HEALTHCARE & GOVERNMENT
California Senate's New Health Chair to Prioritize Mental Health and Homelessness
California state Sen. Susan Talamantes Eggman, a Stockton Democrat who was instrumental in passing Gov. Gavin Newsom's signature mental health care legislation last year, has been appointed to lead the Senate's influential health committee, a change that promises a more urgent focus on expanding mental health services and moving homeless people into housing and treatment. The leadership change is expected to coincide with a Democratic health agenda focused on two of the state's thorniest and most intractable issues: homelessness and mental illness. According to federal data, California accounts for 30% of the nation's homeless population, while making up 12% of the U.S. population. (https://californiahealthline.org/news/article/california-senate-susan-talamantes-eggman-new-health-chair-mental-health-homelessness/)
MEANWHILE, the Biden-Harris Administration Announces Plan to Reduce Homelessness 25% by 2025: The administration has released a federal plan for ending homelessness in America called "All In: The Federal Strategic Plan to Prevent and End Homelessness." The plan recommits the federal government to strategies that have been proven to work, like "Housing First" - the model of care that treats housing as the immediate solution to homelessness, but not the only solution. Once housed, many people need support to stay housed - from health care and job training to legal and education assistance. This model works because it treats people with dignity, personalizes their care, and recognizes that - without housing, every other aspect of a person's life suffers. (https://www.hhs.gov/about/news/2022/12/19/biden-harris-administration-announces-plan-to-reduce-homelessness-25-percent-by-2025.html)
NIH Launches Pilot Program for COVID-19 Telehealth Care
The National Institutes of Health (NIH) has announced the launch of a pilot program that will allow people to receive free testing, consultation and treatment for COVID-19 from their homes. The NIH estimated up to 8,000 eligible individuals will participate in the pilot "Home Test to Treat" program. The agency said it is aiming to offer this service to up to 100,000 people in the U.S. over the next year. (https://thehill.com/policy/healthcare/3801129-biden-administration-launches-pilot-program-for-covid-19-telehealth-care/)
Federal Omnibus Bill Includes Relief from Medicare Payment Cuts, Allows for Medicaid Eligibility Assessments, & Extends Telehealth Flexibilities
The House of Representatives and Senate recently passed an omnibus spending bill that funds the Federal government through Fiscal Year 2023 and contains various provisions affecting healthcare providers. Among other things, the bill ameliorates planned Medicare provider cuts. The legislation also allows states to resume Medicaid eligibility determinations and extends telehealth flexibilities first authorized under the COVID-19 public health emergency. (https://www.kslaw.com/news-and-insights/health-headlines-december-27-2022)
ALSO, Becker's Hospital Review shared eight healthcare- and hospital-specific notes out of the 4,155-page bill: https://www.beckershospitalreview.com/finance/congress-last-minute-1-7-trillion-omnibus-package-8-healthcare-takeaways.html
HHS Offers States Flexibility to Better Address Medicaid Enrollees' Needs
HHS, through CMS, has released guidance on an opportunity for states to address health-related social needs for people with Medicaid coverage through the use of "in lieu of services and settings" in Medicaid managed care. This option will help states offer alternative benefits that take aim at a range of unmet health-related social needs, such as housing instability and food insecurity, to help enrollees maintain their coverage and to improve their health outcomes. (https://www.hhs.gov/about/news/2023/01/04/hhs-offers-states-flexibility-to-better-address-medicaid-enrollees-needs.html)
Meanwhile, the GAO Releases Report & Recommendations to CMS to Address Risks Posed by Provider Enrollment Waivers & Flexibilities Implemented as Part of COVID-19 Response
On December 19, 2022, the U.S. Government Accountability Office released a report titled, "Medicare: CMS Needs to Address Risks Posed by Provider Enrollment Waivers and Flexibilities." The report summarizes GAO's analysis of the 47 waivers and flexibilities that CMS issued to sustain Medicare's provider workforce and ensure that Medicare beneficiaries had access to care during the COVID-19 pandemic. In its report, GAO makes several recommendations to CMS to address the risks posed by the waivers and flexibilities. More info: https://www.kslaw.com/news-and-insights/health-headlines-december-27-2022
CMS Proposes Rule to Require Certain Health Plans to Electronically Share Data with Providers Regarding Prior Authorization Requests
CMS has published a proposed rule requiring certain Medicare, Medicaid, Children's Health Insurance Program, and Qualified Health Plan fee-for-service and managed care plans to share electronic health data directly with hospitals and other providers. The stated goals of the Proposed Rule are to implement an electronic prior authorization process, shorten the time frames for certain payers to respond to prior authorization requests, and establish policies to make the prior authorization process more efficient. (https://www.kslaw.com/news-and-insights/health-headlines-december-12-2022)
U.S. Healthcare-Spending Growth Slowed in 2021 - to Just $4.3 Trillion, Federal Report Finds
Growth in U.S. healthcare spending slowed to 2.7% in 2021 after a 2020 surge in federal outlays on the pandemic, according to a recent report from CMS, which said national healthcare spending grew in 2021 to $4.3 trillion. Overall health spending had risen by 10.3% in 2020, and the more moderate increase in 2021 was largely driven by a drop off in federal spending related to Covid-19. In fact, federal health spending fell 3.5% in 2021 to $1.46 trillion after surging almost 37% in 2020. At the same time, there was an uptick in spending on insurance coverage and healthcare services in 2021. (https://www.wsj.com/articles/u-s-healthcare-spending-growth-slowed-in-2021-federal-report-finds-11671046871?mod=lead_feature_below_a_pos1)
Drug Prices Reach New High - in the Millions
Since August, U.S. or European health regulators have approved four new products intended as one-time treatments for rare genetic diseases that carry list prices of at least $2 million a patient. The price tags mark a new high for medicines, which drugmakers were once reluctant to charge more than six figures for but whose prices have been heading upward. The companies say the cost reflects the drugs' potential to help patients in a single dose, but paying for it could challenge patients and health insurers. Most of the multimillion-dollar treatments are gene therapies, a groundbreaking type of treatment that involves injecting a functional gene into a person to correct a faulty, disease-causing one. (https://www.wsj.com/articles/drug-prices-reach-new-highin-the-millions-11671990099?mod=hp_lead_pos6)
FDA Approves Alzheimer's Drug for Mild, Early-Stage Disease
U.S. health officials have approved a closely watched Alzheimer's drug that modestly slows the brain-robbing disease, albeit with potential safety risks that patients and their doctors will have to carefully weigh. The drug, Leqembi, is the first that's been convincingly shown to slow the decline in memory and thinking that defines Alzheimer's by targeting the disease's underlying biology. The FDA approved it for patients with Alzheimer's, specifically those with mild or early-stage disease. The drug will cost about $26,500 for a typical year's worth of treatment. Eisai said the price reflects the drug's benefit in terms of improved quality of life, reduced burdens for caregivers and other factors. The company pegged its value at over $37,000 per year, but said it priced it lower to reduce costs for patients and insurers. However, the Institute for Clinical and Economic Review, a nonprofit that analyzes drug prices based on their benefit. in a draft report, found that the drug would be cost effective for patients at a price ranging from $8,500 to $20,600 per year. (https://www.modernhealthcare.com/government/fda/legmgi-alzheimer%27s-drug-eisai-biogen) (https://www.wsj.com/articles/new-alzheimers-drug-approved-by-fda-promises-to-slow-disease-11673032312?mod=hp_lead_pos3)
In Response, Blues Plans Launch Synergie to Cut Costs for the Priciest Drugs
Elevance Health (fka Anthem) and a coalition of other Blue Cross and Blue Shield carriers have launched Synergie Medication Collective, an independent company the plans see as a novel solution to costly physician-administered drugs. Nearly every Blue Cross and Blue Shield insurer invested undisclosed sums in the new venture. That makes Synergie one of the largest Blues collaborations in history. These companies cover nearly 100 million members and aim to use their collective muscle to extract better deals and standardized contracts from pharmaceutical companies and the providers that administer drugs, said Synergie CEO Jarrod Henshaw. Drug manufacturers now make most of their profits by developing high-cost treatments intended for small patient populations. Specialty medicines represented the majority of the $407 billion spent on the pharmaceuticals in the U.S. in 2021 - 55%, up from 28% a decade before - according to the data from the IQVIA Institute. Synergie stops short of being a full medical benefit manager because it does not provide utilization management services such as prior authorization or focus on site-of-service delivery by encouraging home visits, Henshaw said; rather it will operate under a transparent, pass-through model, where it hands over cost savings to participating insurers. (https://www.modernhealthcare.com/insurance/blue-cross-synergie-medication-collective-specialty-drug-gene-therapies)
Moderna Signs $35 Million Deal with Cancer Drug Developer CytomX
Moderna Inc. announced a $35 million licensing deal with cancer-focused drug developer CytomX Therapeutics to work on messenger RNA-based therapies for a wide range of diseases. The news comes a month after an experimental cancer vaccine from Moderna based on mRNA technology was shown to work against a type of skin cancer. The companies will work together to discover experimental therapies and Moderna will be responsible for human trials and commercial activities of products. (https://www.reuters.com/business/healthcare-pharmaceuticals/moderna-cytomx-announce-mrna-collaboration-2023-01-05/)
Drug Companies Join Medical Psychedelic Movement - But Without the High
Drug developers are designing new psychedelic compounds to treat depression and other mental-health conditions but skip the trip. Mind-bending psychedelics including MDMA (aka "ecstasy"), "magic mushrooms" and LSD are being studied as potential treatments for depression, post-traumatic stress disorder and addiction. Dozens of companies and academic laboratories are also making changes to the structure of those drugs, or designing similar compounds, to take advantage of their therapeutic properties without the high. (https://www.wsj.com/articles/drug-companies-join-medical-psychedelic-movementbut-without-the-high-11671319811?mod=hp_lista_pos3)
Abortion Pills to Be Available More Widely Under New FDA Rules
The FDA has expanded access to a drug that induces abortion, allowing bricks-and-mortar pharmacies to dispense the pills for the first time. Under the changes the agency issued, any pharmacy can complete and sign a short form to become certified to provide the so-called abortion pill, not just the handful of mail-order pharmacies that were permitted to ship prescriptions during the pandemic. (https://www.wsj.com/articles/abortion-pills-to-be-available-more-widely-under-new-fda-rules-11672789765?mod=hp_lead_pos10)
HEALTHCARE INDUSTRY TRENDS FOR 2023 & BEYOND
Headwinds Are Facing Group Medicare Advantage Growth
New York City's struggle to switch more than a quarter-million retired government workers and their dependents from traditional Medicare to private health insurance could set an alarming precedent for employers and insurers banking on the fast-growing group Medicare Advantage program. Cost-conscious employers offering retiree benefits are increasingly adopting such plans as alternatives to existing commercial health plans or traditional Medicare coverage. Membership through group plans represents nearly 20% of the 29.5 million individuals enrolled in Medicare Advantage, and the number of patients enrolled through this kind of coverage more than doubled over the last decade, according to the latest federal data. But public and private employers seeking to join the trend may face pushback from retirees who fear their benefits will be limited. Some former workers have sued their previous employers to block the switch. Federal investigations into Medicare Advantage carriers and the potential for changes to the program this year from CMS could also present hurdles. (https://www.modernhealthcare.com/insurance/group-medicare-advantage-challenges-growth-medicare-lawsuits)
Top 10 Hospital and Payer Trends to Watch in 2023
Per Healthcare Finance News, here are the Top 10 trends from 2022 that are likely to influence hospital and payer decisions in 2023. See the stories at the link to take a closer look at how and why those trends will continue into 2023. Then check back at the link every week through the end of the year for more coverage.
> The end of the public health emergency: What happens next?
> Technology, digital health and automation: Strategies to streamline, reach patients and goals.
> Hospital finances: Cutting expenses, where to save?
> The retail competition: Amazon, CVS, Walgreens, UnitedHealth move into primary care.
> Payers: Meeting the Transparency in Coverage rule that goes into effect January 1, 2023.
> Hospital at home checks the boxes: an aging demographic and a less expensive alternative.
> Medicare Advantage: Who's in, who's out? Telehealth: Fad or future?
> Mergers, acquisitions and partnerships.
> Interoperability for providers and payers.
SCAN Group Merges with Oregon Managed Medicare & Medicaid Nonprofit
Long Beach-based SCAN Group, a senior healthcare nonprofit, and Portland, Oregon-based CareOregon, a managed care nonprofit, have agreed to merge under the new name HealthRight Group. The merger is intended to give both nonprofits more clout in a marketplace for government-funded healthcare programs increasingly dominated by for-profit managed care providers. The deal is expected to close sometime this year.
In addition to its health plans, HealthRight will operate a diversified business unit comprising assets from both organizations including Welcome Health, a geriatric home-based primary care medical group; Housecall Providers, an in-home primary and palliative care provider; MyPlace Health, a joint venture between Scan Health and Boston-based Commonwealth Care Alliance; Healthcare in Action, a medical group for people experiencing homelessness; and HomeBase Medical, a medical group focused on improving chronic disease management and palliative care for Medicare beneficiaries. (https://labusinessjournal.com/healthcare/medical-center/scan-group-merges-with-oregon-managed-medicare-and-medicaid-nonprofit/)
According to the Wall Street Journal, the deal is the latest sign of how government-backed health coverage, including both Medicare and Medicaid, is increasingly the core of the managed-care business and the main engine of its growth. About 70% of Medicaid enrollees are now in managed-care plans, according to the Kaiser Family Foundation. (https://www.wsj.com/articles/nonprofit-health-plans-with-6-8-billion-in-projected-revenue-set-to-combine-11671038354?mod=hp_lista_pos4)
Meanwhile, Sachin Jain's Top 10 Healthcare Industry Predictions For 2023
In a recent Forbes article, Sachin Jain, President and CEO of SCAN Group and Health Plan, offered some predictions for 2023 - some "pure hunch; others are extensions of trends observed in 2022 that will continue into 2023; and others still are a reflection of my deepest hopes - some of which I hope I will nudge into being by writing it here in this column." In summary they are:
1) Medicare Advantage Will Remain Under A Microscope.
2) A Private Equity and Venture Capital Feeding Frenzy Of A Different Kind.
3) More and More Customer Segmentation.
4) Toxic Positivity Around Value-Based Care Will Abate.
5) Home-Based Care Will Get A Closer Look.
6) Biopharmaceutical Innovation Will Continue to Impress at Prices That Won't.
7) Tech and Retail Will Continue to Inch Into Healthcare Delivery.
8) COVID's Impact Continues.
9) Progress on the True Underlying Causes of Clinician Burnout.
10) Greater Recognition That We Have a Leadership Crisis in American Healthcare
CVS Spends Billions to Expand from a Chain of Drugstores to a Full-Service Healthcare Company
CVS invested $100 million in Carbon Health Inc., a San Francisco-based chain of urgent- and primary-care clinics, according to a recent announcement. Just hours later, Bloomberg News reported that CVS was in negotiations to buy Oak Street Health Inc., a decade-old chain of clinics that service Medicare recipients, for more than $10 billion. (https://www.marketwatch.com/story/cvs-eyes-next-generation-health-clinics-after-amazons-move-for-one-medical-11673313087)
Where Digital Health Funding Could Go in 2023
After a year  of mega-rounds, skyrocketing valuations and a parade of growing digital health startups, the investment landscape looked a lot more tepid in 2022. But there are still plenty of opportunities for startups, especially for companies that can demonstrate their value amid a challenging economic environment, said Dr. Sunny Kumar, partner at GSR Ventures. Kumar sat down with MobiHealthNews to discuss digital health funding and his predictions for 2023. (https://www.mobihealthnews.com/news/qa-where-digital-health-funding-will-go-2023)
AND MORE. . .
How Doctors Treat Their Own Colds and Flus: Squirt Bottles Filled with Saline Solution, Elderberry Tablets & Cans of Chicken Soup
Since Americans are being hit with a barrage of seasonal illnesses right now, the Wall Street Journal asked ear, nose and throat specialists, pediatricians and family doctors about the medicines they take and remedies they swear by when sick. All the doctors said that rest and fluids are key. And everyone said it's important to be up-to-date on flu shots and Covid vaccinations, including boosters. They had more surprising advice too, such as which over-the-counter medications are worth taking, when to stock up on supplies, and how to avoid a potential risk of nasal irrigation. (https://www.wsj.com/articles/when-doctors-get-sick-with-flu-other-viruses-how-to-treat-11671730067?mod=hp_featst_pos3)
Why Human-Animal Hybrid Brains Hold Promise for Neurological Disease
Scientists around the world are implanting tiny blobs of human brain tissue into the brains of rodents, creating hybrid organs called chimeras. In this video, Wall Street Journal's Daniela Hernandez explains how they work and what scientists hope to learn from them: https://www.wsj.com/video/series/daniela-hernandez/why-human-animal-hybrid-brains-hold-promise-for-neurological-disease/C9710C90-FA64-4C9F-A890-3ED5E1970812?mod=hp_featst_pos4
A New Test For Autism Hopes To Help Doctors Diagnose Before Symptoms Show
Researchers have developed a first-of-its-kind test for autism that they say can find markers of risk in a single strand of hair, an innovation that might help clinicians identify it in young children before they miss developmental milestones. The FDA gave LinusBio's test a "breakthrough" designation, which is intended to speed up the regulatory approval process for new technology when there aren't alternatives on the market. The designation does not change approval standards, and the company faces regulatory hurdles before its device could be considered for widespread use in the U.S. (https://www.nbcnews.com/science/science-news/new-test-autism-hopes-help-doctors-diagnose-symptoms-show-rcna61081)