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Federal Court Stays CMS Medicare Broker-Agent Compensation Reform

July 11, 2024 No Comments

A stay issued by a federal court was not well publicized as it came out during the July 4 holiday, but the action could have major implications for the 2025 Medicare Advantage (MA) enrollment season. A federal judge suspended the implementation of the Centers for Medicare and Medicaid Services’ (CMS) MA broker and agent compensation reform changes. The move has major implications for the agency’s efforts to reform what I believe is a badly broken system. What problem did CMS identify? For the past number of years, the number of marketing related complaints have increased dramatically. CMS has attempted to force health plans to have better delegated oversight over the independent third-party marketing organizations (TPMOs) that have grown considerably because of the lucrative nature of enrolling MA members. Agents receive compensation each year a person stays with MA and even more for first-year enrollees. I value the role of agents

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It Is Time For Site-Neutral Payments In Our Healthcare System

July 8, 2024 No Comments

Late last year, the House of Representatives passed a small step toward site-neutral payment policies in Medicare. But the Senate did not pass the bill due to opposition from the hospital industry. Since then, healthcare advocate groups have made a full court press to pass something in 2024. The hospital lobby is strong and has resisted these types of reforms for years. But advocates, health plans, and other parties have made the case that the reform is critical to lowering overall costs in the system as well as rising out-of-pocket costs for everyday Americans. Of course they are right. I have it as a key reform within one of my healthcare reform tenets – price reform. What are site-neutral payment policies? Quite simply, it means paying the same amount for the same service regardless of the place of service or location. Traditionally, outpatient hospital settings have gotten paid far more

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What Does The End Of Chevron Deference Mean For Healthcare?

July 4, 2024 No Comments

In an expected move, the Supreme Court ruled that the so-called 1984 Chevron deference under the nations’ regulatory system is no more. It has now thrown the Supreme Court precedent out. It is a technically complex ruling that has major implications for policymaking throughout government. Chevron was not a precedent just for healthcare agencies but applied to every executive department and agency out there – defense, environment, health, commerce, consumer protection and more. The decision split along rather pure ideological grounds, with six more conservative justices lining up against three more liberal ones. The Chevron doctrine said that courts must give deference to reasonable interpretations of regulations issued by regulatory agencies that may be in part based on laws that are ambiguous. In essence, regulators had reasonably wide discretion to interpret what these ambiguous parts of a law meant and if so, how a law might be implemented. Proponents think that Chevron

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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

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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

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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

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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

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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

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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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What Do The Latest Healthcare Spending Projections Tell Us?

June 24, 2024 No Comments

The latest forecasts from the Centers for Medicare and Medicaid Services (CMS) Office of the Actuary continue to show how out of control America’s healthcare spending is. Each June, the CMS Actuary re-estimates healthcare spending for the coming decade. The latest estimates continue to show a system that is badly in need of reform. While final figures for 2023 will come in December, the latest estimate on 2023 healthcare spending shows it will reach about $4.8 trillion or 17.6% of gross domestic product (GDP). That is up from $4.46 billion or 17.3% in 2022. That is a growth of 7.6% from 2022 to 2023. The major growth was in part related to the high insured rate of 93.1% due to the COVID flexibilities. While Medicaid redeterminations began again in April of 2023, the insured rate remained high in 2023. Medicare spending hit a milestone by growing 8.4% in 2023 and

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