physicians

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February 26, 2024

Not All Is Rosy In Hospital Finance While the hospital industry is recovering overall from the COVID slump, recovery is not universal in the hospital industry. And there are still some bad barometers of financial performance overall. #hospitals Link to Article PBM Reform and Site-Neutral Policy May Not Be Included In Health Bill Due to the major threat of a government shutdown and no consensus yet on the issue, time is running out on passing substantive policy reforms.  Congress is looking at a very skinny health bill and that could mean the death of PBM reform and site-neutral policies this year. A partial or full prospective Medicare doc payment fix will likely still be included. I don’t like the tone and tenor of the PBM reform measures, but would like the site neutral reforms to begin. At the same time, Sen. Chuck Grassley wants a PBM reform vote given the

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2024 Medicare Advantage Compliance And Regulatory Issues

A number of folks have texted, LinkedIn messaged, or emailed and asked if I would give an overview of some of the major compliance and regulatory issues Medicare Advantage (MA) plans need to be aware of as the 2024 year gets going. Here is my best take on the major issues from a compliance and regulatory standpoint: Audits in full swing I am hearing from health plan friends that MA audits have already begun this year with January notices. As promised by the Centers for Medicare and Medicaid Services (CMS), regular program audits are being supplemented with ad hoc audits concerning the 2024 rule requiring major changes to how MA plans perform prior authorization (PA) and utilization management (UM). In addition to adding the ad hoc audits for those under regular program audit, plans can be noticed for just an ad hoc audit as well.  In general, the new rule

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February 23, 2024

Major Cyber Attack On United’s Change Healthcare Change Healthcare announced a major cyber attack on its systems this week.  The event shows how vulnerable major healthcare organizations can be.  Change is owned by The United Health Group, granddaddy of insurance and owner of prominent service entity, Optum.  Change rolls up to Optum.  The attack shows how far-reaching a successful penetration could be. Change is a vendor. It has various products and connects to health plans throughout the country.  It also connects to providers and pharmacies throughout the country. Change says the attacker was a nation-state associated cyber security threat actor.  Little else is known about how far-reaching the attack was or the fallout yet. Additional article here: https://www.modernhealthcare.com/cybersecurity/change-healthcare-outage-cyberattack-2024-update (Some articles may require a subscription.) #cyberattacks #healthcare Link to Article Surge In Weight-Loss Drug Costs Troubles States Interesting assessment of the surge in costs for weight-loss drugs in state employee health plans

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February 22, 2024

New Poll Suggests MA Enrollees Have Issues With Prior Authorization, But Some Use Added Benefits A new poll says Medicare Advantage (MA) enrollees are more likely than those in traditional Medicare fee-for-service (FFS) to experience care delays due to prior authorization, but they do receive supplemental benefits not in the traditional program. While the rates of such use can always be better, a 70% member-use rate is encouraging.  Still, it is indeed time for MA plans to show their value by encouraging the use of all of the added benefits at reasonable rates. Proposed supplemental benefits reporting rules will encourage this trend. Overall, MA plans need to educate members thoroughly on all benefits, lest critics and researchers build a case that there is no added value. The critics continue to argue massive overpayments, which I do not agree with. One point just does not resonate with me. About 12% of

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Part 3: My Courageous Daughter Is Having Brain Surgery!

This is one of a number of blogs that will appear on my daughter.  I call her Kitty.  She is a wonderfully talented, bright, and empathetic individual in her late ‘20s.  She and I agreed I would write this series to impart how important health coverage is. Not only is her decision to have surgery courageous, but so is her decision to share her journey through me. The principal reason to share the journey is because we both want to explain what many average Americans go through financially when they have major operations and do not have the best insurance or no insurance at all.  My daughter is privileged to come from a well-off family and to have consistent and robust insurance.  This will mean that she will pay a tiny amount for a surgery with a sticker price in the hundreds of thousands of dollars.  But for uninsured and

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February 21, 2024

New CMS DSH Rule Will Reduce Medicaid Hospital Payments Medicaid disproportionate share hospital (DSH) payments are being cut by $8 billion annually for the nest five fiscal years based on a new rule finalized by the Centers for Medicare and Medicaid Services (CMS).  The rule is purported to rein in overpayments. A recent study suggested that a liberal formula calculation meant a third of all qualifying hospitals should not have received payments.  CMS has been pushing to reduce such payments in favor of broad coverage. Additional articles: https://www.fiercehealthcare.com/providers/many-disproportionate-share-hospitals-face-lower-medicaid-payments-under-new-final-rule and https://www.modernhealthcare.com/policy/medicaid-dsh-cuts-safety-net-hospitals-cms-final-rule (Some articles may require a subscription.) #medicaid Link to Article HCSC Believes In Medicare Advantage As Cigna decided its investment in Medicare Advantage (MA) was too much on the health plan side, Health Care Service Corporation (HCSC) agreed with most large insurers that MA investments made sense.  It paid $3.3 billion for about 600,000 Cigna MA lives, bringing its total

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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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Part 2: My Courageous Daughter Is Having Brain Surgery!

This is one of a number of blogs that will appear on my daughter.  I call her Kitty.  She is a wonderfully talented, bright, and empathetic individual in her late ‘20s.  She and I agreed I would write this series to impart how important health coverage is. Not only is her decision to have surgery courageous, but so is her decision to share her journey through me. The principal reason to share the journey is because we both want to explain what many average Americans go through financially when they have major operations and do not have the best insurance or no insurance at all.  My daughter is privileged to come from a well-off family and to have consistent and robust insurance.  This will mean that she will pay a tiny amount for a surgery with a sticker price in the hundreds of thousands of dollars.  But for uninsured and

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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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