Partial Shutdown Over
The House voted 217-214 to approve a final spending package for FFY 2026 — 21 Republicans defected from and 21 Democrats supported the bipartisan measure. President Trump has already signed the bill. A number of key healthcare reforms are included. I reported on a list of them in the Newsfeed on January 30.
Among the big items are a set of pharmacy benefit manager (PBM) reforms, including extensive reporting, transparency, and government oversight as well as requirements to pass rebates earned from drug makers to health plans, employers, and patients. PBMs will now have to charge a set fee for services.
The bill requires the groups to report detailed data on drug pricing, rebates, pharmacy reimbursement, and payments retained by PBMs and their affiliates and authorizes audits and enforcement/recoupment actions.
In addition, telehealth was extended for two years and acute hospital-at-home by five years.
Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-congress-government-funding-bill-pbm-telehealth/ and https://www.beckershospitalreview.com/hospital-management-administration/government-reopens-after-partial-shutdown-5-notes/ and https://thehill.com/homenews/house/5721189-democrats-republicans-end-shutdown/?tbref=hp
(Some articles may require a subscription.)
#governmentshutdown #congress #trump #healthcare #coverage #medicare #pbms #drugpricing
Skinny Health Plans Engage In Fat Advertising
Huge premium increases on the health insurance Exchanges have led to major marketing of cheaper, skimpier plans. This includes UnitedHealth Group and other insurers who sell the plans as well as Medi-Share and other Christian ministries that “share” healthcare costs. The campaigns are targeting young adults in great measure. This small sector of products does not have to meet benefit and coverage rules of the Affordable Care Act (ACA).
(Article may require a subscription.)
#exchanges #aca #healthcare #coverage
https://www.modernhealthcare.com/insurance/mh-aca-premium-short-term-health-plans
Huge Enrollment Growth for Some MA Plans
Clever Care Health Plan reports growth of almost 15,000 Medicare Advantage (MA) members, a surge of nearly 50%. Scan Health Plan reports 127,000 members were added during Medicare’s annual enrollment period, a 41% growth.
Additional article: https://www.beckerspayer.com/payer/medicare-advantage/clever-care-health-plan-enrollment-up-50-largest-growth-so-far/
#medicareadvantage #enrollment
https://www.fiercehealthcare.com/payers/scan-adds-127k-members-medicare-annual-enrollment-window
Alternative Payment Models Held Steady
Alternative payment models (APM) remained at about 45% in healthcare in 2024, according to a survey by America’s Health Insurance Plans (AHIP) supported by both the Blue Cross Blue Shield Association (BCBSA) and the Centers for Medicare and Medicaid Services (CMS). The data included Medicare, Medicaid and health plan data. The participants represent 87.5% of covered lives or 271M.
About 29% of healthcare payments had a downside-risk alternative payment model. Seventy percent of health plan respondents anticipate increased APM moves over the next two years. Shared risk/procedure-based episode payments saw the highest growth potential, according to 55% of health plan respondents.
In other news, more fodder for regulators and lawmakers ready to pare back vertically integrated behemoths. A study published in Health Affairs finds that prices rose 11% at ambulatory surgery centers (ASCs) after they were bought by Optum, United’s services and provider entity. The newly acquired providers were able to negotiate higher prices with insurers, perhaps with United itself. The increases meant $10.1 million more in spending annually for just seven common procedures in the two dozen ASC markets. Extrapolating that estimate to all ASC services would mean a financial impact of $67 million a year.
Additional articles: https://www.beckerspayer.com/research-analysis/45-of-2024-healthcare-payments-flow-through-accountable-alternative-payment-models/ and https://www.healthcaredive.com/news/optum-surgery-center-buys-asc-price-inflation-study-health-affairs-cornell/811160/
#apm #vbc #healthcare #medicare #medicaid #commercial #optum #united #verticalintegration
— Marc S. Ryan
