About Covid-19
Coronavirus (COVID-19) Update: FDA Authorizes Changes to Simplify Use of Bivalent mRNA COVID-19 Vaccines The FDA “amended the emergency use authorizations (EUAs) of the Moderna and Pfizer-BioNTech COVID-19 bivalent mRNA vaccines to simplify the vaccination schedule for most individuals. This action includes authorizing the current bivalent vaccines (original and omicron BA.4/BA.5 strains) to be used for all doses administered to individuals 6 months of age and older, including for an additional dose or doses for certain populations. The monovalent Moderna and Pfizer-BioNTech COVID-19 vaccines are no longer authorized for use in the United States.”
Biden Administration Will Fund Program to Keep Covid Vaccines Free for the Uninsured “The Biden administration plans to spend more than $1 billion on a new program to offer free coronavirus shots to uninsured Americans after the vaccines move to the commercial market later this year…
The program for the uninsured, which will be modeled partly on an existing childhood vaccination program and will cover an estimated 30 million people, will include a first-of-its-kind partnership with pharmacy chains in which the government will pay the administrative costs of giving the doses to patients. Pfizer and Moderna have pledged to offer the shots at no cost to those who lack insurance.”
About health insurance/insurers
Trends in Premiums, Claims, and Enrollment for Fully Insured Large Group, Small Group, and Individual Health Plans From 2011 to 2021 “From 2011 to 2021, median annual premium per enrollee grew by 5.9% ($5701 to $6035) for large group plans, 9.6% ($5683 to $6228) for small group plans, and 59.0% ($3574 to $5683) for individual plans. Median claims per enrollee grew faster by 14.9% for large group plans, 21.0% for small group plans, and 96.6% for individual plans.. Large and small group plans had a decline in total enrollment from 49.4 to 41.1 million and from 18.8 to 11.5 million, respectively, while individual plan enrollment increased from 10.9 to 14.9 million.
Across all markets, median annual premiums and claims per enrollee increased for almost every state.”
Elevance Health's profits rise 11% in Q1 to $2B Elevance Health raked in $2 billion in profit for the first quarter of 2023, up 11% year over year, according to the company's earnings report released Wednesday.
Revenue was also up by double digits, according to the report, growing by 10.5% to $39.6 billion. The insurer reported $1.8 billion in profit and $35.8 billion in revenue for the first quarter of 2022.”
SCOTUS Case Could Swing FCA Claims Toward Whistleblowers “The case alleges that the Medicaid-backed programs run by the grocery store’s pharmacies defrauded the company by failing to report “usual and customary” prices accurately to regulators. But the company says that it was audited 12,000 times over more than a decade before the issue was brought up and the lack of better guidance from the government doesn’t make it liable for the alleged scheme.”
Comment: The outcome will depend on the justices’ deciding whether intent is important. Court observers are leaning to the conclusion that it will not matter in this case.
Former Physician Associated with 1-800-GET-THIN Sentenced to 7 Years in Federal Prison for Massive Fraud Against Health Insurers A former doctor has been sentenced to 84 months in federal prison for scheming to defraud private insurance companies and the Tricare health care program for U.S. military service members by fraudulently submitting nearly $120 million in claims related to the 1-800-GET-THIN Lap-Band surgery business, the Justice Department announced today…
Omidi is a former dermatologist whose medical license was revoked in 2009 after state authorities found he had engaged in dishonesty and unprofessional conduct related to his application for his California medical license…
Omidi established procedures requiring prospective Lap-Band patients – even those with insurance plans he knew would never cover Lap-Band surgery – to have at least one sleep study, and employees were incentivized with commissions to make sure the studies occurred.
Omidi used the sleep studies to find a reason – the ‘co-morbidity”’of obstructive sleep apnea – that GET THIN would use to convince the patient’s insurance company to pre-approve the Lap-Band procedure.
After patients underwent sleep studies – irrespective of whether any doctor had ever determined the study was medically necessary – GET THIN employees, acting at Omidi’s direction, often falsified the results. Omidi then used the falsified sleep study results in support of GET THIN’s pre-authorization requests for Lap-Band surgery.”
Price Transparency Impact Report A good summary of where payers and hospitals are in their transparency compliance.
About hospitals and healthcare systems
Analysis of Hospital Operating Margins and Provision of Safety Net Services “In this cross-sectional study of 4219 hospitals, higher levels of uncompensated care, low-compensation care, and area socioeconomic disadvantage were associated with lower operating margin, while providing more essential services or being a critical access hospital were not.”
TWO EXAMPLES OF HOW HOSPITALS CAN RUN AFOUL OF FEDERAL LAWS:
Meharry Medical College Agrees To Settle False Claims Act Allegations “The United States alleged that, from 2016 until March 2020, Meharry submitted fraudulent claims to Medicare seeking payment for physician services provided in the internal medicine, OB/GYN, and psychiatric outpatient clinics, and for psychiatric consultations at Nashville General Hospital. In reality, these services were performed by unsupervised, non-physician residents.”
Sibley Hospital and Johns Hopkins Health System Settle Allegations of Improper Compensation Arrangements “Sibley Hospital (Sibley) and its parent company, Johns Hopkins Health System (Johns Hopkins), have agreed to pay the United States $5 million to resolve allegations arising from claims that Sibley submitted to the Medicare Program, the Justice Department announced today…
Today’s settlement resolves allegations that, from 2008 through 2011, Sibley violated the Stark Law by billing Medicare for services referred by ten cardiologists to whom Sibley was paying compensation that exceeded the fair market value of the services provided. These allegations arose out of conduct that Sibley and Johns Hopkins self-disclosed to the United States.”
About pharma
Alito extends temporary freeze, maintaining abortion pill access for two more days “Justice Samuel Alito maintained the current level of access to a widely used abortion pill for two more days, a temporary measure that gives the high court more time to weigh emergency appeals from the Biden administration and a company that makes the drug.”
Conflicts of Interest [COI] Among Infectious Diseases Clinical Practice Guideline Authors and the Pharmaceutical Industry “We assessed the prevalence of COI associated with guideline-recommended drugs among Infectious Diseases Society of America (IDSA) CPG authors and compliance with Council on Medical Specialty Societies (CMSS) and Institute of Medicine (IOM) guidelines…
Among 10 IDSA CPGs [clinical practice guidelines], approximately one-half of authors (71 of 149 [47.7%]) disclosed a relationship with any pharmaceutical company, and one-third (48 of 149 [32.2%]) had 1 or more COI or high-level COI.”
Inside the Online Market for Overseas Abortion Pills A terrific investigative piece from The NY Times.
About healthcare personnel
Physicians who accept Medicare, Medicaid patients at all-time low of 65% “Reduced Medicare and Medicaid payments are having more physicians considering reducing those patient bases, according to Medscape's ‘Physician Compensation Report’ for 2023.
Sixty-five percent of physicians surveyed said they would continue treating current Medicare or Medicaid patients and take on new ones, according to the report. Medscape said it is the lowest percentage it has seen in its annual compensation reports. Five years ago, 71 percent of physicians said they would continue treating current Medicare or Medicaid patients and take on new ones.”
Comment: Consider the access implications.