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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/

(Some articles may require a subscription.)

#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

(Some articles may require a subscription.)

#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.

(Article may require a subscription.)

#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