Bipartisan Support For 340B Reform
Senators on both sides of the political aisle expressed support for reforming the 340B drug discount program at a Senate HELP committee hearing today. While some expressed urgency for reform, others said that more caution needs to occur with reform to ensure rural facilities are not hurt.
While hospitals have defended their use of the discounts over the years, independent studies question whether discounts are used to benefit the needy and that pricing at 340B-eligible hospitals can be more than at those ineligible for the program. In addition, many say that non-profit hospitals get far more benefit in tax exemptions than given back to poor Americans and charity care.
Senators championed transparency around how revenue is generated in the program and how it is spent as well as more audit dollars. As well, senators want hospitals’ and other facilities’ aggressive debt collection practices curbed and more resources used for uncompensated and discounted care.
The Trump administration is pursuing some reform, including a voluntary pilot to convert the upfront discount to a retrospective rebate. Brand drug makers are endorsing and opting in to the pilot. Bloated hospitals of course hate the change and scrutiny. They are simply protecting their inefficiency and unaccountable empires.
#340b #drugpricing #branddrugmakers #hospitals
https://www.healthcaredive.com/news/help-senate-hearing-340b-reform/803630
Washington Post Finds Massive Increases In Exchange Premiums
Open enrollment for the Exchanges begins November 1 and The Washington Post says Exchange premiums will surge an average of 30%. Healthcare policy group has reported that average premium hikes will be 18%. They also find that subsidized individuals will see hikes of 114% in large part due to the expiration of enhanced Exchange subsidies.
#exchanges #coverage #healthcare #premiums
https://www.fiercehealthcare.com/regulatory/average-aca-premiums-set-30-spike-washington-post
The Controversy Around Phantom Enrollees In The Exchanges
The Paragon Institute has published several analyses that say that phantom enrollees, with zero claims, surged once the enhanced Exchange subsidies went into effect. Paragon says many of these enrollees were fraudulently enrolled by agents and brokers likely were unaware of their enrollment. At the same time, critics of Paragon argue that the analyses are either wrong or overhyped. They point to the fact that it is not uncommon to have a large percentage of individuals with no claims in a given year and that the younger, healthy folks who enrolled in recent years were prime candidates for low or no utilization. In addition, critics say zero-claims analyses show inflated results given plan switching during the year, especially due to longer open enrollments and other exceptions, and partial year enrollments.
Paragon found that in 2021, the percentage of enrollments without any medical claims was 19%. That percentage jumped to 35% in 2024. Critics point to an employer-sponsored insurance study that looked at data from 2018 to 2022. It found an average of 23% of enrollees didn’t use their health insurance.
I get the data that shows some people may not have claims in a given year and that young healthy people are prime candidates to be zero claims. But I still see the Paragon analyses as compelling. I don’t doubt that some younger people pushed the zero-claims count up from 19%, but it is hard to not see some cause (enhanced subsidies) and effect (fraudulent enrollment) to the 35% number.
Additional article: https://kffhealthnews.org/news/article/aca-marketplace-subsidies-tax-credits-insurance-federal-government-shutdown-fraud/
#exchanges #coverage #healthcare #premiums
Claims Scrutiny At Plans
Blue Cross Blue Shield of Massachusetts (BCBSMA) will expand its claims review process for potential overcoding among physicians who routinely bill for high-complexity visits. The reviews will apply to a small subset of clinicians whose billing patterns stand out from peers. BCBSMA will review evaluation and management (E & M) claims from providers who consistently bill visits at the highest complexity levels (4 and 5).
Elevance Health also will potentially penalize hospitals and other contracted facilities that use providers for surgeries and procedures who are not in-network. Facilities could face “an administrative penalty equal to 10% of the allowed amount of the facility’s claims that involve the use of nonparticipating care providers. The Elevance policy is not a bad idea given the problem of non-network physicians performing surgeries in in-network hospitals. This is a big generator of No Surprises Act disputes.
Additional articles: https://www.beckerspayer.com/policy-updates/bcbs-massachusetts-expanding-claims-reviews-to-target-provider-overcoding/ and https://www.beckerspayer.com/policy-updates/anthem-may-penalize-hospitals-10-for-using-out-of-network-providers/
(Some articles may require a subscription.)
#bcbsma #elevancehealth #claimsdenials #healthplans
https://www.modernhealthcare.com/insurance/mh-elevance-health-out-of-network-care-penalties
— Marc S. Ryan
