December 19, 2023

New Antitrust Merger Guidelines

The Federal Trade Commission (FTC) and the Department of Justice (DOJ) finalized new guidelines for mergers and acquisitions. They are not legally binding.  Each deal would receive an assessment based on the uniqueness of the parties and merger. The guidelines give health plans, hospitals, and others in healthcare a look into the decision-making process to determine consistency with antitrust rules. The guidelines and greater scrutiny fulfill a Biden administration pledge and come from an executive order. 

FTC release here: https://www.ftc.gov/news-events/news/press-releases/2023/12/federal-trade-commission-justice-department-release-2023-merger-guidelines . Additional article here: https://www.healthcaredive.com/news/ftc-doj-final-merger-guidelines-healthcare/702897/

At the same time, two hospital entities called off their merger after challenges from the FTC and state of California regulators: https://www.fiercehealthcare.com/providers/john-muir-health-tenet-healthcare-nix-143m-hospital-deal-after-regulatory-pushback

Overall, the scrutiny is good, especially on provider proposals, as most mergers lead to higher costs.

#ftc #doj #mergers #acquisitions #antitrust #hospitals #healthplans

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DOJ Seeks To Stall RADV Lawsuit

The Department of Justice (DOJ) is urging dismissal of Humana’s lawsuit against the new Centers for Medicare and Medicaid Services (CMS) risk adjustment data validation (RADV) rule, arguing Humana is not yet injured as no audits have occurred.  At the very least, it wants the case to be moved from a district friendly to lawsuits regarding agency rule-making.

Humana is right to press the challenge on a number of grounds. More important, plans do deserve a hearing now on the rule given the huge ramifications it would have on plan finances and the program itself. Why should it wait until unreasonable findings may have been made?

#radv #riskadjustment #doj #cms #humana

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Updated NSA Arbitration Fees

The Centers for Medicare and Medicaid Services (CMS) finalized updated fees for the No Surprises Act (NSA) arbitration. Additional articles here: https://www.modernhealthcare.com/legal/humana-medicare-advantage-case-dismissed-doj . and https://insidehealthpolicy.com/daily-news/admin-tweaks-methodology-puts-idr-fee-115-starting-mid-january .

(Some articles may require subscription.)

#nsa #nosurprisesact #cms

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DOJ Opposes Chamber of Commerce Suit on IRA Drug Pricing

In a response to the U.S. Chamber of Commerce lawsuit aiming to blocking the Inflation Reduction Act’s Medicare drug negotiations, the Department of Justice (DOJ) says the venue is improper, the plaintiffs lack standing, the court does not have subject-matter jurisdiction over some of the challenges, and some arguments fail on their merits.

In another drug case, a class action has been filed by certain pharmacies against OptumRx over fees assessed:  https://insidehealthpolicy.com/inside-drug-pricing-daily-news/class-action-lawsuit-challenges-dir-fees-imposed-optumrx

(Articles may require a subscription.)

#doj #ira #drugpricing

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KHN Bill Of The Month – Another Outrage

Kaiser Health News’ Bill of the Month series gives us a great surprise healthcare bill this time.  It shows what is so wrong with the healthcare system – the lack of transparency, how easy it is to make a mistake even if you are an informed consumer, and the sheer greed of some providers. It also shows how there are gaps in the No Surprises Act.

#nosurprisesact #providers #costs

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Oncology Shows There Is Some Hope for Biosimilars

While biosimilars of Humira have not taken hold yet in the market, the uptake of biosimilars for cancer offers hope that biosimilars will serve as a cost restraint in the future. Stopping brand drug makers from blocking acceptance as well as education of providers are needed.

#biosimilars #drugpricing

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State Drug Transparency Laws May Not Be Constraining Costs Enough

This Health Affairs Forefront blog points to research in three states with drug transparency reporting that shows drugs on a post-rebate basis are still going up at unaffordable rates.

(Article may require a subscription.)

#drugpricing #transparency #pricetransparency

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KFF Assessment of Medicaid Drug Trends

The Kaiser Family Foundation (KFF) finds that Medicaid drug spending continues to increase despite a lower number of prescriptions compared with an earlier period.

#drugpricing #medicaid

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Findings On Impact of The Underinsured

A nice Kaiser Family Foundation (KFF) consumer survey that shows how lower income people with employer-sponsored coverage (ESI) face challenges compared to those with higher incomes with such coverage.  Many of these folks are not the 25 million to 30 million who are uninsured, but are among the 55 million to 60 million who are underinsured.  This means their coverage is so expensive when you consider all costs that they cannot afford some or all of the health insurance coverage.  This leads to foregoing or delaying care, the inability to pay for care, and sometimes a decline in health. In some ways, this is as big a problem as the uninsured crisis. It means we do not have truly affordable access.

#uninsured #underinsured #coverage #employercoverage #esi #affordableuniversalaccess #universalaccess

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— Marc S. Ryan

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