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January 25, 2024

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Humana Reconfirms Bad News On Utilization In MA

After an earlier filing, Humana reconfirmed bad news on the medical expense front. Because it is a predominant Medicare Advantage (MA) insurer, it has seen a major and unexpected rise in utilization, which impacted the company’s 2023 numbers and prospects for 2024 and beyond.  Broussard is one of the smartest healthcare leaders out there and he is someone I listen to closely. Given the medical expense rise, rate compression, and regulatory changes (such as the new prior authorization rule), Broussard said he expects similar pricing adjustments from other payers, as the spike in utilization along with ongoing regulatory changes will have major impacts in 2025 and potentially beyond. Broussard says this could very well be industrywide. Humana reduced benefits for 2024 and this could be a continued trend into the future. Humana plans on cutting about $700 million in administrative costs.

It doesn’t mean MA is not a good place to be, but it does show the shortsightedness of the Centers for Medicare and Medicaid Services (CMS) and Capitol Hill as they seek to bind the hands of MA plans too much.

Additional articles: https://www.modernhealthcare.com/finance/humana-cuts-medicare-advantage-changes-earnings and https://www.healthcaredive.com/news/humana-dour-2024-profit-forecast/705537/

(Some articles may require a subscription.)

#medicareadvantage #humana #medicalexpense

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January 24, 2024

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Record Enrollment In Exchanges Nationwide

The Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services (HHS) announced something to celebrate.  Driven in part by Medicaid redetermination enrollment losses and enhanced premium subsidies, state and federal exchange enrollment reached a projected 21.3 million for 2024. An amazing achievement. Over 5 million new enrollees joined over 16 million existing members. Nearly 4.2 million people with incomes of less than 250% of the federal poverty level signed up for 2024 coverage.  They receive both premium subsidies and cost-sharing reductions. About 15% of those enrollment previously had Medicaid.  That translates to a little over 3 million – a small amount of those who lost Medicaid coverage. Over 16 million are in the federal Exchange and about 5 million in various state Exchanges.

CMS press release here: https://www.cms.gov/newsroom/press-releases/historic-213-million-people-choose-aca-marketplace-coverage . CMS Snapshot here: https://www.cms.gov/newsroom/fact-sheets/marketplace-2024-open-enrollment-period-report-final-national-snapshot . HHS press release here: https://www.hhs.gov/about/news/2024/01/24/historic-21-million-people-choose-aca-marketplace-coverage.html

Kaiser Family Foundation analysis here: https://www.kff.org/policy-watch/another-year-of-record-aca-marketplace-signups-driven-in-part-by-medicaid-unwinding-and-enhanced-subsidies/

Other articles here: https://www.modernhealthcare.com/insurance/open-enrollment-breaks-21m-2024 and https://thehill.com/homenews/4426408-obamacare-marks-record-enrollment-5-million/ and https://insidehealthpolicy.com/daily-news/cms-touts-medicaid-marketplace-transitions-enrollments-hit-record-213m

(Some articles may require a subscription.)

#exchanges #aca #obamabcare #enrollment #coverage #medicaid #redeterminations

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January 23, 2024

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Rural Hospitals In Distress

A good measure of the distress rural hospitals: most no longer deliver babies. Over half of the country’s rural hospitals aren’t offering labor and delivery services and more could end such services.

Some would argue that the rural hospitals’ plight could be solved by more money for hospitals overall.  The truth is the abominable hospital price system we have in this country along with the gross inefficiency of most hospitals drains overall healthcare resources and means we do not have enough to respond to true crises, such as those in rural communities.

#ruralhealthcare #hospitals

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January 22, 2024

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Elevance Health All In On AI

Elevance Health CEO Gail Boudreaux gave a keynote speech that shows the second-largest insurer will be all in on AI. She wants her company to use the technology to make healthcare more proactive, predictive and personalized. She wants AI to help people navigate the system and simplify it.

#elevancehealth #ai #digitalhealth

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January 19, 2024

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Weight Loss Drugs Take Nation By Storm

Ozempic and other new drugs are all the rage for weight loss.  These new drugs have both great promise and the potential to be abused and drive up healthcare costs phenomenally.  See some of the trends here.

(Article may require a subscription.)

#weightlossdrugs #healthcare

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January 18, 2024

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Disappointing Medicare Advantage Enrollment Numbers

Huge disappointment for some during the Medicare Advantage enrollment season. My quick math says that overall MA numbers increased a strong 8.7% from January 2023 to January 2024.  That is up from a year ago, which was a little over 6%. But a number of plans did not fare well during the recent enrollment campaign.  Aetna shined.  While United and Humana grew, it was a much lower rates than before.  Centene took a big hit. I will have my usual annual blog looking at all the data on Monday. Stay tuned.

Additional article here: https://www.healthcaredive.com/news/humana-earnings-outlook-cut-high-medical-costs/704865/

(Some articles may require a subscription.)

#medicareadvantage #healthplans #enrollment

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January 17, 2024

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CMS Finalizes Interoperability And Prior Authorization Rule

The Centers for Medicare and Medicaid Services (CMS) finalized a sweeping interoperability rule today that also sets much stricter timelines for medical service prior authorizations.  The rule was published some time ago and garnered a great deal of comments. The rule takes effect in January 2026 and requires 7 day standard and 72 hour expedited prior authorization turnaround times (federal Exchange plans excepted). Plans now have until 2027 to have APIs to allow providers to submit authorizations electronically.  A national format exists for retail prescription drugs, but not a consistent one for medical service requests yet.  The final specifications for medical services will tie to the Davinci Project, which will use the new FHIR standard. But plans will be able to use X12 formats as well. The rule applies to Medicare Advantage (MA), Medicaid, children’s coverage, and the federal Exchanges.

The finalization of this rule follows the 2024 MA and Part D rule going into effect, which substantially restricts MA from using outside evidence-based clinical criteria in prior-authorizations.  Plans will be subject to immediate audit on these new rules.

Additional articles here:

https://www.modernhealthcare.com/policy/prior-authorization-rule-cms-medicare-advantage-medicaid-insurance

https://www.healthcaredive.com/news/cms-final-prior-authorization-rule-payer-deadline/704721/

https://www.medpagetoday.com/practicemanagement/reimbursement/108299

https://thehill.com/policy/healthcare/4413508-biden-rule-health-insurer-prior-authorization/

https://insidehealthpolicy.com/daily-news/cms-finalizes-e-prior-auth-rule-proponents-look-congress-next-steps

https://www.cms.gov/newsroom/press-releases/cms-finalizes-rule-expand-access-health-information-and-improve-prior-authorization-process

https://www.hhs.gov/about/news/2024/01/17/cms-finalizes-rule-to-expand-access-to-health-information-and-improve-the-prior-authorization-process.html

(Some articles may require a subscription.)

#priorauthorization #managedcare #healthcare #fhir #interoperability

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January 16, 2024

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Congressional Leaders Agree on Extension of Funding

The four congressional leaders announced a deal to extend government funding to March 8 to avoid a government shutdown.  This is a concession by House Speaker Mike Johnson, R-LA, who originally said he would not extend government by a short-term continuing resolution (CR). A number of items are left out of the funding package. Conservatives in the House GOP caucus are not happy with Speaker Johnson’s (one of their own) endorsement of the extension.

Additional articles here: https://insidehealthpolicy.com/daily-news/short-term-cr-carries-extenders-through-march-8 and https://thehill.com/homenews/house/4410728-congress-shutdown-conservative-anger/

Additional article on status of healthcare bills, including hospitals’ opposition to site-neutral payments that is in a passed bill that would forestall disproportionate share hospital(DSH) funding cuts: https://www.modernhealthcare.com/politics-policy/congress-spending-deal-hospitals-dsh-medicare-site-neutral

(Some articles may require a subscription.)

#governmentshutdown #crs

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January 15, 2024

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Good Articles On Takeaways From JPM Healthcare Conference

Two good articles summarizing some major trends and topics at the JPM healthcare conference.  Highlights include:

  • Providers emphasizing creating payviders, where provider organizations set up their own insurance arm.
  • Hospital expansion of outpatient and ambulatory site investments given pressures on inpatient.
  • Medicare Advantage Star woes and risk adjustment changes.
  • PBM transparency reforms.

Additional article here: https://www.modernhealthcare.com/finance/jpm-2024-takeaways-commonspirit-mayo-clinic-centene-cvs-cigna-teladoc

(Some articles may require a subscription.)

#healthplans #providers #hospitals #stars #pbms

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January 12, 2024

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What Would A Nikki Haley Healthcare Agenda Look Like?

The Republican debates continue with Donald Trump bowing out and Ron DeSantis and Nikki Haley taking center stage.  A recent CNN debate saw the two sparring, sometimes on healthcare issues. Both Haley and DeSantis declared that they would like to replace the Affordable Care Act (ACA) with a block grant.  It is a horrible idea.

With Chris Christie’s departure from the race and Haley rising in the polls, Kaiser Health News (KHN) did a feature on what a Haley administration’s healthcare agenda may look like.

Additional article on Haley’s views on entitlement reform here: https://www.cnn.com/2023/12/05/politics/nikki-haley-social-security-medicare-reform/index.html

#gopprimary #haley #desantis #trump #healthcare #aca #obamacare

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