ship Archives - The Healthcare Labyrinth

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

January 16, 2024

January 16, 2024 No Comments

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

January 15, 2024

January 15, 2024 No Comments

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

January 12, 2024

January 12, 2024 No Comments

What Would A Nikki Haley Healthcare Agenda Look Like? The Republican debates continue with Donald Trump bowing out and Ron DeSantis and Nikki Haley taking center stage. A recent CNN debate saw the two sparring, sometimes on healthcare issues. Both Haley and DeSantis declared that they would like to replace the Affordable Care Act (ACA) with a block grant. It is a horrible idea. With Chris Christie’s departure from the race and Haley rising in the polls, Kaiser Health News (KHN) did a feature on what a Haley administration’s healthcare agenda may look like. Additional article on Haley’s views on entitlement reform here: https://www.cnn.com/2023/12/05/politics/nikki-haley-social-security-medicare-reform/index.html #gopprimary #haley #desantis #trump #healthcare #aca #obamacare Link to Article Fight (Verbal Anyway) Breaks Out at MedPAC Meeting A verbal clash broke out at a MedPAC meeting, with one member reasonably arguing that MedPAC is not truly as non-partisan as it says it is. I generally

January 11, 2024

January 11, 2024 No Comments

Dysfunction Junction Update: Will Government Shutdown? Faced with an upheaval by the rightists (his very own!) in the House GOP caucus and upended procedural votes, Speaker Mike Johnson, R-LA, met with the Freedom Caucus members to discuss a possible alternative spending bill. This came as a surprise to other leaders. But Johnson could face the same purge that former Speaker McCarthy saw when he tried to do the right thing and comprise to keep government operating. While no one has explicitly said they would call a vote to vacate the speakership, the idea has again been put out there by prominent members of the right-wing fire-setting brigade. Meanwhile, Senate Majority Leader Chuck Schumer, D-NY, has begun drafting a continuing resolution (CR) that extends government while the agreed-upon deal is worked on. Senate Minority Leader Mitch McConnel, R-KY, has said this is needed. Johnson may be softening, but previously ruled out

January 10, 2024

January 10, 2024 No Comments

Oscar Says It Can Be Profitable in 2024 And May Expand To Other Products Insurtech Oscar says its enrollment will hit 1.3 million members in the Exchanges once open enrollment concludes, a 31% increase year-over-year. It also could see positive margins in 2024, as much as 5%. It could expand into individual coverage health reimbursement arrangements (ICHRA) and Medicare Advantage (MA) in the future. Both Oscar CEO Mark Bertolini (former Aetna CEO) and Centene CEO Sarah London are right that the Affordable Care Act (ACA) is here to stay with over 20 million enrollees. ICHRA is a good Trump-era rule that allows employers to make tax-free contributions toward employees’ individual coverage. Oscar would be well-placed to offer a total ICHRA administrative solution coupled with enrollment in individual Exchange enrollment. Bertolini is a genius on this issue. In other news, Alignment Healthcare touted its Star scores. Additional articles: https://www.fiercehealthcare.com/payers/jpm24-oscar-health-eyes-2024-profitability-and-ichra https://www.fiercehealthcare.com/finance/jpm24-day-3-goodrx-expects-least-749m-revenue-2023

January 9, 2024

January 9, 2024 No Comments

NY Wins Medicaid Waiver Approval New York received an 1115 Medicaid waiver approval from the Centers for Medicare and Medicaid Services (CMS) covering a myriad of innovations, including recruitment and retention of Medicaid providers, eligibility to bill social needs spending, primary care investments, behavioral health investments, and health equity pilots. CMS press release here: https://www.cms.gov/newsroom/press-releases/cms-approves-new-yorks-groundbreaking-section-1115-demonstration-amendment-improve-primary-care #medicaid #cms #waivers #socialneeds #healthequity Link to Article Both Cigna And CVS Say They Are Ready For Changes in PBM World Both Cigna and CVS, owners of two of the three largest traditional Pharmacy Benefits Managers (PBMs) say they are ready for the transformation in the world of PBMS that may be coming. Cigna went as far as to say they welcome unbundling, where plans may hire multiple entities to service them in a transparent way. See my Blog on PBM Transparency from December 14 for the emerging changes in the PBM industry: https://www.healthcarelabyrinth.com/pbm-transparency-and-reform-is-a-big-trend-in-the-american-healthcare-system/ #pbms

January 8, 2024

January 8, 2024 No Comments

Aetna Turnaround On Stars And Enrollment Is Amazing At the JP Morgan conference, CVS President and CEO Karen Lynch was taking a well-deserved victory lap. With all that is going on at CVS, the Aetna turnaround on enrollment and Stars in Medicare Advantage (MA) is amazing. It is no small feat given competitiveness in the MA world and the major changes in Star for 2024. #cvsaetna #cvshealth #aetna #medicareadvantage Link to Article Clover Touting Clover Assistant Clover Health also deserves credit for its work creating the Clover Assistant. It has been shown to promote better outcomes, especially in the tough pharmacy adherence area. With prior authorization to take a back seat, data analytics and member and provider engagement are key to reducing and controlling medical expense at health plans. #clover #dataanalytics #engagement #caremanagement Link to Article Alignment Healthcare Bullish On Membership And Positive Margin Alignment Healthcare John Kao expects major

January 5, 2024

January 5, 2024 No Comments

FDA Approves Florida Drug Importation The Food and Drug Administration (FDA) has approved Florida to import prescription drugs from Canada via bulk purchasing. This would mean Florida residents would have access to Canadian wholesale prices, which are far lower than in the United States. Brand drug makers immediately attacked the waiver as reckless and claimed it could endanger health. Nonsense. Canada is a developed country with a great safety record. The waiver also has strict quality control measures in it. This is yet another stunt by Big Pharma to maintain its high prices in the United States. It likely will sue to stop it. Canada, too, could disrupt the plan if it results in shortages there. Although the targeted drugs right now look like they are in reasonable supply, look out for a “manufactured” crisis to emerge. This is a feather in the cap of presidential candidate and Fl. Gov.

January 4, 2024

January 4, 2024 No Comments

Hospitals, Payers Have Better Compliance With Transparency Requirements Hospitals and payers seem to be complying more with required price transparency postings. As well, the Centers for Medicare and Medicaid Services (CMS) has ramped up enforcement. New rules went into effect 1/1 and Congress wants to codify the rules and enhance them. Additional article here: https://www.medpagetoday.com/special-reports/features/108126 #transparency #pricetransparency #healthplans #hospitals #cms Link to Article Physician and Hospital Groups Object To Info-Blocking Penalties In Proposed Interoperability Rule Provider and hospital groups dislike proposed penalties for info-blocking under a new proposed interoperability rule. Penalties include a change in meaningful-use status in federal programs and reductions in payments. Additional article here: https://insidehealthpolicy.com/daily-news/stakeholders-seek-less-severe-penalties-potential-info-blocking-claims (Some articles may require a subscription.) #interoperability #infoblocking #hospitals #providers Link to Article Lawmakers Miss Medicare Advantage’s Benefits Lawmakers at a symposium on Medicare drug pricing complained that healthcare inflation is impacting Medicare provider payments and hurting access for Medicare beneficiaries. They

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