February 27, 2024

Justice Department Launches Antitrust Investigation Of UnitedHealth Group

With the ongoing cyberattack at Change Healthcare ongoing, The Wall Street Journal reports that the U.S. Department of Justice has an active antitrust investigation going on. It centers on certain relationships between the company’s UnitedHealthcare insurance unit and its Optum health services arm.  Optum is the largest service organization associated with an insurer corporately.  Optum’s tentacles are long and hit almost every area of healthcare. Health plans like Cigna and Elevance Health will be watching as they have dreams of having service units as big as Optum.  These service units generate huge revenue and margins as the business is basically unregulated compared with an insurer (which is confined by the minimum medical loss ratio (MLR) requirements in most products)

Additional article here: https://www.reuters.com/business/healthcare-pharmaceuticals/us-launches-antitrust-investigation-into-unitedhealth-wsj-reports-2024-02-27/

#unitedhealthcare #antitrust #optum

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Change Healthcare Cyber Attack Fallout Continues

The Change Healthcare cyber attack continues to have huge impacts on the world of healthcare.  Change, which was only recently acquired by United’s Optum arm, touches so many places in healthcare (hospitals, doctor’s offices, and pharmacies) by impacting claims, billing, and prior authorizations.    

Additional articles: https://www.statnews.com/2024/02/27/change-healthcare-cyber-attack-reveals-consolidation-risks/ and https://www.managedhealthcareexecutive.com/view/change-healthcare-outage-prompts-switch-in-pharmacy-claims-processing-cranks-up-tensions-between-independent-pharmacies-and-pbms

(Some articles may require a subscription.)

#changehealthcare #unitedhealthcare #optum #cyberattack

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What Are Main Areas For AI Regulation?

Good article on the areas that Congress should focus on in terms of AI regulation in healthcare: privacy, transparency, bias, safety, reimbursement, and liability.

Additional article on importance of AI tackling bias and equity as well as ensuring no exacerbation of existing issues: https://www.medpagetoday.com/opinion/second-opinions/108918

(Some articles may require a subscription.)

#ai #healthequity

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Advocates Still Pushing PBM Reform

Despite signs PBM reform will not pass in 2024, some are still pushing hard, including the new transparent PBM coalition.

(Article may require a subscription.)

#pbms #drugpricing

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Study Says MA Rate Reduction Will Be Deeper Than CMS Says

A study commissioned by the Better Medicare Alliance says that the 2025 Medicare Advantage (MA) rate cut will be about 1% vs. the de minimis cut the Centers for Medicare and Medicaid Services (CMS) projected without risk score trends.  A big debate exists on whether risk score trends should be factored in, but regardless 2024 and proposed 2025 rates are well below prior years.  The biggest reason is the phase-in of a new risk adjustment model.  The study is right that this will lead plans to reduce benefits to stabilize financially and meet investor expectations.

The rate situation is complicated by a series of onerous regulatory requirements, such as the risk adjustment data validation (RADV) rule and the new 2024 prior authorization limitation rule.

This all is tragic for seniors and the disabled on fixed incomes.  MA will survive but poor and lower middle-class Medicare enrollees will be hit hard due to the policies.

#medicareadvantage #rates #priorauthorization #riskadjustment #radv

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Exchanges Get More Positive Selection

Interesting article overall on Medicaid Exchange insurers and what is occurring.  Most interesting is discussion by Centene and Molina that Exchange enrollment is skewing younger.  This is a sign that adversity in the program may drop. One can hope for a day when younger folks enroll and begin to lower overall risk and thereby premiums. I would argue that at least some of this is because of the temporary increases in premium subsidies and increased marketing and outreach.  Younger people are more aware of the program and it is more affordable. So while the enhanced subsidies may cost some, it could have the long-term benefit of helping on overall premiums and government costs overall for subsidies.

(Article may require a subscription.)

#obamacare #aca #exchanges #medicaid #coverage

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Air Ambulance Bills $81,000

A great Bill of the Month article by Kaiser Health News looking at an $81,000 bill received by a now-deceased Medicare member.  She was air lifted due to a stroke and aneurysms.  She only had Part A because she could not afford Part B.  Ambulance is covered under Part B and Medicare would have had an allowed charge of $10,000, with the patient paying $2,000.  The private-equity-backed air ambulance firm will concede nothing and is suing the state. Outrageous. Other providers waived fees since she did not have Part B.

America, too, may need to do some more health literacy training of folks who go bare. Some of them might be eligible for state support for Medicare Part B premiums and more. The No Surprises Act is really no help here.

#nsa #nosurprisesact #surprisebilling #privateequityfirms

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Government Shutdown Could Occur

At a White House summit, three congressional leaders from both parties ganged up on Republican House Speaker Mike Johnson on the issue of coming to agreement on a measure that will keep the government open. Johnson says he is optimistic that the government will not shut down but the prospect of a closure is real.  A hard-right part of the GOP House, from which Johnson hails, is demanding deeper cuts.


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Overview Of Surging Weight-Loss Drugs

Great article that provides a wonderful overview of the situation on GLP-1 weight loss drugs. The article discussed the boon for drug manufacturers and the huge impact to health insurers and employer groups.  So far coverage in Medicare and Medicaid is extremely limited to non-existent.

#drugpricing #weightlossdrugs

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How Five Presidents May Have Really Died

Fun article from President’s Day on how five our presidents may have really died. Some of them involve healthcare horror stories!

#presidents #healthcare

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— Marc S. Ryan

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