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May 10, 2024

DOJ Sets Up Antitrust Task Force The U.S. Department of Justice (DOJ) has set up a multi-disciplinary task force to examine healthcare monopolies and collusion. It will facilitate policy advocacy, investigations, and civil and criminal enforcement. #antitrust #mergers #acquisitions #manda https://www.fiercehealthcare.com/providers/justice-department-unveils-task-force-healthcare-antitrust-issues New Spending Regulation Could Force Consolidation In Home Care The new home care 80-20 requirement, which directs 80% of all Medicaid revenue to wages, could have an unseemly outcome.  Small mom-and-pop shops may have to sell off to private equity firms and large home care companies due to the onerous nature of the regulation. (Article may require a subscription.) #nursinghomes #homecare #medicaid https://www.modernhealthcare.com/providers/medicaid-80-20-rule-home-care-consolidation Biden Administration To Propose Cybersecurity Standards The Biden administration will require hospitals to meet minimum cybersecurity standards as an outcome of the Change Healthcare cyberattack.  Ascension, a large hospital chain, just suffered a cybersecurity incident that impacted multiple systems, including its electronic health records. In addition,

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May 9, 2024

CHS Sues MultiPlan Arguing Conspiracy With Health Plans To Fix Commercial Rates Hospital giant Community Health Systems has filed a lawsuit arguing the data analytics firm MultiPlan has conspired with health plans to fix commercial rates in violation of antitrust rules. Visit my blog on the controversy: https://www.healthcarelabyrinth.com/out-of-network-provider-billing-is-yet-another-provider-attack-issue-against-plans/ (Article may require a subscription.) #antitrust #healthplans #providers https://www.modernhealthcare.com/legal/community-health-systems-chs-multiplan-lawsuit Medicare-Medicaid Integration Could Have Pitfalls For Some MA Plans Good article on the evolving mandates to force integration between Medicare and Medicaid.  The Centers for Medicare and Medicaid Services (CMS) has passed several rules that will bring the programs together.  Some Medicare Advantage (MA) plans do not look terribly well-placed to succeed, while others with big Medicaid membership do.  Either way, it will be a huge transformation. (Article may require a subscription.) #snps #specialneedsplans #medicareadvantage https://www.modernhealthcare.com/insurance/medicare-advantage-medicaid-dsnp-centene-molina Medicare PA Bill To Be Reintroduced A bipartisan bill that would levy more prior authorization reform and

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May 8, 2024

Possible Cyberattack At Ascension Catholic hospital system Ascension may have been a victim of a major cyberattack.  It runs 139 hospitals and 40 senior living facilities across the country. Additional article: https://www.modernhealthcare.com/cybersecurity/ascension-possible-data-breach-cyberattack (Some articles may require a subscription.) #cyberattacks https://www.fiercehealthcare.com/providers/systems-clinical-operations-interrupted-ascension-amid-apparent-cybersecurity-event House Ways And Means Passes Telehealth Extension The House Ways and Means Committee passed a two-year extension of telehealth and a five-year addition to the hospital at home waiver. Some pharmacy benefits manager reforms were used as pay-fors. Additional article: https://www.modernhealthcare.com/politics-policy/telehealth-rules-waiver-extension-congress (Some articles may require a subscription.) #telehealth #pbms #hospitalathome https://www.fiercehealthcare.com/regulatory/house-ways-means-committee-reveals-two-year-telehealth-extension-legislation Clover Health Improves Financial Results Clover Health improved its financial performance with a $23 million loss. It also authorized a buyback program.  Clover is one of a few insurtechs doing well, including Alignment, Devoted, and Oscar. #cloverhealth #medicareadvantage https://www.fiercehealthcare.com/payers/clover-health-authorizes-20-million-share-buyback-program Private Equity Healthcare Activity Slowing A new study says private equity investments in healthcare is slowing due to the increased

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May 7, 2024

Telehealth and Hospital At Home Extensions Coming The House Ways and Means Committee may pass a 2-year extension of telehealth as well as a 5-year extension of hospital at home. It would be paid for by some more moderate pharmacy benefits manager (PBM) reforms, including PBM transparency reporting and income based on service fees only. Additional article: https://insidehealthpolicy.com/inside-drug-pricing-daily-news/wm-uses-patchwork-pbm-reforms-pay-telehealth-extenders-bill (Some articles may require a subscription.) #pbms #hospitalathome #telehealth #medicare https://www.fiercehealthcare.com/regulatory/house-ways-means-committee-reveals-two-year-telehealth-extension-legislation Oscar Reports First Quarterly Profit And Low MLR Former Aetna CEO and new Oscar CEO Mark Bertolini has shaken up the financial performance of Oscar Health.  For the first time, Oscar has reported a quarterly profit and it projects a positive margin in 2024. A 42% increase in its Exchange enrollment was reported.  It will exit an alliance with Cigna concerning small group plans. It reported a rough 74% Q1 medical loss ratio and expects to come in right around the

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May 6, 2024

Medicare Part A Trust Fund Has A Bit More Life The Medicare Part A Insurance Trust Fund will be solvent for longer than previously projected says the annual Medicare Trustees report. While there are “significant financing issues,” the program will be able to pay all scheduled benefits until 2036, five years longer than the last report. No one can take policy credit (even though the Biden administration will try to do so) for meaningfully adding years to Medicare’s life.  It is all related to technical issues and occurrences. The truth is no party has a coherent policy to stabilize Medicare or entitlements for that matter. Benefit cuts or tax increases will be big if nothing is done. Additional articles: https://www.beckershospitalreview.com/finance/medicares-financial-picture-brightens-slightly.html and https://thehill.com/policy/healthcare/4647137-medicare-fund-economy-solvent-yellen/ #medicare #entitlements #healthcare https://www.fiercehealthcare.com/payers/medicare-hospital-trust-fund-extended-five-years-2036 States Jumping In To Scrutinize Private Equity Investments Where the feds have failed, states are increasingly jumping in to scrutinize private equity firm investments in

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May 3, 2024

Biden Administration Rule Makes DACA Dreamers Eligible For Exchanges Under a new rule, the Centers for Medicare & Medicaid Services (CMS) will make the Deferred Action for Childhood Arrivals (DACA) or dreamers eligible for Exchange enrollment. There are hundreds of thousands of Dreamers and the administration estimates that 100,000 will enroll. Additional articles: https://www.fiercehealthcare.com/regulatory/daca-recipients-eligible-obamacare-under-cms-rule and https://www.modernhealthcare.com/politics-policy/biden-obamacare-access-daca-affordable-care-act-hhs-xavier-becerra (Some articles may require a subscription.) #exchanges #aca #obamacare https://thehill.com/latino/4639985-biden-obamacare-dreamers-affordable-care-act-daca/ Cigna Says Employer Groups Increasing Coverage Of Weight-Loss Drugs In its investor call, Cigna indicated that more and more employer groups are covering weight-loss drugs. The penetration has increased to about 50%. Larger employers tend to cover these high-cost drugs. #weightlossdrugs #drugpricing #branddrugmakers https://www.beckerspayer.com/payer/cigna-more-employers-covering-weight-loss-drugs.html CVS Buys MA Broker Hella Health CVS has acquired a startup Medicare Advantage (MA) broker based in New York City, Hella Health.  The move is thought to help CVS get a better handle on the quality of the upstream enrollment

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May 2, 2024

Alignment Healthcare Reports Growth In Members But Continued Losses Alignment Healthcare will report 165,000 increased enrollment at its Q1 2024 investor call, but a loss from operations of $41.1 million. This still means the insurtech likely is on its way to profitability. #alignmenthealthcare #medicareadvantage https://www.fiercehealthcare.com/payers/alignment-healthcare-raises-membership-guidance-posts-466-million-loss Hospital Margins Dip In March, But Still Positive For Quarter Hospitals’ margins and revenues took a dip in March, but they still had a strong Q1 2024. #hospitals https://www.fiercehealthcare.com/providers/hospital-finance-metrics-stumble-march-remain-strong-through-q1 Medicaid Disenrollments Exceed Forecasts In Eight States A new study gives a good picture of Medicaid disenrollments with the return of redeterminations. The Robert Wood Johnson Foundation-funded Urban Institute report found Medicaid and Children’s Health Insurance Program (CHIP) enrollment declined by 9 million people from April through November 2023. This outcome is expected except that there is some variability between states. Eight states well exceeded forecasted disenrollments: Arkansas, Idaho, Iowa, Montana, New Hampshire, Oklahoma, South Dakota

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May 1, 2024

Stunning Admission By United HealthGroup CEO It was the roasting that was expected, with both sides of the aisle attacking Andrew Witty when he appeared on Capitol Hill.  The United HealthGroup CEO made a stunning admission when he said that Change Healthcare had legacy architecture and technology based largely on internal data centers. It says it is rebuulding all of it on a cloud-based, modern infrastructure. This alone substantiates a lack of business continuity and disaster recovery readiness. In the last few days, United also admitted that simple multi-factor authentication was not in place and that is how the cyber criminals got into the Change platforms. The testimony adds to my theory that when massive consolidation occurs, technology is not modernized and as I call it “spaghetti-ed together.”  The testimony will lead to additional scrutiny of United, a review of vertical integration and consolidation in healthcare, as well as more

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April 30, 2024

A Peak At United HealthGroup CEO’s Planned Testimony The United HealthGroup CEO plans on giving detailed testimony this week on Capitol Hill.  His testimony outlines how the cyberattackers got in, which may point to a security flaw in Change Healthcare’s system. United has funneled $6.5 billion to providers impacted so far. Additional article here: https://www.modernhealthcare.com/politics-policy/unitedhealth-andrew-witty-congress-change-healthcare-outage (Some articles may require a subscription.) #changehealthcare #cyberattacks https://www.fiercehealthcare.com/payers/unitedhealth-ceo-witty-set-go-congress-week-heres-look-his-testimony Walmart To Exit Primary Care Market Shocking announcement by Walmart that it will exit the primary care health market, including virtual care, as it has not been profitable.  It will close its Walmart Health locations that have opened.  At one time “retail meets healthcare” was thought to be the future for many retail companies.  While there have been some successes, there are also big failures.  This exit could change many plans to tie healthcare settings to retail ones. In related news, the Walmart co-branded Medicare Advantage

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April 29, 2024

New Study Recommends Health-Related Tiering For Access To GLP-1s A new study recommends a tiering of GLP-1 medication access based on health status. The problem is the price of the drugs are exorbitant compared with other developed countries. And wide access to the drugs is often only available in richer health plans. As such, the reasonable proposal is destined for the ash heap for now. #weightlossdrugs #branddrugmakers #drugpricing https://www.fiercehealthcare.com/regulatory/heres-what-fair-allocation-glp-1s-and-other-weight-loss-drugs-could-look Association Health Plans Will Be Barred Under New Rule The Department of Labor (DOL) is expected to release a final rule that will bar Association Health Plans that were put into effect under the Trump administration. The move was a gimmick to make it look like the GOP had a reasonable alternative to the Affordable Care Act (ACA). It didn’t. Additional article: https://insidehealthpolicy.com/daily-news/admin-rescinds-ahp-rule-coalition-backs-senate-bill (Some articles may require a subscription.) #obamacare #aca https://www.fiercehealthcare.com/payers/dol-set-reverse-trumps-association-health-plan-policy New Class-Action Lawsuit Against MultiPlan And Major Insurers A new

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