Senators complain MultiPlan tool leads to 'crazy low' health care prices

By Allison Bell - Sen. Ron Wyden and Sen. Bernie Sanders say the MultiPlan Data iSight tool is just too good at holding down health care bills. Read Full Article…

HVBA Article Summary

1. Congressional Inquiry into MultiPlan's Data iSight Tool: Senators Wyden and Sanders, holding key positions in Senate committees, have initiated an inquiry into MultiPlan's Data iSight tool, which is used by health insurers and self-insured employer health plans to evaluate out-of-network providers' bills. The senators expressed concerns over alleged discrepancies between billed amounts and actual payments to healthcare providers, referring to some payments as "crazy low." The inquiry seeks clarification on issues raised by The New York Times regarding the tool's functionality and its impact on healthcare costs.

2. Controversy Surrounding Data iSight Repricing Tool: MultiPlan's Data iSight system has sparked controversy, with hospital owners like Adventist Health System and Community Health Systems filing antitrust suits, alleging that payments repriced using the tool are unreasonably low. Despite MultiPlan's assertion that the tool prevents overcharging by hospitals, critics argue that it may lead to "surprise bills" for patients, leaving them with unexpectedly high medical expenses. The scrutiny highlights ongoing challenges in ensuring fair pricing and transparency in the healthcare system, particularly regarding out-of-network services.

3. MultiPlan's Response and Commitment to Transparency: In response to both the congressional inquiry and the antitrust suits, MultiPlan defended its Data iSight system as a mechanism to improve healthcare affordability and transparency. The company emphasizes its role in reducing medical bills and out-of-pocket costs for millions of patients. While addressing concerns raised by Senators Wyden and Sanders, MultiPlan asserts its commitment to working with congressional committees to elucidate the complexities of out-of-network medical services and to ensure fairness and affordability in the healthcare industry.

Where payers landed on the Fortune 500 | 2024

By Rylee Wilson - Seven payers landed among the top 25 healthcare companies on the Fortune 500 in 2024. UnitedHealth Group was the largest healthcare company on the list. The healthcare giant rose one spot to No. 4, landing behind Walmart, Amazon and Apple. Read Full Article…

HVBA Article Summary

1. Elevance Health and Centene Make Incremental Gains: Elevance Health and Centene experienced slight rises in their rankings for 2024, with Elevance Health climbing from No. 22 to No. 20 and Centene moving from No. 25 to an unspecified higher position. Both companies saw increases in revenue for 2023, with Elevance Health at $171.3 billion and Centene at $154 billion.

2. Humana Surges in Revenue and Ranking: Humana made significant strides in both revenue and ranking, jumping from No. 42 to No. 38 on the Fortune 500 list. The company's revenue for 2023 surged to $106.4 billion, marking a 14.5% increase, indicating strong performance and growth.

3. UnitedHealth Group and CVS Health Maintain Dominance: UnitedHealth Group and CVS Health retained their dominant positions on the Fortune 500 list, ranking at No. 4 and No. 6, respectively. UnitedHealth Group reported a revenue of $371.6 billion with a 14.6% increase, while CVS Health recorded $357.8 billion in revenue with a 10.9% increase. Both companies showcased robust growth, reinforcing their status as industry leaders.

Weighty decisions: GLP-1 considerations during benefits renewal season

By Andrea Grande R.Ph. - Renewal season is here, and employers are reevaluating their health insurance offerings with one topic heavy on their minds: GLP-1 coverage. It is no surprise that GLP-1 demand continues to rise as their weight-loss benefits are all over the news and social media. Read Full Article…

HVBA Article Summary

1. Adherence to FDA Guidelines: Employers considering coverage of GLP-1 medications for obesity should prioritize adherence to FDA guidelines to ensure safe and effective use. These guidelines specify eligibility criteria, such as BMI thresholds, and caution against off-label usage to mitigate potential health risks associated with misuse.

2. Cost-Benefit Analysis: While the initial cost of GLP-1 medications may seem prohibitive, employers should weigh the long-term benefits against the expenses. By investing in these medications, employers may witness improved employee health, reduced obesity-related healthcare costs, and enhanced employee satisfaction and retention, thus justifying the investment.

3. Comprehensive Support Approach: Implementing a holistic approach to GLP-1 coverage involves thorough due diligence, continuous monitoring, and ongoing education and support. Employers can leverage third-party vendors or pharmacy benefit managers to assist in eligibility assessments, medication monitoring, and employee education, thereby fostering a supportive environment for employees on their wellness journey. Additionally, recognizing the importance of post-treatment support in maintaining weight loss underscores the need for comprehensive wellness and lifestyle programs to sustain long-term benefits beyond medication use.

Are you being overcharged for your employees' healthcare? Here's how to find out

By Deanna Cuadra - With skyrocketing healthcare costs continuing to drive benefit decisions, many employers are searching for a way to take control of their health plans. Given what employers are being charged for care, there's no better time than now. Read Full Article…

HVBA Article Summary

1. Disparity in Pricing: According to the Congressional Budget Office, commercial insurance prices surpass Medicare rates by 182-240% for the same services. However, this overcharging remains opaque, particularly for fully insured employers lacking access to detailed claims data, as highlighted by Eric Bricker, medical director at SimplePay Health.

2. Challenges for Fully Insured Employers: Bricker emphasizes the difficulty for fully insured employers to enact constructive changes due to limited access to claims data. Self-funded employers, conversely, can scrutinize per-member or per-service costs, potentially curbing overpayment and identifying hospitals and providers exceeding Medicare benchmarks.

3. Path to Reform: While advocating for employers to transition to self-funded models, Bricker acknowledges the potential for fully insured employers to audit costs if granted access to substantial claims data. He proposes incentivizing employees towards cost-efficient providers, suggesting tiered plans that reward the use of high-quality, low-cost facilities, a strategy requiring executive buy-in and a shift away from inertia.

Catalyst for Payment Reform, URAC to Develop Value-Based Payment Accreditation 

By David Raths - Catalyst for Payment Reform (CPR), an independent, nonprofit coalition of employers and other healthcare purchasers, and accreditation organization URAC are working to develop an accreditation program for value-based payment programs that will be available in 2025. Read Full Article…

HVBA Article Summary

1. Implementation of Value-Based Payment: Most payers have adopted some form of value-based payment for healthcare providers, impacting payment and care delivery across multiple sectors of the healthcare industry.

2. Lack of National Validation Programs: Despite the widespread adoption of value-based payment models, there are currently no national programs in place to validate whether these models adhere to accepted best practices, leading to variability in implementation and outcomes.

3. Establishing Accreditation Standards: To address this gap, organizations like Catalyst for Payment Reform (CPR) and URAC are collaborating to develop value-based payment principles through consultation with experts and a multi-stakeholder advisory committee. These principles will inform the development of an accreditation program aimed at identifying organizations that meet best practices for value-based payment, providing stakeholders with a standardized framework for evaluation and selection.

As Interest in GLP-1s Explodes, People Living With Diabetes Need Structured Support To Ensure Effective Use

By Arti Masturzo and Angela Fitch - By working together to build an ecosystem of support around people with diabetes, the healthcare system as a whole can ensure that no one slips through the cracks. Read Full Article…

HVBA Article Summary

1. Addressing Misconceptions: The widespread belief that GLP-1s are a "silver bullet" for health issues poses challenges for healthcare providers. Educating patients about the real benefits and limitations of GLP-1s is crucial to developing personalized care plans that integrate these medications into holistic diabetes management programs.

2. Utilizing Predictive Analytics: In the face of ongoing supply shortages, healthcare providers should employ population health management techniques and predictive analytics to identify high-priority candidates for GLP-1 therapy. Proactive outreach efforts can ensure that individuals receive timely access to appropriate resources, including GLP-1 therapy, to enhance their self-management of diabetes.

3. Comprehensive Patient Support: Effective management of GLP-1 therapy requires more than just medication. Providers must offer evidence-based education on the role of GLP-1s in diabetes care, including managing side effects and understanding long-term commitments. Building a community of care around GLP-1 users involves holistic support, including psychological consultation, nutritional counseling, and ongoing coaching to promote long-term success in managing diabetes and overall health.

‘Unnoticed previously,’ hospital medication errors are more common in older children

By Rose Weldon - Medication errors in hospitalized children were more common among older age groups, according to research published in The Journal of Pediatrics. Read Full Article…

HVBA Article Summary

1. Age Dependency in Medication Errors: The study reveals a surprising finding that medication errors are more prevalent among older children (aged 12 years and above) compared to younger age groups. Contrary to expectations, error rates among children aged 12 years and older were recorded at 20.9 per 100 orders, prompting researchers to delve deeper into this age-dependent phenomenon.

2. Clinician Vigilance and Error Prevention: Clinicians appear to exercise greater caution with younger children, possibly due to a perception of higher vulnerability to errors and subsequent harm. This heightened vigilance may contribute to lower error rates in younger age groups, highlighting the importance of clinician awareness and thorough review processes, especially when prescribing for older children.

3. Implications for Healthcare Practices: The study underscores the need for targeted interventions to reduce medication errors across all pediatric age groups. While the reasons behind the observed age association remain unclear, understanding contributing factors is crucial for effective error prevention strategies. Future research, particularly in neonatal and pediatric intensive care units, can provide insights into age-specific medication error patterns and guide tailored interventions to enhance patient safety.

Temporary disability insurance reduces SS applications, new beneficiaries, study finds

By Alan Goforth - The temporary disability insurance typically included in family medical leave programs has spawned a lively debate in the benefits industry. Does this insurance serve as an on-ramp to Social Security's disability insurance program and increase enrollment, or does it enable older workers to adjust to health shocks and resume working? Read Full Article…

HVBA Article Summary

1. Impact of Mandates on Disability Insurance Applications: In states with temporary disability insurance mandates, there's a lower likelihood of potential Social Security disability insurance applicants submitting claims compared to non-mandate states. Specifically, up to four years post-disability onset, only 27% in mandate states versus 39% in non-mandate states applied for benefits.

2. Employment Dynamics: Temporary disability insurance correlates with higher employment rates among potential Social Security disability insurance applicants, particularly in mandate states. Up to four years post-disability, 61% of applicants were employed in mandate states, contrasting with 39% in non-mandate states.

3. Differential Effects on Severity: While temporary disability insurance impacts severe disability cases significantly by reducing Social Security disability insurance applications and slightly affecting the disability rolls, it doesn't influence application rates or acceptances for less-severe impairments. However, it does lead to earlier retirement for individuals with less-severe conditions, raising concerns about its long-term impact.

U.S. Lags Behind All Other High-Income Nations on Maternal Mortality

By Rachael Robertson - Women in the U.S. -- particularly Black women -- have higher rates of maternal death than any other high-income nation, and the U.S. lacks federal policies that could support these women, according to a new report by the Commonwealth Fund. Read Full Article…

HVBA Article Summary

1. Disproportionate Maternal Mortality Rates in the U.S.: In 2022, the United States recorded a staggering 22.3 maternal deaths per 100,000 live births, significantly surpassing other high-income nations. This rate contrasts starkly with countries like Chile and New Zealand, where maternal deaths stood at 14.3 and 13.6 per 100,000 live births, respectively. Notably, Black women in the U.S. experienced the highest mortality rate at 49.5 per 100,000 live births, underlining significant racial disparities in maternal health outcomes.

2. Postpartum Challenges and Lack of Support: The postpartum period emerges as a critical phase, with two-thirds of pregnancy-related deaths in the U.S. occurring during this time. Despite this, American women face inadequate support systems such as home visits and paid leave. This deficiency in support contributes to the persistently high maternal mortality rates, as women lack access to essential care and assistance during a vulnerable period.

3. Healthcare System Gaps and Policy Deficiencies: Disparities in maternity care providers and absence of federal-level support exacerbate the maternal mortality crisis in the U.S. Compared to other high-income nations, the U.S. falls short in the number of obstetricians/gynecologists (ob/gyns) and midwives per 1,000 live births. Moreover, the absence of a federal paid leave policy further compounds challenges faced by new mothers. The report underscores the urgent need for comprehensive policy reforms and systemic changes to address these deficiencies and mitigate maternal mortality rates effectively.

High-Deductible Health Plans, Prior Authorization Can Harm Cancer Survival

By Megan Brooks - Two common cost-containment strategies — high-deductible health plans and stringent prior authorization requirements — can significantly hinder the survival and well-being of patients with cancer, according to two studies presented at the American Society of Clinical Oncology (ASCO) 2024 Annual Meeting. Read Full Article…

HVBA Article Summary

1. Impact of High-Deductible Health Plans on Cancer Survivors:

   • Using data from the National Health Interview Survey (2011-2018), Justin Barnes, MD, and colleagues assessed the effect of high-deductible health plans on both overall and cancer-specific survival.

   • Cancer survivors enrolled in high-deductible plans faced significantly higher risks of overall mortality (HR 1.46) and cancer-specific mortality (HR 1.34) compared to those with standard health plans.

   • Subgroups, including non-Hispanic White patients, higher-income individuals, and those with higher education levels or multiple cancers, experienced worse survival outcomes under high-deductible plans, potentially due to financial barriers to necessary medical care.

2. Human Toll of Prior Authorization Denials for Pain Medication:

   • Analyzing prior authorization requests for outpatient long-acting opioid prescriptions for cancer patients, researchers from Memorial Sloan Kettering Cancer Center found that most requests (89%) were eventually approved.

   • However, denials (5.6%) led to detrimental consequences, including emergency department visits, hospitalizations, out-of-pocket expenses for pain medications, and transitions to hospice care, with some patients dying in pain within weeks of denial.

   • Despite most approvals, the study highlights the high human costs associated with prior authorization processes, urging reconsideration of their necessity and impact on patient outcomes.

3. Call for Increased Awareness and Advocacy:

   • Dr. Alexi Wright emphasized the urgent need for increased awareness and advocacy, particularly for marginalized patients, in light of the adverse effects of high-deductible plans and prior authorization denials on cancer care.

   • The findings underscore the necessity for policy reforms and interventions to address financial barriers and improve access to essential medical care for all patients, regardless of socioeconomic status or insurance coverage.