February 7, 2024

House Republicans Vote To Ban QALYs

House Republicans passed a bill to ban the use of the controversial Quality Adjusted Life Years (QALY) measurement in federal programs. 

Additional article here: https://www.fiercehealthcare.com/payers/house-republicans-vote-ban-pricing-metrics-federal-programs

#qalys #medicare #medicaid

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Fitch Says MA Trends Will Mean A Credit Neutral Outlook

Fitch Ratings says that the spike in medical expense and rate reductions in Medicare Advantage (MA) will end up being credit neutral, arguing plans are well-placed to weather a storm.


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Even With Good 2023, CVS Health Saw Utilization Spike and Cuts Its 2024 Outlook

CVS Health is cutting its 2024 outlook in the face of a utilization and medical expense spike at insurer Aetna. It otherwise had good 2023 results.  CVS also agreed with Humana and Centene that the 2025 rate announcement was inadequate.

Additional articles here: https://www.fiercehealthcare.com/payers/cvs-earns-350-billion-revenue-2023-over-77-billion-profit and https://www.modernhealthcare.com/insurance/cvs-health-medicare-advantage-utilization-2024 and https://www.forbes.com/sites/brucejapsen/2024/02/07/cvs-health-profits-hit-2-billion-as-company-benefits-from-new-provider-businesses/?sh=443dc8d5507b

(Some articles may require a subscription.)

#cvshealth #aetna #medicareadvantage

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Medicaid Rolls Drop By Almost 10 Million

Kaiser Family Foundation (KFF) reports that Medicaid and children’s healthcare rolls have now dropped by about 9.5 million since redeterminations were reintroduced in April.  About 16.4 million have lost coverage, but many later gained it back.  But still, the 10M loss is sure to drive up the uninsured rolls considerably.  Some of the 10M will make their way to employer coverage and the Exchanges. More bad news:  we are only about halfway through the redeterminations.

#medicaid #redeterminations

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For MA, CMS Limits Use of AI In PA; Clarifies Admission Rules

More bad news – not unexpected – from the Centers for Medicare and Medicaid Services (CMS). In a 14-page Frequently Asked Questions (FAQs) memo sent to plans, CMS said that Medicare Advantage (MA) plans may utilize artificial intelligence to assess coverage decisions, but the technology cannot override the traditional benefit and medical necessity rules. This likely will mean manual intervention to comply.  In addition, CMS took a strenuous position on the fact that MA plans also cannot use their own criteria to override physician judgments about admissions versus observation stays. Plans must follow physician judgments if they determine there is a likelihood of a patient being in the hospital for two midnights.

As I predicted, CMS would take a harsh stance in communication and in audits on this new 2024 prior authorization rule.  They clearly have done so.  MA plans need to watch out not only on the compliance front but on the medical expense one, too.

I will follow up with a blog on this subject in the future.

(Article may require a subscription.)

#priorauthorization #ai #medicareadvantage

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Hospitals Want More No Surprise Protections

Despite having an arbitration process that slants toward them and their continued lawsuits against the No Suprises Act (NSA), the American Hospital association is calling for further pro-hospital measures.  Prime on its list is attacking how insurers calculate the qualifying payment amount or median contracted rate for arbitration deliberations.

#nosurprisesact #nsa #surprisebilling #hospitals

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In 2024, Medicare To Surge While Medicaid Drops

The Congressional Budget Office (CBO) predicts that Medicare will increase by about $65 billion in 2024, while Medicaid will decrease by $58 billion. Larger payments to Medicare Advantage and Part D payments will drive Medicare growth, while redeterminations are responsible for the Medicaid drop. Medicare will hit $896 billion in 2024.

(Article may require a subscription.)

#medicare #medicaid #medicareadvantage #redeterminations

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Negotiated Price On Stelara Depends On When Generic Hits Market

The Centers for Medicare and Medicaid Services (CMS) will determine month by month whether Johnson & Johnson’s Stelera will eventually get a maximum fair price this year.  The determination will be based on when Amgen’s biosimilar Wezlana comes to the market.

(Article may require a subscription.)

#ira #drugpricing

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Halvorson Clearly Outlines MA’s Benefits

As usual, former Kaiser Permanente CEO George Halvorson rebuffs the Medicare Advantage (MA) critics by clearly presenting how MA is saving Medicare overall. As George notes, “Critics of the Medicare Advantage program create some fantastical, misleading, unfounded, and completely wrong numbers about the relative cost of Medicare Advantage in several reports that have been written about the program.”  He is right.  Great read.


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How To Solve Drug Shortages

A good article on a congressional hearing on drug shortages. Testimony offered many suggestions on solving the crisis.

#drugshortages #drugpricing

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Addressing Primary Care Shortages In Rural Areas

The rural primary care crisis is real and this Health Affairs Forefront Blog offers many great suggestions to improve care.


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— Marc S. Ryan

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