January 29, 2024

Elevance Health Sues CMS Over Medicare Advantage Star Rating

Interesting article on Elevance Health’s lawsuit against the Centers for Medicare and Medicaid Services (CMS) on Stars.  If this is anything close to true, CMS needs to relook at how it ensure fairness in calculations. How many others may have been impacted?

#elevancehealth #stars #medicareadvantage

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Moody’s Says Medicare Advantage Margins On Downturn

Interesting analysis by Moody’s that says Medicare Advantage (MA) margins have dropped from 4.9% in 2019 to 3.4% in 2022. Margins fell in commercial too but by a smaller amount. Note that these changes occurred before the latest medical expense upswing, lower 2024 rates, and new prior authorization limitations.

Today, I published a blog on the future of MA after some major regulatory changes and a major increase in medical expenses. The boom is over. What will happen? The blog is here: https://www.healthcarelabyrinth.com/with-boom-over-will-medicare-advantage-collapse-or-adjust/

#medicareadvantage #margins #rates

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Better Medicare Alliance Letter Has Huge Support In Senate

Better Medicare Alliance (BMA) got 61 senators to urge the Centers for Medicare and Medicaid Services (CMS) to ensure the stability of the Medicare Advantage (MA) program.  I applaud BMA for its ongoing work, but Capitol Hill and CMS are ripe with anti-MA sentiment lately and the letter likely means little.  The new prior authorization rule regarding use of outside criteria is a good example.  How can senators urge stability, but remain silent on the tragic consequences of the new prior authorization rule, among others. I also cannot find BMA opposing the new prior authorization requirements in the 2024 MA and Part D rule. If they have, I will gladly include a correction. I also see them endorsing other questionable federal bills, including the Timely Access to Seniors Act.

#medicareadvantage #bma

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MACPAC Urges Overhaul Of Appeals Process

I agree with MACPAC that the Medicaid appeals process should be updated. The current process is old and antiquated.  Members deserve a thorough external review by clinicians as all other lines of business have.

Additional article here: https://insidehealthpolicy.com/daily-news/macpac-recommends-changes-denial-appeals-process-mcacs

(Some articles may require a subscription.)

#medicaid #appeals #macpac

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North Carolina Cuts Off Weight-Loss Drugs

North Carolina is cutting off access to weight loss drugs for state employees given costs. This is more evidence of too much of a good thing, contemptible marketing by drug makers, and the high costs of drugs.

Additional article here on what employers need to focus on in terms of access to weight-loss drugs: https://www.fiercehealthcare.com/payers/morgan-health-3-things-employers-should-focus-manage-glp-1s

(Some articles may require a subscription.)

#drugpricing #weightlossdrugs

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CMS Touts Growth of ACO Program

The Centers for Medicare and Medicaid Services (CMS) is touting growing participation in the Accountable Care Organization (ACO) or what technically is the Medicare Shared Savings Program (MSSP).  On its face, the growing interest in the program is impressive.  But the savings in the program has been lackluster.  One study suggest that it has ended up a net loss to CMS when taking into account administrative costs. It points to the fact that reforming the archaic traditional fee-for-service (FFS) program is a losing battle.  CMS should concentrate on supporting Medicare Advantage (MA) as a solution, rather than attacking it as they have done with the new prior authorization limitation rule.

Additional article here showing that about 50% of all traditional Medicare enrollees are in ACOs: https://www.managedhealthcareexecutive.com/view/nearly-half-of-traditional-medicare-beneficiaries-are-in-acos-says-cms

#medicare #acos #mssp #medicareadvantage

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Sen. Baldwin Challenges Drug Makers

Sen. Tammy Baldwin is right.  Brand drug makers are abusing patent declarations in the Food and Drug Administration’s (FDA) Orange Book and that is stopping investment in generics and early introduction to the market.  This is one of the ugly practices brand drug makers use to ensure their high prices for as long as possible. 

Health and Human Services Xavier Becerra has also been active on the issue and HHS officials met with interested parties: https://www.hhs.gov/about/news/2024/01/29/readout-hhs-officials-meeting-private-sector-patient-advocacy-leaders-improve-national-access-important-asthma-medications.html

#drugpricing #brandrugmakers

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Novo Nordisk To Stop Production Of Insulin Product

No wonder brand drug makers have a bad reputation. Novo Nordisk said it is stopping the sales of Levemir insulin in the U.S. It has not announced plans of stopping it in other countries.  It recently announced a major drop in price but will stop making it available altogether.  The article makes a few critical points.  First, it says drug makers may be moving to producing more lucrative drugs, such as weight loss drugs. Second, many insulins are replaced to get folks on much more expensive products, whether these serve the interests of those taking insulin or not. That does not occur in other developed countries, which is likely why Levemir will continue to be available there.  No chance for price speculation there. In America, while drug makers tout their commitment to life-saving drugs, in this insulin case they are saying the sick be damned. For brand drug makers, it is not about healthcare or public health but profits. In the end, this is why we see some states, such as California, looking to produce their own supplies of generic insulins.

#insulin #drugprices #drugshortages

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Fitch Outlines Provider Challenges

Fitch Ratings outlines concerns and challenges for providers in 2024. 

(Article may require a subscription.)

#providers #2024 #hospitals

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Social Isolation Challenging And Medicare Enrollees Missed

This article points out the good Medicare Advantage (MA) is doing in targeting social isolation among Medicare beneficiaries.  It points out that many are being missed and leads to higher overall spending.  To me, the bigger point is that MA is innovating here.  Medicare fee-for-service (FFS) has no such programs. I would also note that these type of programs could be the first to go due to too much regulation, such as the prior authorization rules, that will lead to higher medical expense.

(Article may require a subscription.)

#medicare #medicareadvantage

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No Surprises Act Saved People 10 Million Bills In First Nine Months of 2023

The No Surprises Act (NSA) saved Americans 10 million bills in the first nine months of 2023.  But as AHIP and BCBSA (two insurance trade associations) point out, providers are trying to abuse the law and continue to fight it in court. Showing how off government estimates usually are, 17,000 claims were forecast to go through arbitration. AHIP and BCBSA estimate almost 670,000 claims were submitted to the process in the nine-month period. Also, 71% of resolutions ultimately favor providers.

My view is that the bill’s arbitration process already favors providers and providers want to make it even more so.  This is led by hospitals as well as private equity firms, both of which have gobbled up providers. Studies of state laws with similar arbitration processes show that providers are actually driving up costs in their states.

In related news, a three-judge panel of the U.S. Court of Appeals for the Second Circuit dismissed claims challenging the constitutionality of the NSA.  Providers were arguing the law was unconstitutional as it seized their property as they can no longer sue patients.  

Article on court decision here: https://www.healthcaredive.com/news/appeals-court-rejects-challenge-no-surprises-act/705623/

#nosurprisesact @nsa #surprisebilling

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— Marc S. Ryan

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