About health insurance/insurers
MEDICAL, INSURER GROUPS ASK CMS TO NOT IMPLEMENT PRIOR AUTHORIZATION PROVISIONS “The American Hospital Association (AHA), the American Medical Association (AMA), the Blue Cross Blue Shield Association, and AHIP came together to urge CMS to not proceed with implementing proposed prior authorization (PA) standards that the organizations stated would be costly and conflicting.
In a letter penned to the federal agency, the groups argued that the provisions of the December 2022 Notice of Proposed Rule Making (NPRM) would be detrimental "due to conflicting regulatory proposals that would set the stage for multiple PA electronic standards and workflows and create the very same costly burdens that administrative simplification seeks to alleviate."
The organizations shared their concern that the provisions would establish two different sets of PA standards. While the NPRM would require a combination of both X12 and Health Level 7 (HL7) standards, the Advancing Interoperability and Improving Prior Authorization NPRM would require health plans to offer HL7 Fast Healthcare Interoperability Resources (FHIR)-based application programming interfaces to support electronic PA information exchange.”
Centene could lose its last 4-star Medicare Advantage contract “Centene could end 2023 with no four-star rated Medicare Advantage contracts, CEO Sarah London told investors on a July 28 call.
The company has been working to improve its Medicare Advantage star ratings. The percentage of Centene members with four-star or higher plans dropped from 48 percent to 3 percent in 2022.
Variability in cut points from CMS means Centene's single four-star Medicare Advantage contract's rating could drop this year, Ms. London said.”
About hospitals and healthcare systems
2023 Median Ratios: Not-for-Profit Hospitals and Healthcare Systems “The difficult start to 2022 began with a deepening financial deficit caused by acuity reductions and labor challenges. Macro headwinds started to form in late 2021 and accelerated in early 2022, with labor shortages, inflationary expenses, reduced elective volumes and surgeries, and increased medical admissions to varying degrees across the rated portfolio. These trends continued for much of the rest of the year for the majority of the rated credits, with the median operating margin now at just 0.2%. This means that approximately one- half of our rated portfolio recorded a negative operating margin in 2022, ranging widely from a high of 27% to a low of negative 21.5%.
The more significant signs of operational challenges (defined as operating EBITDA margin) were seen at the lower end of the rating spectrum (the below-investment-grade [BIG] categories). The BIG categories reported a very modest 0.3% operating EBITDA margin, compared with 6.9% in fiscal 2021, a 95.6% decrease. The mid investment-grade (IG) category (A category) reported a 4.8% operating EBITDA margin, versus 8.8% in fiscal 2021, a 45.5% decrease.”
And in two related articles:
Healthcare Restructuring: Trends and Outlook “Key Takeaways:
Healthcare Bankruptcy filings* in the 6 months through June 2023 show a material increase on historical filings since 2019, even prior to the COVID-19 pandemic
Healthcare Bankruptcy filings* in 2023 are trending approximately 3 times the level seen in 2021, with a return of large cases with liabilities over $100 million.
There were 13 Healthcare Bankruptcy filings* with more than $100 million in liabilities 6 months through June 2023, compared to just 15 cases in the prior two years.
The acceleration in Healthcare Bankruptcy filings* seen throughout 2022, especially the uptick seen in Q4 2022, has continued into 2023.
Consistent with previous trends, in 2023, Senior Care and Pharmaceutical subsectors continue to comprise approximately half of the total Healthcare Bankruptcy filings*.
Based on annualized data, 2023 bankruptcy filings across all subsectors* (except hospitals) are trending to exceed annual filings since 2019.
Hospital cases are returning to relevance, with 6 hospital filings in the last 12 months, compared with just 5 filings in the preceding 24-month period.
*Cases labeled in the data source as “Healthcare and Medical” and cases from certain other SIC codes which indicate the healthcare industry. Includes only Chapter 11 cases with greater than $10MM in liabilities.”
National Hospital Flash Report: July 2023 “Key Takeaways
Hospital margins underperformed in June, compared to the previous month.
Despite an overall trend of continued improvement, most hospitals underperformed slightly compared to May. Fiscal year-end accounting adjustments may have also contributed to the performance bump in June.
Average lengths of stay continue to decrease, and emergency department visits are down.
Patient volumes continue to stabilize, and increases in outpatient revenue indicate people are continuing to shift away from inpatient settings.
Bad debt and charity care are increasing.
Hospitals are being affected as states step up efforts to redetermine Medicaid eligibility and more people are disenrolled.
Inflation continues to challenge hospitals’ performance.
Supplies and purchased service expenses remain high. Decreases in labor expenses may indicate higher staff turnover and even reductions in workforce.”
About pharma
US FDA approves second over-the-counter opioid overdose reversal drug “The approval of the drug, called RiVive, will provide patients with another over-the-counter option in the United States, where drug-related overdose deaths surpassed 100,000 in 2021.
Harm Reduction said it anticipates that RiVive will be available early next year, primarily to harm-reduction organizations and state governments. The not-for-profit drugmaker said it would make at least 200,000 doses available for free.”
About the public’s health
Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults: A Guidance Statement From the American College of Physicians
“Guidance Statement 1: Clinicians should start screening for colorectal cancer in asymptomatic average-risk adults at age 50 years.
Guidance Statement 2: Clinicians should consider not screening asymptomatic average-risk adults between the ages of 45 to 49 years. Clinicians should discuss the uncertainty around benefits and harms of screening in this population.
Guidance Statement 3: Clinicians should stop screening for colorectal cancer in asymptomatic average-risk adults older than 75 years or in asymptomatic average-risk adults with a life expectancy of 10 years or less.
Guidance Statement 4a: Clinicians should select a screening test for colorectal cancer in consultation with their patient based on a discussion of benefits, harms, costs, availability, frequency, and patient values and preferences.
Guidance Statement 4b: Clinicians should select among a fecal immunochemical or high-sensitivity guaiac fecal occult blood test every 2 years, colonoscopy every 10 years, or flexible sigmoidoscopy every 10 years plus a fecal immunochemical test every 2 years as a screening test for colorectal cancer.
Guidance Statement 4c:Clinicians should not use stool DNA, computed tomography colonography, capsule endoscopy, urine, or serum screening tests for colorectal cancer.”
Trends in Alcohol-Related Deaths by Sex in the US, 1999-2020 “In this cross-sectional study of 605 948 alcohol-attributed deaths, male individuals had a significantly higher burden of alcohol-involved mortality than did female individuals, with a male to female ratio of 2.88. Temporal trends revealed an increase in alcohol-related deaths among both sexes, with a significantly higher rate of increase observed for female individuals than for male individuals.”
Benefits of Bariatric Surgery Persist for 12 Years “Bariatric surgery produced sustained, long-term glucose control and weight loss for at least 7 years, and for up to 12 years, in some US patients with type 2 diabetes and a baseline body mass index (BMI) of at least 27 kg/m2, according to new study results.
The findings are from ARMMS-T2D, a prospective, controlled trial with the largest cohort and longest follow-up of bariatric surgery reported to date. The results reinforce the potential role of surgery ‘as an option to improve diabetes-related outcomes, including people with a BMI of less than 35 kg/m2,’ said Anita P. Courcoulas, MD, at the recent American Diabetes Association 83rd Scientific Sessions.”
About healthcare IT
Generative AI and the future of work in America Not healthcare specific, but the principles are still the same. One interesting finding: “By 2030, activities that account for up to 30 percent of hours currently worked across the US economy could be automated—a trend accelerated by generative AI. However, we see generative AI enhancing the way STEM, creative, and business and legal professionals work rather than eliminating a significant number of jobs outright. Automation’s biggest effects are likely to hit other job categories. Office support, customer service, and food service employment could continue to decline.”
About health technology
Quest launches blood test for Alzheimer’s disease aimed at general consumers “The clinical testing giant has put forward a blood test designed to help gauge a person’s levels of beta amyloid—one of the hallmarks of the neurodegenerative condition—and it’s now making it available directly to consumers.
Listed for sale on the company’s website, the AD-Detect test retails for $399 plus a $13 physician fee. Quest Diagnostics says the blood test, though not an official diagnostic, is designed for anyone “who has a family history of Alzheimer’s disease, is experiencing memory loss, or is experiencing early cognitive decline.”
FDA identifies GE HealthCare recall of sensors for defibrillators as class I “GE HealthCare announced a recall of arterial oxygen saturation sensors due to a malfunction that may reduce the amount of energy sent to the heart during defibrillation without notification to the care provider.
If the sensors (TruSignal) malfunction, that could prevent delivery of lifesaving therapy and is most hazardous to patients who are hospitalized and may need defibrillation for cardiac arrest, according to an FDA press release.”