This week on the FLATLINING Podcast, Ron and I appeared to touch a nerve with Aledade. Without going into too much detail, we addressed the issues they had with the program and republished it with a statement provided by Aledade.

They have been accused of Medicare fraud by a whistleblower who was fired by the organization in 2021. Aledade denies the allegations.

They asked us to completely remove the episode, even after we addressed their concerns. We have declined to do so.

I encourage you to take a listen to the episode and tells us what you think. Were Ron and I fair in addressing the seriousness of the allegations against Aledade?

Leave a comment

In the news:

South Carolina man sentenced to nine years in federal prison for role in “one of the largest medicare fraud schemes in history” - Justice.gov

Lawsuits against UnitedHealth Group piling up in wake of Change Healthcare attack - Becker’s Hospital Review
LIVE UnitedHealth Group stock price:

Representatives from fifteen payers (including UnitedHealth Group) meet with Biden Administration concerning the Change Healthcare cyber attack - HHS.gov

UnitedHealth, Amedisys deal under more scrutiny - Becker’s Payer Issues

5 things to know about the new ACO payment model from CMS - Becker’s Payer Issues

West Virginia University pharmacists using AI to lessen re-admissions - WVU Today

California Watch

Prop 1 passes in California - The Washington Post via Microsoft Start

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Check out the FLATLINING Podcast from Fulcrum Strategies on these popular podcasting platforms: Apple Podcasts, Spotify, the iHeartRadio app, Amazon Music, Google Podcasts, Stitcher, Pandora, TuneIn, and Audible.

Or listen to the latest episode on YouTube:

Have a good weekend,

Matthew

I have clients around the country that are still feeling the affects of the Change Healthcare cyber attack. UnitedHealth Group’s stock price has only dropped about $30 a share (~5%), so it hasn’t affected markets that much.

Supposedly, UnitedHealth Group says the systems will come back online today according to a report this morning on CNBC’s Squawk Box:

LIVE UnitedHealth Group stock price:

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In the news:

HHS opening investigation into Change Healthcare attack - Healthcare Dive

Opinion: Will the Change Healthcare incident change healthcare? - Health Affairs

Aledade accused of Medicare fraud - MedPage Today

Robin Kelly (D-Illinois) says “We don’t want doctors to cut back on their Medicare patients or to stop doing some of the charity care they do” while discussing Medicare reimbursement reform - POLITICO

Senators push to include PBM reform in March 22 spending push - Modern Healthcare

EPA limiting usage of medical sterilization gas ethylene oxide - STAT

Trump walks back remarks about “cutting” Medicare - The Hill

Lilly adds Amazon Pharmacy to direct delivery service - Health Exec
LIVE Lilly stock price:
LIVE Amazon stock price:

Physician unionization

Mass General Brigham physicians vote to unionize; join AFSCME International - Becker’s Hospital Review

Ascension St. John contracted physicians “inching” toward strike - The Detroit News

California Watch

Mental health funding vote, also known as Prop 1, still too close to call - The Los Angeles Times

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Due to some conflicting schedules, we didn’t record a new episode of the FLATLINING Podcast from Fulcrum Strategies this week, but we will have a new episode next week and another great interview the week after that.

Subscribe to the FLATLINING Podcast on Apple Podcasts, Spotify, the iHeartRadio app, Amazon Music, Google Podcasts, Stitcher, Pandora, TuneIn, and Audible.

Medicare cut reduced

As part of the eleventh hour spending bill to keep the government open, Congress managed to pass some Medicare fee schedule reform that reduces the 2024 cut from 3.4% to 1.7%. As a result, there will be a 2024-A and 2024-B Medicare fee schedule since the new schedule went into effect on March 9th.

While it is progress, it is still a cut. As our President and CEO said on LinkedIn this week, its like someone is “still going to beat you with a stick, [they’re] just going to do it more slowly now.”

My interest was piqued this week when read that there appears to be some bipartisan support to reform the Medicare reimbursement system, out of fears that physicians will stop seeing Medicare patients. I know of some of our clients have started to limit new Medicare patients simply because straight Medicare reimbursement doesn’t cover the costs of the procedures these seniors need.

There is also the added problem that healthcare premiums and out of pocket expenses continue to rise. In an analysis in Health Affairs this week, several reporters correctly pointed out that commercial insurance is often one hundred and fifty to two hundred percent of the Medicare fee schedule. They incorrectly, in my opinion, made the conclusion that if all physicians are paid at Medicare rates or even 150% of Medicare rates, premiums and out of pocket costs would drop immediately, but anyone looking at UnitedHealth Group’s $32 billion in profit would know they could drop premiums at any time.

I’m not claiming the Medicare fee-for-service model is the end all be all. The payment model desperately needs reform. Clearly making reimbursement transparent hasn’t worked. As we have seen in North Carolina with the state employees’ health plan, trying to force everyone on to the same rate doesn’t work.

Congress must evaluate what works about the Medicare fee schedule and what doesn’t. What works is the idea that there is some stability and standard in pricing. What doesn’t work is cutting it every year as the cost of providing that healthcare rises.

To reference Winston Churchill, the Medicare fee-for-service model might be the worst payment method for healthcare, but perhaps it is better than all the rest.

Leave a comment

Have a good weekend,

Matthew

This week on the FLATLINING Podcast from Fulcrum Strategies, Ron and I had a really good discussion with Dr. Damian McHugh, an emergency medicine physician in Raleigh who now works for Curi.

The main topic of our discussion was physician burnout; burnout is one of the leading drivers of the impending doctor shortage that our country will face in the coming years.

Check it out here, listen on YouTube, or wherever you get your podcasts:

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In the news:

Change Healthcare ransomware attack fallout

Change Healthcare is an electronic data interchange and claims clearinghouse that UnitedHealth Group purchased in 2022. The Federal Trade Commission sued to halt the aquisition, but ultimately lost in court. Last month, Change Healthcare was subject to a massive ransomware attack by the criminal group BlackCat. It appears that UnitedHealth Group paid BlackCat the $22 million ransom that it demanded.

Change Healthcare affect the ability for patients to pick up prescriptions, providers getting paid, and much more in the US healthcare system. Here are some updates on the fallout from the cyber attack:

Optum confirms BlackCat attack - Fierce Healthcare

UnitedHealthcare facing class action lawsuit by patients - Becker’s Payer Issues

Aetna, Humana, Elevance, and Kaiser Permanente all affected by ransomware attack - Becker’s Payer Issues

Humana CFO: 20% of provider claims pass through Change Healthcare before getting to Humana; outage creating havoc for paying providers - Bloomberg

Change Healthcare appears to pay $22 million ransom - Krebs on Security

Change Healthcare offering providers temporary loans until systems can be fixed - Medscape

LIVE UnitedHealth Group stock price:

Leave a comment

Other articles of interest:

Weight Loss Drugs Threatened by US Effort to Contain China - Bloomberg

Excellus BCBS posts first loss in 15 years - WXXI News

Operating in the Red: Half of Rural Hospitals Lose Money, as Many Cut Services - KFF Health News

DSH cut delay, doctor pay fix, health center funding bill passes House - Modern Healthcare

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Have a good weekend,

Matthew

I want to kick off this edition by letting you know about some excited updates coming to the FLATLINING Podcast. Starting next week, we will be featuring physicians on the program regularly. They will be sharing their stories and expertise as we discuss the most important issues facing providers and their patients.

Our first guest is Dr. Damian McHugh, an emergency medicine physician who worked in ERs through the COVID-19 pandemic before becoming an advisor for Curi in Raleigh, North Carolina.

Dr. McHugh, Ron Howrigon, and I had a great discussion on burnout and the effect it is having on our healthcare system. And, because I try to make sure not all our episodes are doom and gloom, we talked about what can be done to fix the issue.

I hope you’ll check out our discussion with Dr. Damian McHugh next week. It will, of course, be available here and in your email (if you’re a www.FLATLINING.net subscriber) and wherever you listen to podcasts.

Subscribe to the FLATLINING Podcast on Apple Podcasts, Spotify, the iHeartRadio app, Amazon Music, Google Podcasts, Stitcher, Pandora, TuneIn, and Audible.

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In the news:

UHC’s Change Healthcare crippled by ransomware attack - KFF Health News
LIVE UnitedHealth Group stock price:

Walgreens to accept Medicare Advantage benefits online - BusinessWire
LIVE Walgreens-Boots Alliance stock price:

BCBS NC and Cigna among payers joining White House food security initiative - WhiteHouse.gov
LIVE Cigna stock price:

Payer sponsored analysis says Medicare Advantage members could see (on average) $396 benefit cut next year - Berkeley Research Group

Marijuana use as little as once per month linked to higher risk of heart attack and stroke - NBC News

New study finds that cancer patients who have a behavioral health disorder are more likely to suffer from complications - Journal of the American College of Surgeons, or read about it in MedicalXpress

Current stop-gap spending bill excludes changes to Medicare fee schedule - Modern Healthcare 🔒

Opinion: Health Care: Right, Privilege, or Neither? - Thomas Buckley at The Point

California Watch: State is trying to force physicians to take implicit bias classes; a new lawsuit says it violates the first amendment - The Los Angeles Times

Leave a comment

Payers say they need more money from the federal government

This week on the FLATLINING Podcast, Ron and I discussed a report about a payer-backed lobby group asking Congress to make sure Medicare Advantage payer make more money.

Now, unless you have been living under a rock or haven’t been listening to our podcast, you’ll remember that Medicare Advantage products continue to be the most profitable products for the payers. They are so profitable that it caused Humana () to focus solely on government products and forgoing the commercial market.

The Berkley Research Group (linked above) study was not available to us when we recorded our podcast this week, but it goes to bolster this argument that CMS cuts are going to harms the payers.

This study demonstrates that instead of taking a hit to their own profits, the payers are going to take it out on their members and remove benefits that many seniors have come to rely on.

Of course, Ron and I think the whole situation is a bit laughable given that Congress has cut the Medicare physician fee schedule every year (and even allowed a more than 3% cut this year). But it demonstrates one of the broken factors of our healthcare system: physicians and patients are thought about last.

For more, check out this week’s episode of the FLATLINING Podcast from Fulcrum Strategies by clicking the link below or searching for it where ever you listen to podcasts.

LISTEN NOW

Subscribe to the FLATLINING Podcast on Apple Podcasts, Spotify, the iHeartRadio app, Amazon Music, Google Podcasts, Stitcher, Pandora, TuneIn, and Audible.

Finally…

I wanted to share an interesting technological advancement story that some of my ophthalmology friends might appreciate. Scientists have developed a way to 3D print artificial eyeballs in a more efficient, accurate, and (in our healthcare system most importantly) a cheaper way. Read more in MedicalXpress.

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Have a good weekend,

Matthew

In the news:

Cigna to buy back $3.2B in stock - Becker’s Payer Issues
LIVE Cigna stock price:

$2.5B BCBS Louisiana, Elevance Health sale on hold again - Becker’s Payer Issues
LIVE Elevance stock price:

Congress tiptoes toward healthcare AI legislation - Modern Healthcare

Hospital claims it was ‘drastically’ overcharged by pharma in a federal drug discount program - STAT

Wegovy fuels sharp rise in use of weight-loss drugs for US youth - Reuters

As lawmakers push more 'anti-vaccine' policies, Texas schools report soaring exemption rates - Houston Chronicle

The top 100 critical access hospitals in the country - Becker’s Hospital Review

California Watch: Valley Fever Cases Surge after California’s Atmospheric River Downpour - Scientific American

Bonus California Watch: Enrollment in ACA Plans Sets Records in California -The Times of San Diego via Microsoft Start

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On the podcast this week, Ron Howrigon and I discussed a new push by some members of Congress to eliminate the site of service differential for Medicare payments.

We discussed who benefits and who loses if a change like this were to take effect and what the possibility of its effect might be.

Listen now, wherever you get your podcasts.

LISTEN NOW

Subscribe to the FLATLINING Podcast on Apple Podcasts, Spotify, the iHeartRadio app, Amazon Music, Google Podcasts, Stitcher, Pandora, TuneIn, and Audible.

Have a good weekend,

Matthew

In the news:

CMS announces a pay cut to MA benchmark payments

The Centers for Medicare and Medicaid Services announced this week that there would be an average 0.2% cut to benchmark payments to Medicare Advantage plans. Currently, the cut is merely a proposal, but it was not unexpected by many of the payers. Humana CFO Susan Diamond said the company expected the rate notice to have a negative impact. Read the fact sheet from CMS.

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Louisiana physicians vote no on BCBS LA sale to Elevance; urge members to do the same

The Louisiana State Medical Society members voted and released a letter urging BlueCross BlueShield Louisiana members to vote no on a potential sale to commercial insurer Elevance. As a condition of the sale, BCBS LA policyholders would receive $3000 but the LSMS says that is simply an inducement to vote yes and that members would have to return that money to Elevance in the form of higher premiums. Elevance owns fourteen BlueCross BlueShield plans and this would be their first acquisition in twenty years. Read the letter from the Louisiana State Medical Society.

LIVE Elevance stock price:

Other articles of interest:

These three Blue plans are also becoming providers - Becker’s Payer Issues

FTC taking aim at drug maker “patent thickets” - Fortune

Sen. Elizabeth Warren (D-MA) urges DOJ to investigate Corizon Health's "abusive” bankruptcy tactics - Reuters

Sen. Dick Durbin (D-IL) compares Meta CEO Mark Zuckerberg to tobacco executives; Zuckerberg claimed in a Senate hearing Wednesday that there was no causal link between social media and negative mental health effects - The Hill
LIVE Meta stock price:

Bills protecting physical safety of healthcare workers find support in Congress - Becker’s Hospital Review

CDC study finds Camp Lejeune water contamination connected to range of cancers - CBS News

California Watch: After fighting for healthcare minimum wage hikes, Gov. Gavin Newsom proposes suspending them - The Sacramento Bee via Microsoft Start

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Who should deny your prior authorization requests?

This is a question that Ron Howirgon and I have discussed at length on the FLATLINING Podcast from Fulcrum Strategies.

One of the suggestions that has come up repeatedly for reforming the prior authorization process is only allowing medical directors who are in the same specialty as the requesting provider to review the requests. In other words, if a radiologist asks for PET scan, only a radiologist at the payer can review the claim and then deny it.

That is now the law in New Jersey for certain health plans. The new law does not apply to workers’ compensation plans, “self-insured” plans, auto insurance plans, or TRICARE supplemental plans.

Ron and I discussed the other aspects, including strengths and pitfalls, of the new law on the latest episode of FLATLINING Podcast from Fulcrum Strategies.

LISTEN NOW

Subscribe to the FLATLINING Podcast on Apple Podcasts, Spotify, the iHeartRadio app, Amazon Music, Google Podcasts, Stitcher, Pandora, TuneIn, and Audible.

Have a good weekend,

Matthew

In the news:

CDC alerting physicians about an uptick in measles - CIDRAP

Missouri AG says Liberty Hospital and University of Kansas Health System merger violates state law - Kansas City Star

Judge says BCBS NC’s challenge over state health plan can move forward - The News and Observer

Elevance says it expects no Medicare Advantage growth in 2024 - Becker’s Payer Issues

Some hospitals call for an end of helium balloons amid a shortage of the gas - NBC News

HIPAA Violation of the Week: Humana sent PHI to the wrong address - Becker’s Payer Issues

California Watch: Record number of Californians going to the ER for dog bites - The Sacramento Bee

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Prior Authorizations

Ron and I took some time on the FLATLINING Podcast this week to discuss the new CMS rule that requires certain response times for some prior authorization requests.

Prior authorizations, as I have heard from many physicians, are the bane of the insurance/physician relationship. As we have seen from several class action lawsuits as of late and from my own interview with the late Dr. Dan Hurley, incorrect denials and delays in responding can create significant barriers to patient care.

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Check our podcast from this week:

Listen Now

Subscribe to the FLATLINING Podcast on Apple Podcasts, Spotify, the iHeartRadio app, Amazon Music, Google Podcasts, Stitcher, Pandora, TuneIn, and Audible.

Or listen on Youtube:

Now the state of New Jersey has new regulations for prior authorizations. Governor Phil Murphy signed these into law late last week:

• If a prior authorization is denied, it must be denied by a physician of the same specialty that treats the condition or disease

• If a patient was previously approved by a different health plan, his or her current health plan must cover the treatment for at least sixty days until they determine to continue covering it

• Payers must respond to all prior authorization requests

Now of course, there is the conversation about an enforcement mechanism and what could happen if a payer decides not to play by these rules. We’ll keep looking into it an keep you posted here and on the FLATLINING Podcast.

Leave a comment

Our own Ron Howrigon will be at the American Society of Anesthesiology conference in Las Vegas, Nevada this weekend. If you happen to see him, say hello and let him know you’re a reader of the Friday Pulse Check.

The Detroit Lions are taking on the San Francisco 49ers this weekend for the first time in most of our lifetimes. The game will be at 6:30pm on FOX.

Have a good weekend,

Matthew

In the news:

CMS issues new rule to speed up prior authorization requests

The new rule, finalized on Wednesday, requires payers that sell Medicare, Medicaid, CHIP, and Obamacare plans to turn around urgent prior authorization requests within seventy-two hours and all others within seven days. While it is good that the Biden Administration is trying to help patients and providers navigate the confusing and often problematic prior authorization process, it is not clear what the enforcement mechanism will be. It is also possible that the increased time frame for processing authorizations will cause a more relied-upon use of AI systems by the payers. Those systems are now the cause of lawsuits for organizations such as Cigna and UnitedHealthcare. Read more from the Centers for Medicare and Medicaid Services.

Drug manufacturers’ co-pay assistance now counts toward deductibles

After the Biden administration withdrew its appeal of a September ruling by the U.S. District Court for the District of Columbia, insurance companies must count co-pay and co-insurance payment assistance from the drug companies as part of a patient’s deductible. Previously, insurance companies were not required to count payment assistance programs as counting towards a patient’s deductible. Read more in STAT News. 🔒

BCBS NC seals the deal on FastMed locations

BlueCross BlueShield North Carolina, a non-profit licensee of the BlueCross BlueShield Association, has purchased all of the North Carolina locations of the primary care and urgent care chain FastMed. Previously, it had held a minority stake in the company since 2012. BCBS NC says it will continue to see all patients, not just BCBS NC members. Read more in Becker’s Payer Issues.

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Other articles of interest

Senators file legislation to ban federally-funded healthcare for illegal immigrants - Sen. Bill Cassidy M.D. via Senate.gov

Appeals court says UnitedHealth Group does not have to pay facility fees for out-of-network in-office surgeries - Becker’s Payer Issues

Armed man holes up in Atrium Health Navicent emergency room in Macon, Georgia - WXGA-TV (WXGA News)

United States had COVID-19 sequence weeks before it was released by Chinese government - USA Today

Labor Department sues BCBS Minnesota over provider tax on self-funded products - Becker’s Payer Issues

What Would a Second Trump Presidency Look Like for Health Care? - KFF Health News

California Watch: Voters consider Prop 1, a bill that would create a $6.4 billion bond to build more mental health beds - KFMB-TV (CBS8)

The FLATLINING Podcast from Fulcrum Strategies

This week on the podcast, Ron and I discussed a new website from the Pennsylvania state Department of Insurance that allows patients to appeal claims their health insurer has denied.

We discussed:

• Who is eligible to appeal a claim

• What are some of the pitfalls are of such a system

• What, if any, are the repercussions insurers face for improperly denying claims

LISTEN TO THIS EPISODE

Subscribe to the FLATLINING Podcast on Apple Podcasts, Spotify, the iHeartRadio app, Amazon Music, Google Podcasts, Stitcher, Pandora, TuneIn, and Audible.

Or listen on YouTube:

Who was the most excited person in sports last weekend? Probably Dan Miller on the Detroit Lions Radio Network. Here are the final calls of the Lions/Rams game.

Lions take on the Buccaneers Sunday at 3pm on NBC and Peacock.

Have a good week and GO LIONS!

Matthew

In the news:

Trinity Health and Anthem agree to multi-year value-based deal using Epic

Livonia, Michigan-based Trinity Health and Anthem BCBS have agreed to a new deal using Epic’s electronic health record system to pay the hospital on a value-based basis, marking a strong move away from the fee-for-service model that so many hospitals and providers have become accustomed to. The deal also creates new preventative care initiatives that include annual checkups for patients and administrative reviews. Read more in Becker’s Payer Issues.

PA launches new website for patients to dispute denied claims

As more and more lawsuits are brought against the major payers for wrongfully denying claims, the state of Pennsylvania has launched a new website for patients in that state to dispute claims they believe their health plan incorrectly denied. The state Department of Insurance says that patients still have to dispute the claim with their carrier first and only after they are issued a final adverse determination letter can they approach the state. Pennsylvania has contracted with several independent consulting groups to review the claims and says they have certified there is no conflict of interest between health plans and the companies reviewing the claims. It is likely more states will begin to launch similar websites as more scrutiny is put on the payers for denying routine claims. Check out the website for yourself.

Leave a comment

Other articles of interest:

Hawaii nurses plan seven-day strike - The Star Advertiser

CMS terminates several Medicare Advantage prescription drug plans and suspends all marketing and enrollment activities including: Zing Health, Clear Spring, and Centene’s WellCare in Arizona and North Carolina - Becker’s Payer Issues

What would a Nikki Haley healthcare plan look like? - KFF Health News

FDA allows Ron DeSantis and Florida to import drugs from Canada - STAT News

Opinion: Sorry, but the “drugs from Canada” don’t work - The New York Post

Mark Cuban’s Cost Plus Drug Company signs deal with another small payer - BusinessWire

California Watch: Gavin Newsom thinks more about $25/hr minimum wage for healthcare workers - KFF Health News

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The FLATLINING Podcast from Fulcrum Strategies

This week on the podcast, Ron and I followed up on several stories about healthcare giant Cigna that broke towards the end of the year.

First, we discussed the failed Cigna / Humana merger. Analysts on Wall Street were concerned about that deal from the get-go from an investment perspective. Healthcare watchers were nervous about what would happen to patients. Ultimately the deal failed and Ron and I talked about why.

Then we discussed the news that Cigna has found a buyer for its struggling Medicare Advantage business. Cigna got into the Medicare Advantage business when it purchased Healthspring for $3.8 billion in 2011. Since then, the product has been rife with poor management and missteps along the way. It has struggled to gain new enrollees and it went through a phase where Cigna was barred by CMS from enrolling new members. Reuters reported that Cigna will likely sell the product to HCSC for nearly $4 billion. Ron and I discussed why the product struggled and what it could mean for patients.

LISTEN TO THIS EPISODE NOW

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A brief look at Wall Street:

LIVE Cigna stock price:
LIVE Humana stock price:
LIVE Elevance stock price:
LIVE Centene stock price:
LIVE UnitedHealth Group stock price:
UnitedHealth Group announced a $5.5 billion profit in Q4 2023

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Have a good weekend,

Matthew

In the news:

Jan. 1 sees splits between payers and hospitals

It is that time of year again when we see which payers did and didn’t manage to reach an eleventh-hour deal with the hospitals to ensure that their patients can continue to access high-quality care. Here are three highlights:

• UnitedHealthcare and Greenville, South Carolina-based Prisma Health fail to reach a deal

• UnitedHealthcare and Little Rock, Arkansas-based Baptist Health fail to reach a deal

• Cigna and Raleigh, North Carolina-based WakeMed reach deal to keep hospital in-network

LIVE payer stock prices:
UnitedHealth Group -
Cigna -

RIP Bright Health Group

It seems like only yesterday that Ron and I were discussing Bright Health Group on the FLATLINING Podcast. If you need a refresher: Bright Health Group was a private equity-backed insurance company that was trying to break into the Medicare Advantage and marketplace areas but woefully failed to do so. They were unable to build a profitable customer base and it appeared to be doomed early on. Bright Health Group managed to close or sell a number of its plans at the end of 2022, but its last remaining plan, a Medicare Advantage product in California, was only sold to Molina on January 1. Molina paid $425 million for the Bright Health Group product. Read more in Business Wire and Becker’s Payer Issues.

LIVE Molina stock price -

Listen to episode 25 of the FLATLINING Podcast: The Decline and Fall of Bright Health Group

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Cigna may have found a buyer for its Medicare Advantage business

Remember towards the end of last year when the Wall Street Journal reported that Cigna and Humana were in talks to merge? That deal fell apart after about a week but not before both Cigna’s and Humana’s stock prices fell. Cigna ended up buying back a significant portion of its stock (over $10 billion worth).

Apparently, Health Care Service Corp, also known as HCSC, has agreed to buy Cigna’s Medicare Advantage business for between $3 and $4 billion. Elevance (formerly Anthem) was also looking at buying the business. HCSC operates BlueCross BlueShield plans in Illinois, Montana, New Mexico, Oklahoma, and Texas. Read more in the Wall Street Journal. 🔒

Ron and I first discussed why Cigna would want to sell its Medicare Advantage business and what it means for providers and patients on the FLATLINING Podcast in November.

Listen to episode 70 of the FLATLINING Podcast: Cigna may sell its Medicare Advantage Business

Listen Now

Other articles of interest:

UnitedHealth Group sues two former executives for stealing diabetes management “trade secrets” - Becker’s Payer Issues

CVS to end reimbursement for Humira and instead recommend biosimilars - Reuters
LIVE CVS stock price -
LIVE AbbVie stock price -

NC woman petitions health insurer after company approves — then rejects — her infusions - NC Health News

Ozempic and Wegovy may reduce inflammation - New Scientist
LIVE Novo Nordisk stock price -

CDC: New JN.1 COVID-19 variant is now 30% of cases - FOX News

Opinion: These pro-consumer health bills are ready for the Senate - RealClear Health

Florida surgeon general continues to spread discredited theory about mRNA vaccines - The Hill

California Watch: Blue Shield of California will lay off 140 employees by the end of January - Becker’s Payer Issues

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You have may have noticed over the past few weeks that we have not had new episodes of the FLATLINING Podcast. That is in part because we have been on our usual winter break and we have been sharing our best episodes of 2023. If you’ve missed any of them, check them out below:otolaryngologist

We will have a new episode out next week at the usual time on Wednesday morning. Thanks for continuing to listen and for sharing with your friends and colleagues.

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I hope this first week of 2024 has been good to you and that it continues to stay good for the whole year.

Have a good weekend,

Matthew

In the news:

The Cigna / Humana merger is off

Cigna has ended its attempted negotiations to merge with rival health insurance company Humana. The original news sent both stocks plunging, but Humana’s recovered by the end of the week. Instead Cigna said it is opting for a $10,000,000,000 (billion) stock buyback. Read more in Reuters.

LIVE Cigna stock price:
LIVE Humana stock price:

Ron and I discussed what a Cigna / Humana merger could mean for patients and practices on the FLATLINING Podcast last week:

Humana faces class action lawsuit over Medicare Advantage denials

Since Humana wasn’t in on the fun yet like Cigna or UnitedHealthcare, a lawsuit was filed against them this week alleging that they used artificial intelligence based tool to wrongfully deny Medicare Advantage claims. Funnily enough, it appears that tool is owned by UnitedHealth Group, the parent company of UnitedHealthcare. According to the lawsuit, 90% of denials that are appealed are overturned. Read more in Becker’s Payer Issues.

LIVE UnitedHealth Group stock price:

Subscribe now

Other articles of interest:

Healthcare spending hit $4.5 trillion in 2022 - Axios

New York finalizes removal of medical debt from credit reports - AP

Related:

Poison control centers see 1500% increase in calls related to weight loss drugs - CNN.

California Watch: Rift between CDC and Cal/OSHA widens as the government agencies split over N95 masks - The San Francisco Chronicle via Microsoft Start

HIPAA Violation of the Week: Six recent lawsuits and settlements - Becker’s Hospital Review

Leave a comment

You may have noticed that we had no new episode of the FLATLINING Podcast this week. That is because we have entered our winter break for the program.

Have no fear, however. Starting next week we will be sharing the top three of our best and most listened to episodes of 2023.

If you’ve been unsure about which episode to send to a friend, these “best ofs” are a great way to get them hooked on our podcast. Go ahead and share one (or all) of the links below with them. And remember: you can now listen to us on YouTube as well.

Subscribe to the FLATLINING Podcast on Apple Podcasts, Spotify, the iHeartRadio app, Amazon Music, Google Podcasts, Stitcher, Pandora, TuneIn, and Audible.

Listen on YouTube: Youtube.com/@fulcrumstrategies

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This may also be the last Friday Pulse Check of 2023. If it is, I want pre-emptively thank everyone on the Fulcrum Strategies team who has supported this weekly e-newsletter and thank all of you for reading and sharing it. It means a lot to us at Fulcrum Strategies that you are turning to our understanding and expertise of the challenges that practices and physician groups are facing in today’s world. Thank you.

Have a good weekend,

Matthew

In the news:

Advocacy groups report misleading UHC advertising to FTC and CMS

As we continue to roll on through the open enrollment period for Medicare Advantage plans, several advocacy groups, are calling out UnitedHealthcare for misleading advertising in Connecticut for their dually eligible special needs plans. In their letter to the Federal Trade Commission and the Centers for Medicare and Medicaid Services, the Center for Medicare Advocacy, National Health Law Program, Disability Rights Connecticut, and National Disability Rights Network said the advertisements are aimed at dually eligible individuals and that they advertise extra benefits under a Medicare Advantage plan such as dental or vision. In Connecticut, all Medicaid and D-SNP patients are eligible for dental cleanings and routine vision exams without the need for a Medicare Advantage plan. Read more from Becker’s Payer Issues.

LIVE UnitedHealth Group stock price:

Republicans take aim at big insurance on debate stage

During this week’s debate on NewsNation and SiriusXM, Republican presidential candidates Ron DeSantis and Vivek Ramaswamy shared some ideas for reforming our healthcare system. DeSantis joined former President Donald Trump in saying he was going to repeal and replace the Affordable Care Act. Ramaswamy said it was time to end anti-trust exemptions for health insurance companies. Read more from Becker’s Payer Issues and read the debate transcript from Rev.

Related: Biden Wants States to Ensure Obamacare Plans Cover Enough Doctors and Hospitals - KFF Health News

Related:

Other articles of interest:

Opinion: Ready to Respond to the Trump Obamacare Bruhaha - RealClear Health

Dodging the Medicare Enrollment Deadline Can Be Costly - KFF Health News

Michigan expands Medicaid coverage to include community health workers services - CBS News Detroit

HIPAA Violation of the Week: Missouri AG violating HIPAA by prosecuting transgender laws, lawsuit says - Becker’s Hospital Review

California Watch: CA gave a bankrupt hospital $50 million; it is still struggling to re-open - The Times-Standard via Microsoft Start

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What would a Cigna / Humana merger mean for your practice?

That is the question Ron and I discussed this week on the FLATLINING Podcast from Fulcrum Strategies. Any time insurance companies go out of business or merge or sell, it can create headaches for physician groups.

Remember when Brighthealth shut its doors? If you missed filing your claims, that money is gone.

So what could change at your practice as a result of a Cigna / Humana merger? What will change about your reimbursement or patient mix? We talked about it this week. Listen below on YouTube or wherever you listen to podcasts.

LIVE Cigna stock price:
LIVE Humana stock price:

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Have a good weekend,

Matthew

In the news:

Reports of Cigna and Humana merger

On Wednesday, the Wall Street Journal reported that healthcare giants Cigna and Humana are in talks of merging. The deal would be a combination of stock and cash and would be finalized by the end of the year. Shares of both Cigna and Humana slumped on the news Wednesday and have not totally rebounded. Read more in Reuters.*

LIVE Cigna stock price:
LIVE Humana stock price:

Will there be anti-trust scrutiny?

Undoubtedly this will be subject to some sort of FTC scrutiny. As you may be aware, insurance companies are generally exempt from anti-trust legistlation, but as David Wainer writes in the Wall Street Journal, that scrutiy will likely fall on both Cigna and Humana’s pharmacy benefit manager business. Read more in the Wall Street Jouranl via Microsoft Start.

Why a merger?

As we shared on the FLATLINING Podcast in November, Cigna is exploring getting out of the Medicare Advantage business. That particular company has some how managed to make a product that is extremely lucrative for other insurers a problem for themselves. Additionally, Humana announced earlier this year it would be eliminating its commercial line of business and instead, electing to focus soley on managed Medicare and Medicaid. This makes it so both of these companies have little overlap and are uncompetitive in the marketplace.

That all being said, the stock price slump could signal pushback from shareholders, as reported by CNBC. Watch below:

Wendell Potter, a former Cigna executive shared his thoughts on his Substack, HEALTHCARE un-covered:

HEALTH CARE un-covered

Cigna said to be going after Humana to buy its way into Medicare Advantage

Cigna and Humana, the two big insurers where I worked for nearly two decades, reportedly are in secret talks to join forces. The union–which would create a company much closer in size to UnitedHealthcare and CVS/Aetna, the fifth and sixth largest companies by revenue in America–likely would take shape as an acquisition of Humana by Cigna…

Read more

2 years ago · 22 likes · 4 comments · Wendell Potter

We’ll talk more about this next week on the FLATLINING Podcast and what it could mean for your practice.

*Why a Reuters article instead of the original Wall Street Journal article? The Reuters article isn’t behind a paywall.

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Other articles of interest:

Office of Inspector General: Fourteen states paid managed care organizations for deceased Medicaid enrollees - HHS.gov

BCBS Michigan reaches tentative deal with UAW over striking workers - Becker’s Payer Issues

The FTC is suing U.S. Anesthesia Partners and the private equity firm Welsh, Carson, Anderson & Stowe. Here’s what it means for the private equity discussion - FORTUNE

Ex-director of Detroit VA hospital failed to oversee proper credentialing and quality control - The Detroit News 🔒

Opinion: Sen. Elizabeth Warren (D-MA) has an Obamacare epiphany - The Wall Street Journal 🔒

HIPAA Violation of the Week: Illinois Supreme Court finds medical workers are exempt from certain privacy laws - St. Louis Public Radio

California Watch: FL Gov. Ron DeSantis (R) holds up San Francisco “poop map” during debate with CA Gov. Gavin Newsom (D) on FOX News - The San Francisco Chronicle

Healthcare in the 2024 election

This week on the FLATLINING Podcast, we shared our third Pulse Check on the Candidates episode. This time we focused on former United Nations Ambassador and former South Carolina governor Nikki Haley. Haley, unlike other GOP candidates, has had specific ideas when it comes to healthcare policy.

I don’t want to spend too much time recapping it here since we have been recapping the Podcast on Mondays. I encourage you to check out the program though this weekend.

Listen to this episode

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This week, however, former President Donald Trump made news when he said he wanted to go after the Affordable Care Act again. Trumps renewed criticism of Obamacare was sparked by the Wall Street Journal Editorial Board article that I linked above: Opinion: Sen. Elizabeth Warren (D-MA) has an Obamacare epiphany - The Wall Street Journal 🔒.

Following that article’s publication, Trump said on his Truth Social platform that he was “seriously looking at alternatives” to the Affordable Care Act.

Here is a friendly reminder to you: Trump ran on and tried to repeal the ACA in 2016 and 2017 respectively. He couldn’t do it, even with a Republican-controlled Congress.

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Additionally, no one is really talking about Obamacare anymore because…. most people don’t care about Obamacare anymore. Those who have plans from the Marketplace generally like them and Republicans have learned that it is way too easy for Democrats to say “you’re taking away people’s healthcare” when they talk about repealing the ACA.

There are legitimate criticisms about the ACA: many markets only have one plan so there isn’t enough competition, recent Democratic legislation that expanded ACA subsidies is expensive, or the ACA furthers the problem of large insurers beating down on doctors.

Trump has yet to reveal any sort of replacement plan for the Affordable Care Act. One Republican who is close to the campaign told POLITICO, “There’s not a real ‘there’ there. No one’s working on this.” A Democratic pollster told the magazine that healthcare is a winning issue for Democrats and that for all of Biden’s faults, it is good to know that “Trump can still [f***] up.”

If he wants to survive Democratic attacks on this issue and show those of us in the healthcare world that he is worth our vote, he has to show his ACA replacement plan soon.

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Have a good weekend,

Matthew

In the news:

Priority Health flouts Michigan law requiring it to cover cancer drugs

In a ProPublica investigation published this week, it was revealed that Grand Rapids-based Priority Health refused to cover a cancer treatment for a particular patient. Because of its refusal that patient died this year. How much would it have cost if Priority Health passed it on to its members? Calculations show it could have raised premiums by 9 cents per member. It is a heartbreaking story and one that will likely be told again and again. Read more in ProPublica.

Five states considering adding weight loss drugs to Medicaid coverage

A new Kaiser Family Foundation survey of Medicaid state directors found that Illinois, Massachusetts, New Mexico, Utah, and Vermont are considering adding weight loss drugs to their respective Medicaid programs. It is not immediately clear if that means they will cover newer GLP1 drugs such as Wegovy and Zepbound. Currently, sixteen states cover weight loss drugs such as the older (and less expensive) Orlistat. Will Medicare cover it? Not anytime soon; federal law prohibits Medicare from covering weight loss drugs. Read more from the Kaiser Family Foundation.

LIVE drug manufacturer stock prices:

Eli Lilly -
Novo Nordisk -

Walgreens to close many stores on Thanksgiving

Pharmacy retail giant Walgreens announced that they will close more than 8,000 locations for Thanksgiving day for the first time in the company’s history. This follows a walkout by disgruntled pharmacists on October 31st and November 1st at Walgreens, CVS, and RiteAid (though less than 2% of pharmacists from these companies participated). Walgreens will not be closing nearly 700 of its 24-hour locations so patients can still fill prescriptions there if need be.

LIVE pharmacy retail stock prices:

Walgreens -
CVS -

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Other articles of interest:

UnitedHealthcare facing class action lawsuit over use of AI to deny Medicare Advantage claims - Becker’s Payer Issues

LIVE UHC stock price:

Pharmacists say Biden’s PBM law is backfiring on independent pharmacies - CBS News

President Biden and President Xi agree to curb fentanyl production - Axios

California Watch: Patient who refused to be discharged for weeks being sued by hospital under “commercial blockade” law - The Los Angeles Times

HIPAA Violation of the Week: HHS settles first HIPAA violation involving ransomware - The National Law Review

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The FLATLINING Podcast from Fulcrum Strategies

Ron and I have shared our skepticism of corporate medicine; that is the practice of large entities (such as hospitals or insurance companies) owning physician groups and medical practices.

It is so blatantly obvious that when your insurance company owns your doctor, there is a conflict of interest. Now, both sides can claim all they want that the doctor has the ability to independently practice medicine, but when his or her paycheck is dependent on the person who gets to decide if they are going to pay for the patient’s care, is it really possible to say that?

The American Medical Association debated this issue this week and that was the topic of our discussion on the FLATLINING Podcast. I encourage you to check it out and share it with a friend.

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Have a good weekend and a happy Thanksgiving,

Matthew

In the news:

Another weight loss drug receives approval from FDA

This week the Food and Drug Administration gave the green light to Eli Lilly and its new Ozempic and Wegovy competitor, Zepbound. Zepbound contains the exact same active ingredient as Eli Lilly’s Mounjaro (tirzepatide). Mounjaro is approved for diabetes treatment and Zepbound is approved for weight loss. It will sell for $1060 per month, coming in just cheaper than Novo Nordisk’s Wegovy. Read more in Bloomberg. 🔒

LIVE drug manufacturer stock prices:

Eli Lilly:
Novo Nordisk:

Instacart to accept FSA and HSA payments in app

Grocery delivery service Instacart announced this week that they will begin accepting Flexible Spending Accounts and Health Savings Accounts as payment methods on their popular app. The company said in a statement that this will make it easier for customers since they will no longer have to upload receipts to their FSA or HSA companies to receive reimbursement. Instacart works with thousands of grocery stores and retail pharmacies across the country and already accepts SNAP as a payment method for eligible products. Read more from Instacart.

LIVE Instacart stock price:

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CDC: Childhood vaccine exemptions at all-time high

A new report published by the Centers for Disease Control and Prevention details a record-setting high of childhood vaccination exemptions. In the 2022-23 school year, the number of exceptions nationally spiked from 0.4% of students to 3%. In ten states (Alaska, Arizona, Hawaii, Idaho, Michigan, Nevada, North Dakota, Oregon, Utah, and Wisconsin) the exemption rate exceeded 5%. Idaho’s rate was the highest with 12% of kindergartners receiving an exemption. The CDC did not elaborate as to why a spike in exemption rates occurred, but those of us who have lived in the US longer than the last 10 seconds know that polarization, especially around medical issues, is rampant. Read more from the CDC.

Other articles of interest:

CommonSpirit Health's Virginia Mason Franciscan Health and Amazon's One Medical begin partnership - Becker’s Health IT
LIVE Amazon stock price:

Washington State Hospital Association says proposed NSA changes fall short - Washington State Hospital Association

Opinion: Something is afoot at CMS - RealClear Health

Senate panel clears the way for PBM reforms - STAT 🔒

Senate panel delays hospital cut and shores up physician hit - Modern Healthcare 🔒

California Watch: Systems eyes bankrupt hospital takeover - Becker’s Hospital Review

HIPAA Violation of the Week: Maine says 1.3 million affected by MOVEit hack - The HIPAA Journal

Cigna may be getting out of its Medicare Advantage business

This week on the FLATLINING Podcast from Fulcrum Strategies, Ron Howrigon and I discussed this breaking news from Reuters. If true, it would be one of the largest carriers to get out of what is generally perceived as a profitable line of business.

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It is so profitable for other carriers, in fact, that organizations like Humana () are dropping their commercial plans and only selling Medicare and Medicaid products. It is so profitable that Aetna (), the various Blues, UnitedHealthcare (), Kaiser Permanente, and a handful of new smaller carriers are expanding or getting into the Medicare Advantage business.

Ron, a former Cigna executive, explained that the healthcare giant has always had issues when trying to roll out its Medicare plan and was at one point even forbidden to sell its products by CMS.

All this talk about getting in and out of Medicare plans paints a larger picture of our healthcare system. Medicare Advantage plans were designed to take some of the weight off of the federal government for a benefit that was promised to American seniors. It is largely popular among its members and does provide plenty of benefits to its members.

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However, the frequency and the nonchalance of starting and stopping Medicare Advantage products demonstrate that these companies are more interested in what is profitable to them than the patients they serve.

I say that neutrally. That is the point of those companies of these for-profit, publically-traded companies. Many Americans have these companies in their retirement portfolios and they do have a responsibility to their owners and shareholders to do well. They are not charities.

They also have an ethical responsibility to make sure that their patients aren’t caught in the middle. Since Medicare Advantage is fairly highly regulated, I have no doubt that notices will go to the patients who will no longer be able to renew their Medicare Advantage plans. But it would be great to see them also provide instructions on how to sign up for a new plan before those seniors call a 1-800 number they see on TV.

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Check out the FLATLINING Podcast from Fulcrum Strategies this week for more on this news about Cigna. You can listen wherever you get your podcast or listen on YouTube:

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Subscribe to the FLATLINING Podcast on Apple Podcasts, Spotify, the iHeartRadio app, Amazon Music, Google Podcasts, Stitcher, Pandora, TuneIn, and Audible.

LIVE Cigna stock price:

Further Reading:

4 payers entering Medicare Advantage in 2024 - Becker’s Payer Issues

Major payers to offer Medicare Advantage plans in more counties in 2024 - Becker’s Payer Issues

14 insurers exiting Medicare Advantage in 2024 - Becker’s Payer Issues

If this is your first time reading our weekly e-newsletter, thank you for checking us out. You can find out more about Fulcrum Strategies and the services we provide by clicking here.

If you found it helpful, forward it on to a friend or colleague since that helps us out. We’ll help you stay connected to the healthcare issues that affect your practice and patients and provide some helpful advice along the way.

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Have a good weekend,

Matthew

In the news:

Q3 payer profits announced

Several third quarter reports have dropped including Cigna’s and Humana’s. Now i should clarify from the title that Humana is not actually underwater and lost money in Q3. Rather, their profits have sunk year over year. Here is how much money they made:

Cigna

Q3 Profit = $1,300,000,000 (⬆️ 8.3% year over year)
Total members - 19,000,000 (⬆️ 9.2% year over year)
LIVE Cigna stock price:

Humana

Q3 Profit = $832,000,000 (⬇️ 30% year over year)
Total members - 17,000,00 (⬇️ 0.8% year over year)
LIVE Humana stock price:

Humana is in the process of discontinuing its commercial plan and putting all of its chips in the Medicare Advantage and managed Medicaid plans. Its Medicare Advantage enrollment has grown 14.7% year over year.

Humana’s profit numbers comes as the Office of the Inspector General released a report detailing $117 million in overpayments to CarePlus, a Humana subsidiary. Those payments were from the federal government and date back to 2015.

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Former employees allege UHC violated the WARN Act

Two former employees of UnitedHealthcare filed a lawsuit on Monday, alleging that the health insurance giant did not give proper notice when laying off more than 1,000 employees in August. The plaintiffs’ lawyers said in the filing, “Without informing terminated employees and members of the plaintiff class of their WARN Act rights to 60 days of notice or pay in lieu of notice, UnitedHealth solicited releases from the former employees, which provide less wages for many than the WARN Act notice requirements mandate,” the plaintiffs' attorneys wrote. “In essence, members of the plaintiff class have been fraudulently induced to accept severance pay packages that provide less than 60 days of wages.” Read more from Becker’s Payer Issues.

LIVE UHC stock price:

CVS announces second round of layoffs

Similarly, the pharmacy retail giant CVS, which also owns Aetna, has amended some of its WARN Act filings and begun a second round of layoffs. In August the company announced 5,000 people would be out of a job. The new layoffs are in Illinois, Connecticut, Florida, New York, and New Jersey. Read more from Becker’s Payer Issues.

LIVE CVS stock price:

Other articles of interest:

Nov. 1 is the first day of open enrollment this year for ObamaCare plans - KFF Health News

NYU Langone Health suspends two doctors over social media posts about Israel-Hamas war - The Messenger News

How the Nuka system has improved the lives of Alaska Natives - HEALTH CARE un-covered

High school vaping dropped this year - US News

California Watch: Masks are back in these six California counties - East Bay Times

HIPAA Violation of the Week: Medical management company to pay $100,000 following ransomware attack - Compliance Week

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Who is Surest Health Plans and why have I gotten a UnitedHealthcare amendment for them?

If you’re asking that question as a practice manager, then you might want to check out our podcast from this week. We received word that UnitedHealthcare is launching a new variable co-pay product under the name Surest Health Plans.

What exactly is a variable co-pay health plan? It means there is no deductible and no co-insurance. The only out-of-pocket expense the member pays is the co-pay.

Additionally, that co-pay could be different depending on where the patient goes. Jane Smith OBGYN may have a co-pay of $40 while the co-pay at Jane Doe OBGYN may only be $20. How can they be so different? It probably has to do with their fee schedules.

This is not the first time UnitedHealthcare has tried to incentivize patients to go to cheaper doctors. Last year, Ron and I discussed a plan from UnitedHealthcare to provide ratings for radiologists on their provider directory that were based almost entirely on arbitrary requirements. Physicians who had a lower reimbursing fee schedule would get a higher rating.

So what does this all mean for your practice? It means be on the lookout for amendments and be aware of market changes. And check out this week’s episode of the FLATLINING Podcast from Fulcrum Strategies.

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Finally, as many celebrated Halloween this week and we are quickly approaching the Christmas season, it’s good to take a second on Friday and just have a laugh. Here is a demonstration about how a nephrologist ruined Halloween:

Have a good weekend,

Matthew

In the news:

Sen. Sanders to vote against Biden’s NIH nominee

Last week, I shared that Senator Bernie Sanders (I-VT) had some interesting questions for President Joe Biden’s pick to run the National Institutes of Health. He immediately began questioning Dr. Monica Bertagnolli about the cost of prescription drugs and the role of the pharmaceutical industry in making healthcare decisions. “Dr. Monica Bertagnolli is an intelligent and caring person, but has not convinced me that she is prepared to take on the greed and power of the drug companies and health care industry,” he said in a statement. The NIH has virtually no say when it comes to the cost of prescription drugs. Dr. Bertagnolli’s confirmation is expected to pass with Republican support. Read more in the Hill.

Limited supply of new RSV puts doctors on notice

There is a limited supply of both the RSV vaccine and a new antibody drug intended to treat the disease and providers are taking note of new instructions from the CDC on how to ration it. Sanofi, which makes the RSV drug, said they have an “aggressive supply plan” but said the demand was more than they could currently handle. Read more in Axios.

The most profitable BCBS companies in the first half of 2023

In a report obtained by Becker’s Payer Issues, BlueCross BlueShield Association companies are doing quite well on their own, even the non-profit organizations. Two plans, however, are facing deficits of over a million dollars. Here are the top 10:

1. Elevance Health (14 plans) - $3.2 billion

2. Health Care Services Corporation (5 plans) - $1.2 billion

3. Florida Blue - $408 million

4. BlueCross BlueShield of Tennesee - $286 million

5. Highmark (6 plans) - $283 million

6. BlueShield of California - $259 million

7. Wellmark BlueCross BlueShield - $208 million

8. BlueCross BlueShield of Michigan - $206 million

9. Independence BlueCross - $146 million

10. BlueCross BlueShield of Louisiana - $127 million

BlueCross BlueShield of North Carolina came in at no. 13. See the complete list on Becker’s Payer Issues.

LIVE Elevance stock price:

Other articles of interest:

The Great CEO Resignation - Becker’s Hospital Review

Here is what Apple is paying for some healthcare jobs - Becker’s Health IT
LIVE Apple stock price:

Here is what Amazon is paying for some healthcare jobs - Becker’s Health IT
LIVE Amazon stock price:

High deductible plan sign-ups are falling - Kaiser Family Foundation

California Watch: Gov. Newsom signs slew of healthcare bills; vetos free condoms and legal psychedelics - KFF Health News

HIPAA Violation of the Week: L.A. Care health plan agrees to $1.3 million to settle OCR case that found serious security lapses - HealthcareFinance

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Letting doctors be doctors

This week on the FLATLINING Podcast from Fulcrum Strategies, Ron and I discussed two articles of interest. First, for our clients and listeners in North Carolina, we talked about the recent news that BlueCross BlueShield of NC would purchase all NC locations of the FastMed retail healthcare chain. We talked about how this might affect patient access and what it means for competing providers.

We also talked about a recent phone call Ron had with a managed Medicaid organization on behalf of one of his clients. This particular managed Medicaid organization really wanted Ron’s client to take on risk.

I had to have Ron hold up there and explain what risk means in the healthcare world. In the auto industry, a risk would be a driver with a bad record or in the life insurance industry, an older man who smokes a pack of cigarettes a day. So what does that mean in health insurance? Ron explains and also talks about why downside risk should be avoided by providers when approached by insurance carriers.

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Check out the FLATLINING Podcast from Fulcrum Strategies wherever you listen to podcasts, including YouTube:

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Finally this morning, I wanted to share a report from KFF Health News about another potential disruption to primary care. As healthcare costs rise for smaller business, there is now a push for these business to have their own healthcare clinics.

Large employers have long had their own clinics; they typically include it as a perk similar to the gym in the office or health and wellness incentive programs.

So just how many small and medium-sized businesses are setting up clinics at or near their work sights? About 30% of them. Read more from KFF Health News.

Have a good weekend,

Matthew

In the news:

Henry Ford Health and Ascension Michigan announce joint venture

Two of Metro Detroit’s largest hospital chains announced this week that they are working on a joint venture to provide care to the Motor City. It is not a merger as Ascension, one of the nation’s largest delivery systems, will remain independent and only the hospitals in eastern and mid-Michigan are affected. It will create the lagest hospital system eastern Michigan by revenue. This comes after west Michigan based Spectrum Health and east Michigan base Beaumont merged to form Corewell Health in 2022 to become the state’s largest hospital system. Read more from the Detroit News.

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Biden’s NIH pick has Senate confirmation hearing; derails into drug price arguments

Dr. Monica Bertagnolli, President Biden’s pick to run the National Institutes of Health, finally had her confirmation hearing in front of the Senate Health, Education, Labor, and Pensions Committee this week. Unfortunately, after she was introduced, it immediately went into directions that the NIH has very little control over. Senator Bernie Sander’s (I-VT) first question was about the high cost of perscription drug prices.

Speculation has abounded that Senator Sanders was the one who held up Dr. Bertagnolli’s confirmation. He only appeared to consider the surgical oncologist when President Biden made a deal with Regeneron Pharmaceuticals to make a next-gen monoclonal anti-body treatment for COVID-19 that had a price cap. Read more in KFF Health News.

Other articles of interest:

Business News

Elevance (parent company of Anthem) confident it can close BCBS Louisiana deal - Becker’s Payer Issues
LIVE Elevance stock price:

RiteAid closing nearly one hundred stores with more planned amid bankruptcy - CNN

Research News

Actor Michael J. Fox on how far Parkinson’s research has come - STAT News

Research underway for the “Holy Grail:” A universal flu vaccine - American Council on Science and Health

Scientists may have found new breakthrough for advanced prostate cancer - InsideHook

California Watch

California bans common candy additives - News-Medical

HIPAA Violation of the Week

Healthcare websites continue to transfer data to big tech - Bloomberg 🔒

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“Enforcement discretion” and other absurdities from CMS’ No Surprises Act guidance

The FLATLINING Podcast from Fulcrum Strategies

We have fielded many questions from our clients this week and last about the new CMS guidance on the No Surprises Act. To quote what I said in the podcast, it is woefully unimpressive.

Even after Judge Kernodle told the Department of Health and Human Services to do it right three times, they still have refused to enforce a law that was passed with bipartisan support. The cynic in me thinks this is in part political: this was a Trump Administration law and it doesn’t further the Medicare for All agenda.

It also could be incompetence. I pointed on the podcast that HHS Secretary Xavier Becerra is not a healthcare guy. He is not a doctor and he has never worked for a health plan or in a hospital. He was the attorney general of California. Does that give him good government administration experience? Sure, I’ll give him that. Does it mean he understands outcomes the decisions he’s making? I’m not so sure on that point.

Either way, it is the guidance until another lawsuit will be filed which will be inevitable.

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So what do we expect to see going forward? Payers will likely slow down even more, now that they know they won’t be penalized if the QPA is wrong. They will probably try and send more amendments to cut reimbursement rates to bring the QPA down when they do have to calculate it correctly (so watch your mail). And they will they will probably threaten termination if the provider doesn’t accept the lower rates.

What should providers do? Be on the look out for those communications from the payers; don’t just ignore mail. Be ready with a communication plan so you can explain to your patients and the public why a payer terminated you; don’t let them run the story.

We have more thoughts and conversations on this week’s episode of the podcast. You can listen wherever you get your podcasts, including YouTube.

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With that, I hope everyone has a good weekend.

Matthew

CMS issues new guidelines for the No Surprises Act

CMS issued new guidelines this week for the No Surprises Act after Judge Jeremey Kernodle threw out the previous guidance in the third Texas Medical Association lawsuit. In their new guidance, CMS told payers and insurers that they can act in “good faith” to produce QPA amounts and the method of calculation will not be enforced until March 2024.

CMS appears to have bowed to the payers on this one. The governmental entity said in its new guidance that insurers told them that it would take months or years to calculate new QPAs. What is buried in that statement is the admission that the QPAs (as suspected all along) were calculated incorrectly.

So what are providers to do? Keep holding the line. We are aware that UnitedHealthcare has sent some amendments to groups forcing their fee schedules down to Medicare rates; it is within your right to reject those amendments.

We know that other lawsuits are coming, likely against the payers or the payers and CMS. We’ll keep you updated about it here when that happens.

Read more reactions in Radiology Business.

Other articles of interest:

Medicare Part B premiums to increase slightly in 2024 - CMS.gov

BlueCross BlueShield of Michigan given greenlight to run BlueCross BlueShield of Vermont - Vermont Department of Financial Regulation

Pediatricians having a difficult time getting RSV shots for babies - CBS News

US overdose deaths continue to rise - CNN

California Watch: MDs banned from using “excited delirium” diagnosis - KFF Health News

HIPAA Violation of the Week: Fines increase for inflation - HIPAA Journal

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You probably noticed we didn’t have a new podcast this week. That is because my schedule and Ron’s didn’t jive, but we plan to have a new episode for you next week focusing on these changes for the No Surprises Act.

Have a good weekend,

Matthew

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In the news:

Feds rein in predictive tools for Medicare Advantage plans

UnitedHealthcare () has been using a computerized tool to predict what patient outcomes are after certain diagnoses. KFF Health News talked to one patient who learned that her Medicare Advantage plan would no longer cover her cancer treatment because “she was well enough to go home;” she could barely walk a few feet at the time. The Centers for Medicare and Medicaid Services has rightly said that that is unacceptable and that real humans need to be evaluating patient circumstances, not computers. Read more from KFF Health News.

Other articles of interest:

The Daily Routine of the Best Hitter in the MLB Playoffs - InsideHook

Aetna received an estimated $25.5M in Medicare Advantage overpayments - Becker’s Payer Issues
LIVE CVS stock price:

Why Walmart isn't partnering with hospitals — yet - Becker’s Health IT

Opinion: Pulling the Plug (Again?) on Short-Term - American Enterprise Institute

California Watch: What to know about the largest healthcare workers strike in history - CNN

HIPAA Violation of the Week: Indiana Attorney General sues Carepoint over ransomware - 91.7 WVXU News

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Medicare Advantage

The FLATLINING Podcast from Fulcrum Strategies

This week on the podcast, Ron and I took a good amount of time to talk about Medicare Advantage. Open enrollment is just around the corner so we decided to take a look at what changes have taken place over the years and the new trend of promotional partnerships between retail chains and some of these plans.

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Have a good weekend,

Matthew