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UnitedHealth CEO Admits Frustration Is Understandable

UnitedHealth Group CEO Andrew Witty published an opinion piece in The New York Times today where he acknowledged the rage that has surfaced in the aftermath of the death of his deputy. Witty said health plans play a role in the issues. Witty stated: “We know the health system does not work as well as it should, and we understand people’s frustrations with it.”

Oscar Health CEO Mark Bertolini, who once ran Aetna before its merger with CVS Health, also said that anger at the healthcare system is “justified.” Bertolini says he would eliminate employer-sponsored insurance because employers have little leverage. He thinks that migrating to individual coverage would be better. Oscar is focused on the individual market.

While I understand Witty’s statement in light of what occurred, I think insurers are an actor in a very dysfunctional system. Health plans alone are not the culprits. See my blog here: https://www.healthcarelabyrinth.com/i-am-shocked-by-the-vitriol-post-unitedhealthcare-executives-assassination/

In other news, Pro Publica obtained a UnitedHealthcare playbook that seeks to limit the coverage of autism.

Additional articles: https://www.modernhealthcare.com/insurance/unitedhealth-group-andrew-witty-brian-thompson-nyt-op-ed  and https://thehill.com/policy/healthcare/5039515-oscar-health-ceo-employer-healthcare-unitedhealthcare-shooting/?tbref=hp and https://thehill.com/policy/healthcare/5039630-unitedhealth-ceo-defends-healthcare/ and https://www.fiercehealthcare.com/payers/unitedhealth-strategically-limiting-access-critical-treatment-kids-autism

(Some articles may require a subscription.)

#unitedhealthcare #oscar #tragedy

https://www.fiercehealthcare.com/payers/unitedhealth-group-ceo-acknowledges-outpouring-frustration-healthcare

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Centene Earnings Guidance Released For 2025

Centene released its earnings guidance for 2025 at its investor day. Centene says revenue will be between $166.5 billion and $169.5 billion. It says utilization will continue to be elevated and its medical loss ratio (MLR) will be between 88.4% and 89%.

Centene reaffirmed that it expects to bring in between $143.5 billion and $144.5 billion in premium and service revenue for 2024. Its MLR will be between 88.3% and 88.5% for this year.

Centene expects to lose $250 million on Medicare Advantage (MA) this year but intends to break even by 2027. It also lost 20% of its MA enrollment during the 2025 enrollment season that just concluded.

Centene will gain $200 million in additional MA Star Ratings bonus payments in 2026 after the Centers for Medicare and Medicaid Services (CMS) revised its ratings.

Additional articles: https://www.modernhealthcare.com/insurance/centene-medicare-advantage-ratings-investor-sarah-london and https://www.beckerspayer.com/policy-updates/centenes-predictions-for-trump-administration-policy-3-things-to-know.html

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#centene #medicareadvantage #medicaid #managedcare

https://www.fiercehealthcare.com/payers/centene-expects-earn-least-1665b-revenue-2025

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Bipartisan Bills Seek PBM Divestitures From Health Plans

More evidence that some kind of pharmacy benefits manager (PBM) reform is coming on Capitol Hill: Democratic and Republican lawmakers now have bills to have health plans divest their PBMs. In the Senate, the bill is co-led by a very unlikely pair – liberal Sen. Elizabeth Warren, D-MA, and conservative Sen. Josh Hawley, R-MO. In the House, a companion bill is sponsored by Rep. Jake Auchincloss, D-MA. and Diana Harshbarger, R-TN. Hawley is among those anti-corporate welfare Republicans who are getting more active on healthcare issues.

The Patients Before Monopolies Act of 2024 would require insurers to sell off their PBMs within three years. The bill also would prohibit corporations that own PBMs or health plans from also owning pharmacies.

Other PBM reform proposals continue to gain bipartisan momentum. Some changes could come in the end-of-year stop-gap bill or sometime in 2025.

Additional articles: https://www.modernhealthcare.com/politics-policy/pbm-act-cvs-unitedhealth-cigna-elizabeth-warren-josh-hawley and https://www.healthcaredive.com/news/pbm-act-force-pharmacy-sales-introduced-unitedhealth-cigna-cvs/735233/ and https://thehill.com/policy/healthcare/5035450-bipartisan-lawmakers-want-to-force-health-insurers-pbms-to-sell-off-pharmacies/

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#pbms #healthplans #drugpricing

https://www.fiercehealthcare.com/payers/warren-hawley-introduce-bill-requiring-insurers-offload-pbm-businesses

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Democrats Ramping Up Opposition To Mehmet Oz For CMS Administrator

Democrats are beginning to ramp up efforts in opposition to Mehmet Oz as Administrator of the Centers for Medicare and Medicaid Services (CMS). Democrats question the numerous investments he holds, including in UnitedHealth Group. As well, they question his previous endorsement of Medicare Advantage for All, which would enroll those currently covered by private insurance, all Medicare beneficiaries, and the uninsured in Medicare Advantage (MA). Oz now says he favors expansion of MA not a radical healthcare transformation.

Additional articles: https://insidehealthpolicy.com/daily-news/senate-democrats-scrutinize-oz-s-ma-all-proposal-insurance-ties and https://thehill.com/policy/healthcare/5032680-warren-democrats-oz-medicare-privatization/

(Some articles may require a subscription.)

#medicareadvantage #medicare #oz #trump

https://www.modernhealthcare.com/politics-policy/dr-oz-medicare-advantage-investments-elizabeth-warren-ron-wyden

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Trump Wants PBM Reform

Pressure is mounting to pass pharmacy benefits manager (PBM) reform. Donald Trump came out over the weekend in favor of PBM reform. Brand drug makers have gotten to Trump, getting him to focus on PBMs rather than high brand drug prices at the beginning of the drug channel. Discussions are occurring on whether PBM reform should go in the lame-duck session bill.

(Article may require a subscription.)

#pbms #drugpricing

https://insidehealthpolicy.com/inside-drug-pricing-daily-news/trump-pegs-pbm-reform-priority-wyden-pushes-hard-lame-duck-reforms

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KFF Finds Spending Higher When MA Enrollees Return To Traditional Medicare

A new analysis from Kaiser Family Foundation (KFF) finds higher Medicare spending among those who switch from Medicare Advantage (MA) to traditional Medicare as compared with similar beneficiaries who were in traditional Medicare all along.

KFF says Medicare spent an average of 27% more on those switching in, after adjusting for differences in health status and other characteristics. This amounts to a difference of $2,585 in Medicare spending per person, on average, between the two groups in 2022.

The difference in spending among people with certain health conditions varied from 15% for those with pneumonia to 34% for people with diabetes.

The causes for the higher spending are as follows: skilled nursing facility spending (34%), outpatient hospital spending (23%), and inpatient hospital spending (20%).

Differences in spending were greater for people of color and dual eligibles and increased with age.

KFF asks several questions on the reasons why spending is higher:

  • Were switchers unable to get the medical care they felt they needed while enrolled in MA?
  • Would more MA enrollees make the switch if people with pre-existing conditions did not face barriers to purchasing Medicare supplemental insurance?
  • Do the disenrollments reduce costs and increase profits for MA plans?
  • Does the current MA payment system adequately account for adverse selection into traditional Medicare?

KFF notes that previous KFF and MedPAC, the congressional policy arm, analyses found that people who enroll in MA have lower Medicare spending in the years before they enroll than similar people who remain in traditional Medicare, even after controlling for health status.

I don’t discount that some of the increased costs could come from higher needs of individuals and the potential to receive the care they think they need. But I would also argue that KFF has not covered the fact that MA is more efficient and seems to assume that all the increased spending is in the traditional program is absolutely justified.

Utilization management in MA is not a bad thing. As an example, the highest increased cost area is skilled nursing facility (SNF) care post acute stays. But there is every reason to believe that providers in traditional Medicare are doling out orders for SNF stays without really determining if lower costs of care could serve members just as well. The same holds true for even more expensive inpatient stays.

MA plans’ rate of inpatient (IP) stays and SNF stays has been markedly less. With a 2024 prior authorization change, MA IP and SNF stay costs will likely increase over time as the Centers for Medicare and Medicaid Services (CMS) have told MA plans to abide by the traditional program rules.

In essence, they took the managed care out of managed care. While KFF is largley balanced, it shows some of its anti-MA and big healthcare bias here. This is sure to be used on Capitol Hill and the industry has to be ready to push back.

Press release: https://www.kff.org/medicare/press-release/medicare-spent-an-average-of-27-more-on-people-who-switched-from-medicare-advantage-to-traditional-medicare-compared-to-those-who-were-only-in-traditional-medicare/

#kff #medicareadvantage #medicare #priorauthorization #coverage

https://www.kff.org/medicare/issue-brief/medicare-spending-was-27-percent-more-for-people-who-disenrolled-from-medicare-advantage-than-for-similar-people-in-traditional-medicare/

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Primary Care Market To Shift by 2023

A Bain & Company study on primary care suggests non-traditional providers, including retailers, payers, and advanced primary care providers, are expected to capture 30% of the U.S. primary care market by 2030. Bain says payers will continue to invest in primary care and population-focused models and will capture 20% of the market. How retailers will fare is more of a question. Bain also says providers will pivot to and grow their value-based care focus.

#primarycare #healthplans #insurers #providers

https://www.fiercehealthcare.com/providers/primary-care-market-will-see-major-shifts-2030-payers-nontraditional-providers-gain

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Tragedy In New York

A tragedy in New York today as UnitedHealthcare CEO Brian Thompson, the leader of UnitedHealth Group’s insurance subsidiary, was shot and killed just before an investor meeting in Manhattan. All indications point to the fact that the shooting was premediated and targeted and not a random act. Our thoughts and prayers are with Thompson’s family and the UnitedHealth community.

Additional articles: https://www.modernhealthcare.com/people/unitedhealthcare-ceo-brian-thompson-shot-new-york-city and https://www.healthcaredive.com/news/unitedhealthcare-ceo-brian-thompson-fatally-shot-nyc/734557/

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#unitedhealthcare

https://www.fiercehealthcare.com/payers/reports-unitedhealthcare-ceo-brian-thompson-fatally-shot-manhattan

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Government Spending Bill Needed In Next Two Weeks

With the government running out of money as of December 20, Congress is back for a lame-duck session and needs to pass a permanent funding bill or stop-gap continuing resolution (CR) soon. The latest guess is that the parties will come together in each chamber to pass a stop-gap CR and boot major funding and policy decisions until the next Congress. But that certainly puts Democrats at a disadvantage as they become the minority in both chambers. But the sheer work to get a permanent bill passed is likely just too much right now for anyone.

There is wide speculation on what will happen with various healthcare policy proposals. Many hope for a great deal of healthcare bills to be rolled up into an end-of-year act. But that hope is dying given all that needs to be done.

More likely are some carefully crafted healthcare fixes to get into the new year. Top among them are rolling back the Medicare physician rate cut.  It could be partially or fully rolled back. There is the possibility that it could turn into some hike right now. Certain programs face expiration and could be extended for some time, including telehealth and hospital-at-home. Community health centers are looking for an increase due to major patient load, but it is unclear if that will happen.

Some argue that payfors like site-neutral payments and pharmacy benefit manager (PBM) reform could be included in an end-of-year bill. These would likely face major opposition from lobbyists, but PBM reform could provide savings for some increases.

Look for a three-month CR and a narrow healthcare package.

(Article may require a subscription.)

#crs #governmentshutdown #congress

https://insidehealthpolicy.com/health-insider/congress-returns-scrambling-determine-lame-duck-endgame

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United And Centene Get Star Hikes For 2025

After a federal court ordered the Centers for Medicare and Medicaid Services (CMS) to revise United Healthcare’s 2025 Star ratings, the agency issued new Star ratings for both United and Centene today.

The agency increased the quality ratings for 12 UnitedHealthcare contracts and 7 Centene contracts. Centene now has a sole 4-Star contract under the agency changes. Two United contracts were upgraded to 5 Stars and three contracts to 4 stars. United now will have 37 contracts rated at least 4 stars.

The United and Centene cases surrounded how CMS handled the two call center ratings.

Centene sued like United and the Centene case is still pending. It likely will be withdrawn.

Humana and Elevance Health also sued and both suits are still pending. No changes to Star ratings have yet been made for Humana and Elevance Health. 

One reason could be that the Humana and Elevance suits were rather biting in their suits and went beyond the call center metrics raised in the United and Centene suits.

(Article may require a subscription.)

#cms #stars #medicareadvantage #centene #unitedhealthcare #elevancehealth #humana

https://www.modernhealthcare.com/providers/outpatient-construction-jefferson-health-hackensack%20meridian

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