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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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With Medical Expense Rising, What Are Health Plans To Do?

Insurer stocks were rocked recently by news that both United Healthcare and Humana saw unexpected medical expense increases.  After filings with the Securities and Exchange Commission (SEC) and quarterly investors relations calls, these two companies’ stocks as well as those of other insurers tumbled.  Elevance Health also reported its Q4 2023 and full year 2023 results. It beat the trend.  It reported medical expense in line with expectations, but did note some increases in areas.  We are sure to see other plans report unexpected increases, with the biggest impacts likely seen at plans with major enrollment in Medicare Advantage (MA). And many plans are gearing up for additional layoffs and other administrative cuts due to the medical expense concerns. Why are plans seeing increases in medical costs?  First, utilization is slowly returning to normal in the healthcare industry post the COVID pandemic.  Second, inflation is taking root again and it

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Great News For Insurers and Medicare Beneficiaries: January 2023 to January 2024 Medicare Advantage Growth Rebounds

It is time for my annual Medicare Advantage (MA) enrollment growth assessment. I usually write this in mid-January after we receive the results of the MA open enrollment season that ends on December 7 of the prior year. As I say, MA is the place to be in terms of revenue and margin opportunity. Here is this year’s assessment. I will be adding to this over the next few months as enrollment continues to increase. While some MA health plans are singing the blues after a lackluster MA enrollment season, my analysis of January 2023 to January 2024 growth shows there is reason for the industry to cheer overall. And some of the MA plans reporting disappointing growth in enrollment season actually did quite well throughout 2023. The MA enrollment big picture A few key points before we go into the year-over-year statistics: Why is Medicare Advantage (MA) attractive? As

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January 19, 2024

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

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January 18, 2024

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

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A Trump Second Term Would Be A Schizophrenic Experience On Healthcare

Kaiser Health News recently did a piece on what a second Donald Trump term would mean for healthcare. It was a good piece and there is a link at the bottom of this story. That prompted me to do my own evaluation of the prospects of what might happen in Trump 2. After all, lawsuits and indictments do not appear to be impacting the president’s standing in the GOP primary polls, but we will see what New Hampshire brings with candidate Nikki Haley closing in on Trump. In the general election polls, Trump and President Biden are neck and neck. To be fair to the former president, his tenure on healthcare was a mixed bag. As a bit of an atypical Republican, he ventured into areas not usually seen. Here are some major areas I would call out as the good and then the bad and ugly. The Good Price

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January 17, 2024

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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January 16, 2024

Congressional Leaders Agree on Extension of Funding The four congressional leaders announced a deal to extend government funding to March 8 to avoid a government shutdown.  This is a concession by House Speaker Mike Johnson, R-LA, who originally said he would not extend government by a short-term continuing resolution (CR). A number of items are left out of the funding package. Conservatives in the House GOP caucus are not happy with Speaker Johnson’s (one of their own) endorsement of the extension. Additional articles here: https://insidehealthpolicy.com/daily-news/short-term-cr-carries-extenders-through-march-8 and https://thehill.com/homenews/house/4410728-congress-shutdown-conservative-anger/ Additional article on status of healthcare bills, including hospitals’ opposition to site-neutral payments that is in a passed bill that would forestall disproportionate share hospital(DSH) funding cuts: https://www.modernhealthcare.com/politics-policy/congress-spending-deal-hospitals-dsh-medicare-site-neutral (Some articles may require a subscription.) #governmentshutdown #crs Link to Article More Fallout From MedPAC Report On Medicare Advantage The fallout from the MedPAC meeting continues.  A leading member has argued that the analysis by

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January 15, 2024

Good Articles On Takeaways From JPM Healthcare Conference Two good articles summarizing some major trends and topics at the JPM healthcare conference.  Highlights include: Additional article here: https://www.modernhealthcare.com/finance/jpm-2024-takeaways-commonspirit-mayo-clinic-centene-cvs-cigna-teladoc (Some articles may require a subscription.) #healthplans #providers #hospitals #stars #pbms Link to Article AI Can Help Drive Social Determinant Information And Extraction Stories on the ability for generative AI to identify social determinants of health (SDOH) data in notes is a key development. The study indicates that extraction from clinical notes in tuned models show success in insights into housing, employment status, etc. Language models were able to identify about 94% of cases where SDOH barriers existed compared with 2% using diagnostic codes. We know that social determinants may be a greater predictor of health outcomes than underlying disease status.  This will be key to driving outcomes in the future. Additional article here: https://www.modernhealthcare.com/digital-health/generative-ai-social-determinants-of-health-mass-general-brigham (Some articles may require a subscription.) #sdoh

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The GOP Primary: My Dilemma From A Healthcare Perspective And Other Policy Issues

Update: Posted early on January 1/15/2024 — Martin Luther King Day. The Iowa Republican Caucuses were on 1/15. After the Iowa Caucus results, Vivek Ramaswamy dropped out of the presidential race and endorsed Donald Trump. In Iowa, Trump won at least 20 delegates, at least DeSantis 8, Haley at least 7, and Ramaswamy at least 3. While you have learned I definitely have opinions, I try to keep politics per se out of my blogs. You do know, though, I am a Republican. As we approach the primary season, I have to try to pick a candidate. My decision will be a mix of healthcare and non-healthcare issues. So here is how I view it. As a Florida resident, I have until March 19 to make my decision on whom I want to win the GOP nomination. Forgive my delving into non-healthcare issues, but I believe the nation is on

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