March 22, 2024

Senate Has Funding Bill After House Passage

The Senate will need to pass a huge funding bill before midnight Friday to avert a government shutdown.  The House passed the bill, which includes healthcare funding, on a vote of  286-to-134 (112 Republicans and 22 Democrats voted against the bill). One conservative House member has called for the ouster of House Speaker Mike Johnson, R-LA, who hails from the Freedom Caucus.  She says she has support from folks, but the caucus and some Democrats do not want to see more chaos. The GOP hold on the House will be razor-thin with two early retirements.


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After Win On Prior Authorization, Providers Now To Focus On Denied Claims

Medicare Advantage (MA) and other health plans watch out. Providers will now want strict rules from the Centers for Medicare and Medicaid Services (CMS), Medicaid agencies, and state legislatures regarding claims denials.  This comes after big wins in limiting prior authorizations at the state and federal level.

Providers are touting an industry survey of over 500 hospitals that says providers spent $20 billion in 2022 fighting delayed and denied claims from insurers. Most of it involved private plans. They want action from CMS and other regulators.

The survey says just over half of the total comes from denied claims that are eventually paid, indicating that over $10 billion is truly wasted. About 15% of all claims submitted to private payers are initially denied.

I have my doubts about the veracity of the survey.  It is meant to sensationalize (“billions of dollars”) for Capitol Hill and others.  My view is that, while health plans may need to reform some areas, these initial denials are likely to ensure all medical documentation is sent in and the claim is truly worthy of payment.  That 50% are not paid also points to the potential, waste, fraud and abuse (FWA) in the system.  In the providers’ perfect world, nothing would be denied.  As with the new prior authorization rule in Medicare Advantage (MA), all of this will lead to even greater costs in the healthcare system.  All scrutiny upfront and retrospectively would go away.

Additional article: https://www.fiercehealthcare.com/providers/providers-wasted-106b-2022-overturning-claims-denials-survey-finds

(Some articles may require a subscription.)

#claimsdenials #priorauthorization #healthplans #hospitals #providers

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Walgreens Sells Rhode Island Clinics

More retrenchment at Walgreens as it sells 11 more VillageMD clinics in Rhode Island.

Additional article: https://www.healthcaredive.com/news/walgreens-villagemd-sale-arches-medical-partners-rhode-island/710976/


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Change Healthcare Catching Heat For Cyber Attack Readiness And Response

Change Healthcare is getting more scrutiny on the cyberattack, its readiness, and its response.  What’s more, Change’s status page seems to show that more than 110 services are still offline, with 20 services having resumed.

#changehealthcare #cyberattacks

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Moody’s Says Providers Could See More Revenue Risk From MA

Moody’s predicting that providers, especially hospitals, could see less revenue from Medicare Advantage (MA) because MA is becoming less profitable and plans will tighten oversight further.  It says that the new prior authorization (PA) rule, though, may help providers. 

In truth, I do see further tightening by MA plans and that the new PA rule actually will contribute to it – not help providers. We know that hospitals are terming contracts with MA health plans.  That trend will likely continue, but MA plans may need to tighten networks themselves to deal with medical expense and the effect of the PA rule.

#medicareadvantage #priorauthorization #hospitals #providers

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MedPAC Recommends Star Overhaul Because It Lacks Quality Details

MedPAC, the congressional advisory arm for Medicare, recommends replacing Medicare Advantage’s (MA) quality bonus program because it generates billions in payments to MA plans but gives no meaningful information on quality.

MedPAC staff are very biased against MA as are a number of commissioners. I do think there is plenty of data that shows the value of MA from a quality and supplemental benefit perspective. Numerous studies show that MA delivers better quality and helps many with low income and social determinant barriers.

(Article may require a subscription.)

#medpac #medicareadvantage #stars

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GSK Lowers Asthma Inhaler Prices

GlaxoSmithKline has joined two other brand drug makers in capping out-of-pocket costs for its inhaler products at $35 per month. It also agreed to delist patents in FDA’s Orange Book after being warned by the Federal Trade Commission (FTC) that the listings could violate the law. The other two companies did not delist. Several asthma inhaler companies have yet to reduce prices, but could face action by the FDA as well as competitive pressure that will result in reductions.

(Article may require a subscription.)

#drugpricing #branddrugmakers

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Think Tank Wants MA Reform

The Center for American Progress, a liberal think tank, says Medicare Advantage (MA) plans could be overpaid between $1.3 trillion and $2 trillion over the next decade and wants reforms. It also wants changes in the traditional program that could help it compete with MA. Its MA reforms include coding intensity changes, dealing with selection bias, making MA quality bonuses budget neutral, and having competitive bidding introduced.

MA plans have to take notice as more and more groups are recommending changes.  Plans need their own game plan.

(Article may require a subscription.)

#medicareadvantage #medicare

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A Debate In GOP Over Increasing Social Security Retirement Age

A debate is rising in the GOP over a House Republican Study Committee (RSC) recommendation to increase the Social Security retirement age over time as well as means testing. 

Some in the GOP argue this is an election nightmare.  But the RSC is right to bring up reasonable reforms to a nearly bankrupt program.


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With 14th Anniversary of Obamacare, Biden Unveils Attack Ad On Trump

On the occasion of the 14th anniversary of the Affordable Care Act (ACA or Obamacare), President Biden’s campaign unleashed an attack ad on former President Donald Trump, saying if he is re-elected the ACA could go.

In addition, a new fact sheet from the Centers for Medicare and Medicaid Services (CMS) says over 21 million people are enrolled in the Exchanges and that 45 million have benefited from coverage under the act.

Biden press release here: https://www.cms.gov/newsroom/press-releases/celebration-10-years-aca-marketplaces-biden-harris-administration-releases-historic-enrollment-data

#aca #obamacare #exchanges #medicaid

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Risks To Diabetics Increase Dramatically If They Are In High-Deductible Plans

A study finds that those with diabetes face greater risks and complications if they are in high-deductible health plans (HDHPs) versus more comprehensive coverage. This appears to be the case even though many preventive services are still free under the HDHPs.  Very interesting study that points to the need of ensuring comprehensive coverage.

#diabetes #coverage

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— Marc S. Ryan

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