antitrust

BCBSA Antitrust Settlement Is Bad For Healthcare Competition

This past week, the Supreme Court announced that it declined to hear a case challenging the anti-trust settlement between employer groups and Blue Cross and Blue Shield (BCBS) licensee plans nationwide as well as its association (BCBSA). While no wrongdoing was admitted, BCBS plans were accused of anti-competitive behavior in the employer market by limiting employer group contracts to so-called “home plans” as well as the product options offered. It will pay a substantial settlement and must change some of the association’s practices. You could argue the decision is a small step forward, but the decision shows what is so demonstrably wrong with competitiveness in healthcare in America. It upholds the power of entities acting as an effective monopoly in America and the fallout could even foster further consolidation of health insurers. What are the Blues? The so-called Blues plans originated back in the early 20th century when alliances of

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June 28, 2024

Supreme Court Takes Out Chevron Deference In an expected move, the Supreme Court ruled that the Chevron deference precedent is no more. It has pulled back on the precedent and has now thrown it out.  The precedent said that courts must give deference to regulatory agencies when they make reasonable interpretations of ambiguous laws. Proponents of deference said that it is a necessary power of regulatory agencies and that its elimination will now lead to a Wild West of court decisions in the future. Opponents argued that it created an administrative state that was far-reaching and one that went well beyond legislative intent. I will write a blog on the possible implications for healthcare.  The removal of the deference rule does not change the fact that the Centers for Medicare and Medicaid Services (CMS) has often just got its regulations wrong or ignored them entirely. But it does have vast implications

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June 27, 2024

Walgreens’ Bleeding Continues Walgreens’ stock fell 24% as the drugstore chain slashed its profit outlook. It will reduce the size of its pharmacy footprint and continue to evaluate and right size its investment in VillageMD, primary care clinics tied to retail settings. Additional articles: https://www.healthcaredive.com/news/walgreens-to-reduce-villagemd-stake-close-stores/719984/ and https://www.modernhealthcare.com/providers/walgreens-villagemd-ownership-majority-stake and https://www.modernhealthcare.com/providers/walgreens-boots-alliance-shares-drop-store-closings-ceo-tim-wentworth (Some articles may require a subscription.) #walgreens #retailmeetshealthcare #primarycare https://www.fiercehealthcare.com/providers/walgreens-slashes-profit-guidance-plans-close-more-pharmacy-stores-turnaround HHS, FBI Issue Cyberattack Warning The Department of Health and Human Services (HHS) and Federal Bureau of Investigation (FBI) issued a warning to healthcare entities on cyber criminals’ phishing and ransomware. (Article may require a subscription.) #cyberattacks #healthcare #providers https://www.modernhealthcare.com/digital-health/hhs-fbi-phishing-ransomware-attack-advisory Insurers Have Opaque Requirements Even If They Cover GLP-1s For Weight Loss Insurers are being accused of being vague on requirements that need to be met if the insurance plans cover GLP-1s just for weight loss.  Coverage criteria is sometimes vague, but where is the widespread coverage of the obscene costs

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Strong Growth From May to June In Medicare Advantage

As noted last month, I decided to continue my Medicare Advantage (MA) monthly enrollment blogs because of continuing strong month-over-month increases. Admittedly, the continuing growth is tied to remaining strong benefit packages for 2024 and appears to be isolated to a few big plans. Many plans will rein in benefits and geographies for contract year 2025 due to significantly deteriorating bottom lines. This is being caused by the return of robust utilization, inflation picking up in the healthcare sector (especially at hospitals), poor Star scores, negative rate increases for 2024 and 2025, and new regulatory burdens (such as the new prior authorization restrictions). The recent 2024 Star recalculation, which was precipitated by losses in court by the Centers for Medicare and Medicaid Services (CMS), will mean some plans refile bids and benefits for 2025.  But we are hearing great reluctance to refile by many due to the quick deadlines, the negative

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June 26, 2024

Quarterly Drug Inflation Rebate Caps Save More Dollars For Medicare And Enrollees The Centers for Medicare & Medicaid Services (CMS) announced 64 new drugs subject to quarterly caps because price increases exceeded allowable inflation. This will mean additional rebates and lower out-of-pocket costs for 750,000 enrollees. The provision was passed as part of Medicare drug price negotiations in the Inflation Reduction Act (IRA). In addition, states increasingly are passing protections on drug manufacturers limiting 340b discounts to certain providers.  This came after the Supreme Court upheld such state laws. I do not agree generally with the ruling as it perpetuates an abuse of 340b’s intent. Additional articles: https://thehill.com/policy/healthcare/4740963-biden-lower-prescription-drug-costs-medicare-inflation-reduction-act/ and https://www.modernhealthcare.com/supply-chain/340b-drug-program-discounts-arkansas-missouri-laws Press Release Here: https://www.cms.gov/newsroom/press-releases/hhs-announces-cost-savings-64-prescription-drugs-thanks-medicare-rebate-program-established-biden (Some articles may require a subscription.) #drugpricing #ira #medicare #partd #pdp #medicareadvantage https://www.fiercehealthcare.com/payers/hhs-lowers-64-prescription-drug-prices-under-medicare-rebate-program Sen. Wyden Wants CMS To Protect Small Independent Pharmacies Senate Finance Chair Ron Wyden, D-OR, is asking the Centers for Medicare & Medicaid

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June 25, 2024

Security Group Rates Healthcare Cyber Readiness SecurityScorecard gave healthcare a “B+” in cybersecurity, but some healthcare organizations had low ratings despite the group concluding that ratings were “higher than expected.” I tend to think that ratings are a bit inflated, but nonetheless it is a good service for the nation. #cyberattacks #healthcare https://www.fiercehealthcare.com/health-tech/report-90-healthcare-orgs-get-b-cybersecurity-medical-devices-fall-below-mark Bipartisan Group Of Lawmakers Wants Greater MA Restrictions On AI Use A bipartisan group of senators and representatives are back at it, touting the agenda of provider lobbies.  The group sent a letter to the Centers for Medicare and Medicaid Services (CMS) asking the agency to rein in the use of AI in prior authorizations and to potentially suspend the use of internal criteria until such time CMS rules can be written. Additional articles: https://www.modernhealthcare.com/politics-policy/medicare-advantage-ai-restrictions-prior-authorization and https://insidehealthpolicy.com/daily-news/congress-cms-step-oversight-ai-algorithms-ma-prior-authorization and https://www.beckerspayer.com/policy-updates/tougher-rules-needed-for-medicare-advantage-ai-51-lawmakers-say.html and https://thehill.com/policy/healthcare/4739152-bipartisan-lawmakers-increased-ai-oversight-medicare-advantage-coverage/ (Some articles may require a subscription.) #ai #medicareadvantage #priorauthorization https://www.statnews.com/2024/06/25/medicare-advantage-ai-tools-denial-unitedhealth-lawmawkers-cms/ Analysis Of ACA Preventive Services Lawsuit

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June 24, 2024

Supreme Court Declines To Hear BCBS Antitrust Case The Supreme Court declined to hear a case challenging the anti-trust settlement between the federal government and BCBS plans nationwide.  While no wrongdoing was admitted, BCBS plans were accused of anti-competitive behavior in the employer market because it limited employers to contracting with BCBS entities in their headquarters’ area and required a threshold for Blues revenue. The appeals court argued the settlement does not preclude future actions. The high court agreed. Several employers argued the settlement was not enough and that it did preclude certain actions over time. I will be writing about this soon. While the settlement was somewhat of a defeat for the Blues and its association, it actually tends to underscore the anti-competitive aspects of the broader healthcare market and protects the Blues. Additional articles: https://www.modernhealthcare.com/legal/supreme-court-bcbs-settlement-home-depot and https://www.beckerspayer.com/payer/supreme-court-rejects-home-depots-challenge-to-2-7b-bcbs-settlement.html (Some articles may require a subscription.) #bcbsa #blues #healthcare #coverage #employercoverage

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What Do The Latest Healthcare Spending Projections Tell Us?

The latest forecasts from the Centers for Medicare and Medicaid Services (CMS) Office of the Actuary continue to show how out of control America’s healthcare spending is. Each June, the CMS Actuary re-estimates healthcare spending for the coming decade. The latest estimates continue to show a system that is badly in need of reform. While final figures for 2023 will come in December, the latest estimate on 2023 healthcare spending shows it will reach about $4.8 trillion or 17.6% of gross domestic product (GDP). That is up from $4.46 billion or 17.3% in 2022. That is a growth of 7.6% from 2022 to 2023. The major growth was in part related to the high insured rate of 93.1% due to the COVID flexibilities. While Medicaid redeterminations began again in April of 2023, the insured rate remained high in 2023. Medicare spending hit a milestone by growing 8.4% in 2023 and

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June 21, 2024

Mixed Bag Court Decision On Preventive Services Mandate A Federal Appeals Court issued a mixed-bag ruling on whether free preventive services will continue in the Affordable Care Act (ACA).  It upheld a lower court ruling finding that the government could not compel a Christian-based business to cover certain services that violate its religious beliefs.  At the same time, it struck down the lower court’s bar on enforcement of preventive services nationwide and returned the future of the preventive services mandate back to a lower court. Additional article: https://thehill.com/policy/healthcare/4733629-obamacare-preventive-care-mandate-to-stay-in-place-after-court-ruling/ #aca #obamacare #exchanges #healthcare #coverage #healthcarereform https://www.fiercehealthcare.com/payers/mixed-bag-fifth-circuit-rules-aca-preventive-services-legal-case AI PA Tech Startup Receives Huge Health Plan Backing Humata Health, a prior authorization startup, closed a $25 million funding round, gaining backing from prominent health plan concerns. Blue Venture Funds (a capital fund associated with the majority of Blue Cross Blue Shield plans), United’s Optum Ventures, and Highmark (a PA Blue) Ventures all backed the

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June 20, 2024

Change Healthcare Begins Breach Notification Process Change Healthcare began reaching out to clients who had data compromised in the ransomware attack and breach that brought much of the healthcare system to a standstill earlier this year.  Compromised data includes personal and health information. The breach hit a substantial portion of Americans. An additional article points to the great vulnerability of hospitals to cyberattacks. Additional articles: https://kffhealthnews.org/news/article/hospitals-cyberattacks-ascension-patient-care/ and https://www.modernhealthcare.com/cybersecurity/change-healthcare-data-breach-cyberattack-notification (Some articles may require a subscription.) #changehealthcare #cyberattacks https://www.fiercehealthcare.com/payers/optums-change-healthcare-responding-cybersecurity-issue WHO Says Fake Weight-Loss Drugs Circulating The World Health Organization (WHO) indicates that there are fake GLP-1 weight-loss drugs circulating in the world. (Article may require a subscription.) #weightlossdrugs #drugpricing https://www.modernhealthcare.com/legal/fake-ozempic-europe-us-brazil-who FDA May Usher Interchangeability Of Biosimilars Quickly The Food and Drug Administration (FDA) is seeking guidance on its proposal to eliminate switching studies to gain interchangeable status. If completed, it would help promote adoption of lower-cost biosimilars. (Article may require a subscription.)

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