Latest news with #MCOs
Forbes
14-05-2025
- Business
- Forbes
Trouble At The Top: Epic Faces Mounting Antitrust Allegations Even As It Grows
Epic Systems is perhaps the most successful health technology company in the world. Its electronic health record (EHR) platform is now used by the majority of large health systems in the U.S. Its customers are vocal in their support and are often passionate defenders of the platform's reliability, configurability, and comprehensiveness. And its commercial success continues: according to newly released KLAS Research data, Epic gained even more market share in 2024, widening the gap between itself and competitors. Epic won nearly 70% of hospital deals in 2024. But with that dominance has come increasing scrutiny. Not from regulators yet, but from the companies who say they are being locked out of the future of healthcare innovation. This week, CureIS Healthcare filed a sweeping lawsuit in federal court accusing Epic of unlawful efforts to block competition. CureIS alleges that Epic has systematically interfered with its business, pressured mutual customers to abandon its products, misappropriated trade secrets, and engaged in false advertising - all in an effort to expand Epic's control over adjacent healthcare IT markets. The complaint paints a picture of a company using its EHR and revenue cycle management hegemony as a springboard to colonize other sectors of the healthcare technology landscape. And CureIS isn't alone. Particle Health, a startup focused on health data interoperability, filed a separate antitrust lawsuit against Epic last year, similarly alleging that the Verona-based company is using its market power to restrict third-party access to health data and thwart efforts at interoperability that could benefit patients and the broader health system. Together, the lawsuits suggest that while Epic may be beloved by its customers, its tactics regarding smaller, adjacent vendors may be stirring deeper questions about fair competition and innovation. CureIS is not a household name, but for more than a decade it has provided software that help Medicaid and Medicare managed care organizations (MCOs) clean up and reconcile enrollment, claims, and billing data - an often messy corner of healthcare IT. These tools, such as EnrollmentCURE and RecoveryCURE, rely on data integrations with technology platforms like Epic's EHR and RCM systems to function effectively. According to CureIS's complaint, Epic has deliberately prevented those integrations, blocking CureIS from accessing the data its products require. The lawsuit alleges that Epic pressured mutual customers to terminate their contracts with CureIS, sometimes even after those customers had acknowledged that Epic's competing offerings were inferior or incomplete. Among other issues, the complaint claims that Epic used confidential information shared under non-disclosure agreements to develop its own versions of CureIS products. CureIS says Epic induced customers to share detailed architecture and implementation documents, only to later promise to replicate the functionality internally—often using that very documentation as a roadmap. More seriously, the lawsuit alleges that Epic imposed an 'Epic-First' policy, in which 'any entity utilizing Epic's EHR or RCM software must use Epic's versions of other products too, if it has a version of the product in question.' CureIS argues that this conduct not only harmed its own business but also left customers with worse tools and less flexibility, ultimately undermining efficiency and innovation in a sector that already struggles with outdated workflows and fragmented systems. CureIS's complaint echoes themes raised earlier this year by Particle Health, which similarly claims that Epic's business practices are impeding fair access to patient data and suppressing interoperability. Particle's focus is on the 'last mile' of health data—getting information from disparate systems to where it's needed most. The company argues that Epic's control over the nation's health records gives it undue influence over what data is shared, how it's shared, and who can participate in that exchange. The core concern in both suits is not just Epic's size, but how that size and market power is allegedly being used. In both cases, plaintiffs argue that Epic is no longer simply competing on the merits of its core products, but actively leveraging its power to prevent others from doing so. This dynamic would be easier to dismiss if Epic's platform weren't, by most accounts, genuinely effective. The company is trusted by its users in a way that few software platforms are. It routinely scores top marks for customer satisfaction. It delivers deeply integrated functionality. And for hospital IT departments besieged with too many vendors that don't deliver, Epic has become a true partner. That customer devotion has helped fuel a virtuous cycle. Epic is now expanding beyond EHR and RCM into a broad suite of tools that serve payers, pharmaceutical companies, laboratories and even consumers. By doing so, it is building out network effects that reinforce its central role in the healthcare ecosystem, connecting stakeholders who all increasingly rely on Epic's infrastructure to operate, communicate, and exchange data. From its Cosmos data platform, which aggregates clinical data for research, to its health plan integration features, Epic is creating a flywheel where each new product reinforces demand for others. But that same flywheel, in the eyes of its critics, can look like a walled garden—one where innovation flows only from the center, and others must knock (or sue) to get in. The lawsuit comes against a broader regulatory and legal backdrop that is increasingly skeptical of dominant tech platforms, and how they might be leveraging their power. CureIS explicitly cites Epic's alleged information blocking as a violation of the 21st Century Cures Act and the associated federal regulations implemented by the Office of the National Coordinator for Health IT. These rules prohibit "actors"—including health IT developers—from interfering with the access, exchange, or use of electronic health information. The complaint accuses Epic of exactly that: denying CureIS and mutual customers the data access necessary for CureIS's software to function, despite customer authorization, and without any valid exception under the rule. In a post-Cures Act environment, such conduct isn't just anticompetitive—it may be illegal under federal information blocking provisions. Outside of healthcare, courts are increasingly drawing hard lines around similar forms of platform dominance. In a major ruling last year, Judge Amit Mehta found that Google's $20 billion in annual payments to Apple to remain Safari's default search engine constituted illegal anticompetitive behavior. More recently, the U.S. Department of Justice signaled it is seeking structural remedies that could force a breakup between Google's Chrome browser and its search advertising business. Apple, too, has drawn judicial ire: despite a prior court order requiring it to loosen App Store restrictions that prevent developers from steering users to alternate payment options, a federal judge recently found that Apple continues to flout the order, delaying compliance in ways that sustain its control over app monetization. Together, these cases underscore a growing legal recognition that platform power, when abused to entrench incumbency and exclude competition, is not only harmful but actionable. "Epic believes in free and fair competition, and we also believe our customers are in the best position to choose the right solutions to meet their needs—whether with Epic or by adopting other products and services," an Epic spokesperson said in a request for comment. After two lawsuits alleging unlawful tactics that implicate antitrust concerns, however, the pattern is increasingly difficult to ignore. The company declined to answer specific questions about the case, including whether an 'Epic-First' policy exists. As Epic pushes further into adjacent markets including telehealth, CRM, prior authorization, and more, vendors and investors alike are watching closely. If the company is truly replicating third-party functionality and using integration as a chokepoint, or representing 'vaporware' as a reason to avoid competitors, it raises fundamental questions about the rules of the road in digital health. These questions are especially urgent in light of Epic's market trajectory. Epic continues to win the majority of hospital deals and gain even more ground, especially among large hospitals and health systems. With nearly universal adoption among top-tier academic centers and continued wins among regional health systems, Epic's position is not just dominant—it's bordering on infrastructural. That kind of power brings responsibility not just to customers, but to the broader healthcare innovation ecosystem. Epic's platform is central to how care is delivered, how value is measured, and how data flows. Whether it is also central to how innovation happens—or whether it is increasingly a bottleneck—is now a question for courts, policymakers, and the market to weigh. Epic's size and success could make it a gravitational center that lifts up the innovation ecosystem around it. But if its conduct instead undermines startups that offer real value - especially in underserved areas like Medicaid managed care - then lawsuits like CureIS's may be just the beginning. Healthcare needs platform players that enable innovation, not just defend territory. Epic may be at a crossroads: the company's core EHR product is the reason it continues to gain market share, yet its insistence on leveraging that EHR to advance its growth efforts may bring the type of scrutiny and lawsuits that threaten that success.
Forbes
22-04-2025
- Health
- Forbes
What Does Medicaid Have To Do With Older Adults Anyway?
We soon will learn what Congress and the Trump Administration have in store for Medicaid. But while the state/federal program has become a high-profile target, it is widely misunderstood. And so are the consequences of major Medicaid changes for older adults, people with disabilities, and their families. Yes, Medicaid provides medical insurance for low-income working age people and their children. But Medicaid spends more than half its budget on medical and long-term care for frail, low-income older adults and younger people with disabilities. And about one-quarter of all Medicaid benefits, more than $200 billion, goes to long-term care for about 9 million frail older adults and people with disabilities. While Medicaid is a public insurance program, 94 million recipients get their benefits from private managed care organizations, or MCOs. A few are run by non profits but the vast majority are owned by insurance companies. Those managed care companies often are responsible for both medical and long-term care for those known as dual eligibles, who qualify for both Medicaid and Medicare. About 60 percent of Medicaid LTSS beneficiaries received care through MCOs. While many think Medicaid long-term care is provided only in nursing homes, 85 percent of Medicaid LTSS recipients get their care at home. For most, Medicaid's limited assistance supplements care provided by family members. And there is more you may not know: While some believe Medicaid long-term care is plagued by wealthy enrollees who hide their assets to become eligible for public care, the vast majority of Medicaid LTSS recipients have been poor their entire lives. And those few who had assets when younger likely burned through their savings after long spells of costly medical and long-term care. Keep all this mind as you watch Congress battle over the fate of Medicaid cuts. House Republicans want to make $800 billion in program reductions over the next decade but Senate Republicans appear far less enthusiastic. President Trump's position remains unclear. Those cuts could come through three basic mechanisms, with lots of versions of each: annual caps on the federal contribution to Medicaid, reducing the federal share of Medicaid spending, or imposing work requirements on beneficiaries. The annual caps would be most draconian but appear least likely, given pushback from Republican governors. Under current law, the federal government pays its share of Medicaid costs no matter how much those costs grow. In other words, the feds pay an average of 70 percent of a state's Medicaid costs, no matter how high they are or how fast they rise. But GOP lawmakers want to limit that contribution though either block grants or per-capita caps. Either way, the federal government would pay only a fixed dollar amount of Medicaid costs, rather than a percentage of its expenses. Block grants could be adjusted each year by Congress, rather than rising automatically. The first Trump Administration proposed a per-enrollee cap, though it went nowhere. Another option would lower the federal contribution percentage. Currently, the feds pay a minimum of 50 percent of a state's Medicaid costs. Congress could reduce the federal share or, more likely, eliminate the minimum 50 percent federal match, which would save about $500 billion over 10 years. Thanks to a complex formula, several high-income (mostly Democratic) states fall below that 50 percent threshold. Any version of these changes would sharply reduce the amount the federal government pays for Medicaid, forcing states to either raise taxes to fund more themselves, cut benefits, or limit eligibility to save money. Shrinking federal funding could have important implications for Medicaid LTSS. For instance, states are mandated by law to pay for long-term care in nursing homes but not for home care benefits, which are an optional benefit. If Medicaid funding is cut, states still must provide nursing home care but could drop or reduce optional home care. A work requirement would focus on beneficiaries rather than on federal payments. The first Trump Administration made work requirements optional, but this time Congress could mandate such a requirement. The mandate would exempt older adults and people with disabilities, but what about their family caregivers? It matters because many family caregivers likely are on Medicaid. Nearly 40 percent of White and more than half of Black family caregivers report spending more than 40 hours a week aiding a frail relative. A 2021 survey by the Rosalynn Carter Institute found 40 percent of employed family caregivers had to reduce their hours to support a loved one and nearly one in five quit their jobs. And those most likely to do so are low-income workers who might get caught up in a Medicaid work requirement. Some versions of prior federal legislation would protect family caregivers, while others would not. And even with some protection, such a law would raise many difficult questions. Imagine two siblings caring for their mother. Which of them would be exempt from the Medicaid work requirement? While many of the Medicaid cuts on the table would not directly affect older adults, people with disabilities, and their families, they are likely to have powerful indirect impacts. Keep it in mind as you watch what Congress does to the program.
Los Angeles Times
02-04-2025
- Health
- Los Angeles Times
John Oliver sued by healthcare boss he rebuked on air over ‘bowel movement' comments
A former health insurance boss has taken legal action against 'Last Week Tonight' host John Oliver, filing a defamation lawsuit against the Emmy winner. Dr. Brian Morley, a hospital administrator and former medical director for AmeriHealth Caritas in Iowa, filed his lawsuit Friday in the U.S. District Court for the Southern District of New York. Morley's complaint stems from a Medicaid-themed episode of 'Last Week Tonight' that aired in April 2024. The lawsuit, reviewed by The Times, alleges Oliver and 'Last Week Tonight' producer Partially Important Productions linked Morley to a drastic decrease in Medicaid services and accused him of thinking 'it's ok if people have s— on them for days.' An attorney for Morley did not comment to The Times on Wednesday and a representative for Oliver did not immediately respond to a request for comment. The episode central to Morley's lawsuit aired April 14, 2024, and saw Oliver explore the state of Medicaid, examining healthcare companies' cost-cutting measures and their toll on patients across various states. During the segment, which aired on HBO and is available on YouTube, Oliver explained the role of managed care organizations (MCOs) in the healthcare system and shared a news outlet's video about dwindling patient care. The 2018 news snippet featured a cerebral palsy patient in Iowa named Louis whose care was negatively impacted by MCO involvement. Oliver followed that part of the segment with an audio snippet of Morley's comments about patient care from a 2017 administrative hearing. In the clip, Morley can be heard saying: 'People have bowel movements every day where they don't completely clean themselves and we don't fuss over [them] too much. People are allowed to be dirty. You know, I would allow him to be a little dirty for a couple of days.' The quote garnered a strong reaction from the 'Last Week Tonight' studio audience and led Oliver to say he thought Morley's comments were taken out of context. He explained that he first thought 'there is no way a doctor, a licensed physician, would testify in a hearing that he thinks it's OK if people have s— on them for days.' Oliver continued his segment stating his team obtained the full hearing and that Morley 'said it.' 'He meant it and it made me want to punch a hole in the wall,' Oliver said. The segment returned to the 2018 video of Louis and his mother, both responding negatively to Morley's comments. The 'Last Week Tonight' host had some choice words for Morley — which were cited in Friday's lawsuit. In his complaint, Morley says, 'Defendants' false accusations were designed to spark outrage, and they did. 'The false accusations Defendants made were so heinous that John Oliver felt justified in telling his millions of viewers: 'F— that doctor with a rusty canoe. I hope he gets tetanus of the balls,'' the complaint said. 'Oliver's feigned outrage at Dr. Morley was fabricated for ratings and profits at the expense of Dr. Morley's reputation and personal well-being.' Morley accused Oliver and 'Last Week Tonight' of making him the 'face' of the dramatic decrease in Medicaid care and increased cost-cutting. The lawsuit also raised concerns about how 'Last Week Tonight' allegedly misrepresented Morley's 2017 comments and 'knew and disregarded' various details of the hearing in the April episode. The lawsuit alleges that the 'Last Week Tonight' team 'conveyed the false and defamatory meanings' that Morley denied care to 'Louis and/or the alleged 'similar' individual subject' of his testimony and that he allegedly said it was acceptable for patients who wear diapers or who cannot bathe themselves to 'be left sitting in their own bowel movements for days.' The complaint says that the 'Last Week Tonight' team obtained and reviewed 'an unabridged audio recording' of the 2017 hearing and that one of the show's senior news producers allegedly confirmed to Morley that they had reviewed the hearing. According to the lawsuit, Morley made his 'bowel movement' comments in regard to a 'hypothetical average person, who is independently mobile and can toilet transfer' but who might not have been able to clean themselves entirely after a bowel movement. 'Last Week Tonight' allegedly did not disclose that detail, according to the lawsuit. He accused the show's producers of 'negligence, knowledge of falsity, and/or a reckless disregard for the truth.' Morely also alleges that a 'Last Week Tonight' news producer 'refused' to meet when he offered to explain his comments. The defendants also allegedly refused Morley's October 2024 request that they 'retract their false and defamatory statements.' Morley seeks an unspecified amount in damages including legal fees and additional relief. He also requests that judges order 'Last Week Tonight' to remove the 'false and defamatory statements from all platforms' and keep them from republishing. He is seeking a trial.
Yahoo
05-03-2025
- Health
- Yahoo
Medicaid goes by many names. Will Americans realize if it gets cut?
Apple Health, KanCare, ARHOME, Med-QUEST, and Medi-Cal: What do these have in common? They're all Medicaid programs. States, which administer Medicaid after receiving federal funds, often change the name of the program, sometimes even branding it to reflect state pride, such as Husky Health in Connecticut or SoonerCare in Oklahoma. They also change the name of the federally funded CHIP healthcare program for children, at times with cutesy names like PeachCare for Kids in Georgia and CubCare in Maine. Some Medicaid programs even have a private insurer's name attached to it because many states farm out contracts to managed care organizations, or MCOs, to administer the programs. Those changes, though, can cause confusion. A pair of recent studies noted that state-specific names and MCO plan designs can prevent people from realizing they are receiving a public benefit. That disconnect adds to the larger confusion over Medicaid itself, who it covers, and why. It simply isn't a poor people's program, a stigma that motivates states to change the name in the first place. It covers our children, grandparents, and Americans with disabilities. As cuts to government healthcare programs become a real possibility, experts say it's crucial for Americans to understand the scope and necessity of the Medicaid program. "It's one of those situations where our best intentions can backfire," said Jessica Calarco, a sociologist and professor at the University of Wisconsin-Madison. "When we change the way these programs operate, when we refuse to use words like welfare, it makes it more difficult for people to understand who is and who isn't benefiting from these programs and to see the benefits that they themselves are getting as well." While Medicaid is a joint federal-state program, "states administer Medicaid programs fairly independently," Melissa Hafner, a health policy researcher at the American Institutes for Research, told Yahoo Finance. Certain groups must be eligible for the program, and specific core benefits must be included under Title XIX of the Social Security Act, which established Medicaid. "But beyond that, states have a lot of flexibility in the scope of their Medicaid program," she said. That includes who's eligible, what services enrollees can receive, what states will pay for Medicaid services, and how states pay — either directly to healthcare providers or through MCOs, which are often private health insurers. The federal government provides a portion of the funding to a state's Medicaid program. States with higher rates of poverty receive a higher federal match. Nationally, 1 in 5 people are on Medicaid, according to KFF. That includes nearly 2 in 5 children, 1 in 6 adults, over 1 in 4 adults with disabilities, almost 1 in 2 children with special healthcare needs, and 5 in 8 nursing home residents. In fact, Medicaid is the only federal program that offers Americans long-term care insurance. Medicare does not, and the need for this type of care is only becoming more acute as the baby boomers age and can no longer care for themselves. Medicaid also covers 41% of all births in the US, 29% of non-elderly adults with mental illness, and 40% of non-elderly adults with HIV. One in 5 people on Medicare also receive extra coverage from Medicaid. And yes, it covers our most financially vulnerable Americans — over 8 in 10 children in poverty, and almost half of adults in poverty are on Medicaid. "This is likely something that helps someone you know or love actually make ends meet," said Lauren Rivera, a sociology professor at the Kellogg School of Management at Northwestern University who started a discussion over Medicaid names on social media. "I would say that every person in this country — if they're not already receiving Medicaid — is one step away from needing it." By subscribing, you are agreeing to Yahoo's Terms and Privacy Policy Most experts I spoke to think the reason many states drop the "Medicaid" from their program names is to reduce a stigma and encourage more people who are eligible for the assistance to sign up. While surveys show high support for Medicaid funding overall, enrolling in the program itself on a personal level can bring up mixed feelings. Consider this account from Calarco, who interviewed 250 women from pregnancy through their first couple of years postpartum for her recent book "Holding it Together: How Women Became America's Safety Net." One mother, Erin, and her husband were struggling to afford childcare, both working split shifts to watch their children. Exhausted by that arrangement, Erin dropped out of the workforce to stay at home with their kids, but the couple was going broke trying to afford health insurance at the same time. When Medicaid was expanded in her state, Erin was reluctant to sign up. "She felt like 'it's not for people like us,'" Calarco recounted, saying that they weren't poor enough to need it. There's also an othering factor around Medicaid, said Rivera. It's a program for this group or that group, one "that is different from me. Attempts to rename the programs try to make them more friendly, more appealing, more palatable." Signing up for TennCare or Healthy Connections in South Carolina may not sting as much, and that's exactly the point. The drawback, according to a 2024 study, is the effort "may muddle understanding of the program as a government-provided benefit." "The inner workings of how programs like Medicaid are funded is far too complex for the average person to understand," Calarco said. "It's hard for people to parse out that when we talk about your state Medicaid program, that's connected to and deeply dependent on federal Medicaid funding." There's a similar concern among the 75% of Medicaid enrollees who sign up for a plan managed by an MCO. For example in Georgia, those eligible for Medicaid register for the Georgia Families program, which then provides members a choice of three health plans managed by an MCO for adults. The three health plans are provided by Amerigroup Community Care, CareSource, or Peach State Health Plan. Absent from these plan names? Medicaid. Another study published in 2018 found that Medicaid recipients are less likely to self-report that they are on the program when MCO plans are designed to obscure government involvement. Enrollees are less able to recognize how they personally benefit from Medicaid, the study found, making it more difficult for them "to engage in the civic sphere as informed advocates for their self-interest." And that there is the rub. Senate lawmakers are set later this month to vote on which parts of the government should be slashed to reach the $880 billion in spending reductions the House GOP advanced in its budget resolution last week. The resolution itself didn't state those cuts must come from Medicaid, but the reductions must come from the House Energy and Commerce Committee, which oversees the program and the Children's Health Insurance Program. "When it comes to mobilizing for this much-needed part of our social safety net, it complicates things if people don't necessarily know that they're on it," Rivera said. 'It is really important for people to have a clear understanding that programs like Medicaid are essential for a functioning society." No matter what it's called. Janna Herron is a Senior Columnist at Yahoo Finance. Follow her on X @JannaHerron. Sign in to access your portfolio
Yahoo
28-02-2025
- Health
- Yahoo
Audit: Millions paid to deceased Medicaid members
(COLORADO) — An audit by the Office of the Inspector General (OIG) is reporting that approximately $6 million in payments were made to deceased recipients of Medicaid and care organizations, while the State of Colorado argues the audit is not accurate and it will not be paying back the the $6 million. According to the audit report, Colorado pays Medicaid managed care organizations (MCOs) for health care services provided to Medicaid enrollees; in return, MCOs receive a monthly fixed payment for each enrollee (capitation payment). The OIG said the audit was initiated due to previous audits revealing other states making improper payments on behalf of deceased enrollees. According to the OIG's findings, Colorado made capitation payments to MCOs on behalf of deceased enrollees: Of the 120 capitation payments in a random sample, 109 payments were made on behalf of deceased enrollees whose dates of death preceded the service period covered by the monthly capitation payment. Almost 39,000 unallowable capitation payments were made by the State of Colorado on behalf of deceased enrollees even though their dates of death were accurately recorded in the State's eligibility system. The OIG said it estimates Colorado made at least $3.8 million in unallowable capitation payments to MCOs on behalf of deceased enrollees. In addition, the OIG said Colorado incorrectly reported other Medicaid expenditures to the Centers for Medicare & Medicaid Services (CMS) totaling over $2.2 million. The OIG recommended that Colorado refund the estimated $6 million to the federal government. In a statement from the Colorado Department of Health Care Policy & Financing (HCPF), 'The Department of Health Care Policy & Financing (HCPF) has many control processes to verify that individuals have died and is constantly working to enhance these controls,' the Department said in its statement. 'HCPF disagrees with the OIG's assumption that all members in their sample were actually deceased when identified by the OIG.' HCPF went on to argue that the OIG used 'data analysis of questionable sources' and said it would be performing its own verification of the eligibility system, as the OIG did not independently perform outreach to deceased members' families to ensure the results were accurate. In addition, HCPF said it has sourced information to the OIG showing some cases were closed due to reasons other than death such as failure to respond, residency out of state, etc. 'HCPF does not plan to return the $6 million,' the Department went on to state. 'Based on the OIG's inadequate approach in reaching the financial estimates in this report, HCPF will need to spend time disputing the estimates directly with the Centers for Medicare, Medicaid Services (CMS), rather than attempting to identify and recover unallowable capitation payments made to our Managed Care Organizations solely based on the OIG report. If there was to be any kind of pay back, any final settlement with CMS will take 2-3 years to negotiate.' Copyright 2025 Nexstar Media, Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.
