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While modest, price reform is certainly welcome and essential Hospital prices generally have soared by 250% since 2000 – twice the rate for healthcare and three times inflation. Along with drug pricing, this is driving the overall increase in costs we are seeing each year. But some moves are occurring that suggest that site neutral payment reform will finally happen. Back on May 4, I told you that hospital price reform may be mounting after a stunning Capitol Hill hearing where hospital executives seemingly said that they are willing to discuss reasonable changes to their long-standing opposition to site neural payments in Medicare. Meanwhile, the Trump administration is busy laying the groundwork, if at a slow pace. Under Trump 47, it proposed various changes, only to have some of them reversed by the Biden administration. Now, Trump 47 has been busy passing regulations that press site neutral and other price

More lawsuits and more Star rating scenarios in play Ok, so this is my fifth blog on the fallout from the Clover lawsuit decision, but continuing the saga is certainly merited. The Tukey outlier and guardrail decision in 2024 for SY 2024 Star Ratings certainly was defining in that plans won their point that the Centers for Medicare and Medicaid Services (CMS) was blatantly ignoring the regulatory process. Yet the Clover decision now appears to be going even farther in that Clover Health has exposed the fact that the Stars program as we have known it was not based in statute. More so, it now has created program uncertainty and the real chance that there may be no solid Stars foundation on which to calculate quality outcomes for the near future. Indeed, I am now characterizing what is occurring as the “balkanization of Star Ratings.” Let’s back up and give

NHED data continues to show the healthcare crisis The Centers for Medicare and Medicaid Services (CMS) Office of the Actuary released its projections for healthcare expenditure growth over the next decade, and it continues to show an alarming trend. Healthcare expenditures will grow well above increases in personal income and the gross domestic product (GDP). Setting the stage The CMS Actuary is the supreme authority on everything U.S healthcare. First, it is the main comprehensive source of data for calculating the history and future of healthcare spending. Most other studies rely in some form on the National Health Expenditure Data (NHED) reports. Usually in December of each year, the actuary reports on the details of healthcare spending in the prior year. Usually in June of each year, the actuary will forecast healthcare spending growth for the coming decade. Second, it is a treasure trove of data that helps explain the

June enrollment growth slows, but SNPs surge In a February 16 blog, I detailed the growth in Medicare Advantage (MA) from February 2025 to February 2026 after a delay from the Centers for Medicare and Medicaid Services (CMS) in posting the annual data. As I noted, the January enrollment statistics in both years seemed off so many analysts are comparing February to February each year. Each month since then I have updated with monthly growth numbers. Now, we have June results. For those who may have missed earlier blogs, I am refreshing on some of the annual results. The annual statistics show some of the financial struggles the industry continues to have. Growth is way down compared with prior years in the 2020s due to major geographic contractions as well as plan benefit reductions by major MA players the past few years. As the chart below shows, February 2025 to

The process shows the need for healthcare reform I am not the biggest fan of MedPAC, the congressional Medicare policy arm. For example, I have taken issue with what I think is its slanted views on Medicare Advantage (MA) overpayments. But recently, I did give it some credit on its look at hospital financial health when MA penetration increases. It was a balanced look and concluded that MA penetration is not tied to financial instability as some hospital lobbies suggest. Empirical analyses conducted by MedPAC staff showed no evidence of a significant association between MA market penetration and all-payer margins of hospitals, skilled nursing facilities (SNFs), and home health agencies. Negative impacts do not appear to be the case in rural markets, either. That is Chapter 3 of the MedPAC report (link at end of the blog). I will likely write more about this soon. My real reason for writing

CMS’ approach is right and should move quickly to return the program to its SY 2029 vision This is my fourth Clover-related blog this month, but the ruling was so watershed — and the potential impacts so far-reaching — that I had to tackle the topic again. I, too, wanted to signal to the Centers for Medicare and Medicaid Services (CMS) why it is so important to hold plans harmless now as well as push to salvage its 2029 vision for a more targeted Stars program. For those who are just getting up to speed or need to on the issue, here is a brief synopsis of the events of the last month or so on this important Medicare Advantage (MA) Star Year (SY) 2026 Ratings issue. What did the judge say and what did CMS do for SY 2026? At first, many of us reported that the judge pulled

The Centers for Medicare and Medicaid Services (CMS) announced late Wednesday it is recalculating some Medicare Advantage (MA) contracts’ SY 2026 Star Ratings based on the “better of” the current 2026 ratings or the measures included in the recent Clover decision. A judge struck up to 20 measures. CMS went out of its way to note that this does not set policy for SY 2027 ratings or beyond. CMS said it recalculated using just HEDIS, CAHPS, and HOS measures. No Part D measures were included and the following were removed for Part C: SNP-CM, Complaints, Leave, the two Appeals measures, and Call Center. Based on the HPMS memo, in my view CMS does not appear to have followed the ruling exactly. I am waiting to see some plans’ recalculations to be sure. This could be related to measures that were clearly not covered by the statutes and those that were

This blog is a quick follow-up on the recent federal court decision in favor of Clover Health. The judge ruled that the Centers for Medicare and Medicaid Services (CMS) could not include 20 current measures in the Star Rating program as they either are not allowed via statute or the agency failed to notice their inclusion or changes properly. The judge ordered Clover’s 2026 Star ratings to be recalculated. The agency moved swiftly and in an investor release Clover announced that CMS has recalculated its SY 2026 rating for its largest contract and advised the plan to submit an alternative 2027 bid. SY 2026 Star ratings impact 2027 calendar year payments. If and when the recalculation is applied, all of Clover Health’s 156,000 Medicare Advantage members would now be enrolled in plans rated at least four of five stars, generating some $120M in bonus payments in 2027. But there is

NOTE: With the midterms coming and a bit of a lull in healthcare news, over the past few weeks I have been re-publishing my 2024 election year series on healthcare reform (with a few updates). It remains as relevant for midterms 2026 as it was two years ago. This blog is one in a four-part series that digs into my modest proposal for healthcare reform. See the introductory blog here to review my proposal more broadly: https://www.healthcarelabyrinth.com/a-modest-election-year-proposal-for-healthcare-reform-2/ . Here is the first detailed part on price reform: https://www.healthcarelabyrinth.com/digging-into-my-modest-election-year-proposal-for-healthcare-reform-details-part-1-the-importance-of-price-reform/ . Here is the second detailed part on pivoting to primary care and care management: https://www.healthcarelabyrinth.com/digging-into-my-modest-election-year-proposal-for-healthcare-reform-part-2-pivoting-to-primary-care-and-care-management-from-our-obsession-with-utilization-management/ . Much of my proposal is taken from my book, The Healthcare Labyrinth, available at this site and through leading bookseller websites. It is available in print, ebook, and audiobook forms. Driving to affordable universal access “… Let me add that the health and vitality of our people are at least

The House still looks very likely Democrat, with the Senate still in limbo As the midterms approach, I always give you a fresh look at what could happen in terms of control of Congress. My last look was roughly a quarter ago on March 12. I likely will do so again sometime just after the summer ends as we really get into campaign season. Since I am a political junkie, I might give you a monthly update (and even more frequently at the end) until November 3 hits. As I have said, healthcare will be a big part of how votes are cast in November. Affordability overall is a top issue this election year and healthcare affordability dominates this issue in many ways. The GOP at a disadvantage You can go back to my March 12 blog here ( https://www.healthcarelabyrinth.com/a-look-at-the-status-of-congressional-midterm-elections/ ) but wanted to quickly refresh on the uphill battle