Centene, Aetna, Kaiser Lead in Medicare Advantage Denials: KFF
Modern Healthcare / By Nona Tepper
Aetna, Centene and Kaiser Permanente denied at least one in 10 Medicare Advantage prior authorization requests in 2023, according to a KFF analysis published Tuesday.
Across the industry, Medicare Advantage insurers increased their use of prior authorization by 7.8% to 49.8 million total requests in 2023, the health policy think tank determined using Centers for Medicare and Medicaid Services data. The increase in requests is in line with enrollment growth, KFF said. Insurers denied slightly fewer prior authorization requests in 2023, refusing to cover 6.8% of claims compared with 7.4% in 2022.
Related: Medicare Advantage prior authorization, marketing limits proposed
Legislators and regulators have called out the use of prior authorization in Medicare Advantage in recent years as a growing number of policyholders report confronting barriers to care, particularly in post-acute settings.
People in their last year of life were more than twice as likely to switch from Medicare Advantage to traditional Medicare over care access concerns, according to a 2021 report by the Health and Human Services Office of the Inspector General. Those switching from Medicare Advantage to traditional Medicare cost the federal government 27% more than those who were continuously enrolled in the fee-for-service program, KFF reported in December. At the same time, CMS has fined insurance companies for exaggerating patient conditions to improperly inflate federal reimbursements…
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Yes, the Pain Is All in Your Head
Medscape / By F. Perry Wilson
Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I’m Dr F. Perry Wilson from the Yale School of Medicine.
I’ve been thinking about Dune a lot lately. I think I might be the only person in the world who prefers the bizarre and grotesque David Lynch movie version to the elegantly crafted Villeneuve oeuvre, including David Lynch himself. We lost a real artist with his passing, and a rewatch of Twin Peaks is very much on my to-do list for this winter.
But back to Dune, because one of the pivotal scenes in the novel and both movie versions is one where young Paul Atreides is tested by the Machiavellian Bene Gesserit. Atreides has to put his hand in a box. What is inside? Pain. Ever increasing pain. He must keep his hand in the box, despite all his instincts telling him to pull it out to prove his fundamental humanity — his ability to exercise control over his own instincts.
Because, as the Reverend Mother points out after the ordeal, his hand is unharmed. The pain is a fabrication — pain by nerve induction, she says. There is no physical damage. It’s all in his mind.
And, of course, that’s true of all pain, isn’t it? It’s not your toe that hurts when you stub it. Signals are sent from your toe, up a nerve to your spinal cord, up another nerve to your thalamus, and then onto the cortex to give it context, emotion, intensity, reality. If that chain is broken, pain simply does not occur. It’s all in your mind.
That’s what makes pain so difficult to treat. It is fundamentally subjective. I’ve had patients with wounds that would make me scream for my mother, yet they sat stoically silent while we worked on them. And I’ve had those who, well, seemed like they were hamming it up a bit…
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Trump’s Initial Orders Reverse Biden on Health Care Costs, Protections from Discrimination
Stat News | By Sarah Owermohle, John Wilkerson, Rachel Cohrs Zhang, and Lizzy Lawrence
WASHINGTON — President Trump began his second term Monday with a sweeping order aimed at reversing dozens of former President Biden’s top priorities, from regulations aimed at lowering health care costs, to coronavirus outreach, Affordable Care Act expansions, and protections against gender-based discrimination.
The “initial rescissions” order, signed in front of cheering crowds at the Capital One Arena, revokes dozens of Biden administration policies that the new White House called inflammatory, inflationary, and possibly illegal. They include an October 2022 order to test Medicare and Medicaid models that could lower health care costs, an extension, Biden said, of his administration’s signature achievement to negotiate drug prices in the Inflation Reduction Act.
Trump is also peeling back certain Biden administration efforts to expand access to Covid-19 treatments and vaccines, the 2021 formation of a Gender Policy Council, and multiple gender and sex discrimination protections. He ordered federal workers to return to their offices full time, and he froze federal hiring, with some exceptions.
Separately, Trump ordered the U.S. to begin the process of withdrawing from the World Health Organization, which he blames for mishandling the Covid-19 pandemic.
Trump’s broad proclamations, like any president’s executive orders, generally begin the process of regulations and rulemaking at federal agencies. The reversals could meet legal challenges or congressional intervention. Several of Biden’s orders were tied to laws
passed by Congress…
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How the Incoming Trump Administration Could Impact Home-Based Care
Home Health Care News | By Jim Parker
Questions always abound when a new presidential administration comes in, but Republicans’ focus on cost-cutting hold potential for home-based care — if providers can advocate for themselves in Washington.
Though uncertainties abound when it comes to the Trump administration’s approach to health care, many notable policies have been implemented during Republican administrations. From the establishment of the Medicare Hospice Benefit under Ronald Reagan to the unveiling of Programs for All-Inclusive Care of the Elderly (PACE) under the first Bush administration, this track record can be source of optimism, according to Edo Banach, partner at Manatt Health, a division of the law firm Manatt, Phelps & Phillips, LLP.
“The optimistic note is that a lot of the positive things that have happened in health care over the last 30 years have happened under a Republican Congress, a Republican administration or both,” Banach told Home Health Care News. “I think we’re going to see an increase in opportunities when it comes to caring for vulnerable folks, people who have Medicare and Medicaid, people who are chronically and seriously ill. If the incoming administration wants to solve an economic problem, they can’t solve an economic problem without solving that problem. You’re not going to save money if you simply cut services, so you have to be smarter about the way that you deploy those services.”
Banach previously served as deputy director and senior leader at the U.S. Centers for Medicare & Medicaid Services (CMS) during the Obama administration.
A key component of this is the Republican drive to cut costs, particularly as it pertains to the Medicare trust fund. Home-based care has a proven track record of reducing the total cost of care, which could lead to increased government investment in those services.
Hospice is a great example. Hospice care saves Medicare roughly $3.5 billion for patients in their last year of life, according to a joint report from the National Alliance for Care at Home and NORC at the University of Chicago.
Likewise, participants in the home health value-based purchasing model (HHVBP) have saved Medicare more than $1.38 billion over six years in nine states, according to CMS.
The same principle extends to palliative care. Home-based palliative care could reduce societal health care costs by $103 billion within the next 20 years, the nonprofit economic research group Florida TaxWatch said in a 2019 report…
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Free AI for the Small Business Workforce Series + Toolkit
The Jobs for the Future (JFF) Center for Artificial Intelligence & the Future of Work is introducing a portfolio of resources to small businesses across the country to better prepare them and their workforce for the exciting changes AI is already bringing to the world of business.
JFF is currently recruiting businesses for a series of engagements that will introduce them to new AI resources for small business and provide individualized technical assistance for successful worker-centric AI integration.
How are they doing it? JFF will be offering 3 engagement opportunities to small businesses:
(1) Build a Stronger, More Resilient AI Ready Workforce: Part 1 (Tues, March 4th @ 11a.m. – 12:30 p.m., Mountain Time)
Through this webinar small businesses will be introduced to the JFF AI Ready Workforce Framework that will give them a deep understanding of the anticipated changes in jobs and roles in businesses with guidance on how they can AI proof and strengthen their workforce by acting now. Additionally, they will be introduced to an actionable AI for Small Business Toolkit to help them make decisions and more successfully integrate AI from a worker-centric perspective.
(2) AI for Small Business Toolkit Technical Assistance (March – May 2025)
Organizations who are interested and qualify will be offered three free 1:1 advisory sessions tailored to small businesses to think through and apply the AI for Small Business Toolkit to their individual businesses. Only 10 businesses will be selected for this more exclusive and intensive engagement through an application process. This experience will end with a virtual exchange between the participating businesses to share best practices.
(3) Build a Stronger, More Resilient AI Ready Workforce: Part 2 (June 2025)
Businesses that participate in the technical assistance engagement will return to the bigger audience of small businesses from the first webinar along with AI experts to talk about the successes, challenges and lessons learned around worker-centric AI integration in small business. It is sure to be an honest and illuminating exchange.
To learn more about JFF’s Center for AI and the Future of Work visit www.jff.org.
Register for the March 4th Webinar |
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