Congress Has The Opportunity To Deliver Health Care Price Transparency

By Christopher M. Whaley, Jared Perkins, and Ge Bai - The US health care system has been previously described as “chaos behind a veil of secrecy.” The lack of transparent price information contributes to patient frustration and leaves many employers blind when purchasing health benefits for their workers and families. Read Full Article…

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1. Bipartisan Legislative Efforts to Enhance Price Transparency: Since the 118th Congress began, there has been significant bipartisan effort to build upon and strengthen hospital and insurer price transparency rules introduced in 2019. This includes the Lower Costs, More Transparency Act passed by the House and the Health Care PRICE Transparency Act 2.0 introduced by the Senate. These legislative efforts aim to codify existing transparency requirements, expand them beyond hospitals to include other healthcare entities like clinical diagnostic labs and imaging centers, and increase penalties for noncompliance, highlighting a shared commitment across the political spectrum to address healthcare cost issues.

2. Provisions and Concerns in Price Transparency Legislation: The proposed bills seek to extend transparency to various aspects of healthcare, including pharmacy benefit managers and Medicare Advantage organizations, and to impose more stringent requirements for the reporting and accuracy of price information. However, there are concerns regarding the sufficiency of the information provided, such as the use of estimates and averages instead of actual prices, and the potential impact on the accountability and integrity of price reporting. The House bill, in particular, focuses on ensuring that data reported are true, accurate, and complete, whereas the Senate bill emphasizes the implementation of data standards and prevents the preemption of state price transparency laws.

3. Potential and Challenges for Price Transparency to Drive Cost-Containment: Expanded access to price data holds the promise of transforming the US healthcare system by enabling smarter consumer choices and fostering competition among providers. However, despite the potential for price transparency to empower consumers and incentivize the use of efficient providers, there remain significant challenges, including the complexity of healthcare decision-making and the persistence of market behaviors that do not align with the ideal outcomes of transparency efforts. Additionally, the consolidation within the healthcare sector poses challenges to achieving the full cost-containment potential of price transparency, underscoring the need for further actions to ensure market competitiveness and to leverage transparency for meaningful healthcare reforms.

Should the DOJ Break Up UnitedHealth Group?

By Marissa Plescia - The U.S. Department of Justice has reportedly recently launched an antitrust investigation of UnitedHealth Group, which begs the question of whether the healthcare giant should be broken up. Experts have varying opinions. Read Full Article…

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1. UnitedHealth Group's Comprehensive Influence: UnitedHealth Group not only leads as the largest health insurer in the U.S. but also significantly impacts the healthcare landscape through its employment or contracts with thousands of physicians, ownership of OptumRx (one of the top three pharmacy benefit managers), and its aggressive expansion strategy that has seen it spending over $41.1 billion on 25 acquisitions. The core of its success is attributed to its data analytics arm, Optum, which has played a crucial role in the company's ability to integrate and leverage the businesses it acquires.

2. Federal Scrutiny and Investigations: Recent actions by federal officials signal a growing concern over UnitedHealth Group's market power and its potential effects on competition and the marketplace. The Department of Justice (DOJ) is reportedly investigating UnitedHealth Group, focusing on its practices of vertical integration, particularly the relationships between its insurance arm and health services arm, as well as its effect on competitors and consumers. This scrutiny extends to specific acquisitions, including the pending $3.3 billion purchase of Amedisys, and follows on the heels of a cybersecurity incident at Change Healthcare, one of its acquisitions, which prompted a separate federal probe.

3. Debate on Market Power and Potential Outcomes: Experts and industry insiders are divided on the implications of UnitedHealth Group's size and strategy. Some argue that the DOJ's investigation is warranted given the company's significant control over various aspects of healthcare, from insurance to physician practices, which may hinder competition and affect healthcare costs and quality. Others, however, question why the government allowed such growth if it now sees it as problematic, suggesting that the DOJ's focus might be too narrow or misplaced. Regardless of the investigation's immediate outcomes, there's a broader consensus that the healthcare system itself may require fundamental changes to address issues of competition, cost, and access effectively.

Payers to meet with federal officials over Change attack 

By Jakob Emerson - Federal health officials and payers are expected to meet March 18 to discuss how to support providers still struggling financially following the February cyberattack on UnitedHealth's Change Healthcare, according to a Bloomberg report. Read Full Article…

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1. Financial Support and Recovery Efforts: In response to a significant cyberattack impacting the American healthcare system, payers have been preparing details on their financial support to providers, challenges faced, and recovery efforts. UnitedHealth has advanced over $2 billion to providers and announced a medical claims preparation program. Concerns among payers revolve around the recuperation of advanced funds to providers, with a notable reduction in provider claims to payers by more than one-third due to the cyberattack's impact on financial operations across hospitals, insurers, pharmacies, and medical groups.

2. Government and Industry Response: The cyberattack, described as the most significant in American history, prompted the Department of Health and Human Services (HHS) to ask insurers for interim payments to affected providers and a temporary suspension of prior authorization and other utilization management requirements. The federal government also accelerated payments to hospitals and physicians to mitigate the estimated $6.3 billion cash flow impact. However, AHIP's President expressed concerns over suspending prior authorization requirements, suggesting that individual plans and providers should determine the best approach to maintain timely payments.

3. Policy Adjustments and Investigations: In the wake of the cyberattack and its extensive impact, UnitedHealth temporarily suspended Medicare Advantage and D-SNP prior authorizations for most outpatient services until March 31, a move not yet matched by other large insurers on an enterprise-wide scale. The federal government has also initiated an investigation into UnitedHealth regarding HIPAA compliance in the context of the cyberattack, highlighting the ongoing challenges and responses at both the industry and government levels to address and recover from this unprecedented disruption in the healthcare sector.

Survey: Life insurers want to be better at meeting technology challenges

By John Hilton - Life insurers know that technology is one of their biggest challenges to capitalizing on the enormous market appetite for life insurance and annuities. Read Full Article…

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1. Insurance Executives Acknowledge Technology Shortfalls: A recent survey conducted by LIMRA and Boston Consulting Group highlighted that insurance executives feel they are not meeting their technology goals, particularly in leveraging artificial intelligence for chatbots, voice automation, and voice recognition. This acknowledgment came to light during a session at the LIMRA Distribution Conference, where Bryan Hodgens, a corporate vice president at LIMRA and LOMA, shared insights on the industry's rapid technological changes and the potential yet to be fully exploited by many insurers.

2. Record-High Sales and the Role of Technology: The insurance industry, especially in the annuity segment, witnessed record sales, with a significant 23% year-over-year increase in total annuity sales, reaching $385.4 billion in 2023. This surge underscores the critical role of technology in tapping into the Gen Z and millennial markets, where digital platforms are increasingly becoming the go-to sources for financial information, advice, and transactions. The industry sees technology as a double-edged sword—essential for capturing the vast, untapped market potential but challenging due to the rapid pace of digital evolution.

3. Challenges Beyond Technology – Talent Management: Alongside technology, talent management emerged as a significant concern among insurance executives, as revealed in the LIMRA-BCG survey. The industry struggles with attracting new talent, partly due to the less-than-favorable perception of insurance careers compared to other sectors. The need for digital literacy, creativity, and critical thinking skills is reshaping hiring practices, underscoring the urgency for insurers to enhance their appeal to the next generation of professionals through innovative hiring and training programs to support the sector's growth ambitions.

Medicare Households Spend More on Health Care Than Other Households

By Nancy Ochieng, Juliette Cubanski, and Anthony Damico - Medicare provides health insurance coverage to 66 million adults, including 59 million adults ages 65 and older and more than 7 million adults under age 65 with disabilities. While the vast majority (91%) of Medicare beneficiaries give their Medicare coverage an overall positive rating, health care cost-related problems are not uncommon. Read Full Article…

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1. Significantly Higher Health Care Spending Burden for Medicare Households: In 2022, Medicare households faced a health care spending burden that was double that of non-Medicare households. The analysis revealed that health-related expenses constituted 13.6% of total spending for Medicare households, compared to only 6.5% for non-Medicare households. This disparity reflects not only the higher health care spending by Medicare households, both in annual dollar amounts and as a share of total household spending, but also their lower average total household spending and higher health care usage.

2. Substantial Proportion of Medicare Households Spending More on Health Care: A significant portion of Medicare households spent a larger fraction of their budget on health care in 2022, with nearly 3 in 10 (29%) allocating 20% or more of their total household spending to health-related expenses. This compares to just 7% of non-Medicare households. Furthermore, health care spending by Medicare households rose by 53% from 2013 to 2022, indicating a growing financial strain despite the overall share of health care spending in total household budget remaining stable over the decade.

3. Policy Implications and the Impact of Inflation and COVID-19: The dual challenges of the COVID-19 pandemic and high inflation rates have affected household spending dynamics, with a notable impact on health care expenses. The significantly larger financial burden of health care on Medicare households underscores the need for policy interventions aimed at improving financial protections for Medicare beneficiaries. The Inflation Reduction Act of 2022 and other proposed measures, such as caps on out-of-pocket spending and expanded eligibility for Medicare Savings Programs, highlight ongoing efforts to address these challenges, though they require additional federal investment.

Better Safe Than Sorry: Making Cybersecurity a Priority

By Jasmyne Ray - When organizations decide to invest in a revenue cycle management solution, ideally, cybersecurity personnel would be included from the beginning. Read Full Article…

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1. Recent Shift in Prioritizing Cybersecurity in Healthcare: Healthcare organizations have only started to focus on cybersecurity in recent years. It's essential for cybersecurity teams to be involved in revenue technology discussions early on to establish necessary controls and protections. With cyberattacks becoming more frequent and sophisticated, the proactive safeguarding of patient and employee data is critical.

2. The Importance of Continuous Training and Industry Engagement: Joi Lee, a cybersecurity expert with experience since the early 2000s, emphasizes the necessity for cybersecurity teams to continuously train and stay informed about emerging threats. The healthcare sector, though lagging behind in cybersecurity efforts, requires information roles and cybersecurity specialists to properly implement and safeguard technology solutions. Organizations should ensure their vendors have basic security measures like antivirus and data protection controls.

3. Adopting Proactive Security Measures and Planning: Organizations can protect themselves from cyber risks by following established frameworks like those from the National Institute of Standards and Technology (NIST), which recommend practices such as individual login credentials, password standards, and data encryption. The importance of having a business continuity plan is highlighted by the potential for cyberattacks to disrupt health systems, underscoring the need for organizations to have an updated and tested plan to ensure operational continuity, especially in patient care contexts.

Hospital CEO blames Medicare Advantage for layoffs

By Rylee Wilson - A lack of payments from Medicare Advantage plans is one reason a Connecticut hospital is laying off staff, the Hartford Courant reported March 14. Read Full Article…

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1. Layoffs at Bristol Hospital: Bristol Health, operating a 154-bed hospital and multiple primary care clinics, announced the elimination of 60 positions, 21 of which are currently filled, resulting in layoffs at Bristol Hospital. This decision was driven by the hospital's financial strain attributed to insufficient reimbursement from insurers, as stated by CEO Kurt Barwis to the Courant.

2. Financial Challenges and Cost-Cutting Measures: The hospital faces financial difficulties due to a lack of payment and reimbursement from insurance companies, particularly affecting "nice-to-have" services and staff positions. Kurt Barwis highlighted the issues with Medicare Advantage plans, including frequent claim denials and payment delays, as significant factors contributing to these challenges. Bristol Health expects to save $6 million by cutting these positions.

3. Industry-Wide Concerns and Actions: The article references a broader discontent within the healthcare industry towards Medicare Advantage plans, pointing out their practices of excessive prior authorizations and delayed payments. This dissatisfaction has led to at least 15 hospitals, since September 2023, either dropping some or all Medicare Advantage plans, indicating a growing frustration among hospital executives over these insurance practices.

At HIMSS24, the CDC’s Mandy Cohen Discusses Data

By Mark Hagland - The CDC—the federal Centers for Disease Control and Prevention—is working hard to help to move the entire U.S. healthcare system forward on syndromic data issues, Mandy Cohen, M.D., M.P.H., the CDC Director, told an audience on Tuesday, March 12, during HIMSS24, the annual conference of the Healthcare Information & Management Systems Society, being held this week at the Orange County Convention Center in Orlando. Read Full Article…

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1. Integration of Public Health with Health IT Infrastructure: Dr. Cohen emphasized the strategic approach of integrating public health efforts into the existing health IT infrastructure, rather than building from scratch. This approach aims to enhance the efficiency of data collection and sharing between public health and healthcare delivery systems, utilizing lessons learned from the pandemic to improve quick information sharing, scientific findings dissemination, and the translation of science into actionable policies. Cohen highlighted the importance of modernizing public health communications, breaking down silos, and fostering results-based partnerships to knit together public health and healthcare delivery systems through data.

2. CDC's Public Health Data Strategy: Cohen outlined the CDC's public health data strategy focusing on rapid detection, monitoring, and dissemination of public health threats using standardized data protocols. She highlighted the progress in electronic case reporting (eCR) with a significant increase in the number of healthcare facilities connected from 187 in January 2020 to 32,700 by March 2024. The strategy also includes expanding syndromic data coverage to nearly 88% of emergency department visits for real-time threat monitoring, joining the Trusted Exchange Framework and Common Agreement (TEFCA), and ensuring nationwide adoption of data standards and technical standards for public health systems.

3. Future Goals and Achievements: Cohen reported on specific goals and achievements under her leadership, such as expanding the scope of electronic case reporting across all diseases, aiming to increase the percentage of facilities capable of real-time electronic reporting to 75%, and striving to cover 95% of emergency department visits for syndromic surveillance by the end of 2024. Additionally, she emphasized the importance of collaboration across the federal government, the adoption of Fast Healthcare Interoperability Resources (FHIR) for vital health measures, and the allocation of significant funding to local public health agencies to support various health initiatives. Cohen also shared insights from her experience in North Carolina, highlighting the impact of data-driven strategies on improving vaccination rates and addressing health disparities.

GE Healthcare study shows AI may predict immunotherapy effectiveness

By Jonathan Block - Cancer immunotherapies are among the most expensive therapies available, yet for many patients, they simply don't work well. Artificial intelligence might help. Read Full Article…

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1. Innovative AI Applications in Cancer Treatment: A collaborative study by GE HealthCare Technologies and Vanderbilt University Medical Center has showcased that artificial intelligence (AI) can predict how patients will respond to immunotherapy treatments with a remarkable accuracy of 70% to 80%. The study, highlighted in the Journal of Clinical Oncology Clinical Cancer Informatics, analyzed a wide array of data from thousands of cancer patients, including demographic, genomic, and imaging information, to forecast the effectiveness of treatments and the potential for adverse reactions.

2. Economic Implications and Future Prospects: The study emphasizes the significant financial burden of advanced cancer treatments, like CAR-T-cell therapies, which have shown promising results but come at a high cost. The potential of AI to accurately predict treatment outcomes could revolutionize the approach to cancer care, making it more personalized and possibly more cost-effective. This comes against the backdrop of rising global cancer rates, with predictions suggesting a surge in cancer cases worldwide by 2050. GE HealthCare is exploring ways to commercialize these AI models, aiming to improve therapy development and clinical practice, signaling a future where AI could play a central role in treating cancer and beyond.

3. Expanding the Horizon: Beyond the immediate impact on cancer treatment, the study's findings open doors to applying AI models in other medical fields, such as neurology and cardiology. This multidisciplinary approach could lead to widespread changes in how diseases are treated, making healthcare more predictive and personalized. GE HealthCare expresses a commitment to partnering with various stakeholders in the healthcare ecosystem to further refine and apply these AI models in both research and clinical settings, underlining the transformative potential of AI in healthcare.

Her insurer stopped approving her medicine that worked. Will a new state law help?

By Alan You - Sandra Johnson started feeling short of breath a few years ago, and sometimes it dramatically limited what she could do. Read Full Article…

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1. Personal Impact of Prior Authorization: Johnson, a resident of Plainfield, New Jersey, shares her struggle with severe persistent asthma and how her life was significantly improved by an injectable drug. However, after her insurance company denied reauthorization for her medication, she has been without it for months, illustrating the direct and adverse effects of the prior authorization process on patients' health and quality of life.

2. Legislative Responses and Physician Perspectives: In response to widespread complaints from both physicians and patients about the barriers prior authorization creates in healthcare delivery, states like New Jersey and Washington, along with over two dozen others, have initiated legislation to regulate the process. These laws aim to expedite decisions on prior authorizations to ensure timely patient care. The legislation is a reflection of the healthcare community's frustration, with over 90% of doctors reporting delays in patient care due to prior authorization requirements, sometimes leading to severe patient outcomes.

3. The Debate on Prior Authorization: While prior authorization is criticized for delaying and complicating patient care, representatives from the health insurance industry, like Ward Sanders of the New Jersey Association of Health Plans, argue that the process serves a critical role in ensuring appropriate care and managing healthcare costs effectively. They claim that prior authorization helps in delivering the right care at the right time while also encouraging the consideration of cost-effective treatment alternatives.