February 16, 2024

No Surprises Act Dispute Process Favors Providers

The No Surprises Act (NDA) remains  a huge mess with volume 13 times higher than forecast for 2023.  What’s more, providers won 77% of arbitration cases and health insurers won in 23% of cases. The winning offers were above the qualifying payment amount, which is the median in-network rate.

The good news is that 10 million surprise bills were avoided with the law in the first nine months of 2023.  The bad news is that providers are winning huge in the baseball-style arbitration as they do in other states that have it.  Studies show that rates and premiums rose in those states under the provider-friendly process.  Researchers say that will happen nationwide now.  Yet, providers continue to sue to get things even more slanted toward them.  Congress has to even the playing field.  But they won’t as lawmakers from both sides of the aisle are provider-friendly due to campaign contributions and hospital board seats.

Evidence too that a small number of firms are driving cases. And the three largest are all private equity or venture backed.

Additional article here: https://www.fiercehealthcare.com/regulatory/surprise-billing-disputes-continue-far-outpace-federal-estimates-cms

#privetequityfirms #providers #nsa #nosurprisesact #surprisebilling

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Kaiser Lays Out Savings For Medicare Beneficiaries Due To IRA

Kaiser Health News (KHN) does a good job of laying out how Americans are already saving due to the passage of the Inflation Reduction Act’s (IRA) Medicare drug price negotiations. Most of the savings right now are due to efforts to phase in or limit cost-sharing.

Reductions for cost-sharing in the Part D program, including costs in the catastrophic phase and a drop in maximum out-of-pocket costs to $3,500 in 2024 and $2,000 in 2025.

Interestingly it raises the specter that drug companies could see some increased revenue.  When prices go down, affordability goes up and more could afford medications.

#ira #khn #drugpricing #medicare #partd #medicareadvantage #pdp

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Medicaid Expansion Chances In Southern States

Kaiser Health News (KHN) also has a good article on chances of Medicaid expansion rising in some southern states. Bolstered by Medicaid expansion’s passage and heavy initial enrollment in North Carolina, lawmakers in Alabama, Georgia, and Mississippi are relooking at their opposition in light of public support for Medicaid. More than 600,000 low-income, uninsured people could be covered in these three states. The federal government pays 90% of costs, with an additional 5% kicker in the first two years.

#medicaid #aca #obamacare #nc #al #ga #ms

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Physicians Are Not Singing The Blues About MA Plan Rate Concerns

Medicare physicians are not too upset that Medicare Advantage (MA) plans are facing what plans say is a cut in 2025 to rates.  After all, Medicare docs just got a 3.4% rate cut, part of which may be restored later this year. More to the point, critics, including providers, argue MA plans get reimbursed too much and help drive problems with Medicare. This article even points to the ridiculous arguments of critics, including MedPAC, that MA plans are over-reimbursed by $88 billion annually.

MA plans will be forced to reduce benefits (the way rates work it is really not a choice) or reduce payments.  Providers argue that claims denials and increasing prior authorization (PA) will occur.  But that becomes less likely with new PA restrictions and keen focus on claims denials.  And the risk funds that many providers now get from MA plans will likely have much less upside and have more risk.

(Article may require a subscription.)

#medicareadvantage #providers #rates

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More Coverage On Medicare Drug Price Negotiations

Two good Health Affairs Forefront blogs on Medicare drug price negotiations.  One argues that the federal government would benefit from having access to all data to determine maximum fair prices.  While some data is clear (e.g., Medicaid drug gross and net prices) other data is not (e.g., net drug prices in the commercial world). Some data is not clear due to the secrecy of rebate amounts.  The next article discusses how dialogue between the feds and drug makers might roll out on in terms of setting the maximum price and any confidential rebates.

First article: https://www.healthaffairs.org/content/forefront/knowing-actual-prices-help-hhs-set-maximum-fair-price-under-inflation-reduction-act

(Articles may require a subscription.)

#ira #drugpricing #medicare #partd #medicareadvantage #pdp

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— Marc S. Ryan

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