Literature Review

Humana, Aetna likely to lose Medicare Advantage members Modern Healthcare; by Nona Tepper and Lauren Berryman; 5/14/24 Industry heavyweights CVS Health Aetna and Humana foresee Medicare Advantage membership losses next year. Anticipated changes to health plan offerings and benefit design to achieve long-term business profitability could mean losing a significant portion of their Medicare Advantage membership, executives told investors at the Bank of America Securities Healthcare Conference on Tuesday. ... Headed into next year, Aetna may adjust benefits, tighten its prior authorization policies, reassess its provider networks and exit markets, CVS Health Chief Financial Officer Tom Cowhey told investors.  ... [Humana Chief Financial Officer Susan Diamond] anticipates losing about 5% of its 6.1 million Medicare Advantage members, ... Conversely, UnitedHealth Group’s UnitedHealthcare insurance business appears to be better positioned for growth heading into 2025 ... , executives said. UnitedHealth Group CEO Andrew Witty said, ... “The thing we don't want is unsustainable ups and downs in our performance in any particular regard. ... You should just expect more of the same from us in terms of what we’re doing.” 

A Philadelphia pharmacy’s closure after 26 years highlights the industry’s growing challenges Times Daily; by Lizzy McClellan Ravitch, The Philadelphia Inquirerer; 5/11/24Last Monday, Friendly Pharmacy filled 318 prescriptions. For about 100 of them, insurance companies paid the pharmacy less than $3. In 22 instances that day, the reimbursement was less than the cost of the medication. ... [Managing pharmacist Brad] Tabaac plans to close his doors on May 31 after 26 years in business. ... Independent pharmacies like Friendly, as well as some chains, have been pinched by pricing and fees set by pharmacy benefit managers — the companies that handle prescription drug plans for health insurance. The three biggest pharmacy benefit managers are CVS Health, Optum Rx and Express Scripts. They control nearly 90% of the market, according to the National Community Pharmacists Association (NCPA), and some of their parent companies also own pharmacies.

Medicaid disenrollments higher than expected: Report Becker's Payer Issues; by Rylee Wilson; 5/2/24 The number of people disenrolled from Medicaid through the redeterminations process has surpassed original estimates from the Urban Institute and Robert Wood Johnson Foundation. According to a May 2 report, as of November 2023, nearly 9 million people had been disenrolled from Medicaid. The figure came out to 60.5% of the foundation's original estimate of 14.8 million people losing coverage, with several months remaining in the redetermination process. 

Thyme Care launches virtual palliative care program, appoints medical director MobileHealthNews; by Jessica Hagen; 5/2/24 Value-based cancer care platform Thyme Care is launching Enhanced Supportive Care, a virtual palliative care support program to assist its members and caregivers with managing physical and psychological symptoms accompanying cancer diagnosis and treatment. The program will be led by Dr. Julia Frydman, the company's first medical director for palliative care. Frydman previously worked in the geriatric and palliative medicine program at New York City's Mount Sinai Health System.

MultiPlan, insurance giants sued over out-of-network rates Modern Healthcare; by Nona Tepper; 4/29/24 A rural health system sued technology company MultiPlan and eight of the country's largest insurance companies over alleged schemes to strongarm providers into accepting low out-of-network rates. At issue in the proposed class-action suit are MultiPlan's repricing tools, which allegedly rely on insurers' data to deflate their out-of-network reimbursement payments. 

Drug discount program is exploiting poor patients while corporate giants profit Minnesota Reformer; by David Balto; 4/26/24 ... The federal 340B drug discount program was created three decades ago to help economically vulnerable Americans access affordable prescription medications and providers in underserved areas expand and improve services. Under the program, drug companies participating in Medicaid — known in Minnesota as Medical Assistance — provide sizeable discounts as high as 50% to these ‘safety net’ health care facilities. ... Unfortunately, over time, the tens of billions of dollars flowing through this program have proven irresistible to for-profit corporate entities, including giant health systems and big box chain pharmacies — and there is no guarantee those discounts are reaching patients. 

Generative AI is supposed to save doctors from burnout. New data show it needs more trainingSTAT+; by Casey Ross; 4/25/24After stratospheric levels of hype, early evidence may be bringing generative artificial intelligence down to Earth. A series of recent research papers by academic hospitals has revealed significant limitations of large language models (LLMs) in medical settings, undercutting common industry talking points that they will save time and money, and soon liberate clinicians from the drudgery of documentation.

Payment cuts are having a compounding, dire effect on the home health industry Home Health Care News; by Andrew Donlan; 4/25/24 Home health providers’ fight against cuts to fee-for-service Medicare payment has become a year-by-year battle. But the yearly cuts are compounding, which is exactly what industry advocates are trying to illustrate to Congress prior to the next payment rule proposal. ... Many of the cuts CMS has implemented are permanent, and multiple cuts on top of each other moving forward – plus unsatisfactory adjustments for inflation – are putting significant pressure on providers.

Palliative care’s value-based future Hospice News; by Jim Parker; 4/24/24 Many believe that the fee-for-service model does not sufficiently support a robust palliative care program, meaning that providers must turn to value-based systems for sustainable reimbursement. But primarily, Medicare still reimburses for palliative care through fee-for-service payment programs that cover physician and licensed independent practitioner services. That model does not sufficiently cover the full range of interdisciplinary care, Dr. Julia Friedman, palliative care medical director at Thyme Care, said at the Home Health Care News Cap+Strat Conference.

Medicare Advantage complaints that the plans don’t want – and the review of systems that wasn’t done RACmonitor, by Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI; 4/24/24 ... In the past, I have talked about complaining to your regional Centers for Medicare & Medicaid Services (CMS) office about violations of CMS-4201-F, but Dr. [Eddie] Hu described how to do it to actually get action. [Click on the title's link for details] ... Now, why should you take the time to file these complaints? ... Why should you take the time to file these complaints? Because CMS tracks formal complaints, and a lot of complaints can significantly affect their quality bonus – and we know how when their money is at risk, the MA plans suddenly pay attention. ...

20M fewer Medicaid enrollees means trouble for providersModern Healthcare, by Nona Tepper; 4/23/24Over the past year, states have removed more than 20 million beneficiaries from Medicaid after suspending eligibility redeterminations during the COVID-19 public health emergency. Thousands of those people are Clinica Family Health patients. The Lafayette, Colorado-based community health center felt the pain of lost reimbursements when patients went from having Medicaid coverage to being uninsured, a fate that has befallen almost one-fourth of these former Medicaid enrollees nationwide, according to KFF. Clinica Family Health responded with cutbacks but is still in the hole. 

Mississippi Capitol sees second day of hundreds rallying for ‘full Medicaid expansion now’Mississippi Today - Legislature; by Bobby Harrison and Geoff Pender; 4/17/24Hundreds of people rallied at the Mississippi Capitol for a second day Wednesday, urging lawmakers to expand Medicaid to provide health coverage for an estimated 200,000 Mississippians. ... Speakers recounted their struggles with access to affordable health care in Mississippi and chanted for the Legislature to, “Close the coverage gap now,” and for “Full Medicaid expansion now.” ... [Dr. Randy] Easterling recounted a story of two of his friends diagnosed with similar cancers. One was uninsured and self-employed, and did not get early diagnosis or treatment. He’s now in hospice and on death’s door. The other friend, with insurance, received an early diagnosis and treatment and is now cancer free.

Home care sees largest price jump in history, BLS report finds McKnights Home Care, by Adam Healy; 4/15/24The cost of home care rose faster than ever in the last year, far outpacing inflation across every other healthcare spending category, according to the Bureau of Labor Statistics’ latest Consumer Price Index report. Home care costs rose 14.2% between March 2023 and March 2024 — its most rapid growth since BLS began tracking data for the segment in 2005, according to the CPI. ... During the same period, standard inflation for all medical care services was 2.1%. The costs of hospital services — outpatient hospital services (8.3%), general hospital services (7.5%) and inpatient hospital services (6.9%) — saw the next-highest inflation rates since March 2023, eclipsed only by home care services. Meanwhile, prices for nursing home and adult day service rose by about 3.9%.Editor's Note: This article did not report cost changes for hospice care.