The Hertel Report

Toolbox: The Maternal Healthcare Crisis

Arizona News

National News

Low Uninsurance Rate Holds Steady at 7.6% Into 2024

The Centers for Disease Control and Prevention (CDC) published its early release of quarterly estimates from the National Health Interview Survey which found relatively low uninsured rates across the country from 2023 to June 2024. The report included select estimates of healthcare statistics for the non-institutionalized U.S....

Cigna Dispels Rumors of Humana Merger Talks

After years of churning in the rumor mill, the Cigna Group has directly stated that it is not pursuing a merger or acquisition with Humana Inc. The two companies began talks for a potential merger late last year, but the discussion was tabled after they were unable to reassure investors. Earlier this fall, rumors reignited that the...

CMS Rules

Medicare Part B Premiums and Deductibles to Rise in 2025

Last Friday, the Centers for Medicare and Medicaid Services announced that it would substantially raise standard monthly premiums for Medicare Part B. Medicare Part B covers physicians' services, outpatient hospital services, home health services and other medical and health services not covered by Part A. The premium for Part B will...

Nonprofit Hospitals Fall Under Increasing Scrutiny

Nonprofit hospitals pledge to elide financial incentives for a higher commitment to quality of care and community investment in exchange for tax exemption, but giant nonprofit hospitals that generate huge revenue streams are coming under scrutiny. A recent study showed that 7% of nonprofit hospitals were the beneficiaries of over half...

Report: Payor Provider Fight Over the 2 Midnight Rule - Combatting Inpatient vs Observation-Related Denials

A Kodiak Solutions data analysis found that Medicare Advantage (MA) plans classify three to four times as many hospital visits as observation stays instead of inpatient stays compared to traditional Medicare. Last year, the Centers for Medicare & Medicaid Services (CMS) finalized a rule clarifying that MA plans need to cover the same...

New Interim CEO for Northern Cochise Community Hospital in Willcox

This month Chief Executive Officer Monica "Mo" Sheldon will step down as the CEO of the Critical Access Hospital (CAH) serving Northern Cochise County and Southern Graham County; she will be replaced by Gary Kartchner, RN, the CEO of Benson Hospital, also a CAH. Both rural hospitals are part of the Tucson-based TMC Health...

NAIC 2024 Market Share Report: Top 125 Accident and Health Insurance Groups and Companies

The National Association of Insurance Commissioners report provides financial and market intelligence on the insurance industry - another tool for insurers to identify their competitors and comparative market share. The Hertel Report collected the top 10 leaders in Arizona including UnitedHealth Group, Blue Cross Blue Shield of Arizona...

STUDY: Use of Low-value Services Between Medicare FFS and Medicare Advantage

A new study looks at the effectiveness of capitated payments for Medicare Advantage plans on reducing incentives for clinicians to provide low-value services. The study, published in JAMA Network Open, compared data for beneficiaries enrolled in fee-for-service (FFS) Medicare against those enrolled in Medicare Advantage in order to...

CMS Rules

CMS Finalizes 2025 Physician Fee Schedule Cut

Last week, the Centers for Medicare and Medicaid Services (CMS) finalized the Medicare Physician Fee Schedule for 2025. It includes a 2.9% cut to physician pay. The fee schedule includes policies aimed at improving access to primary care and boosting reimbursement for behavioral health, but the pay cut instantly drew harsh criticism...

CMS Rules

CMS Finalizes 2025 OPPS and ASC Payment System

Last week, the Centers for Medicare and Medicaid Services (CMS) published the CY 2025 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule. Hospital outpatient departments and ASCs will receive a 2.9% raise next year. The boost includes a 3.4% market basket boost...

Walgreens Settles Class Action - Pays $100M for Prescription Overcharging

Retail pharmacy giant Walgreens Boots Alliance (Walgreens) has agreed to a settlement in a class-action lawsuit that claims the retailer fraudulently overcharged customers for generic drugs paid for by private insurance, Medicare and Medicaid. The lawsuit was filed in 2017 by a group of individuals and unions who accused Walgreens of...

Issue Brief: Some Medicare Part D Beneficiaries Hit Out of Pocket Spending Cap by June 2024

As part of the ongoing Inflation Reduction Act Research Series, the Assistant Secretary for Planning and Education (APSE) Office of Health Policy published an issue brief on the number of Medicare Part D enrollees who reached the out-of-pocket cap on prescription drugs by June 2024. The issue brief found that 1.5 million enrollees...

Humana's Q3 Profits Exceeds Expectations - MA Membership Growing, CenterWell Primary Care Segment Stable

For 2025, Humana anticipates adjusted profit to align with or exceed its final 2024 results. Revenue was up $29.4B year-over-year (YOY) but net income and the insurer's profit margin fell 42% and 1.6%, respectively. Analysts project a 2025 profit for Humana of $19.77 per share. Although earnings per share were down for Arizona's...

Generative AI Struggles for Accuracy in the Health Space

Although the field has flooded with artificial intelligence (AI) products, the benefit of these tech products has yet to bear out. The Coalition for Health AI is creating a network of "assurance labs" to validate AI systems and evaluate their performance as health systems are increasingly pressured to incorporate AI products without...

Phoenix Children's Now Out of Network for BCBSAZ Members

Negotiations between the local, popular insurer and one of the nation's premier pediatric health systems failed to produce a new agreement by midnight last night and now Phoenix Children's 50 sites in Arizona, including two hospitals, Phoenix Children's Pediatrics, Phoenix Children's Medical Group, four urgent care centers, specialty...

Issue Brief: MACPAC on Directed Payment Arrangements

The Medicaid and CHIP Payment Access Commission (MACPAC) published an issue brief on the updated regulations for oversight of Medicaid managed care and state allowances for the direction of managed care organizations (MCOs). Earlier this year, the Centers for Medicare and Medicaid Services (CMS) issued a rule for the directed payment...

Seven More Steward Health Care Hospitals Sold - New Interim Manager Approved for St. Luke's Behavioral Health Center

On October 25, U.S. Bankruptcy Court Judge Christopher Lopez approved the sale of seven more Steward hospitals to Nevada-based Healthcare Systems of America, an affiliate of Glendale, Calif.-based American Healthcare Systems. Days earlier, Lopez approved College Medical Center Phoenix as the interim manager of the recently closed 127-bed...

AMA Sues MultiPlan for Price-Fixing Conspiracy

The American Medical Association (AMA) has filed suit in the Northern District of Illinois against data analytics company/claims discounter/wrap network, Multiplan for what it claims is a price-fixing conspiracy on behalf of health insurers. The lawsuit claims that MultiPlan benefits from lowering estimates of out-of-pocket...

Centene's Growth Continues Even After the Medicaid Unwinding

Insurance company Centene defied the odds for the third quarter and overcame issues with Medicaid reimbursement for higher returns than investors had anticipated. Centene reported $713 million in profit for Q3 on $42 billion in revenue, up from $469 million and $38 billion last year. Following the Medicaid redetermination period, more...