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Risk Adjustment Basics and The Controversy Over Medicare RADV

January 4, 2024 No Comments

A few readers have sent me messages and asked me to detail some basics of risk adjustment (RA) — how it works, its benefits, and its challenges — and the controversy surrounding risk adjustment data validation (RADV) in Medicare Advantage (MA) specifically. RA is a complex world, but here is my best effort to keep the overview simple and then move to the coming RADV conflagration. While not practiced in the employer world because of the penetration of self-insured funds under the Employee Retirement Income Security Act (ERISA, where the employer shoulders the entire burden of costs and insurers are not at risk), risk adjustment has become an important and common practice in MA, Medicaid managed care, and Exchange managed care. Quite simply, risk adjustment is critical to ensuring that health plans are compensated fairly to cover the costs of a given individual as well as the population as a

January 3, 2024

January 3, 2024 No Comments

Aggressive Agenda for Healthcare on Capitol Hill Good article on all the healthcare priorities for 2024. This tracks very closely to my predictions for 2024 blog ( https://www.healthcarelabyrinth.com/channeling-nostradamus-the-healthcare-labyrinths-2024-predictions/ ). As I noted, a continuing resolution (CR) or other funding bill must pass soon to keep healthcare agencies open. As well, the article says that price transparency reporting, PBM reforms, and site-neutral payments are on the agenda. Note the reference to the long shot possibility of Medicare Advantage (MA) payment reductions. Troubled by prior authorization and overpayment headlines, Congress could take a bite out of rates for MA plans. This was also a possibility I raised in my predictions. There is also the issue of physician fee cuts in Medicare. (Article may require a subscription.) #transparency #pricetransparency #governmentshutdown # crs #siteneutral #pbms #medicareadvantage #medicare #overpayments #providers #rates Link to Article FDA Approvals Up FDA approvals of new novel drugs are up.

January 2, 2024

January 2, 2024 No Comments

KHN Series On Rural Healthcare Crisis Good article from Kaiser Health News on the rural healthcare crisis. It tackles how primary care doctors may be able to help with the maternal healthcare crisis. #ruralhealthcare #healthcare Link to Article More States Cover Illegal Immigrants’ Healthcare This was surprising to me. Eleven states and Washington, D.C. provide full health insurance coverage to more than 1 million low-income immigrants regardless of their legal status. Most are in California, but even Republican Utah is getting into the act. Coverage is expected to almost double by 2025. In this other article, ABC News reports that CA becomes first state to offer full health benefits to all immigrants regardless of status: https://abcnews.go.com/Health/california-1st-state-offer-health-insurance-undocumented-immigrants/story?id=105986377 #immigrants #coverage #healthcare Link to Article Drug Price Hikes Coming As happens each January, drug makers plan to raise prices in the United States on more than 500 drugs, according to data analyzed by

Channeling Nostradamus: The Healthcare Labyrinth’s 2024 Predictions

January 2, 2024 No Comments

In my last blog, I gave you my healthcare year-in-review for 2023. After that, as I always do each year, I play Nostradamus to prognosticate about what will happen in the next twelve months in the world of healthcare. Despite my Irish last name, I do have French blood (well, 50% French Canadien, so I count it). But I don’t claim to be an oracle or seer like our 16th century physician, apothecary, and astrologer friend. I do take a page from Nostradamus, though, in that my healthcare predictions for 2023 (not really prophecies) will be sometimes deliberately vague (they include a lot of mays, coulds, shoulds, and possibles) so as to amass a reasonable record for those tracking and putting together my forecasting report card for the history books. Here is hoping my crystal ball is clear and not cloudy, but don’t hold me to any of this; I am simply

January 1, 2024

January 1, 2024 No Comments

Happy New Year! The Healthcare Labyrinth Newsfeed is off January 1. We wish you a very Happy and Prosperous New Year! You can read previous Newsfeed entries at the Newsfeed page. Visit out Blog page for the latest Blogs. Also visit Spotify for The Healthcare Labyrinth Podcasts. Search “healthcare labyrinth.” We now have three posted. Stay tuned for our predictions blog coming out tomorrow. Read our year-in-review blog already posted first. As well, our podcast this coming Friday will summarize 2023 healthcare events and go into predictions. — Marc S. Ryan and The Healthcare Labyrinth Website

December 29, 2023

December 29, 2023 No Comments

Devoted Health Has Successful Funding Raise Kudos to Devoted Health for its successful Series E funding raise. Devoted has been one of the few very successful insurtechs. It has excelled in the Medicare Advantage (MA) market as a startup. Run by career veterans with discipline, it is giving big plans a run for their money in some markets. Devoted’s record is very different to some of the other insurtechs, who cratered this year or are performing poorly. (Article may require a subscription.) #insurtechs #devotedhealth #medicareadvantage Link to Article Buchanan Right On Scoring Reform Rep. Vern Buchanan, R-FL and chair of the Ways and Means health subcommittee, wants a bipartisan group of lawmakers to work on legislation to revise the Congressional Budget Office’s (CBO) scoring techniques to include long-term savings from preventive healthcare. Others have backed changes too. Without getting into the technical details of CBOs methodology (I often see it

December 28, 2023

December 28, 2023 No Comments

Retailers Targeting Senior Populations In Primary Care Investments Good article showing why retailers are targeting seniors for their primary care initiatives. Retailers are interested in the potential financial arrangements (risk funds) that Medicare Advantage plans are focusing on. In addition, the seniors will tap other important features of their offerings, including pharmacies. (Article may require a subscription.) #retailhealthcare #medicareadvantage Link to Article Rural Hospitals Cite MA For Plight As Medicare Advantage (MA) grows, rural hospitals are saying that MA is responsible at least in part for their financial plight. The argument is that even if MA plans pay traditional Medicare rates, they are getting so much less due to claim denials. The net is not the same. In addition, you have the wait time to get paid. This may be true in part, but I ask whether there is not waste and abuse in what the traditional system pays. Just

The Healthcare Labyrinth 2023 Year-In-Review

December 28, 2023 No Comments

As I have done for many years, I write a healthcare year-in-review blog to tell you about all the major health stories and trends of the last twelve months. It is meant to be a general assessment and you can check this website’s Newsfeeds and Blogs as well as my LinkedIn posts ( https://www.linkedin.com/in/marc-s-ryan-%F0%9F%87%BA%F0%9F%87%A6-1a99529/ ) for more information. I break the stories and trends into categories to help your understanding. It is clear that 2023 was a busy year for healthcare, so this blog will be a long one! Here we go! Healthcare, Insurers, and Providers In General In general, 2023 was a continuing year of recovery from the COVID pandemic (2020 to 2022). Healthcare utilization was up again and costs/inflation are returning to normal. We shall see this continue into 2024. We saw moderate inflation in the healthcare sector in 2023 with similar projections for next year (5% to

December 27, 2023

December 27, 2023 No Comments

Healthcare Lawsuits To Watch in 2024 Good article on the healthcare lawsuits to watch in 2024, including many challenging the Inflation Reduction Act’s (IRA) Medicare drug price negotiations as well as preventive service mandates in the Affordable Care Act (ACA). #aca #ira #exchanges #obamacare #drugpricing Link to Article Lower Quality When Private Equity Firms Acquire Hospitals There is a lot of good data on hospital combinations leading to higher costs and no improvement in quality. This study points to a rise in adverse events after a private equity takeover of a hospital. This is despite the pool of lower risk patients in PE targeted hospitals. Additional article here: https://www.medpagetoday.com/publichealthpolicy/practicemanagement/108014 #mergers #acquisitions #hospitals Link to Article Insurtech Overview In 2023 Interesting review of insurtechs in 2023. In general, insurtechs have been a huge disappointment for investors over the years and the companies have failed to make important gains in the market.

December 26, 2023

December 26, 2023 No Comments

Predictions That Hospital M and A Will Pick Up in 2024 The article says that hospital mergers and acquisitions will pick up in 2024. A number of factors are cited, including financial pressures and outside forces. Deals were robust before the COVID pandemic and then collapsed. They picked up in 2023 and will grow more in 2024. They won’t hit pre-pandemic levels though. New merger guidelines and the Biden administration’s anti-trust views could be a wild card and impact the ongoing recovery of M and A. (Article may require a subscription.) #hospitals #mergers #acquisitions Link to Article Threats From FTC Push Brand Drug Makers To Change Orange Book Entries The Federal Trade Commission’s (FTC) threats to come after brand drug makers who misrepresent patents in the Food and Drug Administration’s (FDA) Orange Book are leading several drug makers to change or pull patent entries. It is good news as these

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