republicans

Trump Admin Proposes Major Medicare FFS Reform Rule The Trump administration continues its efforts to reform Medicare and make its mark on healthcare reform. A new Medicare fee-for-service (FFS) reform proposal will significantly impact many areas of the sprawling traditional program. The proposed rule would make changes to Medicare accountable care organizations (ACOs), transition away from the physician Merit-based Incentive Payment System (MIPS) to an enhanced value-based care (VBC) pathways program, and update physician payment policies to better reflect modern clinical practice. In part the ACO changes would establish more predictable spending targets to improve planning and participation as well as increase some shared saving rates and make benchmark and other calculation adjustments. Notable quality reporting changes are also proposed. The MIPS successor would also have three new value-based pathways on diabetes, hypertension, and hospital-based care. Physician reimbursement would generally shrink a bit in 2027. Remote patient monitoring would also

Another Stars Lawsuit — This Time From Alignment High-performing MA plan Alignment Healthcare has joined the lawsuit fray on the Clover decision. Alignment has the same argument as Scan. Both indicated CMS erred by including ten measures in the CMS Recalculation scenario when a judge ruled these measures did not go through the correct regulatory vetting process. Alignment says three of its contracts currently rated 4.0 should be at 4.5, netting an additional $50 million. If you are adding up the numbers from lawsuits, here is the total: –Clover = $120M–Elevance Health = $115M–Scan = $125M–Alignment = $50M TOTAL = $410M I had earlier estimated the total costs to be over $1 billion. Alignment lawsuit: https://lnkd.in/entBMgHn #cms #stars #quality #medicareadvantage https://www.healthcaredive.com/news/scan-alignment-sue-cms-ma-star-ratings-recalculation-clover-lawsuits/825091 Plans Oppose No Surprises Bill A health plan group has launched a campaign challenging a congressional bill that would implement even more friendly provider elements in the No Surprises

Scan Now Sues Over Clover Lawsuit And CMS Recalculations A new lawsuit has been filed by non-profit Scan Health Plan. Scan argues that CMS inappropriately recalculated Star Rating for 2026 after the Clover Health decision. Clover received an exact calculation based on the judge’s ruling throwing out 20 measures based on two legal arguments (10 measures were not statutorily allowed and another 10 measures were not properly promulgated via regulation). However, CMS’ recalculation measure set adopted part of the ruling by throwing out some of the judge’s measures, while retaining others. As well, CMS removed some measures not even struck by the court. Elevance Health was the first to sue, arguing it is entitled to a calculation based exactly on what the judge ruled for Clover on the 20 measures. Scan’s suit appears different. Scan argues the court should force CMS to remove the ten measures that CMS failed to

Wearables Growing But Not Integrated The use of wearables for disease monitoring has increased dramatically. About 86% of U.S. physicians report they sometimes review data from their patients’ wearables, including heart physiology, oxygen and breathing, and sleep. But only 6% of doctors say such data is integrated into clinical workflows and that clearly limits growth and  potential. The Trump administration has in part sought to leverage technology and overcome this deficiency by announcing the ACCESS reform pilot, which contracts with technology entities to partner with physicians to monitor chronic disease states. #chronicdiseases #technology #medicare #access https://www.healthcaredive.com/news/physician-wearable-data-use-hindered-workflow-reimbursement-challenges-american-medical-association/824640/ CVS CEO Says Aetna Has Turned Corner Financially At a public speaking event, CVS Health CEO David Joyner said insurer Aetna has finally gotten a handle on medical spending after a turbulent few years. Recently Aetna’s financial reports have shown recovery. In other health plan news: Elevance Health’s Medicaid subsidiary in the District of

Study Says Median Exchange Hike Will Be 14% Thus Far A Peterson-KFF Health System Tracker analysis finds that preliminary rate filings in the Exchanges will mean a median premium rate hike of 14% in 2027. This follows a final median hike of 20% in 2026 after plan switches. This would amount to a one-third increase over two years. While most of the hike will be covered by premium subsidy increases, the hikes will hurt those with little or no subsidy. Peterson-KFF looked at 77 insurers across 16 states and the District of Columbia. The healthcare duo calculated the enrollment-weighted average rate change across its offerings in a state. Most plans are requesting increases of between 10% and 20% for the coming year, though 20 payers have requested an increase of more than 20%. Plans say factors such as high medical costs, the expiration of enhanced exchange subsidies, and tighter enrollment

Pharmacy Group Alleges Price Fixing A community pharmacy group has filed suit against Prime Therapeutics, alleging that the company colluded with fellow pharmacy benefits manager (PBM) Express Scripts to fix prices and engage in anti-competitive behavior. The suit alleges Prime accessed Express Scripts’ network to slash prices. Additional article:https://www.modernhealthcare.com/insurance/mh-prime-therapeutics-lawsuit-express-scripts-pbm/ (Some articles may require a subscription.) #pbms #drugpricing #antitrust #pharmacies https://www.fiercehealthcare.com/payers/independent-pharmacies-hit-prime-therapeutics-antitrust-suit-over-alleged-price-fixing Private Equity Deep In Hospitals Private equity firms are expanding their healthcare reach through joint ventures with nonprofit health systems. A new report finds that more than 500 healthcare facilities operated through these nonprofit joint ventures. #privateequity #hospitals https://www.medpagetoday.com/hospitalbasedmedicine/generalhospitalpractice/122077 Tampa General Sues Eli Lilly On 340B Tampa General Hospital is suing Eli Lilly over its cut off of 340B discounts, saying that violates Florida’s Deceptive and Unfair Trade Practices Act. The hospital alleges the discount change forced the price of Mounjaro from $750.52 per unit to $1,019.74 at wholesale acquisition

ACA Exchange Risk Adjustment Settlements Total $11.7 Billion Health insurers will shuttle $11.17 billion between them due to the 2025 ACA Exchange risk-adjustment settlements. The settlements recognize differences in risk in the program in a given year. UnitedHealthcare will pay $335 million while Centene will receive $751 million, Elevance Health $312 million, Aetna $216 million, and Oscar Health $189 million. (Article may require a subscription.) #exchanges #riskadjustment https://www.modernhealthcare.com/insurance/mh-aca-exchange-risk-adjustment-payments-2025/ Exchange Rolls Saw Drops As Long As A Year Ago According to new data that was quietly published by the federal government, states began seeing steep drops in Exchange enrollment over the past year. Ohio and Oklahoma lost nearly one-third of enrollees. Florida has the most enrollees at nearly 4 million but lost the most at around 443,000. Around 2.6 million fewer Americans had Exchange plans in February compared with the same time last year. #exchanges #coverage #enrollment https://www.medpagetoday.com/washington-watch/washington-watch/122067 Dem Bill Targets