recoveries Archives - The Healthcare Labyrinth

January 30, 2024

January 30, 2024 No Comments

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

January 29, 2024

January 29, 2024 No Comments

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

January 26, 2024

January 26, 2024 No Comments

2023 Bankruptcies Highest In Five Years As was reported earlier, another report also shows that bankruptcies were very high in the healthcare arena in 2023. Hospitals, pharmaceutical and senior care companies were on the list. Additional articles here: https://www.modernhealthcare.com/finance/healthcare-bankruptcies-2023-gibbins-advisors and https://www.healthcaredive.com/news/healthcare-bankruptcies-spike-2023-gibbins-advisors/705738/ (Some articles may require a subscription.) #hospitals #healthcare #bankruptcies Link to Article Biden Administration Strikes Again On Mergers The Federal Trade Commission opposes another prominent merger – Novant Health’s purchase of two Community Health Systems hospitals. Additional article here: https://www.healthcaredive.com/news/federal-trade-commission-sues-block-novant-health-community-health-systems-hospital-acquisition/705648/ #mergers #acquisitions #ftc #antitrust Link to Article Drug Maker CEOs To Appear On Capitol Hill A day after some very bad press, Johnson & Johnson CEO Joaquin Duato, Merck CEO Robert Davis and Bristol Myers Squibb CEO Chris Boerner all said they would appear at hearing on drug pricing. Additional article here: https://www.statnews.com/2024/01/26/merck-johnson-johnson-ceos-drug-prices/ (Some articles may require a subscription.) #drugpricing #branddrugmakers Link to Article Medicaid Enrollment Losses Under Redeterminations

January 25, 2024

January 25, 2024 No Comments

Humana Reconfirms Bad News On Utilization In MA After an earlier filing, Humana reconfirmed bad news on the medical expense front. Because it is a predominant Medicare Advantage (MA) insurer, it has seen a major and unexpected rise in utilization, which impacted the company’s 2023 numbers and prospects for 2024 and beyond. Broussard is one of the smartest healthcare leaders out there and he is someone I listen to closely. Given the medical expense rise, rate compression, and regulatory changes (such as the new prior authorization rule), Broussard said he expects similar pricing adjustments from other payers, as the spike in utilization along with ongoing regulatory changes will have major impacts in 2025 and potentially beyond. Broussard says this could very well be industrywide. Humana reduced benefits for 2024 and this could be a continued trend into the future. Humana plans on cutting about $700 million in administrative costs. It

January 24, 2024

January 24, 2024 No Comments

Record Enrollment In Exchanges Nationwide The Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services (HHS) announced something to celebrate. Driven in part by Medicaid redetermination enrollment losses and enhanced premium subsidies, state and federal exchange enrollment reached a projected 21.3 million for 2024. An amazing achievement. Over 5 million new enrollees joined over 16 million existing members. Nearly 4.2 million people with incomes of less than 250% of the federal poverty level signed up for 2024 coverage. They receive both premium subsidies and cost-sharing reductions. About 15% of those enrollment previously had Medicaid. That translates to a little over 3 million – a small amount of those who lost Medicaid coverage. Over 16 million are in the federal Exchange and about 5 million in various state Exchanges. CMS press release here: https://www.cms.gov/newsroom/press-releases/historic-213-million-people-choose-aca-marketplace-coverage . CMS Snapshot here: https://www.cms.gov/newsroom/fact-sheets/marketplace-2024-open-enrollment-period-report-final-national-snapshot . HHS press release here: https://www.hhs.gov/about/news/2024/01/24/historic-21-million-people-choose-aca-marketplace-coverage.html Kaiser

January 23, 2024

January 23, 2024 No Comments

Rural Hospitals In Distress A good measure of the distress rural hospitals: most no longer deliver babies. Over half of the country’s rural hospitals aren’t offering labor and delivery services and more could end such services. Some would argue that the rural hospitals’ plight could be solved by more money for hospitals overall. The truth is the abominable hospital price system we have in this country along with the gross inefficiency of most hospitals drains overall healthcare resources and means we do not have enough to respond to true crises, such as those in rural communities. #ruralhealthcare #hospitals Link to Article Good Summary Of New Interoperability Rule’s Impact On Health Plans Modern Healthcare has a good article summarizing the provisions and impacts of the new interoperability rule. Among the mandates are a swifter turnaround time for medical service authorizations in 2026 and the new FHIR electronic prior authorization process in

January 22, 2024

January 22, 2024 No Comments

Elevance Health All In On AI Elevance Health CEO Gail Boudreaux gave a keynote speech that shows the second-largest insurer will be all in on AI. She wants her company to use the technology to make healthcare more proactive, predictive and personalized. She wants AI to help people navigate the system and simplify it. #elevancehealth #ai #digitalhealth Link to Article Physicians Want Rollback Of Medicare Cut As Well As New System Not only do physicians want both a rollback of their payment cut, but also a brand new way of paying them in the Medicare traditional system. They are not wrong. Each of the payment formulas has always been controversial and has led to an inability to calculate payments and last-minute rescues by lawmakers. (Article may require a subscription.) #medicare #physicians #providers #payments Link to Article Canada Ramping Up To Stop U.S. Importation Despite visits by U.S. officials, Canada seems intent on

January 19, 2024

January 19, 2024 No Comments

Weight Loss Drugs Take Nation By Storm Ozempic and other new drugs are all the rage for weight loss. These new drugs have both great promise and the potential to be abused and drive up healthcare costs phenomenally. See some of the trends here. (Article may require a subscription.) #weightlossdrugs #healthcare Link to Article Behavioral Health Pilot Announced By CMS The Centers for Medicare and Medicaid Services announced a new behavioral health pilot for traditional Medicare and Medicaid. Physical and mental healthcare providers will form care teams with community organizations to coordinate care for the mentally ill and substance abusers. (Article may require a subscription.) #behavioralhealth #medicare #medicaid Link to Article House Budget Committee Passes Fiscal Commission Bill Three Democrats and all Republicans came together to pass a fiscal commission bill in the House Budget Committee. Such a commission would make recommendations on major fiscal issues, including Medicare. Congress would

January 18, 2024

January 18, 2024 No Comments

Disappointing Medicare Advantage Enrollment Numbers Huge disappointment for some during the Medicare Advantage enrollment season. My quick math says that overall MA numbers increased a strong 8.7% from January 2023 to January 2024. That is up from a year ago, which was a little over 6%. But a number of plans did not fare well during the recent enrollment campaign. Aetna shined. While United and Humana grew, it was a much lower rates than before. Centene took a big hit. I will have my usual annual blog looking at all the data on Monday. Stay tuned. Additional article here: https://www.healthcaredive.com/news/humana-earnings-outlook-cut-high-medical-costs/704865/ (Some articles may require a subscription.) #medicareadvantage #healthplans #enrollment Link to Article Government Shutdown Averted Until Early March Over objections of the right flank in the House, Congress passed a new continuing resolution (CR) to keep government open until early March. New House Speaker Mike Johnson, R-LA, previously said he

January 17, 2024

January 17, 2024 No Comments

CMS Finalizes Interoperability And Prior Authorization Rule The Centers for Medicare and Medicaid Services (CMS) finalized a sweeping interoperability rule today that also sets much stricter timelines for medical service prior authorizations. The rule was published some time ago and garnered a great deal of comments. The rule takes effect in January 2026 and requires 7 day standard and 72 hour expedited prior authorization turnaround times (federal Exchange plans excepted). Plans now have until 2027 to have APIs to allow providers to submit authorizations electronically. A national format exists for retail prescription drugs, but not a consistent one for medical service requests yet. The final specifications for medical services will tie to the Davinci Project, which will use the new FHIR standard. But plans will be able to use X12 formats as well. The rule applies to Medicare Advantage (MA), Medicaid, children’s coverage, and the federal Exchanges. The finalization of

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