Hospital sues data analytics company MultiPlan in US court antitrust case

By Mike Scarcella - Nonprofit hospital system AdventHealth has sued data analytics company MultiPlan (MPLN.N) in U.S. court, accusing it of leading a price-fixing conspiracy that underpaid healthcare providers billions of dollars for out-of-network reimbursements from major insurers. Florida-based AdventHealth, which operates 50 hospitals across the U.S. and says it is the country's largest Protestant hospital system, filed its antitrust lawsuit in Manhattan federal court on Wednesday against MultiPlan, the lone defendant. Read Full Article…

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1. Allegations Against MultiPlan: AdventHealth alleges that MultiPlan, a New York-based cost-management technology provider, uses pricing tools to suppress out-of-network reimbursements to healthcare providers. The lawsuit claims that MultiPlan acquires real-time, confidential pricing information from member healthcare insurers to set reimbursement prices. It is argued that healthcare providers, like AdventHealth, are presented with a "take-it-or-leave-it" offer for reimbursements, resulting in annual alleged underpayments totaling $19 billion.

2. Financial Details and Scope: MultiPlan reported revenues of $1.07 billion in the prior year and $1.11 billion in 2021. In a recent financial report, MultiPlan disclosed processing about $43 billion in claim charges in the second quarter, identifying potential medical cost savings of roughly $5.7 billion.

3. Other Insurers' Involvement: The lawsuit asserts that major insurers such as CVS Health subsidiary Aetna, Cigna, UnitedHealth, and Humana have colluded with MultiPlan to reduce out-of-network reimbursements. Neither AdventHealth representatives nor those from Aetna, Cigna, UnitedHealth, and Humana immediately responded to requests for comments. AdventHealth seeks unspecified monetary damages for their alleged significant economic losses due to underpayments.

House Democrats unveil new legislation that expands the Inflation Reduction Act

By Cyrus Fan - This article is produced as part of GlobalData’s Price Intelligence (POLI) service, the world’s leading resource for global pharmaceutical pricing, HTA and market access intelligence integrated with the broader epidemiology, disease, clinical trials and manufacturing expertise of GlobalData’s Pharmaceutical Intelligence Center. Our unparalleled team of in-house experts monitor P&R policy developments, outcomes and data analytics around the world every day to give our clients the edge by providing critical early warning signals and insights. For a demo or further information, please contact us here. Read Full Article…

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1. Background and New Developments:

   Existing Landscape: The Inflation Reduction Act, passed last summer, was a significant step towards lowering prescription drug prices in the US, particularly for those covered by Medicare. This landmark legislation allowed the US government to negotiate drug prices and imposed rebates on pharmaceutical companies that raised prices above the rate of inflation. The outcome has been hailed as a success, offering considerable savings for Medicare and the general US populace.
   The New Proposal: In July, the Lower Drug Costs for American Families Act was introduced by Democratic House members Frank Pallone Jr., Richard Neal, and Robert Scott. This act seeks to build on the successes of the Inflation Reduction Act. Specifically, it aims to:
   - Extend drug price negotiations to Americans with private health coverage.
   - Apply inflationary rebates to this broader group.
   - Double the number of drugs under negotiation from 20 to 50.
   Projected Impact: If the bill is passed, it could benefit around 164 million Americans with private health insurance and 26 million with marketplace coverage. Furthermore, the expansion of inflationary rebates could result in savings of $40 billion over a decade.

2. Resistance from the Pharmaceutical Industry:

   Immediate Backlash: The proposal has been met with fierce opposition from pharmaceutical giants. Industry group PhRMA claims that the bill grants the US government excessive control over the healthcare system, including in the private market. They argue that this will limit access to treatments and curtail research and development endeavors.

   Economic Ramifications: In response to the Inflation Reduction Act, some pharmaceutical companies have culled drugs from their development pipelines, anticipating decreased profitability. The opposition to the new legislation isn't surprising since many in the industry are already embroiled in legal disputes against the Inflation Reduction Act, alleging constitutional breaches.

3. Looking Forward – Political and Industry Dynamics:

   Government Stance: Despite the backlash and lawsuits from the pharmaceutical sector, the US Government remains steadfast in its mission to further reduce drug prices.

   Potential Hurdles: The path to the bill's enactment is rife with challenges, especially given the Republican majority in the House. Historically, the Republican party opposed the Inflation Reduction Act, and it is anticipated they will adopt a similar stance against this new proposal.

   Implications: A successful enactment of legislation expanding the Inflation Reduction Act could herald a transformative change in US drug pricing. The dynamics between the government's drive to cut costs and the pharmaceutical industry's efforts to safeguard its interests will significantly shape the landscape of healthcare in the US.

74% of Medicare Beneficiaries Concerned About Medicare’s Long-term Sustainability

By Marissa Plescia - A majority of current Medicare beneficiaries, or 74%, are worried about the Medicare program’s long-term sustainability, a new survey shows. The survey was published by eHealth, an online marketplace for health insurance. It was conducted in June and included responses from 3,582 Medicare beneficiaries. The report comes after the Medicare Board of Trustees predicted that funding for Medicare Part A will not be able to cover benefits by 2031. Read Full Article…

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1. Levels of Concern

   • Worry about Sustainability: 20% of Medicare beneficiaries are very worried about Medicare's long-term sustainability, 54% are somewhat worried, and 25% are not worried. This concern spans across political lines, with 74% of Republicans and 76% of Democrats expressing worry. Income levels, however, demonstrate a significant variance, as only 25% of individuals with incomes less than $25,000 express concern, in contrast to 12% of those earning more than $100,000 annually.

   • Worry about Changes: Concerning potential increases in Medicare costs or reduction in benefits, 35% of beneficiaries are very worried, 50% somewhat worried, and 15% are not worried at all. The concern intensifies for those with lower incomes—46% of those earning below $25,000 are very worried, as opposed to 18% of those earning above $100,000.

   • Entitlement and Future Changes: A staggering 97% of respondents feel entitled to Medicare benefits after having paid into the system. However, 84% believe modifications will be crucial to ensure the program's future existence. Interestingly, when asked about potential sacrifices, almost 60% said they wouldn’t accept increased costs or changes to benefits.

2. Suggested Solutions for Medicare’s Future: When considering measures to safeguard the future of Medicare, opinions varied:
   - 47% advocate for an increase in payroll contributions.
   - 21% suggest raising the age for Medicare eligibility.
   - 7% propose an increase in premiums.
   - 4% believe in increasing out-of-pocket expenses.
   - 3% would agree to a reduction in benefits.
   - Conversely, 40% feel that none of these solutions are acceptable.
   

3. Perception of Government’s Role: Grading Government Efforts: Beneficiaries' grades for the government's efforts in securing Medicare's future are mixed:
   - 5% would award an A.
   - 15% would give a B.
   - 36% are at a C level.
   - 23% believe it deserves a D.
   - 21% would give the government an F.
   
   It's noteworthy that Democrat voters are more inclined to assign a higher letter grade than their Republican counterparts.
   
   eHealth CEO Fran Soistman emphasized the beneficiaries' justified sense of entitlement, given their contribution over the years. However, he also highlighted the inherent challenges for policymakers attempting to address the program’s future.

How Organizations Can Address Burnout

By Dayna Lee-Baggley Ph.D. - Burnout first became a classified condition with the publication of ICD-11. It is not listed as a medical diagnosis but as a workplace phenomenon. The WHO emphasizes that burnout is not a problem in the individual that needs to be fixed, but rather the consequence of chronic workplace stress that is not well managed. Read Full Article…

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1. Importance of a Baseline for Change: Before instituting organizational change, it's vital to establish a starting point, known as a baseline. A Plan Do Check Act (PDCA) approach ensures that changes are backed by data, allowing organizations to measure their efforts. The Workplace Psychological Safety Assessment (WPSA) is an evidence-based tool introduced to bridge the gap in available tools for workplaces. This assessment provides organizations with data on various areas including psychological safety, inclusion, health and safety risks, stigma, and organizational programs' awareness and impact, among others. This baseline is essential to understand what changes are needed and later measure if these changes are effective.

2. Approaching Organizational Change: Organizations should prioritize addressing simpler problems first. This approach not only boosts the confidence of those making the change but also helps in gaining trust from the employees as they witness actual efforts being made to solve issues. Implementing changes varies among organizations, but they can lean on guidelines like the CAN/CSA-Z1003 or ISO 45003 to guide them. Another key aspect of change is investing in training leaders and managers. Leaders play a pivotal role in shaping employees' experiences. Proper training, particularly in psychological safety and trauma-informed workplaces, can make a significant difference in today's modern workplace dynamics.

3. Continuous Evaluation and Iteration: Organizational change isn't a one-off process. After implementing changes, it's essential to reassess using tools like the WPSA to ensure the interventions are effective. This reflects the 'check' and 'act' steps of the PDCA model, emphasizing the iterative nature of effective organizational change.

Hub discloses data breach

By Gavin Souter - Hub International Ltd. said Friday that it was hit by a cyber breach late last year, and sensitive data related to some of its employees and customers was accessed. The brokerage said it isolated the affected systems when it became aware of the breach on Jan. 17, started a forensic investigation and began its notification process after it completed its initial data review last month. Read Full Article…

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1. Details of the Breach: An unauthorized individual accessed parts of Hub's website and copied files from December 2022 to January 2023. The breached data pertains to both current and former employees, policyholders, and individuals associated with insurance carriers and employers working with Hub. While the impact was majorly on its U.S. operations, a few Canadians were also affected. The compromised data includes sensitive personal and financial details ranging from Social Security numbers to health and medical information.

2. Hub's Response: The investigation into the breach is still underway. Hub has taken measures to boost its security in the wake of this incident. To support the affected individuals, the company is providing credit monitoring services and has set up a dedicated call center for queries and assistance related to the breach.

3. Context of Insurance Industry Breaches: Hub isn't the first insurance broker to face cybersecurity challenges. The industry has seen a string of cyber-attacks in the past few years, with major firms such as Aon, Ryan Specialty LLC, Marsh, and Arthur J. Gallagher & Co. falling victim to breaches and attacks, highlighting the pressing need for enhanced cybersecurity measures in the sector.

'Like a mafia enforcer for insurers:' AdventHealth sues MultiPlan for alleged price fixing

By Andrew Cass - Altamonte Springs, Fla.-based AdventHealth is suing MultiPlan for an alleged ongoing conspiracy among commercial health insurers to reduce the reimbursement rates they pay to providers for out-of-network services. Read Full Article…

VBA Article Summary

1. Major Allegation: AdventHealth has filed a lawsuit against MultiPlan in New York federal court, claiming that MultiPlan's horizontal repricing agreement with nearly all significant health insurance payers has resulted in an annual underpayment of $19 billion to providers. The affected payers mentioned are UnitedHealth, Health Care Service Corp., Cigna, Centene, Elevance, and Aetna. Furthermore, it's alleged that MultiPlan benefits by taking a percentage of the withheld funds from these providers.

2. Characterization of MultiPlan's Activities: The lawsuit describes MultiPlan's behavior as acting "like a mafia enforcer for insurers". This characterization is based on MultiPlan's widespread agreements with almost every commercial healthcare payor. Due to these agreements, healthcare providers have little choice but to accept the reduced reimbursement rate set by MultiPlan.

3. Demands and MultiPlan's Response: AdventHealth is not only seeking financial compensation for underpayments, lost profits, revenues, and other economic damages but also a permanent injunction to stop the operations of what they term the "MultiPlan Cartel." Despite the allegations, MultiPlan has responded saying they believe the lawsuit lacks merit and they are keen to disprove the baseless claims.

U.S. Insurance Third Party Administrator Market 2023 New Highs - Current Trends and Growth Drivers

By Allied Analytics LLP - According to the report published by Allied Market Research, the U.S. Insurance Third Party Administrator Industry generated $156.08 million in 2020, and is projected to reach $243.26 million by 2030, witnessing a CAGR of 4.6% from 2021 to 2030. The report provides a detailed analysis of changing market dynamics, top segments, value chain, key investment pockets, regional scenario, and competitive landscape. Read Full Article… 

VBA Article Summary

1. Market Drivers and Restraints: The growth of the U.S. Insurance Third Party Administrator market is propelled by the increasing adoption of third-party administration services in health insurance, as well as the growing need for operational efficiency and transparency in the insurance business process. However, this growth is hampered by concerns over security and privacy. Notwithstanding the challenges, there are fresh prospects on the horizon due to advancements in third-party administrator services.

2. Impact of COVID-19: The COVID-19 pandemic positively influenced the market due to the rising trend of digital transformation in insurance and a spike in demand for cloud-hosted or managed third-party administrator solutions. Insurance companies, faced with a high volume of claims, began investing more heavily in third-party administrator services during the pandemic.

3. Key Findings from the Market Analysis:
   Enterprise Type: Large enterprises dominated the market in 2020, holding about two-thirds of the total share. However, Small and Medium Enterprises (SMEs) are projected to grow at a CAGR of 5.6% from 2021 to 2030.
   End User: Life & health insurance was the prominent segment in 2020, holding close to three-fifths of the market. This segment is also forecasted to grow at a CAGR of 5.0% from 2021 to 2030.
   Service Type: Claims management was the leading segment in 2020, but the policy management segment is projected to grow at a CAGR of 7.5% from 2021 to 2030.

Major market players include Charles Taylor, CORVEL, CRAWFORD & COMPANY, and others.

Employers Think They’re Providing Great Benefits. Employees Disagree. What’s the Problem?

By Kathryn Mayer - ​As a myriad of challenges plague employees—from financial stress to mental health issues—it's no wonder workers are looking for more help from their employers. Many employers have answered the call by rolling out or enhancing their benefits offerings. Or, at least, so they think. According to a recent Aflac report, there is a 22 percentage-point gap between employers' perceptions of employee satisfaction with benefits and employees' self-reported satisfaction. Read Full Article… 

VBA Article Summary

1. Disconnect Between Employers and Employees on Benefits: There's a widening gap between how employers and employees view benefits. In 2022-2023, this gap has increased substantially, with a difference of more than 14 percentage points from the previous year. Employers believe they are offering excellent benefits at reasonable prices and are effective in communicating these benefits. In contrast, more employees disagree with these notions. Matthew Owenby, the chief human resources officer at Aflac, mentions that the key issues contributing to this disconnect are rising health care costs, wellness challenges, and inadequate communication between employers and employees.

2. Wellness, Mental Health, and Financial Strains: Employee well-being is an increasing concern, with many employees experiencing financial stress and mental health issues. There has been a notable rise in anxiety and depression among the workforce, exacerbated by societal upheavals and the pandemic. Financial struggles significantly impact an individual's daily life, leading to compounded stress. There's a direct relationship between an employee's overall mental wellness and their engagement, satisfaction, and productivity. Aflac has taken steps to address these concerns, like bringing in financial advisors to educate employees on financial basics and providing mental health professionals on-site.

3. The Importance of Ongoing Communication and Creating a Supportive Environment: Owenby stresses the need for employers to communicate about benefits and related issues throughout the year and not just during annual enrollment. Effective communication is crucial for transparency and understanding, especially as costs rise. Employers have an obligation to support their employees, both in terms of physical and mental well-being. Even if they can't provide specific benefits, they can still connect employees with the necessary resources. HR leaders need to foster a work environment where employees feel comfortable discussing their mental health and financial problems. Owenby advises HR professionals to be open and provide outlets for employees to discuss these sensitive issues, emphasizing that such problems typically don't improve on their own.