January 12, 2024

What Would A Nikki Haley Healthcare Agenda Look Like?

The Republican debates continue with Donald Trump bowing out and Ron DeSantis and Nikki Haley taking center stage.  A recent CNN debate saw the two sparring, sometimes on healthcare issues. Both Haley and DeSantis declared that they would like to replace the Affordable Care Act (ACA) with a block grant.  It is a horrible idea.

With Chris Christie’s departure from the race and Haley rising in the polls, Kaiser Health News (KHN) did a feature on what a Haley administration’s healthcare agenda may look like.

Additional article on Haley’s views on entitlement reform here: https://www.cnn.com/2023/12/05/politics/nikki-haley-social-security-medicare-reform/index.html

#gopprimary #haley #desantis #trump #healthcare #aca #obamacare

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Fight (Verbal Anyway) Breaks Out at MedPAC Meeting

A verbal clash broke out at a MedPAC meeting, with one member reasonably arguing that MedPAC is not truly as non-partisan as it says it is. I generally agree with the member-critic on the congressional policy arm that MedPAC tends to be anti-Medicare Advantage (MA) or at the very least parrots criticisms of the MA opponents.

MedPAC has been on a drumbeat to reduce rates and make other changes. Some reform is needed, but MedPAC seems to always pick on the negatives. It is always about overpayments, an error-prone Star program, risk-adjustment abuses and more.  We just don’t see the same “rigorous analysis” on the fee-for-service (FFS) program or reasonable comparisons of the pros and cons of each program. Objective comparisons might better shine a light on the value in MA. MedPAC also seems to forget that many of the so-called overpayments or additive Star monies are deliberate policy decisions by Congress.

#medpac #medicareadvantage #medicare

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Billing For Messages And Inquiries To Providers

Interesting article on the rise of what is essentially “e-visit” billing by providers when patients send messages or otherwise communicate with the office. In some cases, these may be legitimate billable activities under telehealth. But I would argue many such messages aimed at maintaining someone’s health (especially with follow-ups) is part of being a good primary care physician or provider.

Here is the real back story. Providers, increasingly owned by hospital systems or private equity firms, aim to bill every minute worked.  In most cases, such billing will never get paid. The provider may be capitated as one example. In others, it might be billed to a health plan or the insured.  Other providers justify it by saying it will show the time spent, some of which is never documented. Regardless of payment or not, logging the time as an encounter will allow providers to lobby for more pay in Congress, at state legislatures, and with health plans.

As this newsfeed was written, strangely my family became victim of this new trend.  My wife had been to her primary care practice for an illness.  She did not appear to be getting better.  She called the office to ask advice and to see if she needed to see a specialist.  She waited all day for a call back.  She received a member portal ping that a billable consultation had been logged in her member record, but no call back to her had been made.  Only after she called to inquire about the entry did she get a clinician to talk with her.

Additional article here: https://www.modernhealthcare.com/providers/evisit-billing-rise-jama-study-mychart

(Some articles may require a subscription.)

#telehealth #billing #physicans #providers

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Huge Fight Brewing On Site Neutral Payments

With government funding and time to pass legislation both tight, a huge fight is brewing on site neutral payments, where the same service would be paid the same rate regardless of where the procedure or service is performed in Medicare.  Advocates won a victory when the House passed site neutrality for Medicare Part B drug administration.  But hospitals will die on the sword before it passes Congress as a whole. It shuts down their money machine, regardless of how much it adds to overall healthcare costs. It also would be the camel’s nose under the tent for broader pricing reform. Hospitals and providers are already fighting a number of general rate fights.  I am still hopeful something could happen on site neutrality.

And it is not just about overall costs to the healthcare system.  Consumers are victims every day.  More and more patients are told where they must go, often expensive outpatient hospital settings because the doctor is owned by that hospital.  Under insurance, these visits carry much greater cost-sharing compared with lower out-of-pocket costs for ambulatory or other settings. 

(Article may require a subscription.)

#siteneutral #hospitals

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Efforts to Reduce and Reverse Medicare Physician Pay Cut Alive

A prominent doctor-lawmaker in the House says efforts to forestall the Medicare pay cut in 2024 is still alive and is progressing.  Earlier the House passed a partial pullback of the cut. The programmed cut is 3.4%.

#medicare #physicians #rates

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Dysfunction Junction: Greater Chance of Government Shutdown

The soap opera that is government funding and a possible shutdown continues. Speaker Mike Johnson, R-LA, says his deal struck with Democrats remains in place – this despite an uprising in his own rightist Freedom Caucus over the level of spending,  In truth, Johnson struck a deal that is actually richer than even ousted Speaker Kevin McCarthy on the debt limit. I don’t argue that a final budget deal should be passed at these levels.  But it is ironic that Republicans tossed a capable and conservative speaker for one from their minority sub-caucus who may give them a worse budget.

Democrats have increasingly argued they will not accept any poison pills in funding bills, either. With the Freedom Caucus uprising, Democrats and rightist Republicans teaming up to kill procedural votes, and precious time left, a government shutdown is becoming more likely. The Senate is preparing a new continuing resolution (CR), but it is unknown if the House GOP will bring it up.

Additional articles here: https://insidehealthpolicy.com/daily-news/dems-repeat-approps-message-gop-no-partisan-add-ons and https://insidehealthpolicy.com/daily-news/another-cr-likely-shutdown-possible-approps-efforts-turmoil

(Some articles may require a subscription.)

 #governmentshutdown #spending #crs

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Bad Press For PBM Industry As Reform Looms

Express Scripts and smaller PBMs are being hit with a class-action lawsuit arguing they rigged reimbursement rates and collected higher fees from pharmacies. Bad news for PBMs as reforms await passage in Congress.

(Article may require a subsection.)

#pbms #transparency

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Big Medicaid Insurers Getting Rate Increase To Compensate For Churn And Expected Higher Acuity

Medicaid insurers, such as Centene and Molina, are having success getting sizeable rate increases from states as they lose Medicaid enrollment due to the re-establishment of Medicaid eligibility redeterminations.  The insurers argue that as many exit, acuity will go up as individuals that are more adverse will remain enrolled.

It is a great lobbying effort by Centene and Molina, who have gained nice hikes in 80% to 90% of states. It has softened the blow to investors as well.

(Article may require a subscription.)

#medicaid #managedcare #centene #molina

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United Healthcare Stock Hit Despite Hitting Earnings

United Health Group stock dropped by about 3.5% Friday despite its earnings report that beat expectations.  The principal reason is that the insurer and services behemoth reported a major uptick in medical expenses, which could portend a rougher 2024. The 85% medical loss ratio (MLR) in Q4 was driven by COVID costs, respiratory infection vaccines, and generally higher medical expenses in Medicare lines. That was too much offsetting the good news – Q4 2023 outpaced Q4 2022 for both revenue and earnings. The 2023 year earnings were strong too. United says its 2024 guidance stands.

The stock drop was likely a bit of an over-reaction.  But we will likely see similar reports across the industry, which will hurt values across insurers in the short-term.

Additional articles here:




(Some articles may require a subscription.)

#unitedhealthcare #medicareadvantage

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— Marc S. Ryan

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