priorauthorization Archives - Page 24 of 28

The Insanity of Drug Pricing and Shortages: A Christmas Story

December 26, 2023 No Comments

After what I went through, I asked Santa to bring me a rational drug pricing system for Christmas . But not even the great St. Nick can sort this mess out. Drug shortages or supply disruptions are in the news of late, with serious concerns over the availability of critical cancer and other life-saving drugs. While my drug supply story is not nearly as serious, I write about it today as I have been dealing with it over the Christmas holiday and it shows the pure insanity of our drug supply and pricing system in America. I am withholding the names of the pharmacies and the pharmacy benefits manager (PBM) as not doing so would be unfair to an individual drug chain or PBM. What we see here occurs across the drug supply chain. I am disclosing the drug manufacturers as this helps make clear the complexity of drug pricing.

December 25, 2023

December 25, 2023 No Comments

The Healthcare Labyrinth Is Off For Christmas Merry Christmas and Happy Holidays to all! — Marc S. Ryan and The Healthcare Labyrinth website.

December 22, 2023

December 22, 2023 No Comments

Predictions for Healthcare M and A A good article on what to expect in M and A. Discusses consolidation and technology as well as has suggestions for healthcare leaders. #manda #acquisitons #mergers #healthplans #hospitals #providers #2024 Link to Article Government Shutdown Looms Congress does not appear to be any closer to a deal on a FFY 2024 budget to keep government operating. Some CR funding expires on January 19, with the remaining CR ending in February. House Speaker Mike Johnson, R-LA, has proposed a year-long CR at 2023 spending levels. A few months ago, the hard right from which the Speaker hails declared that such a proposal would be terrible given all the COVID spending that has inflated the budget bottom line over the past few years. This led to the ouster of Kevin McCarthy as Speaker and weeks of paralysis on Capitol Hill. Democrats view flat spending as detrimental

December 21, 2023

December 21, 2023 No Comments

Prospects In 2024 For Payers and Providers A good article on what is in store for payers and providers in 2024. Included is retail healthcare, health plan investments, hospital struggles, and M and A prospects. #manda #retailhealthcare #healthplans #hospitals #providers #2024 Link to Article Star Achievement In Medicare Advantage Is Key Good article on the financial impacts of the drop in Star power in Medicare Advantage and what plans need to do to get things back on track. Focusing on member satisfaction is key as is measuring well into the future to see how changes will impact ratings, including with the Health Equity change. There also is conversion to digital for a number of Star measures (from manual chart review). Technology investments, including data analytics, are also key. #medicareadvantage #stars Link to Article Will PBM Reform Bill Pass in 2024? Good article on the prospects of PBM reform in 2024.

Are Health Plans’ Relationships With Owned Entities Fair? Will They Open Up More Regulatory Scrutiny?

December 21, 2023 No Comments

A late November bipartisan letter from Sens. Elizabeth Warren, D-MA, and Mike Braun, R-IN, to the Health and Human Services (HHS) Office of Inspector General (OIG) has many wondering if lawmakers and policymakers will open up a new regulatory front that will bring heightened scrutiny of health insurers’ finances and internal contractual relationships. Let’s give some history first before diving deeper into the issue. With this set up, what does the letter say? Warren and Braun want the HHS OIG to open an investigation on MLR gaming. They are reacting to a recent Brookings Institution analysis and Wall Street Journal (WSJ) report showing the extent of contracting by major insurers with their own subsidiaries and the impact that could have on costs in the healthcare marketplace, especially for consumers. The letter alleges that certain insurers are using these arrangements to evade the minimum MLR rule. In effect, they say insurers

December 20, 2023

December 20, 2023 No Comments

Feds Expect 19M On Exchanges Based on current enrollments on the Exchanges, the feds say enrollment will break a record with 19 million in 2024. Up from 16.4 million in 2023. This is driven by the extension of the enhanced premium subsidies and other investments in outreach and marketing. Additional articles here: https://insidehealthpolicy.com/daily-news/admin-least-19m-enrolled-aca-plans-nationwide-nov-1 and https://thehill.com/policy/healthcare/4369743-white-house-touts-record-breaking-obamacare-enrollment/ CMS release here: https://www.cms.gov/newsroom/press-releases/healthcaregov-enrollment-exceeds-15-million-surpassing-previous-years-milestones (Some articles may require a subscription.) #aca #obamacare #exchanges #coverage Link to Article Health Equity A Top Goal in 2024 More than 80% of executives from healthcare and life sciences organizations say health equity is a top-10 goal for 2024. #healthequity #healthinsurance Link to Article Hospital At Home Program Interesting interview on prospects of hospital-at-home extension and growth. There are a number of good pilots in several lines of business that show great promise. (Article may require a subscription.) #hospitals #hospitalathome Link to Article Conflicting Reports on ACO Success This study

December 19, 2023

December 19, 2023 No Comments

New Antitrust Merger Guidelines The Federal Trade Commission (FTC) and the Department of Justice (DOJ) finalized new guidelines for mergers and acquisitions. They are not legally binding. Each deal would receive an assessment based on the uniqueness of the parties and merger. The guidelines give health plans, hospitals, and others in healthcare a look into the decision-making process to determine consistency with antitrust rules. The guidelines and greater scrutiny fulfill a Biden administration pledge and come from an executive order. FTC release here: https://www.ftc.gov/news-events/news/press-releases/2023/12/federal-trade-commission-justice-department-release-2023-merger-guidelines . Additional article here: https://www.healthcaredive.com/news/ftc-doj-final-merger-guidelines-healthcare/702897/ At the same time, two hospital entities called off their merger after challenges from the FTC and state of California regulators: https://www.fiercehealthcare.com/providers/john-muir-health-tenet-healthcare-nix-143m-hospital-deal-after-regulatory-pushback Overall, the scrutiny is good, especially on provider proposals, as most mergers lead to higher costs. #ftc #doj #mergers #acquisitions #antitrust #hospitals #healthplans Link to Article DOJ Seeks To Stall RADV Lawsuit The Department of Justice (DOJ) is urging

December 18, 2023

December 18, 2023 No Comments

More “Retail Meets Healthcare” Investments Kroger is piloting value-based primary care clinics like many other retailers. The grocery chain will team up with Better Health Group, a provider network, to build out primary care centers. Kroger in-store clinics will be replaced. There is a senior focus. Walgreens is pulling back on its clinic investments. So, retail healthcare is not without its risks but will continue to grow. #retailhealthcare #kroger Link to Article Molina Reduces Bright Payment for Medicare Advantage Business After diligence, Molina Healthcare will cut how much it will pay for Bright Health Group’s California Medicare Advantage plans to $425 million, from $600 million. Molina did not specify in a news release Monday why it reduced the agreed-upon purchase price by 16.7% from $600 million gross/$510 million net. This is more bad news for the insurtech world, which has seen stunning reversals. (Article may require a subscription.) #brighthealth #molina

National Healthcare Expenditure Data Issued for 2022: What Does It All Mean?

December 18, 2023 No Comments

One of my Christmas traditions is to write about the release of the Centers for Medicare and Medicaid Services (CMS) Actuary’s National Healthcare Expenditure Data (NHED) for a given calendar year. This usually is released in the first half of December each year for the prior year. It literally takes CMS about a year to capture, calculate and categorize all the data for a year given the size and labyrinthine complexity of our healthcare system. Each year as well, usually in the first half of June, the CMS Actuary updates healthcare spending projections for ten outyears. Why is this so important? First, it is the main comprehensive source of data for calculating the history and future of healthcare spending. Most other studies rely on the CMS Actuary’s NHED reports in some way. Second, it is a treasure trove of data that helps explain the inner workings of the healthcare system.

December 15, 2023

December 15, 2023 No Comments

Elevance Health and HCSC Looking At Cigna Medicare Reports suggest Elevance Health and Health Care Service Corporation (HCSC) are looking at acquiring Cigna’s Medicare Advantage (MA) lives. Cigna has just over 600,000 Medicare Advantage lives, but has had lower Star ratings than desired. HCSC has just 180,000 MA lives and would love to acquire a bigger footprint. Elevance Health has just over 2 million lives and is trying to grow Medicare as well. In 2021, Elevance acquired MMM’s almost 300,000 lives in Puerto Rico to help with organic growth. #elevancehealth #hcsc #cigna #medicareadvantage #mergers #acquisitions Link to Article BCBSLA Could Be Acquired by Elevance Health At the same time, Elevance Health may acquire BCBSLA after pausing the process earlier this year. This is based on revised regulatory activity. Elevance Health is the largest for-profit owner of Blue Cross and Blue Shield plans, with 14 states nationwide. Additional article here: https://www.modernhealthcare.com/mergers-acquisitions/elevance-health-blue-cross-louisiana-merger-acquisition

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