Wakely Wire

New Insights

Whitepapers, briefs, press releases and more

Is PC Flex Right for Your ACO?

The Primary Care Flex (PC Flex) model is a new Center for Medicare and Medicaid Innovation (CMMI) model developed to further test how alternative payments for primary care services (PCS) can empower Accountable Care Organizations (ACOs) to use more innovative, team-based, person-centered, and proactive approaches to care that positively impact health care outcomes, quality, and ... Read more

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Week in Washington 06/13/24

MA Stars Lawsuits CMS lost another lawsuit over Medicare Advantage STARS last week. In addition to losing its case against SCAN over failing to follow the Administrative Procedures Act (APA) around changes to the Medicare Stars, CMS lost a similar case to Elevance Health late last week. A US district Court ruled that CMS must ... Read more

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Newsworthy Findings

CMS Releases 2023-2032 National Health Expenditure Projections

The Office of the Actuary projects that over 2023-2032, average annual growth in NHE (5.6%) will outpace average annual growth in gross domestic product (GDP) (4.3%), resulting in an increase in the health spending share of GDP from 17.3% in 2022 to 19.7% in 2032.

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Editor's Note
The NHE is published annually and is often referred to as the “official” estimates of U.S. health spending and health insurance enrollment. The historical and projected estimates of NHE measure total annual U.S. spending for the delivery of health care goods and services by type of good or service (hospital, physician, prescription drugs, etc.) and by payer (private health insurance (PHI), Medicare, Medicaid, etc.)

Weight-Loss Drugs Are So Popular They’re Headed for Medicare Negotiations

The steep prices — and popularity — of Ozempic and similar weight-loss and diabetes drugs could soon make them a priority for Medicare drug price negotiations, with list prices for a month’s supply of the drugs ranging from $936 to $1,349.

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Editor's Note
The Inflation Reduction Act President Biden signed in 2022 paved the way for the federal program to negotiate prices directly with drugmakers for the first time. But for now, the high price of Ozempic, Trulicity and other drugs in the class known as GLP-1 agonists have put them out of reach for many low-income patients.

AMA, lawmakers aim renewed prior authorization crackdown on insurers

The American Medical Association and bipartisan Congressional leaders are advocating for the Improving Seniors' Timely Access to Care Act, which aims to modernize and standardize prior authorization practices in Medicare Advantage, reduce delays, and improve transparency.

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Editor's Note
This legislation, if passed, could significantly impact payers by mandating more efficient and transparent prior authorization processes, potentially reducing administrative burdens but also requiring investment in electronic systems and compliance with stricter deadlines.

AHIP 2024: The hurdles to widespread biosimilar adoption

At AHIP 2024, experts highlighted the potential of biosimilars to reduce pharmacy costs, but emphasized that significant hurdles remain, such as physician education and patient acceptance, in getting these drugs to market and ensuring their use.

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Editor's Note
Overcoming these challenges is crucial as biosimilars can substantially reduce costs; however, this will require investments in educating healthcare providers, simplifying regulatory frameworks, and fostering patient confidence in these alternatives.

Elevance Second Insurer to Win Star Ratings Lawsuit

CMS has been ordered to redetermine the star ratings, which Elevance says should be higher.

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Editor's Note
The win by Elevance follows a lawsuit won by SCAN earlier this month, both over the way calculations for 2024 Medicare Advantage Star Ratings were done by the government.

Bonus Article

Washington State Bans Single-Use Foam That Breaks up and Pollutes Waterways for Orcas and Salmon

Passed back in 2021, a law in Washington state that bans single-use polystyrene food and drink containers has come into effect.
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Just for Fun

Math Joke

What do you get when you take the sun and divide its circumference by its diameter?

Prior Week

Q: What do you call a man who spent all summer at the beach?
A: A Tangent