Inflation Reduction Act is causing 'dramatic' rise in Medicare premiums, experts say

By Nathan Place - The Inflation Reduction Act was supposed to make Medicare cheaper. But in at least one way, it appears to be doing the opposite. As 2023 comes to an end, seniors across the country are finding out what their premiums will be for Medicare Part D, the part that covers prescription drugs, in 2024. And many have learned their bills will be much higher next year. Read Full Article…

VBA Article Summary

1. Significant Premium Increases for Medicare Part D Enrollees: A new report by HealthView Services reveals that premiums for Medicare Part D plans will rise dramatically next year, with increases averaging 42% to 57% in states like California, Florida, New York, Pennsylvania, and Texas. These hikes are attributed to the Inflation Reduction Act, which, while capping out-of-pocket drug expenses at $2,000, has led to higher premiums as insurers adjust to cover these costs.

2. Impact of the Inflation Reduction Act on Premiums and Seniors: The Inflation Reduction Act, initially aimed at reducing healthcare costs and tackling climate change, has inadvertently contributed to the surge in Part D premiums. This act limits annual increases in "base premiums" to 6%, but this cap applies to government negotiations, not what consumers pay. Insurers, now responsible for a larger share of drug expenses under the act, seem to be passing these costs onto enrollees.

3. Role of Financial Advisors and Government in Addressing Rising Costs: Financial advisers are recommended to help seniors navigate these increasing costs. Resources from the State Health Insurance Assistance Program, the Medicare Rights Center, and the National Council on Aging are available for advisors to better understand Medicare. Additionally, there's a call for the Biden administration and Congress to amend the Inflation Reduction Act or introduce new legislation to protect seniors from escalating healthcare expenses.

Federally funded nonprofit PCORI doles out $80M for large studies focused on maternal health

By Anastassia Giladkovskaya- The Patient-Centered Outcomes Research Institute (PCORI) has announced funding awards of $80.5 million to support four new studies focused on disparities in maternal health. Read Full Article…

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1. Focus on Equity and Community Involvement: The research will emphasize clinical and social factors contributing to disparities in maternal morbidity and mortality. It will particularly address the needs of marginalized groups such as Black and Latino communities, rural residents, and low-income populations. Each study will be collaboratively led by investigators from both research institutions and community organizations, aiming to include tens of thousands of participants, including those not traditionally involved in research.

2. Intervention Strategies and Study Structure: The studies will explore a variety of practice-level, community-based, and home-based interventions to tackle prevalent issues in maternal health. Each project will undergo a planning phase of up to one year followed by a research phase of up to five years. The goal is to find effective solutions for the national crisis of maternal death and severe illness, as emphasized by PCORI Executive Director Nakela L. Cook, M.D.

3. Scope and Funding of the Research Projects: These studies are part of 30 comparative clinical effectiveness research projects recently funded by PCORI, with a total investment of over $4.5 billion. Specific partner awards for mental health research include projects like “Comparative Effectiveness of Three Equity Interventions to Improve Maternal Health” and “Delivering HOPE (Helping Women Optimize Prenatal Equity)”. The research will also address issues such as maternal weight, hypertensive disorders during pregnancy, and mood and anxiety disorders, with interventions ranging from social services to at-home monitoring and peer support programs.

UnitedHealth, Cigna face lawsuits over alleged automated claims denials

By Jakob Emerson - UnitedHealthcare and Cigna Healthcare are facing lawsuits from members or their families alleging the organizations use automated data tools to wrongfully deny members' medical claims. The allegations come amid broader ongoing conversations among policymakers around insurers' use of algorithms and artificial intelligence when processing claims or prior authorization requests. Read Full Article…

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1. Lawsuit Against UnitedHealthcare: Filed on Nov. 14 in Minnesota, the lawsuit accuses UnitedHealthcare of wrongfully denying coverage for post-acute care to Medicare Advantage members. The denial is allegedly based on an AI algorithm, nH Predict, developed by naviHealth (acquired by Optum in 2020). The lawsuit claims that UnitedHealthcare's goal was to align skilled nursing facility stay lengths with the algorithm's predictions, leading to disciplinary actions against employees deviating from these estimates. The decisions made by the algorithm are reportedly overturned 90% of the time upon appeal. Optum defends, stating that the tool is used as a guide and coverage decisions are based on CMS criteria and member plan terms.

2. Cigna Group's Legal Challenges: Cigna faces lawsuits from members and a shareholder after a ProPublica report alleged the use of an algorithm, PxDx, for denying large batches of claims without individual review. The report claims that Cigna's physicians denied over 300,000 claims in two months in 2022 using this system. Following the report, state and federal authorities expressed concerns, with some calling for investigations. Cigna counters the allegations, stating that their claims review process adheres to industry standards and the PxDx technology does not use AI or machine learning.

3. Federal Response and Oversight: In response to these developments, federal lawmakers requested increased CMS oversight of AI and algorithms in Medicare Advantage prior authorization decisions. Vice President Kamala Harris and President Joe Biden have also addressed the potential harms of AI in healthcare. Biden's executive order on Oct. 30 called for a federal health agency strategy to oversee AI, tasking HHS with developing an initiative to monitor unsafe AI-related practices in healthcare.

Family Health Insurance Is No Longer Affordable Through Small Employers

By Drew Altman - One thing that really jumped out from our 25th annual KFF employer health benefit survey: Small employers no longer have affordable coverage for workers with families. Read Full Article…

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1. Financial Burden of Health Coverage for Workers at Small Firms: Workers at small firms, defined as those with fewer than 200 employees, face significant financial challenges in affording family health coverage. On average, these workers pay $8,334 annually towards family premiums, which can rise to $12,000 or more for a quarter of them. This is a considerable portion of the average total premium cost of $23,621. Additionally, small firm employees generally pay a higher share of family premiums compared to those at larger firms. Out-of-pocket costs, including deductibles, are also typically higher at small firms. For example, 57% of these families face deductibles over $3,000, and 35% have deductibles of at least $5,000.

2. Widening Affordability Gap and Its Consequences: The cost of health coverage is increasingly unaffordable for the nearly 50 million Americans working at small firms, including very small businesses like pizza shops and bakeries. These workers, earning on average $44,600, compared to $63,200 at larger firms, face significant challenges in managing health costs. The impact is particularly severe for lower-income workers and those with chronic or major illnesses. A large survey revealed that 20-30% of lower-income workers with employer coverage struggle with medical bills.

3. Policy Challenges and Opportunities: The issue of health coverage affordability at small firms is complex and requires careful policy consideration. While the Biden Administration has addressed some aspects, like the Affordable Care Act’s “family glitch”, many workers still have limited options, often choosing between expensive employer coverage or no insurance. Proposals to expand marketplace coverage and provide subsidies for small firm workers are under discussion. This situation underscores two ongoing crises in American healthcare: the impact of national health spending on the country, and the affordability crisis affecting individuals and families.

Breaking Down Barriers for Payer Adoption of Virtual Care Providers

By Sam Holliday - Today, virtual and in-person healthcare providers working together within hybrid collaborative care models are increasingly demonstrating their ability to improve outcomes and accelerate the industry’s shift towards value-based care. Read Full Article…

VBA Article Summary

1. Increasing Traction and Existing Challenges of Virtual Specialty Care: The utilization of virtual specialty care has significantly increased, now accounting for 14–17% of patient visits compared to about 1% in February 2020. However, its full integration faces obstacles such as technological limitations, procedural complexities, and regulatory barriers. These challenges prevent payers from fully embracing virtual care providers, despite a growing patient demand and the recognized potential of virtual care.

2. Barriers to Payer Engagement: Payer organizations encounter specific challenges that hinder the integration of virtual care into their networks. These include outdated systems based on zip codes, which are ill-suited for the geography-agnostic nature of virtual care, and regulatory and policy constraints, such as state licensure requirements and network adequacy policies, that add costs and barriers. Additionally, network abrasion and steerage concerns arise when integrating virtual care providers, requiring careful communication strategies to align with existing health systems and provider groups.

3. Progress and Future Potential: Despite these barriers, there are positive movements in the industry towards embracing virtual care. Insurers are investing in digital platforms and rethinking their credentialing processes to include virtual care providers from outside their traditional geographic coverage areas. This includes significant investments in technology and a push for regulatory and policy advancements. These efforts highlight the crucial role of payers in driving the adoption of virtual care and bridging the gap between innovation and patient access, promising a future where virtual care is more seamlessly integrated into healthcare systems.

A look at budding innovation in state-based ACA marketplaces

By Paige Minemyer - ​With their recent stability, the Affordable Care Act marketplaces are well-positioned for innovation—but there's still room to take what's working nationwide, according to a new report. Read Full Article…

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1. State-Based Marketplaces and Flexibility: As of 2023, 20 U.S. states operate state-based marketplaces for health insurance sign-ups, while the remaining 30 use the federal platform, Healthcare.gov. State-based marketplaces, especially those using their websites, have more flexibility in implementing enrollment campaigns and programs. This flexibility, highlighted in a Commonwealth Fund policy brief, allows for tailored approaches to make the enrollment process easier.

2. Innovative Enrollment Programs: Five state-based marketplaces utilize this flexibility to create "easy enrollment" programs. These programs enable residents to express their interest in insurance coverage through their tax forms, facilitating targeted guidance towards suitable coverage options, including Medicaid. Additionally, four state-based exchanges have introduced auto-enrollment programs to streamline and simplify the consumer experience.

3. Health Equity and Accreditation Efforts: Both state and federal exchanges are increasingly focusing on health equity. Five state-based exchanges have implemented equity-based design requirements for health plans to address disparities in conditions like diabetes and hypertension. Moreover, a growing number of these state marketplaces are mandating accreditation from the National Committee for Quality Assurance for payers, assessing their progress in advancing health equity. The federal marketplace is also taking steps, such as requiring insurers to make efforts in collecting race and ethnicity data. However, despite these innovations, their widespread adoption across all marketplaces remains limited.

State health insurance currently runs $15 million deficit, cites weight loss medication as factor

By Sarah Petrowich - The State Employee Benefits Committee (SEBC) reports there is currently a $15 million deficit in state health insurance funding for this fiscal year. Read Full Article…

VBA Article Summary

1. Delaware's Healthcare Expenditure and GHIP Funding: Delaware spends an average of $1.2 billion on the Group Health Insurance Plan (GHIP) to provide healthcare for active state employees, their families, and state pensioners. Despite facing a significant deficit before the pandemic, the curtailment in healthcare visits during COVID-19 led to a surplus. However, Secretary Claire DeMatteis has requested increased funding for GHIP for fiscal year 2025, noting a $15 million deficit that needs to be addressed by June 30, 2024.

2. Increased Costs from Weight Loss Medication Coverage: A key factor contributing to the current deficit is the coverage of weight loss medications, a decision made last fall. The actual spending on these drugs has far exceeded the initial projections, reaching over $7 million compared to the estimated $2 million. To receive these medications, patients must meet specific criteria, including being diagnosed with comorbidity and having a documented diet and exercise plan.

3. Future Financial Strategies and Concerns: DeMatteis indicated that the funding situation could stabilize if fewer state employees use their health insurance in the coming months, but there might be a need for additional appropriations from the General Assembly to cover the deficit. Raising premium rates for state employees is considered a last resort. The committee plans to closely monitor spending over the next seven months to determine the necessary financial adjustments.

Many autoimmune disease patients struggle with diagnosis, costs, inattentive care

By Andy Miller - ​After years of debilitating bouts of fatigue, Beth VanOrden finally thought she had an answer to her problems in 2016 when she was diagnosed with Hashimoto's disease, an autoimmune disorder. Read Full Article…

VBA Article Summary

1. Hashimoto's Disease and Hypothyroidism: The article highlights the struggles of individuals with Hashimoto's disease, a common cause of hypothyroidism, where the thyroid gland fails to produce sufficient hormones for regulating metabolism. There's no cure for both conditions. Treatments like levothyroxine, a synthetic thyroid hormone, help manage symptoms like fatigue and weight gain, but effectiveness varies. Some patients, like the featured VanOrden, spend thousands of dollars annually on ineffective treatments, experiencing persistent symptoms and emotional distress.

2. Challenges in Autoimmune Disease Management: The article emphasizes the difficulties faced in diagnosing and treating autoimmune diseases, including hypothyroidism. Symptoms often mimic other conditions, and there's a lack of definitive tests, leading to frustrating, expensive, and lengthy diagnostic processes. The overall cost of treating autoimmune diseases is staggering, and patients frequently feel dismissed by healthcare professionals. Moreover, there's insufficient medical education and investment in research around hypothyroidism, hindering understanding and treatment advancements.

3. Patient Experiences and Treatment Limitations: Highlighting patient stories, the article underscores the emotional and financial burden of autoimmune diseases. Health insurance often denies coverage for novel treatments, and patients like Jennifer Ryan incur high out-of-pocket expenses in search of relief. Despite levothyroxine being one of the most prescribed drugs in the U.S., its overprescription and limited effectiveness for some patients are noted. The article also touches on the role of social media in patient support and awareness, while stressing the need for more research funding and medical acknowledgment of hard-to-treat hypothyroid patients.