Making them nervous

HME stakeholders have been fighting Medicare Advantage for some time, particularly when it comes to these plans not following Medicare policy and coverage for complex rehab technology and non-invasive ventilators, two product categories for patients with the greatest needs. 

At the Heartland Conference in June, there was even a panel discussion titled “Dealing with Medicare DISadvantage Plans - Are You Ready, Martha?”

Stakeholders continue to take it up a notch. 

AAHomecare announced in July, for example, that it has engaged Dobson Davanzo & Associates to conduct a study quantifying the differences in outcomes and overall treatment costs for patients with significant respiratory challenges who receive NIV therapy vs. those who don’t. 

Their rationale, I’m guessing: If they can show that NIV improves outcomes and reduces costs, it’ll be another two nails in the coffin of MA plans that deny claims for this therapy without good reason – some to the tune of 86 out of every 100 times. 

As is often the case for the HME industry, which represents less than 2% of overall Medicare spending, it’s a David vs. Goliath situation, with the companies behind most of these MA plans the biggest names in health care. 

UnitedHealthcare and Humana, which had the most Medicare Advantage enrollees in 2023, have large footprints across the country, offering plans in most counties, according to the Kaiser Family Foundation. UnitedHealthcare is offering plans in 87% of counties and Humana is offering plans in 90% of counties in 2024, roughly the same as in 2023, KFF reports. 

But week by week, it seems, the HME industry, as well as the National Community Pharmacists Association, is getting more company in trying to keep these Goliaths in check. 

The Federal Trade Commission published an interim report in July that details how increasing vertical integration and concentration has enabled the six largest pharmacy benefit managers (PBMs) – Humana among them – to manage nearly 95% of all prescriptions filled in the United States. The NCPA called the report “scathing.” 

The Department of Justice announced in May that it had formed a Task Force on Health Care Monopolies and Collusion (HCMC) within its Antitrust Division to guide its enforcement strategy and policy approach, including by facilitating advocacy, investigations and, where warranted, civil and criminal enforcement in health care markets. Health care attorney Jeff Baird says the task force has the potential to rein in the PBMs that are having a significant negative impact on independent pharmacies and could help prevent a similar scenario cropping up in the HME industry (See story page 2). 

Additionally, at press time in July, the Wall Street Journal published an investigation of MA claims that showed big insurers have pocketed $50 billion from Medicare for diseases that no doctor treated. 

Call me anxious, but that’s the kind of attention that I think would make even UnitedHealthcare and Humana  nervous.