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July 8, 2024

New Wall Street Journal Study To Generate Huge Capitol Hill Focus

A Wall Street Journal (WSJ) analysis published today finds that Medicare Advantage (MA) plans filed numerous questionable diagnoses in the risk adjustment program to generate about $50 billion between 2018 and 2021. The WSJ found diagnoses for patients that did not have certain conditions or could not possibly have such conditions. It also found that many conditions were diagnosed at a much higher rate in MA than in the traditional fee-for-service (FFS) prorgam. This adds to numerous other private and public studies that will be fodder for reforms coming from Capitol Hill on MA overpayments.

As many of you know, I am a defender of MA and feel that some accusations of overpayments are not accurate.  I do not doubt there are some inaccuracies in what the WSJ found as well.  At the same time, I have said there are some bad actors who are disproportionately benefiting from certain unscrupulous risk scoring activities.  In addition, I have questioned the manual chart review and health risk assessment submission processes.  See my blog on all this here: https://www.healthcarelabyrinth.com/will-cms-rein-in-risk-adjustment-submissions/ . See my podcast on all this here: https://www.healthcarelabyrinth.com/25-ma-plans-should-ready-for-changes-to-risk-adjustment-submissions/ .

Additional articles: https://science.slashdot.org/story/24/07/08/1540200/insurers-pocketed-50-billion-from-medicare-for-diseases-no-doctor-treated and https://www.beckerspayer.com/payer/insurers-brought-in-50b-through-medicare-advantage-coding-wsj.html .

(Some articles may require a subscription.)

#medicareadvantage #riskadjustment #overpayments #cms

https://www.wsj.com/health/healthcare/medicare-health-insurance-diagnosis-payments-b4d99a5d

Study Shows Better Coverage Meant Less Skipping Of Care

A better endorsement of affordable universal access you will not find. In addition to much lower uninsured rates, a study by the Urban Institute and underwritten by the Robert Wood Johnson Foundation found that nearly 5 million fewer people delayed care from 2019 to 2022.  About 4.75 million non-elderly Americans skipped necessary medical care, dropping from 12.1% to 9.7% in 2022. Much of this was the result of expanded coverage for Medicaid and enhanced premium subsidies for Exchange coverage.

#coverage #healthinsurance #medicaid #aca #exchanges #obamacare

https://www.fiercehealthcare.com/payers/less-adults-are-skipping-medical-care-because-cost-barriers-after-pandemic-era-policies

Major Developments In Cybersecurity

Healthcare industry groups are railing against a new cybersecurity incident reporting rule as overly burdensome and complex. The government is in a no-win situation.  It has not laid out a strong foundation for how the country will guard against additional cyber attacks in light of the Change Healthcare incident.  And now, when it puts teeth in rules, healthcare stakeholders want reductions.  What is clear: Neither the nation nor providers are prepared. Healthcare and hospital groups also want insurers and third-party vendors to be explicitly included.

In other news, federal officials are leaving a private AI coalition that wants to set safeguards for use in healthcare.

Additional articles: https://www.fiercehealthcare.com/ai-and-machine-learning/tripathi-tazbaz-resign-coalition-health-ai and  https://www.modernhealthcare.com/digital-health/coalition-for-health-ai-fda-troy-tazbaz-onc-micky-tripathi and https://www.healthcaredive.com/news/healthcare-cybersecurity-reporting-regulation-cisa-change-heatlhcare/720628/

(Some articles may require a subscription.)

#cyberattacks #providers #healthcare

https://www.fiercehealthcare.com/regulatory/healthcare-industry-rails-against-cisas-redundant-and-burdensome-cyber-incident

Digital Health Investment Continues To Rebound

U.S. digital health startups acquired $5.7 billion across 266 deals in the first six months of 2024.  This shows a continued recovery for digital health. AI and mental health are helping contribute to the recovery.

Additional article: https://www.modernhealthcare.com/digital-health/private-equity-funding-rock-health

(Some articles may require a subscription.)

#ai #mentalhealth #digitalhealth #healthcare

https://www.fiercehealthcare.com/digital-health/digital-health-funding-hit-57b-through-june-track-surpass-2019-and-2023-rock-health

Federal Court Stays FTC Non-Compete Rule

A Texas federal judge stayed implementation of a Federal Trade Commission (FTC) rule that sought to ban non-competition employment clauses in parts of the healthcare world. The judge said the stay was necessary as the FTC violated the Administrative Procedures Act (ACA) and exceeded its statutory authority. There is a “substantial likelihood” that the plaintiffs will win and that the FTC was arbitrary and capricious in its rule. The stay is for the plaintiff and related parties for now.

Additional article: https://www.healthcarefinancenews.com/news/texas-court-stalls-ftc-noncompete-ban

#ftc #noncompetes #healthcare #providers

https://www.healthcaredive.com/news/ftc-noncompete-ban-enjoined-by-texas-judge/720677

Chevron Decision Could Lead To More Questions on ACA Preventive Benefits

The recent Supreme Court case that did away with the Chevron precedent could make it more difficult to preserve preventive benefits under the Affordable Care Act (ACA) as a major case is still inflight after it was returned to a lower court from the appellate level.  In other news, in light of the Chevron case as well Sen. Cassidy is asking the Department of Health and Human Services (HHS) for its legal basis for march-in rights on drug patents. The fallout from the repeal of the Chevron precedent is already happening.

Additional article: https://insidehealthpolicy.com/daily-news/cassidy-targets-march-rights-again-after-supreme-courts-ruling-chevron-deference

(Articles may require a subscription.)

#drugpricing #branddrugmakers #prevention #aca

https://insidehealthpolicy.com/daily-news/chevron-overturn-could-spark-questions-aca-preventative-services-decisions

Forty Contracts Receive Higher Stars In CMS Recalculation

Becker’s Payer Issues shows the 40 health plans (and 63 contracts) that gained increased Stars when the Centers for Medicare and Medicaid Services (CMS) recalculated 2024 Star ratings.

#cms #stars #medicareadvantage

https://www.beckerspayer.com/payer/these-40-insurers-received-medicare-advantage-star-upgrades.html

— Marc S. Ryan

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