coding

S&P Sings The Blues Of Hospitals – But Here Is the Other Side Of The Story Financial firm and rater S & P Global is bemoaning the potential impact of Medicare Advantage (MA) on hospitals. It says in a new report that extended utilization increases could force MA plans to further rein in payments to providers. It also notes that the further expansion of MA hurts hospitals and providers too due to prior authorization (PA) and claims payment delays and practices. Thus, provider margins will be under pressure. And while the provider lobbies got a huge win when the Centers for Medicare and Medicaid Services (CMS) directed MA plans to follow traditional inpatient admission rules, S & P says MA plans could seek to recoup the costs with further restrictions. I do not take issue with S &P’s assessment per se, but there was another report recently that I found

Insurtech Devoted Health Has Major Financial Raise Medicare Advantage (MA) insurtech Devoted Health raised $112 million in its Series E funding round. Devoted has over 227,000 members, up from 142,000 in December 2023. Its Star rating averages 4.6. It is in 13 states and almost 300 counties. Devoted is one of the tech-based startups doing well in MA, along with Clover Health and Alignment Healthcare. Each seems to be bucking the major financial pressures seen by the Big 7 MA national plans. Thus, Devoted has filed to expand into seven new states and will double its county penetration. This doesn’t mean, though, that it won’t rein in benefits due to the erosion of MA rates. It likely will do so to protect its long-term financial health. #medicareadvantage #devotedhealth #insurtechs https://www.fiercehealthcare.com/payers/payer-roundup-devoted-health-raises-112m-la-care-eliminates-prior-auth-codes Another Employer Survey Shows Healthcare Cost Trends Another employer healthcare survey is revealing the troubles employers are having on the

McKinsey & Company Releases Three Briefers On Medicare Advantage’s Future McKinsey and Company has three important briefers on the future of Medicare Advantage. This is a must read. Among the recommendations in the extremely thorough document include: Briefers here: https://www.mckinsey.com/industries/healthcare/our-insights/the-future-of-medicare-advantage #medicareadvantage #partd https://www.beckerspayer.com/payer/3-things-payers-need-for-great-ma-star-ratings-in-2025-and-beyond-mckinsey.html Could Medicare Advantage Support Be Eroding? Growing evidence that Medicare Advantage support could be eroding somewhat in Congress. Both political parties appear to be open to MA reforms. Prominent healthcare policy officials say this should be a warning sign to MA plans, which need to respond. AHIP, the health plan lobby, is creating a seven-figure marketing and lobbying campaign in response. Democrats and populist Republicans are questioning the program’s value and are upping scrutiny. #medicareadvantage #election2024 https://www.fiercehealthcare.com/payers/medicare-advantage-consensus-waning-2024-election Humana Settles Fraud Allegations In Part D Humana will pay $90 million to settle a whistleblower lawsuit by a former actuary who said the MA plan overcharged Medicare for prescription

Harris Economic Plan Includes Continuation of Biden Healthcare Priorities And More In a major economic speech today, Democratic presidential nominee and Vice President Kamala Harris promised to lower drug prices, maintain enhanced premium subsidies in the Exchanges, and curb and retire medical debt. She would expand the Medicare drug price negotiation program to expand insulin and out-of-pocket drug cost-sharing caps to the commercial world. She also promised to combat pharmacy benefits managers’ (PBMs) unfair practices. Additional articles: https://thehill.com/policy/healthcare/4832005-kamala-harris-level-up-biden-admin-health-care-programs/ and https://insidehealthpolicy.com/daily-news/harris-economic-policy-plan-echoes-biden-s-health-cost-agenda (Some articles may require a subscription.) #healthcare #elections2024 #harris https://www.modernhealthcare.com/politics-policy/kamala-harris-health-plan-aca-drug-prices Medicare Drug Negotiations Assessment And Next Steps Medicare drug price negotiations appeared to go well, with half agreeing to prices and the other half staying in the program when a price was imposed. The brand drug makers decry the process as anything but a negotiation, but at the same time have assured investors that the lower prices will not impact

Biden Administration Announces First 10 Negotiated Medicare Drug Prices In a coup for the Biden administration, all manufacturers of the ten drugs subject to negotiation for 2026 either agreed to prices or decided to stay in the Medicare prorgam when a price was imposed. The administration and the Centers for Medicare and Medicaid Services (CMS) say that, if the new prices had been in effect last year, Medicare would have saved an estimated $6 billion, or approximately 22 percent, across the ten selected drugs. The negotiated prices range from 38 to 79 percent discounts from list prices. About nine million people with Medicare use at least one of the ten drugs. In addition to government savings, Medicare beneficiaries with prescription drug coverage will see savings of $1.5 billion in their personal out-of-pocket costs in 2026. The drugs accounted for $56.2 billion in Medicare spending, or about 20 percent of total

Politico Raises Issue Of CMS Premium Stabilization Demonstration For Medicare Part D PDPs The mainstream media is finally covering the potential October Surprise for Democrats. There are possible huge increases in standalone Medicare Part D (PDP) premiums due to the transfer of costs to plans from the government and member out-of-pocket cost reductions in the Inflation Reduction Act (IRA). The Politico article lays it out well. The Centers for Medicare and Medicaid Servies (CMS) created a last-minute demonstration to blunt the impacts and the GOP is accusing Democrats of using the U.S. Treasury for political purposes. I continue to doubt that CMS has the authority to do this.  It usurps Congress’ control. I raised this issue in two blogs several weeks ago (July 24 and July 25) here: https://www.healthcarelabyrinth.com/will-democrats-be-victim-of-an-october-surprise-of-their-own-making/ and https://www.healthcarelabyrinth.com/part-d-premium-woes-due-to-the-inflation-reduction-act/ . In addition to the PDP premium hikes, Medicare Advantage (MA) plans are expected to have benefit cuts for

AHIP To Go On Offensive On Medicare Advantage With Medicare Advantage (MA) facing huge financial difficulties due to lower rates and crippling government regulatory changes, AHIP, the health plan lobby, is underwriting a seven-figure lobbying and advertising campaign to call attention to the challenges, obtain higher rates, and explain the major benefits for Medicare enrollees. Additional article: https://subscriber.politicopro.com/article/2024/08/top-health-insurance-group-outlines-plans-to-protect-medicare-advantage-00173713 (Some articles may require a subscription.) #medicareadvantage https://www.beckerspayer.com/payer/payers-plan-medicare-advantage-lobbying-blitz.html Kaiser Reports Good Financial Results Kaiser Permanente wrapped reported $908 million of operating income (3.1% operating margin) and more than $2.1 billion of net income in Q2 2024. It had $29.1 billion in revenue in the quarter. The numbers were up from a year ago. It had a good 1H 2024 and is overcoming its earlier troubles. Additional article: https://www.fiercehealthcare.com/providers/kaiser-permanente-posts-31-operating-margin-21b-net-income-q2-2024 #kaiserpermanente https://www.healthcaredive.com/news/kaiser-second-quarter-financial-results-operating-margin-geisinger-risant/724065 Mark Cuban Tells Daily Show He Wants To Shake Up Healthcare Mark Cuban appeared on The Daily Show to declare that he

PhRMA Attacks FDA Licensing Affordability Proposal PhRMA, the brand drug manufacturer lobby, is attacking the National Institutes of Health’s (NIH) proposal to tie its licensing process to drug affordability in the United States once products hit the market. The proposal would tie U.S. prices to those in other developed countries. PhRMA argues that it would discourage collaboration by the private sector with NIH. “History demonstrates that placing unreasonable terms on licensing agreements diminishes willingness to engage in public-private partnership,” PhRMA said. But there is nothing wrong with the government tying affordability to any collaboration with the government. So much of what the drug industry eventually markets is tied to government innovation and funding.  The proposal is not unlike march-in rights on patents, which is something to consider as well. It also ties to Medicare drug price negotiations. Let’s remember: the drug market is not a free market and needs reform.