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July 24, 2024

Medicare Advantage Inpatient Days Rising Hospitals cry foul at every pass over Medicare Advantage (MA) plans’ efforts to control inpatient hospital utilization. But a new analysis from the Kaiser Family Foundation (KFF) shows that inpatient days attributable to MA have increased considerably over time. Medicare Advantage’s share of inpatient days grew from 13% to 23% from 2015 to 2022. As of 2022, nearly half (48%) of all Medicare inpatient hospital days were attributable to MA. The MA penetration in that year averaged just short of 46%. There are numerous other great statistics in the analysis. This year, MA plans are required to follow traditional program standards for deciding whether a stay is required and thus the share will increase more. #medicareadvantage #hospitals #priorauthorization https://www.kff.org/medicare/issue-brief/medicare-advantage-enrollees-account-for-a-rising-share-of-inpatient-hospital-days/ 2020 Exchange Risk Adjustment Payment Data Published The Centers for Medicare and Medicaid Services (CMS) published the annual risk adjustment reconciliation data today. Risk adjustment is

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Will Democrats Be Victim Of An October Surprise Of Their Own Making?

For those involved in politics, candidates and parties fear what is known as the October Surprise, a scandal or national or world event that threatens to upend candidacies and partisan control of federal and state bodies. These events can be planned (e.g., by opponents) or unplanned (e.g., a terrorist attack or other world event). With the election very close, especially with the change at the top of the Democratic ticket due to President Biden’s lagging performance, many are thinking these types of events could be potential game changers on Election Day. But are the Democrats forgetting about a potential October Surprise they themselves may have created that could impact their electoral chances? Let me explain. Medicare enrollment season Each October, the enrollment season begins for Medicare Advantage (MA) and Part D plans. In the MA world enrollment is fully voluntary for individual policies. In the standalone Part D (PDP) world,

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July 23, 2024

House Committee Grills Big 3 PBM Executives On Practices Executives from the Big 3 pharmacy benefits managers (PBMs) got grilled today before the House Oversight Committee. The committee just released a report on its over year-long investigation of the Big 3 that found that they are anticompetitive, imperil independent pharmacies, overcharge payers and patients using spread pricing, and enter into brand drug rebate deals that tie to the drugs’ preferential placement on formularies. The report concluded the Big 3 not only don’t save on or control costs but steer patients toward higher-priced drugs and their own pharmacies. The committee argued that the PBMs have created multiple ways to advantage themselves in the vertically integrated world the Big 3 live, including the use of group purchasing organization (GPOs). The executives tried to refute the findings and often were silent in response to questioning. The committee also criticized prior authorization and step

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July 22, 2024

Probable Democratic Presidential Candidate Harris To Left Of Biden On Healthcare With endorsements stacking up, Vice President Kamala Harris looks to be the probable presidential nominee of the Democratic Party after President Biden bowed out this weekend. Thus, the media is looking at her positions, including on healthcare.  In general, Harris appears to be to the left of President Biden on a number of healthcare issues.  Harris will of course take credit for the Medicare drug price negotiations and Exchange premium enhancements. She would want to expand and extend each. She agrees with Biden’s anti-trust platform and was active on the issue as California’s attorney general. She may be to the left of Biden on abortion rights, universal access, and drug pricing.  Harris once backed Bernie Sanders’ Medicare for All, although she stepped it down later and advocated for a lighter form — a decade-long transition with private plans playing

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Vertical Integration Appears Very Profitable For Health Insurers And Is Raising Concern Among Lawmakers And Regulators

I have talked often about horizontal and vertical integration in healthcare in these blog pages and on my podcast. One major blog I wrote on vertical integration is here from December 21, 2023: https://www.healthcarelabyrinth.com/do-health-plans-relationships-with-owned-entities-open-up-more-scrutiny/ . Let me recap a little as background before I get to an extremely interesting infographic Jared Strock did recently. Jared is an actuary and health insurer/Medicare Advantage market and finance expert. He posts daily and is well worth following. I posted his graphic, his LinkedIn, and a recent post he did on LinkedIn below. Key background on vertical integration from my earlier blog In comes Strock’s analysis Strock used his financial skills to comb public company financial disclosures to show just how big related-party transactions have become. Here is a summary of what Strock said in his LinkedIn post (link right below the graphic): Graphic source and notes: Q1 2024 financial information for seven major

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July 19, 2024

Widespread Healthcare IT Outages Due To Security Update Error A widespread global IT outage impacted hospitals and providers worldwide. Electronic health record software was affected in a big way. Procedures and services had to be cancelled. Some states’ 911 call centers were impacted as well. Financial institutions, airlines, and more were all impacted. The outage was the result of a faulty routine software security update by cybersecurity firm CrowdStrike meant for Microsoft computers and systems running Windows. A fix was deployed. Separately, an article discusses 911 outages generally in states as a result of a patchwork and antiquated system nationally. It is one example of our under-reimbursement in public health compared with other developed world nations. Additional articles: https://www.healthcareitnews.com/news/worldwide-it-disruption-disrupts-healthcare-delivery and https://www.modernhealthcare.com/cybersecruity/crowdstrike-outage-ehr-hospitals-epic-mychart and https://www.healthcaredive.com/news/crowdstrike-outage-hits-us-hospitals/721887/ and https://www.medpagetoday.com/special-reports/features/111179 and https://www.modernhealthcare.com/providers/911-outages-massachusetts-emergency-response-system-flaws-mass-general-brigham (Some articles may require a subscription.) #hospitals #providers #healthcare https://www.fiercehealthcare.com/health-tech/global-it-outage-takes-down-health-system-ehrs-forces-hospitals-cancel-non-emergency GoodRx And Drug Maker Team Up On Biosimilar For Humira GoodRx has teamed

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July 18, 2024

Sinister Optum Layoffs And Closures Continue UnitedHealth Group’s Optum services subsidiary continues its shedding of jobs. The layoffs have occurred quietly in many areas of the sprawling and amazingly profitable enterprise post the ChangeHealthcare pandemic. In conversations I have had with health plan executives, the layoffs seem to be impacting numerous areas, putting health plans and providers in tough situations. All systems and services are not up yet post the cyberattack and United seems to be abandoning without notice key health plan and provider functions without any reasonable notice or guidance to clients. This is meant to shed questionably profitable areas and assets in favor of the bottom line. The fact that United is leaving major pieces of the healthcare system at risk is a travesty and should be investigated by the executive and legislative branches. Perhaps the class-action suits against United need to be expanded to cover these unseemly practices

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Hillbilly Heart: Despite His Conservatism, Could GOP VP Nominee JD Vance Be A Healthcare Maverick?

The political world is abuzz about the naming of Ohio Senator JD Vance as former President Donald Trump’s vice presidential running mate. I will stay out of the broader political fray right now, but I thought it was worth writing about how GOP candidates increasingly do not always meet a strict GOP litmus test on every issue. This could be – I emphasize could – with Vance on healthcare. Vance came to fame with his bestselling book, Hillbilly Elegy: A Memoir of a Family and Culture in Crisis, which recounted the social and economic problems his family faced during his upbringing in Kentucky and later in Ohio. Vance recounts the plight of poor white working-class families in Appalachia, including family struggles with alcoholism and drug dependence, as well as the embedded love of culture and country. He tells of his rise from this meager existence in a one-parent household to

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July 17, 2024

Elevance Beats The Street For Q2 Elevance Health beat The Street on both profit and revenue in Q2 2024. The insurer posted $2.3 billion in profit and $43.9 billion in revenue. It signaled it is seeing 5% enrollment declines in Medicaid due to redetermination. That should end later this year. Utilization could increase due to increased acuity in Medicaid. Carelon, its service entity, increased its financial position dramatically. With its win in a lawsuit on Star ratings, Elevance expects 56% of its Medicare Advantage (MA) members to be in 4 Star or greater plans. A huge boost to its MA program. Additional articles: https://www.fiercehealthcare.com/payers/elevance-health-beats-street-q2-it-posts-23b-profit and https://www.healthcaredive.com/news/elevance-second-quarter-2024-medicaid-medicare-advantage/721551/ and https://www.beckerspayer.com/payer/medicaid-utilization-rising-elevance-health-warns.html and https://www.beckerspayer.com/payer/elevance-health-posts-2-3b-profit-in-q2.html (Some articles may require a subscription.) #elevancehealth #medicaid #medicareadvantage https://www.modernhealthcare.com/insurance/elevance-health-profits-medicaid-medical-costs Humana Invests In AI-Driven Medicare Advantage Plan Choice Firm Humana has acquired a minority stake in Healthpilot, which offers consumers artificial intelligence-driven guidance in selecting Medicare Advantage (MA)  plan options.

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July 16, 2024

Despite Conservatism, Vance Has Surprising Record On Healthcare J.D. Vance is seen as a rightist Republican. But Donald Trump may have chosen a bit of a maverick on healthcare for his VP partner. In the past, Vance has criticized the Obamacare repeal because it would have impacted lower income people. In addition, he has signaled support on drug price reform, which is similar to Trump’s position. While he previously endorsed Medicare cuts, he has backed away from this position and has indicated that more should be spent on healthcare. Additional article: https://insidehealthpolicy.com/daily-news/jd-vance-s-record-includes-drug-negotiation-support-mixed-record-medicare-abortion (Some articles may require a subscription.) #election2024 #trump #vance https://thehill.com/policy/healthcare/4775098-vance-healthcare-positions UnitedHealth Reports Q2 Earnings UnitedHealth Group reported that second-quarter net earnings declined 23% year-over-year to $4.2 billion. It reported revenue of $98.9 billion, a 6.5% increase from the prior year period. The medical loss ratio (MLR) was 85.1%, an increase from 83.2% a year ago. High Medicaid and Medicare

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