dualeligibles Archives - The Healthcare Labyrinth

May 16, 2024

May 16, 2024 No Comments

While Admirable, CalAIM Is Struggling California has fashioned an ambitious healthcare and social service experiment known as CalAIM, but some aspects on the community health and services front are struggling. Many states have mimicked California by requesting similar but less ambitious initiatives through Medicaid. With the majority of health outcomes tied to social factors and not underlying clinical conditions, it is a worthy pursuit overall. My fear is that California may be trying too much too quickly. (Article may require a subscription.) #ca #calaim #healthcare #sdohs #socialdeterminants #medicaid #managedcare https://www.modernhealthcare.com/providers/california-medicaid-medi-cal-calaim-gavin-newsom-community-health-workers-nonprofits Private Equity Firms Tout Value In Healthcare Private equity is on a marketing campaign to tout the value it brings. Here is an example of what they are saying, although I think the negatives far outweigh the positives. (Article may require a subscription.) #privateequityfirms #healthcare https://www.modernhealthcare.com/digital-health/blackstone-equity-healthcare-data-costs Ascension Being Credited For Transparency On Cyberattack Multi-state Catholic hospital system is being credited

More Disturbing Trends On Medicare Advantage Prior Authorization

May 16, 2024 No Comments

In these pages I have bemoaned the fact that the Centers for Medicare and Medicaid Services (CMS) and Capitol Hill are taking the managed care out of Medicare Advantage (MA). MA’s value proposition is based on the plans’ ability to save dollars in furnishing traditional Medicare fee-for-service (FFS) benefits and passing on the savings in the form of reduced cost-sharing, filling in gaps in the traditional benefit, and adding additional benefits. But when CMS reins in the ability to save these dollars, it will have a direct impact on the benefits American seniors and people with disabilities see. What’s more, the antiquated FFS system is fraud-ridden and of poor quality. We need innovation not mimicking the old way of delivering care. But by hobbling MA plans’ innovation, CMS and Capitol Hill are setting MA and the overall healthcare system back. Driven by some strange need to ingratiate themselves to provider

May 15, 2024

May 15, 2024 No Comments

Bipartisan Senate Bill Would Reform Medicare Primary Doc Pay A bipartisan bill would tell the Centers for Medicare and Medicaid Services (CMS) to establish hybrid payments to reward primary care providers in the Medicare fee-for-service (FFS) program who provide the best care to their patients, including reducing patients’ emergency visits, hospitalizations, excess specialist services, and other big cost drivers. Additional article: https://insidehealthpolicy.com/daily-news/whitehouse-cassidy-unveil-primary-care-payment-reform-related-rfi (Some articles may require a subscription.) #primarycare #medicare https://www.fiercehealthcare.com/providers/senators-both-sides-aisle-propose-primary-care-payment-reform-seek-industry-feedback Upstate New York Hospital Stops Suits Against Patients Rochester Regional Health has barred all aggressive collection activities, including lawsuits, related to unpaid bills. Others in the nation have followed suit. #surprisebilling #healthcare #hospitals https://www.fiercehealthcare.com/providers/why-one-new-york-health-system-stopped-suing-its-patients New Sanders Report Says Weight-Loss Drugs Could Bankrupt System A new report from Sen. Bernie Sanders, I-VT, says weight-loss drug Wegovy could bankrupt the healthcare system if there is no reduction in price and there is a reasonable uptake of the drug for those overweight

May 14, 2024

May 14, 2024 No Comments

Broussard To Step Down As Humana CEO Bruce Broussard will step down as CEO of Humana on July 1 and be succeeded by Jim Rechtin, who came in as President and COO. Despite some challenges right now financially, he deserves tremendous credit for building a stellar MA business over a decade plus at the helm. He tripled enrollment. Broussard will serve as a strategic advisor through 2026. Additional articles: https://www.fiercehealthcare.com/payers/jim-rechtin-step-humana-ceo-role-july-1 and https://www.modernhealthcare.com/insurance/humana-jim-rechtin-bruce-broussard-ceo (Some articles may require a subscription.) #medicareadvantage #humana #broussard https://www.healthcaredive.com/news/humana-ceo-transition-timeline-broussard-rechtin/716014 Aetna, Humana To Tighten Benefits And Shed MA Members Both Humana and Aetna have reported they will shed some benefits and likely lose membership in 2025. CVS Aetna has come off a stellar increase, perhaps too much so as its MA financial turned upside down. It could shed up to 10% of its membership. Humana is expected to shed about 5%. This is not unlike what happened with

May 13, 2024

May 13, 2024 No Comments

Kaiser Reports Good Financial News Kaiser Permanente reported $935 million of operating income (3.4% operating margin) and more than $2.7 billion of net income. This beats Q1 2023 dramatically. Kaiser is also looking to sell off up to $3.5 billion of its investment stakes. Additional articles: https://www.modernhealthcare.com/finance/kaiser-permanente-investments-wsj and https://www.beckershospitalreview.com/finance/kaiser-posts-935m-operating-profit-in-q1.html (Some articles may require a subscription.) #kaiserpermanente #healthplans #hospitals https://www.fiercehealthcare.com/finance/kaiser-permanente-posts-34-operating-margin-billions-net-income-q1-2024 RAND Study Shows Huge Gap Between Commercial And Medicare Hospital Payments RAND reports in a new study that there is a huge gap between commercial and Medicare’s fee-for-service hospital payments for inpatient and outpatient services. The gap has increased as well. In 2022, employers and private insurers paid hospitals on average 254% of what Medicare pays. This is up from 224% in 2020 and 247% in 2018. Some states had prices that had a gap of over 300%, while others had prices below 200%. See my blog about my daughter’s brain surgery. There

Strong Growth From April to May In Medicare Advantage

May 13, 2024 No Comments

I decided to continue my Medicare Advantage (MA) monthly enrollment blogs because of continuing strong month-over-month increases. While we are outside of the two regular annual enrollment windows, increases in MA are still strong given the aging of America and the ability of some populations, such as dual eligibles, to continue to make changes throughout the year. As I have reported, growth from January 2023 to January 2024 was a robust 8.7% increase or 2.674 million. Enrollment in MA reached 30.799 million in January. Since that time, enrollment has continued to climb: Enrollment in MA has now hit 33.985 million. The growth from January 1 to May 1 represents an additional 1.53% increase or 512,000 lives. MA enrollment has now increased beyond 51% of all Medicare beneficiaries. As we saw with January 2023 to January 2024, PPO growth now significantly outstrips HMO growth. From January 1 to May 1, HMOs

May 10, 2024

May 10, 2024 No Comments

DOJ Sets Up Antitrust Task Force The U.S. Department of Justice (DOJ) has set up a multi-disciplinary task force to examine healthcare monopolies and collusion. It will facilitate policy advocacy, investigations, and civil and criminal enforcement. #antitrust #mergers #acquisitions #manda https://www.fiercehealthcare.com/providers/justice-department-unveils-task-force-healthcare-antitrust-issues New Spending Regulation Could Force Consolidation In Home Care The new home care 80-20 requirement, which directs 80% of all Medicaid revenue to wages, could have an unseemly outcome. Small mom-and-pop shops may have to sell off to private equity firms and large home care companies due to the onerous nature of the regulation. (Article may require a subscription.) #nursinghomes #homecare #medicaid https://www.modernhealthcare.com/providers/medicaid-80-20-rule-home-care-consolidation Biden Administration To Propose Cybersecurity Standards The Biden administration will require hospitals to meet minimum cybersecurity standards as an outcome of the Change Healthcare cyberattack. Ascension, a large hospital chain, just suffered a cybersecurity incident that impacted multiple systems, including its electronic health records. In addition,

May 9, 2024

May 9, 2024 No Comments

CHS Sues MultiPlan Arguing Conspiracy With Health Plans To Fix Commercial Rates Hospital giant Community Health Systems has filed a lawsuit arguing the data analytics firm MultiPlan has conspired with health plans to fix commercial rates in violation of antitrust rules. Visit my blog on the controversy: https://www.healthcarelabyrinth.com/out-of-network-provider-billing-is-yet-another-provider-attack-issue-against-plans/ (Article may require a subscription.) #antitrust #healthplans #providers https://www.modernhealthcare.com/legal/community-health-systems-chs-multiplan-lawsuit Medicare-Medicaid Integration Could Have Pitfalls For Some MA Plans Good article on the evolving mandates to force integration between Medicare and Medicaid. The Centers for Medicare and Medicaid Services (CMS) has passed several rules that will bring the programs together. Some Medicare Advantage (MA) plans do not look terribly well-placed to succeed, while others with big Medicaid membership do. Either way, it will be a huge transformation. (Article may require a subscription.) #snps #specialneedsplans #medicareadvantage https://www.modernhealthcare.com/insurance/medicare-advantage-medicaid-dsnp-centene-molina Medicare PA Bill To Be Reintroduced A bipartisan bill that would levy more prior authorization reform and

MA Plans Should Ready For Changes To Risk Adjustment Submissions?

May 9, 2024 No Comments

Provider groups, anti-Medicare Advantage (MA) advocates and researchers, and even the congressional policy arm MedPAC are busy attacking MA for supposedly being over-reimbursed. Depending on the study you find, these folks will tell you that MA is over-reimbursed by as much as $88 billion annually. Of course, many of these calculations are speculative and throw in policy decisions by Congress to make Stars funding additive as well as to pay some areas of the country more than the fee-for-service (FFS) rate to promote more benefit choice in rural areas. They argue that risk adjustment coding is out of control and that MA has beneficial selection compared with the traditional program. I have told you often in these pages that I come somewhere up the middle here. I discount the critics’ views and analyses. It is strange that critics’ overpayment estimates jumped from under $20 billion for so many years to

May 8, 2024

May 8, 2024 No Comments

Possible Cyberattack At Ascension Catholic hospital system Ascension may have been a victim of a major cyberattack. It runs 139 hospitals and 40 senior living facilities across the country. Additional article: https://www.modernhealthcare.com/cybersecurity/ascension-possible-data-breach-cyberattack (Some articles may require a subscription.) #cyberattacks https://www.fiercehealthcare.com/providers/systems-clinical-operations-interrupted-ascension-amid-apparent-cybersecurity-event House Ways And Means Passes Telehealth Extension The House Ways and Means Committee passed a two-year extension of telehealth and a five-year addition to the hospital at home waiver. Some pharmacy benefits manager reforms were used as pay-fors. Additional article: https://www.modernhealthcare.com/politics-policy/telehealth-rules-waiver-extension-congress (Some articles may require a subscription.) #telehealth #pbms #hospitalathome https://www.fiercehealthcare.com/regulatory/house-ways-means-committee-reveals-two-year-telehealth-extension-legislation Clover Health Improves Financial Results Clover Health improved its financial performance with a $23 million loss. It also authorized a buyback program. Clover is one of a few insurtechs doing well, including Alignment, Devoted, and Oscar. #cloverhealth #medicareadvantage https://www.fiercehealthcare.com/payers/clover-health-authorizes-20-million-share-buyback-program Private Equity Healthcare Activity Slowing A new study says private equity investments in healthcare is slowing due to the increased

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