Centers for Medicare & Medicaid Services’ Post

Over the last few weeks, I've talked with leaders from two large, well respected health systems who offer employee-only health plans. Both health systems do not offer Medicare Advantage (MA) or commercial insurance products. WVU sounds similar. They have an employee-only health plan and expect to launch a Medicare Advantage (MA) plan in early 2024. It's interesting to me how long it's taken many health systems to get into the MA space (it's been around since '97). The MA plan capitated payment model creates a large profit opportunity for health systems as they move care outside the hospital and deploy technology to better engage with and guide patients. I understand that it will take health systems longer to move into the commercial insurance market. Individuals change commercial health insurance every few years. What I don't get is why more providers do not offer MA plans. How can we accelerate the shift of healthcare providers into the MA plan space? What will it take for them to consider launching commercial insurance products?

📢 States Step Up to Reform Prior Authorization Practices Amid Healthcare Delays 🏥💼 A wave of state legislation is sweeping across the US, aimed at reigning in the contentious practice of prior authorization by health insurance companies. This movement seeks to address the growing concerns voiced by both #HealthcareProviders and #Patients over the delays and denials of care due to these #preapproval processes. 🚨 With New Jersey leading the charge through recent legislation that mandates insurance decisions within 24 to 72 hours depending on the urgency, and Washington state implementing similar laws, the message is clear: the current system needs an overhaul. Over 20 states have passed prior authorization bills in 2023 alone, reflecting a nationwide push towards more efficient healthcare delivery. 📜🕒 These state-level initiatives, often more stringent than the proposed federal regulations by the Centers for Medicare & Medicaid Services, signify a critical step towards streamlining patient care and reducing unnecessary administrative burdens on providers. The move has been widely supported by healthcare advocates and professional associations who have long criticized prior authorization for its role in escalating healthcare costs and frustrations among consumers. 🩺💡 While some insurers have begun to roll back these policies, the widespread call for transparency, adherence to clinical guidelines, and swift decision-making underscores a pressing need for systemic change. #HealthcareReform #PriorAuthorization #Legislation #PatientCare #HealthInsurance

Thrilled to release a new report and issue brief from Georgetown University McCourt School of Public Policy's Center on Health Insurance Reforms and West Health on outpatient #facilityfee billing! Our team spent months interviewing stakeholders, policymakers, and other experts and diving into the laws in 11 study states to bring this to you. We explain why concern is growing that hospital outpatient #facilityfees are unnecessarily adding to consumers’ high health care costs in the U.S., both through higher out-of-pocket costs for hospital-billed services and increases in insurance premiums. Bottom line: the growth of #facilityfees, and consumers’ financial exposure to these charges, derives from the intersection of our increasingly consolidated health care provider market, unnecessarily complex billing systems, and frequently inadequate health insurance coverage. I hope you'll take a look at our research to find out more and please reach out if you have any questions.  Special thanks to my report co-authors, Karen Davenport and Rachel Swindle, past and present team members Sabrina Corlette, Megan Houston, Kristen Ukeomah, and Hanan Rakine, and West's Caroline Picher and Cristina Boccuti for their help on this effort. https://lnkd.in/e-GdyhGC

In their new Forefront article, Richard Averill and Michael Kalison discuss how some form of reference pricing linked to the price-setting authority of government payers—what they call a Sustainable Pricing Framework—is a necessary precondition for a functional and more competitive commercial insurance market to emerge. "Unfortunately, there is little incentive for the various segments of the health care industry to work together to resolve this fundamental imbalance in bargaining power. What is needed is health insurance market reform that has a direct impact on the cost of commercial insurance and provides the foundation for a functional and more competitive commercial insurance market. Although seemingly paradoxical, some form of reference pricing linked to the price-setting authority of government payers is a necessary precondition for a functional and more competitive commercial insurance market to emerge. We propose the creation of a sustainable pricing framework (SPF) that strengthens the role of commercial insurers by promoting price stability." Read the full article here: https://bit.ly/455E63H

The American Medical Association (AMA) issued new research today examining the status of digital health advancement in the commercial health insurance industry by comparing current coverage across private health insurers and exploring how coverage decisions are made for digitally enabled care services. https://buff.ly/44WaWmL #MEDMagazine #AMA #DigitalMedicine

Why does the cost of #employer sponsored healthcare coverage keep rising? “The authors evaluated the profit margins of hospitals and health insurance companies and found that #hospitals (both for-profit and nonprofit) have consistently maintained higher profit margins than insurance companies. Price increases for #hospital care have risen faster than the #physician price index or insurance premiums net of medical service costs, the report says. Profits for hospitals have also been higher than those for insurers. Hospitals that enjoy monopoly power as the sole provider in their local market have prices 12.5% higher than markets with four or more hospitals, according to the report. After hospital mergers occur, prices rise by 6% if the merging hospitals were close neighbors”

NEW: A major hospital operator has accused a health-care analytics firm of orchestrating a nationwide price-fixing conspiracy with nearly all of the country’s top health insurance companies to underpay providers for out-of-network services. In an antitrust complaint filed in the US District Court for the Southern District of New York, Tennessee-based Community Health Systems Inc. alleges that provider network operator Multiplan Inc. devised and implemented an anticompetitive scheme using proprietary pricing algorithms to underpay the hospital group by hundreds of millions of dollars on behalf of its health plan clients. The lawsuit claims that prior to the alleged conspiracy, MultiPlan and competing health insurers were incentivized to pay competitive rates to ensure providers would continue to provide care to out-of-network patients. However, starting in 2006, MultiPlan began to market a suite of analytics tools to its competitors that repriced out of network claims at rates far less than insurers would otherwise have paid, the complaint said. By 2017, “MultiPlan had reached agreements with nearly every other significant healthcare insurance payor in the United States to use MultiPlan’s repricing tools to collectively suppress out-of-network reimbursements paid to healthcare providers,” the lawsuit said. And by 2020, “MultiPlan was using its repricing tools to underpay 370,000 out-of-network claims per day for over 700 health insurers, resulting in a total underpayment of approximately $19 billion per year to healthcare providers.” The plaintiffs said that because nearly every commercial payor uses MultiPlan’s repricing services, health-care providers have no choice but to accept the artificially suppressed payments. “MultiPlan knows it can get away with acting, in the words of an analyst, ‘like a mafia enforcer for insurers,’ because virtually every commercial healthcare payor has agreed to use its repricing methodology, leaving healthcare providers with no practical option but to accept the ‘repriced’ reimbursement amount that MultiPlan imposes,” they said in the lawsuit. The complaint mentioned Aetna, a CVS Health Company, Elevance Health, Centene Corporation, Cigna Healthcare, Health Care Service Corporation, UnitedHealth Group, and Humana among the companies involved in the alleged conspiracy. #healthinsurance #antitrust #healthnews #hospitals #doctors

To explore whether and how Plan Finder can be improved to incorporate #IRA-related changes to #PartD, Avalere interviewed state health insurance assistance program staff and directors, as well as advocates at health and aging advocacy organizations. Read our findings: https://lnkd.in/eaC8EGY2 #InflationReductionAct

In the past couple of years, more than two dozen states have considered legislation designed to minimize prior authorization delays and denials, and nine states have enacted new laws, according to the American Medical Association, which has advocated for them. A New Jersey law, for example, sets a 72-hour deadline for most claims. Texas created a “gold card” system that exempts physicians with a 90% approval rate from prior authorization requirements. Washington state sets deadlines and requires insurers to automate the process to speed approvals, while Michigan mandates that prior authorization requirements be based on peer-reviewed criteria. Furthermore, state laws generally apply to state-regulated private health insurance plans, which excludes the 65% of people who work for large firms and are covered by self-funded employer plans. And many of the state laws don’t apply to people on Medicaid, the joint state-federal health care program for people with low incomes, according to the National Association of Insurance Commissioners. Earlier this year, the federal Centers for Medicare & Medicaid Services finalized a rule designed to speed up prior authorization in government insurance programs, including Medicaid and Medicare, the federal health care insurance program for people aged 65 and over and the disabled. The new rule, most of which will go into effect in 2026, requires a decision on “urgent” requests within 72 hours. But it applies only to “medical items and services,” not drugs.