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HEALTHCARE & GOVERNMENT
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CMS Recalculates Medicare Advantage Star Ratings in Major Win for Insurers |
CMS has recalculated plans' quality ratings in the Medicare Advantage program after a series of court rulings challenging the agency's methodology in determining scores for 2024. The redo will result in hundreds of millions in additional taxpayer dollars going to insurers next year, even as regulators try to get a handle on runaway spending in the privately-run Medicare program. Regulators will recalculate each plans' star ratings, but only officially apply them if their stars improve, CMS said. Plans with ratings that would fall under the new methodology won't see their ratings change. Plans that receive four stars or above receive a 5% quality bonus adjustment for the following year and have their benchmark increased. Bidding against a higher benchmark rate and higher rebate percentages give plans a competitive advantage with respect to benefit offerings and plan value. Payers defend their stars fiercely as a result.
If all MA plans had their ratings recalculated based on the rulings, 76 contracts under 44 health insurers would gain at least 0.5 stars, according to an analysis by actuarial consulting firm Milliman. That represents almost 3.5 million MA beneficiaries in higher-ranked plans. Redoing all the ratings could result in upwards of $1 billion in additional bonuses to insurers, according to experts. (https://www.healthcaredive.com/news/cms-recalculates-medicare-advantage-star-ratings/718967/)
MEANWHILE, Becker's Healthcare published a list of the 40 insurers who had contracts upgraded by CMS, according to data published July 2.
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Healthcare Considerations Among Measures Added to California Ballot;
AND, Billions for Medi-Cal at Stake with Health Tax in California 2024 Election |
California voters will be asked to consider 10 ballot measures in November. Among the initiatives: funding Medi-Cal and Medicaid payments for pharmaceuticals. Read More: https://apnews.com/article/california-ballot-initiatives-constitution-november-election-37f294cbcafba65e12fa6a0339820636
AND, Billions for Medi-Cal at Stake with Health Tax in California 2024 Election: Come November it will be up to California voters whether to lock billions of special tax dollars into Medi-Cal or leave the decision up to lawmakers who might be tempted to use the money elsewhere. The budget deal Gov. Newsom recently signed commits roughly $2 billion through 2026 to increase payments to some doctors and health providers who see Medi-Cal patients, encouraging them to accept more low-income patients. The deal relies on a special tax that health insurance companies pay. But there's a catch in the upcoming election, and it could undo some payment increases that are in the budget.
A ballot initiative supported by nearly the entire health care industry seeks to hold Newsom to a promise made last year to permanently secure tax money for health care rather than letting future lawmakers use it to offset cuts to prisons, parks, roads and other services. The tax is expected to generate more than $35 billion over the next four years. Under the initiative, Medi-Cal would get more money, and a different but bigger group of doctors and providers would get higher rate increases than what's currently in the budget. (https://calmatters.org/health/2024/07/medi-cal-mco-tax-initiative/
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HEALTHCARE IN THE COURTS
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Supreme Court Delivers Blow to Power of Federal Agencies, Overturning 40-year-old Precedent |
The Supreme Court's recent ruling involved challenging a regulation dating to 1984, called Chevron v. Natural Resources Defense Council. That decision said judges should defer to federal agencies in interpreting the law when the language of a statute is ambiguous, thereby giving regulatory flexibility to bureaucrats. (https://www.nbcnews.com/politics/supreme-court/supreme-court-delivers-blow-power-federal-agencies-rcna145344)
IN REGARDS TO THE NATION'S HEALTHCARE SYSTEM, the landmark decision is expected to call into question government rules on anything from consumer protections for patients, to drug safety, to nursing home care. Instead of giving priority to agencies, courts will now exercise their own independent judgment about what Congress intended when drafting a particular law. (https://www.sfchronicle.com/health/article/supreme-court-ruling-curbing-federal-agencies-19552454.php)
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Labor Union Ordered to Pay $6M+ to California HCA Hospital |
Service Employees International Union 121RN was ordered May 31 by a Los Angeles-based federal arbitrator to pay Riverside (Calif.) Community Hospital, part of Nashville, Tenn.-based HCA Healthcare, $6.26 million in damages for holding an "unlawful strike" in June 2020. The union was found liable in a May 2023 decision for a 10-day strike that, under the collective bargaining agreement." The awarded damages will cover the cost of replacing employees who left their job during the strike, regardless of hospital leadership warnings that it would violate CBA terms. (https://www.beckershospitalreview.com/legal-regulatory-issues/labor-union-ordered-to-pay-6m-to-california-hca-hospital.html)
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HEALTHCARE ADVANCEMENTS - IN DIGITAL, AI, ALZHEIMER'S
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2024 Half-year Funding: $5.7B Across 266 Digital Health Deals |
According to Rock Health, $5.7B was deployed across 266 digital health startup raises in the first half of the year, meaning 2024 could potentially outperform 2023 if investment pace holds. Emerging startups and AI solutions commanded funders' attention—with early-stage deals (Seed, Series A, and Series B) accounting for 84% of labeled raises, and 34% of total sector funding going to startups leveraging artificial intelligence. The prevalence of unlabeled fundraises also started to taper, suggesting a return to more standard venture patterns with fewer "exceptional" measures needed. Read Rock Health's H1 2024 funding recap to digest the past six months of digital health investments, public exits, acquisitions, and more. (Rock Health Rock Weekly, 7/8/24)
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GenAI is Helping to Transform Healthcare - PwC |
In health services, 76% of executives consider Al and GenAI as priority investments for the next 12 months, according to PwC's latest emerging technology survey. In fact, 54% of the health services executives PwC surveyed are already using GenAI in some areas of their business. Healthcare organizations want GenAI to quickly steer them toward better member, patient and provider experiences, greater productivity, lower administrative costs, and lower costs of care overall, including [in summary]: Streamlined care operating models; Accelerated delivery models; Cost of care reduction; Amplified employee engagement; and Dynamic and context-aware workflow execution.
Payers and providers are leveraging GenAI across different areas of the value chain, including: Support for customer service representatives and for utilization management resources - both through GenAl-powered assistants; Conducting health risk assessments and member information retrieval; Use of natural language processing to help generate data queries for backend IT functions; and Summarizing policies, vendor contracts and state hearing content for streamlined regulatory compliance functions.
Other survey findings include that health services organizations can also leverage GenAI for cyber defense. Read PwC's "GenAI is helping to transform healthcare" for more information.
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OpenAI Expands Healthcare Push with Color Health's Cancer Copilot |
OpenAI is working with startup Color Health to expand the use of artificial intelligence in healthcare by applying its AI models to cancer screening and treatment. Color Health, which was founded as a genetic testing company in 2013, has developed an AI assistant or "copilot" using OpenAI's GPT-4o model. The copilot helps doctors create cancer screening plans, as well as pretreatment plans for people who have been diagnosed with cancer. The copilot is intended to assist doctors, not replace them, according to the startup's CEO. The AI lab announced in April a deal with Moderna where the biotech company uses AI to speed up business processes and tasks like selecting optimal doses for clinical trials. (https://www.wsj.com/articles/openai-expands-healthcare-push-with-color-healths-cancer-copilot-86594ff1)
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How Abridge Became One of the Most Talked About Healthcare AI Startups |
Abridge is an AI-powered platform purpose-built for medical conversations, to improve clinical documentation efficiencies while enabling clinicians to focus on their patients. With support for 14+ languages and 50+ specialties, Abridge is able to support a wide range of clinician and patient encounter. A recent TechCrunch article spotlights the company and reports that large hospitals are buying multi-thousand seat licenses of Abridge and publishing glowing reviews about how the software is changing physicians' lives as a virtual medical note taker recording in the background, so a physician can focus entirely on the patient without having to worry about filling out specific fields in EMR during the visit. Earlier this year, Abridge gained a right to be integrated inside Epic. (https://techcrunch.com/2024/06/18/how-abridge-became-one-of-the-most-talked-about-healthcare-ai-startups/)
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Approval of Newest Alzheimer's Drug Will Accelerate New Era of Treatment |
With drugs such as Eli Lilly's newly approved Kisunla coming online, Alzheimer's treatment promises to slow cognitive decline, if only modestly, and to become more widely used, more like treatment of cancer or rheumatoid arthritis, in which patients flock to get infusions. "You're going to slow down the progression of the decline, and make patients more independent for longer periods of time." A big hurdle to increasing the availability of Alzheimer's treatment will be securing insurance coverage. Kisunla, which is administered monthly, will cost about $12,522 for six months of treatment. Most patients are expected to complete treatment within 18 months, and costs wouldn't recur after that. Lilly expects Kisunla to be covered by Medicare as well. (https://www.wsj.com/health/healthcare/approval-of-newest-alzheimers-drug-will-accelerate-new-era-of-treatment-645bfa25?mod=hp_lead_pos4)
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HEALTHCARE & PEOPLE
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Shrinking Drug Coverage Puts Americans in a Medical & Monetary Bind |
After reviewing more than 3,700 Medicare Part D plans from 2010 to 2024, the prescription drug comparison site GoodRx found health insurers are covering fewer drugs and putting more restrictions on their drug coverage, but are still raising costs for consumers,. Even if insurance helps cover a medication's cost, increasing copays, co-insurance and deductibles can still make the prescription financially out of reach. Over the past 10 years, the average deductible for a single enrollee almost doubled, to $1,644 from $917, nonprofit researcher KFF said. (https://www.usatoday.com/story/money/personalfinance/2024/07/01/shrinking-drug-coverage-insurance-impact/74240289007/)
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US Surgeon General: Social Media Should Come with a Warning Label |
Social media apps should have a warning label about their potential to harm young people's mental health, the U.S. Surgeon General said recently. Vivek Murthy, MD, wrote in a New York Times op-ed that since social media is an "important contributor" to a mental health crisis among young people, a warning label could increase awareness and change behavior. He cited similar warnings applied to tobacco products, and said a warning label would be part of broader regulation for social media.
AND, in this video, CNN's Erin Burnett talks to Dr. Murthy about the risks of social media and phone use in children, and what his plan is with his own kids (to not let them have smart phones until high school). (https://www.cnn.com/2024/06/17/health/video/vivek-murthy-phone-age-kids-ebof-intv-digvid)
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CYBERCRIME IN THE HEALTHCARE INDUSTRY
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At Last! A Health Record Cyberhacker Got Caught! |
A data breach at Geisinger may have exposed the personal information of more than 1.2 million patients, according to a report filed with federal regulators. In late November, the Pennsylvania-based health system discovered a former employee of Nuance Communications, a Microsoft subsidiary, had accessed certain patient information two days after the employee was terminated, according to Geisinger. Law enforcement asked Nuance to delay notifying patients about the breach until now to avoid impacting their investigation. The worker has been arrested and is now facing federal charges, Geisinger said. Data exposed by the employee varied by patient, but could include names, birth dates, addresses, admit and discharge or transfer codes, medical record numbers, race, gender, phone numbers and facility names. No claims or insurance information, financial information or Social Security numbers were accessed by the former employee. (https://www.healthcaredive.com/news/geisinger-nuance-communications-data-breach/720382/)
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