Downcoding is Back From the Dead: Insurers Resurrected a Scheme to Pay Doctors Less That the Courts Banned

By Wendell Potter – Nilsa Cruz, the patient advocate at the Milwaukee Rheumatology Center, has won national awards for fighting Big Insurance practices that hamper care – frequently taking her cases to the state capitol in Madison. But for Cruz, a recent move by the insurance giant Cigna that aims to boost profits by nickel-and-diming physicians on office visits was personal. “I just terminated Cigna,” Cruz said in a recent interview, after the insurer implemented a new policy known as “downcoding” that automatically pays certain doctors and their clinics less money for a patient visit than the health care providers had billed. “You know why? Because I don’t want to have to deal with these shenanigans with them.” And she said she’s looking at ending the rheumatology clinic’s contract with Aetna over similar payment issues. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Resurgence of Downcoding Practices: Two decades after a major lawsuit forced insurers to stop the practice, health insurers like Cigna and Aetna have revived downcoding, which involves automatically reducing the reimbursement rates for doctors' claims. This practice is justified by insurers as a method to combat "waste and abuse," but it effectively reduces payments to physicians, squeezing smaller clinics financially and potentially limiting patient access to care.

2. Impact on Physicians and Patients: Downcoding creates a difficult situation for doctors and patients alike. Physicians face significant revenue losses, with some visits reimbursed at rates more than 26% lower than billed, as reported by Dr. Terry Wagner. Clinics may choose to drop insurers enforcing downcoding, which can lead to longer wait times and treatment gaps for patients, especially in specialized fields like rheumatology.

3. Insurance Industry's Contradictory Coding Practices: While insurers downcode doctors' claims to reduce payouts, they have also been accused of "upcoding" in Medicare Advantage plans to increase federal reimbursements. This dual strategy highlights a pattern where insurers maximize profits by manipulating coding practices to their advantage, raising concerns about fairness and transparency in healthcare billing.

SCOTUS case over health sharing ministry could impact all 'excepted benefits'

By Allison Bell – The U.S. Supreme Court is considering a case filed by two women in New Mexico who want Alice Kane, the state's insurance superintendent, to let them join the Gospel Light Mennonite Church Medical Aid Plan, a health care cost-sharing ministry. The court showed its interest in the case Monday by asking the top lawyer for the administration of President Donald Trump, Solicitor General D. John Sauer, to file a brief expressing the views of the United States on the case. A health care cost-sharing ministry is an organization that helps people who share spiritual beliefs pay for each other's care. Federal law lets ministries established in or after 1999 operate outside the Affordable Care Act rules that apply to providers of major medical insurance. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Supreme Court Review of Health Sharing Ministry Case: The U.S. Supreme Court is reviewing a case involving two New Mexico women who want to join the Gospel Light Mennonite Church Medical Aid Plan, a health care cost-sharing ministry. This case highlights the tension between state insurance regulations and federal exemptions under the Affordable Care Act (ACA) for certain health care arrangements. The court's involvement signals the potential for significant legal clarification on the status of such ministries.

2. Potential Impact on Excepted Benefits and Employer Health Plans: The outcome of this case could influence the regulatory framework for various 'excepted benefits' beyond health care cost-sharing ministries, including short-term health insurance, hospital indemnity, dental insurance, and direct primary care arrangements. Employers might also be affected, especially regarding the use of federal laws like the Religious Freedom Restoration Act to seek exemptions from ACA preventive service requirements. This case could reshape how these alternative health coverage options are treated under state and federal law.

3. Legal and Regulatory Background: Health care cost-sharing ministries are exempt from many ACA requirements, allowing members to avoid penalties previously associated with lacking ACA-compliant insurance. The New Mexico insurance superintendent has challenged the Gospel Light plan as an unregistered health insurer, leading to legal battles culminating in the Supreme Court petition. The case reflects broader debates about religious freedom, state insurance regulation, and the scope of federal health care laws, with the Supreme Court's recent rulings indicating possible sympathy toward religious objections in health coverage contexts.

Health care in US faces ‘a triple shock’

By Susan Rupe – The health care landscape in the U.S. faces what one analyst called “a triple shock.” The scheduled expiration of enhanced Affordable Care Act tax credits, increasing costs for Medicare and Medicaid, and the impact of tariffs on pharmaceuticals and medical supplies have created what Brian O’Connell called “a three-headed monster.” O’Connell is senior insurance plans analyst with InsuranceQuotes.com. “You have this perfect storm right now,” he told InsuranceNewsNet. “Rising Medicare costs, expiration of ACA tax credits, and tariffs and inflation – they’re all bleeding through the medical supply chain and causing a lot of problems.” Read Full Article...

HVBA Article Summary

1. Triple Shock Impacting U.S. Health Care: The U.S. health care system is currently facing a combination of three major challenges: the expiration of enhanced Affordable Care Act (ACA) tax credits, rising costs for Medicare and Medicaid, and tariffs on pharmaceuticals and medical supplies. These factors collectively create significant financial pressure on both consumers and providers, leading to increased premiums and reduced access to care.

2. Rising Costs and Access Issues for Medicare Beneficiaries: Medicare Part B premiums are expected to increase by 11.6% in 2026, with the deductible also rising. Physician networks for Medicare Advantage plans are tightening as doctors face stagnant payments despite a 40% increase in operating costs over the past two decades. This situation is causing some physicians to leave Medicare, which limits access to care for Medicare beneficiaries.

3. Challenges for Consumers and Employers: Without renewal of the enhanced ACA tax credits, families purchasing coverage through the ACA exchanges could see their premiums more than double, making health insurance unaffordable for many. The Congressional Budget Office estimates that 4.2 million Americans could become uninsured by 2035 if the credits expire. Employers are also struggling with rising health care costs, leading some to limit coverage options, which creates difficult choices in balancing cost management with employee care.

Outpatient deductibles double since 2012, driving up out-of-pocket costs

By Alan Goforth – The out-of-pocket portion of health care spending for Americans with employer-sponsored coverage increased faster than both wages and general inflation over the past decade, according to the Peterson KFF Health System Tracker. In recent years, however, there has been a shift in which cost sharing now is growing at a rate more similar to inflation. Total out-of-pocket spending averaged $869 in 2023. The majority of this spending was for outpatient services, followed by prescription drugs and inpatient services. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Significant Increase in Outpatient Deductibles: The average amount paid through deductibles for outpatient care more than doubled from $198 in 2012 to $404 in 2023, making up 60% of outpatient out-of-pocket spending. This increase has been a major driver of rising out-of-pocket costs for Americans with employer-sponsored health coverage. The growth in outpatient deductibles highlights a shift in how patients share healthcare costs, particularly for outpatient services.

2. Stable and Different Cost Sharing Trends for Other Services: While outpatient deductibles have risen sharply, out-of-pocket spending on prescription drugs and inpatient care has shown different patterns. Prescription drug costs increased by only 19% since 2012, with copayments being the dominant form of cost sharing. Inpatient care costs have remained relatively stable, with coinsurance as the main cost-sharing method, but the actual cost for hospitalized individuals can be substantial despite the low average per person.

3. Impact on Healthcare Spending and Plan Coverage: Despite the rise in out-of-pocket spending, health plans continue to cover the majority of enrollees’ health costs, with the share paid by plans increasing slightly over time. The out-of-pocket share of total annual health spending decreased from 15% in 2012 to 13% in 2023. However, enrollees still face higher absolute out-of-pocket costs, which have risen about 24% since 2020 following a temporary decline during the COVID-19 pandemic.

‘Defining moment’ for nursing: Joint Commission recognizes staffing as quality component

By Erica Cerutti – Starting in 2026, The Joint Commission will formally recognize nurse staffing as a national performance goal, meaning hospitals seeking accreditation must meet certain standards related to staffing and oversight. Under the new element of performance, known as Goal 12, healthcare organizations must have a nurse executive responsible for overseeing staffing policies and procedures. The goal stipulates that hospitals have a registered nurse on duty to either directly provide care or supervise nursing services provided by other staff 24/7. This marks the first time the organization has included nurse staffing as a core component of quality. Read Full Article...

HVBA Article Summary

1. Formal Recognition of Nurse Staffing: Starting in 2026, The Joint Commission will officially recognize nurse staffing as a national performance goal, requiring hospitals seeking accreditation to meet specific staffing and oversight standards. This new Goal 12 mandates that healthcare organizations appoint a nurse executive responsible for staffing policies and ensure a registered nurse is on duty 24/7 to provide or supervise nursing care. This is the first time nurse staffing is included as a core quality component by the organization.

2. Impact on Patient Safety and Care Quality: The American Nurses Association praised this move as a defining moment for the nursing profession, emphasizing that adequate nurse staffing is essential to prevent patient harm and improve outcomes. The inclusion of nurse staffing as a performance goal may also influence payers and policymakers in linking reimbursement to care quality, highlighting the importance of safe staffing levels in healthcare settings.

3. Ongoing Advocacy and Implementation: While this change marks significant progress, nursing leaders like Jennifer Mensik Kennedy, president of the ANA, stress the need for continued advocacy to have similar standards adopted by all accrediting bodies. The new standard will take effect on January 1, 2026, and aims to prioritize safe staffing as a top priority in hospitals nationwide.

Glucagon-Like Peptide-1 Receptor Agonist Order Fills and Out-of-Pocket Costs by Race, Ethnicity, and Indication

By Caroline E. Sloan, MD; Foster Goss, DO, MMSc; Anna D. Sinaiko, PhD, MPP – Prescribing of glucagon-like peptide-1 receptor agonists (GLP-1RAs) for diabetes and obesity has soared, yet patients report barriers accessing these medications.1 The impact of out-of-pocket (OOP) costs on access is concerning for patients in racial and ethnic minority groups, who have higher prevalence of these conditions, and can face racial disparities in GLP-1RA receipt,1- 3 and for patients with obesity alone, who can be excluded from insurance coverage.4 The 2024 average retail price of GLP-1RAs—paid by those without insurance—was more than $900 per month.5 Among patients with insurance, how often GLP-1RA orders are filled, the OOP cost per prescription, and differences by patient race and ethnicity or indication are unknown. Read Full Article...

HVBA Article Summary

1. Disparities in Order Fill Rates: The study found that 40% of GLP-1RA medication orders were not filled. Non-Hispanic Black and Hispanic patients were less likely to fill their prescriptions compared to non-Hispanic White patients, with fill rates of 55.3% and 58.4% versus 60.9%, respectively. This suggests racial and ethnic disparities in access to these medications despite similar prescribing rates.

2. Out-of-Pocket Costs Vary by Race and Indication: Among patients who filled their GLP-1RA prescriptions, non-Hispanic Black and Hispanic patients paid lower out-of-pocket costs than non-Hispanic White patients. Additionally, patients with obesity alone faced nearly double the out-of-pocket costs compared to those with diabetes, likely due to less comprehensive insurance coverage for obesity treatment. These cost differences may influence medication adherence and access.

3. Study Limitations and Policy Implications: The study was limited to a single health care system and could not determine reasons for nonadherence or cash purchases. The findings highlight the need for policymakers to explore strategies to improve equitable access to GLP-1RAs, especially given the high retail prices and insurance coverage gaps for obesity. Addressing these disparities is critical to ensuring all patients benefit from these effective treatments.

Employers underestimate employee vulnerability to medical bills

By Kristen Smithberg – Many employees across the U.S. remain highly vulnerable to financial shocks—particularly those tied to unexpected medical expenses—according to Section 3 of a new report from Aflac. While financial fragility continues to be a persistent issue in the workplace, the study revealed a significant disconnect: Many employers believe their workers are financially stable, despite evidence to the contrary. On average, employees said they would need to earn nearly $70,000 more per year to feel financially secure. Even high-income earners aren’t exempt—those already earning more reported needing an additional $87,000 annually to feel secure. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Significant Financial Vulnerability Among Employees: The report highlights that many employees are financially fragile, especially when facing unexpected medical expenses. For instance, 44% of employees said they couldn’t cover a $1,000 unexpected medical bill, and 19% said even a $500 medical expense not covered by insurance would be unaffordable. This financial vulnerability exists across income levels, indicating widespread stress related to healthcare costs.

2. Disconnect Between Employer Perceptions and Employee Realities: Despite evidence of financial fragility, over three-quarters of employers believe their employees are financially capable of handling medical costs. This perception gap suggests employers may underestimate the financial challenges their workforce faces, potentially leading to insufficient support or benefits offerings to address these needs.

3. Importance of Supplemental Benefits and Generational Differences: Supplemental insurance is seen as critical by employees, with 54% considering it a core part of benefits and 90% believing its importance is growing. However, only 34% of employers currently offer such options. Younger workers, especially Gen Z, experience higher anxiety about medical costs, though their financial resilience has improved somewhat since 2021. Additionally, Hispanic and African American workers are more likely to use voluntary benefits, which can help bridge healthcare and financial gaps in underserved communities.