News That Helps Idaho Residents Stay Informed
The purpose of this article is to provide Idaho residents with one consolidated place to reference Medicare News and how it may help them make better decisions. Some of this material will not be found on the Medicare or CMS website and may be rotated off this site as its ‘information value’ decreases with time.
Title: “Breaking Down Why Medicare Part D Premiums Are Likely To Go Up”
Synopsis: ” Increases are expected to mainly affect stand-alone Part D plans, not the drug coverage offered as part of Medicare Advantage, the private sector alternative to original Medicare.
Policy experts say premiums are likely to go up for several reasons, including increased use of some higher-cost prescription drugs; a law that capped out-of-pocket spending for enrollees; and changes in a program aimed at stabilizing price increases that the Trump administration has continued but made less generous.
One thing is surer than ever, say many policy experts: Beneficiaries should not simply roll over their existing stand-alone Medicare drug plans.
“Everyone should shop plans in open enrollment,” said Stacie Dusetzina, a professor of health policy at Vanderbilt University Medical Center.”
Read this article here.
Date published: 8/15/2025
Title: “ Medicare Advantage plans are scaling back.”
Synopsis: “As enrollment in these plans, which are administered by private insurance companies, has ballooned, costs for providers have taken off. In response, Medicare Advantage (MA) plans have been making cuts to some benefits and even increasing deductibles.
“Nearly every Medicare Advantage insurer has either exited the business, such as Cigna, or is retrenching,” said Philip Moeller, a Medicare and Social Security expert who writes the Aging in America newsletter. “UnitedHealthcare is the largest, and its reappraisal could have the biggest impact. “
UnitedHealthcare said in its second quarter earnings call that it plans to drop Medicare Advantage plans that currently serve over 600,000 users, becoming the latest health insurer to announce a scaling back of this magnitude.
“We are seeing higher-than-expected medical cost increases, particularly in outpatient care,” Tim Noel, UnitedHealthcare CEO, said on the earnings call. “The American health system’s long-standing cost problem is accelerating.”
Humana, for example, expects a decline of roughly 550,000 Medicare Advantage members this year, largely driven by the decision to exit certain unprofitable plans and counties. Approximately 40% of those seniors, however, are likely to join other Humana MA plans.
What to expect.
Enrollees can anticipate higher out-of-pocket prescription co-pay costs in some plans and reductions or even the elimination of certain benefits.
You can research your options via the Medicare Plan Finder. Enter the drugs you take, and it will show you if they’re covered by the Advantage plan. When you look at the various plans available where you live, you’ll see annual estimates of the cost of that plan based on the drugs you’ve entered into the tool.
If you switch into traditional Medicare, you should qualify for a special enrollment period because your plan was terminated, which will allow you to get Medigap.
“Consumers should pay extra attention to how these things play out when costs and coverage features for 2026 are announced this fall,” Moeller said.”
Read this article here.
Date published: 8/9/2025
Title: “MedPAC: Medicare Paid MA Plans $38 billion for Non-Medicare Services in 2024.“
Synopsis: “Medicare allows MA plans to offer supplemental benefits with the intent they will make patients healthier or improve access to services, and the plans use them heavily to woo enrollees every year.
Those services included annual physical exams, spending allowance for over-the-counter items, acupuncture, a personal emergency response system, and remote-access technologies like an emergency response system and — in some plans — safety modifications for the home.
Last year, Medicare Advantage (MA) plans spent $38 billion on services traditional Medicare doesn’t pay for, such as gym memberships, meals, transportation, and dental care.
But a report presented to the Medicare Payment Advisory Commission (MedPAC) Thursday lamented the agency’s inability to evaluate the value of those services, to what extent beneficiaries actually used them, and with which companies the plans contract to provide them.
“Gaps in the data make it difficult for us to assess the value that supplemental benefits may provide to enrollees and to the program,” said Stuart Hammond, MPP, MPH, a MedPAC senior analyst.
Read this article here.
Date published: 7/29/2025
Title: “10,000 Daily Step Count Goal Debunked by Huge Study”.
Synopsis: “Based on a meta-analysis of studies published since 2014, increasing daily step counts above 2,000 was associated with a risk reduction, according to Ding (Melody) Ding, PhD, MPH, of the University of Sydney, and colleagues.
There was a significant reduction in risks of all-cause mortality, cardiovascular disease incidence, dementia, and falls in people logging more steps; these outcomes were best around 5,000 to 7,000 steps per day, with no extra benefit beyond that range. Meanwhile, more steps consistently tracked with reduced cardiovascular disease mortality, cancer incidence, cancer mortality, type 2 diabetes incidence, and depressive symptoms.”
Read this article here.
Title: “No let up in sight. Medical cost trend set to grow at 8.5%. Is your playbook ready?“
Synopsis: “For the fourth year, health plan actuaries surveyed annually told us they anticipate medical cost trends for the Group and Individual markets to remain elevated. Based on their input, we’re projecting the medical cost trend in 2026 to remain at 8.5% for the Group market and 7.5% for the Individual market, the same levels as 2025. Pharmacy cost trend was 2.5 points higher than medical trend, reinforcing the urgency of managing pharma care. We’re also restating Group and Individual trends for 2024 and 2025, as all are higher than previously projected.”
Read this article here.
Date: 7/23/2025
Title: “CMS Finds 2.8 Million Americans Potentially Enrolled in Two or More Medicaid/ACA Exchange Plans“.
Synopsis: “Over the past several months, software engineers collaborated with CMS to examine historical program enrollment data and found that in 2024 an average of 1.2 million Americans each month were enrolled in Medicaid/CHIP in two or more states and an average of 1.6 million Americans each month were enrolled in both Medicaid/CHIP and a subsidized Exchange plan.”
Read this article here.
Title: “CMS under Dr. Oz: 12 key actions”.
Synopsis: “CMS Administrator Mehmet Oz, MD, is charting an ambitious path to reshape federal healthcare policy in line with President Donald Trump’s “Make America Healthy Again” agenda.
“From plans to close a Medicaid funding “loophole” to probing hospitals over gender care for minors and clamping down on states using federal Medicaid funds to treat undocumented migrants, here are 12 key actions CMS has taken since Dr. Oz was confirmed as administrator:”
Read this article here.
Title: “Social Security Applauds Passage of Legislation Providing Historic Tax Relief for Seniors”
Synopsis: “The bill ensures that nearly 90% of Social Security beneficiaries will no longer pay federal income taxes on their benefits, providing meaningful and immediate relief to seniors who have spent a lifetime contributing to our nation’s economy.”
Read this article here.
Title: “CMS Launches New Model to Target Wasteful, Inappropriate Services in Original Medicare.
Synopsis: “CMS is committed to crushing fraud, waste, and abuse, and the WISeR Model will help root out waste in Original Medicare,” said CMS Administrator Dr. Mehmet Oz. “Combining the speed of technology and the experienced clinicians, this new model helps bring Medicare into the 21st century by testing a streamlined prior authorization process, while protecting Medicare beneficiaries from being given unnecessary and often costly procedures.”
Read this article here.
Date: 6/29/2025
Title: “DOJ sues major insurers, brokers over alleged Medicare Advantage kickbacks”.
Synopsis: “““Brokers repeatedly directed Medicare beneficiaries to the plans offered by insurers that paid them the most money, regardless of the quality or suitability of the insurers’ plans,” the complaint says. “They incentivized their agents to sell those plans; set up teams of agents who could sell only those plans; and at times ‘shut off,’ or refused to sell, plans of insurers who did not pay or did not pay enough in kickbacks. According to the lawsuit, one broker executive said about Aetna, for example, ‘more money will help drive more sales [be]cause your product is dog sh[*]t.’”
Read this article here.
Date: 5/6/2025
Title: “About 20% of patients who have a total knee arthroplasty are dissatisfied with the result, often due to residual pain.”
Synopsis: “This type of medial pain can be misdiagnosed as tendonitis or pes anserine bursitis. But it often turns out to be an infrapatellar saphenous nerve neuroma that is causing pain,” says Glenn G. Shi, M.D., an orthopedic surgeon at Mayo Clinic in Jacksonville, Florida. “Patients who have a misdiagnosis might be sent to pain clinics or physical therapy with no reasonable outcomes. That leads to a lot of frustration for patients and orthopedic surgeons alike.”
“Mayo Clinic is investigating strategies to treat infrapatellar saphenous nerve neuroma. One approach involves ultrasound-guided hydrodissection of the nerve from the adjacent interfascial planes, followed by a corticosteroid injection. A preliminary Mayo Clinic study found that this minimally invasive procedure significantly reduced medial knee pain for nine of 16 patients studied.
For patients whose pain persists after hydrodissection, Mayo Clinic is exploring options for surgical repair. “We are trying to use a less invasive incision to find the nerve end and place it in an area where it is protected from scar tissue,” Dr. Shi says. A prospective study is using a similar approach during total knee arthroplasty to prevent infrapatellar saphenous nerve neuroma from developing.
“This problem isn’t widely discussed among orthopedic surgeons, but it’s very impactful. Up to 3 million people are expected to have total knee arthroplasty by 2035,” Dr. Shi says. “Our goal is to bring attention to this problem, which we think contributes to patients’ dissatisfaction after total knee arthroplasty. A modified technique for the procedure can potentially avoid the development of neuroma and reduce pain.”
Read this article here.
Date published: 4/29/2025
Title: “The Trump administration’s approach to Medicare Advantage so far: 5 things to know.”
Synopsis: “In April, CMS said plans can expect a payment increase of 5.06% in 2026. The increase is higher than the 3.32% plans received in 2024 and the 3.7% they received in 2023.
Here are five things to know about the Trump administration’s approach to Medicare Advantage so far, and how insurers are responding:
- The Trump administration’s final rate notice for 2026 keeps in place the three-year phase in of risk adjustment changes from the v24 to v28 model. Many payers have decried the model, saying it amounts to a pay cut for MA plans.
- UnitedHealth Group CEO Andrew Witty called the transition an “aggressive price cutting regime.” The insurer lowered its earnings guidance for 2025 based on challenges in its Medicare Advantage and Optum Health businesses.Still, Mr. Witty said UnitedHealth Group was “pleased” to see the increased rate notice for 2026.
- Centene CEO Sarah London told investors the new rates “better reflect the medical cost trend we’ve seen in MA over the last two years.”“There will still be gaps to close between rate and cost across certain geographies, but this step forward was important as we look to deliver value benefits to seniors and return our business to breakeven in 2027,” Ms. London said on an April 25 earnings call.
- CMS also published the final rule for Medicare Advantage and Part D plans in April. The agency included measures to streamline prior authorization and increase oversight of supplemental benefits. CMS did not move forward with the Biden administration’s proposal to cover GLP-1 drugs for weight loss under Medicare and did not finalize rules to place guardrails around how plans can use AI in prior authorization decisions.
- As part of the final rule, CMS rebranded the health equity index reward program. Beginning in 2027, the program will be called Excellent Health Outcomes for All. The change “better captures the goal of ensuring exceptional care for all enrollees,” the agency wrote in its 2026 final rate notice.”
Read this article here.
Date published: 4/29/2025
Title: “White House eyes 30% HHS budget cut: 11 things to know.”
Synopsis: “The Trump administration is looking to cut the HHS budget by around one-third in an effort that would dramatically scale back federal health programs, The Washington Post reported April 16.
The new draft budget comes amid back-and-fourth regarding the recent dismissal of 10,000 HHS employees. In early April, HHS Secretary Robert F. Kennedy Jr. told CBS News that around 20% of affected employees might have their jobs reinstated.
Here are 11 things to know about the budget proposal:”
Read this article here.
Date published: 4/21/2025
Title: “Cancer-related hospitalizations rise: 5 notes.
Synopsis: “The study, published April 18 in Nature Scientific Reports, analyzed National Inpatient Sample data between 2008 and 2019. They identified 371 million hospitalizations, 56 million of which were cancer-related.
Here are five findings:”
Read this article here.
Date published: 4/17/2025
Title: “Will the Trump Administration Fast Track the Privatization of Medicare?”.
Synopsis: “According to MedPAC, an independent, non-partisan agency that advises Congress about Medicare payment, the federal government pays insurers 20% more for Medicare Advantage enrollees than it pays for similar people in traditional Medicare, at a cost of $84 billion in 2025. To put the $84 billion in context, that’s more than Medicare paid physicians under the physician fee schedule to treat traditional Medicare patients in 2024. The higher Medicare spending for Medicare Advantage enrollees results in $13 billion in higher Medicare Part B premiums paid by Medicare beneficiaries, including those who are not in Medicare Advantage.”
Read this article here.
Date published: 3/15/2025
Title: “25 health systems file ‘opt-out’ antitrust lawsuit against Blue Cross Blue Shield.”
Synopsis: “The lawsuit, filed March 4 in a federal court in Pennsylvania, comes after hospitals and other providers opted out of a $2.8 billion class-action settlement reached in October 2024 with BCBS. Physician groups, surgery centers and home health providers have also joined as plaintiffs in the new complaint.
The new lawsuit challenges the adequacy of the 2024 settlement, with hospitals arguing that BCBS’s anti-competitive practices are still happening and continue to harm providers financially. The plaintiffs, which include Temple University Health System, Penn Medicine, Geisinger Health, WellSpan Health, MedStar Health, and Northern Light Health, are seeking treble damages under federal antitrust law, meaning the court could award triple the amount of actual damages awarded to plaintiffs in the prior $2.8 billion settlement. The hospitals are also seeking injunctive relief to permanently ban BCBS companies from continuing their alleged collusive practices.”
Read this article here.
Date published: 3/6/2025
Title: “Mayo Arizona CEO details transformative $1.9B expansion.”
Synopsis: The centerpiece of our transform portion is the creation of Mayo Clinic Platform, which is a collaboration of nearly half of the top 11 healthcare organizations in the world, across four continents, to create a distributed data network that has the depth, breadth and heterogeneity of data on patients across socioeconomic class; urban versus rural; racial, ethnic categories, to ensure we can create and validate the most effective AI models to help anyone.
The rules of the road are that any values-aligned solution developer can leverage Mayo Clinic Platform data to create and validate algorithms, as long as those algorithms are then available on the platform for any healthcare organization that wishes to be part of the platform to take in to benefit their patients. So, that Mayo Clinic Platform piece is to benefit all of healthcare and all of society.”
Read this article here.
Date published: 3/3/2025
Title: “DOJ probes UnitedHealth’s Medicare Advantage billing practices: WSJ”.
Synopsis: The Journal has previously published reports on insurers’ Medicare Advantage billing strategies, including UnitedHealth’s efforts to optimize government payments by increasing members’ documented sickness scores. According to one report, sickness scores for UnitedHealth patients transitioning from traditional Medicare rose by 55% in their first year in Medicare Advantage, compared to a 30% industry average, leading to higher reimbursements.
DOJ attorneys have interviewed healthcare providers named in these reports as recently as Jan. 31, the Journal noted, with interest in the software used by the insurer, diagnoses it promoted for employees to use with patients and incentive arrangements.
Read this article here.
Date published: 2/22/2025
Title: “Rural hospitals’ financial pressures mount as Medicare Advantage grows: 12 things to know Rural hospitals’ financial pressures mount as Medicare Advantage grows: 12 things to know.”
Synopsis: “6. Many seniors opt for MA plans due to supplemental benefits, such as vision and dental coverage, as well as cost-sharing protections. However, for rural hospitals, this shift has led to significant financial and operational challenges.
- Historically, traditional Medicare has reimbursed hospitals at rates below the cost of care, according to the AHA report, which found that MA plans pay even less, reimbursing rural hospitals at just 90.6% of traditional Medicare rates on average. For Medicare-dependent and low-volume hospitals, this rate drops to 85%, while critical access hospitals receive only 95% of their costs under MA plans.
- This payment disparity cost rural hospitals an estimated $1 billion in 2023 alone. Given that Medicare accounts for a larger share of rural hospital revenue than urban hospitals — 43% versus 37% — these lower rates have an outsized impact on rural providers.
- The AHA argues that the financial instability caused by MA policies is accelerating the closure and downsizing of rural hospitals. Over the past decade, more than 100 rural hospitals have closed or converted to other provider types. Additionally, 432 rural hospitals are at risk of closing, according to a Feb. 11 report from Chartis, a healthcare advisory services firm.”
Read this article here.
Date published: 2/21/2025
Title: “The Idaho Department of Health & Welfare’s contracts with Blue Cross of Idaho for Idaho Medicaid Plus (IMPlus) and the Medicare-Medicaid Coordinated Plan (MMCP) will end on June 2, 2025.”
Synopsis: “Dually eligible participants will have the choice to receive Medicaid coverage through Molina or fee-for-service Medicaid from June through December 2025. The Department of Administration’s Division of Purchasing issued an intent to award to United Healthcare and Molina for a service start date of January 1, 2026 for IMPlus and MMCP coverage to dually eligible participants..”
Read this article here.
Date published: 2/18/2025
Title: “Moody’s: Negative outlook for payers in 2025 amid rising costs.”
Synopsis: “Amid these challenges, Moody’s has assigned a positive outlook to only one major insurer, Elevance Health, reflecting its strong market position and operational performance. In contrast, Humana and Health Care Service Corp. have been given negative outlooks. Humana’s negative outlook is driven by its heavy reliance on Medicare Advantage. HCSC’s negative outlook reflects its exposure to Medicaid redeterminations and competitive pressures in its core commercial business.”
Read this article here.
Date published: 2/3/2025
Title: “Republicans target $880B in healthcare cuts; hospitals push back.”
Synopsis: “The budget resolution does not specify how the committee must cut costs by $880 billion, but Medicare and Medicaid are by far the largest programs under its oversight. The $880 billion makes up more than half of the $1.5 trillion total cost reductions Republican lawmakers aim to achieve over the 10-year period. ”
Read this article here.
Date published: 2/12/2025
Title: “Recognizing the Highest Level of Quality Care: Healthgrades Unveils America’s Best Hospitals for 2025.”
Synopsis: “Healthgrades’ clinically validated methodology focuses solely on what matters most–patient outcomes–empowering consumers to choose doctors who practice at high quality hospitals. To determine the top 250 U.S. hospitals, Healthgrades evaluated clinical performance for approximately 4,500 hospitals across more than 30 common procedures and conditions.”
Read this article here.
Date published: 2/10/2025
Title: “Drugmakers increase prices on 800 medications: 5 things to know.”
Synopsis: “The analysis found that while most price increases remained under 10%, certain medications saw significant hikes. For example, Amgen raised the price of its psoriasis treatment, Otezla, by 7%, pushing its monthly cost to about $5,325. ”
Read this article here.
Date published: 1/31/2025
Title: “Why NYU Langone is betting on molecular oncology.”
Synopsis: “Cancer is typically identified pathologically, looking at the biopsy under the microscope. As we’ve made more and more fundamental discoveries in cancer biology, we now know that most of these cancers are really made up of many different subgroups of diseases that could be defined at a molecular level.
What molecular oncology is really designed for is to provide access to cutting-edge molecular profiling. We’re focusing on a type of technology called a liquid biopsy that allows patients to have the most accurate diagnosis, matches them to the most appropriate standard therapies and the most applicable clinical trial, when relevant.
It’s basically a blood test, similar to physicians ordering a normal complete blood count. We use deep sequencing methods to detect pieces of cancer DNA within the blood sample.
The test allows us to diagnose cancers quickly, determine the molecular subtype of the cancer and what specific treatments will target the cancer most effectively. The test can also detect cancer recurrence, often before it is seen on a CAT scan.”
Read this article here.
Date published: 1/17/2025
Title: “Cancer burden shifts as incidence climbs: What to know.”
Synopsis: “In 2025, an estimated 618,120 people will die from cancer in the U.S. The figure represents about 30% of the estimated 2,041,910 new cancer cases the U.S. is expected to see in 2025.
As the cancer mortality rate continues to fall, incidence rates in the U.S. have increased at varying degrees across demographics and state lines, according to the American Cancer Society’s annual cancer statistics report published Jan. 16 in CA: A Cancer Journal for Clinicians.
Here are 10 key findings from the report:.”
Read this article here.
Date published: 1/17/2025
Title: “Customized implants for knee replacements.”
Synopsis: “The customized implants are designed for people who wish to remain active.”
“We use them in patients who want to do vigorous physical activity, such as tennis or downhill skiing. As with other knee prostheses, we don’t advise high-impact activities such as basketball or soccer afterward,” Dr. Clarke says.”
Read this article here.
Date published: 9/18/2018
Title: “Hospital Care, State by State”.
Synopsis: “The sixth annual HealthGrades Hospital Quality in America Study shows the quality of healthcare at the nation’s hospitals varies greatly among states.
Researchers ranked each of the country’s nearly 5,000 hospitals on 26 common procedures and conditions and found better-performing hospitals tended to be in northern or sparsely populated states.
The quality chasm at American hospitals is real, and it is very alarming and concerning — despite evidence of process improvements,” says Samantha Collier, MD, HealthGrades’ vice president of medical affairs, in a news release.
Although there are exceptional hospitals in even the lowest-ranking states, researchers say that, on average, patients get better quality healthcare in the higher-ranking states.
For example, the report shows that a person has a 55% increased chance of dying if he or she had a balloon angioplasty or other similar heart procedure in Texas rather than in New York.
“In Mississippi, your chance of dying from a heart attack is 49% higher, on average, than if you were treated in Colorado,” says Collier.
Researchers say that the greatest differences at the state level were among certain heart procedures, such as balloon angioplasty, stenting, and others. For these procedures, New York was the best performing state and Alaska was the worst.”
Read this article here.
Date published: 1/7/2025
Title: “7 cancers linked to alcohol”.
Synopsis: “Here are seven statistics to know from the surgeon general’s advisory:
- 96,730: The estimated number of alcohol-related cancer cases in 2019.
- 1 million: How many alcohol-related cancer cases have been preventable in the past decade.
- 44,180: The estimated number of alcohol-related breast cancer cases in women in 2019, representing 16.4% of all breast cancer cases in women.
- 741,300: The global burden of cancer cases related to alcohol use in 2020.
- 185,100: How many of those worldwide cases were related to about two or fewer drinks per day.
- 305,000: The annual total of years of potential life lost due to alcohol-related cancer deaths.
- 2: The number of daily drinks that would cause cancer in 5 in 100 women and 3 in 100 men, according to the estimated cumulative absolute risk. .”
Read this article here.
Title: “Molina Healthcare Awarded Dual Eligible Contracts”.
Synopsis: “In Idaho, Molina’s health plan subsidiary, Molina Healthcare of Idaho, is set to administer the state’s Medicare Medicaid Coordinated Plan (MMCP) and Idaho Medicaid Plus Plan (IMPlus) for the dual eligible population. The initial term of these contracts is four years, with a potential one-year extension.
It is noteworthy that Molina Healthcare currently serves approximately 11,000 dual eligible members across Idaho.”
Read this article here.
Date published: 1/4/2025
Title: “An unimaginable year for UnitedHealth”.
Synopsis: “You see so much violence in hospitals and health systems often from people with behavioral health problems,” Scott Becker, founder and publisher of Becker’s Healthcare, said. “But I have not seen this, and it reminds me of the labor disputes in the early 1900s, where corporate CEOs were targeted by labor in a very aggressive way as those wars between unions and companies got very ugly. It’s been a long time since we’ve seen this type of activism and level of hostility. It’s a sad, sad situation.“
Read this article here.
Date published: 1/4/2025
Title: “32 health systems dropping Medicare Advantage plans | 2024”.
Synopsis: “Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers.
Data on this topic is limited. In January, the Healthcare Financial Management Association and Eliciting Insights released a survey of 135 health system CFOs, which found that 16% of systems are planning to stop accepting one or more MA plans in the next two years. Another 45% said they are considering the same but have not made a final decision. The report also found that 62% of CFOs believe collecting from MA is “significantly more difficult” than it was two years ago.”
Read this article here.
Date published: 12/29/2024
Title: “BCBS antitrust settlement provider website goes live”.
Synopsis: “A website containing information for provider class settlement members in Blue Cross Blue Shield antitrust litigation has launched.
The website was launched after the Blue Cross Blue Shield Association, along with the 33 independent BCBS companies, agreed to pay $2.8 billion to settle antitrust claims from healthcare providers, marking the largest settlement of its kind in the healthcare industry. The settlement was reached in October. An Alabama court granted the agreement preliminary approval on Dec. 4.
The settlement class includes providers who currently provide or provided healthcare services, equipment or supplies to any patient who was insured by, or was a member or a beneficiary of, any plan administered by any settling individual Blues plan from July 24, 2008 to Oct. 4, 2024, according to the website.
The deadline to submit a claim is July 29, 2025..”
Read this article here.
Date published: 12/23/2024
Title: “Mark Cuban’s 2025 plans”.
Synopsis: “Nearly three years after its launch, Mark Cuban Cost Plus Drug Co. now manufactures injectables in shortage, works with thousands of healthcare facilities, including pharmacies, hospitals, long-term care sites and clinics, and offers more than 2,000 discounted generics and about a dozen branded medicines.
With its model of selling medicines at cost plus a 15% markup and $10 for shipping and pharmacy labor, several large pharmaceutical companies — including CVS and Express Scripts — have followed Cost Plus Drugs’ example.
In August, Mr. Cuban said Cost Plus Drugs would soon publish its own contracts to offer more transparency in an infamously opaque $4.3 trillion industry. He has also said the pharmaceutical industry has been his easiest industry to disrupt. As of June, the company was operating in a deficit.
The industry, on the care and pharmacy sides, have seen power consolidated in a few players. This is finally the year that can change. It is possible to align the incentives of providers, tax payers and patients, and I think we will finally see that start to happen.”
Read this article here.
Date published: 12/23/2024
Title: “Physicians slam Congress for failure to offset Medicare pay cuts”.
Synopsis: “Congress has signed a pared-down funding bill to prevent a government shutdown but failed to pass measures in a previously proposed bipartisan package that would have offset the 2.83% Medicare pay cut physicians face in 2025.
“The previously agreed-upon [continuing resolution], while not perfect, would have critically averted most of the 2.83% cut to physician reimbursement in Medicare beginning January 1,”
Anders Gilberg, senior vice president of government affairs, said in a statement. “Now physician practices head into the new year facing uncertainty and financial shortfalls that not only negatively impact the viability of their Medicare business, but their commercial contracts tied to Medicare rates, as well as Medicaid reimbursement in states that use Medicare as a benchmark.”
Physicians’ Medicare pay rates have dropped 33% over 20 years, and Congress has ignored inflation adjustments, prior authorization reforms and rising care costs, according to the American Medical Association. ”
Read this article here.
Date published: 12/23/2024
Title: “Higher Utilization, Regulatory Challenges Pressure Medicare Advantage Segment, prompting Some Carriers to Exit Market”.
Synopsis: “A contributing factor to the recent announcements of market exits by some participants include the Inflation Reduction Act of 2022 (IRA), which takes effect in 2025 and includes several provisions aimed at lowering prescription drug expenses for Medicare Part D beneficiaries, shifting a larger share of costs to insurers and drug manufacturers. A separate stabilization demonstration program was enacted earlier this year to support implementation of the redesigned Part D benefit by subsidizing the anticipated premium and cost increases; however, this is available to Medicare Part D-only insurers and does not apply to MA plans that include Part D. Another factor pressuring MA plans are the recent changes in the risk adjustment score calculation that are being phased in over three years starting with 2024; the new calculation drives down the score leading to lower reimbursement rates per member.”
Read this article here.
Date published: 11/7/2024
Title: “Why you should consider Proton Therapy for cancer treatment.”
Synopsis: “Proton therapy, or proton beam therapy, is a type of radiation treatment that uses a beam of protons to deliver radiation directly to the tumor.
Imagine a 196-ton, cancer-killing machine that can target a patient’s tumor with a sub-millimeter precision while sparing nearby healthy tissues and minimizing side effects. In its most simple terms, that’s proton therapy.
Pencil beam technology and IMPT build on the benefits of proton therapy. With a proton beam just millimeters wide, these advanced forms of proton therapy combine precision and effectiveness, offering unmatched ability to treat a patient’s tumor and minimizing the effect on a patient’s quality of life – during and after treatment. They rely on complex treatment planning systems and an intricate number of magnets to aim a narrow proton beam and essentially “paint” a radiation dose layer by layer.
Pencil beam is very effective in treating the most complex tumors, like those in the prostate, brain, eye, and cancers in children, while leaving healthy tissue and other critical areas unharmed. IMPT is best used to deliver a potent and precise dose of protons to complex or concave-shaped tumors that may be adjacent to the spinal cord or embedded head and neck or skull base, including nasal and sinus cavities, oral cavity, salivary gland, tongue, tonsils, and larynx.”
Read this article here and here.
Date published: 11/4/2024
Title: “BCBS reaches record antitrust settlement for $2.8B”.
Synopsis: “The Blue Cross Blue Shield Association, along with the 33 independent BCBS companies, have agreed to pay $2.8 billion to settle antitrust claims from healthcare providers, marking the largest settlement of its kind in the healthcare industry.
In addition to the cash settlement, the plaintiffs stated in an Oct. 14 filing in Alabama federal court that BCBS plans must implement significant operational changes across 16 categories. These changes include how BCBS processes claims, communicates, contracts with, and makes payments to providers.
The new operational requirements are expected to alleviate administrative burdens and inefficiencies experienced by providers, according to the plaintiffs’ counsel. The settlement applies to providers who treated BCBS members between July 2008 and October 2024..”
Read this article here. Read the comments section too.
Date published: 10/16/2024
Title: Early analysis: “How health plans fared in the 2025 Medicare Advantage star ratings.”
- Synopsis: “This year, 62% of membership is attributed to a 4+ star plan, down from 79% the year prior. Notably, only 1.8% of membership is now in a 5 star plan, down from nearly 8% the prior year and 27% in 2022.
- Enrollment in 5 star plans is now negligible. Only 1.8% of members are in this plan tier, down from its peak of 27% in 2022 and 8% in 2024.
- Enrollment in plans with less than 3 stars remained steady at approximately 1%. This is important because plans that score below this threshold in consecutive years cannot market for additional membership or file for new applications or service area expansions (SAEs). They also could be terminated if they are low scoring for 3 years in a row.”
Read this article here.
Date published: 10/14/2024
Title: Senator promises ‘dramatic’ Medicare Advantage investigation.
Synopsis: “Anybody following our hearings and public comments knows our findings will be very dramatic and powerful,” Mr. Blumenthal said. “What we have found is, essentially, there is no advantage for people in Medicare Advantage, all too often.”
Read this article here.
Date published: 10/7/2024
Title: The Great Disruption Coming for Medicare Advantage.
Synopsis: Come mid-October, the Medicare Advantage program will enter its annual enrollment period, marked by significant changes for older adults.
Among these changes are increased government scrutiny, tighter CMS regulations, reduced base payments, and rising healthcare costs.
In response to these market shifts, MA carriers are prioritizing their margins over membership by reducing certain benefits and exiting unprofitable markets. As margins tighten and negotiations with providers become more strained, some health systems are choosing to no longer accept some or all MA plans.
Read this article here.
Date published: 9/9/2024
Title: “Feds Killed Plan to Curb Medicare Advantage Overbilling After Industry Opposition.”
Synopsis: The Justice Department alleged the giant health insurer cheated Medicare out of more than $2 billion by reviewing patients’ records to find additional diagnoses, adding revenue while ignoring overcharges that might reduce bills. The company “buried its head in the sand and did nothing but keep the money,” the DOJ said in a court filing.
Medicare pays health plans higher rates for sicker patients but requires that the plans bill only for conditions that are properly documented in a patient’s medical records.
In a court filing, UnitedHealth Group denied wrongdoing and argued it shouldn’t be penalized for “failing to follow a rule that CMS considered a decade ago but declined to adopt.”
Read this article here.
Date published: 9/6/2024
Title: Medicare Advantage: How Robust Are Plans’ Physician Networks?
Synopsis: For people on Medicare, one of the biggest trade-offs between Medicare Advantage and traditional Medicare is that Medicare Advantage plans have a more limited network of doctors and other providers. Medicare Advantage plans restrict the doctors, hospitals, and other providers from whom their enrollees can receive care, while traditional Medicare allows people to see any provider that accepts Medicare (overwhelming majority of providers). Seniors value having the ability to choose their own doctors as well as keep their existing doctors, and say that the doctors in the network are an important factor in their plan selections.1
Although Medicare Advantage enrollment is rising rapidly, with one in three beneficiaries now in a Medicare Advantage plan, relatively little is known about Medicare Advantage plans’ provider networks.2 The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage plans to include a specified number of physicians for each of the 26 specialties, along with hospitals, and other providers within a particular driving time and distance of enrollees;3 however, little information is available about the extent to which plans go beyond these basic requirements. A prior analysis showed that Medicare Advantage hospital networks vary greatly in size and composition.4 The size and composition of a plan’s physician network can have important implications for Medicare Advantage enrollees, including whether or not they can see a given physician (for HMO enrollees) or how much more they would need to pay for out-of-network care (for PPO enrollees).
When forming their networks, insurers may choose to contract with some but not all physicians for a variety of reasons. For example, the insurer may want to have greater control over the cost or quality of care provided by a physician or they may prefer to limit the number of physicians included in their network for other reasons. Curating and restricting their provider networks may also allow insurers to improve the coordination and efficiency of care for their enrollees.
At the same time, physicians may or may not want to be a part of a Medicare Advantage network. They may not want the extra paperwork and time that may come with accepting another insurer, may not want additional patients, or may have concerns with a plan’s payment rates or other terms of a given plan’s contract.
This report is the first known study to examine the size and composition of Medicare Advantage plans’ networks, focusing on physicians. This analysis draws upon data from 391 plans, offered by 55 insurers, in 20 counties, accounting for 14 percent of all Medicare Advantage enrollees nationwide in 2015. The report analyzes the size of provider networks across and within the 20 counties, overall and by specialty, and looks at the relationship between network size and other plan features, including plan types, premiums, star ratings, and insurers. We defined Medicare Advantage networks as broad if they included 70 percent or more of the physicians in a county, medium if they included between 30 and 69 percent of the physicians in a county, and narrow if they included less than 30 percent of the physicians in a county.
Growing evidence indicates that many plans do not maintain accurate directories.5 For example, in an investigation, CMS found that the directories had many errors and 45 percent of the doctors listed had incorrect information in plans’ directories.6 Unlike CMS, we do not assess the accuracy of the directories, nor do we assess whether the physicians in the directories actually accept the insurance.
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Date published: 9/6/2024
Title: Income and Assets of Medicare Beneficiaries in 2023
Synopsis: This analysis highlights that most Medicare beneficiaries live on relatively low incomes and have modest financial resources to draw upon in retirement if they need to cover costly medical care or long-term services and supports, with notable disparities by age, race and ethnicity, and gender. For example:
- One in four Medicare beneficiaries lived on incomes below $21,000 per person in 2023, while half lived on incomes below $36,000 per person. Median income declined with age among older adults, was lower for women than men, and lower for Black and Hispanic than White beneficiaries.
- One in four Medicare beneficiaries had savings below $16,950 per person in 2023, while half had savings below $103,800 per person. As with income, median savings declined with age among those ages 65 and older, were lower for women than men, and were substantially lower for Black ($22,100) and Hispanic ($20,050) than White ($158,950) beneficiaries.
- One in four Medicare beneficiaries had no home equity at all in 2023, while half of all Medicare beneficiaries had home equity below $124,450 per person.
- More than one in five Black and Hispanic beneficiaries had no savings or were in debt, compared to fewer than one in ten White beneficiaries. Nearly half of all Black and Hispanic beneficiaries had no home equity, compared to one in five White beneficiaries.
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Date published: 9/6/2024
Title: Explaining the Prescription Drug Provisions in the Inflation Reduction Act
Synopsis: The prescription drug provisions included in the Inflation Reduction Act will:
- Require the federal government to negotiate prices for some drugs covered under Medicare Part B and Part D with the highest total spending, beginning in 2026
- Require drug companies to pay rebates to Medicare if prices rise faster than inflation for drugs used by Medicare beneficiaries, beginning in 2023
- Cap out-of-pocket spending for Medicare Part D enrollees and make other Part D benefit design changes, beginning in 2024
- Limit monthly cost sharing for insulin to $35 for people with Medicare, beginning in 2023
- Eliminate cost sharing for adult vaccines covered under Medicare Part D and improve access to adult vaccines in Medicaid and CHIP, beginning in 2023
- Expand eligibility for full benefits under the Medicare Part D Low-Income Subsidy Program, beginning in 2024
- Further delay implementation of the Trump Administration’s drug rebate rule, beginning in 2027
This brief summarizes these provisions and discusses the expected effects on people, program spending, and drug prices and innovation.
Read this article here.
Date published: 8/24/2024
Title: “Use of Prior Authorization in Medicare Advantage Exceeded 46 Million Requests in 2022”
Synopsis: “Virtually all enrollees in Medicare Advantage (99%) are required to obtain prior authorization for some services – most commonly, higher cost services, such as inpatient hospital stays, skilled nursing facility stays, and chemotherapy. This contrasts with traditional Medicare, where only a limited set of services require prior authorization. Prior authorization requirements are intended to ensure that health care services are medically necessary by requiring approval before a service or other benefit will be covered. Medicare Advantage insurers typically use prior authorization, along with other tools, such as provider networks, to manage utilization and lower costs. This may contribute to their ability to offer extra benefits and reduced cost sharing, typically for no additional premium, while maintaining strong financial performance.”
Read this article here.
Published: Aug 08, 2024
Title: Humana to pay $90 mln to settle claim that it overcharged Medicare for drugs.
Synopsis: Humana (HUM.N), opens new tab has agreed to pay $90 million to settle a whistleblower lawsuit by one of its former actuaries accusing the health insurer of overcharging the U.S. government for prescription drugs, the whistleblower’s lawyers announced on Friday.
The whistleblower, Steven Scott, said that Humana, which contracts with the federal Medicare program to administer prescription drug benefits, misrepresented its true costs in order to get a more lucrative contract. It is the first settlement with any insurer over allegations of fraud tied to Medicare’s prescription drug contracting process, according to the law firm Phillips & Cohen, which represents Scott.
Read this article here.
Date published: 8/16/2024
