Category: Medicare and Medicaid

Jul
1

Medicare’s future – Private insurance.

Posted by Joe Paduda on Monday, July 1st, 2024 | Comments

Under a new Trump Administration, Medicare will be privatized, with “Medicare Advantage the default enrollment option” for seniors.

This despite the myriad and well-documented problems with Medicare Advantage –

from Commonwealth Fund

From a Medicare Advantage member:

“I have very little control over my actual medical care,” he says, adding that he now advises friends not to sign up for the private plans. “I think that people are not understanding what Medicare Advantage is all about.”

What’s worse is the member – Richard Timmins – may well not be able to switch back to regular Medicare with a supplemental policy (Medigap) that includes most healthcare providers and covers deductibles and other expenses.

Only four states — Connecticut, Maine, Massachusetts and New York — prohibit insurers from denying a Medigap policy if the enrollee has preexisting conditions such as diabetes or heart disease.

Traditional Medicare – managed by the Centers for Medicare and Medicaid Services – allows access to pretty much any physician, therapist, hospital or facility.

What does this mean for you?

Handing Medicare over to private insurers limits choice, access, and patient control over their healthcare. 

 

Jun
24

State moves that will affect workers’ comp

Posted by Joe Paduda on Monday, June 24th, 2024 | Comments

The state legislation that will MOST affect workers’ comp is often not ABOUT workers’ comp – rather it deals with other parts of the healthcare ecosystem.

For example:

Regulating Pharmacy Benefit Managers

FromWaPo:

At least 41 state legislatures introduced bills targeting pharmacy benefit managers (PBMs), which are third parties that help manage prescription drug benefits on behalf of both public and commercial insurers. That includes California, New Hampshire and Rhode Island, where bills have passed at least one legislative chamber and lawmakers are still in session.

Notably, governors in 13 states signed PBM reforms into law this year. For instance, Washington and Oregon banned spread pricing, in which prescription drug middlemen charge health plans more than they pay pharmacies and keep the difference. Idaho, meanwhile, implemented legislation requiring PBMs to transfer 100 percent of manufacturer rebates on to insurers.

Gotta say some of these are short-sighted and based on faulty understanding of the roe and actual practices of PBMs. That’s not to say PBMs are faultless…my firm has audited a number of work comp payers’ pharmacy programs…and suffice it to say there’s a lot of gaming out there.

By far the worst was the Federal program…

What this means – legislation may well lead to changes in WC PBM contracts and pricing.

Expanding Medicaid:

  • stabilizes hospital financials a lot,
  • helps ensure rural and inner-city facilities keep their ERs open,
  • improves the health of lower-income folks and workers, and
  • likely reduces hospitals’ and health systems’ shifting costs to workers’ comp payers.

One of the last holdouts is Mississippi, the poorest state with the worst health outcomes, highest infant mortality rate, and shortest life expectancy. Pushed by a broad coalition of business, not-for-profits, and consumer groups, at long last the state’s legislature is attempting to expand Medicaid, although it’s doubtful the bill will pass and be signed into law.

Nonetheless, one has to celebrate small victories, and the fact that the legislature is even considering expansion is good news. 

Frankly, detractors’ arguments against expansion are tissue-thin, not fact-based, and when questioned, beyond superficial.

What this means – Medicaid expansion -> healthier workers, more access to care and lower healthcare  costs. 

Hospital and provider consolidation

WaPo – A recent study found that hundreds of hospital mergers have escaped federal antitrust scrutiny in the past two decades because the Federal Trade Commission lacks the funding and staffing to crack down on all anticompetitive deals.

And, states are increasingly concerned about private equity investors’ impact on  healthcare access and cost. 16 state legislatures – both blue and red – have introduced bills dealing with this issue this year.

What this means – a possible slowdown of provider consolidation. 

ALSO – MCM will be changing from WordPress and MailChimp to Substack next week – if you don’t get a blog post notification by July 5 check your spam/junk/trash folder. 

May
10

Good News Friday…Strong economy, lower drug costs, more jobs in Wisconsin, and no more noncompetes

Posted by Joe Paduda on Friday, May 10th, 2024 | Comments

Lots of really good stuff to end your week…

the Economy…

remains quite good with 175,000 new jobs last month. This was not as many in previous months…

BUT it looks increasingly like (From NYT) “the exuberance of the last two years might be settling into a more sustainable rhythm”.

Stock markets jumped (the Dow is up 723 (!!!) points this week), interest rates declined modestly,

Seniors’ lower drug costs…

Insulin prices are capped at $35 per month, a major reduction from an average of $300…even better, next year President Biden’s Inflation Reduction Act will limit seniors’ out-of-pocket costs for all prescription medications $2,000 per year.

There’s activity in Congress and by the Biden Administration that would limit everyone’s cost – young, old, and in-between – for insulin to no more than $35 a month…here’s hoping the pols get this done.

This means...With diabetes affecting more Americans, improving access to insulin means healthier families and employees, which leads to lower healthcare costs.

More good news…the Medicare Hospital Trust Fund’s financial solvency was extended to 2036, a five year extension. Not to worry, there’s no doubt this will be extended again.

This means…better finances for hospitals and seniors.

Lots more jobs in Wisconsin and…No more noncompetes!

In the “government CAN actually make life better” category,  we have…lots of great jobs coming to Wisconsin…AND a ban on non-competes.

Microsoft is building a giant AI Center near Racine, Wisconsin. The city was hit hard by the collapse of the Foxconn deal which promised gazillions of dollars and jobs…but never happened. Supported by the Investing in America project, this brings new investment why private companies in Wisconsin to $5 billion – and counting.

The Federal Trade Commission effectively banned non-competes...thereby freeing you up to…actually control where you want to work.

Non-competes are contractual controls that effectively prohibit employees from working at specific jobs, customers, or companies for a defined period in exchange for a/some defined “benefit(s).”

This is a MAJOR bonus for anyone working today as it allows you – not some corporate entity – to control your life. And, the rule is quite broad, clearly empowering workers.

This from Harvard Business Review…

“Worker” is defined not just as an employee but also includes independent contractors, externs, interns, volunteers, apprentices, or a sole proprietor who provides a service. The rule also broadly defines noncompete clauses not only as terms or conditions of employment that explicitly prohibit a worker from competing with a former employer, but also to mean any other clauses that “penalize a worker for” or “function to prevent a worker from” competing. With this definition, the FTC also prohibits clauses that operate as de facto noncompetes, including overly broad NDAs, nonsolicitation clauses, and TRAPs — training repayment agreement provisions. [Emphasis added]

Have a most excellent weekend!

Apr
5

Good news Friday…booming employment, lower junk fees and drug costs.

Posted by Joe Paduda on Friday, April 5th, 2024 | Comments

Another April snowstorm here in New Hampshire…weather is getting weirder by the week.

Not to worry  – we are keeping the just-arrived birds well fed!

Jobs…

WOW. This just in from BLS…

Total nonfarm payroll employment rose by 303,000 in March, and the unemployment rate changed
little at 3.8 percent, the U.S. Bureau of Labor Statistics reported today. Job gains occurred 
in health care, government, and construction.
March's growth was significantly higher than the average monthly
gain of 231,000 over the prior 12 months.

Payroll company ADP predicted booming private sector job growth with an estimated 184,000 new jobs created last month – a big jump over the forecasted growth of 148,000 jobs.

Construction, financial services, and manufacturing sectors saw significant job growth.

Women’s NCAA tournament

Is breaking every record in sight…ticket prices for the semis are more than twice that for the men’s, viewership is off the charts, and everyone with a pulse knows who Caitlin Clark is.

Gotta love the increasing exposure for women’s sports – this will have incalculable impact on girls for generations to come.

Medicare – is NOT about to go bankrupt.

It is highly likely Medicare funding will be more than sufficient to its pay bills for decades to come. Merril Goozner provides a summary of funding’s vagaries, concluding government policy changes and economic ups and downs bounce around, but nonetheless the Trust Fund survives.

Junk fees..

Cost Americans billions as big finance companies hoover dollars out of our pockets.

Good news – efforts to drastically reduce credit card payment late fees got a big boost when a financial industry challenge to those limits was moved to a court much more likely to protect consumers.

Medicare drug prices

About 60 million folks are covered by Medicare – including your author.

Government action is helping reduce drug costs…the cost of insulin for diabetics on Medicare is limited to $35 per month, a huge drop…

From PBS…

The three major manufacturers we’re talking about, Sanofi, Novo Nordisk, and Eli Lilly, who cap their co-pays at $35, make up more than 90 percent of the insulin market. And the Medicare provisions in the Inflation Reduction Act mean that now about 1.7 million Medicare beneficiaries stand to benefit from that $35 monthly co-pay cap on their insulin. [emphasis added]

But wait…there’s more!

  • prescription costs of certain drugs for Medicare recipients is going to be capped at $3,300 annually.
  • In September the new list prices of 10 major drugs are going to be made public. That was made possible by the Inflation Reduction Act’s provision allowing Medicare to negotiate drug prices with manufacturers. Those prices go into effect in 2026
  • The annual cap on prescription costs will drop to $2,000.

The net – Medicare recipients will save big bucks.

 

Apr
3

Wednesday catch-up – data breach, hospital cutback, and the ACA 10 years on.

Posted by Joe Paduda on Wednesday, April 3rd, 2024 | Comments

For those I caught with my April Fool’s post…I hope you took it in the spirit in which it was intended…

Okay, back to reality (oh no….)

Hospital closures and cutbacks

Another hospital in a non-Medicaid expansion state is closing its ER and shuttering its inpatient care facility. The facility was acquired by a competitor a mile away a few years back…if this goes like most acquisitions folks around Anniston Alabama will likely have poorer outcomes and pay higher prices…

Ignore the corporate happy speak from the owners…this is the same stuff every exec that buys a rival hospital says.

Oh, and here’s research showing the link between Medicaid expansion and hospital closures.

Consolidators are doing just fine…the CEO of CHS just “earned” $8.3 million in pay and perks.

Obamacare…aka the ACA.

Remember way back when folks got all worked up about the ACA, how it was going to kill off old folks, destroy the “best healthcare system in the world”, cost millions of jobs and bankrupt thousands of small employers…and lots of people hated it?

News flash – Americans like it.  A lot.

That’s because:

  • Pre-existing conditions are covered.
  • Kids can be covered under the parent(s)’ insurance till they are 26.
  • 45 million Americans get insurance thru Obamacare and/or benefit from its provisions.
  • Provisions ensure adequate benefits for mental health, emergency care, maternity and child care and seven other key healthcare needs.
  • People who actually had Obamacare plans realized it saved lives.

Oh, and since people with health insurance are healthier than those without, if they’re hurt on the job, they recover faster and employers don’t have to pay to treat co-morbidities. 

We’re going to dive deep into the ACA in a coming week…stay tuned for more facts.

Change Healthcare cyber attack

It isn’t over. Owner United Healthcare recently stated patient data had been stolen by hackers.

This is a much bigger story – with much wider implications – than many think.

What does this mean for you?

More stuff affects you and your business than you may think. 

Mar
26

The Pro-Life solution to the US health crisis

Posted by Joe Paduda on Tuesday, March 26th, 2024 | Comments

There’s a health crisis in the US – more people are dying younger, most from preventable diseases.

The good news is this is fixable. Sure there are any number of causes –

  • the opioid epidemic continues to destroy lives,
  • more kids are killed by firearms than anything else;
  • cancers associated with pollution are a major killer in some states;

all of which require thoughtful and very well-executed policy changes…which will take a lot of time, during which many more of us will die.

Like any complex problem the first task is to determine where the problem is. Thanks to the CDC, we know.

The lightest shaded states have the lowest life expectancy…

And the deepest red indicates states have the longest life expectancy.

8 of the States with the two lowest life expectancies have not expanded access to Medicaid…

And all of the States with the highest life expectancy HAVE expanded Medicaid.

Healthier people – kids, moms, grandparents, the disabled – live longer, more productive lives. And people with access to healthcare are far healthier than those without.

What does this mean for you?

If you are pro-life, the solution is blindingly obvious.

 

Mar
15

Good news Friday – fixing past mistakes, more progress on Medicaid, and lower drug prices

Posted by Joe Paduda on Friday, March 15th, 2024 | Comments

Medicaid

Checking in on Medicaid…41 states have expanded Medicaid, and by dribs and drabs some of the holdouts are moving to do the same.

Georgia may well be the next state to follow suit; a court recently ruled in favor of the Peach State’s approach.

Medicaid is one of those rare programs that delivers way more than it costs – economic impact is strongly positive, beneficiaries are much more likely to be healthy enough to work, clinical outcomes improve…

Oh, and uncompensated care costs drop – a LOT…so health systems and hospitals have less incentive to hoover dollars out of employers’ pockets.

Infrastructure investment – Billions of dollars will be invested to  improve infrastructure in places that need it most. From WaPo:

Earlier this week the White House unveiled $3.3 billion in federal grants to remove or retrofit highways that separate minority neighborhoods in many cities from jobs, entertainment centers, hospitals and other services.

In one of my adopted hometowns – Syracuse – the process is well underway. This rights a wrong done decades ago when politicians steamrolled poor folks in poor neighborhoods to build highways to suburbs.

Employment and long-term care

Yes, healthcare worker staffing is a big issue...the good news is much of the potential shortfall can be addressed by immigrants. 

Longterm care is particularly affected…three out of ten workers in long term care are adult immigrants.

What does this mean for you?

More opportunities, improved health, and more healthcare workers = a better place to live and work and raise a family.

Feb
20

Rural hospitals – and healthcare – are in deep trouble.

Posted by Joe Paduda on Tuesday, February 20th, 2024 | Comments

With the unwinding of Medicaid post-COVID emergency, rural healthcare is falling deeper into financial trouble.

Consulting form Chartis just published their review of rural healthcare…among the findings

The unwinding issue is exacerbating problems in states that failed to expand Medicaid…the vast majority of which are those with the most hospitals in financial distress.  Simply put – they have to deliver way more healthcare to people without health insurance.

FromChartis:

Across the 10 remaining non-expansion states (Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming), the percentage of facilities with a negative operating margin increased year-over-year from 51% to 55%. These states are home to more than 600 rural hospitals…Several of these states are among the most severely affected by hospital closures and a loss of access to care.

The percentage of America’s rural hospitals operating in the red jumped from 43% to 50% in the last 12 months.

418 rural hospitals are “vulnerable to closure” according to a new, expanded
statistical analysis.

Healthcare deserts are a huge problem for rural America, especially in areas with lots of extractive industries (mining, energy, agriculture. Workers in those industries are much more likely to suffer severe occupational injuries, injuries that benefit greatly from care delivered in the “golden hour”.

What does this mean for you?

Not expanding Medicaid is killing rural healthcare.

Feb
8

Drug prices and the power of consensus.

Posted by Joe Paduda on Thursday, February 8th, 2024 | Comments

We Americans pay much more for drugs than anyone else.

Those very high prices are a major contributor to increasing health insurance premiums and Federal and state budgets.

Across the political spectrum, Americans support more government regulation of drug pricing.

Good news is Medicare is now actively negotiating drug prices with manufacturers. That will save patients and taxpayers billions of dollars.

What does this mean for you?

When we agree on what is the right thing to do we get things done.

And will save families and taxpayers lots of money.

Feb
7

Signs of the coming apocalypse

Posted by Joe Paduda on Wednesday, February 7th, 2024 | Comments

Medicare is slashing what it pays physicians, an annual event that – till now – was almost always rejected by Congress.

That will reduce old folks’ access to care, cut workers’ comp fee schedules, and likely lead to more provider consolidation. 

This from Becker’s:

In its 2024 Physician Fee Schedule Final Rule released Nov. 2, CMS reduced overall physician pay by 1.25% and updated the Medicare conversion factor to $32.74, a 3.4% decrease from last year.

Nope, a fix wasn’t in any of the “continuing resolutions” Congress passed last year and earlier in January (“CRs” are a stop-gap, emergency funding step more often seen in desperately poor banana republics than in the “greatest nation in the world.)

As a result, docs’ pay will be cut about 3 1/2%…and they are none too happy about it. (Read this for details on potential implications)

Okay that’s bad, right?

Not as bad as what’s coming.

Reminder – if Congress doesn’t pass a budget – in exactly one month – all Federal agencies – including Medicare, the VA, Defense, the FAA… face budget cuts. Weapons procurement, care for veterans, agriculture inspections, airplane safety inspections (this isn’t a problem, right??) are just a few.

Remember way back (as in two years ago) when Congress’ wait-till-the-last-minute-to-get-stuff-done made us all nuts…if we knew then how dysfunctional the House would be now we’d have been quite happy for what we did have.

Yep, Republicans in the House of Representatives’ refused to even vote on an immigration reform bill – THE hot issue in Washington and around the country – a bill that gave them everything they wanted.

House GOP – Yay, we finally got the soccer ball!  Let’s play! Wait…how do you play? I dunno…you know?  Nope – you? Nuh-uh…you? No clue…you? Uh…I thought it had pointy ends…Someone pick it up…NO way dude! Not me…

What does this mean for you?
To quote HL Mencken, you get the government you deserve, and you deserve to get it good and hard.

PS – Over the lastly 20 years I’ve written a lot about the incredibly screwed-up Medicare reimbursement  process…