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CMS Loses Again In Court On Stars A just released court decision gives the Centers for Medicare and Medicaid Services (CMS) yet another defeat on how the agency runs the Stars program. Judge Jeremy Kernodle, of the U.S. District Court for the Eastern District of Texas, ruled CMS violated the Administrative Procedures Act of 1946 by improperly reviewing UnitedHealth Group’s health plan call center ratings. The judge was rather biting in his assessment. He said that CMS creates the guidelines, identifies the phases, and specifies the criteria for the call center metrics. He concluded that the responsibility for any unreasonable or absurd outcomes therefore lies with the agency not plaintiffs. Other lawsuits have been filed by Humana, Centene and Elevance Health. This could likely lead to recalculations for many plans, although it will not rise to the mass recalculation we saw in 2024. CMS says it is looking to deprioritize

Commonwealth Study Covers The Underinsured A very important study from The Commonwealth Fund found that close to a quarter of people who have health coverage are underinsured. This is consistent with other findings that put the number of uninsured and underinsured at about 85 million Americans. In essence, the underinsured are Americans that have coverage but, in many ways, have a hard time accessing the benefits due to high out-of-pocket costs. In my book, The Healthcare Labyrinth (available at this site), I discuss that affordable universal access is needed to address both the uninsured and underinsured crisis. The Commonwealth Fund polled a national sample of adults aged 18 to 64 and found that 23% are underinsured. Most (about 66%) are in employer-sponsored health plans. About 14% were in individual or Exchange plans and 11% were in Medicaid. About 57% who were underinsured said they skipped care because of the cost. About

More on Mehmet Oz’s Healthcare Positions President-elect Donald Trump’s nominee for the Centers for Medicare and Medicaid Services administrator, Mehmet Oz, has raised concerns with high insulin prices and the role of pharmacy benefit managers (PBMs). At the same time, he has not taken a position on Medicare drug price negotiations. He favors permanent telehealth expansions and has invested in numerous digital health companies over the years. This means he may support artificial intelligence, remote monitoring, wearables, and digital therapeutics. Oz has long been a supporter of Medicare Advantage (MA) and even pushed for the concept of Medicare Advantage for All, which would have eliminated employer coverage and put everyone in private plans outside of Medicaid. Additional articles: https://insidehealthpolicy.com/daily-news/oz-raised-concerns-pbms-insulin-costs-his-ira-views-unclear and https://insidehealthpolicy.com/daily-news/oz-would-bring-support-permanent-telehealth-ai-wearables-dtx-cms and https://thehill.com/policy/healthcare/5000821-trump-oz-cms-medicare-medicaid/ (Some articles may require a subscription.) #oz #cms #trump #medicareadvantage https://www.beckerspayer.com/payer/dr-oz-on-medicare-advantage-5-things-to-know.html PBMs Sue Over FTC Litigation Process The country’s largest pharmacy benefit managers (PBMs) and group purchasing