The PBM industry started in 1970 and initially, IMO..their reimbursements was pretty much on line with the “going rate” that community pharmacies charged and gross profit that they made. “back in the day”, wholesale prices was almost stagnate, but in the mid-late 80’s.. wholesaler prices of Rx meds started to increase dramatically. Little did those in pharmacy knew what was causing these dramatic wholesale price increases. Looking back now, it was apparent as the PBM’s gained more and more control over the Rx meds, the PBM industry – where there was no financial clarity in how they made their money – was apparently implementing their ability to demand kickbacks, rebates, and discount for the pharmas for having their meds on the PBM’s approved formulary. This was probably were the PBM industry was controlling > 50% of all prescriptions.
In this article, it is stated that Medicare-C (Advantage) prgms are going to be covering > 50% of Medicare population. Is all of these large Healthcare corporations walking away from Medicare-C contracts, the beginning of these prgms trying to increase their profits, by limiting/denying expensive care? It looking at some of the offering for 2024 – especially for those people having Medicare & Medicaid – additional benefits and/or perks that MAY have less to do with verifiable health benefits.
Hospitals sour on Medicare Advantage: 8 things to know
With the Medicare open enrollment period underway, some seniors may have fewer provider choices in their respective regions as hospitals and health systems across the country increasingly cut ties with the Medicare Advantage program.
Eight things to know about this trend:
- Becker’s has previously reported on hospitals or health systems across the country that have recently ended some or all Medicare Advantage contracts. Those organizations include San Diego-based Scripps Health; Bend, Ore.-based St. Charles Health System; Louisville, Ky.-based Baptist Health Medical Group; and Corvallis, Ore.-based Samaritan Health Services.
- The reasons behind Medicare Advantage contract terminations vary by system and by payer offering the plan. Some systems have cited steep losses amid excessive prior authorization denial rates and slow payments from insurers. Others have noted that most MA carriers have faced allegations of billing fraud from the federal government and are being probed by lawmakers over their high denial rates.
- The Medicare Advantage landscape is constantly changing, with some health systems dropping only certain MA carriers and maintaining relations with others due to renegotiated contracts. For example, Brunswick-based Southeast Georgia Health System will terminate its contract with Centene’s WellCare Medicare Advantage plan in December but will remain in network with Aetna, Anthem, Humana and UnitedHealthcare MA plans.
- Medicare Advantage contract negotiations between payers and providers have become more public over the last year. According to data shared with Becker’s by FTI Consulting, among the 64 contract disputes reported in the media this year through Sept. 30, 37 involved MA plans, and 10 disputes exclusively involved MA plans. In the third quarter alone, 15 disputes involved MA plans, compared to seven in the third quarter of 2022, or a 115% increase year over year.
- Rural hospitals especially have expressed concern with the growth rate of Medicare Advantage enrollment in non-urban areas and the effect on their financial sustainability as more seniors move away from traditional Medicare. From 2010 to 2023, Medicare Advantage enrollment grew faster in rural and micropolitan areas than in metropolitan areas.
- Though some health systems are moving away from Medicare Advantage, others are partnering with payers, grocers or other systems to launch their own MA plans for 2024.
- CMS issued a final rule in April that aims to streamline Medicare Advantage and Part D prior authorizations, including ensuring consistency with traditional Medicare national and local coverage guidelines. The agency has proposed another rule that would require MA carriers to approve urgent prior authorizations within 72 hours, and within seven days for standard requests. The proposed rule also would require payers to publicly report prior authorization denial rates and provide specific reasoning for denied requests.
- Despite tensions with some health systems, the Medicare Advantage program has bipartisan support in Congress and a 95% quality satisfaction rating among enrolled members in 2023. MA total enrollment is expected to be 33.8 million in 2024, representing more than half of the total Medicare population. There are nearly 4,000 MA plans being offered this year nationwide, and MA members spend an average of $2,434 less on out-of-pocket costs and premiums per year compared to traditional Medicare members.
Filed under: General Problems
If it’s too good to be true, it probably is. In the last several MA plan offers I have received, there are so many freebies, including over $240 to “spend as I please.” SOMEBODY has to pay for this. In the end, it will be the taxpayer and consumer, as per usual. It looks like we are now going to have Healthcare Deserts, just like we have Pharmacy Deserts.
I left pharmacy as a pharmacist and went last year to get licensed to promote Medicare Advantage plans. My partner and I invested 6 months for all the exams, liability insurance, prep courses to pass the exams and tests from every insurer we wanted to be able to promote. Between, myself and my partner, who is also a pharmacist, we spent over $4000 in expenses. Between the two of us we made $900 over those 6 months. We both agreed to get out of this position. Why? Because we found most of these insurance plans are more corrupt than what we were doing in pharmacy, which was bad enough with the PBMs, Convid, drugs that cause more bad than good chronically, etc. Still looking for “something” out of pharmacy where I can go into and enjoy what I am doing. No more just going into a position for a paycheck. We are both past that!