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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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CMS’ TukeyGate Follow-up: Where Could CMS Go To Save On Medicare Stars?

After the TukeyGate court decisions that struck 2024 Medicare Advantage (MA) Star calculations, many are speculating where the Centers for Medicare and Medicaid Services (CMS) may now go to make up some of the increased costs in the Star program (see the TukeyGate blog here: https://www.healthcarelabyrinth.com/cms-tukeygate-lawsuit-decision-threatens-to-unravel-much-of-medicare-advantage-star-scoring-in-2024-and-2025-and-next-years-bids-and-benefits/ ). The increase in Stars could result in at least $1.3 billion in increased costs to Medicare in 2025. The lawsuit loss likely caught CMS by surprise, but the agency was right to recalculate and fix the major expected 2025 benefit declines in filed bids and benefits.  I still think benefits will be reined in but the hurt on seniors and those with disabilities will be less. Given budgetary pressures and the major perception of overpayments in MA, CMS will be under pressure to find savings elsewhere over the next few years. Indeed, they wanted to implement Tukey in 2024 and get the Star

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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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Digging Into My Modest Election-Year Proposal For Healthcare Reform: Part 3 — Driving To Affordable Universal Access

This blog is one in a three-part series that digs into my modest proposal for healthcare reform published at this site on May 27, 2024. See that blog here to review my proposal thoroughly: https://www.healthcarelabyrinth.com/a-modest-election-year-proposal-for-healthcare-reform/ . Much of my proposal is taken from my book, The Healthcare Labyrinth, available at this site and through leading bookseller websites. It is available in print, ebook, and audiobook forms. This blog has information from Chapter 28 of my book — “The Right Healthcare Reform Solution.” — Driving to affordable universal access “… Let me add that the health and vitality of our people are at least as well worth conserving as their forests, waters, lands, and minerals, and in this great work the national government must bear a most important part.” – Teddy Roosevelt, The New Nationalism Speech, August 31, 1910. In my “A Modest Election-Year Proposal For Healthcare Reform” blog on May

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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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