Daily Industry Report - March 6

Your summary of the Voluntary and Healthcare Industry’s most relevant and breaking news; brought to you by the Health & Voluntary Benefits Association®

Jake Velie, CPT
Vice Chairman, President & COO
Health & Voluntary Benefits Association® (HVBA)
Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF
Chairman & CEO
Health & Voluntary Benefits Association® (HVBA)
Daily Industry Report (DIR)

Last Chance ⬇ ⬇

VIP Admission & CE’s On Us!

The Latest in Medicare Telehealth Billing

By Center for Connected Health Policy - Last month the Centers for Medicare and Medicaid Services (CMS) released an updated Telehealth Services Medicare Learning Network (MLN) Fact Sheet reflecting new information for 2024. Most of the guidance remains unchanged and updates largely focus around incorporating already adopted policies from the Consolidated Appropriations Act, 2023 (CAA 2023) and CY 2024 Physician Fee Schedule (PFS) Final Rule. Read Full Article…

VBA Article Summary

  1. CMS Fact Sheet Overview and Telehealth Policies: The CMS Fact Sheet serves as a crucial resource for healthcare providers navigating the complexities of Medicare billing for telehealth services, especially amid the shifting regulations due to the COVID-19 pandemic. It outlines general telehealth coverage rules, pre-pandemic policies, and the extended Public Health Emergency (PHE) flexibilities. Notably, the Fact Sheet highlights the temporary waiver of restrictions on eligible originating sites and distant site providers until December 31, 2024, allowing patients to receive services regardless of their location and enabling more providers to offer distant site telehealth. Moreover, it addresses the allowance for audio-only telehealth services under specific conditions, catering to the diverse needs of Medicare beneficiaries.

  2. Telehealth Billing and Reimbursement Guidance: The document delves into the intricate details of Medicare billing for telehealth, addressing common questions regarding payment rules, coding requirements, and the use of telehealth modifiers and Place of Service (POS) codes. It provides updated guidance for both hospital and non-hospital-based providers on billing practices, including the use of modifier 95 and new POS codes to reflect the delivery of professional telehealth services from various locations. This guidance aims to clarify billing processes and ensure providers are reimbursed correctly for telehealth services, including physical therapy, occupational therapy, speech-language pathology, diabetes self-management training, and medical nutrition therapy.

  3. Updates and Future Directions: The Fact Sheet also informs providers about recent updates and additions to Medicare telehealth services, including new codes for health and well-being coaching and social determinants of health risk assessments. It addresses ongoing and future changes, such as the continuation of payment methodologies for telehealth services by rural health clinics and federally qualified health centers, adjustments to mental health telehealth requirements, and the extension of certain flexibilities through the end of the calendar year 2024. Additionally, it highlights the current issue with POS 10 reimbursements being at a lower rate than expected and promises further clarifications and updates on Medicare telehealth billing issues as new information becomes available, ensuring providers have the latest information to navigate the evolving landscape of telehealth reimbursement.

HVBA Poll Question - Please share your insights

What do you believe is the primary factor contributing to the average 20% increase in pharmacy costs as a percentage of total medical spending for businesses:

Login or Subscribe to participate in polls.

Our last poll results are in!


of Daily Industry Report readers who responded to our last polling question “absolutely believe and would engage in the legal importation of specialty medications” when asked if they would advise clients to import speciality or high cost brand drugs like Ozempic, Mounjaro, Wegovy from abroad to save 35-50% off U.S. prices of $850, $1,070, $1,670 per month respectively.

26.83% of respondents have no opinion on the matter or are neutral, neutral or uncertain, 25.25% would consider it, but not too familiar with the process, while 20.41% do not believe or have trust in medications being sourced outside of the U.S. pharmacies.

Have a poll question you’d like to suggest? Let us know!

White House turns to health care in Biden’s latest move against ‘corporate greed’

By Josh Sisco, Adam Cancryn and Megan R. Wilson - The White House plans to announce a new federal task force focused on easing health care costs, according to three people with direct knowledge of the matter. Read Full Article…

VBA Article Summary

  1. Crackdown on Corporate Greed: President Joe Biden is focusing on combating what he terms "corporate greed," which he blames for high prices impacting the cost of living. This initiative includes a multi-agency task force from the Justice Department, Federal Trade Commission, and Department of Health and Human Services, aiming to enforce actions against high drug pricing and health provider costs. This move is part of Biden's broader domestic economic policy to enhance competition and antitrust efforts, highlighting the administration's focus on reducing healthcare costs and increasing transparency in housing and rental prices.

  2. Healthcare Cost Reduction Efforts: The Biden administration has introduced several measures to tackle healthcare affordability, such as a proposal to seize patents for medicines developed with taxpayer funds to lower drug costs, and efforts to cap the price of insulin and enable Medicare to negotiate drug prices. These efforts are portrayed as significant achievements in the administration's fight to reduce healthcare expenses, complemented by appointments of aggressive antitrust enforcers and the creation of a chief competition officer role within the Department of Health and Human Services.

  3. Addressing Rising Costs Beyond Healthcare: In addition to healthcare, the Biden administration is taking steps to address other areas of economic concern, such as housing costs, rent, and rising food prices. This includes legislative efforts and enforcement actions against mergers and practices deemed anti-competitive, such as the recent FTC lawsuit to block the merger between Kroger and Albertsons. The administration is also focusing on "junk fees" and "shrinkflation" as part of its broader campaign against practices that contribute to the rising cost of living, positioning Biden as a defender against big corporate interests ahead of his State of the Union address.

By Atif Siddiqi - The healthcare industry is facing a mounting talent crisis—one where it’s become imperative for healthcare organizations and hospitals to recruit the next generation of workers. Nearly one in five healthcare workers quit their job during the pandemic, and it’s estimated that there will be 194,500 annual openings for registered nurses between 2020 and 2030. Read Full Article…

VBA Article Summary

  1. Addressing the Impact of an Aging Population on Healthcare Demand and Workforce Composition: The increasing proportion of the U.S. population aged 65 and over, which is expected to reach 21% by 2032, is leading to a higher demand for healthcare services. This demographic shift not only amplifies the need for healthcare support but also poses challenges in maintaining a workforce capable of providing this care, especially considering the significant portion of the current workforce nearing retirement age.

  2. Combating Pandemic Burnout with Work-Life Balance and Flexibility: The pervasive issue of burnout among healthcare workers, exacerbated by the pandemic, underscores the necessity of adopting measures that promote work-life balance and flexibility. The healthcare industry must address the physical and mental fatigue plaguing its workers by offering solutions that cater to their desire for a sustainable lifestyle. This includes adjusting to the gig economy's influence, which has reshaped expectations around work arrangements and independence.

  3. Incorporating New Care Fields and Adapting to the Gig Economy: The healthcare sector must adapt to the evolving landscape marked by the gig economy's rise and the expansion of alternative care fields. By offering competitive incentives, flexibility, and embracing the growth of holistic and alternative medicine, healthcare organizations can attract the next generation of talent. These strategies are essential for filling emerging roles within the industry and ensuring the delivery of diverse, evidence-based care options to meet the growing patient demand for such services.

All drugmakers send in counteroffers in Medicare price negotiations

By Joseph Choi - All of the manufacturers whose drugs were chosen for the federal government’s Medicare price negotiation program have sent back counteroffers for what they consider to be a maximum fair price, the White House said Monday. Read Full Article…

VBA Article Summary

  1. Medicare Drug Price Negotiation Progress: President Biden announced that all manufacturers of the first 10 drugs selected for Medicare price negotiations have submitted counteroffers, marking a key milestone in the effort to reduce prescription drug costs for seniors. These drugs include notable medications like Eliquis, Jardiance, Xarelto, Januvia, and Farxiga. The initial offers were sent by the Centers for Medicare and Medicaid Services (CMS) on Feb. 1, with drugmakers having until March 2 to respond.

  2. Political and Legal Challenges: Despite facing significant opposition from pharmaceutical companies and Republicans in Congress, who have criticized the program and attempted to block it through legal challenges and efforts to repeal the Inflation Reduction Act, the negotiation process is moving forward. President Biden emphasized this achievement as a step towards lowering healthcare costs for families and providing seniors with better deals on prescription drugs.

  3. Timeline and Legal Battles: The negotiation talks are set to continue until Aug. 1, according to CMS guidance, with the maximum fair prices to be published on Sept. 1 and expected to take effect at the start of 2026. Meanwhile, the pharmaceutical industry has initiated several lawsuits against the federal government, claiming the negotiation program is unconstitutional and violates federal law. However, since the beginning of the year, two significant legal victories have favored the federal government, including the dismissal of a lawsuit by PhRMA and a federal judge ruling in favor of Medicare negotiation in a case brought by AstraZeneca.

Even with employer-sponsored health insurance, 43% struggle with medical debt

By Alan Goforth - Employers walk a tightrope as they attempt to provide competitive health benefits to workers while navigating steadily rising premiums. Despite their best efforts, more than 4 in 10 employees report having experienced medical debt. Read Full Article…

VBA Article Summary

  1. Escalating Costs and Increasing Debt: CEO Mike Waterbury of Goodroot highlighted the critical responsibility employers have in providing quality health care benefits amidst rising costs. With the average expense for family coverage per employee surging by nearly 48% since 2013, employers face the challenge of managing these escalating costs while trying to protect their employees from the burden of medical debt. Despite significant spending on health benefits, nearly half of Americans in medical debt owe more than $2,500, and a considerable percentage have had to forgo basic necessities due to medical bills. Moreover, medical debt is a more prevalent issue among younger workers, who are 29% more likely to experience it than older employees.

  2. Underutilization of Hospital Financial Assistance: The article underscores a significant gap in the utilization of hospital financial assistance programs, which are designed to offer free or discounted care to eligible individuals, including those with incomes up to $180,000 in some cases. Despite the availability of these programs, a substantial portion of employees, especially those earning less than $100,000 annually, remain unaware of them or mistakenly believe they are ineligible. This lack of awareness and misunderstanding about eligibility criteria prevent many from seeking the financial help available to them, exacerbating the issue of medical debt.

  3. The Role of Employers in Mitigating Medical Debt: Waterbury emphasizes the importance of employers going beyond merely offering health insurance to actively protect their employees from medical debt. He suggests integrating hospital financial assistance into health benefits and providing a health-cost navigator to help employees navigate their benefits, understand comparison pricing, and negotiate bills. These strategies can play a crucial role in ensuring the financial and physical well-being of employees, enhancing their productivity, and contributing positively to the company culture.

LIMRA: Three Reasons Why the Women’s Market Holds the Key to Life Insurance Industry Growth

By LIMRA - Women’s History Month is a time to recognize women's contributions to American history. As the life insurance industry, we can use this time to continue helping more women build a financially secure future with life insurance. Read Full Article…

VBA Article Summary

  1. Recognition of Insurance Gaps: A significant number of women, 54 million, recognize they have a life insurance gap, with 44% acknowledging they need more coverage. This highlights a substantial market opportunity, as more women are planning to buy life insurance within the year compared to men.

  2. Financial Security Concerns: Women express greater concern over financial security than men, worrying about retirement savings, emergency funds, bill payments, and support if they're unable to work. Life insurance is seen as a solution to these concerns, with women indicating they would use life insurance policies for a variety of financial needs, including covering burial expenses, offsetting financial emergencies, aiding retirement savings, and building multi-generational wealth.

  3. The Search for Financial Advisors: A notable portion of women, especially single mothers, are actively seeking financial advisors who understand their needs. Trustworthiness, experience, and communication skills are the most valued traits in a financial advisor among women. Addressing common misconceptions about life insurance through education and direct engagement, such as through websites and social media, can help close the insurance gap and empower women to secure their financial future.

Why Medicare is adding prior authorization requirements as others cut back

By Maya Goldman - Medicare is taking the rare step of adding pre-treatment approval requirements before patients can get care at certain outpatient surgical facilities that have seen a sharp uptick in billings. Read Full Article…

VBA Article Summary

  1. Medicare's Use of Prior Authorization as a Cost-Control Measure: Despite criticism from healthcare providers and patients, and actions by the Biden administration to streamline prior authorization processes, Medicare's decision to implement these requirements for certain services at ambulatory surgery centers underscores its commitment to using prior authorization as a tool to control healthcare costs. This move aims to prevent wasteful spending on inappropriate care, reflecting the complex balance between ensuring patient access to necessary treatments and managing financial resources efficiently.

  2. Introduction of New Requirements for Ambulatory Surgery Centers: In a move to curb potentially inappropriate billing for services that can serve both cosmetic and medical purposes, Medicare announced it would require ambulatory surgery centers to obtain prior authorization for 40 specific services related to procedures such as rhinoplasty, eyelid lifts, and varicose vein treatments. This policy extension to traditional Medicare follows an observed shift in the provision of these services from hospital outpatient departments, where similar controls were instituted in 2020, to ambulatory surgery centers, indicating an effort to ensure consistent and appropriate use of medical treatments across different healthcare settings.

  3. Concerns and Criticisms from the Healthcare Community: The decision by Medicare has been met with surprise and concern from the ambulatory surgery center industry and medical professionals, who argue that existing mechanisms to combat fraud should suffice and that the new prior authorization requirements may unnecessarily burden providers without addressing significant issues of service utilization. Critics also highlight that the services now requiring prior authorization do not align with the most frequently billed services by these centers, challenging the assumption that these measures are targeted and necessary for reducing unnecessary healthcare spending.

The value of change: Challenges and strategies transitioning to value-based care | Viewpoint

By Zameer Rizvi - In the supermarket, we look for fish that’s sustainably raised. We’re swayed by sustainable practices from hotels and retailers. So why wouldn’t the same standard apply to the most important service industry in the world, healthcare? Read Full Article…

VBA Article Summary

  1. The Unsustainable Fee-for-Service Model: The traditional fee-for-service healthcare model, characterized by charging for each service like blood draws, X-rays, and surgeries, has proven unsustainable, leading to financial losses for health systems and hospital closures, especially in rural areas. This model's volume-driven approach has also contributed to significant burnout among healthcare professionals.

  2. Shift Towards Value-Based Care (VBC): In response to the inefficiencies of the fee-for-service model, there's a growing momentum towards Value-Based Care (VBC) in the U.S. This model focuses on rewarding healthcare providers based on patient outcomes rather than the volume of services provided. It aims at reducing healthcare costs while improving the quality of care, evidenced by the estimated 238.8 million Americans currently receiving healthcare under VBC. This shift is supported by healthcare organizations and facilitated by technologies that enable better patient data management and outcome tracking.

  3. Challenges and Strategies for Transitioning to VBC: Transitioning to VBC presents challenges such as overcoming inertia, fear of income destabilization, and the costs of initial investment. However, opportunities for improved efficiency, reduced overhead costs, and better health outcomes are significant. Strategies for a successful transition include continuous education on VBC principles for healthcare providers, assessing and choosing the appropriate VBC models (like DPC, ACOs, PCMH), and leveraging technology to harness the power of data for improved patient care and operational efficiency.

Hospitals and PBMs seem to have dodged big federal reforms — for now

By Peter Sullivan - Hospitals and pharmacy benefit managers who've repeatedly been targeted in congressional debates over health spending appear to have ducked major federal reforms that could have upended how they do business. Read Full Article…

VBA Article Summary

  1. Status Quo Maintained Amidst Healthcare Cost Concerns: The recently unveiled congressional spending deal, crucial for policy changes before elections, preserves the current state of affairs for healthcare and pharmaceutical industries, potentially leaving patients vulnerable to escalating healthcare expenses. Despite expectations for significant policy shifts through this must-pass package, substantial debates are deferred to a post-election lame-duck session, highlighting the influence of industry lobbying and congressional dysfunction in hindering Medicare payment reforms and the imposition of new price transparency requirements.

  2. Challenges in Addressing Pharmacy Benefit Managers (PBMs) and Hospital Costs: Efforts to regulate PBMs and hospital expenses encountered obstacles, including a lack of consensus among lawmakers and intense industry opposition. While there was bipartisan support for making PBMs more transparent and ensuring they pass discounts onto clients, internal disagreements and industry lobbying prevented the adoption of a unified plan. Similarly, proposed reforms such as site-neutral payments, aimed at reducing healthcare costs by standardizing Medicare payments, faced resistance from hospitals concerned about patient care and the survival of rural healthcare facilities.

  3. Future Prospects and Ongoing Reform Efforts: Despite the current stagnation, there is ongoing support from key lawmakers for healthcare reform, including initiatives to address PBM practices and hospital costs. A forthcoming government funding package presents another opportunity for policy changes, though the complexity and opposition surrounding healthcare policy differences pose significant challenges. The need for reform is underscored by the wonkiness of the proposed changes and the general public's lack of awareness about issues like PBMs, making it difficult to mobilize public support against well-funded industry opposition.