December 28, 2023

Retailers Targeting Senior Populations In Primary Care Investments

Good article showing why retailers are targeting seniors for their primary care initiatives. Retailers are interested in the potential financial arrangements (risk funds) that Medicare Advantage plans are focusing on. In addition, the seniors will tap other important features of their offerings, including pharmacies.

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#retailhealthcare #medicareadvantage

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Rural Hospitals Cite MA For Plight

As Medicare Advantage (MA) grows, rural hospitals are saying that MA is responsible at least in part for their financial plight.  The argument is that even if MA plans pay traditional Medicare rates, they are getting so much less due to claim denials.  The net is not the same.  In addition, you have the wait time to get paid.

This may be true in part, but I ask whether there is not waste and abuse in what the traditional system pays. Just because rural hospitals face challenges does not mean that there is not reform needed in the traditional systems.  The Centers for Medicare and Medicaid Services (CMS) and Capitol Hill lawmakers of course over-react to the lobbying campaigns of providers on prior authorization and claims issues. As such, CMS’ new prior authorization policies could destroy the value of MA and lead to even more costs in Medicare. None of this I guess argues against the real plight of rural healthcare.

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#hospitals #ruralhealthcare #priorauthorization #claimsdenials

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New Study Says Brand Drug Makers Are Not Making Innovation Decisions Based on Medicare Drug Price Law

A number of studies suggest that the impact on innovation of the Inflation Reduction Act’s (IRA) Medicare drug price law will be minimal.  And a new study underscores this. A policy brief by the health care research and advisory services firm ATI Advisory found most drug companies’ innovation decisions in the first half of 2023 were attributed to factors other than the IRA, including macroeconomic or company-specific trends. The consultant group says the same is true of planned research and development (R & D) and pipeline discontinuation. ATI says public company disclosure investor calls show the United States remains an important market and priority.  On the last point, this is likely true because estimates suggest the United States funds 70% of profits worldwide for the industry.  That does not seem to be fair.

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#drugpricing #ira #branddrugmakers

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STAT Investigation Says United MA Denied Rehab Care For Seriously Ill

Medicare Advantage (MA) does not need these types of headlines right now.  In the face of controversy and lawsuits over MA plans using AI to deny claims and prior authorizations (PA), a STAT exclusive finds that United Healthcare’s MA division had a policy to quickly deny rehab services requests with requesting doctors not understanding the criteria used. As headlines began around the Centers for Medicare and Medicaid Services (CMS) new PA rules, United abruptly ended much of the practice in November.

(Article may require a subscription.)

#priorauthorization medicareadvantage #united

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KFF Analysis Shows Gaps In Outcomes Between Whites and Minority Populations in MA

I respect the Kaiser Family Foundation (KFF) and its work on health equity.  Overall, I think the health equity conclusions are good ones – we clearly have disparities in outcomes for many reasons. But I think it is a little unfair to focus the literature review just on MA.  Would we not see similar disparities in the traditional fee-for-service (FFS) program?  And it might also be the case that it will take time to show better results on health equity in MA.  Analysis does seem to show that outcomes are overall better in MA than FFS on a number of outcome fronts.  Further, lower income folks as well as those of minority backgrounds flock to MA because of the value and services it creates for them. It is a critical safety net that is doing good. I hope the KFF review is not taken out of context by providers, advocates, and opponents of MA on Capitol Hill. Full report here: https://www.kff.org/report-section/disparities-in-health-measures-by-race-and-ethnicity-among-beneficiaries-in-medicare-advantage-report/

#healthequity #kff #medicareadvantage

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— Marc S. Ryan

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