Speaker Johnson Says Obamacare Not In Jeopardy
With control of the U.S. House coming down to a small number of the 435 seats in the chamber, House Speaker Mike Johnson said today that Obamacare is not on the so-called hit list. While he acknowledged that healthcare reform is certainly on the agenda, he did admit that the Affordable Care Act (ACA) is part of the healthcare fabric. He disputed Democrats’ campaign assertions that he wants to repeal the law, saying: “The ACA is so deeply ingrained. We need massive reform to make this work, and we’ve got a lot of ideas on how to do that.”
While Johnson said this, on the campaign trail Donald Trump and running mate JD Vance seem to indicate that they have a plan to introduce high-risk pools and move the adverse out of regular insurance pools. Vance later claimed he meant reinsurance would be introduced, leading me to think they really have no idea what alternative they really have as the two concepts are very different. The Harris campaign of course says the ACA is in jeopardy given Trump’s and the GOP’s past efforts to repeal the ACA.
#aca #obamacare #exchanges #speakerjohnson #harris #trump #election2024
https://thehill.com/homenews/house/4962432-johnson-republicans-obamacare-harris/?tbref=hp
Alignment Continues To Grow; Projects Positive Bottom Line Soon
Insurtech Alignment Healthcare reported strong membership growth and revenue for Q3. It had a net loss of $26 million but Medicare Advantage (MA) membership was up 57.7% year-over-year. Quarterly revenue was $692.4 million. Alignment will have an adjusted EBITDA loss of 10 million up to a gain of five million for the end of the year. It expects to be profitable in 2025 with $40 million in adjusted EBITDA.
Alignment was one of seven contracts to earn a 5 Star contract this year. Almost all of Alignment’s contracts are rated 4 Stars or better.
The company serves 8.7 million members in six states.
#alignmenthealthcare #medicareadvantage #star #cms
Beleaguered Humana Showing Positive Signs Financially
Medicare Advantage (MA)-dominant Humana reported $480 million in profit for the third quarter, down from $832 million a year ago. Revenue grew from $26.4 billion in the third quarter of 2023 to $29.4 billion in the third quarter of 2024. These figures beat the street.
Through the first three quarters, Humana had $1.9 billion in profit and $88.5 billion in revenue. By comparison, it reported $3 billion in profit and $79.9 billion in revenue through the first nine months of 2023.
Humana says it is righting its financial ship, investing in quality and Stars, and has sued the Centers for Medicare and Medicaid Services (CMS) over its 2025 Star ratings. It says 2025 profit will be at least in line with this year’s. But due to 2025 Stars, there is a greater risk it won’t return to its target margin in MA by 2027.
Humana had a very high 89.9% medical loss ratio in Q3.
Additional articles: https://www.beckerspayer.com/payer/humana-posts-480m-profit-in-q3.html and https://www.modernhealthcare.com/insurance/humana-earnings-call-medicare-ceo-jim-rechtin and https://www.healthcaredive.com/news/humana-medicare-advantage-boost-2024-guides-flat-2025/731410/
(Some articles may require a subscription.)
#humana #medicareadvantage
https://www.fiercehealthcare.com/payers/humana-updates-guidance-it-beats-revenue-profit-q3
Aetna Stops Broker Comp On Some MA and Part D Plans
Following Centene’s decision to stop compensation in standalone Part D PDP plans, Aetna announced today that it would stop compensating agents and brokers for enrolling Medicare recipients in certain Medicare Advantage (MA) plans and all PDPs. The move is yet another fallout from the major rate issues in MA and the impact of the Inflation Reduction Act’s Part D changes. The Centers for Medicare and Medicaid Services (CMS) continues to stay silent on the major impacts to millions of Medicare beneficiaries.
(Article may require a subscription.)
#agents #brokers #marketing #medicareadvantage #partd #aetna #centene
https://www.modernhealthcare.com/insurance/aetna-medicare-advantage-broker-commission-cuts
PBMs Go All-In On Specialty Pharmacy
Health plans and pharmacy benefits managers (PBMs) are making major investments in specialty pharmacy. The three Big PBMs are making major investments as specialty drugs now account for about half of all drug spend, even though scripts are a small percentage. The market will grow 8% to 12% a year.
PBMs argue their investments here could mean major savings for employers and other lines of business. Others argue that this is yet more vertical integration that has not saved but cost more money to the healthcare system.
(Article may require a subscription.)
#drugpricing #pbms
https://www.modernhealthcare.com/insurance/elevance-cigna-cvs-health-specialty-pharmacy
Is the Medicare Two-Midnight Rule In Effect?
Controversy continues to surround the implementation of the new Centers for Medicare and Medicaid Services (CMS) rule that requires Medicare Advantage (MA) plans to follow the traditional fee-for-service (FFS) coverage rules. One of the biggest impacts is on inpatient authorizations. MA plans now have to follow certifications from providers that inpatient care is needed based on a few criteria. MA plans cannot overrule the view of the doctor. Humana says it is abiding by the new rule and a CMS audit said so. Providers see some relief but believe PAs and denials are still too high.
Additional article: https://www.beckerspayer.com/payer/5-updates-on-the-2-midnight-rule.html
#priorauthorization #medicareadvantage #healthplans #providers #hospitals
Ozempic And Wegovy May Not Be In Shortage Anymore
The Food and Drug Administration’s (FDA) drug shortage list no longer shows any doses of Novo Nordisk’s blockbuster semaglutide GLP-1 diabetes and obesity treatments Ozempic and Wegovy in short supply. This could mean they are removed from the drug shortage list entirely if the brand company convinces the FDA the shortage has truly ended. This could mean the FDA could rule that compounders can no longer formulate the drugs in other forms or dosages.
In general, the FDA has poorly managed the drug shortage issues for GLP-1s. Eli Lilly’s tirzepatide GLP-1s Mounjaro and Zepbound were recently removed from shortage and compounders told they cannot formulate the drugs. After threatened suits from compounders, the FDA reconsidered its position that there was an adequate supply to cover those on treatments across all compounders and those using the brand drugs.
Compounders argue that an adequate period of time must be given to transition folks from formulated drugs to the brand. As well, compounders argue they may be able to continue formulating the drugs as they are creating compounds for the individual needs of patients.
Suffice it to say that lawsuits will fly. Compounders are doing a public service here as their prices are about a fifth or less of what the greedy brand drugmakers charge for GLP-1s. Given the unaffordability of a critical drug to treat disease states and obesity, I care little about arguments about patent infringement.
(Article may require a subscription.)
#glp1s #weightlossdrugs #drugpricing #branddrugmakers
https://www.statnews.com/2024/10/30/novo-nordisk-ozempic-wegovy-fda-available-or-in-shortage/
— Marc S. Ryan
