Editor's Note Access to GLP-1 medications is improving as manufacturers, insurers, and policymakers address high demand, costs, and coverage challenges, Becker’s Hospital Review reported December 13. As detailed in the article, Eli Lilly’s partnership with telehealth company Ro now allows patients to obtain Zepbound prescriptions online and receive shipments directly…

Read More

Editor's Note A Senate report reveals that Medicare Advantage insurers are increasingly prioritizing profits over patient care by ramping up the use of prior authorization to deny necessary services, particularly post-acute care, for older adults, Becker’s Hospital Review reported October 17. In May 2023, the Senate Permanent Subcommittee on Investigations…

Read More

Editor's Note A Medicare policy introduced in 2020, which requires prior authorization for certain procedures done at hospital outpatient departments (HOPDs), has not significantly reduced the volume of surgical procedures being done at these facilities, reports a study by Michigan Medicine, University of Michigan, published on October 9. The policy,…

Read More

Editor's Note CMS has taken the next steps in making prescription drugs more affordable for Medicare recipients, according to an October 9 report from The US Department of Health and Human Services (HHS). The proposed Medicare $2 Drug List Model, developed in line with President Biden’s Executive Order 14087, aims…

Read More

Editor's Note Medicare’s first negotiations on 10 top-selling prescription drugs for older Americans will save the US government $6 billion in the first year, according to an August 15 article in Reuters. Enabled by President Joe Biden’s 2022 Inflation Reduction Act, negotiations for drugs used by Medicare—which covers 66 million…

Read More

Editor's Note Medicare and patient out-of-pocket costs are rising as vertical integration results in more procedures moving to hospital outpatient departments (HOPDs) than to ambulatory surgical centers (ASCs), Becker’s ASC Review reported on August 8. The article summarizes a study published July 25 in Science Direct. Described as "physician vertical…

Read More

Editor's Note The Supreme Court’s recent “Chevron” ruling could offer additional financial security to hundreds of so-called "tweener" rural hospitals—those too large to be considered critical access hospitals but too small to be rural referral centers. Modern Healthcare reported the news July 29. According to the article, critical access hospitals,…

Read More

Some 800,000 knee replacements and 550,000 hip replacements are performed in the US each year. Factoring in the ever-expanding aging population, projections show the figure for knee replacements alone will explode to 3.5 million procedures being done annually by 2030—and that is just one type of procedure within a single…

Read More

Editor's Note On July 10, CMS proposed Medicare payment rates for hospital outpatient and ambulatory surgery center (ASC) services for 2025.  Published annually, the Hospital Outpatient Prospective Payment System (OPPS) and ASC Payment System Proposed Rule will have a 60-day comment period, which this year ends September 9 prior to…

Read More

Editor's Note Private payers initially deny reimbursement on 15% of claims, only to later approve more than half of those initial denials, according to a national survey of healthcare institutions published March 21 by Premiere, Inc. Additionally, the denied claims on average tend to be more prevalent for higher-cost treatments…

Read More