The AMA Debates a Federal Ban on Corporate Medicine

By Maureen Tkacik - The American Medical Association has been considering a resolution to seek a federal ban on the corporate practice of medicine at its interim House of Delegates meeting that concludes on Tuesday. Read Full Article…

VBA Article Summary

1. Resolution Against Corporate Medicine: A resolution challenging the influence of corporate medicine, particularly by Wall Street investment firms, was nearly excluded from consideration at a recent meeting. The resolution, spearheaded by Florida emergency physician Dr. Vicki Norton and backed by the grassroots physician group Take Medicine Back, highlights the growing concern over private equity's role in the medical sector. New Jersey radiologist Christopher Gribbin passionately advocated for the resolution, emphasizing the negative impact of private equity on physician autonomy and patient care.

2. Support and Opposition: Despite initial doubts about its consideration, the resolution gained unexpected support among physicians, indicating a growing resistance to corporate medicine. However, some opposition exists, primarily on procedural grounds, arguing that corporate practice of medicine issues are traditionally governed at the state level. Health law scholars, however, have advised that federal regulation is both possible and precedent, encouraging a focus on the substantive merits of the resolution.

3. AMA's Role and Corporate Practice of Medicine Laws: The American Medical Association (AMA), once a powerful influence in opposing government involvement in healthcare, has seen a decline in its influence. This shift presents an opportunity for physicians advocating against corporate intrusion in medicine. The article highlights the historical and current perspectives on laws prohibiting corporate practice of medicine (CPOM), noting the mixed enforcement record of these laws and the recent shift in opinion by antitrust authorities and health policy experts, who now view CPOM laws as potentially beneficial in combating the negative effects of financialization in healthcare.

UnitedHealthcare hit with class action over alleged use of AI to deny Medicare Advantage claims

By Paige Minemyer - UnitedHealthcare is facing a potential class-action lawsuit following allegations that it used an algorithm to deny claims for post-acute care services in Medicare Advantage (MA). Read Full Article…

VBA Article Summary

1. Class Action Lawsuit Against UnitedHealth: The lawsuit, filed by families of deceased Medicare Advantage members, accuses UnitedHealth of "illegally" using the naviHealth platform to deny necessary care to seniors, alleging a "90% error rate" in the technology. Despite the high error rate, the company reportedly continued using the technology, with less than 1% of members typically appealing denied claims. The plaintiffs argue that UnitedHealth relies on patients' inability to appeal decisions influenced by the AI tool.

2. Investigative Report and UnitedHealth's Defense: Following a Stat investigative report highlighting pressure on UnitedHealthcare employees to use naviHealth to cut costs, UnitedHealth responded by stating that naviHealth is not used for coverage decisions but as a guide for post-acute care. The company asserts that coverage decisions are based on CMS criteria and member plan terms, dismissing the lawsuit as meritless.

3. Allegations of Misuse of AI and Broader Implications: The lawsuit claims naviHealth's predictions often override physicians' determinations, leading to increased denials of post-acute care claims and financial strain on elderly patients and their families. This case adds to growing scrutiny over insurers' use of AI and algorithms in decision-making, as exemplified by similar lawsuits against Cigna regarding its PxDx tool, which also faced allegations of systematic claim denials.

Facing Financial Ruin as Costs Soar for Elder Care

By Reed Abelson, The New York Times and Jordan Rau - Margaret Newcomb, 69, a retired French teacher, is desperately trying to protect her retirement savings by caring for her 82-year-old husband, who has severe dementia, at home in Seattle. She used to fear his disease-induced paranoia, but now he’s so frail and confused that he wanders away with no idea of how to find his way home. He gets lost so often that she attaches a tag to his shoelace with her phone number. Read Full Article…

VBA Article Summary

1. Financial Strain of Caregiving: Feylyn Lewis, 35, and Sheila Littleton, 30, illustrate the severe financial and personal sacrifices made by individuals who become caregivers for their family members. Lewis, returning from England to Nashville, incurred significant debt to care for her mother who suffered a stroke. Littleton, from Houston, struggled with the complex system of Medicaid coverage for her dementia-afflicted grandfather, ultimately leaving him at a psychiatric hospital to ensure care.

2. Growing Elderly Population and Inadequate Long-Term Care Infrastructure: The article highlights the challenges faced by the rapidly aging boomer generation and the inadequacies in the U.S. long-term care system. With millions of older Americans and their families grappling with soaring costs of care and the financial burden of long-term care, the U.S. faces a crisis. The private long-term care insurance market is shrinking, and families are struggling to find affordable care options. This situation is exacerbated by the projected increase in the elderly population, which is expected to rise significantly by 2050.

3. Government Policies and the Burden of Dementia Care: The article discusses the limitations of government programs like Medicare and Medicaid in addressing long-term care needs. Medicare covers limited short-term care, while Medicaid requires individuals to deplete their assets before offering aid, often leaving families with a financial burden. The article also sheds light on the high costs of assisted living and in-home care, particularly for dementia patients, placing an immense financial strain on families and highlighting the need for a comprehensive long-term care system in the U.S.

Boom in weight-loss drugs to drive up US employers' medical costs in 2024 - Mercer

By Leroy Leo and Khushi Mandowara - Booming demand for newer weight-loss and diabetes drugs is expected to accelerate the rise in medical expenses for employers in the United States next year, staff health benefits consultant Mercer said. Read Full Article…

VBA Article Summary

1. Impact of GLP-1 Medications on Employer Healthcare Costs: Mercer's Chief Health Actuary, Sunit Patel, indicated that GLP-1 medications, approved by the U.S. FDA, could add 50-100 basis points to rising employer healthcare costs. The overall costs for U.S. employers are expected to increase by an average of 5.2% next year, as per Mercer's survey. The increased use of GLP-1 drugs, priced at around $1,000 per patient per month, has significantly driven up pharmacy benefit costs, which rose 8.4% in 2023 compared to 6.4% in 2022.

2. Market Expansion and Coverage Debate: The approval of Eli Lilly's weight-loss treatment Zepbound marks a major addition to the market, with predictions of generating $100 billion in annual sales by the decade's end. While GLP-1 drugs are covered for diabetes treatment, there's ongoing debate about covering them for obesity. Approximately 40% of large employers currently cover these drugs for obesity treatment, and 19% are considering it.

3. Employer Strategies and Future Trends: Despite the uptick in healthcare costs, large employers have refrained from passing these costs to employees through higher deductibles or co-pays in 2023. The average insurance premium deductible rose marginally, and employees' share in overall healthcare costs remained steady at 22%. Looking ahead, companies might maintain similar cost-sharing levels in 2024, exploring options like offering multiple plans and encouraging participation in more cost-effective ones. Mercer also forecasts continued healthcare cost growth outpacing general inflation in the coming years.

PBM reform is on, as Senate advances new bill that forces pharmacies to report costs

By Alan Goforth - ​In a rare unanimous, bipartisan vote, the Senate Finance Committee on Wednesday passed a bill that would rein in pharmacy benefit managers – and create a list of discounted drugs with high rebates in Medicare Part D, as well as address several other health-care issues. Read Full Article…

VBA Article Summary

1. Legislative Overview: The Better Mental Health Care, Lower-Cost Drugs and Extenders Act, coupled with the Modernizing and Ensuring PBM Accountability Act, aims to increase transparency and regulation in Pharmacy Benefit Managers (PBMs). However, PBMs are concerned about the potential instability these changes could bring to Medicare Part D plans, especially in light of the recent Inflation Reduction Act's impact on Part D still being unclear.

2. Key Provisions of the Bill: The bill introduces several significant changes, including increasing the Medicare physician fee schedule services rate from 1.25% to 2.5% for 2024, extending eligibility for bonuses under the Health Professional Shortage Area program to non-physician health-care professionals for certain services, and mandating the HHS secretary to provide licensing information for telehealth services. Additionally, Medicare Advantage plans must update provider directories every 90 days, and from 2028, Medicare Part D plan sponsors are required to contract with a significant percentage of essential retail pharmacies, including independent community pharmacies.

3. Impact and Support: Senator Mike Crapo highlights the bill's intended impact, focusing on reducing out-of-pocket medication costs for seniors, improving access to quality mental health services, enhancing accountability in federal health-care programs, and providing support for clinicians and suppliers. These measures are designed to offer comprehensive improvements across various aspects of the health care system.

New AMA policies target GLP-1 coverage, corporate medicine

By Susanna Vogel - The American Medical Association, one of the largest healthcare lobbying groups in the U.S., voted to adopt new policies to advocate for issues facing the healthcare community during its annual interim meeting held in National Harbor, Maryland. Read Full Article…

VBA Article Summary

1. GLP-1 Coverage Expansion: The AMA House of Delegates has advocated for insurance coverage parity for evidence-based obesity treatments, including GLP-1 agonists. These drugs, also used for diabetes treatment, have shown significant weight loss results in trials, but face high costs and limited insurance coverage. The AMA emphasizes the need to reduce access barriers to these treatments due to their potential in managing obesity and its associated health risks.

2. Resistance to Medical Corporatization: The AMA is taking a stand against the increasing corporate influence in medical practices. They argue that the growing presence of healthcare administrators is negatively impacting clinical decisions, leading to higher patient costs and poorer health outcomes. The policy aims to preserve physician autonomy in patient care, resisting pressures to prioritize cost over quality.

3. Buprenorphine Prescribing Flexibility: In response to the escalating opioid crisis, particularly with fentanyl addiction, the AMA calls for removing dose limits on buprenorphine treatments for opioid use disorder. Current FDA-approved dosage limits are considered outdated and restrictive, hindering effective treatment. The AMA advocates for empowering physicians to use their clinical judgment in prescribing, unhampered by strict dosage constraints.

Shaping the future of AI in health care: Senate looks to set ‘guardrails’ for patient safety

By Alan Goforth - The Biden administration recently announced its intention to develop safeguards for the promising but uncertain future of artificial intelligence. Last week, legislators began looking at how to implement the directive in health care. Read Full Article…

VBA Article Summary

1. Potential Benefits of AI in Healthcare: Senators discussed how AI could revolutionize the healthcare sector. It has the potential to reduce administrative work for clinicians, decrease spending, and accelerate drug discovery. AI's capability to analyze data and provide a platform for information sharing was also highlighted, with the technology seen as enhancing, not replacing, clinical practice.

2. Economic Impact and Efficiency: The utilization of AI in healthcare could lead to significant economic benefits. Senator John Hickenlooper mentioned the potential of reducing healthcare spending from 80% of GDP to around 8-10%, aligning with expenditure levels in other countries. This aspect emphasizes AI's role in improving efficiency and cost-effectiveness in the healthcare system.

3. Need for Regulation and Addressing Risks: Despite the potential benefits, there were concerns about the risks associated with AI, such as patient harm and exacerbation of inequities. Senator Edward Markey emphasized the importance of regulating AI to prevent these issues, citing the tendency of big tech to prioritize profit over people. The need for carefully crafted guardrails to ensure safety and ethical use of AI in healthcare was a central theme of the discussion.

Bipartisan bills meant to streamline employers’ healthcare reporting requirements

By Kathleen Steele Gaivin  - Two pieces of legislation meant to streamline employers’ healthcare reporting requirements are drawing support from the long-term care industry. Read Full Article…

VBA Article Summary

1. Introduction of Bills by Bipartisan Senators: Senators Catherine Cortez Masto, John Thune, Mark R. Warner, and Todd Young introduced two bills, the Employer Reporting Improvement Act and the Paperwork Burden Reduction Act, aimed at modernizing and streamlining compliance requirements while protecting privacy.

2. Objectives and Features of the Proposed Legislation: The Employer Reporting Improvement Act would enable electronic filing of certain documents by employers, while the Paperwork Burden Reduction Act seeks to reduce physical paperwork, easing compliance with the Affordable Care Act. These measures aim to alleviate administrative burdens and enhance efficiency.

3. Support from Healthcare and Insurance Sectors: The American Health Care Association / National Center for Assisted Living and the National Association of Benefits and Insurance Professionals have expressed support for these bills. They highlight the benefits of reducing paperwork and modernizing the healthcare reporting system, which aligns with NABIP's decade-long advocacy for employer-reporting relief.

Small biz CEOs worried about economic prospects; keeping a close eye on health care benefits

By Scott Wooldridge - A new report on how smaller employers have been dealing with rising health care costs revealed that more than 40% are considering switching insurers and more than 25% are looking at increasing deductibles and other out-of-pocket costs for employees. Read Full Article…

VBA Article Summary

1. Declining Confidence in the Economy Among Small Businesses: The WSJ/Vistage Small Business Index revealed a decrease in economic confidence among small business CEOs, despite a slowdown in inflation and no interest rate hike in September. A significant 49% of surveyed small businesses anticipate the economy to worsen in the upcoming year, marking a 9-point increase from the previous month.

2. Diverse Health Insurance Strategies Amid Open Enrollment: The report highlighted varied approaches to health insurance by small businesses. Strategies include 44% of CEOs considering or having switched insurers, 25% increasing employee deductibles, and 11% planning to offer Individual Coverage Health Reimbursement Arrangement (ICHRA) plans. Additionally, 11% are looking into a "virtual first" primary health care arrangement, and 5% are exploring networks centered around a single hospital system. However, some businesses, like SI Testing, prioritize health benefits for employee attraction and retention, refusing to cut health care costs.

3. Mixed Outlook on Future Economic Conditions: The survey reflected a generally negative view of the U.S. economy among small business CEOs, with 49% perceiving a deterioration. However, when focusing on their own companies, the outlook was slightly more optimistic, with 40% expecting improved sales and profitability. Hiring plans also showed a mix of expectations, with 48% planning to increase their workforce. Yet, these figures indicate a less optimistic stance compared to previous surveys, underscoring the challenges small businesses face in managing growth amidst rising costs and "profitless prosperity."