longtermcare

Major Changes Occurring in Medicare Part D

As a result of the Inflation Reduction Act (IRA), major changes are occurring in the Medicare Part D retail drug program.  Here is my best effort to explain the changes.  Phases of the program  It is first important to understand the four phases of the program.  Figures change from year to year with inflation so I am outlining the 2024 phases here. Deductible Phase: Here, the Part D member is required to cover all costs of his or her drugs up to the deductible amount.  In 2024, the deductible amount is set at $545.  But remember that both standalone Part D plans (PDPs, who enroll beneficiaries in Medicare Advantage (MA) Part C Only plans or traditional Medicare fee-for-service (FFS)) and MA-Part D plans can lower the deductible in their benefit design.  Some even eliminate it for some or all drugs. Initial Coverage Phase:  Here, costs are split between the plan

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April 12, 2024

Physician Pay Increases, But Hurt By Inflation A survey of physicians shows that pay increased by about 3% in 2023, but it was offset by high inflation. #physicians #providers https://www.fiercehealthcare.com/providers/physician-pay-rose-modest-3-2023-here-are-specialties-saw-biggest-gains Corporate And Hospital Ownership Of Physicians Continues I often talk about the pernicious effect of hospital and private equity ownership on healthcare costs. Hospitals drive changes in practice to higher-cost settings.  Together, the entities continually push fees higher. The ugly effects of the takeover of independent practices continues.  Not too long ago, studies showed about half of all physician entities owned by hospitals or private corporations and about 70% of all physicians employed by them.  Now, the latest stats show the two types of entities owning 58.5% of all physician entities.  They now own 77.6% of all physicians. For the first time, corporate practice ownership (30.1%) exceeded hospital and health system ownership of docs (28.4%). Additional article: https://www.fiercehealthcare.com/providers/more-and-more-physicians-are-working-under-hospitals-corporate-entities-report-finds #physicians #providers

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April 11, 2024

New Alzheimer’s Drug Spending Will Leap In Medicare The Centers for Medicare & Medicaid Services (CMS) says spending on the new Alzheimer’s drug Leqembi will leap well over estimates. CMS estimates that per member per month spending on Leqembi will rise from $1.67 in 2024 to $4.67 in 2025. This will bring spending across all Medicare to $3.5 billion in 2025. This threatens to add demonstrably to Medicare troubles and will hike Part B premiums. #drugpricing https://www.fiercehealthcare.com/regulatory/report-cms-projects-spending-leqembi-will-hit-35b-next-year Federal Appeals Court Reinstates Denial Case Against United A federal appeals court allowed a proposed class action lawsuit to continue. The case alleges that UnitedHealth Group used an algorithm to more stringently review patient claims for substance abuse treatment. Both prior authorization and medical claims denials are being closely scrutinized right now. (Article may require a subscription.) #priorauthorization #claimsdenials https://www.modernhealthcare.com/legal/unitedhealth-behavioral-health-lawsuit-substance-abuse Bipartisan Support For Medicare Doc Fix Senate Finance Chair Ron Wyden, D-OR, and

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Out-Of-Network Provider Billing Is Yet Another Provider Attack Issue Against Plans

The health plan industry has been in turmoil since an April 7, 2024 New York Times article appeared attacking prominent insurers and a data technology vendor, MultiPlan, for seemingly transferring huge out-of-network bills to commercial product patients.  Insurers are already battling major headwinds related to two other issues: So, is the MultiPlan issue yet another front on which health plans may have to fight? The public relations on the article alone has raised lawmakers’ eyebrows. The American Hospital Association has asked the federal Department of Labor to investigate both MultiPlan and large insurers to determine whether they engage in business practices that disadvantage patients and providers under the self-insured ERISA law and regulations. So what does MultiPlan do on behalf of health plans While the data and technology firm has networks and negotiation services, more and more MultiPlan is hired by insurers to scrutinize claims coming in from out-of-network providers

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April 10, 2024

Community Health Centers Suffering From Medicaid Disenrollment A new study of patients at community health centers are reporting major Medicaid disenrollments, which impacts the level of care that can be provided to these individuals.  Community health centers largely serve those in low-income areas. It also finds that about 75% of people who have lost Medicaid coverage are still disenrolled. Further, 32% have chronic conditions, 24% are children, 12% were adults older than 65 years of age and 12% had disabilities. #medicaid redeterminations #primarycare https://www.fiercehealthcare.com/payers/one-year-after-unwinding-community-health-centers-struggle-medicaid-reenrollment Provider Impacts Continue From Cyberattack Physicians continue to see major impacts due to the Change Healthcare cyberattack. This comes from an American Medical Association (AMA) survey of more than 1,400 individuals. Over 77% of those surveyed said they experienced service disruptions beginning Feb. 21 and still feel impacts. Over a third (36%) saw claims payments suspended and 32% have not been able to submit claims. About

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April 9, 2024

CMS Cuts Off Broker Access To SSNs Kudos for Kaiser Health News’ articles and focus on fraudulent switching in the Exchanges by untrustworthy agents.  The trend has caused a lot of misery for enrollees.  One problem was the access by agents and brokers to full social security numbers (SSNs).  As of today, that has been cut off by the Centers for Medicare and Medicaid Services (CMS) in the federal Marketplace.  Henry Kaiser is smiling from heaven. #kff #khn #fwa #exchanges #aca Link to Article Advocates And Insurers Urge Extension Of ACA Premium Enhancements For One Year Advocates and insurers are right that Congress should extend the enhanced premium subsidies for the Exchanges sometime in 2024.  They are set to expire Dec. 31, 2025, but should be extended to the end of 2026.  Why? Because plans submit proposed benefits and rates in early 2025 for 2026. If the premium enhancements are

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April 8, 2024

Study Finds Enrollees Like Zero-Premium Benefit Of MA A Harvard and Inovalon study finds that enrollees in Medicare Advantage (MA) with zero-dollar premiums are three times more likely to be minorities than white. They also are more likely to be urban. Researchers note that MA is not monolithic and that different benefit offerings appeals to enrollees. The same researchers have found that MA enrollees have fewer hospitalizations, yet more social determinant barriers. More are in Health Maintenance Organization (HMO) products which has lower costs. I would note that MedPAC and other critical organizations simply spend too little time on these types of stats.  I would also say that these kind of advantages for low and fixed income seniors will be ruined by poor rate hikes and terrible prior authorization rules that have just been finalized. It is a real shame. #medicareadvantage Link to Article Fitch Says Utilization Spikes Cloud MA

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Finalization of 2025 Policies: Major Changes Coming To Medicare Advantage and Part D

Just recently, the Centers for Medicare and Medicaid Services (CMS) finalized two important notices and rules impacting CY 2025: the 2025 annual rate-setting and policy notice as well as the draft 2025 Medicare Advantage and Part D rule. In this blog, I will write about both the 2025 final rule as well as the policy changes in the 2025 final notice. In my blog on April 4, 2024, I discussed the rate-setting components of the annual rate-setting and policy notice.  That blog is here: https://www.healthcarelabyrinth.com/final-2025-rates-for-medicare-advantage-remain-as-proposed/ . In addition, my February 1, 2024 blog on the draft notice is here and has more details: https://www.healthcarelabyrinth.com/2025-rates-for-medicare-advantage-plans-look-tight/ . They should be read together due to a few changes. In addition to the below, you can see my November 13, 2023 blog on the 2025 Medicare Advantage and Part D rule when it was first announced.  This has additional details but also should be

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April 5, 2024

CMS Allows Absolute Biosimilar Substitution In Part D Medicare Part D plans can now immediately substitute all FDA-approved biosimilars even if they are not deemed interchangeable by the drug approval agency, under the 2025 Medicare Advantage (MA) and Part D rule finalized by the Centers for Medicare and Medicaid Servies (CMS). Interchangeability is an extra step that drug makers take to substitute for brand biologics. The new rule will allow Part D plans to treat formulary substitutions of any biosimilars as maintenance changes as was allowed earlier just for interchangeables. The Biden administration has pushed for biosimilar adoption in many ways and this is yet another. This should begin to mean lower biologic costs for Medicare members. (Article may require a subscription.) #biosimilars #drugpricing #medicareadvantage #partd #medicare Link to Article CMS Changes MTM Criteria, Including Adding HIV/AIDs As Core Disease State The Centers for Medicare and Medicaid Services (CMS) finalized

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April 4, 2024

CVS Executive Pushes Back On Cuban And PBM Transparency Narrative CVS Caremark President David Joyner wrote and op-ed for Fortune to explain the innovation and transparency his pharmacy benefits manager (PBM) is engaged in.  It seeks to counter some of the press Mark Cuban is getting.  I will note that leadership at CVS Health overall is on a path of reform and innovation. #cvshealth #pbms #transparency Link to Article Good Wall Street Journal Article On Why We Need Site-Neutral Payments This Wall Street Journal article tells how hospitals and health systems are buying up physician practices.  In so doing, they are changing practice patterns and forcing their now doctor-employees to practice at hospital-owned settings.  This increases costs for sometimes low professional fees into gigantic bills because facility fees are added on.  The hospital lobby was successful stopping the start of site-neutral payments in Medicare, but I doubt they can hold

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