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Paragon Proposes Medicaid Reforms

The conservative think tank Paragon Institute proposes to phase out the current 90 percent federal matching rate for the Affordable Care Act’s (ACA) Medicaid expansion and begin applying the regular federal match after eight years. It would also reduce the 50% Medicaid reimbursement floor to 40% for the richest states, also phased in over eight years. It says spending would be reduced by $600 billion from 2026 to 2034. Trump is known to pay attention to Paragon. While radical and it threatens to reduce coverage nationally, the proposal is less disruptive than the fundamental remake of the ACA and Medicaid attempted by Republicans during Trump’s first term.

#aca #medicaid #coverage #reimbursement

https://finance.yahoo.com/news/paragon-proposes-bold-medicaid-funding-100000986.html?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAAJzUe6HiQKz3okVpdso7A0yLeZAIPW1Ub2ostzrg7ZONyQ8z1KWrDGM859gWDHSx-g-178HChmqc40o8i1lMq0Z0f8O1tXErWp6qrflxRiOQ5GwC6iEyxQ2Yhd9fdz-o9EckMhY6Yljg3gA_7GDG6JdxppPhxUpCV_1324WzFyBd

Medicare Advantage Inpatient Days Rising

Hospitals cry foul at every pass over Medicare Advantage (MA) plans’ efforts to control inpatient hospital utilization. But a new analysis from the Kaiser Family Foundation (KFF) shows that inpatient days attributable to MA have increased considerably over time.

Medicare Advantage’s share of inpatient days grew from 13% to 23% from 2015 to 2022. As of 2022, nearly half (48%) of all Medicare inpatient hospital days were attributable to MA. The MA penetration in that year averaged just short of 46%. There are numerous other great statistics in the analysis. This year, MA plans are required to follow traditional program standards for deciding whether a stay is required and thus the share will increase more.

#medicareadvantage #hospitals #priorauthorization

https://www.kff.org/medicare/issue-brief/medicare-advantage-enrollees-account-for-a-rising-share-of-inpatient-hospital-days/

House Committee Grills Big 3 PBM Executives On Practices

Executives from the Big 3 pharmacy benefits managers (PBMs) got grilled today before the House Oversight Committee. The committee just released a report on its over year-long investigation of the Big 3 that found that they are anticompetitive, imperil independent pharmacies, overcharge payers and patients using spread pricing, and enter into brand drug rebate deals that tie to the drugs’ preferential placement on formularies. The report concluded the Big 3 not only don’t save on or control costs but steer patients toward higher-priced drugs and their own pharmacies.

The committee argued that the PBMs have created multiple ways to advantage themselves in the vertically integrated world the Big 3 live, including the use of group purchasing organization (GPOs). The executives tried to refute the findings and often were silent in response to questioning. The committee also criticized prior authorization and step therapy use.

In other news, CVS Health agreed to pay at least $45 million to the state of Illinois to settle allegations that rebates were not passed through during a recent four-year period.

I have been a defender of PBMs over the years because they do bring value. But more and more, evidence is coming out regarding some unseemly activities, including rebate deals, spread pricing, and related-party transactions that do disadvantage government programs, companies, and the public at large.  These practices need to change.

But I am amazed at how little focus is on the biggest problem in drug pricing – brand drug makers. Yes, we have Medicare drug price negotiations, but only Democrats have challenged the brand drug makers on high prices and bad practices.  The attack on PBMs is bipartisan, but the GOP has refused to challenge brand drug makers.

Additional articles: https://www.fiercehealthcare.com/payers/pbms-defend-its-business-practices-lawmakers-arent-convinced and https://www.modernhealthcare.com/politics-policy/pbm-hearing-cvs-caremark-express-scripts-optum-rx and https://www.modernhealthcare.com/politics-policy/pbm-congressional-hearing-house-oversight-committee-cvs-cigna-unitehealth and https://www.wsj.com/health/pharma/drug-middlemen-push-patients-to-pricier-medicines-house-probe-finds-80c20fda and https://www.statnews.com/pharmalot/2024/07/23/cvs-caremark-pbm-illinois-medicines-rebates-ftc/

(Some articles may require a subscription.)

#drugpricing #pbms #branddrugmakers

https://thehill.com/policy/healthcare/4788713-pbms-prescription-drug-costs-medication

Probable Democratic Presidential Candidate Harris To Left Of Biden On Healthcare

With endorsements stacking up, Vice President Kamala Harris looks to be the probable presidential nominee of the Democratic Party after President Biden bowed out this weekend. Thus, the media is looking at her positions, including on healthcare. 

In general, Harris appears to be to the left of President Biden on a number of healthcare issues.  Harris will of course take credit for the Medicare drug price negotiations and Exchange premium enhancements. She would want to expand and extend each. She agrees with Biden’s anti-trust platform and was active on the issue as California’s attorney general.

She may be to the left of Biden on abortion rights, universal access, and drug pricing.  Harris once backed Bernie Sanders’ Medicare for All, although she stepped it down later and advocated for a lighter form — a decade-long transition with private plans playing a role. On drug pricing, she wants to benchmark all prices to developed-world countries.  Oddly, Trump agrees with this to a degree.

Additional articles: https://www.modernhealthcare.com/politics-policy/kamala-harris-election-2024-abortion-rights-medicare-health-policy-donald-trump and https://insidehealthpolicy.com/daily-news/harris-enters-presidential-race-health-record-includes-ma-all-option-pharma-lawsuits and https://www.statnews.com/2024/07/21/kamala-harris-on-healthcare-abortion-rights-medicare-for-all-drug-price-caps/ and https://www.medpagetoday.com/washington-watch/electioncoverage/111198 and https://www.beckershospitalreview.com/hospital-management-administration/kamala-harris-healthcare-policy-positions-6-notes.html

(Some articles may require a subscription.)

#election2024 #healthcare #harris #aca #obamacare #drugpricing #medicareforall

https://thehill.com/policy/healthcare/4786867-vice-president-kamala-harris-health-policy