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April 11, 2024

New Alzheimer’s Drug Spending Will Leap In Medicare The Centers for Medicare & Medicaid Services (CMS) says spending on the new Alzheimer’s drug Leqembi will leap well over estimates. CMS estimates that per member per month spending on Leqembi will rise from $1.67 in 2024 to $4.67 in 2025. This will bring spending across all Medicare to $3.5 billion in 2025. This threatens to add demonstrably to Medicare troubles and will hike Part B premiums. #drugpricing https://www.fiercehealthcare.com/regulatory/report-cms-projects-spending-leqembi-will-hit-35b-next-year Federal Appeals Court Reinstates Denial Case Against United A federal appeals court allowed a proposed class action lawsuit to continue. The case alleges that UnitedHealth Group used an algorithm to more stringently review patient claims for substance abuse treatment. Both prior authorization and medical claims denials are being closely scrutinized right now. (Article may require a subscription.) #priorauthorization #claimsdenials https://www.modernhealthcare.com/legal/unitedhealth-behavioral-health-lawsuit-substance-abuse Bipartisan Support For Medicare Doc Fix Senate Finance Chair Ron Wyden, D-OR, and

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April 10, 2024

Community Health Centers Suffering From Medicaid Disenrollment A new study of patients at community health centers are reporting major Medicaid disenrollments, which impacts the level of care that can be provided to these individuals.  Community health centers largely serve those in low-income areas. It also finds that about 75% of people who have lost Medicaid coverage are still disenrolled. Further, 32% have chronic conditions, 24% are children, 12% were adults older than 65 years of age and 12% had disabilities. #medicaid redeterminations #primarycare https://www.fiercehealthcare.com/payers/one-year-after-unwinding-community-health-centers-struggle-medicaid-reenrollment Provider Impacts Continue From Cyberattack Physicians continue to see major impacts due to the Change Healthcare cyberattack. This comes from an American Medical Association (AMA) survey of more than 1,400 individuals. Over 77% of those surveyed said they experienced service disruptions beginning Feb. 21 and still feel impacts. Over a third (36%) saw claims payments suspended and 32% have not been able to submit claims. About

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April 9, 2024

CMS Cuts Off Broker Access To SSNs Kudos for Kaiser Health News’ articles and focus on fraudulent switching in the Exchanges by untrustworthy agents.  The trend has caused a lot of misery for enrollees.  One problem was the access by agents and brokers to full social security numbers (SSNs).  As of today, that has been cut off by the Centers for Medicare and Medicaid Services (CMS) in the federal Marketplace.  Henry Kaiser is smiling from heaven. #kff #khn #fwa #exchanges #aca Link to Article Advocates And Insurers Urge Extension Of ACA Premium Enhancements For One Year Advocates and insurers are right that Congress should extend the enhanced premium subsidies for the Exchanges sometime in 2024.  They are set to expire Dec. 31, 2025, but should be extended to the end of 2026.  Why? Because plans submit proposed benefits and rates in early 2025 for 2026. If the premium enhancements are

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April 8, 2024

Study Finds Enrollees Like Zero-Premium Benefit Of MA A Harvard and Inovalon study finds that enrollees in Medicare Advantage (MA) with zero-dollar premiums are three times more likely to be minorities than white. They also are more likely to be urban. Researchers note that MA is not monolithic and that different benefit offerings appeals to enrollees. The same researchers have found that MA enrollees have fewer hospitalizations, yet more social determinant barriers. More are in Health Maintenance Organization (HMO) products which has lower costs. I would note that MedPAC and other critical organizations simply spend too little time on these types of stats.  I would also say that these kind of advantages for low and fixed income seniors will be ruined by poor rate hikes and terrible prior authorization rules that have just been finalized. It is a real shame. #medicareadvantage Link to Article Fitch Says Utilization Spikes Cloud MA

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April 5, 2024

CMS Allows Absolute Biosimilar Substitution In Part D Medicare Part D plans can now immediately substitute all FDA-approved biosimilars even if they are not deemed interchangeable by the drug approval agency, under the 2025 Medicare Advantage (MA) and Part D rule finalized by the Centers for Medicare and Medicaid Servies (CMS). Interchangeability is an extra step that drug makers take to substitute for brand biologics. The new rule will allow Part D plans to treat formulary substitutions of any biosimilars as maintenance changes as was allowed earlier just for interchangeables. The Biden administration has pushed for biosimilar adoption in many ways and this is yet another. This should begin to mean lower biologic costs for Medicare members. (Article may require a subscription.) #biosimilars #drugpricing #medicareadvantage #partd #medicare Link to Article CMS Changes MTM Criteria, Including Adding HIV/AIDs As Core Disease State The Centers for Medicare and Medicaid Services (CMS) finalized

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April 4, 2024

CVS Executive Pushes Back On Cuban And PBM Transparency Narrative CVS Caremark President David Joyner wrote and op-ed for Fortune to explain the innovation and transparency his pharmacy benefits manager (PBM) is engaged in.  It seeks to counter some of the press Mark Cuban is getting.  I will note that leadership at CVS Health overall is on a path of reform and innovation. #cvshealth #pbms #transparency Link to Article Good Wall Street Journal Article On Why We Need Site-Neutral Payments This Wall Street Journal article tells how hospitals and health systems are buying up physician practices.  In so doing, they are changing practice patterns and forcing their now doctor-employees to practice at hospital-owned settings.  This increases costs for sometimes low professional fees into gigantic bills because facility fees are added on.  The hospital lobby was successful stopping the start of site-neutral payments in Medicare, but I doubt they can hold

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April 3, 2024

Private Equity’s Role In Healthcare Takes Center Stage At Hearing Democrat members of the Senate HELP Committee staged a hearing on the role of corporate greed in healthcare.  Of particular concern was the role of private equity firm monies and whether dollars are diverted out from healthcare to corporate margins.  PE firms have big investments in both hospitals and provider groups. Additional article: https://www.fiercehealthcare.com/regulatory/steward-healthcares-struggles-full-display-clinicians-policy-researchers-tell-senators #privateequityfirms #healthcare Link to Article Clover Health CEO Defends CMS MA Payments for 2025 In a strong but divergent move from other MA plans, Clover Health CEO Andrew Toy defended the Center for Medicare and Medicaid Services’ final rate for 2025.  Depending on whether you count risk score trends increases, the rate would produce either a 3.7% increase or negative 0.16 decrease.  Plans do not believe the risk score trends should be counted. Clover may not be seeing the major increases that other plans are. Other

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April 2, 2024

Scrutiny Of Private Equity Healthcare Investments Expand Private equity investments are already being broadly looked at by Congress and regulators.  Now, the Senate Homeland Security and Governmental Affairs Committee is seeking information on private equity’s role in emergency physician staffing firms that are leaving hospital emergency departments unprepared. Letters were sent to Apollo Global Management, the Blackstone Group and KKR — three of the nation’s largest private-equity firms — and four emergency medicine staffing companies owned by the firms.  It is estimated at least 40% of hospital emergency departments are overseen by staffing companies that are owned by private-equity firms. Additional article: https://www.fiercehealthcare.com/providers/senator-probes-private-equity-physician-staffing-firms-emergency-care-cost-cutting #privateequityfirms #healthcare Link to Article MA Plans Say Rate Hike For 2025 Will Have Dire Consequences Health plans are pummeling the Centers for Medicare and Medicaid (CMS) for finalizing what they see as an inadequate 2025 rate hike.  Plans say this will force them to reduce key

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April 1, 2024

New GLP-1 Survey Says Growth Is Explosive A new survey from Virta Health backs up the bleak cost picture. It says that 43% of health plan leaders are predicting 100% or more growth in GLP-1s for weight loss and obesity in 2024. More than half say GLP-1s will be a top 3 drug in 2024 in terms of spending. One fifth say they will be their most expensive drug class this year. Executives believe the media is misrepresenting GLP-1s and that lifestyle programs should be tried first. At the same time, a Vitra Health-linked study comes to a different conclusion on what occurs after stopping GLP-1s.  It says those who stop taking GLP-1s can avoid negative effects on glycemia and body weight if they are properly engaged in their healthcare, including proper nutrition. See my blog today on the subject: https://www.healthcarelabyrinth.com/whats-all-the-clamor-over-glp-1s-for-weight-loss/ #weightlossdrugs #drugpricing Link to Article CMS Maintains Insufficient Rate

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March 29, 2024

NBA Player Robert Horry’s Healthcare Adventures Are Proof We Need Affordable Universal Coverage Touching story on NBA great Robert Horry’s healthcare adventures with his daughter, who lived with a genetic disorder and died in her 18th year.  It is a testament to why we need affordable universal access to healthcare.  Horry is now with a company promoting Individual Coverage Health Reimbursement Arrangements (ICHRA), which allows businesses to cover portions of healthcare premiums and allows employees to privately procure insurance (usually on the Exchange). To me, it is one of the few positive healthcare developments from the Trump administration. #ichra #obamacare #aca #exchanges Link to Article Huge Bounty On BlackCat Cyberattackers The State Department has issued a reward for information that could find people working with BlackCat, the cyberattacker that got into the Change Healthcare systems. #changehealthcare #cyberattacks Link to Article CVS Health Aiming To Transform Customer Experience Karen Lynch, CEO

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