Data & Analytics

ONC Head Touts Interoperability Wins, Poses AI Questions

Micky Tripathi, Ph.D., National Coordinator for Health Information Technology, touted the Biden administration’s progress on implementing regulations mandating the interoperability of health care systems and price transparency during a Feb. 22 Health Affairs event. He also described himself as an “AI optimist,” but emphasized the administration’s position that artificial intelligence tools must not exacerbate or worsen health inequities.

With increasing interoperability and EHR adoption, Tripathi said, the Biden administration expects that providers, health plans and public health officials will be able to make smarter decisions using population health data. They will also have to meet standards set by the Office of the National Coordinator for Health Information Technology (ONC) to comply with quality measures used by CMS, among other organizations, Tripathi said. He also said that a focus on health equity is a key consideration in recent regulations governing AI.


Surprise Billing Disputes Far Outpace Federal Projection

The federal government received 13 times more surprise billing disputes in the first half of 2023 than it initially estimated to receive over the course of a full calendar year, according to new CMS data.

The No Surprises Act (NSA), passed in 2021, established a Federal Independent Dispute Resolution (IDR) process that out-of-network providers and insurers can use to determine the OON rate for qualified IDR items or services after an unsuccessful open negotiation period. That process replaces the pre-NSA status quo of an OON provider sending a surprise bill to a patient. Of the 288,810 disputes filed through the Federal IDR portal over the first six months of 2023, about 46% were closed, with providers winning 77% of payment determinations.


New Medicare Out-of-Pocket Drug Cost Cap Will Benefit Millions in 2025

Millions of Medicare Part D beneficiaries will save money after the introduction of a $2,000 out-of-pocket (OOP) spending cap for prescription drugs, a provision that is included in the Inflation Reduction Act of 2022 and takes effect next year, according to a recent KFF analysis.

Based on KFF’s review of drug claims data for Part D enrollees who do not qualify for the low-income subsidy (LIS), the analysis projected that, if the $2,000 cap had been in place in 2021, 1.5 million Medicare Part D beneficiaries — who spent $2,000 or more OOP on prescription drugs — would have saved money. Over the 10-year period between 2012 and 2021, a total of 5 million enrollees had OOP drug costs of $2,000 or more in at least one year.


Health Insurer Executive Compensation Database, 2019-2022

CEOs of health insurance companies have received increasing pay packages over the past few years, AIS Health’s Executive Compensation Database shows. The database includes major health insurers’ executive compensation from 2019 to 2022 — collected from individual companies, state insurance documents and U.S. Securities and Exchange Commission filings — and their national membership information as of the third quarter of 2023, per AIS’s Directory of Health Plans. The database will be updated annually.

Several states do not disclose compensation data for specific executives at health insurance companies or do not collect compensation data. Some insurance companies made leadership changes over the years.


CMS, Senate Seek to Crack Down on Insurer Use of AI

In a recent memo, the Biden administration clarified restrictions on the use of artificial intelligence in Medicare Advantage coverage decisions. Congress may also eventually weigh in on AI use in federal health insurance programs: The Senate Finance Committee on Feb. 8 held a hearing in which senators indicated they may tighten the rules on payer and provider use of AI, particularly in Medicare and Medicaid.

In its Feb. 6 memo, CMS sought to address questions it received after finalizing a rule last April that made technical changes to the MA program. The frequently asked questions (FAQ) document confirmed that “an algorithm or software tool can be used to assist MA plans in making coverage determinations,” but it also emphasized that plans must base coverage decisions “on the individual patient’s circumstances.” According to one D.C. insider, the rule may force plans to move faster to curb misuse of AI and algorithms in decision making.


MCO Stock Performance, January 2024

Here’s how major health insurers’ stock performed in January 2024. UnitedHealth Group had the highest closing stock price among major commercial insurers as of Jan. 31, 2024, at $511.74. Humana Inc. had the highest closing stock price among major Medicare insurers at $378.06.


Preventable Hospitalizations Are More Common Among Black Medicaid Enrollees

Black Medicaid enrollees were more likely to be hospitalized for preventable reasons than white enrollees, regardless of whether they were enrolled in the Supplemental Security Income (SSI) program, according to an Urban Institute study.

Using data from CMS, the analysis studied preventable hospitalization rates across 21 states and among Medicaid enrollees ages 19 to 64 for the three most common types of preventable conditions: asthma/chronic obstructive pulmonary disease (COPD), diabetes, and heart failure. For all three conditions, preventable hospitalization rates were significantly higher for people enrolled in Medicaid through the SSI program — meaning they have a qualifying disability — compared with those who enrolled through other pathways.


News Briefs: CMS Sends Initial Offers in Medicare Drug Price Negotiation Program

CMS on Feb. 1 sent initial price offers to the manufacturers of the 10 medications that were selected for the Medicare drug price negotiation program, which goes into effect in 2026. The agency announced the 10 medications in August 2023 and said they accounted for about 20% of total Part D gross covered prescription drug costs from June 1, 2022, to May 31, 2023. The drug companies have 30 days to respond by either accepting the offer or providing a counteroffer. The negotiation period ends on Aug. 1. The drug price negotiation program was implemented as part of the Inflation Reduction Act.

In 2023, 79 health care companies filed for Chapter 11 bankruptcy, according to Gibbins Advisors, a health care restructuring advisory firm. That was up from 46 filings in 2022 and the highest number of Chapter 11 filings in the past five years; the next-highest was 51 in 2019. Gibbins noted that most of the filings involved pharmaceutical and senior care companies. The firm added that 12 hospitals filed for Chapter 11 bankruptcy in 2023, which compares to 11 total between 2020 and 2022. Gibbins analyzes bankruptcies for debtors with at least $10 million in liabilities.


National Health Care Spending Growth Returned to Pre-COVID Levels in 2022

Total U.S. health care spending increased by 4.1% in 2022, hitting $4.5 trillion, according to CMS. The growth rate appeared to return to the average annual rate of the 2010s, while the share of the gross domestic product (GDP) devoted to health care (17.3%) also fell to pre-pandemic levels.

The rise in overall health care expenditures reflected faster growth in spending for administration costs, retail prescription drugs and long-term services from 2021 to 2022, which was offset by a decline in federal public health spending, according to an analysis by KFF. As the pandemic entered its third year, public health spending dropped by $33 billion compared to 2020.


News Briefs: CMS Appeals to Public for More Medicare Advantage Data

The Biden administration on Jan. 25 released a Request for Information to seek feedback about the best way to enhance Medicare Advantage data capabilities and increase public transparency. In a press release, HHS pointedly noted that “transparency is especially important now that MA has grown to over 50% of Medicare enrollment, and the government is expected to pay MA health insurance companies over $7 trillion over the next decade.” To that end, the agency said it’s seeking data-related input on aspects of the MA program including access to care, prior authorization, provider directories and networks, supplemental benefits, marketing; care quality and outcomes, value-based care arrangements and equity, and “healthy competition in the market, including the effects of vertical integration and how that affects payment.”