February 9, 2024

Senate To Tackle Medicare Physician Formula

A bipartisan group of senators will tackle long-term reform of the Medicare physician pay formula. On 1/1, a 3.4% reduction went into effect due to the existing formula.  Some have accused physicians of spending more time lobbying on health plan prior authorization reform than on their own rate issues.

#medicare #physicians

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CMS Wants Tougher Regulation Of Accrediting Organizations

A proposed rule from the Centers for Medicare and Medicaid Services (CMS) wants reform of how accreditation organizations operate, including conflict of interest and other requirements in force for other organizations.

CMS Fact Sheet here: https://www.cms.gov/newsroom/fact-sheets/accrediting-organization-proposed-rule-fact-sheet

Additional article here: https://www.fiercehealthcare.com/regulatory/cms-proposes-greater-oversight-consulting-limitations-accrediting-organizations

(Some articles may require a subscription.)

#cms #healthplans

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Provider Lobbies Pushing PA Reform At State Level

A number of states have enacted and more will enact broad reforms of prior authorization (PA).  Generally these reforms revolve around electronic PA transmission, tighter turnaround times, and so-called state-level gold carding, where PA cannot occur if a provider achieves a threshold of approved PAs over time.

(Article may require a subscription.)

#pa #priorauthoriation #healthplans #providers

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Insurers Had Positive Margins In 2023

Despite the Q4 results for some plans, overall health insurers did reasonably well in 2023.  But the key is that 2023 was a relatively good year for rate hikes in Medicare Advantage (MA).  The bad rates have yet to take effect and could impact results the next few years. Those plans with large concentrations of revenue in MA will need to rein in benefits and cut expenses to achieve their results.

#medicareadvantage #margins #healthplans

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Becerra Says ACA Will Survive Under Any Administration

At an appearance at the National Press Club, Health and Human Services Secretary Xavier Becerra made a bold declaration about the Affordable Care Act (ACA). He indicated that the ACA would survive legal and law-making attempts to impact or repeal the law.  Becerra argued that the court of public opinion would win the day.  I think he is right.  The ACA has reached such a critical juncture that lawmakers would have trouble repealing it.  And courts have almost always upheld the law.  There is the preventive benefits provision still to be reviewed, though.

Due to Medicaid redeterminations, the number of Americans benefiting from Medicaid’s expansion or the Exchanges will come down from well over 40M to a lower number.  Time will tell. But it still will likely be 35M to 40M.  How do you tear coverage from that many people.  Sanity in each party would prevail.

(Article may require a subscription.)

#medicaid #rdeterminations #aca #obamacare

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More Fallout From Drug Price Hearing

Some new articles have come out on the drug price hearing session Thursday.  The heads of various brand drug makers gave no assurance that prices would come down.  The CEOs had little in their favor other than arguing innovation would suffer and trying to point blame at PBMs. The Democrats pointed out that the drug makers stop generics coming to market and highlighted the vast price differences with other developed countries.  Some sycophantic Republicans sang from the same hymnal as the CEOs, arguing free-market economics. Yet, the drug market is not a free market. Some Republicans were very reasonable, such as Sens. Susan Collins and Mike Braun.

Additional article here: https://insidehealthpolicy.com/inside-drug-pricing-daily-news/ceos-merck-jj-bristol-myers-squibb-hit-pbms-don-t-commit-lowering

In addition, an additional article speaks to the Congressional Budget Office (CBO) continuing to update impacts of the Medicare drug price negotiation bill: https://insidehealthpolicy.com/inside-drug-pricing-daily-news/cbo-still-weighing-ira-s-effect-drug-innovation-economic-outlook

(Some articles may require a subscription.)

#ira #drugpricing #brandrugmakers

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Site-Neutral Payments May Be In Limbo

Adoption of any site-neutral payment policies looks to be in limbo given the government shutdown threat and other policy issues. Hospitals continue to lobby against this common-sense reform. It’s latest stunt is to argue site-neutral payments would further impact rural hospitals that are in crisis.  That is easily dealt with (the House bill did so).

(Article may require a subscription.)

#siteneutral #healthcarereform #hospitals

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Academic Centers Oppose March-In Provision On Drug Patents

The Association of American Medical Colleges (AAMC) and similar groups are asking for the withdrawal of the proposed march-in-rights provision, where the government could effectively seize a drug patent if the drug is highly priced and the government contributed to the development.  The academic groups say it would chill partnerships between their groups and pharma.


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— Marc S. Ryan

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