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The Latest Edition Of The Stars Roadmap

Published in partnership with Lilac Software: https://lilacsoftware.com Figuring out exactly what will happen in the Star measure program over time is no small feat. The Centers for Medicare and Medicaid Services (CMS) certainly does not make it easy to create a Stars roadmap so you are ready for a new measure maturing to Stars.  CMS will use a variety of means to telegraph what might occur. These include annual Medicare Advantage (MA) and Part D rules, the so-called Advanced and Final Notices/Announcement annually, and other CMS communications. Even then, pulling it all together is tough. Things can change from proposed rules to finalized rules. CMS may give direction on a change in one year only to backtrack the next. You can never be 100% sure until the Advance Notice is finalized for the coming year. This usually drops in April of a given year. Sometimes, as they did with Star

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January 22, 2025

CMS Appealing UnitedHealthcare’s 2025 Stars Win In very odd timing, the Centers for Medicare and Medicaid Services (CMS) has said it will appeal a federal judge’s order to recalculate UnitedHealthcare’s Medicare Advantage (MA) Star ratings. CMS did not state the grounds for its appeal.  Coming out of a federal judge’s decision siding with United in its suit, CMS did revise UnitedHealthcare’s and Centene’s star rating scores for 2025. UnitedHealthcare received higher ratings in 12 contracts and Centene in seven contracts. Centene’s suit closely mirrored United’s. Additional article: https://www.modernhealthcare.com/legal/cms-unitedhealth-medicare-advantage-star-ratings-appeal (Some articles may require a subscription.) #cms #stars #medicareadvantage https://www.fiercehealthcare.com/payers/cms-will-appeal-unitedhealthcares-ma-star-ratings-court-win Hospitals Had More Downgrades Than Upgrades in 2024 Credit downgrades for nonprofit hospitals outpaced upgrades in 2024, despite generally better financial performance in the industry overall. Moody’s, S&P, and Fitch collectively issued 95 downgrades and 37 upgrades in 2024, as opposed to 116 and 33 in 2023. Healthcare providers plan on another

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January 21, 2025

Some Trump Executive Orders Impact Healthcare As expected, re-minted President Donald Trump issued sweeping executive orders on day one of Trump 47 impacting almost all aspects of government. By and large, healthcare was less impacted. But here are some highlights: In other news, the brand drug industry will ask Trump to pause the second round of Medicare drug price negotiations in part due to ongoing litigation. Proponents urge Trump to continue and argue there is no basis for any pause. Last, advocates are asking Trump to avoid drastic Medicaid cuts and restructuring and targeting key moderates in the Senate in a public relations and advocacy campaign. Additional articles: https://www.healthcaredive.com/news/trump-reverses-biden-healthcare-executive-orders-withdraws-world-health-organization/737838/ and https://www.modernhealthcare.com/politics-policy/trump-medicare-drug-price-negotiations and https://www.modernhealthcare.com/politics-policy/donald-trump-joe-biden-ai-executive-order-repeal and https://www.modernhealthcare.com/politics-policy/donald-trump-world-health-organization-us-exit-reconsider and https://thehill.com/policy/healthcare/5097280-trump-who-executive-order/ and https://www.fiercehealthcare.com/regulatory/trump-pulls-us-out-who-condemned-public-health-experts and https://thehill.com/policy/healthcare/5098715-trump-executive-order-biden-prescription-drug-costs/ and https://insidehealthpolicy.com/daily-news/advocates-defend-medicaid-appeal-trump-massive-ad-campaign and https://www.statnews.com/2025/01/20/trump-executive-orders-health-care-drug-pricing-aca-covid-gender-discrimination/ (Some articles may require a subscription.) #trump #healthcare #first100days #medicaid #medicare #drugpricing #aca #obamacare #regulations #ai #who https://www.fiercehealthcare.com/regulatory/what-trumps-first-day-orders-mean-healthcare-ditched-drug-models-pauses-rules-and-hiring More On DOJ Suit Against Walgreens More

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The Torch Is Passed On This Inauguration Day: A Republican’s Reflection On Biden And Healthcare

Biden deserves credit for some key healthcare accomplishments Today is Inauguration Day and the torch is being passed from President Biden to President-elect Donald Trump. Many have argued that Joe Biden’s presidency will be remembered as less than stellar, but I wanted to take this chance today as a Republican to reflect on some of Joe Biden’s healthcare accomplishments as he leaves office. My views on healthcare are somewhat unique as a Republican I am a Republican, but I always tell you that I am a maverick one on healthcare. Part of my college discipline was in economics. As such I studied how the market works, consumer behavior, and micro and macro trends. I was also in politics before making my leap to healthcare. As a state budget director, I was known as a fiscal disciplinarian, who always sought low taxes and a balanced budget. At the state level, we

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January 17, 2025

Biden Releases Next 15 Medicare Drugs To Be Negotiated In a parting shot at the incoming Trump administration, outgoing President Biden’s administration issued the next list of 15 drugs subject to negotiations in Medicare. The list was due by February 1, so the early release is a challenge to the Trump administration not to repeal the negotiation law included in the Inflation Reduction Act (IRA). The prices on the 15 drugs would go into effect on January 1, 2027 after a process in 2025. In 2024, prices for the first 10 drugs were set and take effect on January 1, 2026. The Centers for Medicare and Medicaid Servies (CMS) says that between November 2023 and October 2024 about 5.3 million people with Medicare Part D coverage used these drugs to treat a variety of conditions, such as cancer, type 2 diabetes, and asthma. The drugs accounted for about $41 billion

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January 16, 2025

UnitedHealth Group Reports Lower Margins While revenue was up for the year, UnitedHealth Group reported lower annual margins due to high medical expense. Its stock dropped on the news. United is the largest insurer and biggest integrated healthcare company in the nation. Its medical loss ratio (MLR) grew to 87.6% across its lines of business in Q4. Its earnings were still above estimates. United CEO Andew Witty also said he would ease prior authorizations (PAs) and work with policymakers to overhaul processes. And faced with threats of major regulation of its pharmacy benefits manager (PBM), OptumRx, the CEO also committed to passing through to plans and employer groups 100% of drug manufacturer rebates. Many will be skeptical of the significance of this gesture given PBMs receive many forms of revenue and could easily find ways to maintain current levels of profit streams. Additional articles: https://www.modernhealthcare.com/insurance/unitedhealth-andrew-witty-prior-authorization and https://www.modernhealthcare.com/insurance/unitedhealth-group-earnings-call-share-price-andrew-witty-medical-costs-revenue and https://www.healthcaredive.com/news/unitedhealth-unh-2024-record-revenue/737477/ (Some

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Star Program Changes In 2026 Advance Notice

Major new Star measure changes slated by CMS The Centers for Medicare and Medicaid Services’ (CMS) 2026 Advance Notice had major changes and information related to the Medicare Advantage (MA) and Part D Star programs for Star Year (SY) 2026 and beyond. The advance notice provides information and updates on Star ratings as mandated by regulations and solicits input on future measures and concepts. All substantive measure specification changes, the addition of new measures, and methodological changes must go through rulemaking. The 2026 notice outlines non-substantive measure specification updates; solicits initial feedback on substantive measure specification updates and comments on new measure concepts as well as display measures; and solicits preliminary feedback on adding geography to the Health Equity Index (HEI) reward.  Here are the key advance notice highlights: Deadlines Final 2026 Star Year Measures Disasters for Star Year 2026 As well, starting with the 2026 Star Ratings CMS will

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January 15, 2025

Overall Record Enrollment in ACA Programs As discussions are opening up in 2025 on whether enhanced premium subsidies are extended or not, the Kaiser Family Foundation (KFF) released a new analysis that said in 2024 Affordable Care Act (ACA) enrollment was 44 million. This includes federal and state Exchange Marketplaces, Medicaid expansions (ten states have not expanded), and the Basic Health Plan (in a small number of states). In 2024, Exchange Marketplace enrollment hit a record of 21.4 million people. Medicaid expansion enrollment was 21.3 million in 2024. Basic Health Plan enrollment in 2024 was 1.3 million. Exchange enrollment in 2025 will hit at least 24 million, so those helped via the ACA will actually be about 47 million. These gains could be reduced over the next several years if the enhanced rebates expire at the end of 2025, if the Exchange benefits and subsidies are changed in other ways,

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January 14, 2025

Outgoing Biden FTC Fires Another Shot At PBMs CVS Caremark, Express Scripts and OptumRx – the Big 3 pharmacy benefits managers (PBMs) — dramatically mark up specialty generic drugs to affiliated pharmacies, according to a new report from the Federal Trade Commission (FTC). This is the second of two scathing reports. The FTC analyzed 51 specialty generic drugs from 2017 to 2022 and found that the PBMs’ affiliated pharmacies acquired $7.3 billion in excess revenue when compared to the National Average Drug Acquisition Cost (NADAC), an estimate of what it costs a pharmacy to acquire a drug. Further, the report says the conclusion could be an underestimation. PBMs generally defended themselves by saying that the report is misleading because it is based on a subset of drugs, that clients not PBMs choose networks, and they bring many savings to the system. But the report does show that PBM-affiliated pharmacy dispensing

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January 13, 2025

MA Pay Hike Inadequate; Physicians Upset Health plans stocks did well on the news that Medicare Advantage (MA) rate hikes would improve in 2026, but many are still calling the increase inadequate and hope the incoming Trump administration will offer more relief. Advocates for MA are saying individual plan offerings will still have to decrease in 2026 after a major contraction in 2025. See my blog today digesting the announcement: https://www.healthcarelabyrinth.com/calling-all-plans-advance-notice-released-for-2026-ma-and-part-d-rates-and-other-policies/ . In related news, physicians are very upset that health plans will see an increase while they will see a fifth year of reductions. Docs feel plans are getting preferential treatment. I see the docs’ point. In other news, the Centers for Medicare and Medicaid Services (CMS) want to continue a premium stabilization program for standalone Part D (PDP) plans. A spike in premiums would have occurred without the program. Republicans think the program could be extra-legal (as I

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