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February 20, 2024

Analysts Say Digital Health Facing Funding Challenges After record years of funding, digital health ventures are facing lean times to stay solvent. (Article may require a subscription.) #digitalhealth #healthcare Link to Article 2024 Financial Woes For Medicare Advantage Plans Excellent Healthcare Dive article on the potential financial woes for Medicare Advantage (MA) plans resulting from rising medical expense and insufficient rates.  I covered some of this in my blog here: https://www.healthcarelabyrinth.com/with-boom-over-will-medicare-advantage-collapse-or-adjust/ #medicareadvantage #rates Link to Article New Challenges For Providers On Medicare Drug Price Negotiations Interesting article on the impediments to provider entities suing on their fallout from the Medicare drug price negotiations. A judge found they have a lack of standing right now to sue. (Article may require a subscription.) #ira #drugpricing Link to Article AI Task Force In The House Similar to Senate interest, the House Speaker has formed a bipartisan task force on regulating AI in healthcare.

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February 19, 2024

A Look At Growing Provider-Payer Disputes In California A good article from Kaiser Health News (KHN) that looks at growing contract disputes between providers and payers.  This one was in CA, but this is occurring nationwide.  KHN mentions higher costs coming from provider consolidation as well as increasing leverage when payers merge. The Biden administration is on to something with its anti-trust initiative. #providers #healthplans #coverage #payments Link to Article Wakely’s Assessment Of The 2025 Medicare Advantage Advance Notice As it does each year, Wakely has issued its annual assessment of the advanced notice for Medicare Advantage (MA).  My analysis is here: https://www.healthcarelabyrinth.com/2025-rates-for-medicare-advantage-plans-look-tight/ . #2025 #rates #medicareadvantage Link to Article Dual Eligible Special Needs Plan Analysis By Kaiser Family Foundation The Kaiser Family Foundation (KFF) published a look at Dual Eligible Special Needs Plans (D-SNPs).  Among the findings: My own research shows that SNPs in general, most of it dual

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February 16, 2024

No Surprises Act Dispute Process Favors Providers The No Surprises Act (NDA) remains  a huge mess with volume 13 times higher than forecast for 2023.  What’s more, providers won 77% of arbitration cases and health insurers won in 23% of cases. The winning offers were above the qualifying payment amount, which is the median in-network rate. The good news is that 10 million surprise bills were avoided with the law in the first nine months of 2023.  The bad news is that providers are winning huge in the baseball-style arbitration as they do in other states that have it.  Studies show that rates and premiums rose in those states under the provider-friendly process.  Researchers say that will happen nationwide now.  Yet, providers continue to sue to get things even more slanted toward them.  Congress has to even the playing field.  But they won’t as lawmakers from both sides of the

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February 15, 2024

Cigna To Start Stock Buyback Cigna said it would repurchase $3.2 billion in stock as part of a repurchase of $5 billion of common stock over the first half of 2024. This will help enhance its stock price.  Cigna will get $3.7 billion for its Medicare Advantage sale to Health Care Service Corporation (HCSC) when it closes. #cigna #hcsc Link to Article New Bill To Establish “Essential Hospital” Designation Lawmakers are sponsoring a bill that would designate about 1,000 hospitals as “essential health systems” under federal statute.  This would provide a vehicle to shelter these hospitals from negative programmatic decision (similar to critical access hospitals and sole community hospitals) as well as target new dollars for health equity and related initiatives. Hospitals would need to meet certain Medicare or Medicaid thresholds. #hospitals #medicare #medicaid Link to Article Capitol Hill Interest In AI Legislation But Little Progress A good article on the interest

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February 14, 2024

Elevance Health Takeover Of BCBSLA On Hold Again Facing pushback from Louisiana regulators, the governor and some lawmakers, BCBSLA has again withdrawn its application for sales to Elevance Health. BCBSLA sought permission to transition to a for-profit entity. Additional article: https://www.modernhealthcare.com/mergers-acquisitions/elevance-health-blue-cross-louisiana-merger-called-off (Some articles may require a subscription.) #bcbsla #elevancehealth Link to Article Biden Administration To Scrutinize Middlemen In Drug Shortage Controversy The Biden administration has issued a Request for Information (RFI) about the role of drug channel middlemen in creating drug shortages. The middlemen include group purchasing organizations (GPOs) and drug wholesalers. About six entities dominate. The Federal Trade Commission (FTC) and the Department of Health and Human Services (HHS) are leading the effort. The agencies will look at market concentration, contracting practices, and regulatory exemptions. In addition, GPOs’ sole-source agreements that prevent hospitals and other providers from acquiring drugs elsewhere will be examined. HHS Press Release here: https://www.hhs.gov/about/news/2024/02/14/ftc-hhs-seek-public-comment-generic-drug-shortages-competition-amongst-powerful-middlemen.html Additional

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February 13, 2024

Showing Strain In MA, PE Deals Dropped Significantly Private equity firms’ investment in the Medicare Advantage (MA) space are way down from a peak in 2021. This is a sign that rising medical expense and regulation is impacting the industry. Just 4 deals occurred in 2023, down from 19 in 2021. Additional article here: https://www.modernhealthcare.com/finance/private-equity-medicare-advantage-pesp-report (Some articles may require a subscription.) #medicareadvantage #privatequityfirms Link to Article Site-Neutral Payment Fight Great Kaiser Health News article on the fight over site-neutral payments.  Advocates want site neutral and won passage in a small way on Part B drug infusion in the House.  Hospitals are using their weight and dollars to keep it out of any bill.  In a related move, advocates are proposing a possible rural exception to a site neutrality to get the reform passed. See here: https://insidehealthpolicy.com/daily-news/site-neutral-proponents-float-rural-exemption-hospitals-flag-risks (Some articles may require a subscription.) #siteneutral #medicare Link to Article Texas Federal Judge

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February 12, 2024

Kaiser Turns Around Performance Kaiser Permanente moved from a $1 billion loss in 2022 to about breakeven at least in terms of operating income in 2023.  Its income was $4.1 billion with investments.  It reached the $100 billion mark in both operating revenues and expenses. #kaiserpermanente #managedcare Link to Article Article Summing Up Congressional And Regulatory Issues On AI A good article on all the activities surrounding the use of AI and possible regulations.  The article discusses potential Capitol Hill bills, recent rules and guidance from the Centers for Medicare and Medicaid Services (CMS) and lawsuits against insurers on AI issues. #ai #claimsdenials #priorauthorization Link to Article Humana Study Shows Discrimination In Healthcare A new study sponsored by Humana focused on structural determinants of health rather than social determinants.  The study found that 88% of respondents reporting healthcare discrimination were black. While similar and related to social determinants, structural determinants

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February 9, 2024

Senate To Tackle Medicare Physician Formula A bipartisan group of senators will tackle long-term reform of the Medicare physician pay formula. On 1/1, a 3.4% reduction went into effect due to the existing formula.  Some have accused physicians of spending more time lobbying on health plan prior authorization reform than on their own rate issues. #medicare #physicians Link to Article CMS Wants Tougher Regulation Of Accrediting Organizations A proposed rule from the Centers for Medicare and Medicaid Services (CMS) wants reform of how accreditation organizations operate, including conflict of interest and other requirements in force for other organizations. CMS Fact Sheet here: https://www.cms.gov/newsroom/fact-sheets/accrediting-organization-proposed-rule-fact-sheet Additional article here: https://www.fiercehealthcare.com/regulatory/cms-proposes-greater-oversight-consulting-limitations-accrediting-organizations (Some articles may require a subscription.) #cms #healthplans Link to Article Provider Lobbies Pushing PA Reform At State Level A number of states have enacted and more will enact broad reforms of prior authorization (PA).  Generally these reforms revolve around electronic PA transmission,

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February 8, 2024

Weighty Lesson For Employers From NC State Employee Plan Experience On GLP-1 Drugs A lesson for employer groups as weight-loss drugs take off in popularity.  An analysis of data says that just 25 of over 6,200 prescribers in the North Carolina State Employee Plan accounted for 8 percent of the costs of prescriptions for costly weight loss drugs. These include GLP-1 meds Wegovy and Saxenda. These drugs accounted for 10% of total costs – or over $100 million. The state wanted to rein in costs with some ideas, but its pharmacy benefit manger shot them down. Shame on the healthcare players to not work with employers battling these cost issues. As important, there are telehealth entities now emerging, backed by private equity, advertising solely to prescribe such meds.  It is corrupt. #weightlossdrugs #drugpricing Link to Article Good News From Oscar Health; It Favors ACA Subsidy Extension Oscar reported major enrollment

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February 7, 2024

House Republicans Vote To Ban QALYs House Republicans passed a bill to ban the use of the controversial Quality Adjusted Life Years (QALY) measurement in federal programs.  Additional article here: https://www.fiercehealthcare.com/payers/house-republicans-vote-ban-pricing-metrics-federal-programs #qalys #medicare #medicaid Link to Article Fitch Says MA Trends Will Mean A Credit Neutral Outlook Fitch Ratings says that the spike in medical expense and rate reductions in Medicare Advantage (MA) will end up being credit neutral, arguing plans are well-placed to weather a storm. #medicareadvantage Link to Article Even With Good 2023, CVS Health Saw Utilization Spike and Cuts Its 2024 Outlook CVS Health is cutting its 2024 outlook in the face of a utilization and medical expense spike at insurer Aetna. It otherwise had good 2023 results.  CVS also agreed with Humana and Centene that the 2025 rate announcement was inadequate. Additional articles here: https://www.fiercehealthcare.com/payers/cvs-earns-350-billion-revenue-2023-over-77-billion-profit and https://www.modernhealthcare.com/insurance/cvs-health-medicare-advantage-utilization-2024 and https://www.forbes.com/sites/brucejapsen/2024/02/07/cvs-health-profits-hit-2-billion-as-company-benefits-from-new-provider-businesses/?sh=443dc8d5507b (Some articles may require a subscription.) #cvshealth

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