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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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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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Value-Based Care Payments And Arrangements Explained

A few readers have written in and asked if I could explain the various value-based-care (VBC) payment and arrangement frameworks. Specifically, they asked about my references to global and partial risk funds for providers.  Here is my best effort to explain what I see as the two overall types of VBC payments/arrangements we see in the marketplace today. Purpose VBC payments are meant to move from the fee-for-service (FFS) transactional payment system to one driven by efficiency and quality.  What do I mean by transaction payments? For the past many decades, most payments in our healthcare system were made as a fee for each service transacted in the healthcare system.  That can be the case when we go to the primary care physician (PCP), where he or she will be paid a fee by the insurer for the visit as well as other services provided. Similarly, a specialist may be

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2025 Rates for Medicare Advantage Plans Look Tight

My latest blogs have touched upon the fact that while Medicare Advantage (MA) continues to grow, MA plans in the program are facing a number of financial challenges: While MA plans prepared for the worse, the advanced notice of MA payments for 2025 could very well compound the problem, even with increased enrollment – which is robust and driven by the clear difference between the value of MA vs. the traditional fee-for-service (FFS) program. It will remain that way. See my last blog on all this: https://www.healthcarelabyrinth.com/with-boom-over-will-medicare-advantage-collapse-or-adjust/ So let’s take a look at the advanced 2025 MA rate notice. Controversy over calculations Each year there is a robust debate on how to even calculate what the year over year increases will be in MA. It revolves around risk score trends. Risk scores tend to inflate each year in the program. MA plans would argue risk scores predict the costs of

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January 31, 2024

Another Flat Year For Medicare Advantage Before Risk Score Trends The Centers for Medicare and Medicaid Services (CMS) announced the 2025 rate hike for Medicare Advantage will be relatively flat. This is similar to what happened in 2024 after big increases in 2022 and 2023.  The effective growth rate was up, but the phase-in of a new risk adjustment model basically offsets those gains. The final notice may push these numbers up a bit. If you include risk score trends, MA revenue could increase by about 3.7%. So real revenue should be up, but health plans don’t like thinking of it that way as they think risk score trends tie to increased medical exposure.  I include all these articles here but read with caution as many reporters interpret things differently. In the end, this is not the worst news, but it is bad in the face of some major medical

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January 30, 2024

Health Policies To Watch In 2024 The Peterson-Kaiser Family Foundation Health Tracker has a good briefer on expected healthcare policy issues to watch in 2024.  Among the many include site-neutral policies, price transparency, drug pricing and trends, PBM reform, drug price differences around the developed world for weight-loss drugs, value-based care and payments, and anti-trust activity.  A great primer! #peterson #kff #healthcare #healthcarereform Link to Article Kaiser Family Foundation Publishes Analysis Of Medicare Advantage Enrollment Drivers The Kaiser Family Foundation (KFF) briefer on why Americans are choosing Medicare Advantage (MA) is an important read.  I do not agree with everything in it, including references to a recent MedPAC analysis, but MA proponents will have a very good understanding of the threats presented. KFF providers ten reasons. MA is expected to hit at least 60% of beneficiaries by 2030 and that payments to MA are right now about 123% higher, or

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January 29, 2024

Elevance Health Sues CMS Over Medicare Advantage Star Rating Interesting article on Elevance Health’s lawsuit against the Centers for Medicare and Medicaid Services (CMS) on Stars.  If this is anything close to true, CMS needs to relook at how it ensure fairness in calculations. How many others may have been impacted? #elevancehealth #stars #medicareadvantage Link to Article Moody’s Says Medicare Advantage Margins On Downturn Interesting analysis by Moody’s that says Medicare Advantage (MA) margins have dropped from 4.9% in 2019 to 3.4% in 2022. Margins fell in commercial too but by a smaller amount. Note that these changes occurred before the latest medical expense upswing, lower 2024 rates, and new prior authorization limitations. Today, I published a blog on the future of MA after some major regulatory changes and a major increase in medical expenses. The boom is over. What will happen? The blog is here: https://www.healthcarelabyrinth.com/with-boom-over-will-medicare-advantage-collapse-or-adjust/ #medicareadvantage #margins #rates

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With Boom Over, Will Medicare Advantage Collapse Or Adjust?

After I posted my last blog Thursday ( https://www.healthcarelabyrinth.com/with-medical-expense-rising-what-are-health-plans-to-do/ ) and people digested what was happening with insurers’ stocks last week, a number of readers contacted me asking me to opine further on what was happening in MA. Many asked: “Is the Medicare boom over and is Medicare Advantage (MA) somehow collapsing under the weight of growing medical expense and government regulations?” They told me that they read many articles that implied MA was done — kaput! Indeed, my blogs have struck an alarmist cord at times about what is happening in MA, while other times I continue to extol the value and continued success of MA. So what’s up? It is a fair question and impression after the MA news over the past few weeks. Indeed, I give you a mixed review on MA on this site for good reasons. Refresh on issues Let’s refresh a bit on that

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