Unbiased Analysis of Today's Healthcare Issues
Medical debt in the U.S. is a major problem. While over 90% of individuals have health insurance, many people are uninsured and even those with insurance may be liable to high deductibles and copayments. A Kaiser Family Foundation (KFF) analysis uses data from Survey of Income and Program Participation (SIPP) and finds that: …20 million…
Medicare Advantage (MA) plans have a number of advantages and drawbacks over traditional Medicare (TM) (i.e., fee-for-service). One advantage of MA plans is that cost sharing is often lower. Another benefit is that enrollees may receive additional coverage benefits. One drawback is that enrollee provider choice may be restricted. Fewer provider options may be bad…
One reason is that reimbursement rates for Medicaid are lower than for Medicare or commercial insurance. Another (often overlooked) factor, however, is physician’s risk of payment denials and the administrative hassle they face trying to get reimbursed by Medicaid. A paper by Dunn et al. (2024)–cleverly named “A Denial a Day Keeps the Doctor Away“–shows…
Many researchers are interested in how cost sharing impacts health care utilization, cost and patient outcomes. This is especially true as high-deductible health plans (HDHP) have become more common in the US. In 2023, 29% of covered workers in the US had a HDHP. One helpful type of data for analyzing HDHPs is claims data.…
Medicaid policies vary from state-to-state. With the advent of new, GLP-1 medications (and others) to treat obesity and overweight, there are potentially significant health benefits to be gained. However, are State Medicaid Agencies actually covering these medications? This is the question asked by Liu et al. (2024). They use data from public state Medicaid formulary…
Perhaps so according to the health policy editor at the Guardian. He writes that as NHS has grown weaker, private medical insurance is becoming a more attractive option. The long delays for NHS care that are now endemic – and cause so much worry, risk and harm to those left waiting – are not going…
Initially yes, but not after this initial penalty. That is the finding from a paper by Kettlewell and Zhang (2024) using an analysis of the Australian health care system. Financial penalties for delayed enrollment could be useful tools to encourage people to enroll earlier in health insurance markets, but little is known about how effective…
One approach CMS has is the Cell and Gene Therapy (CGT) Access Model. Under the CGT Access Model, CMS (at the federal level) will negotiates outcomes based agreements (OBAs) with manufacturers, which will include pricing terms and outcomes to be evaluated. Then states can elect to participate in the contract terms negotiated by CMS or…
When we think of utilization management (e.g., prior authorizations, step edits), we often think payers only use these for higher cost branded products including biologics. Generic drugs should have low cost sharing and limited utilization management. One question, however, is whether payers’ utilization management practices for biosimilars mirror those of biologic products, or small-molecule generics,…
A CMS proposed rule would expedite the prior authorization approval process. CMS summarizes key provisions of the rule as follows: Proposals include requiring implementation of a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorization. They also include requirements for certain payers to include a specific reason…