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Digging Into My Modest Election-Year Proposal For Healthcare Reform: Part 3 — Driving To Affordable Universal Access

This blog is one in a three-part series that digs into my modest proposal for healthcare reform published at this site on May 27, 2024. See that blog here to review my proposal thoroughly: https://www.healthcarelabyrinth.com/a-modest-election-year-proposal-for-healthcare-reform/ . Much of my proposal is taken from my book, The Healthcare Labyrinth, available at this site and through leading bookseller websites. It is available in print, ebook, and audiobook forms. This blog has information from Chapter 28 of my book — “The Right Healthcare Reform Solution.” — Driving to affordable universal access “… Let me add that the health and vitality of our people are at least as well worth conserving as their forests, waters, lands, and minerals, and in this great work the national government must bear a most important part.” – Teddy Roosevelt, The New Nationalism Speech, August 31, 1910. In my “A Modest Election-Year Proposal For Healthcare Reform” blog on May

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Digging Into My Modest Election-Year Proposal For Healthcare Reform: Part 2 — Pivoting To Care Management From Our Obsession With Utilization Management

This blog is one in a three-part series that digs into my modest proposal for healthcare reform published at this site on May 27, 2024. See that blog here to review my proposal thoroughly: https://www.healthcarelabyrinth.com/a-modest-election-year-proposal-for-healthcare-reform/ . Much of my proposal is taken from my book, The Healthcare Labyrinth, available at this site and through leading bookseller websites. It is available in print, ebook, and audiobook forms. — Pivoting to care management from our obsession with utilization management In my “A Modest Election-Year Proposal For Healthcare Reform” blog on May 27, 2024, I stressed that the cornerstones of reform are three key tenets – driving affordable universal access, reforming price, and pivoting to care management (CM) from our obsession with utilization management (UM). This week I cover the need to rethink how we approach management of patients or members. In the May 27, 2024, blog, I argue that America is obsessed

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Digging Into My Modest Election-Year Proposal For Healthcare Reform: Part 1 — The Importance Of Price Reform

This blog is one in a three-part series that digs into my modest proposal for healthcare reform published at this site on May 27, 2024. See that blog here to review my proposal thoroughly: https://www.healthcarelabyrinth.com/a-modest-election-year-proposal-for-healthcare-reform/ . Much of my proposal is taken from my book, The Healthcare Labyrinth, available at this site and through leading bookseller websites. It is available in print, ebook, and audiobook forms. — The importance of price reform In my “A Modest Election-Year Proposal For Healthcare Reform” blog on May 27, 2024, I stressed that the cornerstones of reform are three key tenets – driving affordable universal access, reforming price, and pivoting to care management from our obsession with utilization management. I am going to start with price reform in this blog and in later blogs cover the other two tenets. In the May 27, 2024 blog, I argue that we need to fundamentally tackle price

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CMS’ TukeyGate: Lawsuit Decision Threatens To Unravel Much of Medicare Advantage Star Scoring in 2024 and 2025 and Next Year’s Bids And Benefits

A bombshell legal decision this week from a federal district judge threatens to unravel much of the Centers for Medicare and Medicaid Services (CMS) Star process. CMS may have to revisit 2024 Star ratings across the Medicare Advantage (MA) industry, pay out several hundred million more in bonuses, and revisit the bids and benefit designs already in flight for next calendar year. The entire issue is a bit arcane, so let’s break it down here and then get to the implications. The lawsuit and decision Scan Group, a prominent and highly successful non-profit MA plan based in California and serving a number of western states, has successfully won a challenge in a federal district court on its Star ratings for 2024. The case centers on the introduction of the Tukey outlier formula that CMS implemented beginning with the 2024 ratings. The court decision said CMS violated the Administrative Procedures Act

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Hospitals Drive Up Overall Healthcare Costs Considerably

As a former board member of two hospitals (a children’s medical center and academic medical center), I am sympathetic to the unique services that hospitals provide and the role many of them play in the education of doctors, nurses, and more. But it is also clear that hospitals are inefficient organizations that continue to drive up costs overall in the healthcare system. While some hospitals are reforming, others cling to the status quo. Hosptial lobbies are also stuck in the past and bucking change. Here are a few areas and recent studies that point to the role hospitals play in driving up healthcare costs: Hospital consolidations drive up costs, not lower them. Quality often suffers. New statistics from the Federal Trade Commission suggest that about 90% of hospital markets are highly concentrated due to the massive mergers and consolidations that have occurred over the past many years. What’s more studies

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Medicare Advantage Will Grow Even With Plan Financial Woes and Benefit Reductions

I have received a number of pings and messages to explain why I predict Medicare Advantage (MA) enrollment will continue to rise even with some extensive geographic contraction and benefit reductions in the market by some leading national health plans. Here are some of my thoughts on the subject. I would love to hear others’ impressions as well. What is happening with plans? Low or negative rate increases, a return of medical utilization, low Star achievement, and new restrictions on prior authorization are leading to a huge surge in some Medicare Advantage (MA) plans’ medical loss ratios. As such, margins have been reduced considerably. Almost every large national MA plan has raised concerns, but impacts appear to have been greatest over the past few years on Centene, CVS Aetna, Humana, and Cigna. Centene was forced to reduce benefits and geographic expansions already and may do so again. Humana did so

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A Modest Election-Year Proposal For Healthcare Reform

In a recent blog, I made the case that Election 2024 will come down to a handful of states and districts/counties deciding both  the presidency and control of the House of Representatives. In the Senate, almost every competitive race has an incumbent Democrat or open Democratic seat.  Everything would have to go right for them to maintain control of the Senate. I also stated that I think healthcare could be a bit of a sleeper issue even though it theoretically ranks low on the list of Americans’ priorities this year. I say theoretically because pocketbook issues do rank high and healthcare is a key component of that. More important, these swing states and areas tend to have independents and more moderate voters who will decide outcomes. They may indeed prioritize healthcare more than the rest of the nation. See my recent blog at this link for my election analysis and

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Election Update And The Potential Role of Healthcare Issues

While healthcare has been displaced by other economic issues and immigration as the compelling Election 24 issues of the day, I have taken the position that healthcare could very well play a role in this year’s election outcome. How so? How close is it? Let’s take a look at how close things are for the presidency and the houses of Congress. For reliable forecasts on elections, I always go to at RealClear Politics. It is very reliable and unbiased.  I also like the fact it uses polling averages to determine the current prospects of various political contenders. In addition, I have a special connection as its publishing arm, RealClear Publishing, was one of the publishers of my book, The Healthcare Labyrinth (available via this site). I went to RealClear Politics for the presidential and Senate races and looked at a few other sources for the House races. Presidential race –

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What The Recent Report On The Medicare Trust Funds Tells Us About Healthcare Policy

Each year, the trustees of both the Social Security and Medicare Trust Funds issue reports about the fiscal health of the funds. The practice is meant to spark a public policy analysis within the executive and legislative branches, but it almost never does. This year is no different. The Biden administration touted the recent report on the extension of the solvency of the Medicare Part A Trust Fund as some sort of evidence that it has worked diligently to ensure Medicare’s future. In its election-year press release from Health and Human Services (HHS) Secretary Xavier Becerra, it touted supposed remarkable achievements on the Medicare stabilization front: “The Biden-Harris Administration has left no stone unturned in our efforts to strengthen and preserve Medicare, not just for our parents and grandparents but for our children and generations to come.” But nothing could be further from the truth. The administration and Democrats have

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More Disturbing Trends On Medicare Advantage Prior Authorization

In these pages I have bemoaned the fact that the Centers for Medicare and Medicaid Services (CMS) and Capitol Hill are taking the managed care out of Medicare Advantage (MA). MA’s value proposition is based on the plans’ ability to save dollars in furnishing traditional Medicare fee-for-service (FFS) benefits and passing on the savings in the form of reduced cost-sharing, filling in gaps in the traditional benefit, and adding additional benefits. But when CMS reins in the ability to save these dollars, it will have a direct impact on the benefits American seniors and people with disabilities see. What’s more, the antiquated FFS system is fraud-ridden and of poor quality. We need innovation not mimicking the old way of delivering care. But by hobbling MA plans’ innovation, CMS and Capitol Hill are setting MA and the overall healthcare system back. Driven by some strange need to ingratiate themselves to provider

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