Healthcare groups say cyber rule should explicitly name insurers, vendors

By Emily Olsen - The long-awaited rulemaking from CISA aims to help the federal government rapidly deploy resources to assist critical infrastructure providers and collect information on cyberattacks. More than 316,000 entities could be covered under the rule, according to agency estimates. Read Full Article…

HVBA Article Summary

1. Inclusion of Insurers and Third-Party Vendors in Reporting Criteria: Healthcare and hospital groups argue that the federal cybersecurity reporting proposal should explicitly include insurers and third-party vendors, highlighting the potential widespread impact of cyberattacks, such as the one experienced by Change Healthcare. They emphasize that the interconnected nature of the healthcare industry means that disruptions to a single entity can have significant repercussions across the sector.

2. Challenges and Burdens of Reporting Timelines: Industry groups express concern over the proposed rule's reporting timelines, which require cyber incidents to be reported within 72 hours and ransom payments within 24 hours. They argue that these stringent deadlines could impose significant burdens on healthcare providers, potentially diverting resources away from patient care during crises. Groups like CHIME and America’s Essential Hospitals call for more flexible reporting processes and financial support to help under-resourced hospitals manage these requirements effectively.

3. Need for Financial and Technical Support: Essential hospitals, represented by America’s Essential Hospitals, stress the need for financial and technical assistance to comply with the proposed cybersecurity reporting rules. They highlight that limited cybersecurity budgets and staffing shortages make it challenging to meet the reporting requirements without compromising patient care. They advocate for an extended and phased reporting process, along with technical assistance, to ensure that critical incidents are managed effectively while maintaining financial stability and patient care standards.

FTC says PBMs ‘exercise vast control’ over healthcare, but stops short of calling for antitrust action

By Drew Armstrong - Federal antitrust regulators issued a report describing the PBM industry as highly concentrated among a handful of companies that use their market power to put pressure on clients and competitors, and called for further investigation of an industry that has fought back against the probe. Read Full Article…

HVBA Article Summary

1. Investigation Findings and Recommendations: The FTC report concludes that the practices of pharmacy benefit managers (PBMs) urgently warrant further scrutiny and potential regulation. Despite not calling for immediate action, such as breaking up PBMs from insurers and drugstores or limiting their business practices, the report highlights the significant market control and influence PBMs wield, controlling 94% of all US drug prescriptions.

2. Impact on Pharmacies and Drug Prices: The report details how PBMs leverage their market power to favor their own networks and drive out smaller pharmacies, using tactics like specialty drug classifications and reclassification to their own pharmacies. This practice, according to the FTC, results in higher costs and reduced access for patients, counteracting the competitive market's intended benefits of lower prices and increased access.

3. Industry Response and Criticism: PBM industry representatives argue that their negotiating tools help lower drug prices, with CVS Health asserting that limiting PBM practices would reward pharmaceutical companies. The Pharmaceutical Care Management Association labeled the FTC's conclusions as biased and pre-determined. The report also highlights the lack of cooperation from PBMs, particularly in disclosing information about their relationships with drugmakers and group purchasing organizations, suggesting these entities might have been created to circumvent regulatory reforms.

Feds target noncompetes for part-time hospital physicians

By Mariah Taylor - New York City-based Mount Sinai Health System is facing scrutiny over the issue of part-time physicians signing noncompete employment contracts, according to a June 18 complaint filed with the National Labor Relations Board. Read Full Article…

HVBA Article Summary

1. Complaint Details and Allegations: The complaint against Mount Sinai involves a no-poaching and confidentiality clause in the employment agreements for part-time physicians. The contracts stipulate that for one year following termination, these physicians may not recruit, solicit, or induce the termination of employment of hospital system employees or independent contractors. The complaint alleges that this language "interferes with, restraints, and coerces employees," in violation of the National Labor Relations Act (NLRA).

2. Mount Sinai's Response and Hearing Schedule: Mount Sinai must respond to the complaint by July 16, and an administrative law judge is scheduled to hear the case on September 24. Mount Sinai declined to comment on the matter when approached by Becker's.

3. Context of the FTC's Noncompete Ban and NLRB Statistics: The complaint comes shortly after the FTC voted to indefinitely prohibit noncompete clauses, a ban that is currently being challenged in federal court. FTC Chair Lina Khan stated that noncompete clauses suppress wages, hinder innovation, and reduce economic dynamism. Additionally, in the first six months of 2024, unfair labor practice charges filed with the NLRB have increased by 7%, from 9,612 in 2023 to 10,278 in 2024.

Here's why a proposal for prior authorization CPT codes returned to the drawing board

By Noah Tong - A recent proposal to report prior authorization to insurance plans through CPT codes was withdrawn at the eleventh hour when its physician advocate made an unexpected discovery: For certain codes and in very narrow circumstances, the prior auth requirements were already in place. Read Full Article…

HVBA Article Summary

1. Proposal for Physician Compensation on Prior Auth Claims: Dr. Alex Shteynshlyuger, director of urology at New York Urology Specialists, proposed a system to ensure physicians are compensated for the time spent on prior authorization (PA) claims. He aimed to reduce the number of claim requirements and appeals, potentially improving patient outcomes. However, he had to withdraw the proposal after learning that prior authorization is already included in the long descriptions of half a dozen CPT codes, which necessitated a revision of his proposal for resubmission.

2. Lack of Awareness and Accessibility of CPT Long Descriptions: The American Medical Association (AMA) revealed that prior authorization requirements are mentioned in the long descriptions of certain CPT codes, which are not commonly accessed by physicians. These long descriptions are stored in databases available for purchase, but many physicians are unaware of their existence. Dr. Shteynshlyuger noted that the AMA had revised these descriptions a few years ago without adequately informing physicians, leading to a gap in knowledge and application.

3. Future Efforts and AMA Resources for Physicians: Dr. Shteynshlyuger plans to resubmit his proposal with dedicated codes to address scenarios where current CPT codes cannot be used for reimbursement. He believes this will allow for better study of prior authorization effects and improve healthcare delivery. Meanwhile, the AMA provides resources like the CPT Changes book, an online data manager, and the CPT Assistant to help physicians navigate coding and billing, appeal insurance denials, and prepare for workflow adjustments due to updated guidelines. The AMA also announced plans to publish new guidance to help physicians understand evaluation and management codes related to prior authorization.

Digital health deals rallied in the first half of 2024, though funding still trails last year

By Shelby Livingston - Digital health startups raised $5.7 billion in the first half of 2024, slightly less than the $6.1 billion in the same period in 2023, according to venture and advisory firm Rock Health. Read Full Article…

HVBA Article Summary

1. Strong Start to 2024 Funding: In the first half of 2024, 266 digital health deals were made, surpassing the 244 deals from the same period last year. This momentum suggests a positive alignment between investors and founders, indicating renewed energy and excitement in the digital health sector.

2. Shift in Funding Stages and Deal Types: Analysis shows that 84% of funding for labeled rounds went to Seed, Series A, and Series B stage companies. Mental health emerged as the top-funded clinical condition, with a significant portion of investments going to AI-leveraging startups. Additionally, the percentage of unlabeled deals decreased significantly from 55% in Q4 2023 to 33% in Q2 2024, a positive indicator of market stability.

3. Renewed Public Market Activity: After a 21-month hiatus, three digital health companies—Nuvo (remote monitoring), Waystar (payments), and Tempus AI (genomics)—went public. This resurgence in IPOs may inspire other startups to consider going public, though upcoming political uncertainties may pose additional risks.

Texas fines Cigna $600K for claims disputes issues

By Jakob Emerson - Texas has fined Cigna $600,000 for failing to comply with multiple independent claims dispute resolution requirements under state law. Read Full Article…

HVBA Article Summary

1. Non-compliance with IDR Requests: Since 2020, Texas has prohibited surprise billing for most out-of-network claims and provided a mediation and arbitration system for settling bills between payers and providers. Despite this, Cigna struggled to keep up with its Independent Dispute Resolution (IDR) requests in late 2022 through 2023, failing to meet multiple statutory and rule-based timelines for a significant portion of its requests, according to a June 6 statement from Texas' insurance commissioner.

2. State Intervention and Corrective Action Plan: Despite Texas offering to train Cigna and address the compliance issues, the problem persisted into October 2023. The state mandated that Cigna develop and implement a corrective action plan by 2024, which Cigna failed to do. This led to increased scrutiny and intervention by the Texas Department of Insurance (TDI).

3. Cigna's Commitment to Compliance: In response to the state's concerns, Cigna stated it has properly assigned resources to its IDR program and aims to achieve full compliance by August 15, 2024. Cigna also committed to implementing additional controls, fully monitoring its IDR process, and promptly alerting TDI of any systemic or trending issues to ensure ongoing compliance.

Popular weight-loss and diabetes medications linked to lower risk of some cancers, study finds

By Deidre McPhillips - GLP-1 medications such as Ozempic and Wegovy may help lower the risk of certain cancers, a new study suggests. People who are overweight or obese have a higher risk of getting 13 types of cancer, and the risk increases the longer a person is overweight and the more excess weight they gain. Read Full Article…

HVBA Article Summary

1. High Cancer Association with Excess Weight: According to the US Centers for Disease Control and Prevention (CDC), approximately 40% of new cancer diagnoses are linked to excess weight. In 2021, this translated to about 170 new cancer diagnoses for every 100,000 people.

2. Impact of GLP-1 Drugs on Cancer Risk in Type 2 Diabetes Patients: A study published in JAMA Network Open revealed that individuals with type 2 diabetes treated with GLP-1 drugs had a significantly lower likelihood of being diagnosed with 10 out of 13 obesity-associated cancers compared to those using insulin. The risk reduction was particularly notable for gallbladder cancer, meningioma, pancreatic cancer, and hepatocellular carcinoma, with the risk cut by more than half.

3. Mechanisms of Excess Weight and GLP-1 Drugs: Excess weight can lead to changes in the body, such as chronic inflammation and elevated levels of insulin, insulin-like growth factor, and sex hormones, which can contribute to cancer development. GLP-1 medications, which interact with systems related to insulin production, may help mitigate these risks.

Why Workers Need Emergency Savings Accounts

By Brian Anderson - Research released from Empower this week shows why employers may want to jump on offering the new SECURE 2.0-enabled emergency savings accounts program—as 37% of Americans can’t afford an emergency expense over $400. Read Full Article…

HVBA Article Summary

1. Financial Precarity and Lack of Savings: The new Empower research reveals that nearly a quarter (21%) of Americans lack any emergency savings, highlighting widespread financial vulnerability. Rising prices and inflation are straining household finances, with almost half (47%) of respondents indicating that their regular monthly expenses are too high to save any money.

2. Emergency Fund Usage and Gender Savings Gap: The survey found that 25% of people had to dip into their emergency savings for basic living expenses in the past year, with the median emergency savings being $600. A significant gender gap exists, as men have a median emergency savings of $1,000 compared to $500 for women. Despite these challenges, 43% of Americans, including 51% of Baby Boomers, have contributed to their emergency funds in the past year.

3. Stresses and Priorities in Financial Planning: Over half (54%) of Americans stress about potential disaster expenses, with Millennials being the most concerned (60%). Rising prices prevent 57% from building emergency funds, and 57% prioritize paying down debt over saving for emergencies. However, 34% believe they could handle emergency expenses, and 30% of adults keep their emergency savings in cash, with many exploring high-yield savings accounts.

Tirzepatide led to greater real-world weight loss than semaglutide for adults with obesity

By Michael Monostra - Adults with overweight or obesity lost more weight with the GIP/GLP-1 dual agonist tirzepatide than the GLP-1 receptor agonist semaglutide, according to findings published in JAMA Internal Medicine. Read Full Article…

HVBA Article Summary

1. Significant Weight Loss: Adults with overweight or obesity using the GIP/GLP-1 dual agonist tirzepatide (Mounjaro/Zepbound) experienced greater weight loss compared to those using the GLP-1 receptor agonist semaglutide (Ozempic/Wegovy). At 3, 6, and 12 months, weight loss with tirzepatide was 5.9%, 10.1%, and 15.3% respectively, while semaglutide users lost 3.6%, 5.8%, and 8.3%.

2. Comparable Adverse Events: Moderate to severe gastrointestinal adverse events, including conditions like bowel obstruction and pancreatitis, were similar between tirzepatide and semaglutide users, indicating no significant difference in the safety profiles of the two medications.

3. Implications for Patient Care: The study's findings, derived from a large and diverse patient population using real-world data, provide timely insights into the effectiveness of tirzepatide for weight loss. This information can help inform patient care decisions today, emphasizing the need to consider individual circumstances, medication availability, and insurance coverage when prescribing these medications.