longtermcare

With Medical Expense Rising, What Are Health Plans To Do?

Insurer stocks were rocked recently by news that both United Healthcare and Humana saw unexpected medical expense increases.  After filings with the Securities and Exchange Commission (SEC) and quarterly investors relations calls, these two companies’ stocks as well as those of other insurers tumbled.  Elevance Health also reported its Q4 2023 and full year 2023 results. It beat the trend.  It reported medical expense in line with expectations, but did note some increases in areas.  We are sure to see other plans report unexpected increases, with the biggest impacts likely seen at plans with major enrollment in Medicare Advantage (MA). And many plans are gearing up for additional layoffs and other administrative cuts due to the medical expense concerns. Why are plans seeing increases in medical costs?  First, utilization is slowly returning to normal in the healthcare industry post the COVID pandemic.  Second, inflation is taking root again and it

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January 24, 2024

Record Enrollment In Exchanges Nationwide The Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services (HHS) announced something to celebrate.  Driven in part by Medicaid redetermination enrollment losses and enhanced premium subsidies, state and federal exchange enrollment reached a projected 21.3 million for 2024. An amazing achievement. Over 5 million new enrollees joined over 16 million existing members. Nearly 4.2 million people with incomes of less than 250% of the federal poverty level signed up for 2024 coverage.  They receive both premium subsidies and cost-sharing reductions. About 15% of those enrollment previously had Medicaid.  That translates to a little over 3 million – a small amount of those who lost Medicaid coverage. Over 16 million are in the federal Exchange and about 5 million in various state Exchanges. CMS press release here: https://www.cms.gov/newsroom/press-releases/historic-213-million-people-choose-aca-marketplace-coverage . CMS Snapshot here: https://www.cms.gov/newsroom/fact-sheets/marketplace-2024-open-enrollment-period-report-final-national-snapshot . HHS press release here: https://www.hhs.gov/about/news/2024/01/24/historic-21-million-people-choose-aca-marketplace-coverage.html Kaiser

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January 23, 2024

Rural Hospitals In Distress A good measure of the distress rural hospitals: most no longer deliver babies. Over half of the country’s rural hospitals aren’t offering labor and delivery services and more could end such services. Some would argue that the rural hospitals’ plight could be solved by more money for hospitals overall.  The truth is the abominable hospital price system we have in this country along with the gross inefficiency of most hospitals drains overall healthcare resources and means we do not have enough to respond to true crises, such as those in rural communities. #ruralhealthcare #hospitals Link to Article Good Summary Of New Interoperability Rule’s Impact On Health Plans Modern Healthcare has a good article summarizing the provisions and impacts of the new interoperability rule.  Among the mandates are a swifter turnaround time for medical service authorizations in 2026 and the new FHIR electronic prior authorization process in

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January 22, 2024

Elevance Health All In On AI Elevance Health CEO Gail Boudreaux gave a keynote speech that shows the second-largest insurer will be all in on AI. She wants her company to use the technology to make healthcare more proactive, predictive and personalized. She wants AI to help people navigate the system and simplify it. #elevancehealth #ai #digitalhealth Link to Article Physicians Want Rollback Of Medicare Cut As Well As New System Not only do physicians want both a rollback of their payment cut, but also a brand new way of paying them in the Medicare traditional system. They are not wrong.  Each of the payment formulas has always been controversial and has led to an inability to calculate payments and last-minute rescues by lawmakers. (Article may require a subscription.) #medicare #physicians #providers #payments Link to Article Canada Ramping Up To Stop U.S. Importation Despite visits by U.S. officials, Canada seems intent on

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Great News For Insurers and Medicare Beneficiaries: January 2023 to January 2024 Medicare Advantage Growth Rebounds

It is time for my annual Medicare Advantage (MA) enrollment growth assessment. I usually write this in mid-January after we receive the results of the MA open enrollment season that ends on December 7 of the prior year. As I say, MA is the place to be in terms of revenue and margin opportunity. Here is this year’s assessment. I will be adding to this over the next few months as enrollment continues to increase. While some MA health plans are singing the blues after a lackluster MA enrollment season, my analysis of January 2023 to January 2024 growth shows there is reason for the industry to cheer overall. And some of the MA plans reporting disappointing growth in enrollment season actually did quite well throughout 2023. The MA enrollment big picture A few key points before we go into the year-over-year statistics: Why is Medicare Advantage (MA) attractive? As

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January 19, 2024

Weight Loss Drugs Take Nation By Storm Ozempic and other new drugs are all the rage for weight loss.  These new drugs have both great promise and the potential to be abused and drive up healthcare costs phenomenally.  See some of the trends here. (Article may require a subscription.) #weightlossdrugs #healthcare Link to Article Behavioral Health Pilot Announced By CMS The Centers for Medicare and Medicaid Services announced a new behavioral health pilot for traditional Medicare and Medicaid. Physical and mental healthcare providers will form care teams with community organizations to coordinate care for the mentally ill and substance abusers. (Article may require a subscription.) #behavioralhealth #medicare #medicaid Link to Article House Budget Committee Passes Fiscal Commission Bill Three Democrats and all Republicans came together to pass a fiscal commission bill in the House Budget Committee.  Such a commission would make recommendations on major fiscal issues, including Medicare. Congress would

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January 18, 2024

Disappointing Medicare Advantage Enrollment Numbers Huge disappointment for some during the Medicare Advantage enrollment season. My quick math says that overall MA numbers increased a strong 8.7% from January 2023 to January 2024.  That is up from a year ago, which was a little over 6%. But a number of plans did not fare well during the recent enrollment campaign.  Aetna shined.  While United and Humana grew, it was a much lower rates than before.  Centene took a big hit. I will have my usual annual blog looking at all the data on Monday. Stay tuned. Additional article here: https://www.healthcaredive.com/news/humana-earnings-outlook-cut-high-medical-costs/704865/ (Some articles may require a subscription.) #medicareadvantage #healthplans #enrollment Link to Article Government Shutdown Averted Until Early March Over objections of the right flank in the House, Congress passed a new continuing resolution (CR) to keep government open until early March.  New House Speaker Mike Johnson, R-LA, previously said he

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A Trump Second Term Would Be A Schizophrenic Experience On Healthcare

Kaiser Health News recently did a piece on what a second Donald Trump term would mean for healthcare. It was a good piece and there is a link at the bottom of this story. That prompted me to do my own evaluation of the prospects of what might happen in Trump 2. After all, lawsuits and indictments do not appear to be impacting the president’s standing in the GOP primary polls, but we will see what New Hampshire brings with candidate Nikki Haley closing in on Trump. In the general election polls, Trump and President Biden are neck and neck. To be fair to the former president, his tenure on healthcare was a mixed bag. As a bit of an atypical Republican, he ventured into areas not usually seen. Here are some major areas I would call out as the good and then the bad and ugly. The Good Price

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January 17, 2024

CMS Finalizes Interoperability And Prior Authorization Rule The Centers for Medicare and Medicaid Services (CMS) finalized a sweeping interoperability rule today that also sets much stricter timelines for medical service prior authorizations.  The rule was published some time ago and garnered a great deal of comments. The rule takes effect in January 2026 and requires 7 day standard and 72 hour expedited prior authorization turnaround times (federal Exchange plans excepted). Plans now have until 2027 to have APIs to allow providers to submit authorizations electronically.  A national format exists for retail prescription drugs, but not a consistent one for medical service requests yet.  The final specifications for medical services will tie to the Davinci Project, which will use the new FHIR standard. But plans will be able to use X12 formats as well. The rule applies to Medicare Advantage (MA), Medicaid, children’s coverage, and the federal Exchanges. The finalization of

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January 16, 2024

Congressional Leaders Agree on Extension of Funding The four congressional leaders announced a deal to extend government funding to March 8 to avoid a government shutdown.  This is a concession by House Speaker Mike Johnson, R-LA, who originally said he would not extend government by a short-term continuing resolution (CR). A number of items are left out of the funding package. Conservatives in the House GOP caucus are not happy with Speaker Johnson’s (one of their own) endorsement of the extension. Additional articles here: https://insidehealthpolicy.com/daily-news/short-term-cr-carries-extenders-through-march-8 and https://thehill.com/homenews/house/4410728-congress-shutdown-conservative-anger/ Additional article on status of healthcare bills, including hospitals’ opposition to site-neutral payments that is in a passed bill that would forestall disproportionate share hospital(DSH) funding cuts: https://www.modernhealthcare.com/politics-policy/congress-spending-deal-hospitals-dsh-medicare-site-neutral (Some articles may require a subscription.) #governmentshutdown #crs Link to Article More Fallout From MedPAC Report On Medicare Advantage The fallout from the MedPAC meeting continues.  A leading member has argued that the analysis by

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