valuebasedcare

A bombshell legal decision this week from a federal district judge threatens to unravel much of the Centers for Medicare and Medicaid Services (CMS) Star process. CMS may have to revisit 2024 Star ratings across the Medicare Advantage (MA) industry, pay out several hundred million more in bonuses, and revisit the bids and benefit designs already in flight for next calendar year. The entire issue is a bit arcane, so let’s break it down here and then get to the implications. The lawsuit and decision Scan Group, a prominent and highly successful non-profit MA plan based in California and serving a number of western states, has successfully won a challenge in a federal district court on its Star ratings for 2024. The case centers on the introduction of the Tukey outlier formula that CMS implemented beginning with the 2024 ratings. The court decision said CMS violated the Administrative Procedures Act

As a former board member of two hospitals (a children’s medical center and academic medical center), I am sympathetic to the unique services that hospitals provide and the role many of them play in the education of doctors, nurses, and more. But it is also clear that hospitals are inefficient organizations that continue to drive up costs overall in the healthcare system. While some hospitals are reforming, others cling to the status quo. Hosptial lobbies are also stuck in the past and bucking change. Here are a few areas and recent studies that point to the role hospitals play in driving up healthcare costs: Hospital consolidations drive up costs, not lower them. Quality often suffers. New statistics from the Federal Trade Commission suggest that about 90% of hospital markets are highly concentrated due to the massive mergers and consolidations that have occurred over the past many years. What’s more studies

I have received a number of pings and messages to explain why I predict Medicare Advantage (MA) enrollment will continue to rise even with some extensive geographic contraction and benefit reductions in the market by some leading national health plans. Here are some of my thoughts on the subject. I would love to hear others’ impressions as well. What is happening with plans? Low or negative rate increases, a return of medical utilization, low Star achievement, and new restrictions on prior authorization are leading to a huge surge in some Medicare Advantage (MA) plans’ medical loss ratios. As such, margins have been reduced considerably. Almost every large national MA plan has raised concerns, but impacts appear to have been greatest over the past few years on Centene, CVS Aetna, Humana, and Cigna. Centene was forced to reduce benefits and geographic expansions already and may do so again. Humana did so

In a recent blog, I made the case that Election 2024 will come down to a handful of states and districts/counties deciding both  the presidency and control of the House of Representatives. In the Senate, almost every competitive race has an incumbent Democrat or open Democratic seat.  Everything would have to go right for them to maintain control of the Senate. I also stated that I think healthcare could be a bit of a sleeper issue even though it theoretically ranks low on the list of Americans’ priorities this year. I say theoretically because pocketbook issues do rank high and healthcare is a key component of that. More important, these swing states and areas tend to have independents and more moderate voters who will decide outcomes. They may indeed prioritize healthcare more than the rest of the nation. See my recent blog at this link for my election analysis and

While healthcare has been displaced by other economic issues and immigration as the compelling Election 24 issues of the day, I have taken the position that healthcare could very well play a role in this year’s election outcome. How so? How close is it? Let’s take a look at how close things are for the presidency and the houses of Congress. For reliable forecasts on elections, I always go to at RealClear Politics. It is very reliable and unbiased.  I also like the fact it uses polling averages to determine the current prospects of various political contenders. In addition, I have a special connection as its publishing arm, RealClear Publishing, was one of the publishers of my book, The Healthcare Labyrinth (available via this site). I went to RealClear Politics for the presidential and Senate races and looked at a few other sources for the House races. Presidential race –