AMA, lawmakers aim renewed prior authorization crackdown on insurers

By Noah Tong - The American Medical Association (AMA) and a bipartisan group of Congressional leaders are looking to stop unfair prior authorization practices from health plans. Read Full Article…

HVBA Article Summary

1. Legislative Goals and Scope: Introduced by Rep. Suzan DelBene, the Improving Seniors’ Timely Access to Care Act aims to reform Medicare Advantage (MA) prior authorization practices. The bill, backed by a significant bipartisan coalition, seeks to standardize processes across MA plans, enhance transparency, and establish clear deadlines for authorization decisions. Its passage in the House underscores broad support for modernizing an outdated system that often delays essential medical care.

2. Industry and Stakeholder Support: The legislation has garnered widespread endorsement from key healthcare stakeholders, including the American Medical Association (AMA), Premier, MGMA, and the American Academy of Family Physicians (AAFP). Over 370 organizations have lent their support, highlighting consensus among healthcare providers and industry groups on the urgent need for reform. Stakeholders emphasize that current prior authorization requirements impose substantial burdens on physicians and patients, leading to unnecessary delays and denials of medically necessary care.

3. Debate and Future Outlook: While proponents argue that streamlined prior authorization processes will improve patient outcomes and reduce costs, insurers assert that such protocols are essential for managing expenses and ensuring appropriate care. Despite varying perspectives, there is growing momentum towards legislative change, with proponents optimistic about achieving reform this legislative cycle. Efforts are also underway to hold insurers accountable for policies that potentially undermine patient care, reflecting broader concerns within the medical community about the impact of administrative hurdles on healthcare delivery.

Health Insurers Increasingly Prevent Care for Children, New Congressional Report Finds

By Wendell Potter - One of the most important Capitol Hill initiatives around health care is House Energy and Commerce Committee Ranking Member Frank Pallone’s ongoing investigation into aggressive prior authorization used by health insurance companies. Prior authorization is a slippery practice, and when doctors are forced to get approval from an insurer before treating their patients and get a denial, many patients sadly accept the outcome and do not appeal, often putting their lives in jeopardy. Read Full Article…

HVBA Article Summary

1. Congressional Inquiry and Legislative Action: Representative Pallone's dedication to scrutinizing and addressing the misuse of prior authorization by insurers marks a commendable effort towards legislative remedies. By advocating for prohibitions on these practices, Pallone aims to ensure that necessary care is not obstructed by bureaucratic hurdles imposed by insurers.

2. Impact on Vulnerable Populations: The Government Accountability Office's findings highlight significant disparities in how private insurers managing state Medicaid plans handle prior authorization for children's preventive and diagnostic care. This inconsistency risks depriving children, especially those in low-income families, of essential health screenings that are crucial for early intervention and long-term health outcomes.

3. Policy Recommendations and Future Outlook: The report suggests a critical need for federal oversight, particularly from the Centers for Medicare and Medicaid Services, to examine whether insurers can ethically impose prior authorization requirements for preventive care where no such regulations exist. This issue underscores broader concerns about insurers prioritizing profit margins over patient care in both Medicaid and Medicare Advantage programs, contrasting starkly with the more patient-friendly policies of traditional Medicare.

Who Should Be Responsible for Rationing GLP-1s?

By Marissa Plescia - GLP-1s have proven to be effective in weight loss, but the nation is grappling with shortages and high costs of the drugs. So who should be making the call on which patients get access to the drugs? Read Full Article…

HVBA Article Summary

1. Physicians as Primary Decision-Makers: Dr. Timothy Law advocates for a model where physicians, who regularly interact with patients, should determine the allocation of medicines like GLP-1s based on patient need. He emphasizes that insurers should facilitate this process rather than dictate it, viewing themselves as conduits to care rather than impediments.

2. Challenges of Individual Provider Decision-Making: Dr. Melanie Jay counters the idea of leaving medication decisions solely to individual providers, arguing that this approach could exacerbate health inequities. She highlights the importance of systemic solutions and public health strategies to ensure equitable access to medications, rather than leaving decisions to individual discretion.

3. Role of Insurers and Pressure on Pharma: Law underscores the need for broader accountability in healthcare, suggesting that insurers shouldn't bear the burden of rationing medications like GLP-1s. Instead, he calls for increased pressure on pharmaceutical companies to improve supply and lower prices, likening it to the efforts seen during the COVID-19 pandemic for essential supplies like masks. He also discusses ongoing policy adjustments among insurers, such as tiered coverage approaches, to manage costs and coverage decisions effectively.

Walgreens' US health president: Stop conflating retailers' healthcare businesses

By Jakob Emerson - It's been a tough year for retail healthcare, with organizations such as Walmart, Walgreens' VillageMD and Dollar General all shuttering or scaling back services. Read Full Article…

HVBA Article Summary

1. Financial and Operational Challenges Leading to Closures and Cuts: Walmart's decision to close 51 clinics and end telehealth services was driven by financial difficulties, including a challenging reimbursement environment and rising operating costs. Similarly, Dollar General terminated its mobile clinic pilot after 18 months due to profitability concerns. Meanwhile, Walgreens' exit from certain states and sale of VillageMD locations was part of a broader $1 billion cost-cutting initiative following a $5.8 billion loss, largely attributed to the devaluation of VillageMD.

2. Diverse Models and Consumer Demand in Retail Healthcare: Despite the closures and cuts, Walgreens Boots Alliance remains optimistic about the role of retail in healthcare. Mary Langowski emphasized the distinction between various healthcare models, including advanced/value-based primary care, fee-for-service retail clinics, and urgent care. She highlighted ongoing consumer demand for healthcare in retail settings due to convenience and accessibility.

3. Strategic Shifts and Future Outlook: Despite recent challenges, Walgreens Boots Alliance, as the majority owner of VillageMD, sees retail healthcare as central and anticipates its evolution. The company aims to leverage its core assets to partner effectively with providers and payers across the U.S. Tim Wentworth's statement reflects a proactive approach to reevaluating Walgreens' strategy in the evolving retail healthcare landscape, emphasizing adaptation to find the optimal model for sustained success.

CMS projects national health spending grew 7.5% in 2023 to $4.8T

By Dave Muoio - National health spending is estimated to have outpaced the rest of the country’s economy in 2023, growing by 7.5% with projected expenditures of $4.8 trillion, according to newly published calculations from the government’s actuary. Read Full Article…

HVBA Article Summary

1. Historic High Health Insurance Coverage: Due to pandemic policies, health insurance coverage in the US reached a record high of 93.1% of the population. This surge was driven by increased enrollment in Medicaid and marketplace plans. However, Medicaid enrollment is expected to decline as pandemic-related policies requiring continuous enrollment phase out.

2. Healthcare Spending Trends: Medicare spending in 2023 grew by 8.4% to over $1 trillion, marking an acceleration from previous years. Private health insurance spending also increased by 11.1%, with out-of-pocket expenditures rising 7.9%. Conversely, Medicaid spending growth slowed from 9.6% in 2022 to 5.7% in 2023.

3. Future Projections and Challenges: Over the next decade, healthcare spending is projected to grow annually by 5.6%, outpacing nominal GDP growth. By 2032, healthcare spending is expected to constitute 19.7% of GDP. Medicare will see significant growth due to increasing enrollment of baby boomers, while Medicaid spending and enrollment are anticipated to decrease despite shifts to private and marketplace plans.

BCBS Michigan to drop weight loss drug coverage

By Rylee Wilson - Blue Cross Blue Shield of Michigan will no longer cover GLP-1 drugs to treat obesity beginning in January, Bloomberg reported June 12. Read Full Article…

HVBA Article Summary

1. Insurance Coverage Change: Blue Cross Blue Shield (BCBS) of Michigan, the state's largest insurer, announced it will discontinue coverage of GLP-1 drugs for weight loss in fully insured, large group commercial plans. This decision affects nearly 10,000 members who are currently using these medications.

2. Reasons for Decision: BCBS Michigan cited concerns over the safety, effectiveness, and rising costs associated with GLP-1 drugs as primary reasons for discontinuing coverage. Pharmaceutical costs, including a significant increase in GLP-1 drug expenses, reportedly rose by $350 million in 2023, contributing to a broader $1.8 billion increase in overall costs.

3. Industry and Consumer Response: The decision has prompted reactions from pharmaceutical companies like Novo Nordisk, which expressed disappointment. Meanwhile, the broader trend among employer-sponsored plans, such as Ascension and the University of Texas System, indicates a growing reluctance to cover weight loss drugs, reflecting a shift in insurance policy amid rising healthcare expenditures.

Ascension: Cyberattacker stole files likely containing protected health, identity data

By Dave Muoio - Ascension believes that the cyberattacker who brought its systems down last month also stole a subset of its files that "may contain protected health information and personally identifiable information for certain individuals," a spokesperson wrote in an update posted Wednesday morning. Read Full Article…

HVBA Article Summary

1. Extent of Breach and Impact:

   • The ransomware attack compromised files from seven of Ascension's approximately 25,000 network servers, primarily used for routine tasks rather than patient records or clinical systems.

   • Despite ongoing investigations, Ascension has not yet determined the specific data affected or which patients might be impacted, necessitating a comprehensive review of potentially compromised files.

2. Operational and Recovery Efforts:

   • Ascension has been gradually restoring its electronic health record (EHR) systems across different markets, targeting full nationwide restoration by mid-June.

   • While clinical operations remained largely functional through offline procedures, the attack prompted the temporary suspension of certain non-emergent services and required clinicians to revert to paper records and alternative communication methods.

3. Response and Legal Implications:

   • Facing patient lawsuits alleging negligence in cybersecurity measures, Ascension has committed to notifying affected individuals if sensitive data is confirmed to have been compromised.

   • The nonprofit is offering complimentary credit monitoring and identity theft protection services to affected patients and associates upon request, reflecting its response to safeguard individuals potentially affected by the breach.

Telehealth startup Done's execs arrested and charged for alleged Adderall scheme, DOJ says

By Shelby Livingston - Top executives at the telehealth startup Done Global have been arrested and charged for allegedly peddling easy access to Adderall and other potentially addictive stimulants, in many cases when they weren’t medically necessary, the US Department of Justice said Thursday. Read Full Article…

HVBA Article Summary

1. Criminal Conspiracy Allegations: Ruthia He and David Brody, executives at Done, are accused of conspiring to aggressively push Adderall prescriptions through deceptive marketing and improper clinical practices. The Department of Justice (DOJ) highlights this as the first criminal prosecution related to telemedicine prescribing by a digital health company, marking a significant crackdown on abuse within the industry.

2. Financial Fraud and Deceptive Practices: Done allegedly orchestrated a massive scheme, generating over $100 million in revenue by misleadingly promoting Adderall prescriptions. The company targeted drug seekers with misleading advertisements, instructed prescribers to overlook patient qualifications, and defrauded pharmacies, Medicare, Medicaid, and other insurers through false claims and policies.

3. Exploitation of Regulatory Flexibility During Pandemic: Like several telehealth startups, Done took advantage of relaxed regulations during the COVID-19 pandemic to facilitate online prescriptions of controlled substances without traditional in-person consultations. This regulatory flexibility, intended to enhance patient access during the pandemic, was allegedly exploited by Done for financial gain, resulting in significant harm to public health and financial systems, according to DOJ allegations.

Biden administration advances plan to remove medical debt from credit scores

By Noam N. Levey - Americans would no longer have to worry about medical debts dragging down their credit scores under federal regulations proposed Tuesday by the Consumer Financial Protection Bureau. Read Full Article…

HVBA Article Summary

1. Expansion of Protections: The proposed rules aim to significantly enhance protections for tens of millions of Americans grappling with unmanageable medical bills. This includes preventing medical debts from appearing on credit reports, which can devastate credit scores and hinder access to housing and jobs.

2. Government Action and Advocacy: The Biden administration's initiative fulfills a commitment to tackle healthcare debt, a pervasive issue affecting approximately 100 million Americans. It encourages states to curb hospital debt collection practices and increase charity care, while also urging local governments to purchase and retire medical debt, thereby alleviating financial burdens on vulnerable individuals.

3. Impact on Patients and Industry Concerns: Advocates argue that excluding medical debt from credit reports is crucial for financial security and health equity. Conversely, industry leaders caution that such regulations could lead to unintended consequences like higher upfront costs for healthcare services. Despite these concerns, calls for federal and state-level reforms persist to address systemic challenges in medical debt management and consumer protection.

White House partners with Microsoft, Google on cybersecurity for rural hospitals

By Emily Olsen - Cyberattacks against the U.S. healthcare sector increased 128% from 2022 to 2023, according to the Office of the Director of National Intelligence. Read Full Article…

HVBA Article Summary

1. Partnership for Enhanced Cybersecurity: The White House, in collaboration with Microsoft and Google, has initiated a program to fortify cybersecurity in rural hospitals. This effort aims to counter the rising frequency of cyberattacks targeting the healthcare sector, which has recently seen notable disruptions due to incidents like the ransomware attack on Change Healthcare.

2. Access to Critical Resources: Recognizing the resource constraints faced by rural hospitals, Microsoft and Google will provide free or heavily discounted cybersecurity products. Microsoft offers up to a 75% discount on security products for smaller critical access hospitals, along with no-cost advanced security suites for larger providers. Google focuses on endpoint security advice, software migration funding, and tailored security capabilities through pilot programs with select rural hospitals.

3. Impact on Patient Care and Community Resilience: Cyberattacks not only jeopardize patient data but also disrupt healthcare services, potentially necessitating patient transfers to distant facilities. This initiative seeks to enhance the security and resilience of rural hospitals, crucial in areas where access to alternative medical facilities can be limited, thereby safeguarding continuous patient care and community health.