tmos

This past week, the Supreme Court announced that it declined to hear a case challenging the anti-trust settlement between employer groups and Blue Cross and Blue Shield (BCBS) licensee plans nationwide as well as its association (BCBSA). While no wrongdoing was admitted, BCBS plans were accused of anti-competitive behavior in the employer market by limiting employer group contracts to so-called “home plans” as well as the product options offered. It will pay a substantial settlement and must change some of the association’s practices. You could argue the decision is a small step forward, but the decision shows what is so demonstrably wrong with competitiveness in healthcare in America. It upholds the power of entities acting as an effective monopoly in America and the fallout could even foster further consolidation of health insurers. What are the Blues? The so-called Blues plans originated back in the early 20th century when alliances of

As noted last month, I decided to continue my Medicare Advantage (MA) monthly enrollment blogs because of continuing strong month-over-month increases. Admittedly, the continuing growth is tied to remaining strong benefit packages for 2024 and appears to be isolated to a few big plans. Many plans will rein in benefits and geographies for contract year 2025 due to significantly deteriorating bottom lines. This is being caused by the return of robust utilization, inflation picking up in the healthcare sector (especially at hospitals), poor Star scores, negative rate increases for 2024 and 2025, and new regulatory burdens (such as the new prior authorization restrictions). The recent 2024 Star recalculation, which was precipitated by losses in court by the Centers for Medicare and Medicaid Services (CMS), will mean some plans refile bids and benefits for 2025.  But we are hearing great reluctance to refile by many due to the quick deadlines, the negative

The latest forecasts from the Centers for Medicare and Medicaid Services (CMS) Office of the Actuary continue to show how out of control America’s healthcare spending is. Each June, the CMS Actuary re-estimates healthcare spending for the coming decade. The latest estimates continue to show a system that is badly in need of reform. While final figures for 2023 will come in December, the latest estimate on 2023 healthcare spending shows it will reach about $4.8 trillion or 17.6% of gross domestic product (GDP). That is up from $4.46 billion or 17.3% in 2022. That is a growth of 7.6% from 2022 to 2023. The major growth was in part related to the high insured rate of 93.1% due to the COVID flexibilities. While Medicaid redeterminations began again in April of 2023, the insured rate remained high in 2023. Medicare spending hit a milestone by growing 8.4% in 2023 and

After the TukeyGate court decisions that struck 2024 Medicare Advantage (MA) Star calculations, many are speculating where the Centers for Medicare and Medicaid Services (CMS) may now go to make up some of the increased costs in the Star program (see the TukeyGate blog here: https://www.healthcarelabyrinth.com/cms-tukeygate-lawsuit-decision-threatens-to-unravel-much-of-medicare-advantage-star-scoring-in-2024-and-2025-and-next-years-bids-and-benefits/ ). The increase in Stars could result in at least $1.3 billion in increased costs to Medicare in 2025. The lawsuit loss likely caught CMS by surprise, but the agency was right to recalculate and fix the major expected 2025 benefit declines in filed bids and benefits.  I still think benefits will be reined in but the hurt on seniors and those with disabilities will be less. Given budgetary pressures and the major perception of overpayments in MA, CMS will be under pressure to find savings elsewhere over the next few years. Indeed, they wanted to implement Tukey in 2024 and get the Star

This blog is one in a three-part series that digs into my modest proposal for healthcare reform published at this site on May 27, 2024. See that blog here to review my proposal thoroughly: https://www.healthcarelabyrinth.com/a-modest-election-year-proposal-for-healthcare-reform/ . Much of my proposal is taken from my book, The Healthcare Labyrinth, available at this site and through leading bookseller websites. It is available in print, ebook, and audiobook forms. This blog has information from Chapter 28 of my book — “The Right Healthcare Reform Solution.” — Driving to affordable universal access “… Let me add that the health and vitality of our people are at least as well worth conserving as their forests, waters, lands, and minerals, and in this great work the national government must bear a most important part.” – Teddy Roosevelt, The New Nationalism Speech, August 31, 1910. In my “A Modest Election-Year Proposal For Healthcare Reform” blog on May

This blog is one in a three-part series that digs into my modest proposal for healthcare reform published at this site on May 27, 2024. See that blog here to review my proposal thoroughly: https://www.healthcarelabyrinth.com/a-modest-election-year-proposal-for-healthcare-reform/ . Much of my proposal is taken from my book, The Healthcare Labyrinth, available at this site and through leading bookseller websites. It is available in print, ebook, and audiobook forms. — Pivoting to care management from our obsession with utilization management In my “A Modest Election-Year Proposal For Healthcare Reform” blog on May 27, 2024, I stressed that the cornerstones of reform are three key tenets – driving affordable universal access, reforming price, and pivoting to care management (CM) from our obsession with utilization management (UM). This week I cover the need to rethink how we approach management of patients or members. In the May 27, 2024, blog, I argue that America is obsessed