Healthcare system and insurance news and discussion

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weatheriscool
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Healthcare system and insurance news and discussion

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Insurance giant's new ER policy called 'dangerous' by critics.
Source: USAToday
Insurance giant UnitedHealthcare is cracking down on emergency room visits with a new policy starting July 1 that the American Hospital Association says will jeopardize patients’ health and threaten them with financial penalties. The American College of Emergency Physicians said it fears the change will cause patients to avoid using emergency rooms because they will be responsible for their hospital bills when UnitedHealthcare rejects them.

UnitedHealthcare this month told its network hospitals in 34 states including Florida that it will assess emergency room claims to determine if visits were indeed medical emergencies. Claims that are determined not to be tied to emergencies will be subject to no coverage or limited coverage based on the patient’s insurance plan, according to the insurer’s notice sent to hospitals. As many as 1 in 10 claims could be rejected, said Tracey Lempner, spokeswoman for the Minnesota-based insurer.

UnitedHealthcare’s policy affects commercially insured patients with employer-sponsored plans and does not apply to patients with Medicare Advantage or contracted Medicaid coverage with UnitedHealthcare, Lempner said. UnitedHealthcare in 2018 said it had more than 30 million Americans with commercial or employer-sponsored plans. “If the event is determined to not be an emergency, the claim will be paid based on the member’s benefits,” Lempner said, adding, “We estimate that nationally less than 10% of (Emergency Department) claims will be classified as non-emergent through this program.”

The policy will take effect in 34 states and the District of Columbia, Lempner said. They are: Alabama, Arizona, Arkansas, Colorado, Connecticut, Washington, D.C., Delaware, Florida, Georgia, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Mississippi, Nebraska, Nevada, New Hampshire, New Jersey, New York, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, West Virginia and Wisconsin.
Read more: https://www.usatoday.com/story/news/hea ... 629006002/
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WH budget office approves Biden's plan to retract insulin, epipen discounts: report
The measure aimed to require some community health centers to deliver savings to low-income patients

https://www.foxbusiness.com/politics/wh ... nts-report
By Brittany De Lea FOXBusiness
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Innovation in health care will be led by ‘explosion of data’: Rubicon Founders CEO

The White House this week gave President Biden the greenlight to move forward with removing a Trump-era health care policy designed to bring down the price of insulin.

Biden’s bid to retract the rule was approved on Monday, as reported by Politico, with the expectation that the Department of Health and Human Services could publish the retraction within the coming days.

The measure, signed off on under the previous administration in December, aimed to require some 340B community health centers to deliver savings to low-income patients for insulin and epinephrine in a bid to bring down unaffordable prices.

Spokespeople for the White House and the Department of Health and Human Services did not return FOX Business’ request for comment.


Evil to the core! :twisted:
weatheriscool
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Medicare copays for new Alzheimer's drug could reach $11,500
https://apnews.com/article/government-a ... 401a88efe3

By RICARDO ALONSO-ZALDIVAR

WASHINGTON (AP) — A new $56,000-a-year Alzheimer’s drug would raise Medicare premiums broadly, and some patients who are prescribed the medication could face copayments of about $11,500 annually, according to a research report published Wednesday.

The drug, called Aduhelm, was approved by the Food and Drug Administration only this week. It’s the first Alzheimer’s medication in nearly 20 years, though it doesn’t cure the life-sapping neurological condition. Some experts question whether Aduhelm provides any benefit to patients, but the FDA determined it can reduce harmful clumps of plaque in the brain, potentially slowing dementia.

Wednesday’s analysis by the nonpartisan Kaiser Family Foundation comes as congressional Democrats are trying to build consensus around legislation that would empower Medicare to negotiate prescription drug prices.

The chairman of the Senate Finance Committee, Democratic Sen. Ron Wyden of Oregon, said the list price for the Alzheimer’s drug was “unconscionable.” Although President Joe Biden has called for granting Medicare negotiating authority, prospects for the bill are uncertain.
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caltrek
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Supreme Court Rejects Republican Challenge to Affordable Care Act
by Sam Baker
June 17, 2021

Introduction:
(Axios) The Supreme Court Thursday morning tossed aside conservatives' latest challenge to the Affordable Care Act, rejecting the Trump administration’s bid to get the entire health care law thrown out.

Why it matters: The 7-2 ruling will allow the ACA, which covers some 20 million people and has been the law of the land for 11 years, to continue operating. It also shows there are some limits to how much of the Republican agenda can be accomplished through the courts, even with a solid conservative majority.

Details: The court said Republican attorneys general did not have the legal standing to bring their lawsuit, which aimed to get the entire ACA struck down. It's the third time the Supreme Court has saved the law.

How we got here: The ACA required most Americans to either purchase health insurance or pay a tax penalty. When the law first passed, that mandate was seen as essential to making the law’s other provisions work, particularly its protections for people with pre-existing conditions.
Some points that occur to me in reading this:
  • The ACA "has been the law of the land for 11 years" - Ok, this is one of those you are living in the future moments. Wow. Has it really been eleven years?
  • The Supreme Court is sometimes is not as reactionary as I feared it might be. This is yet another example of that happening.
  • Another example of how utterly right-wing are many Republican attorneys general
Don't mourn, organize.

-Joe Hill
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caltrek
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The Biden administration today indicated that it is issuing an Executive Order with potentially far reaching economic consequences. The health care industry will be one of several sectors to be impacted. Here is that portion of a White House statement that concerns health care delivery:
The proposed Order tackles four areas where lack of competition in healthcare increases prices and reduces access to quality care.

Prescription Drugs: Americans pay more than 2.5 times as much for the same prescription drugs as peer countries, and sometimes much more. Price increases continue to far surpass inflation. As a result, nearly one in four Americans report difficulties paying for medication, and nearly one in three Americans report not taking their medications as prescribed.

These high prices are in part the result of lack of competition among drug manufacturers. The largest pharmaceutical companies are able to wield their market power to reap average annual profits of 15-20%, as compared to average annual profits of 4-9% for the largest non-drug companies.

One strategy that drug manufacturers have used to avoid competing is “pay for delay” agreements, in which brand-name drug manufacturers pay generic manufacturers to stay out of the market. That has raised drug prices by $3.5 billion per year, and research also shows that “pay for delay” and similar deals between generic and brand name manufacturers reduce innovation—reducing new drug trials and R&D expenditures.

In the Order, the President:

Directs the Food and Drug Administration to work with states and tribes to safely import prescription drugs from Canada, pursuant to the Medicare Modernization Act of 2003.

Directs the Health and Human Services Administration (HHS) to increase support for generic and biosimilar drugs, which provide low-cost options for patients.

Directs HHS to issue a comprehensive plan within 45 days to combat high prescription drug prices and price gouging.

Encourages the FTC to ban “pay for delay” and similar agreements by rule.

Hearing Aids: Hearing aids are so expensive that only 14% of the approximately 48 million Americans with hearing loss use them. On average, they cost more than $5,000 per pair, and those costs are often not covered by health insurance. A major driver of the expense is that consumers must get them from a doctor or a specialist, even though experts agree that medical evaluation is not necessary. Rather, this requirement serves only as red tape and a barrier to more companies selling hearing aids. The four largest hearing aid manufacturers now control 84% of the market.

In 2017, Congress passed a bipartisan proposal to allow hearing aids to be sold over the counter. However, the Trump Administration Food and Drug Administration failed to issue the necessary rules that would actually allow hearing aids to be sold over the counter, leaving millions of Americans without low-cost options.

In the Order, the President:

Directs HHS to consider issuing proposed rules within 120 days for allowing hearing aids to be sold over the counter.

Hospitals: Hospital consolidation has left many areas, especially rural communities, without good options for convenient and affordable healthcare service. Thanks to unchecked mergers, the ten largest healthcare systems now control a quarter of the market. Since 2010, 139 rural hospitals have shuttered, including a high of 19 last year, in the middle of a healthcare crisis. Research shows that hospitals in consolidated markets charge far higher prices than hospitals in markets with several competitors.

In the Order, the President:

Underscores that hospital mergers can be harmful to patients and encourages the Justice Department and FTC to review and revise their merger guidelines to ensure patients are not harmed by such mergers.

Directs HHS to support existing hospital price transparency rules and to finish implementing bipartisan federal legislation to address surprise hospital billing.

Health Insurance: Consolidation in the health insurance industry has meant that many consumers have little choice when it comes to selecting insurers. And even when there is some choice, comparison shopping is hard because plans offered on the exchanges are complicated—with different services covered or different deductibles.

In the Order, the President:

Directs HHS to standardize plan options in the National Health Insurance Marketplace so people can comparison shop more easily.
https://www.whitehouse.gov/briefing-roo ... n-economy/
Don't mourn, organize.

-Joe Hill
weatheriscool
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US sues Kaiser Permanente over alleged Medicare fraud
Source: AP
SAN FRANCISCO (AP) — The federal government has sued Kaiser Permanente, alleging the health care giant committed Medicare fraud and pressured doctors to list incorrect diagnoses on medical records in order to receive higher reimbursements, officials said Friday.

The U.S. Department of Justice lawsuit, filed Thursday in federal court in San Francisco, consolidates allegations made in six whistleblower complaints.

Kaiser, based in Oakland, California, is a consortium of entities that together form one of the largest nonprofit health care plans in the U.S. with more than 12 million members and dozens of medical centers.

The lawsuit said Kaiser entities gamed the Medicare Advantage Plan system, also known as the Medicare Part C program, which gives beneficiaries the option of enrolling in managed care insurance plans, according to a statement from the U.S. Department of Justice.
Read more: https://apnews.com/article/business-hea ... 80050cbf0a
weatheriscool
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UnitedHealthcare will pay $15.7M in settlement of denial of care charges
Source: StarTribune

UnitedHealthcare, the largest U.S. health insurer, has settled federal and New York state charges it illegally denied coverage to thousands of patients suffering from mental health problems and substance abuse.

The U.S. Department of Labor said on Thursday that UnitedHealth Group, the insurer's parent company, will pay about $15.7 million, including $13.6 million in restitution and a $2.1 million fine, to settle with that agency and New York Attorney General Letitia James.

Authorities accused UnitedHealthcare of violating federal and state laws by imposing more restrictive limits on coverage and treatment for mental health and substance abuse disorders than it imposed for physical health conditions. UnitedHealthcare also was accused of overcharging patients for out-of-network mental health services by reducing reimbursements.

Without admitting liability, UnitedHealthcare agreed to stop using algorithms, including in a program called ALERT, that required extra layers of review before continuing mental health treatment and often resulted in coverage being cut off.

Read more: https://www.startribune.com/unitedhealt ... 600087607/
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Kevin Ryan's AlleyCorps is Giving These Physicians $100 Million to Invest in Healthcare
by Connie Loizos
September 30, 2021

https://techcrunch.com/2021/09/30/kevin ... ealthcare/

Introduction:
(TechCrunch) Kevin Ryan — the New York-based investor and entrepreneur who first rose to prominence as CEO of the early online ad business DoubleClick — could have launched or joined a traditional venture firm many years ago. Instead, he has launched one company after another with largely his own capital at the outset to get them going. Think Business Insider and Gilt Groupe, MongoDB and Zola.

Ryan is still at it, investing a $500 million evergreen fund with primarily personal capital through a growing team that also chips into the fund and helps him both fund startups as well as to incubate them. Interestingly, despite that Ryan has no background in healthcare, more of those dollars have been moving into healthcare, too. His investment firm, AlleyCorp, has already made 20 healthcare related bets in recent years. Now, it’s carving out $100 million for a new fund to double down on the sector.

The fund, chaired by Ryan, is being led by Brenton Fargnoli, M.D., a one-time resident physician at Brigham & Women’s Hospital in Boston who was able to arrange a research elective with FlatIron Health back in 2016, which brought him to New York and into the world of entrepreneurship. (Fargnoli later did double-duty, working as a medical director at Flatiron and also as an attending physician at Memorial Sloan Kettering Cancer Center.)

Fargnoli is also being joined by another M.D., Jeff De Flavio, a physician-entrepreneur who has launched numerous companies, including Tempest, a holistic alcohol recovery program backed by AlleyCorp, and Pearl Health, a primary care physicians group that he created inside of AlleyCorp and just received Series A backing led by Andreessen Horowitz.

The team also includes medical students Omar Njie and Sherman Leung, as well as Jane Suh, who previously worked at Andreessen Horowitz.
Don't mourn, organize.

-Joe Hill
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US announces big hike in Medicare premiums [View all]
Source: CNN

The federal government announced a large hike in Medicare premiums Friday night, blaming the pandemic but also what it called uncertainty over how much it may have to be forced to pay for a pricey and controversial new Alzheimer's drug.

The 14.5% increase in Part B premiums will take monthly payments for those in the lowest income bracket from $148.50 a month this year to $170.10 in 2022. Medicare Part B covers physician services, outpatient hospital services, certain home health services, medical equipment, and certain other medical and health services not covered by Medicare Part A, including medications given in doctors' offices.

The Centers for Medicare and Medicaid Services played down the spike, pointing out that most beneficiaries also collect Social Security benefits and will see a cost-of-living adjustment of 5.9% in their 2022 monthly payments, the agency said in a statement. That's the largest bump in 30 years.

"This significant COLA increase will more than cover the increase in the Medicare Part B monthly premium," CMS said. "Most people with Medicare will see a significant net increase in Social Security benefits. For example, a retired worker who currently receives $1,565 per month from Social Security can expect to receive a net increase of $70.40 more per month after the Medicare Part B premium is deducted."


The actual spike -- the largest since 2016 -- could hurt some seniors financially.
It "will consume the entire annual cost of living adjustment (COLA) of Social Security recipients with the very lowest benefits, of about $365 per month," said Mary Johnson, a Social Security and Medicare policy analyst for The Senior Citizens League, an advocacy group. "Social Security recipients with higher benefits should be able to cover the $21.60 per month increase, but they may not wind up with as much left over as they were counting on."

Read more: https://www.cnn.com/2021/11/12/health/m ... index.html
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Medicare Advantage Plans Often Deny Needed Care, Federal Report Finds
Source: NY Times
Every year, tens of thousands of people enrolled in private Medicare Advantage plans are denied necessary care that should be covered under the program, federal investigators concluded in a report published on Thursday.

The investigators urged Medicare officials to strengthen oversight of these private insurance plans, which provide benefits to 28 million older Americans, and called for increased enforcement against plans with a pattern of inappropriate denials.

Advantage plans have become an increasingly popular option among older Americans, offering privatized versions of Medicare that are frequently less expensive and provide a wider array of benefits than the traditional government-run program offers.



The industry’s main trade group claims people choose Medicare Advantage because “it delivers better services, better access to care and better value.” But federal investigators say there is troubling evidence that plans are delaying or even preventing Medicare beneficiaries from getting medically necessary care.
Read more: https://www.nytimes.com/2022/04/28/heal ... eport.html
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