What I'm reading in health care this week.

All the things you need to know in health care.

PRIOR AUTHORIZATION: Denials are way up; doctors are burning out, pleading with officials for help

Cost of Denials Saw 67% Increase in 2022

HealthLeaders Media reports that:

The average hospital system saw 110,000 claim denials due to prior authorization and other factors in 2022, according to a recent survey Denials rose to 11% of all claims last year, up nearly 8% from 2021. Prior authorization denials on inpatient accounts were a key driver behind the dollar value of denials increasing by 67% in 2022.

Providers push CMS to enact prior authorization reforms

Healthcare Finance News reports that:  

Chiquita Brooks-LaSure, administrator for the Centers for Medicare and Medicaid Services, and U.S. Surgeon General Vice Admiral Vivek H. Murthy recently convened an in-person roundtable discussion on reforming prior authorization in federally-sponsored healthcare programs, at which providers pressed CMS to finalize the reforms to alleviate administrative burdens. The Biden administration has said it's looking to remedy documented abuses in the prior authorization program and ensure patients' timely access to medically necessary care. 

States jump into fight over prior authorization requirements

Axios reports that:

 Efforts to overhaul the prior authorization process are hitting a crescendo in state legislatures, with at least 40 states expected to consider measures that would streamline the way doctors must obtain health plan sign-offs before they can order procedures, tests or treatments. (O)fficials like Surgeon General Vivek Murthy are blaming administrative burdens like prior authorizations for physician and health worker burnout…(C)linicians say the situation has worsened in recent years, causing delays for patients, including those with chronic conditions that haven't changed in years.

OUT-OF-SIGHT OUT-OF-POCKETS: Awful for diabetes patients; what employers should do

Employers should carefully weigh benefits of high-deductible health plans: study

Fierce Healthcare reports that: 

Diabetes patients suffer when their employers move them into high-deductible health plans, increasing the odds that they will need to be rushed to emergency departments for severe hyperglycemia by 25%, a new study shows. The odds of this happening increase by 5% for each year an employee’s enrolled in a high-deductible health plan (HDHP). Mayo Clinic researchers concluded that “individuals with low income and from minoritized racial and ethnic groups were especially susceptible to the detrimental outcomes of HDHP transition. HDHP enrollees may be rationing or foregoing necessary care, which is detrimental to their health and ultimately increases the morbidity, mortality, and costs associated with diabetes.”

Half of Patients with High-Deductible Health Plans Have Received an Unexpected Bill

HealthLeaders Media reports that:

Half of the respondents in HDHPs said they've received a surprise medical bill, with 53% saying they had received a bill that did not match the upfront price estimate. More than a third (34%) of those with HDHPs stated they've been harassed by a medical debt collector, while 44% said they had experienced financial hardship from bills.

OOP Costs Are High Despite the Level of Care, Study Finds

Managed Healthcare Executive reports that: 

A recent study found that out-of-pocket (OOP) costs for emergency surgeries are higher despite the level or quality of care received. Authors of the study, which was published in Jama Network, found that patients with commercial insurance had total and OOP costs that varied by facility for common EGS conditions without any association with quality of care, even after adjusting for patient, insurance, and clinical factors. According to the report, one in five households in the United States are in medical debt, totaling $88 billion.

INSURERS RAIDING THE MEDICARE TRUST FUND: WSJ, KHN weighs in; retirees waking up

The Government Thinks It Is Overpaying for Medicare, Spelling Trouble for Insurers

Wall Street Journal reports that:

Health insurers had the best of both worlds last year. Their stocks benefited from a rotation into value and their profits weathered the inflationary environment as healthcare utilization remained low. But as managed-care companies kick off earnings season, sentiment has shifted. That isn’t because of what the most recent earnings will show. In fact, industry behemoth UnitedHealth Group Inc. earlier this month reported a 12% increase in revenue to $82.79 billion, topping analyst expectations. Yet that did nothing for the stock, which is down 8.2% for the year. The trouble brewing for insurers centers around potential government action on Medicare Advantage, the private plans that have grown increasingly popular with seniors. The plans also are very profitable for insurers. A recent Kaiser Family Foundation analysis showed that average gross margins for Medicare Advantage plans were double those of plans in the marketplace and commercial group markets. But as more seniors switch to Medicare Advantage, questionable practices that drive up their profitability have come under increasing scrutiny and the federal government seems intent on making changes that could affect their bottom line.

Did Your Health Plan Rip Off Medicare?

Kaiser Health News reports that: 

Its review of 90 previously secret government audits revealed millions of dollars in overpayments to Medicare Advantage health plans for seniors. The audits, which cover billings from 2011 through 2013, are the most recent financial reviews available, even though enrollment in the health plans has exploded over the past decade to over 30 million and is expected to grow further. KHN has published the audit spreadsheets as the industry girds for a final regulation that could order health plans to return hundreds of millions, if not billions, of dollars or more in overcharges to the Treasury Department — payments dating back a decade or more. The decision by the Centers for Medicare & Medicaid Services is expected by Feb 1.

New York City's Medicare Advantage plan 'dead,' city leaders say

Becker’s Payer Issues reports that: 

A plan to shift New York City retirees' coverage to Medicare Advantage has stalled indefinitely. Courts have blocked the city's proposal to charge retired city employees who opt out of a Medicare Advantage plan a $191 monthly premium, ruling it violates a city law that requires retirees receive free health coverage for life. New York City Mayor Eric Adams has asked the city's council to change the city's laws to allow the fee. Council leadership has said it has no plans to vote on the bill, the New York Daily News reported.

Legislative leaders oppose plan to move retirees insurance into Medicare Advantage plans

Vermont Biz reports that:

State legislative leaders said they’re “deeply concerned” about the Administration’s stated intention to move Medicare-eligible state retirees from the State of Vermont’s insurance plan into Medicare Advantage plans without the support of state retirees. We are particularly concerned about the potential legal, financial and health implications and believe this shift undermines collective bargaining rights.