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ILASN June 2024 News Updates


Fewer Than Half of Nursing Homes in 45 States Have Staff to Meet New RequirementsCMS' finalized nursing home staffing requirement rules, released in April, are too stringent for almost 50 percent of the facilities in 45 states according to analysis by Kaiser Family Foundation. Worser still, the share of facilities that meet these requirements ranges is as low as 5 percent or lower in four states (AR, TN, TX and LA). The KFF analysis shows that only 19 percent of all nursing homes will meet all three criteria within the rule. To read the analysis, click here.


ARPA-H Launches UPGRADE Program to Bolster Cybersecurity in Health FacilitiesThe Advanced Research Projects Agency for Health (ARPA-H) introduced the Universal Patching and Remediation for Autonomous Defense (UPGRADE) program last week, an ambitious initiative aimed at fortifying cybersecurity defenses within healthcare facilities. With an investment surpassing $50 million, UPGRADE wants to empower IT teams with cutting-edge tools to safeguard critical hospital environments, ensuring the continuity of patient care amid escalating cyber threats.  Click here to read the ARPA-H press release.


Key Senator Urges FTC, SEC to Investigate UnitedHealth Cybersecurity NeglectIn a letter to Federal Trade Commission and U.S. Securities and Exchange Commission, Senate Finance Committee Chair, Ron Wyden (D-OR) urged the agencies to hold UnitedHealth Group accountable for negligent cybersecurity practices that led to the ransomware attack on Change Healthcare in February. "This incident and the harm that it caused was, like so many other security breaches, completely preventable and the direct result of corporate negligence," Wyden wrote. Click here for the full letter.


CBS News: Some For-Profit Nursing Homes Endanger PatientsOf the more than 15,000 nursing homes in the U.S., more than 70 percent are for-profit, many with complex ownership arrangements. These types of arrangements are leading to changes in care that endanger patients in favor of profits, according to an investigation by CBS News. Looking at one in particular that one of their reporters just happen to have a family member residing, the organization found that negligence "on a daily basis," including patients not receiving their medication on time. Read the full report, click here.


HHS Unveils Strategic Framework for National Plan on AgingHHS has released a comprehensive strategic framework titled "Aging in the United States: A Strategic Framework for a National Plan on Aging." The report, developed in collaboration with leaders from 16 federal agencies and departments, sets the stage for a unified effort to address the evolving needs of older adults across the nation. Emphasizing collaboration between public and private sectors, along with input from older adults, family caregivers, and community stakeholders, the framework outlines key objectives such as advancing healthy aging, fostering age-friendly communities, and ensuring equitable access to essential services. The report highlights forthcoming engagements, including a public webinar and stakeholder consultations, to inform the development of a comprehensive national plan on aging. Click here to access the HHS press release and the strategic framework.


CMMI Extends, Updates Enhanced Oncology ModelCMS' Innovation Center is seeking applications for a second cohort of participants in its Enhanced Oncology Model (EOM) and is making adjustments that will apply to everyone in the program, including extending the model for two years, making higher payments and establishing a higher threshold for when a provider would owe a performance-based recoupment to the agency. Click here for details from CMMI.


​​​More $$$ for some MA plans. The federal government is rescoring the quality ratings of this year's Medicare Advantage plans, which could lead to an additional $1 billion of taxpayer money flowing into the coffers of health insurance companies. Click here for CMS' 2-page memo to plans. Recent court decisions required the Biden administration to make these changes to insurers' star ratings, many of which came in lower than companies had expected and cost them hundreds of millions of dollars in bonuses. The government also is reopening the process for Medicare Advantage insurers to submit their 2025 plans to account for these changes.


Prior Authorization Legislation ReintroducedAfter failing to move forward in the last Congress due to a $16 billion price tag, a new bill aimed at streamlining the use of prior authorization in Medicare Advantage was reintroduced in both the House and Senate last week. Sens. Roger Marshall (R-KS), Kyrsten Sinema (I-AZ), John Thune (R-SD), and Sherrod Brown (D-OH), and Reps. Mike Kelly (R-PA), Suzan DelBene (D-WA), Larry Bucshon, M.D. (R-IN) and Ami Bera, M.D. (D-CA) released an updated version of the bill. It will now not have a cost to the government. Under the bill, MA plans would be required to implement an electronic prior authorization program and enhance transparency reporting. In order to remove the cost, the new legislation requires that MA plans adhere to decision-making timeframes set by HHS instead of a real-time decision requirement and expedited decision-making process. Click here for the legislation, and here for the section-by-section of the bill.


MedPAC Scrutinizes Medicare Advantage Plans, Prior Auth a Key IssueIn the annual June report to Congress, the Medicare Payment Advisory Commission reviewed Medicare Advantage plans to find both positive and negative aspects of the insurers that cover half of Medicare beneficiaries. A chief issue being prior authorization requirements. MedPAC found that 95 percent of 37.5 million prior authorization requests by the plans in 2021 had "fully favorable decisions," and 80 percent of the negative prior authorization decisions also had "fully favorable decisions" upon redetermination. The report did find that shortcomings remain in the data on patient-provider encounters that MA plans submit to CMS. "Complete and accurate encounter data could be used to provide more rigorous oversight of Medicare's payments to MA plans," according to MedPAC's. Medicare paid MA plans $455 billion in 2023. Click here for the full June report.


Big MA Plans Looking to DownsizeTwo of the biggest insurers with Medicare Advantage plans are considering lowering their footprint by downgrading plan benefits and geographic presence for next year. This could lead to hundreds of thousands of seniors with MA plans being forced to look for new insurance plans and many are suggesting that UnitedHealth could pick up the beneficiaries to make their market domination even larger. This comes as reports continue to show that margins on plans are decreasing as seniors use more services than insurers expected. For more on the potential MA market changes, click here.

  • The rapid growth of MA, Medicaid managed care, and the ACA Marketplace leads to around 100 million Americans receiving subsidized health care administered by private insurers who are showing record profits, click here.


More Insurers Look to Expand Beyond Insurance, Be More Like UnitedHealthUnitedHealth has built and bought its way into being the largest health insurer in the U.S. and other insurers are taking notice. By expanding their business beyond insurance to owning physician practices, pharmacy benefit managers, and specialty pharmacies - among others - UnitedHealth Care has become a financial behemoth.  As part of its series on health consolidation, the Wall Street Journal digs into the "vertically integrated insurance conglomerates." The WSJ lays part of the blame on the ACA and the Medical Loss Ratio policy. Click here to view the article.

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