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CMS Suspends Agents Operating On The Exchange Enrollment Platform The Centers for Medicare and Medicaid Services (CMS) has suspended 450 agents and brokers from selling products through healthcare.gov, which enrolls the uninsured in the Exchange program. The move was one in a number of reforms to stop illegal switching of enrollees and fraudulent enrollments. (Article may require a subscription.) #exchanges #aca #obamacare #marketing #fwa https://insidehealthpolicy.com/daily-news/cciio-suspends-450-agents-brokers-selling-through-healthcaregov Hospital Groups Wants Government To Take Action on J & J’s 340B Policy Change Hospital groups want the federal government to take action against Johnson & Johnson for requiring hospitals and other eligible providers to pay full price up front for two medications before the drug maker then pays a rebate or discount later. The federal government has warned J & J it must accept payment of the discounted amount from eligible providers. (Article may require a subscription.) #340b #hospitals #providers #drugpricing #branddrugmakers https://www.modernhealthcare.com/legal/johnson-johnson-340b-drug-pricing-aha-aeh-hrsa Hospital

Fallout From Part D Legislation Remains The fallout from the major reductions in out-of-pocket (OOP) costs and transfer of liability to Part D plans in the Inflation Reduction Act (IRA) continues. The Centers for Medicare and Medicaid Services (CMS) saw massive increases in standalone Part D plans when bids for 2025 were submitted by insurers and the agency quickly created what I think is an extra-legal special subsidy program to limit premium increases in the program. The changes also impact Medicare Advantage (MA) and will contribute to cuts and premium increases there as well for 2025. The GOP in Congress has asked the congressional Government Accountability Office (GAO) to investigate and now is asking the Congressional Budget Office (CBO) what costs will be. I will have a special blog on this next week. My previous blogs on this are 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/ . I have argued that while the

Oregon Hospital Price Ceilings Reduce Plan And Patient Costs But Could Increase Utilization A good article discussing Oregon’s law capping maximum in-network hospital payments to 200% of Medicare and out-of-network prices at 185% at 24 urban hospitals. These are modest reforms, but good ones. They tie to my recent blog on center-left think tank Third Way finding commercial prices can come down and hospitals can make a profit (blog here: https://www.healthcarelabyrinth.com/the-truth-about-hospital-costs-and-payments/ ). One study of the Oregon experience thus far found health plan savings of $108 million in the first 27 months. A second study finds reduced out-of-pocket costs for patients of 9.5% or about $800,000 annually in the first 27 months. The law began in October 2019. There is some evidence that the lower hospital costs drove some utilization. A 4.8% uptick in outpatient procedures per enrollee per year was registered.  But in my view, this could be good

Biden Administration Announces Exchange Navigator Grants The Centers for Medicare and Medicaid Services (CMS) announced navigator grants totaling $100 million to forty-four organizations to aid in enrollment in the Exchanges. The agency will distribute up to $500 million over the next five years. The organizations are in twenty-eight states with federally facilitated marketplaces. CMS Press Release: https://www.cms.gov/newsroom/press-releases/biden-harris-administration-awards-100-million-navigators-who-will-help-millions-americans (Some articles may require a subscription.) #aca #exchanges #obamacare #marketing https://www.modernhealthcare.com/policy/insurance-navigators-grants-cms-open-enrollment-2024 McKesson To Acquire Majority In FL Oncology Group McKesson signed a definitive agreement to acquire a 70% controlling stake in Community Oncology Revitalization Enterprise Ventures LLC, or Core Ventures, for $2.5 billion in cash. The group owns Florida Cancer Specialists & Research Institute, a major specialty provider group. McKesson’s oncology platform will be integrated into the FL group’s care. This is a good example of vertical integration as McKesson is a major force in the drug supply chain. Additional article: https://www.modernhealthcare.com/mergers-acquisitions/mckesson-corp-core-ventures-controlling-stake (Some

Healthcare Services Company Evolent Health Could be Sold; United Healthcare Could Acquire Surgery Group Evolent Health, a company that offers software and clinical solutions to providers and health plans, could be acquired by either a private equity firm or Elevance Health. In other news, Surgery Partners, a major surgery center, urgent care, and provider group, could be sold to United Healthcare. Additional article: https://www.modernhealthcare.com/mergers-acquisitions/tpg-unitedhealth-group-surgery-partners (Some articles may require a subscription.) #manda #acquisitions #consolidations #healthcare #unitedhealthcare https://www.fiercehealthcare.com/payers/evolent-health-considers-sale-pe-stock-price-leaps Harris Promises To Defend Affordable Care Act and Medicare In her Democratic presidential acceptance speech, Vice President Kamala Harris promised to defend the Affordable Care Act and Medicare. (Article may require a subscription.) #election2024 #harris #medicare #aca #obamacare #exchanges https://insidehealthpolicy.com/daily-news/harris-promises-defend-aca-medicare-nomination-speech Clover Health Not Impacted By Medicare Advantage Headwinds Clover Health says it has avoided the headwinds impacting many other Medicare Advantage (MA) plans. Clover Health has over 80,000 members, almost all of them in Preferred

Big Pharma’s Verbal Gymnastics On Drug Price Negotiations I found this article worthy of top billing tonight due to the laughter I get from hearing Big Pharma talking out of both sides of its mouth. As we know, brand drug makers lobbied hard against the passage of the Inflation Reduction Act’s (IRA) Medicare drug price negotiations and have filed numerous lawsuits to stop it (all without success so far). Brand drug makers argued passage would cripple innovation and the drug industry. Since that time, the first ten drug prices have been set and brand companies have been arguing to their investors that the IRA will not have negative impacts on long-term margins. With the possibility of Democrats again winning both houses of Congress and the White House, Big Pharma is in panic mode due to commitments by Democrats to expand Medicare drug price negotiations. In comes the brand pharmaceutical lobby,

S&P Sings The Blues Of Hospitals – But Here Is the Other Side Of The Story Financial firm and rater S & P Global is bemoaning the potential impact of Medicare Advantage (MA) on hospitals. It says in a new report that extended utilization increases could force MA plans to further rein in payments to providers. It also notes that the further expansion of MA hurts hospitals and providers too due to prior authorization (PA) and claims payment delays and practices. Thus, provider margins will be under pressure. And while the provider lobbies got a huge win when the Centers for Medicare and Medicaid Services (CMS) directed MA plans to follow traditional inpatient admission rules, S & P says MA plans could seek to recoup the costs with further restrictions. I do not take issue with S &P’s assessment per se, but there was another report recently that I found

Insurtech Devoted Health Has Major Financial Raise Medicare Advantage (MA) insurtech Devoted Health raised $112 million in its Series E funding round. Devoted has over 227,000 members, up from 142,000 in December 2023. Its Star rating averages 4.6. It is in 13 states and almost 300 counties. Devoted is one of the tech-based startups doing well in MA, along with Clover Health and Alignment Healthcare. Each seems to be bucking the major financial pressures seen by the Big 7 MA national plans. Thus, Devoted has filed to expand into seven new states and will double its county penetration. This doesn’t mean, though, that it won’t rein in benefits due to the erosion of MA rates. It likely will do so to protect its long-term financial health. #medicareadvantage #devotedhealth #insurtechs https://www.fiercehealthcare.com/payers/payer-roundup-devoted-health-raises-112m-la-care-eliminates-prior-auth-codes Another Employer Survey Shows Healthcare Cost Trends Another employer healthcare survey is revealing the troubles employers are having on the

McKinsey & Company Releases Three Briefers On Medicare Advantage’s Future McKinsey and Company has three important briefers on the future of Medicare Advantage. This is a must read. Among the recommendations in the extremely thorough document include: Briefers here: https://www.mckinsey.com/industries/healthcare/our-insights/the-future-of-medicare-advantage #medicareadvantage #partd https://www.beckerspayer.com/payer/3-things-payers-need-for-great-ma-star-ratings-in-2025-and-beyond-mckinsey.html Could Medicare Advantage Support Be Eroding? Growing evidence that Medicare Advantage support could be eroding somewhat in Congress. Both political parties appear to be open to MA reforms. Prominent healthcare policy officials say this should be a warning sign to MA plans, which need to respond. AHIP, the health plan lobby, is creating a seven-figure marketing and lobbying campaign in response. Democrats and populist Republicans are questioning the program’s value and are upping scrutiny. #medicareadvantage #election2024 https://www.fiercehealthcare.com/payers/medicare-advantage-consensus-waning-2024-election Humana Settles Fraud Allegations In Part D Humana will pay $90 million to settle a whistleblower lawsuit by a former actuary who said the MA plan overcharged Medicare for prescription

Harris Economic Plan Includes Continuation of Biden Healthcare Priorities And More In a major economic speech today, Democratic presidential nominee and Vice President Kamala Harris promised to lower drug prices, maintain enhanced premium subsidies in the Exchanges, and curb and retire medical debt. She would expand the Medicare drug price negotiation program to expand insulin and out-of-pocket drug cost-sharing caps to the commercial world. She also promised to combat pharmacy benefits managers’ (PBMs) unfair practices. Additional articles: https://thehill.com/policy/healthcare/4832005-kamala-harris-level-up-biden-admin-health-care-programs/ and https://insidehealthpolicy.com/daily-news/harris-economic-policy-plan-echoes-biden-s-health-cost-agenda (Some articles may require a subscription.) #healthcare #elections2024 #harris https://www.modernhealthcare.com/politics-policy/kamala-harris-health-plan-aca-drug-prices Medicare Drug Negotiations Assessment And Next Steps Medicare drug price negotiations appeared to go well, with half agreeing to prices and the other half staying in the program when a price was imposed. The brand drug makers decry the process as anything but a negotiation, but at the same time have assured investors that the lower prices will not impact