optumrx Archives - Page 10 of 11 - The Healthcare Labyrinth

December 1, 2023

December 1, 2023 No Comments

Cigna-Humana Deal Could Pass Muster While federal and state regulators will look closely and potentially oppose a combination, experts seem to think that the Cigna-Humana merger could eventually go through. As I have indicated as well, the company profiles are quite different than earlier deals that fell through. #cigna #humana #mergers #acquisitions Link to Article Our Primary Care Problem The article makes a couple key points. It notes the vast difference between primary care and specialist compensation. We are clearly over-specialized in the United States. It also discusses an important bill sponsored by Sen. Bernie Sanders, I-VT, and Sen. Roger Marshall, R-KS, that would invest $26 billion to bolster primary care, increase training opportunities for doctors and nurses, and expand access to community health centers. We do need to invest in so many ways in primary care so we can pivot healthcare from utilization management to care management. #utilizationmanagement #caremanagement #healthplans

November 30, 2023

November 30, 2023 No Comments

Walgreen’s Launches Drug Tool Similar to others, Walgreen’s has launched a drug price transparency and saver tool for its customers. No monthly fee applies. #drugpricing #walgreens Link to Article Investors Look To Medicaid Managed Care Interesting article on investors now looking to Medicaid managed care as the Medicare Advantage market cools and is dominated by big players. While Medicaid margins are skinnier, Medicaid has been growing and states have been pushing more and more lives into managed care. Rolls will drop with redeterminations coming out of COVID, but aging and long-term care remains a big opportunity for plans and investors. (Article may require subscription.) #medicaid #managedcare Link to Article United Details 2024 Outlook Healthcare behemoth United Healthcare detailed its outlook for 2024. Trends it sees will likely match the industry. United sees slower growth in Medicare Advantage, continued efforts to employ physicians, and increased investments in technology. Additional article here:

November 29, 2023

November 29, 2023 No Comments

Cigna and Humana Exploring A Merger Stunning news on the health plan front with speculation that Cigna and Humana are entertaining a merger. This explains reports not too long ago that Cigna was thinking about giving up its Medicare Advantage (MA) line of business. The merger seems like a match made in heaven. Cigna is a commercial powerhouse, but its MA line is much smaller than Humana’s. Its MA line is struggling from a Star perspective. It sold its only Medicaid assets a few years ago. Humana is second only to United in MA and has a growing Medicaid line. Both plans have some provider assets as well. And Express Scripts, Cigna’s PBM and one of the nation’s big three, would be a huge asset for Humana. Humana has a subscale PBM asset. Earlier mega mergers (Aetna-Humana and Cigna-Anthem) fell apart due to federal and state pushback and footprint overlaps.

November 28, 2023

November 28, 2023 No Comments

Innovation In State And Federal ACA Exchange Programs Interesting article on policy brief from the Commonwealth Fund on various innovations occurring in the state-based and federal Exchange programs. As of 2023, 20 states operate a state-based marketplace and 30 rely on Healthcare.gov for sign-ups. Some state-based exchanges use the federal website for enrollment. States are experimenting with enrollment campaigns, simplified enrollment, auto-enrollment programs, health-equity requirements, and more. Article at link. The actual study is here: https://www.commonwealthfund.org/publications/issue-briefs/2023/nov/policy-innovations-affordable-care-act-marketplaces #aca #obamacare #exchanges #commonwealthfund Link to Article Mark Cuban’s Firm Partners With Expion Mark Cuban’s Cost Plus Drugs (CPD) is partnering with Expion to tackle the high costs of specialty drugs. A press release says CPD will integrate into Expion’s dynamic pricing technology. It says “consumers can be confident they are getting a fair price and the convenience of medication mailed directly to their homes.” #cuban #costplusdrugs #drugpricing #expion Link to Article Healthcare Bankruptcies

November 27, 2023

November 27, 2023 No Comments

Pro Publica Article on Health Plans Not Covering Mandated Services Pro Publica article recounts where health plans have not covered mandated services in state laws. It is easy to sensationalize mistakes, but health plans every day are approving treatments timely. (May require subscription.) #plandenials #healthplans Link to Article Will New Marketing Rules Hurt Big Plan Performance? Interesting article that says the new Medicare Advantage (MA) marketing rules could mean smaller plans now have a fighting chance against bigger ones, which seemed to enter into the variable and extraordinary compensation with agents and other entities to attract members. A new marketing clampdown in the 2025 rule would stop most of this. Note, too, a plan official saying that there may be loopholes in the new proposed rule. (May require subscription.) #marketing #medicareadvantage Link to Article Per Worker Healthcare Costs Increased 5.2% in 2023 More evidence that inflation is increasing for employer-provided

November 23 and 24, 2023

November 23, 2023 No Comments

The Healthcare Labyrinth Newsfeed will be off on November 23 and 24 for the Thanksgiving holiday. We will be back on November 27. Happy Thanksgiving to all! Stay safe! — Marc S. Ryan

November 22, 2023

November 22, 2023 No Comments

CMS’ UM Rule for Medicare Advantage Already Being Debated The new CMS 2024 Medicare Advantage (MA) rule prohibiting the use of most evidence-based criteria by MA plans is already being debated. Hospital lobbies are saying plans are out of compliance and January 1 has not even hit yet. Read my new companion blog at the blog tab on this site. I tell you why this rule is a terrible idea. Additional article here: https://www.modernhealthcare.com/politics-policy/health-plans-2024-medicare-advantage-rule-aha-cms-unitedhealthcare #hospitals #medicareadvantage #medicare #ncd #lcd #priorauthorization Link to Article Interesting Article on Cancer Care Between MA and FFS Interesting study on cancer care differences between MA and FFS. Touches on prior authorization and networks. Something for MA plans to think about as the PA debate heats up and the new UM rule comes unto effect. #medicare #medicareadvantage #cancercare #priorauthorization #networkadequacy Link to Article FL Blue Using AI to Speed Authorizations While many plans are being criticized

November 21, 2023

November 21, 2023 No Comments

Out For Blood Is Right: Great Example of Outrageous Prices And The Need For Reform Kaiser Health News, the healthcare news aggregator, also does tremendous original news stories. One of its series is “Bill of the Month,” where it features one person’s heartache related to a recent healthcare bill. In this article, KFF intervened to get the patient’s bill cancelled, but she is among the lucky ones. It is also important to remember that not all surprise bills you receive will suddenly go away under the No Surprises Act. This surprise bill was from an in-network provider (hospital), which was charging outrageous lab fees on everyday tests. The health plan negotiated a poor discount and the patient’s plan had the insured covering a percentage of allowable costs. The article touches upon the need for site neutral payments to lower costs in the system and protect consumer’s from high costs. Why

November 20, 2023

November 20, 2023 No Comments

Improper Payments Detailed By CMS CMS touts that improper payments were under 10% in traditional Medicare and in Medicaid, but it is nothing to be proud of. The traditional estimator of 10% for fraud, waste, and abuse (FWA) is a misnomer. Recent studies suggest that true FWA is perhaps 25% of all healthcare expenditures. In 2021, healthcare expenditures were $4.3 trillion. That means almost $1.1 trillion is true FWA. #fwa #medicare #medicaid Link to Article Providers Impacted As Well When Star Ratings Fall Good article describing how providers suffer too when Star ratings fall in Medicare Advantage. Many have entered into partial or global risk-sharing arrangements with health plans and share in bonus revenue. (May require subscription.) #medicareadvantage #providers #stars Link to Article New Speaker’s Healthcare Advisor Named New House Speaker Mike Johnson (R-LA) has named Drew Keyes, a former Republican Study Committee staffer, as his senior health policy advisor.

November 17, 2023

November 17, 2023 No Comments

Civil Rights Groups Issuing Report Cards On State Medicaid Redetermination Processes With a large proportion of the 10M Medicaid disenrollees cut from the program for procedural reasons, a group of civil rights entities are issuing report cards to states. The report cards seek to call out whether each state has done the necessary due diligence during unwinding to ensure those who remain eligible retain coverage. While states and the Centers for Medicare and Medicaid Services (CMS) are at some fault, Congress is really to blame for not passing legislation that allowed for a longer transition time. #medicaid #redterminations Link to Article FTC Moves To Stop Hospital Merger in California Kudos to the Federal Trade Commission (FTC) on taking action to stop the merger of two California hospitals. The Biden Administration, including the FTC, Justice and Health and Human Services, have been active in calling attention to the massive consolidation occurring

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