HHS’ Proposed HIPAA Changes Are a Step in the Right Direction, But Some Providers May Struggle to Comply

By Katie Adams - Among myriad acronyms in the healthcare industry, HIPAA is one of the most referenced. At the end of last year, the Department of Health and Human Services proposed major updates to this law — named the Health Insurance Portability and Accountability Act — for the first time in more than a decade. Read Full Article…

HVBA Article Summary

1. Standardization of Cybersecurity Protocols: HHS is proposing to eliminate the distinction between "required" and "addressable" HIPAA security rules, making all cybersecurity protocols mandatory for healthcare providers. This includes implementing measures such as two-factor authentication, data encryption, and network segmentation to ensure consistent protection across all health data systems.

2. Increased Documentation Requirements: The proposal mandates that healthcare providers maintain detailed, ongoing documentation of cybersecurity policies and procedures, including asset inventory, network mapping, and risk analyses. This aims to improve visibility and control over how sensitive data is stored, transferred, and managed, helping organizations strengthen their data security infrastructure.

3. Challenges for Smaller Providers: While larger healthcare organizations may have the resources to comply, smaller providers could face significant financial and operational burdens. Compliance may require partnerships with tech firms for data management and security expertise, raising concerns about affordability and resource allocation for rural hospitals and clinics.

Supreme Court to hear ACA preventive care coverage case

By Jakob Emerson - The Supreme Court said Jan. 10 it would hear the landmark case that challenges a federal task force's authority to require insurers to cover preventive care services under the ACA. Read Full Article…

HVBA Article Summary

1. Religious Freedom Challenge and Initial Ruling: Braidwood Management, a Texas company, sued HHS in 2021, arguing that the ACA's requirement to cover preexposure prophylaxis (PrEP) for HIV prevention under its employee health plan violated the company's religious freedoms. In March 2023, U.S. District Judge Reed O'Connor ruled that USPSTF recommendations made after 2010 do not need to be followed, blocking the federal government from enforcing them across all private health insurance plans.

2. Appeals Court Decision and Narrowing of Scope: In June 2023, the 5th U.S. Circuit Court of Appeals ruled that Braidwood could not be compelled to pay for PrEP but reversed the broader injunction preventing the federal government from enforcing preventive care mandates. The court limited the decision to the plaintiffs and questioned the authority of the USPSTF due to its members not being Senate-confirmed, while preserving the preventive care mandate for the broader public.

3. Potential National Impact and Supreme Court Review: Although the current ruling affects only the original eight plaintiffs, it raises significant constitutional questions about preventive care coverage under the ACA. The outcome of the pending Supreme Court decision, expected in the spring, could have widespread implications for the coverage of over 100 preventive health services benefiting millions annually.

Some Say US Healthcare Quality is Among The Best In the World: It Is Not!

By William H Bestermann Jr. MD - Since the first of the year, I have been writing about the Singapore health system that is a model for what our healthcare system could be. One of my readers made a comment that deserves a post of its own because it clearly illustrates a point of confusion. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Distinction Between Innovation and Quality: The U.S. excels in medical innovation, advanced technology, and specialized care, but these factors alone do not equate to high-quality healthcare. Quality in chronic disease management depends on consistent delivery of optimal medical therapy (OMT) and not just access to cutting-edge treatments after complications have developed.

2. Optimal Medical Therapy (OMT) as a Quality Measure: OMT for chronic diseases like diabetes is a systematic process aimed at achieving specific health targets (e.g., A1C, blood pressure, LDL cholesterol). The quality of care can be measured by how many patients concurrently meet all OMT targets, which strongly predicts better clinical and financial outcomes.

3. Six Sigma Principles for Healthcare Quality: Quality in chronic disease management should be measured using Six Sigma principles, emphasizing minimal variation and consistently high performance. Currently, most healthcare systems fail to meet even basic benchmarks, indicating the need for systemic improvements in the delivery of best-practice care.

Ozempic, Trulicity among Medicare's priciest drugs, report finds

By Ken Alltucker - Popular diabetes drugs such as Ozempic and Trulicity are among 25 drugs Medicare has spent the most on but hasn't yet selected for price negotiation, according to a report released Thursday. Read Full Article…

HVBA Article Summary

1. Rising Drug Prices and Medicare Impact: The AARP Public Policy Institute report highlights that the average list prices of 25 drugs have nearly doubled since their market entry, costing Medicare and taxpayers almost $50 billion in 2022. This substantial spending affects approximately 7 million older adults on Medicare, many of whom face out-of-pocket expenses, contributing to financial strain and medication nonadherence, with 1 in 5 skipping doses to save money.

2. Medicare Price Negotiations and Legislative Efforts: Under the Inflation Reduction Act of 2022, Medicare gained the authority to negotiate drug prices for a limited number of medications, achieving discounts ranging from 38% to 79% for the first round, effective in 2026. Additional rounds of negotiations will continue through 2028, targeting high-cost drugs like Eliquis, Jardiance, and Xarelto. AARP officials emphasize the importance of these negotiations to curb annual price hikes and support taxpayer savings.

3. Pharmaceutical Industry Response and Policy Limitations: The pharmaceutical industry, represented by PhRMA, argues that focusing on list prices is misleading since rebates and insurance discounts often reduce net costs. However, many drugs have seen price increases exceeding inflation rates, prompting federal penalties under the 2022 law. Experts warn that while the policy addresses price hikes over time, it doesn't prevent high initial pricing when new drugs enter the market.

UnitedHealth units ordered to collectively pay $165 million for misleading Massachusetts consumers

By Nate Raymond - Three UnitedHealth-owned (UNH.N) insurance companies collectively must pay over $165 million for engaging in widespread deceptive conduct that misled thousands of consumers in Massachusetts into unknowingly buying supplemental health insurance, a state court judge has ruled. Read Full Article…

HVBA Article Summary

1. Significant Legal Penalties and Consumer Protection Victory: Massachusetts Attorney General Andrea Campbell praised Judge Helene Kazanjian's decision, which imposed $50.1 million in restitution and $115.1 million in civil penalties against HealthMarkets and its subsidiaries for deceptive insurance sales practices, marking the largest civil penalties recovered under the state's consumer protection law.

2. Deceptive Sales Practices and Targeting Vulnerable Consumers: The court found HealthMarkets and its subsidiaries guilty of misleading consumers by bundling insurance products and concealing the costs of individual policies between 2012 and 2016, targeting financially vulnerable individuals who were deceived into purchasing unnecessary or unaffordable policies.

3. Appeal and Historical Context: Despite the substantial judgment, it fell short of the $368 million sought by the state due to insufficient proof of harm from misleading advertisements. UnitedHealthcare plans to appeal the decision, claiming it is unsupported by evidence, while the case traces back to prior settlements and violations dating to 2009 and 2011.

The healthcare reality check of 2025

By Nayya - It is the start to a fresh year. There are, it seems, endless possibilities to grow, to improve, to learn, and to share. 2024 was a fascinating year with respect to “trust.” Read Full Article…

HVBA Article Summary

1. Restoring Trust through Transparency: The article highlights growing public distrust in institutions, including politics, central banking, and social media, as seen in significant political re-elections, Bitcoin's surge, and Australia's social media ban. Nayya emphasizes the importance of transparency in 2025 to restore trust, particularly within healthcare and financial services, by shedding light on systemic inefficiencies and consumer exploitation.

2. Identifying Key Healthcare Challenges: Nayya has identified five critical areas in healthcare requiring reform: (1) Supplemental health insurance practices, (2) Pharmacy Benefit Management industry practices, (3) Health insurance price transparency, (4) Outsourced benefit administration inefficiencies, and (5) Opaque enrollment firm compensation. Each area involves systemic issues where a lack of transparency and accountability has resulted in financial harm to consumers.

3. A Commitment to Change: Nayya commits to holding the healthcare industry accountable by promoting consumer-first practices, increasing public awareness of exploitative practices, and working with industry leaders to drive positive change. The company pledges to measure progress by the end of 2025, emphasizing the need for objective data, public discourse, and a rebalancing of power to favor everyday consumers.

4 health benefits trends for chronic conditions

By Kurt Cegielski - As we enter a new year, the healthcare landscape for employers will continue to experience major changes. From increased costs due partly to the surge of GLP-1s, and the rise of people managing multiple chronic conditions, the challenges — and opportunities — are becoming more complex. Staying ahead will require our industry to adopt strategies that are holistic, data-driven, and value-based. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Accountability for Vendors with Proven ROI: Employers are demanding immediate, measurable results from benefits vendors, requiring data-backed evidence of cost reductions, particularly in high-expense populations managing chronic conditions. Vendors unable to demonstrate real-time impact will struggle to remain competitive.

2. Cost-Smart Management of GLP-1s: As GLP-1 usage rises across various chronic conditions, employers must adopt integrated care strategies to balance financial sustainability with effective health outcomes. Managing these high-cost medications will require a focus on holistic, cross-condition care rather than isolated treatments.

3. Whole-Person Care Over Single-Point Solutions: The trend is shifting from isolated condition-specific digital tools to comprehensive care models addressing interconnected health issues like mental health, sleep, and nutrition. Employers will increasingly favor holistic approaches that drive long-term health improvements and cost reductions.