Unbiased Analysis of Today's Healthcare Issues
While CMS has a target of getting 100% of Medicare beneficiaries into value-based payment (VBP) programs–such as accountable care organizations–by the end of the decade, implementing VBP in practice will be challenging. An editorial by Navathe et al. (2024) in Health Affairs provides some key considerations. Providers forego certain revenue for uncertain ‘bonus’ payments. “One…
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…
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…
The Biden Administration promised more access to Medicare data. Then the reverse happened. ProPublica explains: In January, the Biden administration pledged to increase public access to a wide array of Medicare information to improve health care for America’s most sick and vulnerable. Some Medicare plans’ lack of transparency “deprives researchers and doctors of critical data…
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…
Now that 51% of Medicare beneficiaries are enrolled in Medicare Advantage (MA), one key question is how restrictive are MA narrow networks? While beneficiaries enrolled in Medicare fee-for-service can choose any provider, MA plans can impose restrictions on enrollee’s provider choices. Measuring how restrictive an MA plan is, however, is difficult because “restrictiveness” is a…
Just this year a majority of Medicare beneficiaries enrolled in a Medicare Advantage plan. While these plans are popular with patients, I recently wrote that some rural providers are refusing to accept Medicare Advantage due to low reimbursement. A recent article from Kaiser Health News finds that provider frustration with Medicare Advantage is spreading to…
Via the Kaiser Family Foundation: In 2023, more than half (51%) of eligible Medicare beneficiaries – 30.8 million people out of 60.0 million Medicare beneficiaries with both Medicare Parts A and B – are enrolled in Medicare Advantage plans. Medicare Advantage enrollment as a share of the eligible Medicare population has jumped from 19% in…
That is the finding from a recent report from the Congressional Budget Office (CBO) on the activities of the Centers for Medicare and Medicaid Innovation (CMMI) CBO previously estimated that CMMI’s activities would reduce net federal spending but now estimates that they increased that spending during the first 10 years of the center’s operation and will…