Humana prepares for ‘frustration’ over Medicare Advantage changes, 13 market exits

https://www.beckerspayer.com/payer/theres-going-to-be-a-lot-of-frustration-humana-prepares-for-medicare-advantage-market-exits-benefit-changes.html

Humana will stop offering Medicare Advantage in 13 counties in 2025, CFO Susan Diamond said Sept. 4.

Speaking at an investor conference, Ms. Diamond said the company will no longer offer several plans in 2025. The exits will affect around 560,000 beneficiaries, 10% of Humana’s MA membership. The company expects to retain around half of the members affected by plan exits.

In most areas where Humana is ending plans, the insurer has another plan available, Ms. Diamond said. She did not specify which counties Humana planned to exit.

“There are very few places, literally 13 counties, where we will have no presence at all — completely insignificant,” she said.

In July, Ms. Diamond said the company expected to lose a few hundred thousand members in 2025. 

Humana ended plans that did not have a path to profitability, Ms. Diamond said.

Rising medical costs and lower reimbursements from CMS led Humana and other insurers to plan market exits in 2025.

CVS Health executives said they expect to lose up to 10% of Aetna’s MA membership next year. Centene is also planning to exit Medicare Advantage markets in six states.

There will be disruption across the MA industry as Humana and its competitors exit markets and adjust benefits to account for rising costs, Ms. Diamond said.

Ms. Diamond said the company acknowledges that there is “going to be a lot of frustration” among beneficiaries about the level of changes being made.

“Even if they’re frustrated by the level of benefit change we made, if that plan is still the best option, they will typically stay in the plan,” Ms. Diamond said. “That’s what we’ve seen historically in cases where we’ve had to make so many types of changes.”

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US allows increased production of Takeda’s ADHD drug to address shortage

https://www.reuters.com/business/healthcare-pharmaceuticals/us-allows-increased-production-takedas-adhd-drug-address-shortage-2024-09-04/

The U.S. Drug Enforcement Administration (DEA) has increased the production limit for Takeda Pharmaceutical’s (4502.T)

UK-based Hikma Pharmaceuticals (HIK.L),  and Indian drugmaker Sun Pharmaceutical Industries (SUN.NS)

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Pain Identified as Dominant Symptom in Long COVID

https://reachmd.com/news/pain-identified-as-dominant-symptom-in-long-covid/2467986/

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Oversight Chair Knocks PBM Execs for July Testimony Under Oath

https://ncpa.org/newsroom/news-releases/2024/08/28/oversight-chair-knocks-pbm-execs-july-testimony-under-oath

Calls on them to provide any necessary corrections to the record within three weeks

Isn’t lying under oath called perjury? According to this article, three top execs of the 3 largest PBMs LIED under oath to the  House Committee on Oversight and Accountability

Chairman James Comer (R-Ky.) called on executives from Express Scripts, CVS Caremark, and OptumRx to correct the record for statements.

What kind of political BS is this, the law says a fine or FIVE YEARS IN PRISON. Those corporations will pay just about any fine that would be imposed. Each of those companies are worth hundreds of millions each.  Throw those 3 exec’s ass in JAIL FOR 5 YEARS and watch all those PBMs rapidly start changing their processes.  Repeal the   https://en.wikipedia.org/wiki/ McCarran%E2%80%93Ferguson_Act McCarran–Ferguson Act  gives the insurance industry an exemption to the Sherman Antitrust Act and then let the FTC have their way with the monopolistic practices of our insurance industry.

ALEXANDRIA, Va. (Aug. 28, 2024) – The National Community Pharmacists Association released the following statement from CEO B. Douglas Hoey, pharmacist, MBA, after House Committee on Oversight and Accountability

Chairman James Comer (R-Ky.) called on executives from Express Scripts, CVS Caremark, and OptumRx to correct the record for statements they made under oath during their appearance before the committee in July:

“PBM-insurers’ days of reckoning are continuing. Congress and the FTC aren’t falling for their nonsense, and the heat on them has never been higher. PBM-insurers exert so much influence on which drugs patients have access to and how much they cost that calling out their mistruths and working to hold them accountable is critical, and we applaud Chairman Comer for doing so. We also need to emphasize that Congress must absolutely pass PBM reforms this year. The time for waiting is over because PBM-insurers showed they will fudge the truth wherever they can and they’ll only change their ways if they are forced.”

In a statement released after the July hearing, Hoey called out

the excuses and at times downright lies the PBM executives were attempting to feed members of the committee about the roles their organizations play in increasing prescription costs and decreasing patient access to health care.  

Making sure to note that under the law,

those who are untruthful in committee testimony under oath run the risk of a fine or five years of imprisonment,

Comer’s letters to the PBM executives specifically highlight their statements that contradict the committee’s and the Federal Trade Commission’s findings about the PBMs’ self-benefitting practices that jeopardize patient care, undermine local pharmacies, and raise prescription drug prices; claims that they do not steer patients to PBM-owned pharmacies; and claims contradicting the committee’s and FTC’s findings regarding contract negotiations, contract opt-outs, and payments to pharmacies. The committee is asking the big three PBMs to provide their corrections to the record by Sept. 11, 2024.

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I have been wanting to post about this but waited till there was some progress. Back the end of Jan 2024 Barb ended up having lumbar surgery. Her pain had reached a level that even upping her doses of opioids over several months could not suppress her increased pain.

She debated on having the surgery for several months before relenting to having it done. The Surgeon what we chose, was recommended by the surgeon that had done my partial knee replacement in mid-2023.

This surgeon is an employee of a very large and very well known and respected ortho surgeon group that has been around for maybe 5+ decades, and the practice is owned by one of the three major hospital system in a city that is the largest city in the state and there is also a nearby medical school.

Barb went back for a 6 weeks follow up. The surgeon seem to start off with THE INCISION IS INFECTED!  After we expanded our pharmacy into providing home medical equipment and then we started dealing with pts who were bed or wheelchair confined and experiencing “bed sores” and/or “decubitus ulcers“. Barb got the opportunity to get certified as a tissue therapist. So she could help pts and their caregivers try to prevent those decubitus ulcers and/or help them to heal those if they already had them. She knew the outwards signs if a broken skin, bedsore, surgical incision was infected, and I learned them via osmosis being married to her.  I knew from clinical standpoint what lab tests would suggest that the pt had an infected decubitus.  A infected decubitus typically had necrotic (dead) tissue around the perimeter, had a bad odor, their blood work should show elevated white blood cell count and pts would have at least a low grade elevated temp.

Barb’s labs nor her surgical incision showed any indication that it was infected, but the surgeon was insistent that he had to debride Barb’s incision STAT.. sent her directly from his office to the hospital and had her admitted. Two days later she was in surgery again. While Barb “survived” the surgery. The overall care that Barb received was no where ideal nor close to best practices and standard of care.

https://www.cms.gov/medicare/quality/quality-improvement-organizations

The above organization QIO, followups on complaints from Medicare pts and the pt’s care in a hospital environment.  I filed a complaint with this organization around the end of April 2024 and just got a return phone call from one of their representatives, as a follow up. This representative was basically quoting from the physician reviewer report/summary. First of all the ortho surgeon NEVER provided any of Barb’s medical records from his practice. The representative said that, my complaints would be forward on to CMS (Center for Medicare/Medicaid Services) to deal with the ortho surgeon’s lack of response of providing medical records.

Most of what I heard, was the reviewer could not document most of my complaints from the medical records from the various providers, starting with the hospital itself down to several vendors who provided Barb’s home services.

When all was said and done, the representative told me that I could have a second reviewer to look over my complaints and also said that I could add any more information.  I had provided them with 7-8 pages of  typed (word processor) detailed complaints and I told the representative that I felts that my complaint was VERY DETAILED!

There was a pause in the conversation and then the representative said “that is a good description”. I asked the representative that if I asked for another reviewer to look at my complaint that if I could ask that the reviewer focus on the what appeared to be that most of the medical documentation – IMO – did not come close to what I understand as what should be a standard of care and best practice.   The representative stated that she would state that and highlight it on my request for a second reviewer to evaluate the quality of medical records that were provided.

Apparently the jury is still out!

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