Haunted Health: Beware the Ghost Networks This Halloween (And All Year Long)

By Joey Retting - This Halloween, as you prepare for haunted houses and spooky stories, let me tell you about a specter that doesn’t just lurk on October 31 – but instead every day of the year for far too many Americans. I’m talking about the ghost network lurking inside your health insurance plan. Read Full Article… 

HVBA Article Summary

1. Inaccuracy in Provider Directories: Many health insurance provider directories are outdated or inaccurate, with studies showing that a majority of listed mental health professionals are unavailable for appointments—only 18% in a Senate Finance Committee study and just 8% in a Seattle Times analysis.

2. Profit Motive Behind Ghost Networks: Health insurers profit from creating the illusion of a robust in-network provider base while providing little actual access to care. This leads patients to abandon their search or choose costly out-of-network options, resulting in lower claims costs for insurers as patients continue to struggle with mental health issues.

3. Need for Legislative Change: Recent legislation like the No Surprises Act aims to improve provider directory accuracy, but enforcement is weak. Proposed measures such as the Behavioral Health Network and Directory Improvement Act could enforce stricter standards. Additionally, increasing reimbursement rates for mental health providers may attract more professionals to networks, improving access to care and reducing ghost networks.

Survey: Employers fear rising health costs could force trade-offs with wages, salaries

By Paige Minemyer - Employers are concerned that rising healthcare costs could force them to rethink salary or wage increases, according to a new study. The National Alliance of Healthcare Purchaser Coalitions released its 2024 "Pulse of the Purchaser" survey, which polled 188 employers across multiple organizations. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Impact of Rising Healthcare Costs: Approximately 74% of surveyed individuals believe that increasing healthcare costs lead to trade-offs in wage or salary increases, with a significant portion (38%) expressing strong agreement. This cycle of rising costs is seen as unsustainable and detrimental to the economy, contributing to health inequity and job losses.

2. Concerns Over Healthcare Expenses: The survey identified prescription drug prices, high-cost claims, and hospital prices as the primary concerns for employers. Nearly all respondents (99%) view drug prices as a major threat to affordability, with substantial percentages also expressing concern over high-cost claims (84%) and hospital prices (79%).

3. Shifts in Pharmacy Benefit Management (PBM): More than half (52%) of employers are considering changing their pharmacy benefit manager within the next one to three years, seeking greater transparency and control over pricing and formulary options. Additionally, 94% want assurance that their benefits advisers are not influenced by PBM compensation, reflecting a push for more accountability in healthcare spending.care and reducing ghost networks.

‘You Almost Have to Be Doing It’: Why Scott Gottlieb Thinks All Doctors Will Use LLMs Soon

By Katie Adams - Large language models (LLMs) are poised to become a much bigger part of doctors’ clinical workflows, according to Scott Gottlieb, who served as commissioner of the FDA during the Trump administration. Read Full Article… 

HVBA Article Summary

1. Performance of LLMs on Medical Exams: A recent study assessed the accuracy of five LLMs, with OpenAI’s ChatGPT-4o achieving an impressive 98% accuracy on challenging U.S. Medical Licensing Examination questions, significantly surpassing the passing score requirement of 60%. This highlights the potential of LLMs as valuable tools for medical professionals.

2. Challenges in Integration: Despite the promising capabilities of LLMs in clinical decision support, their widespread adoption in healthcare settings is hindered by a lack of HIPAA-compliant options and the need for health systems to develop or customize their own models. Gottlieb emphasizes that most physicians currently do not utilize these technologies due to accessibility issues.

3. Future Potential and Research: Gottlieb is optimistic about the future role of LLMs in healthcare, noting ongoing research that demonstrates ChatGPT-4o's ability to achieve 100% accuracy on clinical vignettes from the New England Journal of Medicine. He advocates for the integration of LLMs into clinical practice, particularly for complex cases, suggesting that they could enhance diagnostic processes and support medical professionals in their decision-making.

5 strategies to support employees throughout their cancer journey

By Mark Stadler - Large U.S. employers are shifting their employee benefits priorities for next year to control rising health care costs, which are expected to jump nearly 8% in 2025, according to a recent survey by the Business Group on Health. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Rising Cancer Diagnoses and Employer Challenges: Cancer is the leading condition driving healthcare costs, with 72% of employers noting increased prevalence among employees and families. The global rise in early-onset cancer diagnoses highlights the need for employers to enhance cancer benefits to support employees effectively while managing costs.

2. Comprehensive Support Across the Care Journey: Effective cancer support programs should address the entire care spectrum, from early diagnosis to post-treatment recovery. Employers need to provide resources that assist employees in navigating medical and emotional challenges, including returning to work after a diagnosis.

3. Targeted Interventions and Integration with Existing Benefits: Employers can lower costs and improve care by targeting high-cost cases and leveraging data for early intervention. Integrating cancer support with existing benefits is essential; clear communication during open enrollment and prompt resource connection can enhance employee engagement and experience in managing their care.

‘Dreamers’ Can Enroll in ACA Plans This Year — But a Court Challenge Could Get in the Way

By Julie Appleby - When open enrollment for the Affordable Care Act, or Obamacare, starts nationwide this week, a group that had previously been barred from signing up will be eligible for the first time: The “Dreamers.” Read Full Article…

HVBA Article Summary

1. DACA Enrollment in Obamacare: Under a new rule by the Biden administration, Deferred Action for Childhood Arrivals (DACA) recipients can enroll in Obamacare and potentially receive premium subsidies, with an estimated 100,000 previously uninsured individuals expected to sign up starting November 1.

2. Legal Challenges: The rule is facing legal challenges from Kansas and 18 other states, which argue it will impose administrative burdens and encourage unauthorized immigration. A federal court hearing is set, with potential rulings affecting the rule's implementation before open enrollment begins.

3. Implications of the Ruling: The outcome of the legal case could either delay the rule's implementation or allow it to proceed. A judge's decision may also vary in its application, impacting either just the states involved in the challenge or potentially setting a nationwide precedent.

AMA panel changes major reporting requirement for remote monitoring, removing barriers for the industry

By Emma Beavins - The American Medical Association’s (AMA's) CPT Editorial Panel has removed the requirement for a patient to transmit 16 days’ worth of data for providers to bill remote physiologic monitoring codes, effective January 2026, a public document (PDF) says. Read Full Article…

HVBA Article Summary

1. Revised Billing Requirements: The AMA's CPT Editorial Panel has removed the previous requirement for patients to submit data for at least 16 days in a 30-day period to qualify for billing remote patient monitoring (RPM) services. This change addresses the industry's concerns that the 16-day threshold was unrealistic and hindered reimbursement for services.

2. Concerns About Billing Fraud: The Department of Health and Human Services Office of Inspector General (HHS OIG) has raised alarms regarding potential billing fraud in RPM, highlighting that many patients do not receive the comprehensive monitoring intended. Approximately 43% of enrollees did not receive all three components of the monitoring, prompting questions about the effectiveness and intent of RPM services.

3. Future Adjustments to Reimbursement: The AMA’s valuation committee (RUC) is set to reconsider the pricing for RPM codes in January 2025. Experts anticipate that reimbursement for data submitted for less than 16 days may be lower than the current rates, reflecting the ongoing adjustments in the remote monitoring billing landscape.

Healthcare history: How U.S. health coverage got this bad

By Evan Zimmer - In the U.S. healthcare system, even the simplest act, like booking an appointment with your primary care physician, may feel intimidating. As you wade through intake forms and insurance statements, and research out-of-network coverage, you might wonder, "When did U.S. health care get so confusing?" Read Full Article…

HVBA Article Summary

1. Historical Context and Evolution: The U.S. healthcare system has significantly changed over the past century, from 1930s hospital-based health plans to key legislation like Medicare and Medicaid in 1965, and the Affordable Care Act (ACA) in 2010. These developments reflect responses to societal needs and illustrate the complexity of healthcare's integration with social policies.

2. Impact of the Affordable Care Act: The ACA transformed healthcare access by requiring all Americans to have insurance, creating marketplaces, and imposing penalties on employers without adequate coverage. This law aimed to make coverage more accessible and affordable for a more mobile workforce.

3. Emergence of Individual Coverage Health Reimbursement Arrangements (ICHRAs): Introduced in 2019, ICHRAs allow employers to reimburse employees for individual health insurance premiums tax-free. This approach promotes portability in an evolving job market, democratizing access to healthcare and fostering competition among insurers for better, more tailored plans.