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CMS Should Institute Special Enrollment Period in 2025 For Medicare Beneficiaries

CMS needs to stop hiding the ball on coverage impacts and make amends for misleading Medicare beneficiaries I am generally a supporter of the Centers for Medicare and Medicaid Services (CMS). I think it tries very hard to help deliver quality care and regulate Medicare Advantage (MA) and providers reasonably. As a former government official and regulator, I am sympathetic to the agency’s need to constantly walk a tight rope when it comes to policy decisions. I have even backed some CMS decisions when the health plan industry has been vehemently opposed. But I am sorry to say that I have lost some faith in CMS recently. In blogs and newsfeeds I have questioned some of the agency’s actions. I see the agency reacting much more politically of late. This is especially true for MA and Part D decision-making in the last year or so. What happened in Medicare Advantage? While

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Docs Need Rate Relief In Medicare Program

The time has come for a real fix to Medicare physician fees. The big stall is hurting healthcare. Poor Medicare docs. They have been on a proverbial reimbursement roller coaster for decades now. The ups and downs have undermined independent practices, led to our primary care deficit, and actually fostered physician group acquisitions that increase costs in the healthcare system in several ways. More background A caution before I give you details on the history of Medicare physician pay — I am by no means a traditional Medicare fee-for-service (FFS) program rate expert. So, I am keeping this short and giving you a broad overview. The long and short of it is that Medicare physicians have had a rather broken rate system dating back to 1992. The bad system has been undermined further with various budget reduction requirements applied to the physician rates along the way. Congress created the Medicare

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The Biggest Lie Of The VP Debate: Trump Salvaged Obamacare!

Trump did not salvage the Affordable Care Act — he sabotaged it. Tall tales are always part of politics and candidate debates. America takes it for granted. But the biggest lie of the vice-presidential debate Tuesday night was quite the doozy and I could not let it go without some explanation. The big lie can be credited to GOP vice presidential candidate JD Vance. Vance attempted to concoct a story that somehow former President Trump salvaged the Affordable Care Act (ACA) when it was on the verge of collapse. This of course is true only in Vance’s and Trump’s minds. Vance’s fanciful rewrite of history went like this. Vance said Trump “actually implemented some of these regulations when he was president of the United States. … And I think you can make a really good argument that it salvaged Obamacare, which was doing disastrously until Donald Trump came along. I

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WSJ Editorial Wrong On FTC Lawsuit On PBMs

I promised to follow up on my newsfeed on The Wall Street Journal’s (WSJ) editorial on the Federal Trade Commission’s (FTC) lawsuit against the Big 3 pharmacy benefits managers (PBMs) – CVS Caremark, Cigna’s Express Scripts, and United’s OptumRx. I feel so much is wrong with what the WSJ editorial board is saying about the lawsuit. So here are some additional thoughts on the subject. The editorial is at a link below so you can read as well. What does the lawsuit charge? The FTC’s bombshell lawsuit charges that the PBMs have used formulary placement and rebates to rig the system and disadvantage the American public at the point of sale. While the FTC believes the anticompetitive activities permeate the entire system and apply to almost all brand drugs, it is focused in this lawsuit on insulin prices. The FTC says that the PBMs use the formulary and rebate scheme to

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FTC Lawsuit Could Be Defining Moment For Pharmacy Benefits Managers

The Federal Trade Commission (FTC) unveiled a bombshell lawsuit last week against the Big 3 pharmacy benefits managers (PBMs) – CVS’ Caremark, Cigna’s Express Scripts, and United’s OptumRx. The FTC charges that the PBMs have used formulary placement and rebates to rig the system for themselves and disadvantage the American public. The FTC says that the PBMs use formularies and rebates to line their pockets and to attract business. This leaves those with expensive disease states, such as diabetics dependent on insulin, with high prices and often an inability to pay. While the FTC believes the behavior by the PBMs impact many drugs and disease states, the lawsuit focuses on insulin drugs and prices right now.  In the past, I have defended PBMs for some of the good they do. They do promote the use of generics and keep down overall costs with prior authorization (PA) and other utilization management

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Commonwealth Fund “Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System” Shows How Much Of A Healthcare Outlier America Really Is

Every three years, The Commonwealth Fund does a great public service by publishing its “Mirror Mirror” analysis of developed world healthcare systems. This is the eighth report, which relies on surveys as well as national and international healthcare data. The 2024 analysis accounts for the COVID pandemic impacts and results are consistent with previous years.  In effect, the Commonwealth Fund ranks healthcare systems’ performance based on leading access, efficiency, quality, and value metrics. It looks at 70 health system performance measures in five areas: access to care, care process, administrative efficiency, equity, and health outcomes. This year it compared statistics in ten countries instead of 11: Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and the United States. Norway dropped off the analysis list because in 2022 the country exited the International Health Policy Survey. Norway was ranked number 1 in the 2021 analysis. The

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Driven By Drugs, Employer Coverage Headed For Huge Increases

One of the most important surveys performed to understand the year-to-year status as well as long-term trends in employer coverage is the Business Group on Health’s annual healthcare strategy survey. The 2025 survey was fielded between June 3 and July 12, 2024. The survey was completed by 125 employers, which cover more than 17.1 million lives in the United States. U.S. and multinational companies completed the survey and range from under 10,000 employees to 100,000 employees and over. About 73% of respondents had more than 10,000 employees. They represent a broad range of industries. Remember that close to a majority of Americans are covered by employer-furnished insurance, usually self-insured ERISA coverage. What does the survey tell us overall? Looking at projected annual increases before plan design changes, the projected trend rose from 6% in 2022 to almost 8% for 2025. Even after design changes, actual healthcare costs continued to grow

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Growth From August To September In Medicare Advantage

I decided to continue my Medicare Advantage (MA) monthly enrollment blogs because of continuing month-over-month increases. The growth is tied to remaining strong benefit packages for 2024.   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, new regulatory burdens (such as the new prior authorization restrictions), and the greater costs MA plans will bear due to the Inflation Reduction Act’s (IRA) Part D changes. See my earlier blogs on this Part D topic here: https://www.healthcarelabyrinth.com/will-democrats-be-victim-of-an-october-surprise-of-their-own-making/ and https://www.healthcarelabyrinth.com/part-d-premium-woes-due-to-the-inflation-reduction-act/ . While we are outside of the two regular annual enrollment windows, increases in MA enrollment still occur given the aging of America and the ability of some populations, such as dual eligibles, to continue to make changes

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Two Key CMS Announcements MA Plans Must Follow

Medicare Advantage (MA) plans are going to want to take note of two recent HPMS memos from the Centers for Medicare and Medicaid Services (CMS). Each touches on major areas of controversy for the program. Supplemental Benefits User Group CMS will host a user group to provide an overview of supplemental benefits data submission for encounter data records on September 26, 2024, 2:00 p.m. – 3:00 p.m. ET. You need to register in advance. See the flyer distributed with the September 10 HPMS memo on the topic. The issue of supplemental benefits is an explosive one right now. Opponents of MA say that MA plans are submitting bids that misrepresent supplemental benefit utilization and thereby inflating their margins. CMS has little to go by because encounter data for supplemental benefits is rarely submitted. CMS did two things to attack the controversial issue. First, it issued a memo requiring plans to submit

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Oliver Wyman Has Lessons For Today’s Medicare Advantage Plans

As management advisory firm Oliver Wyman noted in its recent study on Medicare Advantage’s (MA) woes, “history has a way of repeating itself.” And so it is with MA’s plight today. Oliver Wyman says MA plans can learn a great deal from what plans went through during the Medicare+Choice days almost thirty years ago. Oliver Wyman admonishes plans to avoid the Medicare+Choice mistakes lest MA plans suffer the same fate of many Medicare+Choice plans back then. What is Medicare+Choice and what happened? Medicare+Choice is the same program we have today but under its earlier name. While there was managed care in Medicare for a few decades, Medicare+Choice was formally established as Part C of the program via the Balanced Budget Act of 1997 (BBA). Plans were rolled out effective January 1, 1999. Medicare+Choice was renamed Medicare Advantage as part of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) in

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