urgentcare Archives - The Healthcare Labyrinth

August 5, 2024

August 6, 2024 No Comments

Another Devastating Piece From The Wall Street Journal On Medicare Advantage Yet another piece from The Wall Street Journal (WSJ) is bound to generate huge attention on Capitol Hill and among regulators. In its latest expose on Medicare Advantage (MA) finances, WSJ finds that MA home visits’ diagnoses for risk adjustment generated $15 billion in extra pay from 2019 to 2021. WSJ says nurses are pushed to make diagnoses the patient does not have and such diagnoses are never treated by hospitals or physicians. A July article found that $50 billion in overpayments occurred from 2019 to 2021 tied to risk adjustment submissions not treated by healthcare providers. I am a supporter of MA, but I have made the case that a small number of bad actors are generating a huge amount of overpayments and giving all plans a bad name. I have told plans to expect that the Centers

August 2, 2024

August 2, 2024 No Comments

State Affordability Boards Taking On Drug Makers Where The Feds Have Failed Frustrated by high drug prices and inadequate policy changes at the federal level (save for slow-moving Medicare drug price negotiations), states are setting up drug affordability boards that can have vast powers to reduce drug costs. This includes setting an upper limit for sales in their state for certain coverage and the uninsured. This is similar to the Medicare drug price negotiations. Due to federal pre-emption, these boards only apply to commercial plans. Medicaid has a federal rebate law that allows for federal and state rebates. Medicare is not covered as private plans negotiate prices with drug makers through pharmacy benefits managers or directly. Under the self-insured employer ERISA law, employer groups appear to be able to opt in and thus this has been built into some state laws. So far, eleven states have approved establishing drug affordability

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

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

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

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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