House Republicans press HHS to end COVID-19 emergency, but hospitals want extension

Posted on by • Posted in American Hospital Association (AHA), Center for Medicare and Medicaid Services (CMS), Coronavirus, Dept of Health and Human Services (HHS), Federation of American Hospitals, Health Policy, Health System, Hospital, Hospital Industry, Pandemic, Public Health Emergency (PHE) • Leave a comment
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House Republicans are demanding the Biden administration starts winding down the COVID-19 public health emergency, while hospital lobbying groups are pressing it to do the opposite.

A group of more than 70 House Republicans wrote Thursday to Department of Health and Human Services (HHS) Secretary Xavier Becerra asking to start the process to wind down the COVID-19 public health emergency (PHE), which was recently extended until April. At the same time, several hospital advocacy groups are hoping the agency keeps the PHE beyond this spring and wants a 60-day notice as to when it will end.

“Although the PHE was certainly necessary at the outset of the pandemic, it was always meant to be temporary,” according to the GOP letter led by Rep. Cathy McMorris Rodgers, R-Washington, ranking member of the House Energy and Commerce Committee.

Republicans want HHS to release a concrete timeline for when the agency plans to exit the PHE.

“We recognize that the PHE cannot end overnight, and that certain actions must be taken to avoid significant disruption to patients and healthcare providers, including working with Congress to extend certain policies like maintaining access to telehealth services for our nation’s seniors,” the letter added.

The PHE granted major flexibilities for providers to get reimbursed by Medicare for telehealth, but those powers will go away after the PHE. It also gave flexibility on several reporting requirements and eased other regulatory burdens.

Another major issue is that states are going to be able to start eligibility redeterminations for Medicaid, which have been paused since the PHE went into effect in January 2020. State Medicaid directors are seeking a heads-up on when the emergency will go away, as states can start to disenroll ineligible beneficiaries after the PHE expires.

Republicans also want Becerra to cite any programs that should be made permanent, and they want “swift action” to lift all COVID-19 vaccine mandates.

The Supreme Court upheld the Biden administration’s healthcare worker vaccine mandate, overturning a lower court’s stay that affected half of the country. The Centers for Medicare & Medicaid Services has deadlines for states to comply with the vaccination mandate, and facilities that don’t fully comply could risk losing participation in Medicare and Medicaid.

The Republicans charge that the mandates have not “stopped the spread of COVID-19 but have alienated many Americans and have caused staff shortages at hospitals and other healthcare facilities.”

Key drivers of the staff shortages, however, have been a massive surge of the virus overwhelming facilities caused by the omicron variant along with increased expenses facilities have faced for temporary nursing staff. Those lingering expenses are the reason hospital groups are pressing for HHS to do the opposite and extend the PHE beyond April.

The Federation of American Hospitals (FAH) also wrote to Becerra Thursday (PDF) seeking to continue to extend the PHE “well beyond its current expiration date in April 2022.” Even though the omicron surge appears to be easing, the virus is still creating major operational challenges for providers, FAH said.

It also wants the administration to give hospitals a 60-day heads-up when it plans to end the PHE.

“Unwinding the complex web of PHE waiver-authorized operations, programs and procedures—which will have been in place and relied on for more than two years—is a major undertaking that, if rushed, risks destabilizing fragile healthcare networks that patients rely on for care,” the letter said.

The American Hospital Association also wrote to congressional leaders Tuesday seeking for more relief from Congress to help systems overcome staffing shortages that have exacerbated due to the omicron surge.

“The financial pressures hospitals and health systems faced at the beginning of the public health emergency continue, with, for example, ongoing delays in non-emergent procedures, in addition to increased expenses for supplies, medicine, testing and protective equipment,” the letter said.

FAH President Chip Kahn told Fierce Healthcare on Friday that the issues Republicans address in the letter are different from the priorities of the FAH, namely that the association doesn’t focus on mask or vaccine mandates.

“What we are saying is that the PHE has many aspects to it, and so … we think [it] should be extended, but if you don’t then we need to have a lengthy or carefully thought through transition,” Kahn said.

He added that Becerra’s predecessor, acting Secretary Eric Hargan, told providers that they would get a 60-day notice before the end of the PHE. That deadline for such a 60-day notice is Feb. 15.

Kahn said he understands the administration may be under political pressure to end the emergency, but prior notice is absolutely needed.

“I don’t know how they will respond but if they do choose to pull out, we just want to make sure that it doesn’t leave anything behind,” he said.

UnitedHealth was 2021’s most profitable payer

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https://www.fiercehealthcare.com/payers/unitedhealth-was-2021s-most-profitable-payer-heres-look-what-its-competitors-earned?utm_source=email&utm_medium=email&utm_campaign=HC-NL-FierceHealthcareWeekly&oly_enc_id=8564C4000334E5C

UnitedHealth Group was the most profitable payer in 2021, bringing in more than double the profit of its next-closest competitor with $17.3 billion in earnings.

CVS Health recorded the second-highest profit for the year among six major national insurers, earning $7.9 billion. CVS did bring in the highest revenue for the year, though, edging out UnitedHealth with $292.1 billion.

UHG reported $287.6 billion in revenue for 2021, according to the company’s earnings report.

Both healthcare giants expect to top $300 billion in revenue this year, according to their forecasts.

UnitedHealth was also the fourth quarter’s most profitable company, raking in $4.1 billion, which matched what its competitors earned combined, according to the filings. 

UnitedHealth Group’s results represented significant growth over both the full-year and fourth quarter of 2020. According to its earnings report, this was driven in part by gains in Medicare Advantage and Medicaid at UnitedHealthcare as well as another quarter of double-digit growth at Optum.

CVS was also the next-highest earner in Q4, with $1.3 billion in profit on $76.6 billion in revenue. UHG was just behind on revenue with $73.7 billion.

CVS Health executives said that the retail business outperformed expectations in the fourth quarter amid increased demand for COVID-19 tests and booster shots. 

The healthcare giant performed 32 million tests and 59 million vaccine doses over the course of the year, with 8 million tests and 20 million vaccinations reported in the fourth quarter alone.

While CVS and UnitedHealth duked it out for the top spot, all six of the big national payers were profitable for 2021, though Humana did post a $14 million loss for the fourth quarter.

Centene Corporation lands in sixth place for the year in profitability, bringing in $1.3 billion in profit on $126 billion in revenue. It also reported $599 million in profit for Q4.

Humana earned $2.9 billion for the year and $83.1 billion in revenue despite the Q4 loss, according to the company’s earnings report. Executives said the insurer braced for headwinds related to COVID-19 during the year and also saw disappointing growth in new Medicare Advantage members.

As a result, Humana has kicked off a $1 billion value creation effort to reinvest in its core MA business in hopes of bouncing back from the underwhelming enrollment during the annual period.

Centene has been conducting a similar project throughout the year in an effort to streamline its operations.

Anthem and Cigna fall in the middle of the pack, according to our review. They both reported about $1.1 billion in profit for Q4, though Cigna was ahead with $45.7 billion in revenue.

Cigna reported $174.1 billion in revenue and $5.4 billion in profit for the year, and on its earnings call noted that a major growth opportunity moving forward its Evernorth subsidiary, which includes a slew of businesses such as Express Scripts, Accredo and MDLive.

Anthem earned $6.1 billion in profit on $138.6 billion in revenue for the year, and executives shrugged off concerns about the Medicare Advantage market, saying its performance in open enrollment met expectations. In addition, it’s seeing growth at its in-house pharmacy benefit manager, IngenioRx, as it expands clientele.

34 states where child care costs more than college tuition 

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The annual expense of child care for an infant exceeds the annual cost of in-state tuition at a public four-year university in 34 states, according to the most recent data from the Economic Policy Institute. 

At this point in the pandemic, healthcare is among the top three industries when it comes to people quitting or changing jobs. The quality and cost of child care is top of mind for healthcare decision-makers given its strength as a determining factor to push people from the U.S. labor force. Mothers continue to shoulder the majority of family caregiving responsibilities, making child care a heavier tip of the scale for healthcare, where women make up the majority of the front-line workforce (66 percent) and managers (59 percent), according to research from McKinsey. 

Infant care expenses exceed college tuition in 34 states and Washington, D.C. Below is each state ranked by how much infant care costs exceed or compare to the cost of tuition at a four-year public university, along with the median family income in each state and infant care as a share of income. 

4 possible scenarios for the pandemic’s next act

Posted on by • Posted in Coronavirus, Coronavirus Delta Variant, Coronavirus Mutation, Coronavirus Omicron Variant, Infection Control, Infectious Virus, Pandemic, Unvaccinated, Vaccination, Vaccine, Vaccine Booster, Vaccine Efficacy, Vaccine Safety, Vaccine Supply • Leave a comment
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As COVID-19 cases fall and hospitals tiptoe out from yet another surge, the nation is left collectively asking one major question: What comes next?

By now, health experts have made it clear COVID-19 will always be around in some capacity but have stressed uncertainty about the potential scope and severity of future surges.

While difficult to predict what the pandemic’s next act could look like, several potential scenarios have emerged in recent months. 

Below are four possible paths the pandemic could take in the future, as outlined by physicians, epidemiologists and global health officials: 

1. Delta rebound. Delta has seemingly fallen out of the collective pandemic lingo amid omicron’s dominance in recent months, though there is still a chance delta — thought to be the deadliest strain thus far — makes a comeback. 

In a Jan. 24 op-ed for The Washington Post, Ashish Jha, MD, dean of Brown University’s School of Public Health in Providence, R.I., said “It is possible, though unlikely, that the delta variant returns and co-circulates with omicron in different populations, contributing to ongoing infections and hospitalizations.” 

It’s important to note that delta is still dominant in some parts of the world, health experts told The Atlantic, adding that while unlikely, there is a chance it could morph into something that catches up with omicron, allowing the two to tag-team — a dangerous combination given delta’s brutality and omicron’s transmissibility. 

2. COVID-19 may become a seasonal virus. Dr. Jha said this scenario is likely, whether delta makes a comeback or not. 

“That means we are likely to see surges in Southern states this summer (as people there spend more time indoors) and in Northern states next fall and winter as the weather turns cold again,” he wrote in a Jan. 24 op-ed for The Washington Post. 

Emerging evidence suggests COVID-19 may be a seasonal disease, though the research is still preliminary. A July 2021 study from the University of Pittsburgh projected a seasonal COVID-19 pattern in North America with three repeating waves: one starting in New England in the spring, the second starting in the South in the summer, and the third kicking off in the Dakotas in the fall. Based on these findings, researchers predicted the U.S. would see a summer 2021 wave in the South and a fall 2021 wave in North-Central states, which is similar to what happened with the delta and omicron surges. As of November 2021, the study had not been peer reviewed. 

3. A new variant emerges. If there’s one thing on this list that’s near certain, it’s that there will be new variants in the future. Global health officials have said they expect future variants to be even more transmissible than omicron.

“Omicron will not be the last variant that you will hear us talking about,” Maria Van Kerkhove, PhD, the World Health Organization’s technical lead on COVID-19, said Jan. 25. “The next variant of concern will be more fit, and what we mean by that is it will be more transmissible, because it will have to overtake what is currently circulating.” 

Health officials aren’t so much concerned about the emergence of new variants themselves but whether they will cause more or less disease severity. WHO officials have warned against assuming the virus will become milder as it continues to mutate.

“There is no guarantee of that,” Dr. Van Kerkhove said. “We hope that is the case, but there is no guarantee of that and we can’t bank on it,” she added, emphasizing the importance of interventions such as ramping up global vaccination coverage to prevent the emergence of new variants. 

Health experts are also concerned white-tailed deer may become a reservoir for the virus to mutate and spread to other animals or back to humans in the form of a new variant. 

“This is a top concern right now for the United States,” said Casey Barton Behravesh, who directs the CDC’s One Health Office, which focuses on connections among human, animal and environmental health. “If deer were to become established as a North American wildlife reservoir — and we do think they’re at risk of that — there are real concerns for the health of other wildlife species, livestock, pets and even people,” she told The New York Times. 

Preliminary findings recently found white-tailed deer on New York’s Staten Island infected with omicron, the first time the strain has been detected in wild animals in the U.S. Scientists are still exploring a number of questions regarding the virus’s spread among deer, such as how they contract the virus, how the pathogen might mutate inside the host, and whether deer could pass the virus back to humans.

4. The omicron subvariant may spread globally, prolonging the current COVID-19 surge in some parts of the world. 

Research shows BA.2 is more transmissible than BA.1, the original omicron strain, though there is no evidence to suggest the subvariant causes more severe illness. The WHO said it expects cases of the omicron subvariant to increase globally due to its growth advantage over BA.1. 

“We expect to see BA.2 increasing in detection around the world,” Dr. Kerkhove said during a Feb. 8 media briefing. 

In late January, Nathan Grubaugh, PhD, an epidemiologist at the Yale University School of Public Health in New Haven, Conn., told The New York Times he was “fairly certain” the subvariant will become dominant in the U.S. but is unclear on “what that would mean for the pandemic.”

The BA.2 variant could spur a new surge, but it’s more likely that U.S. cases will continue to decrease, according to Dr. Grubaugh. If anything, the variant may simply slow the decline.  

Overall, most experts told the Times that BA.2’s presence would not significantly alter the course of the pandemic, and so far, data backs this up. COVID-19 cases have been falling nationwide since peaking in mid-January, and modeling from Rochester, Minn.-based Mayo Clinic predicts this trend will continue over the next 14 days.

The weekly number of BA.2 sequences identified in the U.S. has also fallen since mid-January, according to a Feb. 11 U.K. Health Security Agency’s report. The U.S. confirmed 191 BA.2 sequences in the week of Jan. 17, which fell to 116 in the week of Jan. 24. In the week of Jan. 31, just four sequences were confirmed, according to supplemental data from the report. 

Mayo Clinic halts scheduling of out-of-network Medicare Advantage patients

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https://www.healthcarefinancenews.com/news/mayo-clinic-halts-scheduling-out-network-medicare-advantage-patients

The Mayo Clinic in Minnesota is no longer scheduling appointments for patients in most Medicare Advantage plans, and has been gradually notifying patients throughout the year, in a move that could have consequences for insurers operating plans in the area, according to a Mayo Clinic spokesperson.

Some insurers, such as UnitedHealthcare, have been negotiating with the Mayo Clinic to bring them in-network for Medicare Advantage, in some cases asking them to outline their requested terms, but Mayo to date has yet to send out proposals.

Mayo has long been out of network for most Medicare Advantage plans, but has historically treated out-of-network MA patients and accepted their benefits, according to Mayo Clinic spokesperson Karl Oestreich.

According to the Star Tribune, the change occurred because Mayo saw a significant increase in patients covered by “non-contract” MA insurers. That increase, officials said, threatens to crowd out patients covered by in-network insurers.

Non-contract MA plans are those in which insurance companies have not negotiated payment rates for services with Mayo.

UnitedHealthcare, which has been out of network, is negotiating to bring Mayo in-network for MA members, according to Dustin Clark, vice president for communications at UHC.

“We have asked Mayo Clinic to outline requested terms to join our network for Medicare Advantage and haven’t received a proposal,” he told Healthcare Finance News. “We are committed to reaching an agreement at an affordable cost for the people we serve. We stand at the ready to work with Mayo to end this disruption.”

For UHC, it’s especially important that MA patients who traditionally received care at Mayo can continue to do so in the future.

“Although Mayo Clinic does not participate in our network for Medicare Advantage, many of our members have received treatment from its physicians as part of their out-of-network benefits,” said Clark. “We understand how difficult this situation is for some of our members, which is why we are working with Mayo to ensure our Medicare Advantage members who are currently undergoing treatment or have an established relationship with the clinic can continue to see their physician.”

Mayo Clinic spokesperson Karl Oestreich said that medical need is the primary criteria for obtaining an appointment.

“In situations where medical need does not apply and to ensure appointments remain available for our Mayo Clinic patients, we no longer schedule routine visits for those whose coverage does not include Mayo Clinic,” he said. “Continuity of care and relationships with existing local and regional patients won’t be compromised.”

The primary issue, said Oestreich, is capacity, not reimbursement. He said Mayo doesn’t have the capacity to serve an ever-increasing number of patients, and needs to remain a good steward with its contracted plans.

“There was not a policy change, but a shift in enforcement to ensure Mayo has access for our contracted plans (not just Medicare) and those who truly need Mayo’s medical expertise,” he said. “This long-standing policy applies to all payers, not just Medicare Advantage.”

“The impact is to non-contract Medicare Advantage plans,” said Oestrich. “Mayo does not have contracts with these plans. Mayo is open to entering new contracts, but also must keep in mind the impact on capacity to ensure that we can continue to see those patients (regardless of payer) who are in the greatest need of the care Mayo provides.

“We understand that affected patients may be disappointed and frustrated. Patients should always ask their brokers and insurers whether their plans specifically have in-network coverage at Mayo Clinic.”

THE LARGER TREND

UnitedHealthcare, which already has significant market control with its MA plans, said it will strengthen its foothold in the space by expanding its MA plans in 2022, adding a potential 3.1 million members and reaching 94% of Medicare-eligible consumers in the U.S.

While UnitedHealthcare has a massive foothold in the Medicare Advantage space, it underwent scrutiny from the federal government earlier this month, when the Centers for Medicare and Medicaid Services blocked four Medicare Advantage plans from enrolling new members in 2022 because they didn’t spend the minimum threshold on medical benefits. Three UnitedHealthcare plans and one Anthem plan failed to hit the required 85% mark three years in a row.

Medicare Advantage plans are required to spend a minimum of 85% of premium dollars on medical expenses. Failure to do so for three consecutive years triggers the sanctions.

For UHC, the penalties apply to its MA plans in Arkansas, New Mexico and the Midwest, which encompasses Missouri, Kansas, Nebraska and Iowa. UHC plans cover about 83,000 members, and the Anthem plan covers about 1,200 members. They cannot offer select plans to members until 2023, assuming they hit the 85% threshold next year – what’s called the medical loss ratio. If they fail to hit the threshold for five years in a row, the government will terminate the contracts.

UHC representatives told Bloomberg that it missed the 85% benchmark in certain markets in part because of patients deferring medical care due to the COVID-19 pandemic.

Mark Cuban’s pharmacy started with a cold email

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A Dallas-based generic drug startup bearing Mark Cuban's name just came out of stealth

The Mark Cuban Cost Plus Drug Co. launched its online pharmacy in January, offering low-cost versions of high-cost generic drugs. And it all started with a cold email. 

Alex Oshmyansky, MD, PhD, fired off an email to Mr. Cuban with a simple subject line: “Cold pitch.” The then 33-year-old radiologist told Mr. Cuban about work he was doing in Denver with a compounding pharmacy and the business plan behind a company he founded in 2018, Osh’s Affordable Pharmaceuticals. 

“I asked him a simple question, because this was when the whole pharma bro thing was going down,” Mr. Cuban said on NPR podcast The Limits, referring to convicted felon Martin Shkreli. “I was like, ‘Look, if this guy can jack up the prices 750 percent for lifesaving medicines, can we go the opposite direction? Can we cut the pricing? Are there inefficiencies in this industry that really allow us to do it and really make a difference?'”

Dr. Oshmyansky answered yes. Their weekly email correspondence continued for months. The Mark Cuban Cost Plus Drug Co. was quietly founded in May 2020, and Dr. Oshmyansky now serves as its CEO. The company is organized as a public-benefit corporation, meaning it is for-profit but claims its social mission of improving public health is just as important as the bottom line.

“We basically created a vertically integrated manufacturing company that will start with generic drugs,” Mr. Cuban told NPR. A major component of the strategy is to bypass pharmacy benefit managers, which Mr. Cuban likens to bouncers at a club.

“They’re the ones who say, ‘Hey, I’m controlling access to all the big insurance companies. If you want this insurance company to sell your drug, you’ve got to pay the cover charge. All these drugs pay the cover charge to these PBMs through rebates, and because they’re paying the cover charges, the prices are jacked up,” Mr. Cuban told NPR. “We said we’re going to create our own PBM, we’re going to work directly with the manufacturers, and we’re not going to charge the cover charge.”

The Mark Cuban Cost Plus Drug Co. marks the prices of its drugs up 15 percent, charges a $3 pharmacy fee to pay the pharmacists it works with, and a fee for shipping. “That’s it,” Mr. Cuban said on NPR. “There’s no other added costs. The manufacturers love what we’re doing for that reason.”

Others have set out before to disrupt pharma the way Mr. Cuban and Dr. Oshmyansky intend, but their downfall is cooperating or giving in to the PBMs, the entrepreneur noted. 

“People always ask, well why didn’t somebody do this before? The reality is there’s so much money there, it’s hard not to be greedy,” Mr. Cuban said on the podcast. “If you get to any scale at all, those PBMs will start throwing money at you and saying, ‘Look, just play the game.’” 

Mr. Cuban has indicated he has no intention to play the game. 

“I could make a fortune from this,” Mr. Cuban told Texas Monthly last fall. “But I won’t. I’ve got enough money. I’d rather f— up the drug industry in every way possible.”

Florida physician convicted of $110M fraud

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Report from the Department of Justice Fraud & Abuse Control for 2017 sheds light upon the importance of compliance - The Coding Network

A Florida physician was convicted Feb. 10 for his role in a healthcare fraud scheme that involved billing health insurance companies for $110 million in medically unnecessary services, according to the Justice Department. 

Mark Agresti, MD, of Palm Beach, Fla., unlawfully billed insurers for $110 million of drug testing services that were medically unnecessary. The patients who received the unnecessary drug tests were residents of Good Decisions Sober Living in West Palm Beach. Dr. Agresti was the medical director of the facility, according to the Justice Department. 

“Patients at GDSL were required to submit to excessive, medically unnecessary urine drug tests as a condition of residency approximately three or four times per week,” the Justice Department said. “These [urinalysis] drug tests cost as much as $6,000 to $9,000 per test.”

According to evidence presented at trial, Dr. Agresti also had Good Decisions Sober Living patients sent to his own medical practice to fraudulently bill for services. 

Dr. Agresti was convicted of 11 counts of healthcare fraud and one count each of conspiracy to commit healthcare fraud and wire fraud. He is scheduled to be sentenced April 21. 

Kaiser sees net income top $8B in 2021, operating income fall sharply

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Kaiser sees net income top $8B in 2021, operating income fall sharply - NewsBreak

Driven by strong investment gains, Oakland, Calif.-based Kaiser Permanente recorded a net income of $8.1 billion in 2021, an increase of $1.7 billion from 2020, according to its financial results released Feb. 11. However, its operating income fell sharply.

For the 12 months ended Dec. 31, the integrated healthcare provider with 39 hospitals recorded an operating revenue of $93.1 billion, up from $88.7 billion recorded last year. Additionally, Kaiser saw its expenses rise 6.9 percent to $92.5 billion in 2021. 

In 2021, Kaiser saw its operating income fall to $611 million, an operating margin of 0.7 percent. This compares to a $2.2 billion operating income in 2020 and an operating margin of 2.5 percent. 

Kaiser attributed the sharp decrease in operating income to an increase in care delivery expenses due to COVID-19 surges.

Total other income and expenses, which includes investment income, reached $7.5 billion in 2021. In 2020, Kaiser saw a gain of $4.1 billion.

“Our financial performance underscores the strength of our integrated model, which allows us to weather unexpected challenges such as the COVID-19 pandemic while continuing to serve our members,” said Kathy Lancaster, Kaiser Permanente executive vice president and CFO.

In 2021, Kaiser also said its health plan membership grew by 185,000 members. It now has more than 12.5 million members.

Read more here.