November 28, 2023

Innovation In State And Federal ACA Exchange Programs

Interesting article on policy brief from the Commonwealth Fund on various innovations occurring in the state-based and federal Exchange programs.  As of 2023, 20 states operate a state-based marketplace and 30 rely on Healthcare.gov for sign-ups. Some state-based exchanges use the federal website for enrollment.

States are experimenting with enrollment campaigns, simplified enrollment, auto-enrollment programs, health-equity requirements, and more. 

Article at link.  The actual study is here: https://www.commonwealthfund.org/publications/issue-briefs/2023/nov/policy-innovations-affordable-care-act-marketplaces

#aca #obamacare #exchanges #commonwealthfund

Link to Article

Mark Cuban’s Firm Partners With Expion

Mark Cuban’s Cost Plus Drugs (CPD) is partnering with Expion to tackle the high costs of specialty drugs.  A press release says CPD will integrate into Expion’s dynamic pricing technology. It says “consumers can be confident they are getting a fair price and the convenience of medication mailed directly to their homes.” 

#cuban #costplusdrugs #drugpricing #expion

Link to Article

Healthcare Bankruptcies Soar

Healthcare entity bankruptcies soar, with many things impacting success. Forty companies with more than $10 million in liabilities have filed for various forms of bankruptcy in the first six months of 2023. Despite financing and innovation, the sector is not without risk.

The article calls out five notable bankruptcies and why they ran into trouble:

  • Envision Healthcare – primarily due to the No Surprises Act’s delayed and lower payments.
  • American Physician Partners – for similar reasons to the above
  • Rite Aid – squeezed between CVS and Walgreens as well as opioid settlement lawsuits.  It is selling PBM Elixir.
  • Babylon – uncertainties on AI
  • Pear Therapeutics – lack of uptake on its digital health apps

#ai #bankruptcies #innovation #healthcare #healthtech

Link to Article

Part D Changes In The Inflation Reduction Act Final Rule

Inside Health Policy has a good article on the final rule for various changes to the Part D program in the Inflation Reduction Act (IRA). The IRA eliminates the coverage gap in 2025 by shifting from the current coverage gap discount program to a new manufacturer discount program. In addition, cost-sharing in the catastrophic phase is eliminated.  In essence, the manufacturers’ discounts become available in both the initial and catastrophic phases and lowers plans’ liability on the negotiated price of drugs. (May require subscription.)

#partd #drugpricing #medicareadvantage #medicare

Link to Article

More On Provider Complaints on MA Plans Skirting CMS’ New PA Rule

More on the controversial Centers for Medicare and Medicaid Services (CMS) rule that eliminates outside evidence-based criteria in favor of Medicare Advantage (MA) plans using traditional Medicare program guidance. I wrote about this in an earlier newsfeed.  This is covered again in this article. 

More specifically, this article reviews the two-midnight rule. Under the traditional Medicare program, a hospital is entitled to reimbursement for an inpatient stay if the admitting physician has a reasonable expectation that the patient would stay for acute care spanning two midnights. Providers say MA plans are currently retroactively reviewing certain days for medical necessity and denying them or paying at observation day rates. Providers say plans will continue to do so despite the rule. See also the following opinion piece on the subject and proposals from the Federation of American Hospitals (FHA): https://www.modernhealthcare.com/opinion/improving-medicare-advantage-plans-prior-authorization-federation-american-hospitals . (May require subscription.)

#hospitals #medicare #medicareadvantage #priorauthorization #claimsdenials

Link to Article

Are 340B Discounts Being Used For The Public Good?

Analysis seems to indicate that massive 340B drug discounts to hospitals are not being used for the care of low-income patients, but to buy physician practices, open up medical sites in upper income areas, etc. I am of two minds here. I agree with anything that reduces drug prices and reins in big pharma. On the other hand, the 340B program does not seem very accountable and needs to be reformed.

#340b #drugpricing

Link to Article

Democrats Pounce on Trump Comment on Repealing the ACA

Democrats have pounced on former President Donald Trump’s statement that he would like to repeal the Affordable Care Act (ACA). As a Republican, I agree with the Democrats. They are right in noting that about 40M have benefitted from healthcare coverage either through the expansion of Medicaid or creation of the Exchanges. There is no question that upfront coverage will save dollars down the road. (May require subscription.)

#aca #obamacare #exchanges #medicaid #healthinsurance

Link to Article

Center-Left Think Tank Unveils Smart Proposals to Finish ACA And Bring US Closer To True Affordable Universal Coverage

A center-left think tank, Third Way, has just unveiled a white paper and a series of proposals to finish the job of the Affordable Care Act (ACA). Although I am a Republican, I must be venturing to the center-left as I agree with most of the organization’s proposals. They think single payer is not a smart bet and most of their proposals are also in my book, The Healthcare Labyrinth (available to purchase at right). The organization says getting to affordable universal coverage will include:

— Provide subsidies for and cap out-of-pocket costs for additional income groups to make coverage more affordable. This would begin to tackle the huge problem of the underinsured. Many people simply cannot afford healthcare even if they are covered.

— Fix the coverage gap created by ten states that have not expanded Medicaid under the ACA. In these states, I say some are in a no-man’s land in terms of coverage. They are seemingly too rich for Medicaid but too poor for Exchange coverage.

— Auto-enrollment of people who clearly qualify for coverage in healthcare programs.

— Abolish medical debt. I agree — most of it is based on obscene provider billed charges or charge masters that have no basis in fact.

— Stop runaway costs in the traditional fee-for-service world.

— Invest in low-cost care, including primary care and alternatives to nursing homes, such as home care.

— Tackle health equity and social determinant barriers to care.

The white paper is a must read. It is short, simple, and reasonable.

#healthcarereform #healthinsurance #healthcare #coverage #thirdway #exchanges #aca #obamacare #chip #medicaid #medicare #universalaccess

Link to Article

Vox Notes That Some States Are Approaching Universal Access

Vox has a good article noting that some states are indeed approaching universal coverage. While the federal uninsured rate last reported in at about 8% (this will increase due to coverage losses through Medicaid redeterminations), at least half of the uninsured actually are eligible for coverage. As well, ten states have used the ACA and more to get close to what most would call universal access. In other developed nations, the uninsured rate is about 1%. Ten states have an uninsured rate below 5%. The article speaks to a number of innovations states have used.

#aca #exchanges #obamacare #universalaccess #healthcarereform #healthinsurance #coverage

Link to Article

Senate GOP Distanced Itself From Trump on Repealing the ACA

Thankfully, thoughtful Republican senators are distancing themselves from former President Donald Trump’s call to revisit the Affordable Care Act (ACA).

Some other articles on reactions to Trump’s ACA repeal comments:

Washington Post: https://www.washingtonpost.com/politics/2023/11/27/trump-repeal-obamacare/

New York Times: https://www.nytimes.com/2023/11/27/us/politics/trump-biden-obamacare.html

Axios: https://www.axios.com/2023/11/28/trump-obamacare-aca-alternatives-democrats-biden

(Some articles may require subscription.)

#aca #obamabcare #exchanges #medicaid

Link to Article

Excellent Suggestions On Fair Price Under IRA

The Health Affairs Forefront blog has an excellent blog on borrowing some good practices from other developed nations when setting fair prices in Medicare under the Inflation Reduction Act. I include some of these in my book, The Healthcare Labyrinth (available for purchase at right). While CMS plans a domestic reference pricing scheme against some or all drugs therapeutic alternatives in a therapeutic drug class, suggestions from the blog include looking beyond a given drug class, establishing a rating scale, including formal cost-effectiveness analyses (including both cost and benefit), and pushing for an amendment to the law to allow for a health assessment technology body. (May require a subscription)

#drugpricing #ira #medicare #medicareadvantage

Link to Article

Lawsuits On Insulin Prices

A growing number of states and localities are suing insulin makers and pharmacy benefits managers for conspiring to illegally drive up prices. (May require a subscription.)

#insulin #drugpricing #pbms #brandphrma

Link to Article

Small Business Healthcare Coverage No Longer Affordable

Good Kaiser Family Foundation (KFF) analysis concludes that healthcare coverage offered by 3.2 million small businesses to almost 50 million people is largely unaffordable due to premiums and required cost-sharing. This makes this group a part of the 85 million who are technically underinsured (includes uninsured). Some employees refuse the coverage and become uninsured.

#underinsured #uninsured #healthcare #healthinsurance #coverage #kff #smallemployer

Link to Article

— Marc S. Ryan

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