medpac Archives - Page 2 of 20 - The Healthcare Labyrinth

July 3, 2024

July 3, 2024 No Comments

CMS Published Recalculated 2024 Medicare Advantage Star Scores The Centers for Medicare and Medicaid Services (CMS) made public its revised Star scores for 2024 for Medicare Advantage (MA) plans today. The agency will have to fund an additional $1.3 billion after being rebuked by two courts on how it ignored regulations when setting guardrails for 2024. Actuarial firm Milliman says seventy-six MA contracts from 44 insurers (with almost 3.5 million members) saw increased Star scores. (Article may require a subscription.) #medicareadvantage #stars #cms https://www.modernhealthcare.com/medicare/medicare-advantage-star-ratings-recalculation-scan-elevance Application Backlogs And Lagging Redeterminations In Medicaid Healthcare policy advocates are reporting that more states might be falling behind in processing Medicaid applications due to all going on with redeterminations. The Centers for Medicare and Medicaid Services (CMS) recently said nine states and the District of Columbia will go past the June 2024 deadline for processing redeterminations. (Article may require a subscription.) #medicaid #coverage #redeterminations https://insidehealthpolicy.com/daily-news/latest-unwinding-data-show-states-falling-behind-medicaid-application-processing

July 2, 2024

July 2, 2024 No Comments

KFF Analysis Says MA Still Has Highest Margins A Kaiser Family Foundation (KFF) analysis says that the highest gross margins were found in Medicare Advantage (MA) in 2023. At the end of 2023, gross margins per enrollee in MA were $1,982 on average compared to $1,048 in the individual market. Medicaid was the lowest at $753. Group plans fell in the middle at $910. Despite some of the troubles health plan are having with MA right now, the data proves MA is still a good place to be, with high revenues per enrollee and the ability to reduce spending to generate good margins. KFF Analysis: https://www.kff.org/medicare/issue-brief/health-insurer-financial-performance/ #medicareadvantage #healthplans https://www.fiercehealthcare.com/payers/kff-insurance-market-had-highest-gross-margins-last-year Five States Extend Medicaid To Incarcerated Individuals Residents in Illinois, Kentucky, Oregon, Utah and Vermont will receive Medicaid or children’s health insurance coverage prior to release to minimize gaps in insurance coverage. #medicaid #chip #managedcare #coverage #healthcare #healthcarereform https://www.fiercehealthcare.com/payers/hhs-approves-incarceration-transition-coverage-five-states Biden And

July 1, 2024

July 1, 2024 No Comments

Healthcare World Panicking Over Chevron Deference Being Struck By Supreme Court With the Supreme Court striking down the Chevron deference as the backbone of promulgating regulations, the healthcare world is officially in panic. Most argue it will grind rule-making to a halt, create court backlogs and inconsistent rulings, and jeopardize health. I touch upon many of these points in my Thursday blog. I have mixed views on the ruling. I am not sure the world comes to an end as many think, but it will have vast implications. #chevrondeference #cms #hhs #regulations #healthcare https://kffhealthnews.org/news/article/supreme-court-chevron-deference-doctrine-health-care-policy-shockwaves/ House GOP Wants Fraud Investigation Of Exchanges Based on tens of thousands of Americans being illegally switched in the Exchange program and estimates that five million may wrongly be receiving premium subsidies, House GOP leaders are calling for the Department of Health and Human Services Office of Inspector General (HHS OIG) and the Government Accountability office

BCBSA Antitrust Settlement Is Bad For Healthcare Competition

July 1, 2024 No Comments

This past week, the Supreme Court announced that it declined to hear a case challenging the anti-trust settlement between employer groups and Blue Cross and Blue Shield (BCBS) licensee plans nationwide as well as its association (BCBSA). While no wrongdoing was admitted, BCBS plans were accused of anti-competitive behavior in the employer market by limiting employer group contracts to so-called “home plans” as well as the product options offered. It will pay a substantial settlement and must change some of the association’s practices. You could argue the decision is a small step forward, but the decision shows what is so demonstrably wrong with competitiveness in healthcare in America. It upholds the power of entities acting as an effective monopoly in America and the fallout could even foster further consolidation of health insurers. What are the Blues? The so-called Blues plans originated back in the early 20th century when alliances of

June 28, 2024

June 28, 2024 No Comments

Supreme Court Takes Out Chevron Deference In an expected move, the Supreme Court ruled that the Chevron deference precedent is no more. It has pulled back on the precedent and has now thrown it out. The precedent said that courts must give deference to regulatory agencies when they make reasonable interpretations of ambiguous laws. Proponents of deference said that it is a necessary power of regulatory agencies and that its elimination will now lead to a Wild West of court decisions in the future. Opponents argued that it created an administrative state that was far-reaching and one that went well beyond legislative intent. I will write a blog on the possible implications for healthcare. The removal of the deference rule does not change the fact that the Centers for Medicare and Medicaid Services (CMS) has often just got its regulations wrong or ignored them entirely. But it does have vast implications

June 27, 2024

June 27, 2024 No Comments

Walgreens’ Bleeding Continues Walgreens’ stock fell 24% as the drugstore chain slashed its profit outlook. It will reduce the size of its pharmacy footprint and continue to evaluate and right size its investment in VillageMD, primary care clinics tied to retail settings. Additional articles: https://www.healthcaredive.com/news/walgreens-to-reduce-villagemd-stake-close-stores/719984/ and https://www.modernhealthcare.com/providers/walgreens-villagemd-ownership-majority-stake and https://www.modernhealthcare.com/providers/walgreens-boots-alliance-shares-drop-store-closings-ceo-tim-wentworth (Some articles may require a subscription.) #walgreens #retailmeetshealthcare #primarycare https://www.fiercehealthcare.com/providers/walgreens-slashes-profit-guidance-plans-close-more-pharmacy-stores-turnaround HHS, FBI Issue Cyberattack Warning The Department of Health and Human Services (HHS) and Federal Bureau of Investigation (FBI) issued a warning to healthcare entities on cyber criminals’ phishing and ransomware. (Article may require a subscription.) #cyberattacks #healthcare #providers https://www.modernhealthcare.com/digital-health/hhs-fbi-phishing-ransomware-attack-advisory Insurers Have Opaque Requirements Even If They Cover GLP-1s For Weight Loss Insurers are being accused of being vague on requirements that need to be met if the insurance plans cover GLP-1s just for weight loss. Coverage criteria is sometimes vague, but where is the widespread coverage of the obscene costs

Strong Growth From May to June In Medicare Advantage

June 27, 2024 No Comments

As noted last month, I decided to continue my Medicare Advantage (MA) monthly enrollment blogs because of continuing strong month-over-month increases. Admittedly, the continuing growth is tied to remaining strong benefit packages for 2024 and appears to be isolated to a few big plans. Many plans will rein in benefits and geographies for contract year 2025 due to significantly deteriorating bottom lines. This is being caused by the return of robust utilization, inflation picking up in the healthcare sector (especially at hospitals), poor Star scores, negative rate increases for 2024 and 2025, and new regulatory burdens (such as the new prior authorization restrictions). The recent 2024 Star recalculation, which was precipitated by losses in court by the Centers for Medicare and Medicaid Services (CMS), will mean some plans refile bids and benefits for 2025. But we are hearing great reluctance to refile by many due to the quick deadlines, the negative

June 26, 2024

June 26, 2024 No Comments

Quarterly Drug Inflation Rebate Caps Save More Dollars For Medicare And Enrollees The Centers for Medicare & Medicaid Services (CMS) announced 64 new drugs subject to quarterly caps because price increases exceeded allowable inflation. This will mean additional rebates and lower out-of-pocket costs for 750,000 enrollees. The provision was passed as part of Medicare drug price negotiations in the Inflation Reduction Act (IRA). In addition, states increasingly are passing protections on drug manufacturers limiting 340b discounts to certain providers. This came after the Supreme Court upheld such state laws. I do not agree generally with the ruling as it perpetuates an abuse of 340b’s intent. Additional articles: https://thehill.com/policy/healthcare/4740963-biden-lower-prescription-drug-costs-medicare-inflation-reduction-act/ and https://www.modernhealthcare.com/supply-chain/340b-drug-program-discounts-arkansas-missouri-laws Press Release Here: https://www.cms.gov/newsroom/press-releases/hhs-announces-cost-savings-64-prescription-drugs-thanks-medicare-rebate-program-established-biden (Some articles may require a subscription.) #drugpricing #ira #medicare #partd #pdp #medicareadvantage https://www.fiercehealthcare.com/payers/hhs-lowers-64-prescription-drug-prices-under-medicare-rebate-program Sen. Wyden Wants CMS To Protect Small Independent Pharmacies Senate Finance Chair Ron Wyden, D-OR, is asking the Centers for Medicare & Medicaid

June 25, 2024

June 25, 2024 No Comments

Security Group Rates Healthcare Cyber Readiness SecurityScorecard gave healthcare a “B+” in cybersecurity, but some healthcare organizations had low ratings despite the group concluding that ratings were “higher than expected.” I tend to think that ratings are a bit inflated, but nonetheless it is a good service for the nation. #cyberattacks #healthcare https://www.fiercehealthcare.com/health-tech/report-90-healthcare-orgs-get-b-cybersecurity-medical-devices-fall-below-mark Bipartisan Group Of Lawmakers Wants Greater MA Restrictions On AI Use A bipartisan group of senators and representatives are back at it, touting the agenda of provider lobbies. The group sent a letter to the Centers for Medicare and Medicaid Services (CMS) asking the agency to rein in the use of AI in prior authorizations and to potentially suspend the use of internal criteria until such time CMS rules can be written. Additional articles: https://www.modernhealthcare.com/politics-policy/medicare-advantage-ai-restrictions-prior-authorization and https://insidehealthpolicy.com/daily-news/congress-cms-step-oversight-ai-algorithms-ma-prior-authorization and https://www.beckerspayer.com/policy-updates/tougher-rules-needed-for-medicare-advantage-ai-51-lawmakers-say.html and https://thehill.com/policy/healthcare/4739152-bipartisan-lawmakers-increased-ai-oversight-medicare-advantage-coverage/ (Some articles may require a subscription.) #ai #medicareadvantage #priorauthorization https://www.statnews.com/2024/06/25/medicare-advantage-ai-tools-denial-unitedhealth-lawmawkers-cms/ Analysis Of ACA Preventive Services Lawsuit

June 24, 2024

June 24, 2024 No Comments

Supreme Court Declines To Hear BCBS Antitrust Case The Supreme Court declined to hear a case challenging the anti-trust settlement between the federal government and BCBS plans nationwide. While no wrongdoing was admitted, BCBS plans were accused of anti-competitive behavior in the employer market because it limited employers to contracting with BCBS entities in their headquarters’ area and required a threshold for Blues revenue. The appeals court argued the settlement does not preclude future actions. The high court agreed. Several employers argued the settlement was not enough and that it did preclude certain actions over time. I will be writing about this soon. While the settlement was somewhat of a defeat for the Blues and its association, it actually tends to underscore the anti-competitive aspects of the broader healthcare market and protects the Blues. Additional articles: https://www.modernhealthcare.com/legal/supreme-court-bcbs-settlement-home-depot and https://www.beckerspayer.com/payer/supreme-court-rejects-home-depots-challenge-to-2-7b-bcbs-settlement.html (Some articles may require a subscription.) #bcbsa #blues #healthcare #coverage #employercoverage

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