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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 its 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. 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 https://www.fiercehealthcare.com/payers/supreme-court-declines-hear-challenge-27b-bcbs-settlement HHS Finalizes Info-Blocking Rule The Department of Health and Human Services (HHS) finalized a rule on information blocking under interoperability, outlining penalties for hospitals, providers, and accountable care organizations. Additional articles: https://www.modernhealthcare.com/policy/ehr-information-blocking-rule-ban-hhs (Some articles may require a subscription.) #interoperability #healthcare https://www.fiercehealthcare.com/regulatory/hhs-finalizes-info-blocking-disincentives-hospitals-clinician-groups-acos Employers And Health Plans Have

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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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June 19, 2024

Hold Harmless Provision Change In Star Would Cost Plans Dearly A Modern Healthcare article speaks to the fact that highly rated Medicare Advantage plans could lose billions in Star dollars if a change to the hold harmless provision for the quality improvement measures is changed.  I will have a LinkedIn post tomorrow on this and other changes the Centers for Medicare and Medicaid Services (CMS) could make to save dollars. (Article may require a subscription.) #medicareadvantage #stars #cms https://www.modernhealthcare.com/insurance/medicare-advantage-star-ratings-centene-molina-bonuses White House Espouses Drug Purchaser Incentives And Penalties To Help Curb Drug Shortages A White House official pointed to a lack of transparency in the drug supply chain, concentrations of supply, and issues at manufacturing facilities for drug shortages. But the official correctly also noted that drug buyers, such as hospitals, should be incentivized (and penalized) to examine ways to procure from high-quality manufacturers and protect against shortages (including buffer stocks).

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June 18, 2024

Major Developments In Direct To Consumer Pharmacy Market Two major developments in the direct-to-consumer pharmacy market. A study published in the JAMA Health Forum suggests that most people that are insured are better off going through their insurance than through Mark Cuban’s Cost Plus Drug Company, although some deals are better for certain medications for the insured and those uninsured benefit.  I am not sure the purpose of the story. Of course, insurance should be a better deal than not going through insurance.  But the fact is that often Cuban’s outfit can offer better deals due to the opaqueness of the drug supply channel. The fact that 100 million of 844 million prescription fills (of 124 generic drugs) would have been cheaper under Cuban’s paradigm than insurance proves the system needs reform. Cuban is on to something. In other news, Amazon Pharmacy has extended Amazon Pharmacy Rx Pass membership to

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June 17, 2024

Scan CEO Right On MA and FFS Scan CEO Sachin Jain, MD is one of the brightest minds in healthcare.  He has the right outlook on Medicare Advantage (MA) – it does a lot that is good but also needs reform.  In addition, he rightfully is asking why the traditional fee-for-service (FFS) program does not face reasonable scrutiny for its over-utilization. #scan #medicare #medicareadvantage https://www.fiercehealthcare.com/payers/ahip-2024-cutting-through-nostalgia-traditional-medicare More On CMS’ Recalculation Of MA Stars Additional information is coming out on the recalculation of Medicare Advantage (MA) Stars for 2024.  CMS is expected to have to pay out at least $1.3 billion in additional bonus payments in 2025 for 2024 Stars. (Article may require a subscription.) #medicareadvantage #stars #cms https://www.modernhealthcare.com/medicare/2024-medicare-advantage-star-ratings-elevance-aetna-scan House GOP Grills Medicare Innovation Director House Energy and Commerce Committee Republicans grilled the Centers for Medicare and Medicaid Services (CMS) innovation center director on the financial track record of Medicare reform pilots.

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June 14, 2024

New Study Suggest FTC Scrutiny Of Hospital Mergers Is Meager A new study says the Federal Trade Commission’s (FTC) scrutiny of mergers is low and mergers lead to increased prices. Part of the issue is low funding for the FTC. (Article may require a subscription.) #ftc #manda #mergers #acquisitions #hospitals https://www.modernhealthcare.com/mergers-acquisitions/antitrust-enforcement-falls-short-hospital-mergers-study More On 2024 MA Star Recalculations Additional articles on the Centers for Medicare and Medicaid Services (CMS) decision to recalculate Star scores for 2024 and reopen bids for those who received higher scores. Reports suggest 76 contracts with 44 health insurers would gain at least 0.5 Stars. This could mean an additional $1 billion in revenue to plans, which goes out to members in added benefits. Some big plans receive additional dollars. Additional article: https://www.fiercehealthcare.com/payers/report-medicare-advantage-quality-ratings-get-new-calculations #medicareadvantage #stars #cms https://www.healthcaredive.com/news/cms-recalculates-medicare-advantage-star-ratings/718967 Are Lawmakers Serious On Stabilizing Medicare? Members on each side of the aisle on the House Budget Committee said they

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June 13, 2024

CMS To Recalculate 2024 Medicare Advantage Star Ratings After losing two lawsuits on their methodology, the Centers for Medicare and Medicaid Services announced it has recalculated 2024 Star measures for Medicare Advantage (MA) plans.  It will give plans that saw increases a short window to revise 2025 plan bids and benefits that have already been submitted. Additional article here: https://insidehealthpolicy.com/daily-news/scan-cms-recalculate-ma-star-ratings-rebidding-process-come (Some articles may require a subscription.) #medicareadvantage #stars #cms https://www.beckerspayer.com/payer/cms-to-recalculate-medicare-advantage-star-ratings-report.html Major MedPAC Recommendations In Annual Report MedPAC, the congressional policy arm for Medicare, issued its annual report today. It analyzes and makes recommendations for reforming Medicare physician pay, prior authorization in Medicare Advantage (MA), and MA encounter data. I will do an in-depth blog in the near future on the MA recommendations. (Article may require a subscription.) #medpac #medicare #providers #medicareadvantage #healthplans https://insidehealthpolicy.com/daily-news/medpac-june-report-examines-physician-fee-pay-prior-auth-irf Progressive Warns Of Medicare Drug Negotiation Repeal The Center for American Progress (CAP), a progressive policy group

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June 12, 2024

National Healthcare Spending Projections The Centers for Medicare & Medicaid Services (CMS) Office of the Actuary released its annual re-estimates of spending over a 10-year horizon.  While 2023 healthcare expenditures will be finalized in December, current estimates are that national healthcare spending grew by 7.5% in 2023 to about $4.8 trillion, or 17.6% of gross domestic product (GDP). Part of the costs were record coverage. Medicare spending is projected to have grown 8.4% in 2023, with costs over $1 trillion. Private health insurance spending is expected to have increased 11.1%.  Medicaid spending is expected to have grown by 5.7%.  This is lower due to dropping enrollment. National health expenditures will rise to $7.7 trillion and capture nearly one-fifth of the U.S. economy by 2032. I will have a blog next week digging into all the stats. Additional articles: https://www.modernhealthcare.com/policy/national-health-spending-projected-reach-77t-2032-cms and https://www.healthcaredive.com/news/national-healthcare-spending-growth-cms-report/718718/ and https://www.cms.gov/newsroom/press-releases/cms-releases-2023-2032-national-health-expenditure-projections (Some articles may require a subscription.)  #healthcare

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June 11, 2024

More Information On Elevance Health Star Lawsuit Win Yesterday we told you about Elevance Health’s win in court on the 2024 Star calculations.  Other healthcare publications have written stories today.  The pressure is on the Centers for Medicare and Medicaid Services (CMS) to respond.  I have also linked the lawsuit below. Additional articles: https://www.modernhealthcare.com/insurance/elevance-medicare-advantage-star-ratings-lawsuit-cms and https://www.beckerspayer.com/payer/elevance-health-gets-partial-victory-in-star-ratings-lawsuit.html#:~:text=The%20judge%20ruled%20partially%20in,only%20for%20BCBS%20of%20Georgia.  and https://www.healthcaredive.com/news/elevance-wins-medicare-advantage-star-ratings-lawsuit-hhs/718550 Opinion: https://www.documentcloud.org/documents/24740919-elevance_becerra_6724_order (Some articles may require a subscription.) #medicareadvantage #stars #cms https://www.fiercehealthcare.com/payers/elevance-health-earns-partial-win-legal-fight-over-ma-star-ratings Hospitals Raise Issues With Medicare Rate Hike And Requirements Hospitals pushed back on the Centers for Medicare and Medicaid Services’ (CMS) proposed regulatory changes and rate hikes. Hospitals raised concerns about new quality reporting requirements and changes to medical residency training programs.  It claimed the 2.6% rate hike was inadequate. At the same time, hospitals are opposing site-neutral payments, which would save the system and patients huge sums. #hospitals #medicare https://www.fiercehealthcare.com/providers/hospital-groups-push-back-cms-woefully-inadequate-inpatient-pay-bump-fy2025 Humana Finds VBC Payments Impact Kidney Care Humana has

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