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June 10, 2024

Elevance Wins Star Lawsuit A second lawsuit has been decided in favor of a Medicare Advantage (MA) plan and against the Centers for Medicare and Medicaid Services (CMS) on the calculation of Star scores. In this case, Elevance Health won its suit and a judge declared that Georgia contract scores must be revised. It will be increasingly difficult for CMS to ignore these rulings. I will write on this on LinkedIn tomorrow. (Article may require a subscription.) #medicareadvantage #cms #stars #elevancehealth https://www.modernhealthcare.com/insurance/elevance-medicare-advantage-star-ratings-lawsuit-cms White House Announces Cybersecurity Support For Hospitals The White House announced that Microsoft and Google will provide free or discounted support to help hospitals strengthen their cybersecurity. (Article may require a subscription.) #hospitals #cybersecurity https://www.modernhealthcare.com/politics-policy/google-microsoft-cybersecurity-rural-hospitals-safety-net Supreme Court To Hear Hospital Funding Case The Supreme Court said it will review a lower court decision that limits Medicare payments for hospitals under the federal disproportionate share hospital program. It is a rather

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Digging Into My Modest Election-Year Proposal For Healthcare Reform: Part 1 — The Importance Of Price Reform

This blog is one in a three-part series that digs into my modest proposal for healthcare reform published at this site on May 27, 2024. See that blog here to review my proposal thoroughly: https://www.healthcarelabyrinth.com/a-modest-election-year-proposal-for-healthcare-reform/ . Much of my proposal is taken from my book, The Healthcare Labyrinth, available at this site and through leading bookseller websites. It is available in print, ebook, and audiobook forms. — The importance of price reform In my “A Modest Election-Year Proposal For Healthcare Reform” blog on May 27, 2024, I stressed that the cornerstones of reform are three key tenets – driving affordable universal access, reforming price, and pivoting to care management from our obsession with utilization management. I am going to start with price reform in this blog and in later blogs cover the other two tenets. In the May 27, 2024 blog, I argue that we need to fundamentally tackle price

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June 7, 2024

Oscar Continues Good Performance, Lays Out Strategy Oscar Health reports its first quarterly net profit and hit 1.5 million enrollees in the Exchanges. It plans on investing in individual coverage health reimbursement arrangements (ICHRA) in tandem with its Exchanges offerings as well as re-entering Medicare Advantage. Additional article: https://www.beckerspayer.com/payer/oscar-health-plans-to-double-its-membership-5-things-to-know.html #oscar #exchanges #aca #obamacare #ichra #medicareadvantage https://www.fiercehealthcare.com/payers/oscar-health-growth-ambitions-doubling-its-footprint-planned-ichra-products-launch-and-more The Troubles Of Retail Meets Healthcare Good article on the general struggles with low-reimbursed primary care and additional challenges retailers have had. #retailmeetshealthcare #primarycare #healthcare https://www.fiercehealthcare.com/retail/industry-voices-walmarts-exit-health-centers-reflects-broader-challenges-primary-care Kroger Health Offering GLP-1s Kroger Health joins a growing number of providers driving expensive GLP-1 weight-loss drugs.  This is bound to continue to drive the shortages those with disease states face. (Article may require a subscription.) #kroger #weightlossdrugs #drugpricing https://www.modernhealthcare.com/patient-care/kroger-health-little-clinics-glp-1s-wegovy-zepbound Walgreens Will Not IPO Boots Struggling Walgreens Boots Alliance Inc. is killing an initial public offering for its UK Boots drug chain. It may still be looking for

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June 6, 2024

Medicaid Redeterminations Challenge Plan Finances More coverage of the challenges facing Medicaid managed care with dropping enrollments and rising risk.  I pointed out this possibility in a recent blog here: https://www.healthcarelabyrinth.com/health-plan-economics-part-3-how-falling-medicaid-enrollment-is-impacting-health-plans-and-providers-alike/ (Article may require a subscription.) #medicaid #redeterminations #healthplans managedcare https://www.modernhealthcare.com/insurance/how-medicaid-redeterminations-process-affecting-insurers CVS, Humana Will Lead Cuts To Medicare Advantage A very good article reporting on the current issues facing Medicare Advantage (MA) plans in 2025.  Many plans, especially Humana and CVS Aetna, are expected to pare added benefits back dramatically and could even contract geographies. Hundreds of thousands are expected to have to change plans.  How this all plays out is anyone’s guess, but United could pick up many lives. One interesting note is that margins are eroding but appear to be better with Dual Eligible Special Needs Plans (D-SNPs). In 2021, D-SNPs had margins of 6.4% vs. 2.2% for MA overall. See these blogs I did on the MA

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CMS’ TukeyGate: Lawsuit Decision Threatens To Unravel Much of Medicare Advantage Star Scoring in 2024 and 2025 and Next Year’s Bids And Benefits

A bombshell legal decision this week from a federal district judge threatens to unravel much of the Centers for Medicare and Medicaid Services (CMS) Star process. CMS may have to revisit 2024 Star ratings across the Medicare Advantage (MA) industry, pay out several hundred million more in bonuses, and revisit the bids and benefit designs already in flight for next calendar year. The entire issue is a bit arcane, so let’s break it down here and then get to the implications. The lawsuit and decision Scan Group, a prominent and highly successful non-profit MA plan based in California and serving a number of western states, has successfully won a challenge in a federal district court on its Star ratings for 2024. The case centers on the introduction of the Tukey outlier formula that CMS implemented beginning with the 2024 ratings. The court decision said CMS violated the Administrative Procedures Act

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June 5, 2024

Nursing Home Staffing Mandate Under Fire President Biden’s pro-union nursing staffing mandate is now facing bipartisan opposition in Congress. The rule threatens to create a consolidation in the nursing home industry with small, independent firms selling to big chains because they cannot meet or afford standards. A lawsuit also seeks to challenge Biden’s authority to set such staffing requirements. (Article may require a subscription.) #nursinghomes #healthcare https://www.modernhealthcare.com/providers/cms-nursing-home-staffing-mandate-james-lankford-joe-manchin Antitrust Case Against Sutter Will Again Proceed A U.S. appeals court overturned a 2022 ruling that said Sutter Health did not engage in anticompetitive practices. The case is now reopened due to the fact that the jury did not hear crucial evidence. (Article may require a subscription.) #antitrust #healthcare https://www.modernhealthcare.com/legal/sutter-health-antitrust-lawsuit-verdict-appeal Prominent Senator Lays Blame on HHS For Cyberattacks Senate Finance Chairman Ron Wyden, D-OR, laid blame for the recent Change Healthcare cyberattack on the Department of Health and Human Services (HHS), saying it

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June 4, 2024

Scan Wins Lawsuit Over Star Ratings A federal judge said the Centers for Medicare and Medicaid Services violated the Administrative Procedures Act when it deviated from current regulations to calculate Star scores for 2024.  It was a significant win for Scan and Medicare Advantage (MA) plans in general.  It also could throw 2025 bids and benefit designs as well as 2025 Star measure calculations into flux.  I will have a blog on this on Thursday.  In the meantime, check out my LinkedIn post on the issue here: https://www.linkedin.com/posts/marc-s-ryan-%F0%9F%87%BA%F0%9F%87%A6-1a99529_scan-wins-medicare-advantage-star-ratings-activity-7203759541530808320-CEd6?utm_source=share&utm_medium=member_desktop Additional articles: https://www.beckerspayer.com/payer/scan-beats-cms-in-medicare-advantage-star-ratings-lawsuit.html and https://www.fiercehealthcare.com/payers/judge-sides-scan-health-plan-dispute-cms-over-medicare-advantage-star-ratings and https://www.healthcaredive.com/news/scan-health-plan-medicare-advantage-star-ratings-lawsuit/717976/ (Some articles may require a subscription.) #stars #medicareadvantage #cms https://www.modernhealthcare.com/law-regulation/scan-medicare-advantage-star-ratings-lawsuit-cms Steward Gets Permission On Timeline To Sell Assets Bankrupt Steward Health Care received permission from a bankruptcy judge to sell off its assets on an aggressive timeline.  Federal and state regulators have complained that they may not be able to perform adequate reviews. It is

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June 3, 2024

BCBS KC Will Exit Medicare Advantage Blue Cross and Blue Shield Kansas City has announced it will exit the Medicare Advantage (MA) program.  This shows the challenges created by some poor decisions by the Centers for Medicare and Medicaid Services (CMS).  I had said that many regional plans would pick up lives as major plans offload them due to investor concerns.  Will this be a trend or an exception? #medicareadvantage #coverage #cms https://www.fiercehealthcare.com/payers/blue-kc-exiting-medicare-advantage-market-2025-due-regulatory-demands Cigna Layoffs Cigna’s Evernorth services arm will lay off some specialty health center employees in favor of a focus on primary care. (Article may require a subscription.) #cigna #evernorth #healthcare #layoffs https://www.modernhealthcare.com/insurance/cigna-evernorth-care-layoffs-closings CVS Searching For Investment Partner For Oak Street This article speculates a good deal on CVS Health’s search for an investment partner to expand Oak Street, its primary care arm. (Article may require a subscription.) #cvshealth #primarycare https://www.modernhealthcare.com/providers/cvs-health-oak-street-private-equity-investment Grassley Wants To Understand Ascenion’s Ties To

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Hospitals Drive Up Overall Healthcare Costs Considerably

As a former board member of two hospitals (a children’s medical center and academic medical center), I am sympathetic to the unique services that hospitals provide and the role many of them play in the education of doctors, nurses, and more. But it is also clear that hospitals are inefficient organizations that continue to drive up costs overall in the healthcare system. While some hospitals are reforming, others cling to the status quo. Hosptial lobbies are also stuck in the past and bucking change. Here are a few areas and recent studies that point to the role hospitals play in driving up healthcare costs: Hospital consolidations drive up costs, not lower them. Quality often suffers. New statistics from the Federal Trade Commission suggest that about 90% of hospital markets are highly concentrated due to the massive mergers and consolidations that have occurred over the past many years. What’s more studies

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May 31, 2024

HHS Clarifies Responsibility For Change Healthcare Breach Notifcation The Department of Health and Human Services (HHS) announced today that UnitedHealth Group would inform people about privacy breaches resulting from the Change Healthcare cyberattack. Providers, payers, and others may direct United to do so.  Previous guidance was ambiguous.  HHS FAQs were updated and clarified the issue. HHS FAQs: https://www.hhs.gov/about/news/2024/05/31/ocr-updates-change-healthcare-cybersecurity-incident-faqs.html (Some articles may require a subscription.) #changehealthcare #cyberattacks #providers #payers https://www.modernhealthcare.com/cybersecurity/change-healthcare-hack-notification-requirements-hhs Centene Also Reports Pressure on Medicaid Finances On the tail of United, Centene is now reporting significant medical expense pressure tied to the Medicaid disenrollment due to the return of Medicaid redeterminations.  The article discusses that other plans are not seeing severe pressure.  It also discusses Medicare Advantage (MA) financial problems. Medicaid plans had received relief in the form of higher rates during COVID, but as I noted earlier state revenue is drying up and might spell issues for Medicaid managed

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