quality

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 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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What’s Up? Medicare Costs Will Be Up in 2024, While Medicaid Will Be Down At The Same Time

The Congressional Budget Office (CBO) has reported one of those weird conundrums in healthcare when it outlined expected cost increases in Medicare and Medicaid for 2024.  The CBO said that Medicare is expected to shoot up dramatically just as Medicaid expenditures will drop considerably as well. How is that possible? Let’s dig in here. Medicare The CBO says that Medicare spending will increase by about $65 billion in 2024 to $865 billion.  That is an increase of about 8%.  The significant rise in expected Medicare costs is driven by a few different things: In the outyears, outlays for Medicare will equal 3.2 percent of gross domestic product (GDP) in 2025 and increase to 4.2 percent of GDP in 2034. Medicaid On the flip side, the CBO says Medicaid expenditures will decrease by $58 billion to $557 billion.  This is a drop of about 9%.  The reason for this drop is driven by

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Senate HELP Committee Hearing On Drug Pricing Shows The Deep Divide In Congress

While I covered the topic in my Newsfeed on February 8 and 9, I thought it was important to blog about the February 8 Senate Health, Education, Labor and Pension (HELP) drug price hearing. I have listened to every minute of the almost three-hour drug maker CEO hearing (where three brand drug makers testified) as well as an additional thirty-minute hearing presenting the views of advocates and researchers. I want to share my reaction. First, it is important to remember that, while I am a Republican, I march up the middle of the spectrum on health policy in general and share many of the views that Democrats do on drug pricing. I tend to favor what the Democrats have done on drug pricing because I think movement needs to happen and what has passed in the Inflation Reduction Act’s (IRA) Medicare drug price negotiations is a good experiment. Second, the

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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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Part 1: 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 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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February 6, 2024

Centene Reports Good Numbers, But Cautions On MA Rates Centene reported good numbers to Wall Street today, with notable increases in its Exchange line of business. Medicaid enrollment dropped due to redeterminations. But like Humana, Centene is cautioning that the Medicare Advantage (MA) 2025 rate announcement was inadequate and could lead to further benefit and other changes in its MA line. It also notes that other regulatory changes are impacting its MA investment.  Centene has already pared back benefits and geographies to bring its MA line to a better financial position. Additional articles here: https://www.modernhealthcare.com/insurance/centene-medicare-advantage-rate-cut-2025-sarah-london and https://www.healthcaredive.com/news/centene-medicare-advantage-rate-drop-2023-earnings/706620/ Two other articles on the fallout from MA rates and regulatory changes here: https://www.modernhealthcare.com/insurance/medicare-advantage-rate-cut-2025-reimbursements-benefits-unitedhealth-humana and https://www.statnews.com/2024/02/05/cano-health-bankruptcy-medicare-advantage/ These articles underscore what I said in these blogs: https://www.healthcarelabyrinth.com/with-boom-over-will-medicare-advantage-collapse-or-adjust/ and https://www.healthcarelabyrinth.com/2025-rates-for-medicare-advantage-plans-look-tight/ (Some articles may require a subscription.) #centene #medicareadvantage Link to Article Another Big Week For Drug Policy Much like last week, this week is very

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