WSJ Finds Excess Rx Refills At Medicare Plans Via Mail Order
Many argue The Wall Street Journal has it out for health plans as it has had many hard-hitting investigations of fraud and bad practices over the past year or so. Some parts of the industry have accused the Journal of being wrong or behind the times, but the newspaper seems to constantly find scandal afoot, especially among the big national plans. Some of its findings, which are hard to question, have led to ongoing investigations by federal regulators and Capitol Hill.
The Journal’s latest expose finds that mail order pharmacies – again the biggest owned by the big national healthcare players — regularly overfill Medicare prescriptions. The Journal finds that excessive filling is a common practice at mail order firms. Too-frequent refills by all U.S. pharmacies cost Medicare and patients $3 billion between 2021 and 2023 says the Journal.
Mail-order pharmacies filled just 9% of Medicare prescriptions in the study period but accounted for 37% of the excess dispensing. Practices that continue overfilling include automatic 90-day refills and early refills. While federal rules require health plans to limit early refills (e.g., no earlier than 75% of the way through a prior supply or 68 days for a 90-day supply), the Journal analysis found that UnitedHealth Group’s mail-order pharmacies sent refills sooner than the 68-day threshold 11% of the time. That was almost nine times the rate of all other Medicare pharmacies.
The reason is clear: vertically integrated companies’ insurers cut great deals with their sister companies and the vertical behemoths then find many pathways to derive as much revenue as possible in the unregulated entities. The Journal has found yet another use case of this fact.
#medicareadvantage #partd #fwa #healthplans
Work Requirement Opacity
A good article in Modern Healthcare about the mass confusion and lack of guidance to states on work requirement implementation in Medicaid stemming from the One Big Beautiful Bill Act (OBBBA). States and health insurers complain that very little has been published guiding states on implementation. Work requirements go into effect on 1/1/2027. Quote of the day from a consultant: “At this point, CMS has released 50 pages of guidance in the last three weeks and managed to clarify almost nothing.”
(Article may require a subscription.)
#workrequirements #medicaid #obbba
https://www.modernhealthcare.com/politics-regulation/mh-medicaid-work-requirements-cms-guidance
Policy Experts Weigh In On Exchange Changes
Researchers at Cornell University’s Health Policy Center polled 64 healthcare and health policy experts about various affordability issues. Here is what they found:
- 70% said they believe it would worsen affordability to deposit the value of the recently expired enhanced premium tax credits into a Health Savings Account (HSA) rather than apply it directly to the premium. Just 10% said they believe it could improve affordability, with 13% saying they believe it would have no real impact on the affordability of Exchange plans.
- 75% said they believe that even small mandatory premiums per month would have a measurable impact on overall enrollment, but 37% said they believe it would lead to a decrease in fraudulent enrollment.
- 81% said elimination of automatic re-enrollment for many people with subsidies would have a substantial impact on enrollment.
I am a fan of comprehensive coverage and reaching some compromise on Exchange subsidies, but it is hard to argue against reasonable anti-fraud measures, including minimum premiums and annual election of coverage.
#exchanges #affordability #healthcare #coverage
Trump To Bully Health Plans
President Donald Trump said he will meet with 14 insurance companies soon to pressure them to lower prices for Americans. “We’re trying to solve the healthcare problem. We’re trying to get better healthcare at a lower price,” Trump told House Republicans at a strategy session. Trump also demanded that lawmakers redirect federal healthcare dollars away from insurers and toward consumers directly.
While vertically integrated behemoths overall do well and need to be reined in, Trump repeated falsehoods about insurers in general. “Let the money go not to the big fat cats and the insurance companies that made 1,700% over the last short period of time. Let the money go directly to the people where they can buy their own healthcare,” Trump said. From 2019 to 2024, insurers proper had negative total margins. And he is misdiagnosing the cause — price in the system is uncontrolled and leads to unaffordability. No party is willing to tackle the real culprit and instead look for bogeymen
In other news, the House is expected to vote this week on a three-year subsidy extension, although a similar bill failed to get 60-votes in the Senate. But a compromise could emerge. About 4 million could lose coverage if enhanced subsidies are not extended in the Exchanges.
#healthplans #trump #margins #exchanges #hsas #healthcare #coverage
https://www.beckerspayer.com/payer/trump-says-he-will-meet-with-14-insurers-over-pricing/
— Marc S. Ryan
