News

"State and local officials are increasingly turning their policy focus to efforts to eliminate or prevent medical debt, complementing recent efforts at the federal level to tackle the crisis. [This] article highlights these efforts, underscoring the exciting policy boomlet currently underway. It also offers recommendations for further policy steps needed to eliminate, alleviate, and prevent medical debt."

"Relative to our 2023 estimates, [a] hypothetical couple retiring in 2024 will need to save approximately $7,000 more if they have Original Medicare plus Medigap and Part D coverage, and $8,000 less if they have Medicare Advantage plus Part D coverage, all else being equal."

17 pages."This memo contains an overview of the 2022 benefit year HHS- RADV error rate methodology, a summary of the 2022 benefit year HHS-RADV results, and information to assist issuers in understanding their results." [Also available: Appendix A: National Program Benchmarks -- 2022 Benefit Year HHS-RADV ( XLSX ); Appendix B: 2022 Benefit Year RA State Market Risk Pool Weighted Average HHS-RADV Error Rates ( XLSX ); and Appendix C: 2022 Benefit Year HHS-RADV Failure Rate Group Definitions ( XLSX ).]

"[The Council urges] the administration and Congress to continue to work to restore competition and prevent further consolidation in health care markets in order to lower health care costs for American families.... [1] Expand site-neutral payment reforms.... [2] Restrict hospital billing practices that fuel consolidation and mask what should be the appropriate payment amounts.... [3] Ensure that federal antitrust laws are fully applied to horizontal and vertical integration in the health care system.... [4] Remove barriers to employer innovation by restricting anti-competitive contracting provisions that impede value-driven care."

"HHS is extending policies related to the treatment of telehealth and audio-only services that were put in place in response to the increased need to expand the use of telehealth services during the COVID-19 public health emergency for the 2020 through 20231 benefit years to the 2024 benefit year and beyond. HHS is extending these policies for purposes of the HHS-operated risk adjustment program under section 1343 of the [ACA] due to changes in patterns of care and higher levels of use of telehealth and audio-only services that can be expected to continue into future benefit years."

"Workers fed up with rising health care costs, which also eat into their wages, are filing lawsuits aiming to hold employers accountable for cutting what they say are bad deals with firms that manage their health benefits.... The heightened legal threat is contributing to employers' efforts to take a harder line with health insurers, pharmaceutical middlemen and other benefits administrators."

"In 2022, across all hospital inpatient and outpatient services (including both facility and related professional claims), employers and private insurers paid, on average, 254 percent of what Medicare would have paid for the same services at the same facilities.... Prices for common outpatient services performed in ambulatory surgery centers (ASCs) averaged 171 percent of Medicare prices but would have averaged approximately 107 percent of Medicare prices if paid using Medicare payment rates for hospital outpatient departments (HOPDs)."

"New transparency around the price of health care services and workers' mounting frustration with costs are emboldening some employers to get tough in negotiations with hospitals and provider groups.... There are some major limits to this strategy. For instance, it's more difficult to play hardball in smaller cities or rural areas with fewer provider options."

"[1] Regularly review and update plan documents ... [2] Conduct thorough due diligence on current and potential vendors ... [3] Implement strategies to proactively identify and mitigate potential threats to the plan's financial stability and participant satisfaction.... [4] Compliance adherence and conflict of interest avoidance ... [5] Education and training ... [6] Maintain open lines of communication with plan participants ... [7] Engage independent third-party reviewers ... [8] Maintain detailed records of all decisions ... [9] Proactive cost-containment efforts."

18 pages. "Over two-thirds of CFOs view health benefit cost as a significant or very significant concern compared to other operating expenses.... Over a third of CFOs are not confident that long-term health benefit cost management strategies that require investment are saving money -- and 19% don't have enough information to say.... One third of respondents with fully insured plans are at least considering converting to a different funding mechanism."

"[T]his cap will apply to 'health care entities,' which include providers such as hospitals, facilities, outpatient clinics, large physician groups and clinical laboratories, payors and fully integrated delivery systems.... [T]he cost target for 2025 is non-enforceable. For years 2026 and after, however, OHCA will have the authority to take enforcement action against health care entities that exceed the boundary of the target."

24 pages. "[O]ver one-third of respondents were integrating accountable care strategies that pay for quality over service volume into their ESI.... In the context of making health benefit decisions, respondents ranked expanding preventive care, increasing access to primary care, and focusing on whole-person health as the top three tenets of accountable care.... Mental health resources are a focus for future enhancements, with greater than 20 percent of respondents intending to primarily enhance these resources in the next few years."

"The decision eliminates an option that was geared toward bringing primary care to residents of underserved markets.... For the strategy to succeed, ... Walmart would have had to overcome recent systemic trends.... Legacy providers are dealing with the same headwinds but generally have more margin for error."

"[The authors] recommend that the agencies collect and make available systematic, high-quality data on the ownership structures of health care entities, with a particular focus on improving the data available on physician practices.... [CMS] should collect systematic data on physician practice ownership as part of the Medicare enrollment process, as it does for institutional providers.... CMS should take steps to improve the quality of entity-reported data."

261 pages. "The Medicare projections have been significantly affected by the enactment of the Inflation Reduction Act of 2022 (IRA).... The total effect of the IRA is to reduce government expenditures for Part B, to increase expenditures for Part D from 2027 through 2030, and to decrease Part D expenditures beginning in 2031.... In the year of asset depletion, which is projected to be 2036 in this report, HI revenues are projected to cover 89 percent of incurred program costs."

"The Old-Age and Survivors Insurance (OASI) Trust Fund will be able to pay 100 percent of total scheduled benefits until 2033, unchanged from last year's report. At that time, the fund's reserves will become depleted and continuing program income will be sufficient to pay 79 percent of total scheduled benefits.... The Hospital Insurance (HI) Trust Fund will be able to pay 100 percent of total scheduled benefits until 2036, 5 years later than reported last year. At that point, that fund's reserves will become depleted and continuing program income will be sufficient to pay 89 percent of total scheduled benefits."

20 pages. "On February 15, 2024, the Departments of Health and Human Services, Labor, and the Treasury released the first two public-use files (PUFs), which contain data from the first two quarters of IDR operations in calendar year 2023. The Departments also published certain federal IDR supplemental tables that summarize the relevant data to provide additional transparency. This report provides an overview and analysis of the data contained in the PUFs and supplemental tables." [R48058 May 2, 2024]

"Recent revelations about a data analytics firm's role in determining medical payments have heightened concerns about possible price fixing in health care and led to a call for a federal investigation.... Senator Amy Klobuchar asked federal regulators to examine whether algorithms used by the firm, MultiPlan, have helped major health insurers conspire to cut payments to doctors and leave patients with large bills."

38 pages. "89% of survey respondents said their EPC has a provider network that includes options that are convenient for them.... One in five respondents reported using a cost comparison tool. Among those who did, almost 60% say it changed their behavior and some chose less expensive treatment options.... Most people were aware that their employer-provided plan covers preventative services at no out-of-pocket cost, but awareness varied by age, health status, and urbanicity."

"[T]he Departments and OPM will exercise their enforcement discretion under the relevant No Surprises Act provisions for any plan or issuer, or party to a payment dispute in the Federal IDR process, that uses a QPA calculated in accordance with the methodology under the July 2021 interim final rules and guidance in effect immediately before the decision in TMA III, for items and services furnished before November 1, 2024. Similarly, for items and services furnished before November 1, 2024, HHS will exercise enforcement discretion under the relevant No Surprises Act provisions for a provider, facility, or provider of air ambulance services that bills, or holds liable, a participant, beneficiary, or enrollee for a cost-sharing amount based on a QPA calculated in accordance with the methodology under the July 2021 interim final rules and guidance in effect immediately before the decision in TMA III."

"Transplant insurance policies are a way for employers to mitigate both the severity and frequency of catastrophic health claims stemming from transplant procedures. These policies are often called transplant carve-outs, because the financial risk posed by transplant procedures is being 'carved out' from the regular plan and covered with a supplementary insurance policy. Transplant carve-outs promotes predictability rather than variability of cost in terms of budgeting, thus helping to stabilize a group's stop loss rates."

"Walmart, citing "lack of profitability," announced plans to close all 51 of its health centers in five states, while the retailer will continue to operate its 4,600 pharmacies and more than 3,000 Vision centers."

"According to the suit, Mayo and Medica did not provide accurate information to participants on how they calculate out-of-network reimbursement costs and deductibles.... This claim continues a trend of fiduciary litigation against employers and their plans ... Health plan sponsors may now have an increased risk of legal challenges by employees as negotiated prices for health care services become public through new transparency laws and regulations. " [S.M.O. v. Mayo Clinic, No. 24-1124 (D. Minn. complaint filed Apr. 2, 2024)]

"[T]he average annual incurred medical cost per dependent exceeds $6,860, and a DEV audit yields a 3%-10% removal rate of ineligible dependents.... Ineligible dependents can inadvertently lead to denied insurance claims, creating unnecessary administrative burdens and financial strain for both employers and participants.... By verifying dependent eligibility, employers can enhance their financial controls and reduce the risk of fraud."

"Compared to low-telemedicine health systems, patients of high-telemedicine health systems had 'modest' increases in office visits, care continuity, and prescription drug adherence; fewer ED visits; no differences in testing or preventive service; and a small spending increase due largely to inpatient services and drug costs."