December 14, 2023

Medicare Drug Reform Law Working

The Centers for Medicare & Medicaid Services (CMS) says 48 prescription drugs will have lower Part B beneficiary coinsurances in the first quarter of 2024 due to price hikes by drug makers that exceeded allowable increases, with out-of-pocket costs decreasing by $1 to as much as $2,786 per average dose. Over the last four quarters, 64 drugs in total had prices that increased faster than inflation and may be subject to inflation rebates because of the Inflation Reduction Act (IRA). It is hard to argue that the Medicare drug reforms are not working in this case.  At the same time, CMS issued a letter to plans and PBMS urging fair reimbursement to pharmacies and urging preparation for 2024 changes under Part D. CMS letter here: https://www.cms.gov/newsroom/fact-sheets/cms-letter-plans-and-pharmacy-benefit-managers . Additional article here: https://www.medpagetoday.com/publichealthpolicy/healthpolicy/107878 . The CMS announcement and backup material here: https://www.cms.gov/newsroom/press-releases/cms-releases-revised-guidance-medicare-prescription-drug-inflation-rebate-program . Similar Health and Human Services release and info here: https://www.hhs.gov/about/news/2023/12/14/new-hhs-actions-and-research-highlight-how-president-bidens-administration-lowering-prescription-drug-costs.html .

#drugpricing #ira

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Provider Analysis Says Providers Hurt By Rising Claim Denials

Providers are going all out on Capitol Hill to rein in claim denials and prior authorization. In this study, providers claim their revenue cycle is being hurt by rising denials and longer payment timeframes. Health plans should expect these kinds of issues to continue to be raised along with attacks on AI-driven processes.

#priorauthorization #claimdenials #healthplans #providers

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Providers and Payers Commit To Biden Executive Order on AI

Providers and payers have said they will follow Biden’s Executive Order and commit to safe use of AI and using it to improve healthcare along the way. Meanwhile, in this article, Democrats and Republicans clash on Capitol Hill on the EO: https://insidehealthpolicy.com/daily-news/house-ec-dems-gop-divided-biden-s-ai-executive-order . Health and Human Services press release here: https://www.hhs.gov/about/news/2023/12/14/fact-sheet-biden-harris-administration-announces-voluntary-commitments-leading-healthcare-companies-harness-potential-manage-risks-posed-ai.html .

(Some articles may require a subscription.)

#ai #healthplans #hospitals #providers

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2022 National Healthcare Expenditures

The Kaiser Family Foundation and the Peterson-KFF Health System Tracker have a nice explorer tool on the recent 2022 national healthcare data posting from the CMS Actuary. Peterson-KFF Tool here: https://www.healthsystemtracker.org/health-spending-explorer/?display=U.S.%2520%2524%2520Billions&service=Hospitals%252CPhysicians%2520%2526%2520Clinics%252CPrescription%2520Drug . Additional KFF info at link.

#healthcare #costs

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Kaiser Analysis of LTSS Demographics

Kaiser Family Foundation has a good analysis of the demographics of nearly 6 million Medicaid beneficiaries who use long term care services and supports (LTSS).

#ltss #ltc #longtermcare #medicaid #medicare

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Kaiser Analysis of Sources of Coverage for Medicare Beneficiaries

Kaiser recently posted an updated analysis of Medicare enrollment numbers, demographics, and sources of coverage of Medicare beneficiaries. Good info on secondary coverage is provided.

#medicare #coverage #healthcare

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Interesting Brief About New HCBS Rule

Kaiser also recently posted an analysis of issues and status of the implementation of a new Centers for Medicare and Medicaid Services (CMS) rule on home and community-based services (HCBS). The rule responds to the requirements of the Olmstead decision almost 25 years ago. Olmstead determined that people have a right to live in the community as opposed to institutionalization — and cost does not play a part. States have claimed that the rule impacts budgets in many ways as it is difficult to create truly safe and cost-effective community settings for certain individuals.

In this case, CMS lays out requirements in HCBS waivers to be consistent with Olmstead. The rule began earlier this year but was actually passed in 2014, showing the difficulty of this issue. The rule is known as the “settings rule.” The new requirements for HCBS settings include full integration of individuals into the community and rights to privacy, dignity, and autonomy for people receiving services.

#medicaid #olmstead #hcbs #ltc #longtermcare

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— Marc S. Ryan

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