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March 21, 2024

Medicare To Cover GLP-1s For Specific Conditions Medicare Part D will cover obesity drugs if they are approved for specific medical conditions. For example, Novo Nordisk’s Wegovy, just received approval from the Food and Drug Administration (FDA) to reduce risk of stroke or heart attack in people with cardiovascular disease and who are obese/overweight. The same rule will apply to Medicaid. The decision does not make these weight-loss drugs available more broadly. Additional article on trials showing GLP-1s slowing kidney disease progress and cardiovascular events: https://www.managedhealthcareexecutive.com/view/ozempic-reduces-kidney-disease-progression-cardiovascular-events-by-24- Additional articles: https://www.fiercehealthcare.com/payers/wsj-cms-broadens-part-d-coverage-obesity-drugs and https://www.medpagetoday.com/publichealthpolicy/medicare/109305 #weightlossdrugs #medicare #medicaid Link to Article GOP Senators Want HHS To Explain Delay In Responding To Cyberattack Senate HELP Committee Ranking Member Bill Cassidy, R-LA, and member Tommy Tuberville, R-AL, have asked why it took the Department of Health and Humans Services (HHS) almost two weeks to respond to the Change Healthcare cyberattack. Check out my blog here on

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The Change Healthcare Cyberattack:  What It Is and Its Implications

A number of Healthcare Labyrinth blog readers asked me if I would write on the Change Healthcare cyberattack and its implications. Below is what I have culled together over the past month and my thoughts about what happened and repercussions. I will attempt to write at a high level and not get too technical – in part because details are still scarce. Overview of what happened We are a month into the Change Healthcare cyberattack. On February 21, 2024, Change Healthcare reported that it was a victim of a cyberattack. It appears that the attack was a ransomware attack by the BlackCat organization and affiliates. It is known to target the healthcare industry. Change Healthcare may have paid a ransom of as much as $22 million, but this has not been confirmed. The attackers claimed about six terabytes of PHI and PII data were stolen (this could be tens of

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March 20, 2024

Both Class-Action And Provider Lawsuits Filed Against Change Change healthcare will face both class-action lawsuits from patients as well as lawsuits from providers impacted by the Change Healthcare cyberattack. Meanwhile, provider groups, including the American Hospital association, are arguing the government and UnitedHealth Group responses have been inadequate and are pressing lawmakers to intervene with the Department of Health and Human Services (HHS).  The complaint is that advanced payments are simply not enough. Congress is also asking HHS if a bill needs to pass granting the agency flexibility in collecting advanced payments. My blog tomorrow will be a comprehensive review of the Change cyberattack. Additional articles: https://www.modernhealthcare.com/politics-policy/change-update-aha-financial-help-congress and https://insidehealthpolicy.com/daily-news/lawmakers-does-hhs-need-authority-allow-flexible-repayments-after-cyberattack (Some articles may require a subscription.) #changehealthcare #cyberattacks Link to Article Health Equity In MA Star Ratings Could Be Boon For Some, Hurt Others A new health equity bonus formula will come to the Medicare Advantage (MA) star program in a

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March 19, 2024

Elevance Health To Buy Kroger Specialty Pharmacy In an effort to further build out its Carelon service subsidiary, Elevance Health is buying Kroger Specialty Pharmacy.  This will add to its growing PBM offerings. Additional articles: https://www.fiercehealthcare.com/payers/elevance-health-acquire-kroger-specialty-pharmacy and https://www.modernhealthcare.com/finance/elevance-health-carelonrx-kroger-specialty-pharmacy (Some articles may require a subscription.) #kroger #elevancehealth Link to Article ERISA Update RFI Means Battle Lines Drawn A House committee issued a request for information to see how the employer self insurance laws (ERISA) should be updated after 50 years.  Providers of course are asking for major regulation, while employers want to ensure pre-emption of state laws. Abandoning pre-emption would add demonstrably to costs.  ERISA provides the most coverage in America and it should not be played with. #erisa #coverage #employers #providers Link to Article PBM Reform Dead For Now No deal could be reached on pharmacy benefit manager (PBM) reforms despite bipartisan support in each house of Congress.  Reforms will

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March 18, 2024

Progress And Support During Change Healthcare Cyber Attack Some services have been restored by Change Healthcare and more are readying.  Change says that claim preparation software for providers will soon come back online. Electronic payments have come back online. United says it has made more than $2 billion in advanced payments from its program. United as an insurer, Highmark, and the Blue Cross and Blue Shield Association have developed advanced payment programs for providers, but many other insurers are moving slowly on the idea. Other insurers are contracting with Change competitors to help providers file claims. They also are extending claim deadlines. Provider groups say aid is not enough. The Centers for Medicare and Medicaid Services is also asking states to submit state plan amendments so they can advance Medicaid payments. Additional articles here: https://www.modernhealthcare.com/cybersecurity/change-update-unitedhealth-systems-progress and https://www.modernhealthcare.com/insurance/change-outage-prior-authorization-pay and https://www.modernhealthcare.com/government/change-update-cms-medicaid-reimbursements and https://www.healthcaredive.com/news/change-healthcare-cyberattack-medicaid-flexibilities-american-hospital-association-survey/710561/ (Some articles may require a subscription.) #changehealthcare #cyberattacks Link

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Strong Medicare Advantage Enrollment Growth Continued From February To March

In my January 22, 2024 Healthcare Labyrinth Blog ( https://www.healthcarelabyrinth.com/great-news-for-insurers-and-medicare-beneficiaries-january-2023-to-january-2024-medicare-advantage-growth-rebounds/ ), I told you about the exciting news of Medicare Advantage’s (MA) continued strong growth (from January 2023 to January 2024) as well as a nice recovery from a bit of a sluggish increase from January 2022 to January 2023. As I always do, I publish a follow-up blog in the first few months of each year given continuing growth outside of the main enrollment season from October 15 to December 7. This is because of a somewhat recent change that allows members enrolled in a MA plans to change to a different MA plan or go back to traditional Medicare (and also choose a standalone Part D (PDP) plan. This occurs from January 1 to March 31 of each year. Because of this, MA plans continue to advertise vigorously to attract additional members and there is net new enrollment

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March 15, 2024

Medicare Households Spend The Most On Healthcare Costs Good article from Fierce Healthcare and analysis from Kaiser Family Foundation on healthcare spending in Medicare households. Medicare households spend more on healthcare than other households. Health spending burden was twice as high. Analysis by KFF: https://www.kff.org/medicare/issue-brief/medicare-households-spend-more-on-health-care-than-other-households/ #coverage #costs #medicare #medicareadvantage Link to Article AHA Survey Says 94% Of Hospitals Impacted By Change Cyber Attack While for-profit hospitals are going out of their way to send a message of stability after the Change Healthcare cyber attack, an American Hospital Association (AHA) says 94% of hospitals were impacted. Mounting evidence from providers (impacted by up to $1 billion a day in revenue) and health plans (claims dried up!) that this will have big and lingering impacts. While some systems are back online, the sheer magnitude of the missed throughput of transactions is amazing and will take time to work through the backlog and

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March 14, 2024

Change Pharmacy Network Back On While insurtechs overall have struggled, at least three – Alignment Healthcare, Devoted Health, and Clover Health – appear to be doing well.  Clover Health had an adjusted EBITDA loss of $19.1 million in the fourth quarter and a full-year loss of $44.7 million last year.  This is significantly better than in 2022. Its medical loss ratio (MLR) is projected to be just 81.2% for 2024. It expects adjusted EBITDA profit up to $20 million. Since it began, it, too, amassed a sizeable membership. #clover #insurtechs Link to Article Federal Appeals Court Deals Drug Makers A Blow On 340B A federal appellate court said that a state law could be reconciled with the federal 340B drug discount program. Drug makers are fighting to rein in the discounts they give to various pharmacies and hospitals.  While I find Big Pharma’s constant lawsuits defending their unreasonable pricing system

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The Trump-Biden Great Entitlement Debate

After promising not to touch Social Security and Medicare throughout his campaign, GOP 2024 candidate and former President Donald Trump seemingly reopened his views on the issue – only to have Biden attack him and then Trump having to clean up after. Here is the back and forth (this could be the only real debate we see from the candidates) : In comments to a journalist on whether he had changed his views on entitlements, Trump declared: “So first of all, there is a lot you can do in terms of entitlements in terms of cutting and in terms of also the theft and the bad management of entitlements, tremendous bad management of entitlements. … There’s tremendous amounts of things and numbers of things you can do. So I don’t necessarily agree with the statement.” It seems reasonably clear that Trump likely was talking about cleaning up administration and fighting

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March 13, 2024

Clover Health Readying For Positive Margin While insurtechs overall have struggled, at least three – Alignment Healthcare, Devoted Health, and Clover Health – appear to be doing well.  Clover Health had an adjusted EBITDA loss of $19.1 million in the fourth quarter and a full-year loss of $44.7 million last year.  This is significantly better than in 2022. Its medical loss ratio (MLR) is projected to be just 81.2% for 2024. It expects adjusted EBITDA profit up to $20 million. Since it began, it, too, amassed a sizeable membership. #clover #insurtechs Link to Article Feds Investigating Change Healthcare The federal government has launched an investigation into UnitedHealth Group and its Change Healthcare subsidiary after a major cyber attack.  While I am always weary of government investigations based on headlines, in this far-reaching incident it is important to understand what happened and whether there was negligence.  In related news, major for-profit

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