About health insurance/insurers
Medicare Advantage: Questionable Use of Health Risk Assessments [HRA] Continues To Drive Up Payments to Plans by Billions “What OIG Found
Diagnoses reported only on enrollees’ HRAs and HRA-linked chart reviews, and not on any other 2022 service records, resulted in an estimated $7.5 billion in MA risk-adjusted payments for 2023. The lack of any other followup visits, procedures, tests, or supplies for these diagnoses in the MA encounter data for 1.7 million MA enrollees raises concerns that either: (1) the diagnoses are inaccurate and thus the payments are improper or (2) enrollees did not receive needed care for serious conditions reported only on HRAs or HRA-linked chart reviews.
In-home HRAs and HRA-linked chart reviews generated almost two-thirds of the estimated $7.5 billion in risk-adjusted payments. In-home HRAs and HRA-linked chart reviews may be more vulnerable to misuse because these tools are often administered by MA companies or their third-party vendors and not enrollees’ own providers. Diagnoses reported only on these types of records heighten concerns about the validity of the diagnoses or the coordination of care for MA enrollees.
Just 20 MA companies drove 80 percent of the estimated $7.5 billion in payments. Also, these MA companies generated a substantially greater share of payments resulting from HRAs or HRA-linked chart reviews for certain health conditions, including serious and chronic illnesses, such as diabetes and congestive heart failure.”
UnitedHealth Group accounted for $3.7 billion of the questionable payments. See the full report as well.
CMS lifts enrollment suspension on UnitedHealthcare Medicare Advantage plan “CMS has lifted an enrollment suspension on a UnitedHealthcare subsidiary's Medicare Advantage plan following three years of not meeting the required 85% medical loss ratio.”
Results from an Annual Medicaid Budget Survey for State Fiscal Years 2024 and 2025 Exerpted highlights from this KFF report:
”PROVIDER RATES AND MANAGED CARE
--States had implemented (in FY 2024) and were planning (in FY 2025) a wide range of fee-for-service (FFS) rate increases across provider types and very few states were implementing rate restrictions. More than half of states (26 states) reported increasing both inpatient and outpatient hospital FFS base rates in FY 2024, and many states reported increases in both hospital FFS base rates and total non-DSH supplemental payments.
--About two-thirds of responding MCO states (25 of 41) reported seeking CMS approval for a capitation rate amendment to address shifts in the average risk profile (or “acuity”) of MCO members in FY 2024 and/or FY 2025.
BENEFITS AND PRESCRIPTION DRUGS
--Most states continue to implement benefit enhancements, particularly for mental health and/or substance use disorder (SUD) services. and mortality and addressing racial/ethnic health disparities.
--Twelve state Medicaid programs reported covering GLP-1s (glucagon-like peptide-1s) when prescribed for the treatment of obesity, under FFS as of July 1, 2024.
SOCIAL DETERMINANTS OF HEALTH AND REDUCING HEALTH DISPARITIES
--A number of states are expanding or enhancing Medicaid coverage to help address enrollee social determinants of health (SDOH) or associated health-related social needs (HRSN).
--States are implementing strategies to reduce racial and ethnic health disparities, including through changes in managed care contracts.
--States may also tie MCO financial quality incentives to reducing health disparities. About one-third of states reported at least one MCO financial incentive tied to reducing racial/ethnic disparities in place in FY 2024, most commonly linking capitation withholds or pay for performance incentives to improving health disparities.”
About hospitals and healthcare systems
Celebrating Excellence: Healthgrades Names Leading Hospitals for Specialty Care in 2025 FYI.
Sanford, Marshfield Clinic to create 56-hospital system “The integration is expected to close by the end of 2024, with the parties remaining separate, independent organizations ahead of closing.”
About pharma
Thousands of bottles of popular antidepressant recalled “Thousands of bottles of a popular antidepressant medication are being recalled due to the presence of what the National Library of Medicine describes as a toxic chemical, according to a notice from the U.S. Food and Drug Administration.
The recall involves the medication duloxetine, which is sold under the brand name Cymbalta, according to the FDA's notice of the voluntary recall, which began Oct. 10.”
About the public’s health
In boon for Pfizer and Merck, CDC panel backs expanded use of pneumococcal vaccines “In a 14-1 vote, the panel moved to expand its usage recommendation for both Pfizer’s Prevnar 20 and Merck’s Capvaxive to include all adults aged 50 and older as well as adults between 19 and 49 years of age with certain risk factors. Previously, the broad recommendation for PCV shots was for those older than 65.”
About healthcare finance
General Catalyst:Announcing Fund XII “Today, we are announcing that we have raised approximately $8B of new capital, including around $4.5B for our core VC funds focused on seed and growth equity (across our Ignition, Endurance, and Health Assurance strategies), $1.5B for our Creation strategy, and $2B of separately managed accounts. As a global investment company that seeks to partner with the world’s most ambitious entrepreneurs to drive transformation, resilience, and applied AI, we believe this capital will turbocharge our investment theses across AI, Defense & Intelligence, Climate & Energy, Industrials, Healthcare and Fintech.”