FTC, DOJ finalize merger guidelines that could impede healthcare M&A

By Rebecca Pifer - The DOJ and FTC received more than 30,000 public comments on the proposed guidelines, with some healthcare industry groups urging the agencies to retain old guidance that was more favorable to industry tie-ups. Read Full Article…

VBA Article Summary

1. Stricter Mergers and Acquisitions Guidelines: The Federal Trade Commission (FTC) and the Department of Justice (DOJ) have finalized more stringent guidelines for mergers and acquisitions, particularly impacting the healthcare sector. These guidelines provide a framework for review but are not legally binding. Despite being similar to the draft guidelines released in July, these updated guidelines reflect a significant shift in antitrust scrutiny and are expected to make healthcare deals more challenging to close.

2. Updated Guidance Reflecting Market Evolution: The new merger guidelines, which hadn't been significantly updated for over a decade, now better align with the evolving deal structures and market forces. This is particularly relevant in the healthcare industry, where consolidation has been linked to increased medical costs. The guidelines address concerns raised during the comment period and modify some language without materially altering the agencies' approach to mergers. They also incorporate more recent court cases, including the FTC's victory against Illumina, to support their theories on vertical and cross-market mergers.

3. Implications for Healthcare Mergers: The updated guidelines are more critical of mergers and provide regulators with stronger tools to challenge vertical and cross-market deals, which were historically hard to contest. This includes heightened scrutiny of private equity roll-ups. While the guidance lacks specific details about permissible M&A activities, it suggests that a broader range of mergers could now be viewed as anticompetitive. This could lead to increased caution among healthcare companies pursuing various deals and potentially benefit large market players like UnitedHealth and CVS by preventing their rivals from growing through mergers and acquisitions.

White House touts record-breaking ObamaCare enrollment

By Nathaniel Weixel - The White House on Wednesday touted the record-breaking numbers of people signing up for health insurance plans through the Affordable Care Act’s exchanges, with almost a month left in open enrollment. Read Full Article…

VBA Article Summary

1. Record Enrollment and Projected Increase: Over 15 million people have enrolled in health insurance plans, marking a 33% increase from the previous year. The U.S. administration anticipates this number to rise to over 19 million by the January 16 deadline, representing a significant growth of 7 million since President Biden's inauguration.

2. Historical Significance and Policy Impact: December 15 saw the highest single-day enrollment in HealthCare.gov’s history, with over 745,000 people selecting plans. President Biden attributes these numbers to his administration's policies, which he claims have saved Americans significant amounts on their insurance premiums. He criticizes "extreme Republicans" for opposing these efforts and siding with interests that keep prescription drug prices high.

3. Strategic Focus in Presidential Campaign: The White House is positioning health care as a key issue for the 2024 presidential campaign, especially in light of former President Trump's recent comments about repealing ObamaCare. Biden is emphasizing his administration's efforts to reduce health care costs, expand coverage, and confront the pharmaceutical industry, setting a clear contrast with Trump's approach. The enrollment period for HealthCare.gov has been extended to January 16, 2024, due to a federal holiday, allowing more time for people to sign up for coverage starting February.

Medicare is about to add hundreds of thousands more mental health providers

By Maya Goldman - The largest expansion of Medicare's mental health services in a generation can provide a critical lifeline to America's seniors — if enough providers sign up. Read Full Article…

VBA Article Summary

1. Expansion of Medicare Coverage for Mental Health Providers: Starting January 1, marriage and family therapists and mental health counselors, comprising about 40% of the U.S. mental health workforce, can now accept Medicare payments. This change follows years of advocacy and comes at a time when the mental health crisis is significantly impacting seniors. Previously, these providers were inaccessible to Medicare enrollees who couldn't afford out-of-pocket payments.

2. Legislative and Social Context: The decision to include these mental health professionals in Medicare coverage marks the first expansion of mental health providers in the program since 1989. It was motivated in part by the COVID-19 pandemic highlighting the shortage of mental health professionals available to Medicare recipients. This move is seen as especially beneficial for rural areas and states with high concentrations of these professionals.

3. Implementation and Challenges: While this change is a significant step forward, there are concerns about the speed of its implementation and the level of provider participation. Only a small percentage of eligible providers have registered for Medicare payments so far, partly due to concerns over reimbursement rates and bureaucratic complexities. The article highlights the importance of this expansion in providing continuity of care for patients, especially seniors, who previously had to discontinue therapy or switch providers upon becoming Medicare enrollees.

Why the Senate HELP Committee is investigating how hospitals spend 340B money

By Maia Anderson - As the second-largest federal prescription drug program behind Medicare Part D, 340B has been at the center of numerous challenges over the past few years, from federal lawsuits to a Supreme Court ruling. Read Full Article…

VBA Article Summary

1. Investigation into the 340B Program: Senator Bill Cassidy, a key member of the Senate Health, Education, Labor, and Pensions Committee, has independently initiated an investigation into the 340B program. This program mandates that Medicaid-participating drug companies provide certain drugs at discounted prices to qualifying hospitals. The investigation stems from concerns over the lack of transparency regarding how hospitals utilize these profits, especially in light of reports that some 340B recipients have announced record-setting profits without clear evidence of patient benefits.

2. Hospitals' Use of 340B Savings: Hospitals participating in the 340B program, such as Richmond Community Hospital and Cleveland Clinic, have been specifically scrutinized in the investigation. These hospitals are required to use the savings from discounted drugs to support their operations and provide care, especially to underserved communities. However, there is a debate about whether these savings are being directly passed on to patients or used more broadly to finance hospital operations and services.

3. Drugmakers’ Perspective and Program Sustainability: The pharmaceutical industry, represented by groups like PhRMA, expresses concern that there's no assurance the 340B discounts reach the patients. They argue for a change in the program to ensure that hospitals share the discounts with patients based on income levels. The industry hopes for legislative changes to make the program sustainable and more focused on aiding vulnerable and underserved communities.

Key Facts about the Uninsured Population

By Jennifer Tolbert, Patrick Drake, and Anthony Damico- Throughout the coronavirus the pandemic, the coverage expansions put in place by the Affordable Care Act (ACA), including Medicaid expansion and subsidized Marketplace coverage, served as a safety net for people who lost jobs or faced other economic and coverage disruptions. Read Full Article…

VBA Article Summary

1. Significant Decrease in Uninsured Rates in 2022: The article highlights that in 2022, there was a notable decrease in the number of nonelderly uninsured individuals in the United States. This reduction, from 27.5 million in 2021 to 25.6 million in 2022, corresponds to a drop in the uninsured rate from 10.2% to 9.6%. This downward trend is attributed to pandemic-era policies such as continuous Medicaid enrollment and enhanced Marketplace subsidies, which have improved the affordability of private coverage and protected low-income individuals against coverage losses.

2. Characteristics and Challenges of the Uninsured Population: The article delves into the characteristics of the uninsured population, noting that most uninsured people belong to low-income families with at least one working member and that there are significant racial and ethnic disparities in coverage. A major barrier to insurance is the high cost, with 64% of uninsured nonelderly adults citing this as the primary reason for lacking coverage. The uninsured are more likely to delay or forgo medical care due to costs, and they often face substantial financial burdens when they do seek care.

3. Implications of Policy Changes and Coverage Trends: The article discusses the impact of policy changes on health coverage trends during the pandemic, with a focus on the American Community Survey's data from 2019 to 2022. It highlights the increase in Medicaid coverage and the role of the Affordable Care Act (ACA) in these trends. However, there are concerns about the potential reversal of these gains due to the end of the Medicaid continuous enrollment provision, which could lead to an increase in the uninsured rate and exacerbate disparities in health outcomes and access to care.

Mapping UnitedHealth’s consumption of our health care system – from the ‘70s to today

By Krista Brown and Sara Sirota - “Things changed after Optum took over.” That was the statement of a case manager with naviHealth, a technology company that used predictive algorithms to manage post-acute care for Medicare Advantage patients. The company sought to limit unnecessary hospital stays and minimize waste, a problem that has plagued the U.S. health care system for decades. Read Full Article…

VBA Article Summary

1. Transformation and Criticism of naviHealth: After being acquired by Optum, a subsidiary of UnitedHealth Group, naviHealth faced criticism for denying coverage to elderly patients against doctors' recommendations, leading to significant out-of-pocket expenses. Employees claimed they were pressured by UnitedHealth executives to deny coverage or risk losing their jobs. These actions resulted in a class-action lawsuit, marking a shift in naviHealth's focus from managing post-acute care to prioritizing profit maximization, a change referred to as being "UnitedHealth-ified."

2. UnitedHealth's Expansion and Market Dominance: Since the 1970s, UnitedHealth Group has grown by acquiring a vast array of companies in different sectors of the health care industry, including health insurers, pharmacy benefit managers, and medical data companies. This strategy has enabled UnitedHealth to gain substantial influence over which health care providers and medications are accessible to millions of Americans, along with determining their costs and coverage. The article outlines UnitedHealth's journey from its beginnings in the 1970s, highlighting its expansion and integration into nearly every aspect of the health care system.

3. Impact of UnitedHealth's Business Practices and Acquisitions: UnitedHealth's aggressive acquisition strategy, especially in the 2000s and 2010s, has raised concerns about the concentration of market power and potential conflicts of interest in the health care industry. The company has faced criticism for practices such as pushing high-deductible health plans and employing physicians directly, which some argue could lead to conflicts of interest. Despite regulatory scrutiny, UnitedHealth continues to expand its reach, acquiring key players in various health care sectors, further entrenching its dominance in the market. The article emphasizes the need for a nuanced analysis of UnitedHealth's practices to understand the broader implications of its market power and its impact on patients and the health care system.

Legislative and Grassroots Efforts Bring Price Transparency to Healthcare Consumers

By Cynthia A. Fisher & Ge Bai - On Monday, the House of Representatives passed the bipartisan Lower Costs, More Transparency Act, aimed at reining in the healthcare cost burden on patients, employers, unions, and workers. The legislation codifies and strengthens a hospital price transparency rule that took effect in January 2021, requiring hospitals to publish both their cash prices and negotiated prices with insurance plans. This move is a crucial step toward disclosing actual prices necessary to protect Americans from rampant hospital overpricing and empower them to find affordable care. Read Full Article…

VBA Article Summary

1. Introduction of Hospital Price Files Finder: PatientRightsAdvocate.org has launched the Hospital Price Files Finder, a comprehensive dashboard that aggregates price disclosures from over 6,000 U.S. hospitals. This tool standardizes hospital price files into a user-friendly spreadsheet format, enhancing accessibility and enabling users to compare healthcare prices effectively. It aims to address issues of billing fraud and errors, and helps users to audit healthcare bills efficiently.

2. Impact on Employers and Economic Benefits: The dashboard is particularly beneficial for employers, who provide health coverage for nearly 160 million Americans. It facilitates informed decision-making in benefit design, helping to control health plan costs that have been escalating and affecting workers' wages. Employers and unions can use the dashboard to select affordable care options, potentially leading to higher wages and lower premiums for workers, thus stimulating the economy and addressing the rising cost of living.

3. Advancing Price Transparency and Compliance: The Hospital Price Files Finder also supports government agencies in enforcing price transparency regulations. While compliance among hospitals is currently limited, the tool makes it easier to identify and address non-compliance. Increased price transparency can protect patients from overcharging and medical debt, encouraging competition and potentially leading to lower healthcare costs. The development of this tool signifies a movement towards greater accountability and integrity in the U.S. healthcare system.

Most doctors have not yet tried AI but are 'cautiously optimistic' about the benefits

By Heather Landi - The hype around healthcare artificial intelligence has reached a fever pitch, but most doctors are holding back from trying it out in their medical practice, for now. Read Full Article…

VBA Article Summary

1. Low Adoption Rate of AI-Powered Medical Scribe Solutions: A recent survey by Elation Health has revealed that 67% of primary care physicians have not yet tried AI-powered medical scribe solutions. Instead, they are relying on electronic health record (EHR) vendors to guide them towards options that seamlessly integrate with their existing systems.

2. Obstacles to Adoption: Among the physicians who have not adopted AI scribe tools, key obstacles include concerns about accuracy, lack of integration with existing tools, and the time required for researching options. These issues have hindered the widespread adoption of AI-based solutions in medical practice.

3. Physician Expectations and Optimism: Physicians who have not yet tried AI scribe tools are optimistic about the potential benefits. The survey shows that they anticipate reduced documentation burden, improved quality of documentation, reduced cognitive burden, and enhanced job satisfaction. Additionally, they expect AI tools to improve patient focus and allow more time for care coordination.

Lower Income Adults with Employer Sponsored Insurance Face Unique Challenges with Coverage Compared to Higher Income Adults

By Rayna Wallace, Kaye Pestaina, Gary Clayton, and Matthew Rae - The KFF Consumer Survey assessed consumers’ experiences with their health insurance coverage, their understanding of their coverage, problems they may face with their insurance, and if they believe that their insurance coverage is adequately meeting their needs. Read Full Article…

VBA Article Summary

1. Financial Burdens and Health Care Access for Lower Income Adults with Employer-Sponsored Insurance (ESI): Lower income adults with ESI are more likely to experience financial difficulties in paying for medical bills, leading to delayed treatment and a decline in health due to insurance problems. While they report similar rates of insurance issues as higher income adults, their outcomes are more severe, indicating a significant disparity in health care access and affordability.

2. Provider Availability and Quality Concerns: Lower income adults with ESI are more likely to rate the availability and quality of network providers as fair or poor. This group also faces more challenges in signing up for coverage and comparing plan options, which exacerbates their difficulties in accessing adequate health care services. These challenges reflect broader systemic issues in the health insurance landscape, particularly for those with limited financial resources.

3. Impact on Behavioral Health Services and Overall Health Outcomes: Lower income adults with ESI encounter more problems in accessing timely and quality behavioral health services compared to higher income adults. These challenges contribute to worse health outcomes and increased medical debt. The difficulties in navigating insurance options, combined with the financial barriers to accessing care, highlight the need for more robust support systems and policy interventions to improve health equity.

Hidden hospital prices harm patients: Can this new pricing tool make a difference?

By Ken Alltucker - The day before she underwent surgery to remove an ovary, Laurie Cook drove to a Nashville hospital for a written estimate of how much its operation would cost. Read Full Article…

VBA Article Summary

1. Unexpected Medical Bill Shock: Laurie Cook, an elementary school teacher and mother of two from Nashville, Tennessee, experienced a shocking discrepancy in medical billing. Despite receiving an initial estimate of $5,535 for her surgery, which included the surgeon’s fee, operating room charges, nursing services, medications, lab tests, and other expenses, she later received a bill amounting to $61,314. This unexpected bill was over 11 times higher than the estimate, causing significant financial strain, as her insurance plan required a $12,000 out-of-pocket payment before coverage began.

2. Lack of Hospital Billing Transparency: Cook’s case highlights the notorious lack of transparency in healthcare pricing. Despite her efforts to understand the costs upfront and budget accordingly, she faced an astronomical charge. Her request for a detailed breakdown and an audit of the bill from the hospital remains unaddressed. This situation underscores the challenges patients face in navigating complex and often opaque medical billing systems.

3. Federal Law for Price Transparency: The incident with Cook sheds light on the importance of the federal hospital price transparency law that was implemented in 2021. This legislation mandates hospitals to publicly disclose cash prices and rates negotiated with health insurers for a wide range of procedures in a format that is easily accessible and analyzable. The law aims to prevent surprise medical charges like those experienced by Cook, empowering consumers to avoid unexpectedly large bills through better-informed decision-making.