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End-Of-Year Stop Gap Funding In Flux With the House staying Republican, some are saying the stop gap measure to fund government by the end of the calendar year is now in flux. Some Republicans want to punt any substantive legislative action to the new Congress when the GOP is fully in control. Others want to pass substantive legislation, including several healthcare initiatives. They could include pharmacy benefit manager reform, hospital transparency, and site-neutral payments. One of the top issues that many aim to pass in the lame-duck session is instituting site-neutral payment rules for outpatient care. This is heavily opposed by the hospital lobby, but it is gaining bipartisan momentum. It is unknown how expansive any proposal would be (some or all outpatient services) and whether it would apply just to Medicare or include commercial. The Congressional Budget Office (CBO) projects that the most robust site-neutral legislation would save more

DOJ And States Oppose UnitedHealth Acquisition Of Amedisys The federal Department of Justice and four states have sued to stop UnitedHealth Group’s acquisition of home care entity Amedisys. It is the latest in the Biden administration’s move to scrutinize acquisitions as part of its antitrust agenda in healthcare. While Donald Trump is predicted to be more friendly to business, there is no guarantee that these types of acquisitions will not be challenged under a new president. I am suspicious of overly broad challenges by the government, but their arguments in the suit are reasonably compelling in terms of the control United would have on the industry in about half of states and the impact on price. Additional articles: https://www.modernhealthcare.com/legal/doj-unitedhealth-amedisys-lawsuit-home-health and https://www.healthcaredive.com/news/doj-challenges-unitedhealth-amedisys-deal/732721/ (Some articles may require a subscription.) #unitedhealthcare #homecare #providers #antitrust #biden https://www.fiercehealthcare.com/payers/doj-sues-block-unitedhealths-33b-acquisition-amedisys Elevance Bullish On Exchanges As It Faces Pressures In Care and Caid Elevance Health is bullish on

Cigna Not Acquiring Humana Cigna confirmed it is not pursuing an acquisition of Humana, squashing long-standing rumors. It will make a more official statement soon. Cigna CEO David Cordani is known not to like the Medicare Advantage (MA) insurance line and is selling its underperforming MA lives to Health Care Service Corporation (HCSC). Humana currently struggles financially. Cigna is focused on growing its Evernorth service unit. It is using its free cash and the future MA sales proceeds on stock buybacks. So far it has bought back $6 billion in stock. Additional articles: https://www.modernhealthcare.com/insurance/cigna-humana-merger-ends-share-buybacks-medicare and https://www.healthcaredive.com/news/cigna-confirms-humana-deal-off/732488/ and https://www.beckerspayer.com/m-and-a/cigna-not-pursuing-humana-merger.html (Some articles may require a subscription.) #cigna #medicareadvantage #humana https://www.fiercehealthcare.com/payers/cigna-officially-confirms-its-not-pursuing-humana-acquisition Kaiser Permanente Books Loss in Q3 Kaiser Permanente posted a $608 million operating loss in Q3. It is struggling with higher medical expenses due to higher-than-expected utilization, acuity, pharmacy costs and inflation. It has enacted a cost-cutting program. Showing the extent of

OIG Says Hospitals Not Complying With Hospital Transparency Requirements The Health and Human Services Office of Inspector General (HHS OIG) says many hospitals are not publishing their prices in accordance with the price transparency requirements. The HHS OIG analyzed data from 30 hospitals that were part of the country’s three largest health systems as well as a random sample of 5,504 facilities. Researchers reviewed hospital websites between Jan. 17, 2023 and March 14, 2023. HHS OIG found that more than a third of the 100 hospitals did not post machine readable pricing data files correctly or at all. Most of the errors involved not disclosing rates with insurers, metadata errors, and outdated information. The Centers for Medicare and Medicaid Services (CMS) says some entities have already corrected errors, but it shows just how lax CMS enforcement is years into the law. (Article may require a subscription.) #hospitals #transparency #pricetransparency #cms

Health Insurer Q3 Financial News Oscar Health reported slipping financials and at least part of its long-term success is dependent on the continuation of enhanced premium subsidies in the Exchanges. After two quarters of net profit, Oscar posted a $54 million loss in Q3. But total revenue was $2.4 billion, a 68% year-over-year increase. Its medical loss ratio (MLR) climbed to 84.6%. It did raise revenue guidance and said EBITDA will be at the higher end of its earlier reported range. Exchange-focused Oscar has 1.65 million members in total. The company added 73,000 members in the quarter. Its growth has been explosive during the Biden administration. It expects more big growth in 2025 as the premium enhancements are still in place. Oscar Health CEO Mark Bertolini’s had a rather stern message and challenge for what is expected to be a totally GOP controlled Washington. Bertolini says the GOP would allow

Healthcare Media Reacting To Trump Win A series of articles appeared today reacting to Donald Trump’s victory in the presidential election. The articles predict as expected that the Exchanges and Medicaid will be reined in through a number of regulatory and statutory efforts. It notes that Trump may not again go after the Affordable Care Act (ACA), but that extension of the enhanced premium subsidies in the Exchanges are very much in doubt. At the same time, his incoming VP JD Vance outlined a potential change to premium setting in Exchanges. On Medicare Advantage (MA), Trump is said to be much more enamored with the program as an alternative to the traditional system. I, however, feel Trump and lawmakers will still seek some reforms and savings in MA. Pharmacy benefits manager (PBM) reform likely moves forward, given bipartisan congressional support and previous positions taken by the former president. Trump is

Biden No Surprises Act Interpretation Wins At Appellate Level After being struck down at the federal district level several times, the 5th Circuit Court of Appeals sided with the Biden administration’s original interpretation of the No Surprises Act in determining how a key metric in billing disputes is calculated. The court said that insurers can use a wider variety of rates in calculating the key qualifying payment amount (QPA) metric that helps arbitrators determine fair payment amounts. Now, the law remains heavily skewed to providers, who win three in four cases thus far in arbitration. The law itself favors providers in that it is baseball-style arbitration. The Biden administration wanted to tell arbitrators to give deference to the QPA, but this remains struck down by the courts. But the QPA determination is at least a small win that could begin to change things for the better. #nosurprisesact #nsa #surprisebilling #providers

Trump And Johnson Silent On Reforming Employer Healthcare Deductibility Donald Trump and House Speaker Mike Johnson, R-LA, are not saying whether they support the House Republican Study Committee’s (RSC) proposals to potentially cap the tax exclusion for employer-sponsored coverage. Employers can deduct premiums from federal and payroll taxes. Workers’ shares of premiums are also exempt from income taxes. These tax breaks cost about $300 billion combined a year today. The RSC is a conservative policy caucus within the House GOP members. Its proposal on employer healthcare tax deductibility is unclear, but its budget document certainly infers the deduction may be limited and it also calls for equalizing individual and employer deductibility. There are a few ways to limit the tax deduction, either capping what an employer can take outright or taxing individuals over certain amounts individually. Opponents argue the unfettered deduction drives up healthcare costs. To some degree this may

Bipartisan Senate Team Wants To Move On Site Neutral Payments Sens. Bill Cassidy, R-LA, and Maggie Hassan, D-NH, unveiled their support for a bill that would begin paying hospital outpatient facilities lower Medicare reimbursements much more consistent with what other places of service receive for the same services – known as “site-neutral” payments. The bill would equalize payments for common outpatient services at hospital-owned offsite locations, ambulatory surgery centers, and other clinics. Check out my blog on site neutral payments here:  https://www.healthcarelabyrinth.com/it-is-time-for-site-neutral-payments-in-our-healthcare-system/ . We know that the lack of site neutral payments cost us huge sums and we need to reform this in Medicare. Commercial payments would then be transitioned as many commercial plans base rates on Medicare. The hospital lobby’s ridiculous arguments may finally be giving way to common sense. Kudos to Cassidy and Hassan. We need full site neutral payments as quickly as possible. There is the possibility

Medicare Advantage Penetration Saves Medicare Dollars A new study from Elevance Health says that growth in Medicare Advantage (MA) leads to lower overall Medicare spending. This in part counters the shouts of MA opponents who cry about overpayments in the program. The study found that Medicare spending was $431 billion less from 2010 to 2020 than the Congressional Budget Office (CBO) predicted. The difference was per enrollee spending during the timeframe. The lower spending trend due to MA growth is most noticeable in midwestern and southern counties, but weaker in northwest and western counties. Researchers found that a 10% percent higher MA penetration in a county points to a 1.9% decrease in Medicare spending, correlating to a $204 decrease in per person spending. This resulted in up to $144 billion cumulative savings from 2012 to 2021. One theory is that higher penetration of MA introduces a change in provider behavior