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April 4, 2024

CVS Executive Pushes Back On Cuban And PBM Transparency Narrative CVS Caremark President David Joyner wrote and op-ed for Fortune to explain the innovation and transparency his pharmacy benefits manager (PBM) is engaged in.  It seeks to counter some of the press Mark Cuban is getting.  I will note that leadership at CVS Health overall is on a path of reform and innovation. #cvshealth #pbms #transparency Link to Article Good Wall Street Journal Article On Why We Need Site-Neutral Payments This Wall Street Journal article tells how hospitals and health systems are buying up physician practices.  In so doing, they are changing practice patterns and forcing their now doctor-employees to practice at hospital-owned settings.  This increases costs for sometimes low professional fees into gigantic bills because facility fees are added on.  The hospital lobby was successful stopping the start of site-neutral payments in Medicare, but I doubt they can hold

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April 3, 2024

Private Equity’s Role In Healthcare Takes Center Stage At Hearing Democrat members of the Senate HELP Committee staged a hearing on the role of corporate greed in healthcare.  Of particular concern was the role of private equity firm monies and whether dollars are diverted out from healthcare to corporate margins.  PE firms have big investments in both hospitals and provider groups. Additional article: https://www.fiercehealthcare.com/regulatory/steward-healthcares-struggles-full-display-clinicians-policy-researchers-tell-senators #privateequityfirms #healthcare Link to Article Clover Health CEO Defends CMS MA Payments for 2025 In a strong but divergent move from other MA plans, Clover Health CEO Andrew Toy defended the Center for Medicare and Medicaid Services’ final rate for 2025.  Depending on whether you count risk score trends increases, the rate would produce either a 3.7% increase or negative 0.16 decrease.  Plans do not believe the risk score trends should be counted. Clover may not be seeing the major increases that other plans are. Other

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April 2, 2024

Scrutiny Of Private Equity Healthcare Investments Expand Private equity investments are already being broadly looked at by Congress and regulators.  Now, the Senate Homeland Security and Governmental Affairs Committee is seeking information on private equity’s role in emergency physician staffing firms that are leaving hospital emergency departments unprepared. Letters were sent to Apollo Global Management, the Blackstone Group and KKR — three of the nation’s largest private-equity firms — and four emergency medicine staffing companies owned by the firms.  It is estimated at least 40% of hospital emergency departments are overseen by staffing companies that are owned by private-equity firms. Additional article: https://www.fiercehealthcare.com/providers/senator-probes-private-equity-physician-staffing-firms-emergency-care-cost-cutting #privateequityfirms #healthcare Link to Article MA Plans Say Rate Hike For 2025 Will Have Dire Consequences Health plans are pummeling the Centers for Medicare and Medicaid (CMS) for finalizing what they see as an inadequate 2025 rate hike.  Plans say this will force them to reduce key

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April 1, 2024

New GLP-1 Survey Says Growth Is Explosive A new survey from Virta Health backs up the bleak cost picture. It says that 43% of health plan leaders are predicting 100% or more growth in GLP-1s for weight loss and obesity in 2024. More than half say GLP-1s will be a top 3 drug in 2024 in terms of spending. One fifth say they will be their most expensive drug class this year. Executives believe the media is misrepresenting GLP-1s and that lifestyle programs should be tried first. At the same time, a Vitra Health-linked study comes to a different conclusion on what occurs after stopping GLP-1s.  It says those who stop taking GLP-1s can avoid negative effects on glycemia and body weight if they are properly engaged in their healthcare, including proper nutrition. See my blog today on the subject: https://www.healthcarelabyrinth.com/whats-all-the-clamor-over-glp-1s-for-weight-loss/ #weightlossdrugs #drugpricing Link to Article CMS Maintains Insufficient Rate

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March 29, 2024

NBA Player Robert Horry’s Healthcare Adventures Are Proof We Need Affordable Universal Coverage Touching story on NBA great Robert Horry’s healthcare adventures with his daughter, who lived with a genetic disorder and died in her 18th year.  It is a testament to why we need affordable universal access to healthcare.  Horry is now with a company promoting Individual Coverage Health Reimbursement Arrangements (ICHRA), which allows businesses to cover portions of healthcare premiums and allows employees to privately procure insurance (usually on the Exchange). To me, it is one of the few positive healthcare developments from the Trump administration. #ichra #obamacare #aca #exchanges Link to Article Huge Bounty On BlackCat Cyberattackers The State Department has issued a reward for information that could find people working with BlackCat, the cyberattacker that got into the Change Healthcare systems. #changehealthcare #cyberattacks Link to Article CVS Health Aiming To Transform Customer Experience Karen Lynch, CEO

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March 28, 2024

Change Cyberattack Could Open Americans Up To Multiple Notifications Of Breach We don’t know yet if Change’s breach will be a record.  But based on the 6 terabyte report of compromise as well as the breadth of the Change system, it very well could be. United is reporting that it may be hard to tell who was impacted by the breach.  Further, because of Change’s tentacles in the market with providers and payers, it could be that people are notified multiple times from different providers and a payer that their data was impacted.  There could be hundreds of millions (even billions) of notifications.  This will cause mass confusion. In other events, United seems to be complaining that some insurers and providers are slow to reconnect to Change systems, which is needed to get the flow of information and claims.  Some complain that they do not know yet if Change is

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March 27, 2024

Improper Payments Huge In Federal Programs A new Government Accountability Office analysis finds that the federal government made nearly $236 billion in improper payments in 2023. The payments were largely in Medicare, Medicaid, Pandemic Unemployment Assistance, the Earned Income Tax Credit and Paycheck Protection Program loan forgiveness. Medicare had the largest improper payments at $51.1 billion.  Medicaid had $50.3 billion. GAO Report here: https://www.gao.gov/products/gao-24-106927 #fwa #medicare #medicaid Link to Article New Rule Simplifies Medicaid and Children’s Insurance Enrollment A new Centers for Medicare & Medicaid Services (CMS) final rule will help enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) coverage. Among changes include transfer from Medicaid and CHIP if Medicaid is lost, renewals no sooner than every 12 months, no waiting periods, and sufficient time to respond to state inquiries on coverage. Federal press release and fact sheet: https://www.cms.gov/newsroom/press-releases/biden-harris-administration-builds-success-affordable-care-act-streamlining-enrollment-medicaid-and and https://www.cms.gov/newsroom/fact-sheets/streamlining-medicaid-childrens-health-insurance-program-and-basic-health-program-application Additional articles: https://www.modernhealthcare.com/government/cms-medicaid-chip-enrollment-renewal-rule and https://insidehealthpolicy.com/daily-news/cms-finalizes-rule-overhauling-medicaid-enrollment-eligibility-processes (Some articles may

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March 26, 2024

The Looming Election Year Debate Over The Affordable Care Act This article captures the big divide between advocates and detractors of the Affordable Care Act (ACA). Good links to various studies. Proponents say that over 21 million are enrolled in the Exchanges and a total of about 45 million gained coverage including Medicaid expansion.  Opponents argue costs have been huge — 36,798 per additional private insurance enrollee and 20,739 per additional non-group enrollee.  This is well above original estimates. Further, critics say insurers have benefited disproportionately. Here is my Republican defense of the ACA – as strange as that sounds. I also am dubious of the study that says 3 in 4 (73%) U.S. adults “report that in one way or another the healthcare system is failing to meeting their needs.”  Other surveys would suggest general contentment with their coverage and insurer. #healthcare #healthcarereform #aca #obamacare #exchanges #medicaid  Link to

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March 25, 2024

Biden Signs Funding Bill President Joe Biden signed a $1.2 trillion spending package on Saturday, avoiding a government shutdown. The package includes funding for the Department of Health and Human Services (HHS). The Senate passed the measure 74-24, technically after the deadline. Additional article: https://www.modernhealthcare.com/politics-policy/spending-bill-passes-hhs-funding (Some articles may require a subscription.) #governmentshutdown #spending #healthcare Link to Article Change Ready To Turn On Last Major Products Involving Claims UnitedHealth Group said that its largest clearinghouse, called Relay Exchange, will be back online this weekend.  Further, after testing by clients, $14 billion in medical claims will be processed through a system. It also unveiled a timeline for remaining products to come online – roughly through mid-April. Another article speaks to a new bill that would open up funding during cyberattacks if providers have met certain cyber standards. As well, the American Hospital Association (AHA) is opposing proposals that would tie cyber standards

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March 22, 2024

Senate Has Funding Bill After House Passage The Senate will need to pass a huge funding bill before midnight Friday to avert a government shutdown.  The House passed the bill, which includes healthcare funding, on a vote of  286-to-134 (112 Republicans and 22 Democrats voted against the bill). One conservative House member has called for the ouster of House Speaker Mike Johnson, R-LA, who hails from the Freedom Caucus.  She says she has support from folks, but the caucus and some Democrats do not want to see more chaos. The GOP hold on the House will be razor-thin with two early retirements. #governmentshutdown Link to Article After Win On Prior Authorization, Providers Now To Focus On Denied Claims Medicare Advantage (MA) and other health plans watch out. Providers will now want strict rules from the Centers for Medicare and Medicaid Services (CMS), Medicaid agencies, and state legislatures regarding claims denials. 

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