A bipartisan group of senators will tackle long-term reform of the Medicare physician pay formula. On 1/1, a 3.4% reduction went into effect due to the existing formula. Some have accused physicians of spending more time lobbying on health plan prior authorization reform than on their own rate issues.
#medicare #physicians
A lesson for employer groups as weight-loss drugs take off in popularity. An analysis of data says that just 25 of over 6,200 prescribers in the North Carolina State Employee Plan accounted for 8 percent of the costs of prescriptions for costly weight loss drugs. These include GLP-1 meds Wegovy and Saxenda. These drugs accounted for 10% of total costs – or over $100 million.
The state wanted to rein in costs with some ideas, but its pharmacy benefit manger shot them down.
Shame on the healthcare players to not work with employers battling these cost issues.
As important, there are telehealth entities now emerging, backed by private equity, advertising solely to prescribe such meds. It is corrupt.
#weightlossdrugs #drugpricing
House Republicans passed a bill to ban the use of the controversial Quality Adjusted Life Years (QALY) measurement in federal programs.
Additional article here: https://www.fiercehealthcare.com/payers/house-republicans-vote-ban-pricing-metrics-federal-programs
#qalys #medicare #medicaid
Centene reported good numbers to Wall Street today, with notable increases in its Exchange line of business. Medicaid enrollment dropped due to redeterminations.
But like Humana, Centene is cautioning that the Medicare Advantage (MA) 2025 rate announcement was inadequate and could lead to further benefit and other changes in its MA line. It also notes that other regulatory changes are impacting its MA investment. Centene has already pared back benefits and geographies to bring its MA line to a better financial position.
Additional articles here: https://www.modernhealthcare.com/insurance/centene-medicare-advantage-rate-cut-2025-sarah-london and https://www.healthcaredive.com/news/centene-medicare-advantage-rate-drop-2023-earnings/706620/
Two other articles on the fallout from MA rates and regulatory changes here: https://www.modernhealthcare.com/insurance/medicare-advantage-rate-cut-2025-reimbursements-benefits-unitedhealth-humana and https://www.statnews.com/2024/02/05/cano-health-bankruptcy-medicare-advantage/
These articles underscore what I said in these blogs: https://www.healthcarelabyrinth.com/with-boom-over-will-medicare-advantage-collapse-or-adjust/ and https://www.healthcarelabyrinth.com/2025-rates-for-medicare-advantage-plans-look-tight/
(Some articles may require a subscription.)
#centene #medicareadvantage
Showing that healthcare remains a risky place, Cano Health announces bankruptcy and a spectacular collapse for the provider organization that enters into risk arrangements with Medicare Advantage (MA) and Medicaid managed care. The MA market has been tough for both plans and providers. The new CEO has been trying to refocus efforts in better market areas by exiting questionable areas. Questions are being raised about why Humana, a major stakeholder, will not buy the firm outright.
Additional articles here: https://www.modernhealthcare.com/digital-health/cano-health-bankruptcy-mark-kent and https://www.healthcaredive.com/news/cano-health-chapter-11-bankruptcy-restructuring-agreement/706546/
(Some articles may require a subscription.)
#medicareadvantage #humana #providers
Cigna CEO David Cordani told investors today that he believes in Medicare Advantage (MA) but it is better for his service business, not his insurance line. In an upbeat investor call, Cordani said that the Medicare line would have required major investments that were not justified based on the size of the portfolio, but that Medicare holds great promise as a service element of its growing Evernorth business. He said Cigna will double down on Evernorth grow. Its report on medical loss ratio was very good as were the financials. Some still question the decision to shed the MA lives. In the current environment for MA, Cordani’s decision may look right. But will it be the right one over the long term? Or, is this a short-term calculation and Cordani will go back after Humana again down the road? Stay tuned.
Additional articles here: https://www.modernhealthcare.com/finance/cigna-evernorth-health-services-medicare-advantage-sale-hcsc and https://www.managedhealthcareexecutive.com/view/cigna-s-2023-revenue-grew-8-to-195-3-billion and https://www.healthcaredive.com/news/cigna-medicare-evernorth-2024-outlook/706346/
(Some articles may require a subscription.)
#medicareadvantage #cigna #humana
This article focuses on Medicare Advantage (MA) troubles – rates, utilization, medical expense, and punitive regulatory requirements – and how they impact insurers, value-based-care providers, and vendors. My intel suggests that the traditionally flush global and partial risk funds that insurers have with providers around the country (providers share in profits when they help reduce costs and improve quality) have dried up or are drying up. Providers are already attacking insurers on numerous issues and this development will only make such relationships even worse.
Note as well the reference to MA plans emphasizing profitability by reining in market growth and benefits. I say just this in my blog on the topic here: https://www.healthcarelabyrinth.com/with-boom-over-will-medicare-advantage-collapse-or-adjust/ . As well, see my just published blog on the 2025 MA payment proposal: https://www.healthcarelabyrinth.com/2025-rates-for-medicare-advantage-plans-look-tight/
(Article may require a subscription.)
#medicareadvantage #vbc #providers
The Centers for Medicare and Medicaid Services (CMS) announced the 2025 rate hike for Medicare Advantage will be relatively flat. This is similar to what happened in 2024 after big increases in 2022 and 2023. The effective growth rate was up, but the phase-in of a new risk adjustment model basically offsets those gains. The final notice may push these numbers up a bit. If you include risk score trends, MA revenue could increase by about 3.7%. So real revenue should be up, but health plans don’t like thinking of it that way as they think risk score trends tie to increased medical exposure.
I include all these articles here but read with caution as many reporters interpret things differently. In the end, this is not the worst news, but it is bad in the face of some major medical expense and utilization increases. See my recent blog here for where MA is headed: https://www.healthcarelabyrinth.com/with-boom-over-will-medicare-advantage-collapse-or-adjust/
The CMS Fact Sheet is at the link. Additional government releases and fact sheets here: https://www.cms.gov/newsroom/press-releases/cms-releases-proposed-payment-updates-2025-medicare-advantage-and-part-d-programs and https://www.hhs.gov/about/news/2024/01/31/cms-releases-proposed-payment-updates-2025-medicare-advantage-part-d-programs.html and https://www.hhs.gov/about/news/2024/01/31/biden-harris-administration-strengthening-medicare-protecting-and-serving-americas-seniors.html
Additional articles here: https://www.fiercehealthcare.com/payers/cms-proposes-37-pay-rate-increase-ma-plans-redesigning-part-d-program and https://www.modernhealthcare.com/politics-policy/cms-proposes-medicare-advantage-pay-cuts-2025-ahip and https://insidehealthpolicy.com/daily-news/cms-expects-37-ma-pay-bump-after-2024-s-advance-notice-tumult and https://www.statnews.com/2024/01/31/medicare-advantage-2025-proposed-payment/ .
(Some articles may require a subscription.)
#medicareadvantage #rates #payments
The Peterson-Kaiser Family Foundation Health Tracker has a good briefer on expected healthcare policy issues to watch in 2024. Among the many include site-neutral policies, price transparency, drug pricing and trends, PBM reform, drug price differences around the developed world for weight-loss drugs, value-based care and payments, and anti-trust activity. A great primer!
#peterson #kff #healthcare #healthcarereform
Interesting article on Elevance Health’s lawsuit against the Centers for Medicare and Medicaid Services (CMS) on Stars. If this is anything close to true, CMS needs to relook at how it ensure fairness in calculations. How many others may have been impacted?
#elevancehealth #stars #medicareadvantage
