HHS restores nondiscrimination protections, expands provisions to telehealth, AI

By Emma Beavins - The Department of Health and Human Services (HHS) finalized a rule reinstating certain regulatory protections against discrimination in healthcare that were stripped in a previous Trump-era rule. Read Full Article…

VBA Article Summary

1. Expansion of Anti-Discrimination Protections: The final rule solidifies protections under Section 1557 of the ACA, extending its anti-discrimination provisions to encompass LGBTQI+ patients. This expansion ensures that healthcare activities cannot discriminate based on sex, race, color, national origin, age, disability, sexual orientation, gender identity, pregnancy, related conditions, and limited English proficiency.

2. Inclusion of Telehealth and AI: Notably, the rule clarifies that telehealth services and artificial intelligence used in patient care are subject to nondiscrimination requirements. This mandates that healthcare entities, including hospitals, providers, and payers, ensure compliance with civil rights laws in their utilization of telehealth technologies and AI tools.

3. Obligations for Healthcare Entities: Hospitals, providers, and payers are now obligated to assess whether algorithms used in patient care, including those for screening, diagnosis, treatment planning, and resource allocation, incorporate discriminatory factors such as race, color, national origin, sex, age, or disability. Additionally, the rule outlines "reasonability" standards to safeguard against discriminatory outcomes in AI-driven decision-making, with measures to address complaints of algorithmic discrimination.

Patients Hitting GLP-1 Plateaus? Here's How to Help

By Fatima Cody Stanford, MD and Richard Frank, MD - Drugs like semaglutide (Wegovy) and tirzepatide (Zepbound) are changing the game in obesity care. In clinical trials, they helped people lose as much as 15 to 20% of their body weight over the course of about a year -- and we've seen similar results in the real world since the drugs were approved for chronic weight management. Read Full Article…

VBA Article Summary

1. Managing Plateaus: Acknowledging the Inevitable: Plateaus are a common occurrence in weight loss journeys, including those involving GLP-1 medications. Despite initial successes, individuals may eventually reach a point where further weight loss becomes challenging due to factors like metabolic adaptation and hunger hormone responses. Educating patients about the likelihood of plateaus at the onset of treatment is crucial for managing expectations and fostering ongoing dialogue between physicians and patients regarding potential interventions.

2. Holistic Support for Sustainable Change: While GLP-1 medications offer promising avenues for weight loss, they are most effective when combined with lifestyle modifications. Providing patients with personalized dietary support from registered dietitians and integrating health coaching for tailored exercise routines can enhance the effectiveness of GLP-1 therapy. By prioritizing behavior modification alongside medication, patients can mitigate side effects, prevent malnutrition, and sustain healthy weight loss over time.

3. Addressing Underlying Factors: Mental Health and Obesity: Obesity often intersects with mental health conditions such as depression, anxiety, and disordered eating, presenting complex challenges to weight management. Recognizing the interconnectedness of mental health and obesity, integrating cognitive behavioral therapy (CBT) alongside GLP-1 therapy can help patients address harmful thought patterns and behavioral tendencies. By prioritizing mental health support, healthcare providers can mitigate the risk of exacerbating underlying conditions and promote holistic well-being throughout the weight loss journey.

UnitedHealth grew very big. Now, some lawmakers want to chop it down.

By Dan Diamond, Christopher Rowland, and Daniel Gilbert - After becoming pregnant, Alexandra Day, a 31-year-old consultant living in South Carolina, sought out neonatal genetic testing that was covered in her health insurance policy. But her insurer, UnitedHealthcare, balked at paying for the December 2022 test, claiming there was no proof Day needed it, and billed her $3,900, according to documents reviewed by The Washington Post. Read Full Article…

VBA Article Summary

1. Struggle for Transparency and Fairness: Alexandra Day's experience highlights the challenges individuals face in navigating the complex health-care system dominated by UnitedHealth Group. Despite persistent efforts to negotiate and reduce her bill, Day ultimately settled for a payment of $650, relinquishing further attempts due to the intricate bureaucracy. This episode underscores broader issues of opacity and difficulty in accessing affordable care, particularly as UnitedHealth's contracting disputes threaten patients' access to essential services.

2. Critique of Consolidation and Complexity: UnitedHealth's extensive reach across various sectors of the health-care industry, including insurance, hospitals, outpatient centers, and home health services, reflects a trend towards vertical integration. Critics argue that such consolidation contributes to a convoluted system that prioritizes corporate profits over patient welfare. The company's $22 billion profit in the previous year raises concerns about its focus on shareholder returns at the expense of escalating costs for consumers, prompting calls for regulatory scrutiny and potential antitrust action.

3. National Security Implications and Regulatory Response: The recent cyberattack targeting a UnitedHealth subsidiary, which disrupted medical claims processing and prescription services nationwide, underscores the vulnerability posed by the company's centralized operations. With over a third of the nation's health-care expenditures flowing through UnitedHealth's systems daily, policymakers and regulators are increasingly viewing the company's dominance as a potential national security risk. Congressional hearings and regulatory investigations signal a shift towards more stringent oversight and potential legislative measures to address UnitedHealth's market influence and safeguard against future disruptions.

Biden plan to reduce Medicaid appointment wait times faces pushback

By Maya Goldman - The Biden administration wants to make sure Medicaid enrollees don't have to wait too long to see a doctor, but state officials and health insurers that administer the program argue a new plan to speed up appointment wait times is unrealistic. Read Full Article…

VBA Article Summary

1. Addressing Access Disparities: The Biden administration's mandate to ensure Medicaid beneficiaries can see primary care providers within 15 business days aims to tackle long-standing disparities in access to care. Historically, low-income individuals and those with disabilities faced prolonged wait times for appointments due to providers' reluctance to accept Medicaid's lower reimbursement rates compared to private insurance.

2. Impact on Medicaid Managed Care: The new standards will apply to Medicaid managed care plans, which cover a majority of program enrollees. Starting July 2027, a 15-day limit for primary care and OB-GYN services, and a 10-day requirement for mental health and substance use care, will be enforced. States will utilize "secret shopper" methods to ensure compliance, with possible remedies including increasing provider pay or cutting Medicaid payments to insurers failing to meet standards.

3. Challenges and Future Implications: While the policy addresses access issues, concerns remain about underlying provider shortages and the feasibility of compliance. Managed care plans worry about being held accountable for factors beyond their control, urging for more flexibility such as telehealth options. The effectiveness of wait time limits, especially without addressing provider shortages, remains uncertain. Varying enforcement approaches across states may lead to uneven relief for Medicaid enrollees awaiting appointments, highlighting the complexity of improving access to care in the Medicaid system.

FTC Finalizes Changes to Health Breach Notification Rule

By Eric Wicklund - Federal officials are making sweeping changes to regulations around digital health apps and platforms in an effort to combat data breaches and fill in the gaps around the Health Insurance Portability and Accountability Act (HIPAA). Read Full Article…

VBA Article Summary

1. Closing Loopholes for Data Protection: The revised Health Breach Notification Rule (HBNR) addresses gaps in data protection caused by the proliferation of third-party apps in the digital health ecosystem. By expanding definitions to include health apps not covered by HIPAA and clarifying breach criteria, the rule aims to enhance security measures and give healthcare providers and consumers more control over their health data.

2. Enhanced Transparency and Notification: With the updated HBNR, there's an emphasis on transparency and notification. Entities now must provide clear and effective notice to consumers via electronic means, expanding the scope of notification content to include the identity of third parties acquiring health information. These changes empower consumers with better information regarding breaches of their personal health records, fostering trust in digital health companies and products.

3. Stricter Compliance and Timely Reporting: The final rule introduces new timing requirements mandating that entities notify the FTC simultaneously with affected individuals for breaches involving 500 or more individuals. This enforces stricter compliance standards and ensures timely reporting, promoting accountability and swift action in addressing breaches of security. Additionally, improvements in readability aim to facilitate better understanding and adherence to the regulations among stakeholders in the healthcare industry.

The Press Is Beginning to Take Notice of How Health Insurers Are Raiding The Medicare Trust Fund

By Trudy Lieberman - Sometimes a health policy story comes along that should be shouted from the rafters — well at least reported by media that cover the subject. Brett Arends’ story for Dow Jones’ MarketWatch is one of those stories. Read Full Article…

VBA Article Summary

1. Medicare Advantage Overbilling Exposed: Arends sheds light on a recent report by the Medicare Payment Advisory Commission (MedPAC), revealing that Medicare Advantage plans are overcharging taxpayers by a staggering $83 billion annually, equating to a 22% overpayment compared to traditional Medicare costs. This revelation underscores a longstanding issue within the Medicare system that has largely gone unaddressed by policymakers and the media.

2. Historical Context of Overpayments: MedPAC, established in 1997, has consistently highlighted the overpayments to private health plans managing Medicare Advantage. Despite decades of evidence showing the inefficiencies of the current system, little action has been taken to rectify the situation, allowing private insurers to dominate more than half of the Medicare market.

3. Implications and Resistance: Arends warns that the current trajectory of Medicare Advantage threatens the existence of traditional Medicare, as the inefficiencies of the former drive up overall costs. However, resistance from advocates like David Lipschutz suggests that awareness of Medicare Advantage's flaws is growing among both the media and policymakers, indicating a potential shift towards addressing these issues and preserving traditional Medicare.

Walmart to shutter health centers, virtual care service in latest failed push into health care

By Annika Kim Constantino and Melissa Repko - Walmart on Tuesday said it will close all of its health-care clinics across the country, a stunning reversal of its plans to bring its low-priced reputation to the dentist and doctor’s office along with the grocery aisle. Read Full Article…

VBA Article Summary

1. Unexpected Closure: Walmart's decision to close all of its health-care clinics nationwide, including its telehealth provider, marks a surprising reversal of its earlier plans to expand its presence in the medical field, highlighting challenges in operating a profitable business amidst rising costs and a challenging reimbursement environment.

2. Operational Challenges: The closure of 51 clinic locations across multiple states is attributed to Walmart's acknowledgment of a broken business model, compounded by the increasing costs of operation and labor, as well as the shortage of health-care workers in the United States.

3. Implications and Industry Dynamics: Walmart's retreat from the health-care sector signifies the difficulty in disrupting and improving the American health-care system. Despite Walmart's initial ambitions and competitive pricing strategies, it faced hurdles in execution, including competition from CVS Health, Walgreens Boots Alliance, and Amazon, among others. This move adds to a string of failed attempts by prominent companies to revolutionize health care, including the dissolution of the joint venture between JPMorgan Chase, Berkshire Hathaway, and Amazon in 2021, indicating the complexities and challenges inherent in the industry.

California Approves 3 Percent Statewide Healthcare Spending Growth Target

By David Raths - Like several other states, California is getting serious about trying to limit the growth of statewide healthcare spending. The California Department of Health Care Access and Information (HCAI)’s Office of Health Care Affordability’s Board has approved a statewide healthcare spending growth target of 3 percent. Read Full Article…

VBA Article Summary

1. Phased Spending Targets: The spending target in California will be gradually implemented, starting at 3.5 percent for 2025 and 2026. It will then decrease to 3.2 percent for 2027 and 2028, finally settling at 3 percent for 2029 and beyond. This phased approach aims to manage healthcare costs effectively over time.

2. Statewide Cost Growth Initiatives: California is among several states adopting measures to control healthcare expenditure. As the tenth state to implement such legislation, California follows in the footsteps of pioneers like Massachusetts, which introduced healthcare cost-growth benchmarks in 2012. These initiatives aim to set annual spending targets tied to economic growth and establish mechanisms for accountability.

3. Enforcement and Accountability: The Office of Health Care Affordability (OHCA) will oversee the enforcement of spending targets. Healthcare entities, including health plans, provider organizations, and hospitals, will be subject to progressive enforcement actions if they exceed the designated spending growth target. Such measures include technical assistance, performance improvement plans, and potential financial penalties. This enforcement mechanism aims to ensure compliance and ultimately make healthcare more affordable for Californians.

New Research Highlights Premium Impact of Provider Markups on Specialty Drugs

By AHIP - Provider markups on specialty drugs increased 2024 commercial health insurance premiums by $13.1 billion in 2024, according to new research from Oliver Wyman commissioned by AHIP. On average, providers charge 42% more than a specialty pharmacy for the same drug. Read Full Article…

VBA Article Summary

1. Preventing Price Markups: Specialty pharmacies play a crucial role in preventing hospitals and physicians from adding markups to the cost of specialty medicines. By sourcing these drugs themselves, specialty pharmacies eliminate the need for additional charges, ultimately reducing healthcare costs for patients, employers, and taxpayers.

2. Reduced Premiums: When patients are administered lower-priced drugs through specialty pharmacies, it directly translates to lower premiums for everyone. The avoidance of markups by providers leads to significant savings, with consumers and employers potentially saving an average of $50 for single coverage and $175 for family coverage in premiums by 2024.

3. Potential Cost Savings: The impact of specialty pharmacies on healthcare affordability is substantial. The report suggests that if providers charged the same prices for specialty drugs as specialty pharmacies, the total savings in health insurance premiums and premium equivalents could reach as high as $13.1 billion in 2024. This underscores the importance of promoting price competition among providers and specialty pharmacies to drive down costs and improve accessibility to vital medications and services.

US Supreme Court urged to strike lawyers' $667 mln fee in Blue Cross case

By Mike Scarcella - The U.S. Supreme Court was asked on Thursday to strike down $667 million in legal fees and costs won by the plaintiffs’ lawyers in a $2.7 billion class-action settlement with Blue Cross Blue Shield accusing it of nationwide insurance overcharges. Read Full Article…

VBA Article Summary

1. Petition Challenging Legal Fees: A member of the class involved in the Blue Cross Blue Shield antitrust settlement filed a petition at the Supreme Court, arguing that the legal fees awarded were excessively high. The petitioner contended that the fee, based on a "percentage of the fund" calculation, exceeded what they deemed reasonable.

2. Basis of the Challenge: The petitioner proposed that legal fees should have been determined using the "lodestar" approach, which calculates fees based on the number of hours worked by lawyers multiplied by an hourly rate. They argued that the awarded fee of 23.47% of the settlement fund was disproportionate, advocating for a fee closer to $194 million, the lodestar amount.

3. Broader Legal Context: The challenge reflects broader concerns over the scrutiny of legal fee applications in cases involving common funds. It also intertwines with another pending Supreme Court case regarding the terms of the Blue Cross settlement, with Home Depot raising objections over the settlement's implications for future antitrust litigation.