valuebasedcare Archives - Page 15 of 16 - The Healthcare Labyrinth

November 27, 2023

November 27, 2023 No Comments

Pro Publica Article on Health Plans Not Covering Mandated Services Pro Publica article recounts where health plans have not covered mandated services in state laws. It is easy to sensationalize mistakes, but health plans every day are approving treatments timely. (May require subscription.) #plandenials #healthplans Link to Article Will New Marketing Rules Hurt Big Plan Performance? Interesting article that says the new Medicare Advantage (MA) marketing rules could mean smaller plans now have a fighting chance against bigger ones, which seemed to enter into the variable and extraordinary compensation with agents and other entities to attract members. A new marketing clampdown in the 2025 rule would stop most of this. Note, too, a plan official saying that there may be loopholes in the new proposed rule. (May require subscription.) #marketing #medicareadvantage Link to Article Per Worker Healthcare Costs Increased 5.2% in 2023 More evidence that inflation is increasing for employer-provided

November 23 and 24, 2023

November 23, 2023 No Comments

The Healthcare Labyrinth Newsfeed will be off on November 23 and 24 for the Thanksgiving holiday. We will be back on November 27. Happy Thanksgiving to all! Stay safe! — Marc S. Ryan

November 22, 2023

November 22, 2023 No Comments

CMS’ UM Rule for Medicare Advantage Already Being Debated The new CMS 2024 Medicare Advantage (MA) rule prohibiting the use of most evidence-based criteria by MA plans is already being debated. Hospital lobbies are saying plans are out of compliance and January 1 has not even hit yet. Read my new companion blog at the blog tab on this site. I tell you why this rule is a terrible idea. Additional article here: https://www.modernhealthcare.com/politics-policy/health-plans-2024-medicare-advantage-rule-aha-cms-unitedhealthcare #hospitals #medicareadvantage #medicare #ncd #lcd #priorauthorization Link to Article Interesting Article on Cancer Care Between MA and FFS Interesting study on cancer care differences between MA and FFS. Touches on prior authorization and networks. Something for MA plans to think about as the PA debate heats up and the new UM rule comes unto effect. #medicare #medicareadvantage #cancercare #priorauthorization #networkadequacy Link to Article FL Blue Using AI to Speed Authorizations While many plans are being criticized

November 21, 2023

November 21, 2023 No Comments

Out For Blood Is Right: Great Example of Outrageous Prices And The Need For Reform Kaiser Health News, the healthcare news aggregator, also does tremendous original news stories. One of its series is “Bill of the Month,” where it features one person’s heartache related to a recent healthcare bill. In this article, KFF intervened to get the patient’s bill cancelled, but she is among the lucky ones. It is also important to remember that not all surprise bills you receive will suddenly go away under the No Surprises Act. This surprise bill was from an in-network provider (hospital), which was charging outrageous lab fees on everyday tests. The health plan negotiated a poor discount and the patient’s plan had the insured covering a percentage of allowable costs. The article touches upon the need for site neutral payments to lower costs in the system and protect consumer’s from high costs. Why

November 20, 2023

November 20, 2023 No Comments

Improper Payments Detailed By CMS CMS touts that improper payments were under 10% in traditional Medicare and in Medicaid, but it is nothing to be proud of. The traditional estimator of 10% for fraud, waste, and abuse (FWA) is a misnomer. Recent studies suggest that true FWA is perhaps 25% of all healthcare expenditures. In 2021, healthcare expenditures were $4.3 trillion. That means almost $1.1 trillion is true FWA. #fwa #medicare #medicaid Link to Article Providers Impacted As Well When Star Ratings Fall Good article describing how providers suffer too when Star ratings fall in Medicare Advantage. Many have entered into partial or global risk-sharing arrangements with health plans and share in bonus revenue. (May require subscription.) #medicareadvantage #providers #stars Link to Article New Speaker’s Healthcare Advisor Named New House Speaker Mike Johnson (R-LA) has named Drew Keyes, a former Republican Study Committee staffer, as his senior health policy advisor.

November 17, 2023

November 17, 2023 No Comments

Civil Rights Groups Issuing Report Cards On State Medicaid Redetermination Processes With a large proportion of the 10M Medicaid disenrollees cut from the program for procedural reasons, a group of civil rights entities are issuing report cards to states. The report cards seek to call out whether each state has done the necessary due diligence during unwinding to ensure those who remain eligible retain coverage. While states and the Centers for Medicare and Medicaid Services (CMS) are at some fault, Congress is really to blame for not passing legislation that allowed for a longer transition time. #medicaid #redterminations Link to Article FTC Moves To Stop Hospital Merger in California Kudos to the Federal Trade Commission (FTC) on taking action to stop the merger of two California hospitals. The Biden Administration, including the FTC, Justice and Health and Human Services, have been active in calling attention to the massive consolidation occurring

November 16, 2023

November 16, 2023 No Comments

CMS Changes Network Adequacy And Open Enrollment For State Exchanges The Centers for Medicare and Medicaid Services (CMS) is mandating that State Exchanges follow federal network adequacy as well as open enrollment periods, among other changes. #networkadequacy #cms #aca #exchanges #obamacare Link to Article Commonwealth Fund Study Shows Impact of High Cost Healthcare System In The U.S. Must read report from the Commonwealth Fund on the impact of our high costs in America on citizens’ access to healthcare. Commonwealth compares us to eight other countries and finds that Americans skipped medical care more often and had more problems handling or paying a bill. American adults face wider income-related disparities in healthcare affordability compared to adults in other high-income countries. This all links back to the fact that America is the only developed nation without affordable universal access to healthcare. It should be noted that other developed nations do much better than

November 15, 2023

November 15, 2023 No Comments

Great Series on America’s Long-Term Care Problem Congratulations to the Kaiser Family Foundation and The New York Times on the first in a series of articles on America’s long-term care crisis. America needs an aging policy. The series shows real-life examples of the impact of not having a national agenda on aging. It clearly shows that the lack of adequate supports for the elderly also impacts other generations, including children’s loss of income to take care of an elderly loved one. In my book (available for purchase on this website), I devote a chapter to aging and recommend ways to make services available to all in an income-based buy-in strategy. Not addressing aging will only drive long-term care and medical costs even higher in the future. In addition to the NYT story and press release at the link below, here is a link to the KFF summary of a survey

November 14, 2023

November 15, 2023 No Comments

Health Tech Still Growing Despite some notable failures in the health tech world and tightness in equity markets, deals and mergers continue. Two notable examples in this article. #digitalhealth #healthtech Link to Article Kaiser Sees Deep Drop in Star Scores Kaiser Permanente saw deep drops in its Medicare Advantage Star scores for 2024, with four of its seven plans losing out on bonus payments (dropped below 4 Star). The CMO of Kaiser discusses this in the article below. Plans big and small suffered the past two years (2023 and 2024 Star Years). While achieving and maintaining high scores has always been a challenge, that a strong integrated system’s plans was a victim speaks volumes. You could always count on most Kaiser plans to be 5 Stars. Weighting, statistical changes, and new complex measures are catching plans by surprise. Based on the Stars road map, this will continue. Plans need data-driven

November 13, 2023

November 13, 2023 No Comments

Startup PBMs See Growth in Price Transparency A series of startup PBMs are seeing some success signing up health plans by riding the price transparency train. They have even set up their own trade group to differentiate themselves from traditional PBM lobbying efforts. An interesting development, but one that will take time to break the dominance of the three giants, which control about 80% of all the business. (may require subscription) #medicareadvantage #commercial #medicaid #pbms #pricetransparency Link to Article Health Affairs Forefront Blog on FDA Process I am a notable critic of the FDA. I see it as a revolving door agency (FDA to brand PhRMA and back again) and dominated by pressure from the drug industry to approve drugs that are not often ready for launch. In fairness to the FDA, here is a good article on the process and challenges FDA has, including from advocates. (may require subscription)

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