ncd

My seventh Clover blog updates on the Elevance Health lawsuit (the first that was filed). The lawsuit Elevance Health filed on July 1 on its Medicare Advantage (MA) Star Year (SY) 2026 Ratings is moving along. While a great deal remains unknown, the Elevance case could help us understand the timing of and conditions of any further changes in SY 2026 and what might be done in SY 2027. Elevance filed on July 1, while Scan did so about a week later and Alignment about 10 days later. Note my use of the words “could” and “might” as a great deal remains unknown. Here is a quick update on the Elevance Health lawsuit since the complaint was filed. In its July 1 Complaint, Elevance Health argued the Centers for Medicare and Medicaid Services (CMS) acted arbitrarily and capriciously in calculating Clover Health’s Star rating change based on the judge’s “Clover

Conservative think tank has important points for the future of healthcare In the past few weeks, I have had both a blog series and podcast series on healthcare reform. Now out comes a detailed report by the influential and conservative Paragon Health Institute calling for major healthcare reforms. These include federal funding cuts or reductions in tax allowances impacting all health plan lines of business as well as cuts to providers and programs more broadly. As I have said before, people should pay attention to what Paragon is saying. The institute’s president was in Trump 45. Many Paragon staffers are in Trump 47. Paragon fellows hold or have held key positions in Trump 47. People pay attention to what Paragon says given its impact on the One Big Beautiful Bill Act (OBBBA). It, too, has influenced various regulatory proposals from the Trump administration, especially regarding improper enrollments and fraud in

The Clover lawsuit saga just doesn’t want to die OK — I lied. I seemed to imply last time that I was done writing about the Clover decision. But this is number 6 – six blogs since the Clover Health lawsuit decision. Tiring yet? Me too! But I will not promise this is the end of my blogging on this subject as this thing appears to have a life of its own. Who knows what new lawsuit will be filed or what happens next. It is truly mystifying! I still have incoming questions on what all this means and how to sort out this seminal decision over the next few years. So here are the latest updates. Measure set scenario tracker To try to sort all these suits out in my head, I put together a measure set scenario tracker that I think encompasses all the possibilities for SY 2026,

While modest, price reform is certainly welcome and essential Hospital prices generally have soared by 250% since 2000 – twice the rate for healthcare and three times inflation. Along with drug pricing, this is driving the overall increase in costs we are seeing each year. But some moves are occurring that suggest that site neutral payment reform will finally happen. Back on May 4, I told you that hospital price reform may be mounting after a stunning Capitol Hill hearing where hospital executives seemingly said that they are willing to discuss reasonable changes to their long-standing opposition to site neural payments in Medicare. Meanwhile, the Trump administration is busy laying the groundwork, if at a slow pace. Under Trump 47, it proposed various changes, only to have some of them reversed by the Biden administration. Now, Trump 47 has been busy passing regulations that press site neutral and other price

More lawsuits and more Star rating scenarios in play Ok, so this is my fifth blog on the fallout from the Clover lawsuit decision, but continuing the saga is certainly merited. The Tukey outlier and guardrail decision in 2024 for SY 2024 Star Ratings certainly was defining in that plans won their point that the Centers for Medicare and Medicaid Services (CMS) was blatantly ignoring the regulatory process. Yet the Clover decision now appears to be going even farther in that Clover Health has exposed the fact that the Stars program as we have known it was not based in statute. More so, it now has created program uncertainty and the real chance that there may be no solid Stars foundation on which to calculate quality outcomes for the near future. Indeed, I am now characterizing what is occurring as the “balkanization of Star Ratings.” Let’s back up and give

NHED data continues to show the healthcare crisis The Centers for Medicare and Medicaid Services (CMS) Office of the Actuary released its projections for healthcare expenditure growth over the next decade, and it continues to show an alarming trend. Healthcare expenditures will grow well above increases in personal income and the gross domestic product (GDP). Setting the stage The CMS Actuary is the supreme authority on everything U.S healthcare. First, it is the main comprehensive source of data for calculating the history and future of healthcare spending. Most other studies rely in some form on the National Health Expenditure Data (NHED) reports. Usually in December of each year, the actuary reports on the details of healthcare spending in the prior year. Usually in June of each year, the actuary will forecast healthcare spending growth for the coming decade. Second, it is a treasure trove of data that helps explain the

June enrollment growth slows, but SNPs surge In a February 16 blog, I detailed the growth in Medicare Advantage (MA) from February 2025 to February 2026 after a delay from the Centers for Medicare and Medicaid Services (CMS) in posting the annual data. As I noted, the January enrollment statistics in both years seemed off so many analysts are comparing February to February each year. Each month since then I have updated with monthly growth numbers. Now, we have June results. For those who may have missed earlier blogs, I am refreshing on some of the annual results. The annual statistics show some of the financial struggles the industry continues to have. Growth is way down compared with prior years in the 2020s due to major geographic contractions as well as plan benefit reductions by major MA players the past few years. As the chart below shows, February 2025 to

The process shows the need for healthcare reform I am not the biggest fan of MedPAC, the congressional Medicare policy arm. For example, I have taken issue with what I think is its slanted views on Medicare Advantage (MA) overpayments. But recently, I did give it some credit on its look at hospital financial health when MA penetration increases. It was a balanced look and concluded that MA penetration is not tied to financial instability as some hospital lobbies suggest. Empirical analyses conducted by MedPAC staff showed no evidence of a significant association between MA market penetration and all-payer margins of hospitals, skilled nursing facilities (SNFs), and home health agencies. Negative impacts do not appear to be the case in rural markets, either. That is Chapter 3 of the MedPAC report (link at end of the blog). I will likely write more about this soon. My real reason for writing

CMS’ approach is right and should move quickly to return the program to its SY 2029 vision This is my fourth Clover-related blog this month, but the ruling was so watershed — and the potential impacts so far-reaching — that I had to tackle the topic again. I, too, wanted to signal to the Centers for Medicare and Medicaid Services (CMS) why it is so important to hold plans harmless now as well as push to salvage its 2029 vision for a more targeted Stars program. For those who are just getting up to speed or need to on the issue, here is a brief synopsis of the events of the last month or so on this important Medicare Advantage (MA) Star Year (SY) 2026 Ratings issue. What did the judge say and what did CMS do for SY 2026? At first, many of us reported that the judge pulled

The Centers for Medicare and Medicaid Services (CMS) announced late Wednesday it is recalculating some Medicare Advantage (MA) contracts’ SY 2026 Star Ratings based on the “better of” the current 2026 ratings or the measures included in the recent Clover decision. A judge struck up to 20 measures. CMS went out of its way to note that this does not set policy for SY 2027 ratings or beyond. CMS said it recalculated using just HEDIS, CAHPS, and HOS measures. No Part D measures were included and the following were removed for Part C: SNP-CM, Complaints, Leave, the two Appeals measures, and Call Center. Based on the HPMS memo, in my view CMS does not appear to have followed the ruling exactly. I am waiting to see some plans’ recalculations to be sure. This could be related to measures that were clearly not covered by the statutes and those that were