Ray Lankin’s Post

In this episode (#327) of The Drive, I speak with Saum Sutaria, M.D., the Chairman and CEO of Tenet Healthcare and a former leader in McKinsey & Company’s Healthcare and Private Equity Practices, where he spent almost two decades shaping the field. Saum unpacks the complexities of the U.S. healthcare system, providing a detailed overview of its structure, financial flows, and historical evolution. We delve into topics such as private insurance, Medicare, Medicaid, employer-sponsored coverage, drug pricing, PBMs and the administrative burdens impacting the system. Saum’s insights help connect healthcare spending to broader economic issues while exploring potential reforms and the role of technology in improving efficiency. Saum highlights how choice and innovation distinguish the U.S. healthcare system, explores the reasons behind exorbitant drug prices, and examines the potential solutions, challenges, and trade-offs involved in lowering costs while striving to improve access, quality, and affordability. Here’s a glimpse of what we discuss: - Overview of how the US healthcare system currently works and how we got here - How misaligned incentives have driven up drug prices in the US - Health outcomes: why life expectancy is lower in the US despite excelling at extending lifespan beyond 70 - Feasibility of a universal Medicare program, and what a real path to sustainable healthcare looks like - More https://bit.ly/3VepYCj

2024 was a challenging year for healthcare, with patent cliffs and declining reimbursement rates taking a toll. Looking ahead to 2025, policy uncertainty and innovation are setting the stage for a transformative year. Explore the trends shaping the future of healthcare in this blog post from AlphaSense.

Check out the latest findings from our study: The Provider Perspective: Insights on Policy, Practice, and Patient Care. Healthcare providers are bracing for a perfect storm—shifting reimbursement policies, financial uncertainty, and rising operational costs. What does this mean for pharma? The need to adapt, support, and prove value has never been greater. 🔹 Part 2: https://hubs.ly/Q034KzjN0 🔹 Missed Part 1? https://hubs.ly/Q034KyQY0 Stay tuned for Part 3 next week, where we explore healthcare access challenges for vulnerable populations. For a summary of the series, check out the press release: https://hubs.ly/Q034KBG-0 We’d love to hear your thoughts—what are the biggest challenges you see providers facing this year? Join the conversation below! #HealthcarePolicy #Pharma #HCPInsights #ShapiroRaj

2024 was a challenging year for healthcare, with patent cliffs and declining reimbursement rates taking a toll. Looking ahead to 2025, policy uncertainty and innovation are setting the stage for a transformative year. Explore the trends shaping the future of healthcare in this blog post from AlphaSense.

Are You Prepared for Medicare Advantage Market Upheavals? Market disruptions are neither new nor a thing of the past; they are here to stay and costly if you’re not equipped with a thorough response plan to protect patient relationships. Health plan contract terminations, plan pullouts, mergers, and acquisitions threaten your Medicare patient base. Retaining patients requires smart planning, ongoing patient engagement, a systemwide commitment, and a focused communications strategy. Mobilizing with speed and an ability to pivot if the insurer pulls a surprise, can make a difference in smooth patient/plan transitions while minimizing administrative hassles and market share loss. MedicareCompareUSA and its consulting division—MCUSA Communications—have helped hundreds of hospitals and medical groups around the country successfully tackle such upheavals; and we can assist you, too. We have the track record of helping navigate changes in MA network participation and can help you provide patients with clear and compliant Medicare information. We’re the nation's leader in helping healthcare organizations prepare, implement, and achieve Medicare strategies geared toward Medicare population management, retention, and growth. We're here to help. Contact us today. https://lnkd.in/gFSrDQKf

Highmark Health's first-quarter earnings reflect broader industry trends, with both positive and concerning aspects. Positive Indicators: - Strong Top-Line Growth: Highmark is pleased with overall revenue growth. - Solid Net Operating Gain: Profitability remains healthy despite challenges. - enGen Performance: Highmark's IT services company delivered strong operating revenue. - Dental Business Gains: The dental segment achieved positive operating results. Challenges and Concerns: - Increased Medical Service Utilization: Rising healthcare utilization across Medicare Advantage mirrors national trends, impacting costs. - Rising GLP-1 Drug Costs: Demand for GLP-1 medications for diabetes is increasing, putting pressure on expenses. - Allegheny Health Network (AHN) Performance: AHN's net income declined compared to the previous year, with emergency room visits rising. Learn more: https://hubs.ly/Q02zxNcb0

Insightful article featuring Dr. Steve Kim, co-founder and CEO at Valer, a provider of prior authorization automation technology. Steve founded Valer out of his frustrations with manual prior authorization processes and its toll on everyone in the healthcare provider ecosystem- staff, providers, and most of all, patients. Steve shares his insights on the outlook for Medicare Advantage legislation reform and its benefits for patients, staff, and providers. Legislation only addresses the ambiguity of prior authorization requirements and it's still a future benefit, but it's a start. Combined with automation to address the costliest, most complex part of prior authorization management-- submissions and verification when a prior auth is required-- we're moving in the right direction. Join us at valer.health to #fixpriorauth.

Last night Congress released a continuing resolution which includes a list of regulations on PBM's, Plan Sponsors, Brokers/Consultant, etc. that is far reaching and difficult to comprehend. I've been feeling like the United States is headed towards its "Defund the Police" moment with the Healthcare industry after the national response to Brian Thompson's murder and the fact that any advocacy for the role larger PBM's or Health Insurers play is met with swift retribution. I was skeptical upon release of the legislation and its unintended consequences - but much of the content here makes practical sense. Included in the provisions: *Banning of Spread Pricing on Medicare/Medicaid (expected) *Banning of spread on rebates for all plan sponsors with the exception of bona fide fees....whatever that means. *A standardization of the term generic or brand in contracting (welcomed). *Incredibly comprehensive reporting requirements - in machine readable format including the amount of rebates received. *Disclosure of any and all payments to brokers, consultants and any other intermediary *Disclosure (within 30 days) of any contracts with pharmaceutical manufacturers to plan sponsors (this one seems like a stretch). *Mandatory NADAC reporting for pharmacies It's a bit stunning in its comprehensiveness. I don't know what the final bill will look like. The regulatory burdens will drive costs for PBM's up. The pass-through provisions will shift costs from the sick to the healthy in the form of Part D premium increases and payroll deduction increases. But the transparency provisions should help for a more efficient marketplace, especially on rebates. More efficiency and higher regulatory costs typically favor entrenched incumbents and place a burden on smaller players - so this may be the beginning of the thinning of the herd in the PBM marketplace (its already thin in Medicare/Medicaid/Fully Insured - but the commercial self-funded space is far more competitive than people realize). Fortunately or unfortunately depending on your perspective. This will be an interesting 72 hours to passage. As this is new for all of us I'd love to know everyones thoughts/perspectives as I'm still forming my own.

January 1, 2026, payers would be required to build and maintain a Fast Healthcare Interoperability Resources (FHIR) API that providers could use to determine if a prior authorization is required for a given item or service. Providers would also use the FHIR API to facilitate the request and indicate request statuses.

With 𝗼𝗻𝗹𝘆 𝟰𝟬% 𝗼𝗳 MA #healthplans expected to earn 4 or more stars in 2025, #MedicareAdvantage star ratings are seeing a continued decline. This trend has significant implications for both patient care and plan performance, as star ratings not only guide beneficiaries but also impact reimbursement. #MedicareAdvantage #StarRatings #Healthworksai