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May 24, 2024

Nursing Homes Sue On Staffing Ratios Nursing home associations are suing in federal court to overturn a new staffing ratio rule. The rule will lead to a massive consolidation in the industry and the loss of independent homes. Additional articles: https://www.modernhealthcare.com/providers/nursing-home-staffing-mandate-ahca-lawsuit and https://insidehealthpolicy.com/daily-news/nursing-homes-sue-cms-over-staffing-rule-aarp-backs-agency (Some articles may require a subscription.) #nursinghomes #staffing https://www.fiercehealthcare.com/providers/nursing-home-groups-file-lawsuit-block-cms-staffing-mandate More Layoffs At Highmark Highmark Health, a PA-based Blue, is undergoing a third round of layoffs. Additional article: https://www.modernhealthcare.com/labor/highmark-health-layoffs-engen (Some articles may require a subscription.) #healthcare #healthplans #layoffs https://www.beckerspayer.com/workforce/a-third-round-of-highmark-job-cuts.html House Budget Committee Rallies Around Consolidation Scrutiny And Site-Neutral Policies The House Budget Committee seems to have a bipartisan consensus on reining in hospital consolidations and mergers. As well, there seems to be consensus on the need to enact site-neutral payments.  Hospitals will vigorously object and try to torpedo any bill. A bill to begin such policies passed the House but did not in the Senate. #hospitals #consolidations #mergers #manda

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May 23, 2024

Physician Pay Up; Docs Want Medicare Fix Physician pay increased by 5.9% in 2023 after dropping 2.4% in 2022. At the same time, physician groups were on Capitol Hill lobbying for a Medicare physician payment fix and more changes to prior authorization. Some indicated that it was hard to compete against hospital-owned docs because of higher payments. The independent docs want site-neutral payments implemented. Additional article: https://www.fiercehealthcare.com/providers/20-highest-paid-specialties-2023-doctors-see-6-boost-pay-doximity #physicians #rates #medicareadvantage #medicare #priorauthorization #siteneutral https://www.medpagetoday.com/practicemanagement/reimbursement/110302 Numerous Layoffs Hitting Healthcare Numerous layoffs are hitting healthcare. In the health plan world there have been notable layoffs, including at United’s Optum. UPMC’s health system is laying off as is Walmart in its soon-to-be-shuttered healthcare division. Additional articles: https://www.fiercehealthcare.com/finance/fierce-healthcare-layoff-tracker-highmark-axes-200-jobs-march and https://www.modernhealthcare.com/providers/walmart-health-layoffs-virtual-care-phoenix (Some articles may require a subscription.) #walmart #upmc #healthcare https://www.fiercehealthcare.com/providers/upmc-mckinsey-layoffs-organizational-restructure-university-pittsburgh-medical-center Express Scripts Embracing Independent Pharmacies In an effort to boost its image after bad press regarding pharmacy benefits managers (PBMs), Express Scripts is entering

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Election Update And The Potential Role of Healthcare Issues

While healthcare has been displaced by other economic issues and immigration as the compelling Election 24 issues of the day, I have taken the position that healthcare could very well play a role in this year’s election outcome. How so? How close is it? Let’s take a look at how close things are for the presidency and the houses of Congress. For reliable forecasts on elections, I always go to at RealClear Politics. It is very reliable and unbiased.  I also like the fact it uses polling averages to determine the current prospects of various political contenders. In addition, I have a special connection as its publishing arm, RealClear Publishing, was one of the publishers of my book, The Healthcare Labyrinth (available via this site). I went to RealClear Politics for the presidential and Senate races and looked at a few other sources for the House races. Presidential race –

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May 22, 2024

Providers Lose 340B Lawsuit Appeal To Drug Makers A U.S. Court of Appeals ruled that drug makers can limit and impose conditions on pharmacies participating in the 340B drug discount program. The federal government had sided with providers, but a federal court ruled against that position. I am no friend of drug makers but this ruling is a good one.  The 340B program has been corrupted and abused by providers. It is not fulfilling its mission of getting discounted drugs to the most vulnerable.  Additional article: https://insidehealthpolicy.com/inside-drug-pricing-daily-news/second-appeals-court-rules-drug-makers-can-impose-340b-restrictions (Some articles may require a subscription.) #340b #drugmakers #hospitals #providers https://www.healthcaredive.com/news/appellate-court-rules-drugmakers-340b-novartis-pharmacies-specialty/716814 Hospitals Attack Drug Makers On Price and Shortages — But Here Is The Other Story A new analysis by a hospital lobby says that drugmaker price hikes as well as drug shortages jeopardize patient access to care. I do not doubt the conclusion, but would also point out that hospitals abuse the system

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May 21, 2024

Wyden Wants Tough Stance On Exchange Agents and Brokers Finance Chair Ron Wyden wants the Centers for Medicare and Medicaid Services (CMS) to crack down on rogue brokers and agents in the nation’s Exchange signup process.  (Article may require a subscription.) #exchanges #agents #brokers #fwa  https://www.modernhealthcare.com/insurance/ron-wyden-cms-exchange-marketers-aca Huge Proliferation Of Firms Devoted Just To GLP-1s More and more startups are popping up to promote GLP-1 use just for weight loss.  This caters to the better off.  Hims and Hers has been around for awhile and is jumping on the bad wagon but by offering compounded versions, largely due to the shortages. The overall trend has been a disservice to the nation as it tends to create shortages for those who need the drugs for disease state treatment. A new analysis by Kaiser says high prices of such drugs also lock out those with modest incomes. Additional article: https://www.modernhealthcare.com/digital-health/hims-hers-wegovy-weight-loss-drugs-novo-nordisk-eli-lilly-zepbound (Some articles may

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May 20, 2024

Optum Announces Transparent-Like Pharmacy Model Pressured by the rise of transparent pricing models, Optum Rx has announced its own approach to greater transparency. I would call it transparency-like. It is offering a single per member cost, encompassing retail, home delivery, specialty drug and rebate components. #transparency #pbms #optumrx https://www.fiercehealthcare.com/payers/optum-rx-puts-emphasis-predictability-new-pricing-model Health Plan CEO Compensation Fierce Healthcare assembles the top 5 in terms of health plan compensation in 2023. #healthplans https://www.fiercehealthcare.com/payers/unitedhealth-ceo-andrew-witty-was-2023s-highest-paid-payer-ceo-heres-what-his-peers-earned Government To Fund $50 Million For Cybersecurity The Department of Health and Human Services’ (HHS’) research funding agency will provide more than $50 million to developers who can build a scalable cybersecurity platform to protect hospitals for cyberattacks. Additional articles: https://www.modernhealthcare.com/cybersecurity/hhs-arpa-h-hospital-cyberattacks-unitedhealth-change-healthcare-ascension and https://www.healthcaredive.com/news/healthcare-cybersecurity-arpa-h-upgrade-program/716609/ and https://www.healthcareitnews.com/news/hhs-offers-50m-help-providers-patch-ransomware-vulnerabilities (Some articles may require a subscription.) #cyberattacks #healthcare https://www.fiercehealthcare.com/health-tech/hhs-arpa-h-offering-over-50m-hospital-cybersecurity-platform-pitches Senate Finance Joins HELP Committee In Wanting To Reform Medicare Doc Pay The Senate Finance Committee joins the HELP Committee in wanting to fix the Medicare physician payment

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What The Recent Report On The Medicare Trust Funds Tells Us About Healthcare Policy

Each year, the trustees of both the Social Security and Medicare Trust Funds issue reports about the fiscal health of the funds. The practice is meant to spark a public policy analysis within the executive and legislative branches, but it almost never does. This year is no different. The Biden administration touted the recent report on the extension of the solvency of the Medicare Part A Trust Fund as some sort of evidence that it has worked diligently to ensure Medicare’s future. In its election-year press release from Health and Human Services (HHS) Secretary Xavier Becerra, it touted supposed remarkable achievements on the Medicare stabilization front: “The Biden-Harris Administration has left no stone unturned in our efforts to strengthen and preserve Medicare, not just for our parents and grandparents but for our children and generations to come.” But nothing could be further from the truth. The administration and Democrats have

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May 17, 2024

Mental Health Inequities Have Huge Toll Inequities in mental health will cost $332 billion on premature death and $116 billion in productivity loss in 2024. These combined numbers could grow to $1.3 trillion by 2040. The inequities also mean greater healthcare spending. $5.3 billion in 2024 excess costs are tied to overutilization and excessive reliance on the emergency room for acute mental health incidents. That number could rise to $17.5 billion in 2040. #mentalhealth #behavioralhealth #healthcare https://www.fiercehealthcare.com/payers/mental-health-inequities-cost-478b-unnecessary-expenses-2024 Bipartisan Group Of Senators Want To Reform Retail Drug PA A group of senators want to further rein in and reform prior authorization (PA) for retail prescription drugs.  The proposed bill has no details, but senators say they want to digitize PAs.  Perhaps they don’t understand that Medicaid, Medicare Advantage, and Part D have some of the strictest turnaround times and there is a robust electronic PA process in America. (Article may require

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May 16, 2024

While Admirable, CalAIM Is Struggling California has fashioned an ambitious healthcare and social service experiment known as CalAIM, but some aspects on the community health and services front are struggling. Many states have mimicked California by requesting similar but less ambitious initiatives through Medicaid. With the majority of health outcomes tied to social factors and not underlying clinical conditions, it is a worthy pursuit overall.  My fear is that California may be trying too much too quickly. (Article may require a subscription.) #ca #calaim #healthcare #sdohs #socialdeterminants #medicaid #managedcare https://www.modernhealthcare.com/providers/california-medicaid-medi-cal-calaim-gavin-newsom-community-health-workers-nonprofits Private Equity Firms Tout Value In Healthcare Private equity is on a marketing campaign to tout the value it brings. Here is an example of what they are saying, although I think the negatives far outweigh the positives. (Article may require a subscription.) #privateequityfirms #healthcare https://www.modernhealthcare.com/digital-health/blackstone-equity-healthcare-data-costs Ascension Being Credited For Transparency On Cyberattack Multi-state Catholic hospital system is being credited

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More Disturbing Trends On Medicare Advantage Prior Authorization

In these pages I have bemoaned the fact that the Centers for Medicare and Medicaid Services (CMS) and Capitol Hill are taking the managed care out of Medicare Advantage (MA). MA’s value proposition is based on the plans’ ability to save dollars in furnishing traditional Medicare fee-for-service (FFS) benefits and passing on the savings in the form of reduced cost-sharing, filling in gaps in the traditional benefit, and adding additional benefits. But when CMS reins in the ability to save these dollars, it will have a direct impact on the benefits American seniors and people with disabilities see. What’s more, the antiquated FFS system is fraud-ridden and of poor quality. We need innovation not mimicking the old way of delivering care. But by hobbling MA plans’ innovation, CMS and Capitol Hill are setting MA and the overall healthcare system back. Driven by some strange need to ingratiate themselves to provider

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