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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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