December 7, 2023

United Health Foundation Says Chronic Conditions Rising

The United Health Foundation released a study that concludes chronic conditions are rising in the U.S. It also released its annual “America’s Health Rankings” report, which tracks health across the country based on 87 measures and 28 data sources.

United finds that persons with multiple chronic conditions has reached their highest levels since they were first tracked. Mental health and diabetes have risen.  It also found health condition disparities exist for asthma, COPD, and diabetes. United also found that more people have multiple co-morbidities.

United calls for investments in care management as well as health equity.

As I note in my book, The Healthcare Labyrinth (available on this website), one of America’s key problems is a lack of investment in health, wellness, and care management.  Other developed nations concentrate resources here and have much better outcomes, fewer people with disease states and conditions, and have better maintenance of conditions. 

There is no question plans need better data and analytics in order to intervene not only at the member level, but also at the group level to tackle social determinant barriers and health equity. This is a good place for plans to focus as the prior authorization area becomes much more constrained via regulation.

#healthcare #chronicconditions #disparities #healthequity

Link to Article

Survey Says Generative AI Will Surge in 2024

Interesting article on a KLAS Research report that says 58% of healthcare executives surveyed say their organizations will implement or purchase a solution using generative AI in 2024.  That is up from 25% this year. This will be used to automate clinical documentation and improve patient communication. Larger insurers and hospitals are more likely to invest in a solution than smaller organizations. This comes  just as AI use in clinical decision-making is being scrutinized. The article also goes into great detail on leading solutions and their investments. Additional article: https://www.healthcaredive.com/news/healthcare-generative-ai-adoption-klas-research/701891/ Report here: https://klasresearch.com/report/generative-ai-2023-what-are-organizations-current-adoption-and-future-plans/3296 . As well, Capitol Hill hearing discussed various oversight issues and concerns on AI: https://insidehealthpolicy.com/daily-news/house-lawmakers-drill-down-use-ai-health-care

(Some articles may require subscription.)

 #ai #digitalhealth #hospitals #healthplans

Link to Article

New Guidance Would Allow Government To Seize Patent Rights Of Expensive Drugs

Under new guidelines, the Biden administration is proposing to allow the seizure of patents via rarely used “march-in rights” if the drug was created using federal funding and pricing is excessive (among other standards). The rule requires comment as to the framework.  Brand drug makers and members of the GOP are objecting.  Drug price reduction advocates are wary and watching to ensure the framework is right.  This is a clear gambit by the Biden administration to pressure drug makers on prices.  While I am a Republican who backs drug price negotiations and lower prices, this proposal may go a little beyond my comfort zone. But I understand advocate and patient frustration.  In many cases, affordable access means the difference between life and death. Too, I have stated that many drugs have been developed using federal funding or support and that should be included in determining drug prices. 

Additional articles here: https://insidehealthpolicy.com/daily-news/biden-agrees-let-high-prices-drive-march-rights-advocates-still-wary and https://thehill.com/homenews/administration/4346435-white-house-announces-ready-to-deploy-march-in-rights-high-drug-prices/

(Some articles may require a subscription.)


Link to Article

Clover Leaving ACO REACH

Clover will leave the ACO REACH program in 2024.  ACO REACH is the accountable care organization program in the traditional Medicare program.  Clover remains focused on Medicare Advantage.

#medicare #medicareadvantage #clover

Link to Article

Fitch Evaluates Health Plan Sector For 2024

The rating firm Fitch has evaluated the health insurance sector and come up with five factors that will influence health plan financials in 2024.  Fitch rates the health insurance sector as neutral. You have heard many of these themes here on this newsfeed. They are:

1 – Medicare Advantage Costs – will continue to see rising utilization post COVID and cost increases.  Plans will look for ways to control them.

2 – Star ratings – revenue pressures due to Star performance.

3 – Inflation and contracts – inflation will continue to drive up costs and hospitals will demand bigger rate hikes due to pressures there and labor impacts.  This will cause premiums to increase.

4 – Interest rates – Here, high interest rates can help insurers’ investments

5 – Medicaid redeterminations – this will mean losses of revenue and could also mean remaining populations have higher risk/costs

Good summation by Fitch, which said: “Fitch believes that the health insurance sector is facing a shift from pandemic-related risks to increasing regulatory strains and economic pressures, but will continue to demonstrate resilience.”

(Article may require subscription.)

#insurers #healthplans #fitch #medicareadvantage #hospitals

Link to Article

Hospital Sector Forecast For 2024

Here is the evaluation for hospitals and notable factors for 2024:

1 – Inflation pressures operations. Labor costs remain a major concern.

2 – Patient volumes are returning but are mixed.

3 – Regulators are cracking down on mergers and acquisitions.

4 – Operating margins improving, but very slowly. Some are still struggling in the red.

5 – The cost of expansion is high.

Additional articles here discussed hospitals recovery and the mixed outlook rating agencies are giving the hospital industry: https://www.modernhealthcare.com/finance/hospital-labor-costs-credit-ratings-fitch and https://www.fiercehealthcare.com/providers/tough-labor-market-holds-fitchs-nonprofit-hospital-outlook-deteriorating

(Some articles may require subscription.)


Link to Article

Deloitte Sees A Tough 2024 In Healthcare

Deloitte surveyed 60 healthcare executives on prospects for 2024 and just 3% of health system executives and 7% of health plan executives had a positive outlook. Deloitte sees a number of trends to keep an eye on:

1 – Hospital consolidation will continue.  But I note the regulators will closely scrutinize and stop some.

2 – AI and digital transformation will continue. Retirement of legacy systems will also be a priority.

3 – There will be major workforce shortages and challenges.

4 – Outsourcing and offshoring could be a focus.

5 – Due to affordability, there will be a continued focus on aiding consumers (and providers) to seek out more cost-effective care.

#healthcaretrends #hospitals #healthplans

Link to Article

Series of PBM Bills Pass Out Of Key House Committee

The House Energy & Commerce Committee advanced several pharmacy benefit manager reforms and drug pricing policies. This makes it likely that some changes will pass this year or early next year.  The PBM measures include pricing reform, reporting, biosimilar promotion, and further Part D reforms, among other changes.

(Article may require subscription.)

#pbms #drugpricing #biosimilars #partd #medicare

Link to Article

New Initiative On Ownership Transparency

The Biden administration has announced new policies to improve ownership transparency among Federally Qualified Health Centers and Rural Health Clinics, increase oversight of Medicare Advantage, and generally tackle anti-competitiveness in healthcare.  A number of agencies will work together on the initiative. The changes regarding “march-in rights: on drug patents noted earlier also is part of this initiative.  The Biden administration has been hyper-focused on mergers and acquisitions in the hospital world and other healthcare entities as well as private equity firms investments in various healthcare entities.  It will look closely at the expected merger between Cigna and Humana. Studies show that consolidations of provider entities are clearly increasing costs.

(Article may require subscription.)

#mergers #consolidations #ftc #healthplans #hospitals #privateequityfirms

Link to Article

Hospitals Mounting Efforts Against Site-Neutral Payment

Hospitals are turning up the heat on Congress not to pass site-neutral payment policies. But advocates are very committed to this given the impact on consumers.  The same services should be paid at the same price no matter a place of service.  Hospitals are busy acquiring physicians and these physicians are being told to use more-expensive hospital-owned settings.  This not only leads to higher costs in the system but in patient cost-sharing as well. A House bill would begin site-neutral payment for Medicare Part B drugs and administration.

(Article may require subscription.)

#siteneutral #hospitals

Link to Article

Congress Pushing Limitation on CMS Authority on Coverage Determinations

The Centers for Medicare and Medicaid Services (CMS) has just told Medicare Advantage (MA) plans that they must follow National Coverage Determinations (NCDs) and Local Coverage Determinations (LCD) and not other evidence-based criteria.  Now, Congress wants to limit CMS’ ability on limiting access to services through the NCD and LCD process.  The first will increase costs dramatically in MA.  If this concept passes Congress, costs will increase further.

(Article may require subscription.)

#priorauthorization #ncd #lcd

Link to Article

Resource Published By Kaiser Health News On Medicare Enrollment

Good resource that covers the dos and don’ts of open enrollment in Medicare and government programs available.

#medicare #medicare advantage #partd

Link to Article

Sanders To Hold Hearing On Diabetes and Weight-Loss Drugs

Sen. Bernie Sanders, I-VT, will hold hearings on costs on diabetes and weight-loss drugs.


Link to Article

— Marc S. Ryan

Leave a Reply

Your email address will not be published. Required fields are marked *

Available Now