January 9, 2024

NY Wins Medicaid Waiver Approval

New York received an 1115 Medicaid waiver approval from the Centers for Medicare and Medicaid Services (CMS) covering a myriad of innovations, including recruitment and retention of Medicaid providers, eligibility to bill social needs spending, primary care investments, behavioral health investments, and health equity pilots. CMS press release here: https://www.cms.gov/newsroom/press-releases/cms-approves-new-yorks-groundbreaking-section-1115-demonstration-amendment-improve-primary-care

#medicaid #cms #waivers #socialneeds #healthequity

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Both Cigna And CVS Say They Are Ready For Changes in PBM World

Both Cigna and CVS, owners of two of the three largest traditional Pharmacy Benefits Managers (PBMs) say they are ready for the transformation in the world of PBMS that may be coming. Cigna went as far as to say they welcome unbundling, where plans may hire multiple entities to service them in a transparent way.

See my Blog on PBM Transparency from December 14 for the emerging changes in the PBM industry: https://www.healthcarelabyrinth.com/pbm-transparency-and-reform-is-a-big-trend-in-the-american-healthcare-system/

#pbms #transparency

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Court Approves Sale Of Rite Aid’s Elixir PBM To MedImpact

A federal bankruptcy court approved the sale of Rite Aid’s Pharmacy Benefit Manager (Elixir) to rival PBM MedImpact. MedImpact is a mid-tier PBM that now will have more lives.

(Article may require a subscription.)

#elixir #pbms #medimpact

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Cigna CEO Outlines Strategy At JPM Conference

In some cases, Cigna CEO David Cordani is taking a decidedly different approach on growing Cigna than some of his other peers, although some strategies match up. At the JPM conference, Cordani said:

  • He has been supremely focused on building his services organization EverNorth to compete with United’s Optum. He is looking at acquisitions that could expand Cigna’s in-home care offerings and insurance services as well as vendors that offer specialty care in home and virtual care. In scope are provider management services organizations as well. Investments are also being made in targeted health programs for certain conditions.
  • While he would not address it outright, Cigna is looking to shed its Medicare Advantage (MA) business while others are investing there. This could open up another round of merger talks with Humana down the road. He did say that regulatory scrutiny is up.
  • He reiterated a strategy of building services for providers, rather than buying or employing providers as United and Humana have done.
  • Its Pharmacy Benefit Manager (PBM) ExpressScripts is growing care management services for using specialty drugs.
  • He says the PBM has not yet seen major demand among commercial customers to unbundle PBM services as most do not have the sophistication or desire to do this.

(Article may require a subscription.)

#cigna #cordani #medicareadvantage #evernorth #pbms

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Keeping Government Open Has Some Wrinkles

While the five congressional leaders and the president have a deal on aggregate funding levels for federal fiscal year 2024 (ends 9/30/2024), there is some anxiety on Capitol Hill over the agreement’s fate. Democrats remain fully committed, as does Senate Republican Leader Mitch McConnell.

Republican House Speaker Mike Johnson negotiated it, but he is facing a backlash from rightist Republicans, the wing from which he hails. They argue spending is too rich and doesn’t even meet the debt limit agreement levels due to tweaks agreed to by Johnson. How many of the GOP right flank will jump off the bills? Will the Speaker stop procedural votes that could sink bills? There also is the question of so-called poison pill policies Republicans may place in bills that may be objectionable to moderate Republicans as well as all Democrats. That could cost votes, too.

McConnell is saying another stop gap CR is needed, but Johnson previously has said no to additional short-term solutions. He appears to be softening a bit, but this agreement is simply not a done deal yet. The first CR expires on Jan. 19, with the second expiring on Feb 2.

Additional articles here:



#governmentshutdown #crs

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Healthcare Players Concerned About Government Funding Deal

Some healthcare players are sounding the alarm on what will happen in healthcare with the agreement on FFY 2024 funding levels. The funding levels may not let some priorities get passed. On the agenda are transparency, pharmacy benefit manager reform, site-neutral policies, and restoring some or all of the Medicare physician pay cut. The turmoil over the deal could mean priorities do not move at all and at least some get axed due to lack of funding.

(Article may require a subscription.)

#governmentshutdown #healthcare #transparency #providers #pbms #siteneutral

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KFF Reports Most Non-Profit Hospitals And Health Systems Had Strong Cash Reserves in 2022

While margins declined, a Kaiser Family Foundation (KFF) analysis finds that non-profit hospitals and health systems had reasonably strong cash reserves to weather the tail of the COVID pandemic for several years. Over 90% had adequate to extremely strong cash reserves. KFF analyses here:




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Canada’s Statement On Drug Importation

As Canada promised, it is taking a hardline on the approval by the Food and Drug Administration (FDA) to allow Florida to import drugs from Canada on a wholesale basis. Canada issued a statement that said: The Government of Canada is taking all necessary action to safeguard the drug supply and ensure Canadians have access to the prescription drugs they need and has been clear in its position: bulk importation will not provide an effective solution to the problem of high drug prices in the U.S.,” It says it will fight exports if reimportation poses a threat to the supply of certain drugs in Canada.

#drugpricing #fl #drugimporation

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Good MHK Blog On New 2024 Prior Authorization Audits

This MHK blog details the ad hoc program audits that will occur with regular ones on the 2024 rule significantly reining in the use of evidence-based criteria in prior authorizations by Medicare Advantage (MA) plans. The new Centers for Medicare and Medicaid (CMS) rule largely limits MA plans to using the traditional fee-for-service (FFS) programs criteria, the National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). And the Centers for Medicare and Medicaid Services (CMS) will immediately audit on compliance with the new prior authorization requirements. See CMS audit memo here: https://granepbm.com/wp-content/uploads/2023/12/2024_Program_Audits_Updates.pdf . Based on some of the headlines out there already, I expect some MA plans to attempt to continue to use their own criteria in certain areas (especially inpatient) and push CMS on this. It could even lead to a court fight — a worthy pursuit.

 I have written three blogs that touch upon on this new rule and I think what CMS has done is atrocious. I am a strong supporter of CMS and its oversight practices. But CMS bowed to providers’ political lobbying and Capitol Hill pressures here. The new rule will add costs and hurt MA as a program. It will significantly impact MA’s value and impact supplemental benefits over time – benefits that are crucial to lower- and moderate-income seniors and the disabled. It could drive a stake through the heart of the only program that can save Medicare as we know it.

See my earlier blogs on this topic below:




#medicareadvantage #priorauthorizations #ncd #lcd #medicare #2024rule

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New Polling Shows Huge Support For Price Transparency

A new Marist poll for the nonprofit Patient Rights Advocate (PRA) found that 94 percent of adults agreed that hospitals, health plans, and doctors should “be legally required to disclose all of their prices, including discounted prices, cash prices, and insurance negotiated rates across hospitals and across plans in an easily accessible place online.”

#pricetransparency #transparency #healthcare #healthcarereform

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— Marc S. Ryan

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