Medicare Advantage Programs Not Helping with US Healthcare Spending
Medicare Advantage is a program set up by the US federal government to allow private plans to provide government-funded healthcare services to older adults. Although the goal was to offset spending per Medicare beneficiary, it’s done the opposite, with Medicare Advantage plans often costing much more per member than Medicare Parts A and B.
CMS Issues Final Rule on Medicare Advantage Prior Authorization Requirements
The US Centers for Medicare and Medicaid Services (CMS) has issued its final rule on prior authorization requirements for Medicare Advantage (MA) plans. The rule changes ensure that prior authorization approvals last as long as medically necessary, that plans must only use prior authorization policies to check diagnoses, and that plans must give beneficiaries a 90-day transition period when changing plans.
The End of the COVID-19 PHE Draws Near
The COVID-19 public health emergency (PHE) is set to expire in the US next week, leaving much up in the air. The pandemic-era pause on Medicare redeterminations will hit patients soon, kicking millions off of healthcare coverage. In addition, vaccines and treatments for COVID will hit the private market, although uninsured Americans will still have access to the drugs free of charge.
Negative Makena Confirmatory Data Didn’t Affect Reimbursement
Negative confirmatory data for the preterm birth drug Makena did not affect payers’ decisions to reimburse the drug, according to an analysis published in Health Affairs Forefront. The drug was granted accelerated approval by the US Food and Drug Administration (FDA) back in 2011 based on a small sample size. It was then recommended to be pulled from the market last October by the FDA Center for Drug Evaluation and Research advisory committee based on larger pools of post-market data showing no reduction in pre-term births. The agency finalized Makena’s approval withdrawal in early April this year.
US Inflation Reduction Act Places More Financial Liability on Insurers and Drugmakers
Speakers at a panel at the 2023 Specialty Pharmacy Summit in Las Vegas, Nevada discussed how provisions in the Inflation Reduction Act, passed in the US last year, would pass more liability onto drugmakers and payers. One reason for this are inflation-based rebates that drugmakers must pay if they raise the price of drugs higher than inflation for Medicare Part B and D plans.
US PBM Bill Markup Hearing Postponed Until May 11th
US Senators were geared up for a hearing to markup a bill targeting practices of the pharmacy benefit manager (PBM) industry that are alleged to be anticompetitive and drive up drug prices. However, this meeting has been delayed until May 11th so that the markup can occur after a May 10th hearing featuring testimony from major pharma and PBM leaders.
States Increasingly Coordinating Care for Dual Eligibles with Managed Care, FAIs, and PACE
Dual eligible special needs plans often run up against significant difficulties coordinating care for beneficiaries. A recent analysis by the Kaiser Family Foundation (KFF) examined how states accomplish this complex task, finding that many use managed care, a Financial Alignment Initiative (FAI), or rely upon the Program of All-Inclusive Care for the Elderly (PACE).
Paying for Legal Psychedelic Therapeutics in Australia
This summer, providers in Australia can legally prescribe psychedelics, MDMA and psilocybin, to patients suffering from post-traumatic stress disorder (PTSD) and depression that has not responded to other treatments. How these drugs will be paid for, however, is still up in the air. Due to a lack of cost-effectiveness analysis, it is unclear whether the therapeutics will be publicly subsidized.
CMS Announces New Rules to Improve Medicaid and CHIP Programs
In two back-to-back announcements, the US Centers for Medicare and Medicaid Services (CMS) has revealed policies targeting healthcare access and quality for patients on Medicaid and the Children's Health Insurance Program (CHIP) The rules changes would standardize fee-for-service (FFS) reimbursement rates and improve access for both programs.
Study Finds Safety-Net Hospitals with High Uncompensated Care Rates in Disadvantaged Areas Have Lower Margins
A recently published study in Health Affairs finds that safety-net hospitals’ margins are lower in disadvantaged areas or when they have high rates of uncompensated care. The Disproportionate Share Hospital (DSH) program was designed to compensate hospitals who treat underserved communities, but state-level policies can cause disparities in payments to different health centers.
Study Finds Medicaid Supplement Payments Need Restructuring
Research released by the Robert Woods Johnson Foundation finds that Medicaid supplement payments are inefficiently distributed, requiring a significant overhaul to fix. For example, disproportionate share hospital payments are based on figures from 1992 and leave some states receiving less than $100 for uninsured patients, much less than the $1,500 that others receive per uninsured patient.
US Congress Continues Push for Lower Prescription Drug Prices
Members of the US Congress aren’t slowing down in the effort towards lowering prescription drug prices, following last year’s Inflation Reduction Act that established the upcoming Medicare drug price negotiations. One bill put forward by Democrats would shorten the timeframe before a drug can be negotiated. A bipartisan effort led by Bernie Sanders (I-VT) and Bill Cassidy (R-LA) will propose four bills related to reducing high drug prices.
Medicaid Redetermination Process to Take Coverage from Millions of Children
With the COVID-19 public health emergency on its way out, states are set to start up the redetermination for Medicaid beneficiaries. Among the millions who will lose healthcare coverage in this process are children, who make up the majority of Medicaid recipients. The number of children to be dropped is still uncertain, but it is estimated to be around 1/3 of kids on the program.
US House Committee to Hold PBM Hearing
Today, April 26th, a representative for the pharmacy benefit manager (PBM) industry will speak before the US House Energy and Commerce Health Committee in a hearing focusing on improving transparency and countering anti-competitive practices. The industry, to be represented by Kristen Bass of the Pharmaceutical Care Management Association (PCMA), has faced significant public and congressional scrutiny in recent years over allegations that their processes are opaque and push smaller pharmacies out of the market.
Value-Based Care Front and Center at NAMCP Spring Forum
Value-based care will be a major theme of discussion at this week’s National Association of Managed Care Physicians (NAMCP) Spring Managed Care Forum. In addition, speakers will cover managed care decision-making in a variety of disease contexts, covering how to improve patient outcomes and reduce costs. The final focus is oncology.
AHIP Launches Campaign Tearing into Pharma for Drug Prices
AHIP, representing members of the US health insurance industry, is targeting pharma in its latest ad campaign. The campaign lays the blame for high prescription drug prices at pharma’s feet, highlighting anti-competitive practices, unjustified price hikes, and high profit margins for the largest pharmaceutical companies. However, pharma argues that payers themselves contribute to the problem.
Integrating Behavioral Health and Primary Care Through Value-Based Payment Models
To improve patient mental health outcomes and reduce healthcare costs, behavioral health needs to move to a value-based payment model and be better integrated into primary care. However, significant hurdles stand in the way. Payers could play a pivotal role in addressing the problem, but this will require careful cooperation with providers.
Program Targeting Food Insecurity Cut Healthcare Costs for People with Type 2 Diabetes
Food insecurity leads to a poor diet that can exacerbate symptoms of type 2 diabetes, significantly increasing healthcare costs for patients and payers. A recent program by Pack Health targeted food insecurity by delivering meals and providing education to food-insecure people with diabetes type 2. Results showed that the program cut healthcare costs by $139 per month and improved health outcomes.
Finch Ratings: Medicaid Disenrollment Set to Financially Impact Not-For-Profit Hospitals
A new analysis from Finch Ratings finds that non-profit hospitals’ bottom lines will be hurt by upcoming Medicaid disenrollment triggered by the imminent end of the COVID-19 public health emergency. Many patients going to not-for-profit hospitals were covered by Medicaid expansions. Since a large number of these patients will be disenrolled, Finch predicts that they will have to receive charity care that hospitals will not be paid for, hurting their revenue.
CMS Publishes Proposal to Improve the Prior Authorization Process
The US Center for Medicare and Medicaid Services’ (CMS’s) Interoperability and Patient Access Final Rule ensures patient acccess to clinical data, adjucated claims, and other health information. The newly published Advancing Interoperabilty and Improving Prior Authorization Processes Proposed Rule would, if implemented, extend the prior rule with 5 key proposals targetting health data access and prior authorization.
5 Tips for Achieving Reimbursement for Digital Health Solutions
The reimbursement landscape has shifted notably during the pandemic, opening pathways for digital health technologies and telehealth services. However, achieving reimbursement status can be challenging, especially considering the uncertainties surrounding the process. In a new Mobi Health News article, Timothy Lee and Dr. Liz Kwo give 5 takeaways to help digital health developers navigate this new environment. The first tip is to work with self-insured employers.
Unlocking the Potential of Price Transparency Data to Advance Value-Based Care
Despite new rules in the US requiring providers to collect and report pricing transparency data, just over three quarters of hospitals are lagging behind. If this data can be accurately collected and analyzed, it could help establish fair value-based pricing models that could benefit both patients and providers. In addition, the law targets payer-related data.
Examining the Effect of CMMI Value-Based Care
The Association of American Medical Colleges (AAMC) released an issue brief that details the impact of Centers for Medicare and Medicaid Innovation (CMMI) value-based care on patient outcomes and healthcare costs. The AAMC notes that although these value-based care payment models have helped patients, better data collection practices are needed to advance health equity.
US CMS Passes Rule Targeting Misleading Ads for Medicare Advantage Programs
The US Centers for Medicare and Medicaid Services (CMS) has implemented a new rule to limit misleading advertisements for Medicare Advantage programs. The rule would ban companies from producing advertising that would lead consumers to believe they are official government messaging. In addition, it would force companies to name the specific plans in their advertising.
28 US States Will See Medicaid Enrollment Drop to Near Pre-Pandemic Levels
Just as US states begin the Medicaid redetermination process, a new report by Moody’s Investors Services finds that 28 states will see enrollment drop to numbers equivalent to pre-pandemic levels. Some states, the report notes, will settle on enrollment levels higher than those seen before the pandemic-era Medicaid redetermination pause.
