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December 3, 2024

Government Spending Bill Needed In Next Two Weeks With the government running out of money as of December 20, Congress is back for a lame-duck session and needs to pass a permanent funding bill or stop-gap continuing resolution (CR) soon. The latest guess is that the parties will come together in each chamber to pass a stop-gap CR and boot major funding and policy decisions until the next Congress. But that certainly puts Democrats at a disadvantage as they become the minority in both chambers. But the sheer work to get a permanent bill passed is likely just too much right now for anyone. There is wide speculation on what will happen with various healthcare policy proposals. Many hope for a great deal of healthcare bills to be rolled up into an end-of-year act. But that hope is dying given all that needs to be done. More likely are some

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December 2, 2024

United And Centene Get Star Hikes For 2025 After a federal court ordered the Centers for Medicare and Medicaid Services (CMS) to revise United Healthcare’s 2025 Star ratings, the agency issued new Star ratings for both United and Centene today. The agency increased the quality ratings for 12 UnitedHealthcare contracts and 7 Centene contracts. Centene now has a sole 4-Star contract under the agency changes. Two United contracts were upgraded to 5 Stars and three contracts to 4 stars. United now will have 37 contracts rated at least 4 stars. The United and Centene cases surrounded how CMS handled the two call center ratings. Centene sued like United and the Centene case is still pending. It likely will be withdrawn. Humana and Elevance Health also sued and both suits are still pending. No changes to Star ratings have yet been made for Humana and Elevance Health.  One reason could be

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November 27, 2024

Paragon Says DOGE Could Save $2.1 Trillion In Healthcare Donald Trump has created the informal Department of Government Efficiency (DOGE) to reduce the size of government. He is also looking for budget cuts to help pay for extension of his 2017 tax cuts. As such, healthcare spending cuts are anticipated. Trump is chummy with certain conservative healthcare policy groups, including the Paragon Health Institute. Paragon has put together some possible healthcare cuts amounting to $2.1 trillion in savings over a decade. The possible reductions include the following. While Trump has said he will preserve Medicare, some Medicare cuts are below. The proposals are not a radical reform of current healthcare programs, but would remove a great deal of funding, shift costs to states and citizens, and mean reduced coverage overall. Some proposals, such as site neutral payments and certain Medicaid and Medicare abusive hospital funding practices, are tremendous ideas. As

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November 26, 2024

New MA And Part D Rule Issued As Parting Policy Shot By Biden Administration The Biden administration issued its draft 2026 Medicare Advantage (MA) and Part D rule today. A draft is available, but the Federal Register indicates the rule was pulled back for additional clarifications and would be reposted on December 10. Due to its late posting, the rule would not be finalized before the Trump administration takes office and therefore could simply be revamped rather than be rescinded. In some ways, the rule does not have some of the mega changes that some expected in the areas of Star, risk adjustment, and more. This could be due to some sensitivity to the current financial woes of the MA industry. But there is plenty for the industry to object to. I have not done a thorough read yet of the 700-plus page draft rule, but I will do so

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November 25, 2024

Media Attacking Trump Healthcare Picks As Contrarians The mainstream media are busy attacking Donald Trump’s healthcare picks as public health and healthcare contrarians. They worry the administration could aim to set vaccine policy that is outside of the so-called mainstream. So far, Trump has named the following to lead key agencies: The media are less concerned about Oz and Makary and most concerned with Kennedy and Weldon. Some of the criticism is unfair, especially toward Makary. During the COVID years, Makary stood out as a man of science and great educator, calling out the need for COVID vaccines for those most vulnerable to the virus but reasonably pushing back on COVID vaccine hysteria and other excesses. Additional article: https://www.managedhealthcareexecutive.com/view/trump-names-picks-for-top-jobs-at-fda-and-cdc-and-also-surgeon-general  (Article may require a subscription.) #healthcare #trump #election2024 #hhs #cms #fda https://www.modernhealthcare.com/politics-policy/donald-trump-health-nominees-vaccines-fda-marty-makary-cdc-dave-weldon Hospital Price Transparency Dropping Not Increasing New findings by Patient Rights Advocate finds that just 21.1% of hospitals are

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November 22, 2024

CMS Loses Again In Court On Stars A just released court decision gives the Centers for Medicare and Medicaid Services (CMS) yet another defeat on how the agency runs the Stars program. Judge Jeremy Kernodle, of the U.S. District Court for the Eastern District of Texas, ruled CMS violated the Administrative Procedures Act of 1946 by improperly reviewing UnitedHealth Group’s health plan call center ratings. The judge was rather biting in his assessment. He said that CMS creates the guidelines, identifies the phases, and specifies the criteria for the call center metrics. He concluded that the responsibility for any unreasonable or absurd outcomes therefore lies with the agency not plaintiffs. Other lawsuits have been filed by Humana, Centene and Elevance Health. This could likely lead to recalculations for many plans, although it will not rise to the mass recalculation we saw in 2024. CMS says it is looking to deprioritize

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November 21, 2024

Commonwealth Study Covers The Underinsured A very important study from The Commonwealth Fund found that close to a quarter of people who have health coverage are underinsured. This is consistent with other findings that put the number of uninsured and underinsured at about 85 million Americans. In essence, the underinsured are Americans that have coverage but, in many ways, have a hard time accessing the benefits due to high out-of-pocket costs. In my book, The Healthcare Labyrinth (available at this site), I discuss that affordable universal access is needed to address both the uninsured and underinsured crisis. The Commonwealth Fund polled a national sample of adults aged 18 to 64 and found that 23% are underinsured. Most (about 66%) are in employer-sponsored health plans. About 14% were in individual or Exchange plans and 11% were in Medicaid. About 57% who were underinsured said they skipped care because of the cost. About

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November 20, 2024

More on Mehmet Oz’s Healthcare Positions President-elect Donald Trump’s nominee for the Centers for Medicare and Medicaid Services administrator, Mehmet Oz, has raised concerns with high insulin prices and the role of pharmacy benefit managers (PBMs). At the same time, he has not taken a position on Medicare drug price negotiations. He favors permanent telehealth expansions and has invested in numerous digital health companies over the years. This means he may support artificial intelligence, remote monitoring, wearables, and digital therapeutics. Oz has long been a supporter of Medicare Advantage (MA) and even pushed for the concept of Medicare Advantage for All, which would have eliminated employer coverage and put everyone in private plans outside of Medicaid. Additional articles: https://insidehealthpolicy.com/daily-news/oz-raised-concerns-pbms-insulin-costs-his-ira-views-unclear and https://insidehealthpolicy.com/daily-news/oz-would-bring-support-permanent-telehealth-ai-wearables-dtx-cms and https://thehill.com/policy/healthcare/5000821-trump-oz-cms-medicare-medicaid/ (Some articles may require a subscription.) #oz #cms #trump #medicareadvantage https://www.beckerspayer.com/payer/dr-oz-on-medicare-advantage-5-things-to-know.html PBMs Sue Over FTC Litigation Process The country’s largest pharmacy benefit managers (PBMs) and group purchasing

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November 19, 2024

The Land of Oz: Trump Nominates Mehmet Oz As CMS Administrator President-elect Donald Trump has nominated television personality and surgeon Dr. Mehmet Oz to oversee the Centers for Medicare and Medicaid Services (CMS). Oz had a successful TV show for thirteen years, although has become controversial over supplements, alternative treatments, and COVID treatment. He lost to John Fetterman in a 2024 Senate race. He is a cardiothoracic surgeon and went to Harvard and Penn. He holds patents on a variety of devices related to heart surgery. Additional articles: https://www.modernhealthcare.com/politics-policy/donald-trump-mehmet-oz-cms-administrator and https://www.healthcaredive.com/news/trump-dr-oz-nominate-medicare-medicaid-cms/733416/ and https://insidehealthpolicy.com/daily-news/oz-s-embrace-alternative-medicine-could-influence-cms-policy and https://www.beckershospitalreview.com/hospital-management-administration/president-elect-trump-taps-dr-oz-for-cms-administrator-10-things-to-know.html and https://thehill.com/policy/healthcare/4998738-trump-oz-cms-nomination/ (Some articles may require a subscription.) #cms #trump #healthcare #healthcarereform https://www.fiercehealthcare.com/payers/tv-personality-and-surgeon-dr-oz-nominated-run-medicare-medicaid AMA Study Says Health Insurance Is Highly Concentrated A new study by the American Medical Association (AMA) finds that many regions are “stubbornly highly concentrated” when it comes to commercial health coverage. The AMA study found that 95% of metropolitan statistical area

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November 18, 2024

Retiree Coverage Dropping Dramatically; Employers Rely More On Medicare Advantage The Kaiser Family Foundation (KFF) finds that the number of employers providing retiree coverage is dropping dramatically. Among large employers that offer health benefits to active workers, the share offering retiree coverage has dropped from 66% in 1988 to 24% in 2024. The trend will create huge new affordability issues for the nation as aging continues. Still, that covers 14.5 million Medicare beneficiaries with important secondary coverage to fill in the big holes in the traditional Medicare program. In order to continue coverage and limit costs, employers more and more are turning to wrapping the retiree benefit around Medicare Advantage (MA), known as EGWPs. About 56% of large employers offering retiree health benefits in 2024 offer coverage to at least some retirees through an MA plan, more than double the share in 2017 (26%). About 53% require enrollment in MA.

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