save more than $100 billion over 10 years. Including commercial, savings are even greater.

In other news, healthcare advocates are saying that extending Exchange premium subsidy enhancements may be a long shot but they see pathways to victory. They will argue the impact to coverage will be great if enhanced subsidies sunset. There could be some concessions on the size of the enhancements and who is eligible. The CBO says reupping the enhancements permanently would cost about $335 billion over 10 years. A sunset could mean 4 million join the ranks of the uninsured.

Additional articles: https://www.modernhealthcare.com/politics-policy/site-neutral-payment-bill-congress and https://insidehealthpolicy.com/daily-news/advocates-see-fight-over-aptcs-hard-winnable-alternative-approaches-may-be-play

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#crs #governmentshutdown #congress

https://insidehealthpolicy.com/daily-news/election-throws-uncertainty-lame-duck-package-size-timing

DOJ And States Oppose UnitedHealth Acquisition Of Amedisys

The federal Department of Justice and four states have sued to stop UnitedHealth Group’s acquisition of home care entity Amedisys. It is the latest in the Biden administration’s move to scrutinize acquisitions as part of its antitrust agenda in healthcare.

While Donald Trump is predicted to be more friendly to business, there is no guarantee that these types of acquisitions will not be challenged under a new president. I am suspicious of overly broad challenges by the government, but their arguments in the suit are reasonably compelling in terms of the control United would have on the industry in about half of states and the impact on price.

Additional articles: https://www.modernhealthcare.com/legal/doj-unitedhealth-amedisys-lawsuit-home-health and https://www.healthcaredive.com/news/doj-challenges-unitedhealth-amedisys-deal/732721/

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#unitedhealthcare #homecare #providers #antitrust #biden

https://www.fiercehealthcare.com/payers/doj-sues-block-unitedhealths-33b-acquisition-amedisys

Cigna Not Acquiring Humana

Cigna confirmed it is not pursuing an acquisition of Humana, squashing long-standing rumors. It will make a more official statement soon. Cigna CEO David Cordani is known not to like the Medicare Advantage (MA) insurance line and is selling its underperforming MA lives to Health Care Service Corporation (HCSC). Humana currently struggles financially. Cigna is focused on growing its Evernorth service unit. It is using its free cash and the future MA sales proceeds on stock buybacks. So far it has bought back $6 billion in stock.

Additional articles: https://www.modernhealthcare.com/insurance/cigna-humana-merger-ends-share-buybacks-medicare and https://www.healthcaredive.com/news/cigna-confirms-humana-deal-off/732488/ and https://www.beckerspayer.com/m-and-a/cigna-not-pursuing-humana-merger.html

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#cigna #medicareadvantage #humana

https://www.fiercehealthcare.com/payers/cigna-officially-confirms-its-not-pursuing-humana-acquisition

OIG Says Hospitals Not Complying With Hospital Transparency Requirements

The Health and Human Services Office of Inspector General (HHS OIG) says many hospitals are not publishing their prices in accordance with the price transparency requirements. The HHS OIG analyzed data from 30 hospitals that were part of the country’s three largest health systems as well as a random sample of 5,504 facilities. Researchers reviewed hospital websites between Jan. 17, 2023 and March 14, 2023.

HHS OIG found that more than a third of the 100 hospitals did not post machine readable pricing data files correctly or at all. Most of the errors involved not disclosing rates with insurers, metadata errors, and outdated information.

The Centers for Medicare and Medicaid Services (CMS) says some entities have already corrected errors, but it shows just how lax CMS enforcement is years into the law.

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#hospitals #transparency #pricetransparency #cms

https://www.modernhealthcare.com/providers/hospital-price-transparancy-compliance-oig

Health Insurer Q3 Financial News

Oscar Health reported slipping financials and at least part of its long-term success is dependent on the continuation of enhanced premium subsidies in the Exchanges. After two quarters of net profit, Oscar posted a $54 million loss in Q3. But total revenue was $2.4 billion, a 68% year-over-year increase. Its medical loss ratio (MLR) climbed to 84.6%. It did raise revenue guidance and said EBITDA will be at the higher end of its earlier reported range.

Exchange-focused Oscar has 1.65 million members in total. The company added 73,000 members in the quarter. Its growth has been explosive during the Biden administration. It expects more big growth in 2025 as the premium enhancements are still in place.

Oscar Health CEO Mark Bertolini’s had a rather stern message and challenge for what is expected to be a totally GOP controlled Washington. Bertolini says the GOP would allow the enhanced premium subsidies to expire at great risk. Almost two-thirds of Exchange enrollees live in GOP-led states and enrollment in those states grew 76% from 2023 to 2024. That Exchange enrollment is slanted toward GOP states is because ten of them did not expand Medicaid.

Oscar stock dropped over 15% following Trump’s electoral win — a seven-month low.

Medicare Advantage-focused Clover Health also reported Q3 news. After its first quarterly net profit in Q2, Clover posted a net loss of $8.8 million from Q3. But that still is a 74% improvement from Q3 2023. Clover is bullish on the 2025 enrollment season and has been less impacted by the fallout seen by larger plans. It achieved a 4 Star rating in 2025.

Other news:

• The Q3 MLRs reported so far.
• A Kaiser family Foundation overview of the 2025 Exchange enrollment season.

Additional articles: https://www.fiercehealthcare.com/payers/clover-health-pushing-growth-shows-74-net-income-boost and https://www.kff.org/policy-watch/ten-things-to-watch-for-2025-aca-open-enrollment/ and https://www.beckerspayer.com/payer/payers-ranked-by-q3-mlr-ratios.html

#exchanges #aca #obamacare #medicareadvantage #coverage #trump

https://www.fiercehealthcare.com/payers/oscar-health-racks-55m-net-loss-aca-uncertainty-returns

Healthcare Media Reacting To Trump Win

A series of articles appeared today reacting to Donald Trump’s victory in the presidential election.

The articles predict as expected that the Exchanges and Medicaid will be reined in through a number of regulatory and statutory efforts. It notes that Trump may not again go after the Affordable Care Act (ACA), but that extension of the enhanced premium subsidies in the Exchanges are very much in doubt. At the same time, his incoming VP JD Vance outlined a potential change to premium setting in Exchanges.

On Medicare Advantage (MA), Trump is said to be much more enamored with the program as an alternative to the traditional system. I, however, feel Trump and lawmakers will still seek some reforms and savings in MA.

Pharmacy benefits manager (PBM) reform likely moves forward, given bipartisan congressional support and previous positions taken by the former president.

Trump is also seen as less antitrust focused than the current administration. But again, many GOP lawmakers in the Senate have grave concerns about consolidation.

An open question is what will happen to Medicare drug price negotiations. Trump took no real position on it during the campaign and he had policies that were in favor of drug price reform and reductions.

Health insurer stocks, especially those focused on MA, were up after Tuesday considerably.

Additional articles: https://www.fiercehealthcare.com/payers/insurers-prep-trump-admin-friendly-medicare-advantage-and-mergers-hostile-medicaid-and-aca and https://www.modernhealthcare.com/politics-policy/trump-healthcare-policy-medicare-aca-second-term and https://www.modernhealthcare.com/insurance/unitedhealth-humana-cvs-stocks-trump-election-win and https://insidehealthpolicy.com/daily-news/fate-ira-negotiations-uncertain-after-trump-election-victory

#election2024 #healthcare #healthcarereform #trump

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https://www.fiercehealthcare.com/regulatory/trumps-white-house-return-poised-tangle-health-care-safety-net

Biden No Surprises Act Interpretation Wins At Appellate Level

After being struck down at the federal district level several times, the 5th Circuit Court of Appeals sided with the Biden administration’s original interpretation of the No Surprises Act in determining how a key metric in billing disputes is calculated. The court said that insurers can use a wider variety of rates in calculating the key qualifying payment amount (QPA) metric that helps arbitrators determine fair payment amounts.

Now, the law remains heavily skewed to providers, who win three in four cases thus far in arbitration. The law itself favors providers in that it is baseball-style arbitration. The Biden administration wanted to tell arbitrators to give deference to the QPA, but this remains struck down by the courts. But the QPA determination is at least a small win that could begin to change things for the better.

#nosurprisesact #nsa #surprisebilling #providers #healthplans

https://www.healthcaredive.com/news/appeals-court-reverses-lower-court-rulings-surprise-billing/731855

Trump And Johnson Silent On Reforming Employer Healthcare Deductibility

Donald Trump and House Speaker Mike Johnson, R-LA, are not saying whether they support the House Republican Study Committee’s (RSC) proposals to potentially cap the tax exclusion for employer-sponsored coverage. Employers can deduct premiums from federal and payroll taxes. Workers’ shares of premiums are also exempt from income taxes. These tax breaks cost about $300 billion combined a year today.

The RSC is a conservative policy caucus within the House GOP members. Its proposal on employer healthcare tax deductibility is unclear, but its budget document certainly infers the deduction may be limited and it also calls for equalizing individual and employer deductibility. There are a few ways to limit the tax deduction, either capping what an employer can take outright or taxing individuals over certain amounts individually.

Opponents argue the unfettered deduction drives up healthcare costs. To some degree this may be true, but capping it would likely increase employer costs dramatically or transfer it to workers. The RSC also does not instill confidence that individual purchasing, which it clearly favors, would in fact mean robust and comprehensive coverage for all. With its other healthcare proposals, coverage would dramatically change and likely lead to fallout.

America is the only developed country with an employer-based healthcare system as its base, which puts businesses at a major competitive disadvantage compared with other nations. And remember, this is a tax deduction and not a credit – so business pays the lion’s share of costs and not the federal government.

I still believe a refined Cadillac tax, passed as part of the Affordable Care Act (ACA) and later repealed, is the best way to rein in healthcare costs without hurting overall tax deductibility of healthcare costs. Unless there is something truly better that gets us to affordable universal access, the tax deduction for employer-sponsored insurance has to stay in place as it drives overall coverage in America.

The Congressional Budget Office (CBO) says a cap could save between $500 billion and $900 billion over a decade. A Republican Congress and a President Trump could take some piece of employer insurance deductibility to pay for the extension of the Trump tax cuts.

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#employercoverage #healthcare

https://insidehealthpolicy.com/daily-news/trump-johnson-silent-tax-treatment-employer-coverage

Bipartisan Senate Team Wants To Move On Site Neutral Payments

Sens. Bill Cassidy, R-LA, and Maggie Hassan, D-NH, unveiled their support for a bill that would begin paying hospital outpatient facilities lower Medicare reimbursements much more consistent with what other places of service receive for the same services – known as “site-neutral” payments. The bill would equalize payments for common outpatient services at hospital-owned offsite locations, ambulatory surgery centers, and other clinics.

Check out my blog on site neutral payments here:  https://www.healthcarelabyrinth.com/it-is-time-for-site-neutral-payments-in-our-healthcare-system/ . We know that the lack of site neutral payments cost us huge sums and we need to reform this in Medicare. Commercial payments would then be transitioned as many commercial plans base rates on Medicare. The hospital lobby’s ridiculous arguments may finally be giving way to common sense. Kudos to Cassidy and Hassan. We need full site neutral payments as quickly as possible.

There is the possibility of inclusion in a lame deck session bill. Wisely, their bill would use some savings to support rural and other critical hospitals.

(Article may require a subscription.)

#siteneutral #hospitals #medicare

https://www.modernhealthcare.com/politics-policy/senators-look-expand-site-neutral-payment-policy

Medicare Advantage Penetration Saves Medicare Dollars

A new study from Elevance Health says that growth in Medicare Advantage (MA) leads to lower overall Medicare spending. This in part counters the shouts of MA opponents who cry about overpayments in the program.

The study found that Medicare spending was $431 billion less from 2010 to 2020 than the Congressional Budget Office (CBO) predicted. The difference was per enrollee spending during the timeframe.

The lower spending trend due to MA growth is most noticeable in midwestern and southern counties, but weaker in northwest and western counties. Researchers found that a 10% percent higher MA penetration in a county points to a 1.9% decrease in Medicare spending, correlating to a $204 decrease in per person spending. This resulted in up to $144 billion cumulative savings from 2012 to 2021.

One theory is that higher penetration of MA introduces a change in provider behavior in both MA and FFS. There is a halo effect over the traditional fee-for-service (FFS) program as providers concentrate on outcomes and lower costs for all their patients.

Even with risk-adjustment payments factored in, $116 billion in savings remained. And the magnitude of such overpayments are certainly debatable.

Changes in some reimbursement and risk adjustment reform may be needed, but the study counters the gross exaggeration of MA opponents that somehow the MA program is simply a play for companies to make money with no concomitant benefits to enrollees or the program. This as well as key Better Medicare Alliance studies showing better outcomes should be the playbook to defend MA.

#medicareadvantage

https://www.fiercehealthcare.com/payers/higher-ma-enrollment-linked-lower-medicare-spending-report