lcd Archives - Page 41 of 42 - The Healthcare Labyrinth

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

November 30, 2023 No Comments

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

November 29, 2023

November 29, 2023 No Comments

Cigna and Humana Exploring A Merger Stunning news on the health plan front with speculation that Cigna and Humana are entertaining a merger. This explains reports not too long ago that Cigna was thinking about giving up its Medicare Advantage (MA) line of business. The merger seems like a match made in heaven. Cigna is a commercial powerhouse, but its MA line is much smaller than Humana’s. Its MA line is struggling from a Star perspective. It sold its only Medicaid assets a few years ago. Humana is second only to United in MA and has a growing Medicaid line. Both plans have some provider assets as well. And Express Scripts, Cigna’s PBM and one of the nation’s big three, would be a huge asset for Humana. Humana has a subscale PBM asset. Earlier mega mergers (Aetna-Humana and Cigna-Anthem) fell apart due to federal and state pushback and footprint overlaps.

November 28, 2023

November 28, 2023 No Comments

Innovation In State And Federal ACA Exchange Programs Interesting article on policy brief from the Commonwealth Fund on various innovations occurring in the state-based and federal Exchange programs. As of 2023, 20 states operate a state-based marketplace and 30 rely on Healthcare.gov for sign-ups. Some state-based exchanges use the federal website for enrollment. States are experimenting with enrollment campaigns, simplified enrollment, auto-enrollment programs, health-equity requirements, and more. Article at link. The actual study is here: https://www.commonwealthfund.org/publications/issue-briefs/2023/nov/policy-innovations-affordable-care-act-marketplaces #aca #obamacare #exchanges #commonwealthfund Link to Article Mark Cuban’s Firm Partners With Expion Mark Cuban’s Cost Plus Drugs (CPD) is partnering with Expion to tackle the high costs of specialty drugs. A press release says CPD will integrate into Expion’s dynamic pricing technology. It says “consumers can be confident they are getting a fair price and the convenience of medication mailed directly to their homes.” #cuban #costplusdrugs #drugpricing #expion Link to Article Healthcare Bankruptcies

November 27, 2023

November 27, 2023 No Comments

Pro Publica Article on Health Plans Not Covering Mandated Services Pro Publica article recounts where health plans have not covered mandated services in state laws. It is easy to sensationalize mistakes, but health plans every day are approving treatments timely. (May require subscription.) #plandenials #healthplans Link to Article Will New Marketing Rules Hurt Big Plan Performance? Interesting article that says the new Medicare Advantage (MA) marketing rules could mean smaller plans now have a fighting chance against bigger ones, which seemed to enter into the variable and extraordinary compensation with agents and other entities to attract members. A new marketing clampdown in the 2025 rule would stop most of this. Note, too, a plan official saying that there may be loopholes in the new proposed rule. (May require subscription.) #marketing #medicareadvantage Link to Article Per Worker Healthcare Costs Increased 5.2% in 2023 More evidence that inflation is increasing for employer-provided

The Importance of Price Transparency In Healthcare Reform

November 27, 2023 No Comments

While website postings of hospital and health plan negotiated prices may not seem of particular importance, the nation’s modest move toward price transparency should bear fruit over time. It is one of the more important initiatives we have seen in healthcare reform as of late. With interoperability of data, price transparency will finally give us some useful information on the inner workings (even machinations) of negotiations between health plans and providers. What are the price transparency requirements? Both health plans (effective July 1, 2022) and hospitals (effective January 1, 2021) have been required to post various pricing information on their websites. Hospitals must report all their gross and net charges in a machine-readable format as well as at least 300 shoppable services (cash and payer prices) in a consumer-friendly format. Health plans must report allowed amounts and contracted rates for hospitals and other provider services for all in-network covered services

November 23 and 24, 2023

November 23, 2023 No Comments

The Healthcare Labyrinth Newsfeed will be off on November 23 and 24 for the Thanksgiving holiday. We will be back on November 27. Happy Thanksgiving to all! Stay safe! — Marc S. Ryan

November 22, 2023

November 22, 2023 No Comments

CMS’ UM Rule for Medicare Advantage Already Being Debated The new CMS 2024 Medicare Advantage (MA) rule prohibiting the use of most evidence-based criteria by MA plans is already being debated. Hospital lobbies are saying plans are out of compliance and January 1 has not even hit yet. Read my new companion blog at the blog tab on this site. I tell you why this rule is a terrible idea. Additional article here: https://www.modernhealthcare.com/politics-policy/health-plans-2024-medicare-advantage-rule-aha-cms-unitedhealthcare #hospitals #medicareadvantage #medicare #ncd #lcd #priorauthorization Link to Article Interesting Article on Cancer Care Between MA and FFS Interesting study on cancer care differences between MA and FFS. Touches on prior authorization and networks. Something for MA plans to think about as the PA debate heats up and the new UM rule comes unto effect. #medicare #medicareadvantage #cancercare #priorauthorization #networkadequacy Link to Article FL Blue Using AI to Speed Authorizations While many plans are being criticized

CMS’ Medicare Advantage Utilization Management Rule Sets A Terrible Precedent

November 22, 2023 No Comments

I have mentioned the new 2024 Medicare Advantage (MA) Utilization Management (UM) rule in two of my blogs recently. But here is a relatively short one to drive home the idea that the rule sets a terrible precedent. What does the rule do? It takes external evidence-based criteria off the table in favor of the policies used in the traditional Medicare program. Unless a FFS policy is not fully established, an MA plan must rely strictly on the traditional FFS program criteria instead of outside evidence-based clinical criteria. “Fully established” is not well defined, but CMS likely will argue that the NCDs and LCDs are fully established except in some small and extreme circumstances. Let’s set my argument up with three points. First, the rule was a direct result of the aggressive lobbying by provider groups opposed to the growth of managed care in Medicare. The Biden administration is sympathetic

Medicare Advantage Will Have Huge Challenges Ahead

November 20, 2023 No Comments

Medicare Advantage (MA) has been known as the most profitable sector of any health plan. With high premiums, a lucrative Star quality bonus, and chance to reduce medical expenses compared to the traditional fee-for-service program, plans have been able to register higher percentage and overall dollar margins in MA as compared with commercial and Medicaid. But as we have seen throughout the last few years, MA is not without its challenges and that will continue into the future. Surprisingly, at least one major player could be shopping its Medicare Advantage portfolio and getting out of the business. Here are the top challenges I see and areas MA plans need to keep an eye on. The collapse of the insurtechs Just a few years ago, the insurtechs were the darlings of investors. Investors believed that the insurtechs would leverage technology to transform healthcare, reduce costs, and drive quality. The investors also

2024 Star Ratings Turmoil Creates Huge Vulnerability for Medicare Advantage Plans

November 16, 2023 No Comments

While the Medicare Advantage (MA) Star Program has always made it difficult for plans to achieve and maintain high Star scores, the Star roller coaster ride has been much more profound over the past several years. We now have had two years of pretty bad news, which puts a blemish on the program (fair or not). What’s more, the percentage of high-scoring contracts and the percentage of enrollment in them are now below pre-COVID years. To refresh a bit on this, during the COVID pandemic, the Centers for Medicare and Medicaid Services (CMS) created fairly major calculation allowances for both Star 2021 (2019 and 2020 data) and 2022 (2020 and 2021 data). These allowances had the effect of boosting Star scores. We saw a surge in Star scores in 2022, including for plans that historically did not have a great track record of consistently hitting 4 Stars and above. However,

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