interoperability

National Healthcare Expenditure Data Issued for 2022: What Does It All Mean?

One of my Christmas traditions is to write about the release of the Centers for Medicare and Medicaid Services (CMS) Actuary’s National Healthcare Expenditure Data (NHED) for a given calendar year.  This usually is released in the first half of December each year for the prior year.  It literally takes CMS about a year to capture, calculate and categorize all the data for a year given the size and labyrinthine complexity of our healthcare system.  Each year as well, usually in the first half of June, the CMS Actuary updates healthcare spending projections for ten outyears. Why is this so important?  First, it is the main comprehensive source of data for calculating the history and future of healthcare spending.  Most other studies rely on the CMS Actuary’s NHED reports in some way.  Second, it is a treasure trove of data that helps explain the inner workings of the healthcare system.

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December 15, 2023

Elevance Health and HCSC Looking At Cigna Medicare Reports suggest Elevance Health and Health Care Service Corporation (HCSC) are looking at acquiring Cigna’s Medicare Advantage (MA) lives. Cigna has just over 600,000 Medicare Advantage lives, but has had lower Star ratings than desired. HCSC has just 180,000 MA lives and would love to acquire a bigger footprint. Elevance Health has just over 2 million lives and is trying to grow Medicare as well. In 2021, Elevance acquired MMM’s almost 300,000 lives in Puerto Rico to help with organic growth. #elevancehealth #hcsc #cigna #medicareadvantage #mergers #acquisitions Link to Article BCBSLA Could Be Acquired by Elevance Health At the same time, Elevance Health may acquire BCBSLA after pausing the process earlier this year. This is based on revised regulatory activity. Elevance Health is the largest for-profit owner of Blue Cross and Blue Shield plans, with 14 states nationwide. Additional article here: https://www.modernhealthcare.com/mergers-acquisitions/elevance-health-blue-cross-louisiana-merger-acquisition

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December 14, 2023

Medicare Drug Reform Law Working The Centers for Medicare & Medicaid Services (CMS) says 48 prescription drugs will have lower Part B beneficiary coinsurances in the first quarter of 2024 due to price hikes by drug makers that exceeded allowable increases, with out-of-pocket costs decreasing by $1 to as much as $2,786 per average dose. Over the last four quarters, 64 drugs in total had prices that increased faster than inflation and may be subject to inflation rebates because of the Inflation Reduction Act (IRA). It is hard to argue that the Medicare drug reforms are not working in this case.  At the same time, CMS issued a letter to plans and PBMS urging fair reimbursement to pharmacies and urging preparation for 2024 changes under Part D. CMS letter here: https://www.cms.gov/newsroom/fact-sheets/cms-letter-plans-and-pharmacy-benefit-managers . Additional article here: https://www.medpagetoday.com/publichealthpolicy/healthpolicy/107878 . The CMS announcement and backup material here: https://www.cms.gov/newsroom/press-releases/cms-releases-revised-guidance-medicare-prescription-drug-inflation-rebate-program . Similar Health and Human Services release and info here: https://www.hhs.gov/about/news/2023/12/14/new-hhs-actions-and-research-highlight-how-president-bidens-administration-lowering-prescription-drug-costs.html . #drugpricing #ira

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PBM Transparency And Reform Is A Big Trend In The American Healthcare System

The push for lower drug prices in general and reform of America’s Pharmacy Benefit Management (PBM) industry specifically are major focuses of Capitol Hill and state and federal regulators. With these trends taking center stage, I thought it would be interesting to lay out where the impetus for reform is coming from and what the future likely holds. I don’t pretend this is an exhaustive piece, but it is meant to set the table for future discussions and blogs. It is clear to me that the push for reform substantially is coming from outside the industry, but there are clear trends even within the drug and PBM industry toward change. What is the current status? It is critical to recognize that PBMs alone do not set prices in American healthcare. We have a tremendously opaque drug supply channel that begins with drug makers. The below walk-through is simplified and does

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December 13, 2023

CMS Actuary Releases 2022 Healthcare Statistics The CMS Actuary has released its analysis of 2022 national healthcare expenditures. I will write a blog on this in the next week. At the link is the website where the data is uploaded. Centers for Medicare and Medicaid release here: https://www.cms.gov/newsroom/fact-sheets/national-health-expenditures-2022-highlights . In addition, four other articles on the new data: https://www.fiercehealthcare.com/payers/back-normal-health-care-spending-growth-rates-down-pandemic-era-times and https://www.healthaffairs.org/content/forefront/ahead-print-national-health-spending-2022 and https://www.modernhealthcare.com/policy/us-health-care-spending-rose-over-4-trillion-2022 and https://insidehealthpolicy.com/daily-news/cms-2022-health-spending-report-finds-medicaid-drove-federal-spending . Healthcare spending increased 4.1% in 2022 to $4.5 trillion. In 2022, the share of the economy devoted to healthcare spending as a percentage of gross domestic product (GDP) was 17.3 percent. Healthcare’s share of GDP as well as the percentage cost increase both went down in part due to lower government spending on the pandemic from prior years. In addition, Medicaid spending due to enrollment growth was very high. (Some articles may require a subscription.) #healthcare #costs Link to Article ONC Finalizes AI And

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December 12, 2023

A Rare Occurrence For Healthcare Costs In a rare occurrence, medical service costs at hospitals increased 2% in the first three quarters of 2023. This is about the 1.9% that the economy grew. Generally, hospital costs tend to far exceed economic growth and inflation. The report is from Turquoise, a new price transparency startup.  The findings also show that costs can vary across regions/markets as well as within markets. #pricetransparency #healthcare Link to Article At The Same Time, Overall Healthcare Costs Rising Advisory firm WTW surveyed 266 insurers across 66 countries and found that 58% are bracing for “higher or significantly higher” healthcare cost increases in the three upcoming years. Global costs increased by 10.7% in 2023, up from a 7.4% increase in 2022. The average cost trend insurers expect is 9.9% next year. #healthcare #healthinsurance Link to Article Excellent Pro Publica Analysis of Waste and Abuse in Medicare Latest estimates

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New Poll Shows Americans Want To Work To Improve The Current Healthcare System Not Replace It

In my last blog on December 7, I argued that former President Donald Trump gave Democrats an issue to run on in 2024 when he stated on two occasions that he wanted to repeal the Affordable Care Act (ACA). I argued that the Republican party has a “compassion gap” and Trump signaling he would repeal the ACA widens that gap and gives a leg up to the Democrats. A recent Kaiser Family Foundation (KFF) poll showed that the ACA was a very important issue for about half of those surveyed and that about a third of Republican voters felt that way. In general, on healthcare issues, the poll underscored that voters may trust the Democrats more. As I noted, my blog was published on December 7 and later that day a new poll was published that underscores my views. The poll had 2,000 respondents and was conducted by the Partnership

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Republicans Have a Compassion Gap But Trump Gives Democrats Momentum on Healthcare Anyway

Former President Donald Trump recently brought up the possible repeal of the Affordable Care Act (ACA) and has put his (and my) party in a bind. Republicans suffered at the polls on the very issue Trump has resurrected. Why is he raising the status of the landmark act again? In a post on Truth Social on November 25, Trump declared: “The cost of Obamacare is out of control, plus, it’s not good Healthcare. I’m seriously looking at alternatives.” He clearly caught his party by surprise. You could hear the collective signs and groans coming from Capitol Hill Republicans who survived the issue in the past. After some criticism, Trump sought to clarify his remarks but actually reiterated his stand. On November 29 on Truth Social, Trump stated: “I don’t want to terminate Obamacare, I want to REPLACE IT with MUCH BETTER HEALTHCARE. Obamacare Sucks!!!” Fellow candidate and FL Gov. Ron

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Medicare Advantage Insurers Focusing On Special Needs Plans And Growth Shows It

While Medicare Advantage (MA) has seen huge increases in enrollment since the beginning of the decade, forecasts suggest that enrollment growth will be reduced moving forward.  Many things factor into the slowdown, including a new rate environment, poor Star performance, and reaching saturation in certain areas of the country.  Nonetheless, MA continues to be a strong program and the most-lucrative place to be if you are an insurer. One segment of the MA program, Special Needs Plans (SNPs), however, are destined to continue to grow significantly moving forward.  This is driven in part by policies from the Centers for Medicare and Medicaid Services (CMS) and the significant financial opportunity plans see. As of November 2023, SNP and related program enrollment stood at over 6.6 million.  That is a 15% growth since January 2023. There are three types of SNPs: (1) Institutional SNPs or I-SNPs (the individual is a resident of

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American Healthcare Is A Huge Outlier In Terms Of Costs and Outcomes

I am writing this blog from the United Kingdom on the occasion of the 75th anniversary of the National Health Service (NHS). The British newspapers this year, as they were five years ago for the 70th Anniversary, were filled with a curious mix of messages about the NHS. On the one hand, Britons defend the NHS and take pride in the system that has been built over the last 75 years.  The NHS is always at or near the top of the most important issues at election time. At the same time, Britons are frustrated with many elements of the system, including long wait times and the hoops that must be jumped through for certain services as well as notable staff shortages and other deficiencies.  Some blame privatization over the past few decades as well as the miserly increases given to the NHS during the conservative government’s tenure over the

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