Health Tech Still Growing
Despite some notable failures in the health tech world and tightness in equity markets, deals and mergers continue. Two notable examples in this article.
Kaiser Sees Deep Drop in Star Scores
Kaiser Permanente saw deep drops in its Medicare Advantage Star scores for 2024, with four of its seven plans losing out on bonus payments (dropped below 4 Star). The CMO of Kaiser discusses this in the article below. Plans big and small suffered the past two years (2023 and 2024 Star Years). While achieving and maintaining high scores has always been a challenge, that a strong integrated system’s plans was a victim speaks volumes. You could always count on most Kaiser plans to be 5 Stars. Weighting, statistical changes, and new complex measures are catching plans by surprise. Based on the Stars road map, this will continue. Plans need data-driven solutions that allow them to constantly evaluate progress during the year (may require subscription).
#kaiser #medicareadvantage #partc #partd #stars #quality
Less Than Half Of Rural Hospitals Now Deliver Babies
Where are we as a nation when fewer than half of rural hospitals in the U.S. still offer labor and delivery care and hundreds more may bow out of deliveries due to financial challenges. We clearly have a price problem in the U.S., especially when it comes to hospitals. But we also have a crying need to solve the problem of rural healthcare as well as address health equity. There is more than enough money in the system even with savings to address these problems. But it starts with the will to debate comprehensive reform.
#hospitals #commercial #quality
More Bad News in Use of AI in Claims and PA Denials
United facing a lawsuit over NaviHealth’s use of AI algorithms to deny post-acute care services. This is not the first challenge on AI-driven algorithms and it won’t be the last (may require subscription).
#priorauthorization #claimsdenials #medicareadvantage
Express Scripts Offering Price Transparent Pricing
In an effort to respond to the growing push for price transparency in the PBM world, Cigna’s ESI is creating a “cost-plus” drug pricing model for its clients next year. Employers, health plans and government organizations will have the option to pay for prescription medications at their estimated acquisition costs, plus a fee of up to 15% of the drug’s cost and a flat pharmacy dispensing fee.
This may or may not net savings to the plans or employer groups but represents a reaction to what some of the PBM startups are trying to do as well as congressional demands for greater transparency (may require subscription).
Advocates Rail Against Medicaid Disenrollments
Advocates are railing against the massive procedural or administrative disenrollments occurring due to the return of redeterminations in the Medicaid program post the COVID pandemic. States are not ready for the process. Avalere now says that up to 30M could lose coverage, up from 15M to 17M in earlier studies. While that number may be very high, it appears enrollment losses will exceed 15M to 17M and our uninsured rate will leap as some folks will not transition to CHIP, Exchange, or employer coverage (may require subscription). Additional article on topic here ( https://thehill.com/policy/healthcare/4309364-drop-medicaid-enrollment/ ). KFF research on topic ( https://www.kff.org/medicaid/press-release/medicaid-officials-anticipate-sharp-enrollment-declines-and-increases-in-state-spending-on-medicaid-as-pandemic-era-policies-continue-to-unwind/ ).
#uninsured #uninsuredrate #medicaid #redetermintations #exchanges #chip #avalere #kff
House Passes CR Bill to Keep Government Open
The House late Tuesday (Nov. 14) passed a two-step continuing resolution (CR) to temporarily fund the federal government through early next year. This will ensure government programs, including healthcare, remain funded. The Senate will have no choice but to endorse the Speaker’s proposal. The bill passed with major dissenting Republican votes and was carried by Democratic votes (may require subscription).
AMA Wants All Insurers To Cover Weight Loss Drugs
The AMA wants all insurers and government programs to cover weight loss drugs. Diabetes treatments like Ozempic and Mounjaro have been used off-label for weight loss and the FDA is now clearing the ay for these drugs and others specifically for weight loss. While obesity is a real problem in America, insurers will want to go slow on these very expensive drugs.
#drugpricing #weightlossdrugs #AMA #commercial #medicare #medicaid
Biden Administration Wants Broader Coverage of HIV PrEP
The Biden Administration wants Medicare to cover both oral and injectable medications to those individuals at high risk of HIV infection. Physicians would make the determination of patients who could be considered to have greater risk of HIV infection. Certain HIV drugs are mandated as $0 copay drugs in the ACA. I was amazed to learn that nearly half of all Americans living with HIV are 50 years or older. The article also explains that HIV PrEP use uptake has been low.
#HIV #PrEP #medicare #medicareadvantage #partd #pdp
— Marc S. Ryan