Centene and Molina Could Be Hurt By Medicaid Cuts
Medicaid managed care-dominant insurers Centene and Molina could be hurt by Republicans’ plans for cuts to Medicaid. The House GOP has a target of $800 billion in healthcare spending reductions. While President Trump and GOP leaders have promised no dramatic changes to Medicaid, the targets would clearly mean deep reductions. While work requirements and fraud cuts are certain, other impacts could be reimbursement changes at the state level.
Centene is the largest Medicaid managed care insurer with 13 million Medicaid beneficiaries as of Dec. 31. The membership generates 62% of the company’s revenue. Medicaid represents 88% of Molina’s membership and nearly 80% of its revenue for 2024.
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#medicaid #managedcare #budgetreconciliation #trump #congress #molina #centene
https://www.modernhealthcare.com/insurance/medicaid-cuts-centene-molina-healthcare
WSJ Says DOJ Probing United
The Wall Street Journal reports that the Department of Justice (DOJ) is probing UnitedHealth Group’s billing practices in Medicare Advantage (MA). At issue could be evidence that the mega healthcare entity and insurer has been systematically upcoding MA risk adjustment to gain revenue. The Journal has reported on this in earlier articles. Studies I have seen would show as well that United is one of a handful of large entities that appear to generate a disproportionate of MA overpayments via risk adjustment.
United faces other inquiries from DOJ, the agency is conducting a broad antitrust investigation of UnitedHealth’s practices, which is looking at United’s acquisitions of health-care providers and data companies.
Additional articles: https://www.modernhealthcare.com/legal/unitedhealth-medicare-billing-doj-investigation
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#unitedhealthcare #overpayments #riskadjustment #antitrust #fwa #medicareadvantage
Drug Makers Commit To More Domestic Manufacturing And Lower Prices To Avoid Tariffs
Coming out of a meeting with President Trump, executives from Big Pharma said they had committed to revitalizing domestic drug manufacturing in the United States and lowering drug costs for patients. The industry wants exemptions from tariffs. In whatever way possible, Trump should ensure prices come down to those in other developed world countries. Tariffs would likely increase costs throughout the healthcare system.
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#drugpricing #branddrugmakers #tariffs
FDA Says Semaglutide Drugs No Longer In Shortage
The Food and Drug Administration (FDA) announced that semaglutide, the active ingredient in GLP-1 weight-loss drugs Ozempic and Wegovy, is no longer in short supply. That means that compounders may have to stop creating generic alternatives that have taken off given the high price of the brand GLP-1s – several hundred dollars a month vs. $1,000 or more on a list price basis.
The FDA decision could impact telehealth startups as well as those taking the generic versions. The compounders could sue, arguing they can compound on another basis other than because the brands were in shortage.
Tirzepatide, active ingredient in GLP-1s Mounjaro and Zepbound, has been declared not in shortage, but lawsuits are challenging that decision as well.
Additional articles: https://insidehealthpolicy.com/daily-news/blow-compounders-fda-says-tirzepatide-no-longer-shortage and https://www.modernhealthcare.com/digital-health/fda-semaglutide-shortage-hims-stock and https://insidehealthpolicy.com/inside-drug-pricing-daily-news/fda-declares-semaglutide-shortage-over-compounders-aim-adjust and https://thehill.com/policy/healthcare/5158023-ozempic-and-wegovy-officially-moved-off-fdas-drug-shortage-list/
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#glp1s #weightlossdrugs #branddrugmakers #drugpricing
Advocates Oppose Oz Nomination
About 75 advocacy groups, including Public Citizen, are urging the Senate to reject Dr. Mehmet Oz’s nomination as administrator of the Centers for Medicare and Medicaid Services (CMS). The chief worries include privatization of healthcare via Medicare Advantage (MA) and impartiality regarding dietary supplements. They say privatization could jeopardize access to care for seniors and people with disabilities. They also worry about major conflicts of interest due to his investments.
In other news, advocates are also urging lawmakers to ask Oz whether he would enforce the Affordable Care Act (ACA) preventative services mandates, uphold a court’s ruling on copay accumulators, and oppose limiting drug coverage for Medicare Part D’s six protected classes. Preventive services are now at the Supreme Court for review.
Additional article: https://insidehealthpolicy.com/daily-news/oz-likely-face-questions-copay-accumulators-aca-rules
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#oz #cms #medicare #medicaid #healthcare #coverage #medicareadvantage
Arizona Would Ban AI For Claims Denials
Arizona state lawmakers advanced a bill that would ban the use of artificial intelligence (AI) to deny medical claims.
#claimsdenials #ai #healthcare
https://thehill.com/policy/technology/5158238-arizona-bill-bans-ai-from-denying-medical-claims/
— Marc S. Ryan
