Most common No Surprises Act complaints against payers, providers

By Andrew Cass - CMS released a report on Aug. 20 detailing complaints related to No Surprises Act and ACA compliance. In total, 16,073 complaints were received. More than 12,000 of the complaints received were related to No Surprises Act compliance. Read Full Article…

HVBA Article Summary

1. Complaint Distribution: A total of 16,073 complaints were lodged, with the majority (10,300) aimed at providers, facilities, and air ambulance services. The remaining 1,777 complaints targeted nonfederal governmental plans and issuers, highlighting significant issues within these sectors.

2. Resolution and Relief: The Centers for Medicare & Medicaid Services (CMS) has effectively resolved 12,700 of these complaints. Through their investigative efforts, CMS has directed the involved parties to implement remedial and corrective measures, resulting in $4.18 million in monetary relief being paid out to either consumers or providers.

3. Nature of Complaints: The three most common complaints included surprise billing for non-emergency services at in-network facilities, surprise billing for emergency services, and issues with good-faith estimates for providers. For payers, the main issues were noncompliance with qualifying payment amounts, delays in payments post-independent dispute resolution, and failures in meeting 30-day payment or denial notice requirements.

New eligibility for semaglutide would cost Medicare billions in spending

By Andrew Rhoades - High BMI eligibility for semaglutide could cost Medicare up to $145 billion annually, a brief report published in the Annals of Internal Medicine revealed. According to Alexander Chaitoff, MD, MPH, a research fellow at Brigham and Women’s Hospital, and colleagues, Medicare announced it would allow Part D plans to cover Wegovy (semaglutide, Novo Nordisk) for patients with a BMI of 27 kg/m2 or higher and established CVD, regardless of diabetes status. Read Full Article…

HVBA Article Summary

1. Eligibility for Semaglutide under Medicare: The expansion of Medicare coverage for semaglutide, a drug shown to reduce cardiovascular events, varies significantly based on the definition of established cardiovascular disease (CVD). With a narrow definition, only 3.6 million Medicare beneficiaries become eligible, whereas a more liberal definition could extend eligibility to over 15 million people.

2. Impact of Different CVD Definitions on Eligibility: The research utilized data from the National Health and Nutrition Examination Survey and considered four potential definitions of established CVD. The findings highlight a stark difference in eligibility numbers, indicating that many beneficiaries who could benefit from GLP-1 drugs like semaglutide may remain uncovered due to narrow definitions of CVD.

3. Financial Implications and Coverage Limitations: The potential increase in Medicare spending could range from $10 billion to $145 billion annually, depending on how broadly CVD is defined and the uptake of semaglutide. Despite the expansion, many high-risk patients might still not qualify for coverage due to various limitations such as out-of-pocket costs, formulary placements, and other management strategies, underscoring the complexity of expanding drug coverage in Medicare.

Health spending now exceeds prepandemic levels as utilization of care remains uneven

By Alan Goforth - Both health care spending and utilization have changed significantly since before the pandemic, the new Peterson-KFF Health System Tracker found. Read Full Article…

HVBA Article Summary

1. Increased Annual Growth in Health Services Spending: Since the onset of the COVID-19 pandemic, there has been a significant rebound in the growth of health services spending, which now exceeds pre-pandemic rates. This increase is attributed to factors such as inflation and workforce shortages that have driven up hospital costs. Notably, hospital services spending has shown double-digit growth rates since early 2023, outpacing previous years.

2. Shift in Care Utilization Patterns: While overall spending on health services has increased, the utilization of these services has varied across different settings. Hospital discharges have not returned to pre-pandemic levels, remaining about 0.5 million short compared to 2018 and 2019 figures. In contrast, there has been a noticeable shift from inpatient to outpatient care, with increasing numbers of outpatient visits and a growing trend of procedures like imaging, diagnostics, and less-complex surgeries being performed in outpatient centers.

3. Recovery and Redistribution of Care: The utilization of emergency and outpatient services has shown recovery and redistribution trends. Emergency department visits have rebounded to 20.7% of adults reporting a visit in the past year, matching pre-pandemic levels. Outpatient visits have also recovered, showing a slight increase compared to pre-pandemic figures. This suggests a realignment in how and where patients are choosing to receive care post-pandemic.

How alternative risk financing is changing

By Chris Davis - Carl Bloomfield, president and chief operating officer of Graham Company, a Marsh McLennan Agency Company, has seen first-hand the changes in the landscape of alternative risk financing over the years. Read Full Article…

HVBA Article Summary

1. Growth of Alternative Captive Structures: Bloomfield highlights the growing popularity of segregated cells and rental type captives in the insurance industry. These structures are favored due to their low capitalization costs and ease of access, making them a viable option for companies looking for alternative financing solutions. This shift is largely driven by the increasing costs of traditional insurance policies and a market that is becoming more restrictive.

2. Flexibility and Innovation in Captive Insurance: Newer captive structures like segregated cell Series LLC and rental captives are not only easier and quicker to establish but also offer significant flexibility in covering various risks. These innovative approaches are particularly relevant in today’s rapidly evolving risk landscape, where traditional insurance falls short. For instance, Bloomfield discusses project-specific insurance for unique risks, such as a cyber liability policy tailored for a construction project at the University of Pennsylvania using Integrated Project Delivery and BIM technology.

3. Broader Strategic Risk Management: Beyond traditional insurance, Bloomfield emphasizes the need for comprehensive risk management strategies that address both insurable and non-insurable risks. He outlines the PRIME Process used at Graham Company, which involves preparation, prevention, risk transfer, insurance, mitigation, and education to proactively manage and mitigate risks. Additionally, the partnership with Marsh McLennan Agency enhances their capabilities to support clients in navigating complex risk environments and securing their operations against a diverse range of challenges.

Biden administration blocks 2 private sector enrollment sites from ACA marketplace

By Julie Appleby - Federal regulators have blocked two private sector enrollment websites from accessing consumer information through the federal Obamacare marketplace, citing “anomalous activity.” Read Full Article…

HVBA Article Summary

1. CMS Action Against Unauthorized Enrollment: The Centers for Medicare & Medicaid Services (CMS) took decisive steps by suspending two private enrollment sites, Benefitalign and Inshura, following over 200,000 complaints of unauthorized ACA plan enrollments and switches facilitated by rogue agents. These platforms were suspended to investigate compliance issues with CMS data standards and were subsequently removed from the list of approved sites to prevent further unauthorized access.

2. Legal Challenges and Allegations: In an ongoing civil lawsuit, both Benefitalign and Inshura, along with other entities, face allegations of misleading advertising and unauthorized changes to ACA policies aimed at generating commissions. The lawsuit, which seeks class-action status, accuses these companies of engaging in activities that violate the federal Racketeer Influenced and Corrupt Organizations Act (RICO), detailing a scheme that exploits vulnerable consumers by switching their health plans without consent, often leading to lost access to doctors and medications.

3. Legislative and Industry Responses: Amidst rising complaints, lawmakers have introduced legislation to stiffen penalties for unauthorized enrollments, reflecting the broader political and regulatory challenges the Biden administration faces in ensuring fair and secure ACA plan enrollment. Meanwhile, CMS has tightened controls by requiring three-way calls for policy changes and advocating for the adoption of two-factor authentication, measures supported by legitimate agents aiming to restore trust in the enrollment process.

Business Group on Health: Healthcare Costs Expected to Surge at Highest Rate in 15 Years

By Marissa Plescia - Employers’ projected healthcare cost trend, reflecting the expected annual percentage increase in patient treatment costs, rose from 6% in 2022 to nearly 8% by 2025, according to a new survey from the Business Group on Health. Read Full Article…

HVBA Article Summary

1. Significant Increase in Healthcare Costs: Ellen Kelsay, president and CEO of Business Group on Health, highlighted a stark projection from the 2025 Employer Health Care Strategy Survey indicating that healthcare costs could rise to more than 50% of 2017 levels by 2025. This increase, the highest in over 15 years, is driven by factors including rising pharmacy costs, which in 2023 accounted for 27% of healthcare spending, up from 24% in 2022.

2. Concerns Over Specific Drug Costs and Utilization: The survey revealed deep employer concerns regarding the cost and use of GLP-1 medications, which are heavily influencing overall healthcare expenses. Employers are worried about the long-term implications of these and other weight management drugs, with a majority employing prior authorization measures to manage their use.

3. Employer Strategies to Manage Rising Costs: Despite the increase in healthcare costs, employers are committed to absorbing most of these costs to ease the financial burden on employees. They are also reevaluating vendor partnerships, with plans to utilize the RFP process more extensively to secure better pricing and improve service quality from health plans and pharmacy benefit managers (PBMs).

Health benefits matter for U.S. employees: employers must follow suit

By Robert E. Andrew - When I completed my service in Congress in 2014, it was evident that much more work needed to be done to fix the broken U.S. health care system. As an original author of the Affordable Care Act, my understanding of the complex undertaking, along with the May 2015 Call to Action by the American Health Policy, I welcomed the opportunity to join with forward-looking employers to catalyze a new approach to securing better health coverage for employees, retirees and their families. Read Full Article…

HVBA Article Summary

1. Financial Benefits from Healthy Workforces: Over the last nine years, some of America's largest employers have discovered significant financial savings by investing in the health of their employees. The correlation is clear: healthier employees mean reduced healthcare costs for employers, which translates into direct financial benefits. This supports the notion that providing high-quality and accessible healthcare is not just beneficial for employees' well-being but also advantageous for an employer's bottom line.

2. Rejecting the Trade-off Myth: The prevailing wisdom that employers must choose between cost-effective healthcare and high-quality care is being challenged. By focusing on high-quality healthcare services, employers can actually enhance health outcomes for employees while also reducing healthcare expenses. This dual benefit helps employers retain a competitive edge by attracting and retaining talent who prioritize health benefits in their employment decisions.

3. Strategic Healthcare Management by Benefits Leaders: The lessons learned by healthcare and benefits leaders from top American companies, such as understanding the value of data, choosing high-quality providers, and insisting on effective partnerships with carriers, are shaping a new landscape in employee healthcare management. These strategies not only enhance employee retention and job satisfaction but also contribute to broader efforts aimed at improving the U.S. healthcare system overall, demonstrating that thoughtful healthcare benefits design can yield both substantial economic returns and healthier, more productive employees.

Medicare Advantage could lead to lower hospital credit ratings: S&P

By Ellen Rudolph - Health systems have for years lamented the low reimbursement rates from traditional Medicare, but Medicare Advantage (MA) — the profitable government-funded plans managed by commercial insurers — has quickly become the new villain. Read Full Article…

HVBA Article Summary

1. Rising Tension with Medicare Advantage Plans: The popularity of Medicare Advantage (MA) plans has increased significantly among seniors, from 26% in 2010 to 52% in 2023. However, these plans are becoming less favorable with health systems due to delays in payments, claims denials, and stringent preauthorization processes. Some health systems have even stopped accepting patients with MA plans, highlighting the growing friction.

2. Impact on Hospital Credit Ratings: According to a new analysis by S&P Global Ratings, the operational challenges posed by Medicare Advantage plans, such as lower reimbursement rates and delayed payments, are putting financial pressures on hospitals. This situation could potentially affect their credit scores, as hospitals find themselves financially stretched to manage increasing patient visits and higher post-pandemic care costs.

3. Regulatory Adjustments and Future Outlook: The Centers for Medicare and Medicaid Services (CMS) has recognized the overpayment issues associated with MA plans and is taking steps to adjust reimbursements to more accurately reflect actual costs. This includes a nearly flat rate increase for 2025, despite a nominal 3.7% rise, indicating a tightening of payments to insurers. These adjustments are expected to influence MA plans to cut costs, potentially affecting the level and types of services offered to seniors, further complicating the financial landscape for both insurers and healthcare providers.

Workplace insurance could soon be stripped down

By Tina Reed - Surging demand for blockbuster GLP-1 weight-loss drugs like Wegovy and Ozempic is helping drive up the cost of workplace insurance, leading some to predict pared-down benefits next year. Read Full Article…

HVBA Article Summary

1. Economic Pressures on Employers: In the face of a tight labor market, employers have been reluctant to transfer the rising costs of health care to their workers. However, the continuous increase in demand for expensive medical care, including specialty drugs and outpatient services, is pushing companies to a potential breaking point. The projected increase in health care costs for 2025 is nearly 8%, signaling a significant financial strain that could force employers to reconsider their current benefits structures.

2. Impact of High-Cost Therapies: Specialty therapies, particularly GLP-1s and gene therapies, which can cost millions of dollars per treatment, are identified as key drivers of soaring health costs. Although used by a relatively small number of employees, the demand for costly injectable weight-loss drugs is surging. Companies are increasingly feeling the pressure, with a significant percentage acknowledging these drugs as major contributors to escalating expenses, leading to a reconsideration of pharmacy benefit management strategies.

3. Strategies and Adjustments by Employers: To manage these escalating costs, employers are implementing more stringent control measures such as prior authorization, step therapy, and changes to drug formularies. These strategies are aimed at curbing the high utilization of expensive medications and treatments. Furthermore, employers are contemplating changes to their health plan designs and vendors to better manage costs without overly burdening employees with increased out-of-pocket expenses.