About health insurance/insurers
Medical cost trend: Behind the numbers 2024 PwC’s Health Research Institute “projects medical cost trend to be 7.0% in 2024, up from 6.0% in 2023.”
Comment: Tread the study to learn the “why” of the predicted increase.
Analysis of Medicare Advantage Enrollee Demographics, Utilization, Spending, and Quality Compared to Fee-for-Service Medicare Among Enrollees with Chronic Conditions An Avalere study:“Key Findings
—Among beneficiaries with 1 or more of the 3 conditions studied, MA had a higher proportion of beneficiaries who identify as racial and ethnic minorities than FFS (28.1% in MA vs. 12.8% in FFS) or who were enrolled in Medicare due to a disability (27.0% in MA vs. 21.6% in FFS).
—Beneficiaries in MA had lower rates of inpatient utilization and ER visits, and higher rates of physician visits. The average length of inpatient stay was higher for beneficiaries in MA than in FFS.
—Regardless of the specific chronic condition, MA beneficiaries in these subgroups had lower overall healthcare spending than FFS beneficiaries, on a PMPM basis across all expenditure types in the analysis (including acute inpatient, ambulatory outpatient, prescription drug, and all other medical costs).
—Quality was similar between MA and FFS beneficiaries on several measures, including all-cause readmissions and adherence of certain medications.
—Differences between dual-eligible beneficiaries in MA and FFS were also analyzed. Trends in utilization, spending, and quality among dual-eligible beneficiaries in MA and FFS across all the 3 studied condition subgroups were similar to MA and FFS beneficiaries in the full sample population.
How Often Do Health Insurers Say No to Patients? No One Knows. “ProPublica, in collaboration with The Capitol Forum, has been examining the hidden world of insurance denials. A previous story detailed how one of the nation’s largest insurers flagged expensive claims for special scrutiny; a second story showed how a different top insurer used a computer program to bulk-deny claims for some common procedures with little or no review.
The findings revealed how little consumers know about the way their claims are reviewed — and denied — by the insurers they pay to cover their medical costs.
When ProPublica set out to find information on insurers’ denial rates, we hit a confounding series of roadblocks….
The limited government data available suggests that, overall, insurers deny between 10% and 20% of the claims they receive. Aggregate numbers, however, shed no light on how denial rates may vary from plan to plan or across types of medical services.”
Comment: The entire article is worth reading.
11 charged in $2B telehealth fraud scheme “The Justice Department has charged 11 individuals in connection with telehealth fraud schemes that resulted in more than $2 billion in false claims.
The fraud schemes, which occurred in two different states with multiple different individuals, included:
One in the Southern District of Florida in which the Justice Department alleged that the CEO, former CEO and vice president of business development at purported software companies generated and sold templates of clinicians' orders for orthotic braces and pain creams that were not medically necessary and not eligible for Medicare reimbursement. The scheme resulted in "the submission of $1.9 billion in false and fraudulent claims to Medicare," according to a June 28 press release from the Justice Department. The scam involved a telemarketing operation that targeted elderly and disabled people.
The second case occurred in the Eastern District of Washington, where a licensed physician was accused of signing more than 2,800 fraudulent orders for orthotic braces. The physician signed the orders in less than 40 seconds and included orders for patients who had already undergone limb amputations, according to the Justice Department.
Medical equipment company owner found guilty in $24M fraud scheme “A federal jury found a California woman guilty of leading a scheme that billed Medicare more than $24 million in fraudulent claims for medically unnecessary durable medical equipment and repairs.
Tamara Motley, 54, of Redondo Beach, was found guilty on 20 counts of healthcare fraud, two counts of aggravated identity theft and one count of conspiracy to commit money laundering, according to a June 27 Justice Department news release.”
UnitedHealthcare to waive cost-sharing in 24/7 Virtual Visit program for some fully insured plans “UnitedHealthcare will nix out-of-pocket costs for its 24/7 Virtual Visits in some of its fully insured plans beginning July 1.
The insurance giant revealed the change through a notice to its brokers about the new offering. The $0 cost for these urgent care visits will become available upon renewal or at new enrollment for the eligible plans, according to the alert…
The changes to cost-sharing will extend to people in high-deductible health plans, which can offer ease of mind for members and families who have yet to meet their deductible for the year.”
About hospitals and healthcare systems
FTC floats changes to merger review process that could slow down deal-approval timelines “Newly proposed changes to the Federal Trade Commission’s (FTC's) pre-merger notification requirements would give regulators more information to review during a deal’s initial waiting period—likely giving the agency more fuel to block mergers it views as anticompetitive.
The proposed changes also would nearly quadruple the per-hour filing burden on merging organizations…
The 133-page proposed amendments document also cites multiple deals and articles related to healthcare industry mergers and acquisitions within its footnotes.
Major changes included in the proposal include requirements that merging entities provide:
More details on the rationale of their transaction as well as any surrounding investment vehicles or corporate relationships
Information related to horizontal products or services and non-horizontal business relationships
Projected revenue streams, descriptions of market conditions and the structure of involved entities
Details regarding prior acquisitions
Disclosures of information that would help screen for labor market concerns”
Demand for urgent care facilities is increasing “Increased investment in urgent care centers is needed as health care delivery models change and patients with non-life-threatening conditions opt for ease of access, according to a recent analysis by Colliers.
The analysis notes several data points to back up its message. The Urgent Care Association found that since 2019 patient volume has spiked by 60%, while Data Bridge Market Research has predicted a compound annual growth rate of 5.35% between 2022 and 2029…
The surge is being driven by the convenience and accessibility of urgent care centers which are often located in high traffic retail locations and offer extended operating hours...”
About pharma
BioMarin scores long-awaited US nod for Roctavian gene therapy “BioMarin Pharmaceutical said Thursday it has received FDA approval for Roctavian (valoctocogene roxaparvovec-rvox), making it the first gene therapy cleared in the US to treat adults with severe haemophilia A. The one-time treatment was authorised for the same condition last year in the EU, where the product's net price is estimated to be about €1.5 million ($1.6 million).
Roctavian works by delivering a functional copy of the missing gene that would help haemophilia A patients make FVIII blood-clotting protein.”
About the public’s health
An update on the air quality problem: Over 80 million are under air quality alerts as smoke from Canada wildfires drifts into the US “More than 80 million people from the Midwest to the East Coast are under air quality alerts as smoke from Canadian wildfires sweeps across parts of the US, prompting beach closures, warnings of reduced visibility, and calls for people to stay indoors.
Canada is seeing its worst fire season on record with hundreds of wildfires raging across the country – more than 250 of them burning ‘out of control,’ according to the Canadian Interagency Forest Fire Centre. The wildfires have led to the highest annual emissions on record for the country, according to a Tuesday report from Copernicus, a division of the European Union's space program.”
CDC Recommends RSV Vaccine For Older Adults “CDC Director Rochelle P. Walensky, M.D., M.P.H., endorsed the CDC Advisory Committee on Immunization Practices’ (ACIP) recommendations for use of new Respiratory Syncytial Virus (RSV) vaccines from GSK and Pfizer for people ages 60 years and older, using shared clinical decision-making. This means these individuals may receive a single dose of the vaccine based on discussions with their healthcare provider about whether RSV vaccination is right for them.
Adults at the highest risk for severe RSV illness include older adults, adults with chronic heart or lung disease, adults with weakened immune systems, and adults living in nursing homes or long-term care facilities. CDC estimates that every year, RSV causes approximately 60,000–160,000 hospitalizations and 6,000–10,000 deaths among older adults.”
Hepatitis C Virus Clearance Cascade — United States, 2013–2022 From the CDC: “An analysis of the HCV clearance cascade using 2013–2022 national HCV testing data found that the prevalence of viral clearance among persons with diagnosed hepatitis C was only 34% overall and was even lower (16%) among persons aged 20–39 years with other payor (client or self-pay) insurance.
What are the implications for public health practice?
Increased access to diagnosis, treatment, and prevention services for persons with hepatitis C would prevent progression of disease and ongoing transmission and achieve national hepatitis C elimination goals.”
Quantifying Quantified Health Data from wearables reveal lifestyle factors that affect health care utilization.
This actuarial study links data from wearables (exercise duration and intensity, sleep times and pulse) to risk of hospitalizations. You should, at least look at the graphs.
Aspartame sweetener used in Diet Coke a possible carcinogen, WHO’s cancer research agency to say - sources “Aspartame, used in products from Coca-Cola diet sodas to Mars' Extra chewing gum and some Snapple drinks, will be listed in July as ‘possibly carcinogenic to humans’ for the first time by the International Agency for Research on Cancer (IARC), the World Health Organization's (WHO) cancer research arm, the sources said.”
Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial “Opioids should not be recommended for acute non-specific low back pain or neck pain given that we found no significant difference in pain severity compared with placebo. This finding calls for a change in the frequent use of opioids for these conditions.”
About healthcare personnel
Supreme Court strikes down affirmative action in college admissions, and Biden ‘strongly’ disagrees “The Supreme Court on Thursday struck down affirmative action in college admissions, declaring race cannot be a factor and forcing institutions of higher education to look for new ways to achieve diverse student bodies.
The court’s conservative majority overturned admissions plans at Harvard and the University of North Carolina, the nation’s oldest private and public colleges, respectively.
Chief Justice John Roberts said that for too long universities have ‘concluded, wrongly, that the touchstone of an individual’s identity is not challenges bested, skills built, or lessons learned but the color of their skin. Our constitutional history does not tolerate that choice.”
Comment: While the rulings were about undergraduate admissions, the same principles will apply to professional schools, e.g., medicine, nursing, pharmacy, etc.
About healthcare finance
Lilly agrees to acquire cell therapy developer Sigilon for up to $310 million “Eli Lilly on Thursday announced a definitive agreement to acquire Sigilon Therapeutics, which is working on non-viral engineered cell-based therapies aimed at offering functional cures for patients with acute and chronic diseases.”