socialdeterminants Archives - Page 19 of 20

2025 Rates for Medicare Advantage Plans Look Tight

February 1, 2024 No Comments

My latest blogs have touched upon the fact that while Medicare Advantage (MA) continues to grow, MA plans in the program are facing a number of financial challenges: While MA plans prepared for the worse, the advanced notice of MA payments for 2025 could very well compound the problem, even with increased enrollment – which is robust and driven by the clear difference between the value of MA vs. the traditional fee-for-service (FFS) program. It will remain that way. See my last blog on all this: https://www.healthcarelabyrinth.com/with-boom-over-will-medicare-advantage-collapse-or-adjust/ So let’s take a look at the advanced 2025 MA rate notice. Controversy over calculations Each year there is a robust debate on how to even calculate what the year over year increases will be in MA. It revolves around risk score trends. Risk scores tend to inflate each year in the program. MA plans would argue risk scores predict the costs of

With Boom Over, Will Medicare Advantage Collapse Or Adjust?

January 29, 2024 No Comments

After I posted my last blog Thursday ( https://www.healthcarelabyrinth.com/with-medical-expense-rising-what-are-health-plans-to-do/ ) and people digested what was happening with insurers’ stocks last week, a number of readers contacted me asking me to opine further on what was happening in MA. Many asked: “Is the Medicare boom over and is Medicare Advantage (MA) somehow collapsing under the weight of growing medical expense and government regulations?” They told me that they read many articles that implied MA was done — kaput! Indeed, my blogs have struck an alarmist cord at times about what is happening in MA, while other times I continue to extol the value and continued success of MA. So what’s up? It is a fair question and impression after the MA news over the past few weeks. Indeed, I give you a mixed review on MA on this site for good reasons. Refresh on issues Let’s refresh a bit on that

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

January 25, 2024 No Comments

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

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

January 22, 2024 No Comments

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

A Trump Second Term Would Be A Schizophrenic Experience On Healthcare

January 18, 2024 No Comments

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

The GOP Primary: My Dilemma From A Healthcare Perspective And Other Policy Issues

January 15, 2024 No Comments

Update: Posted early on January 1/15/2024 — Martin Luther King Day. The Iowa Republican Caucuses were on 1/15. After the Iowa Caucus results, Vivek Ramaswamy dropped out of the presidential race and endorsed Donald Trump. In Iowa, Trump won at least 20 delegates, at least DeSantis 8, Haley at least 7, and Ramaswamy at least 3. While you have learned I definitely have opinions, I try to keep politics per se out of my blogs. You do know, though, I am a Republican. As we approach the primary season, I have to try to pick a candidate. My decision will be a mix of healthcare and non-healthcare issues. So here is how I view it. As a Florida resident, I have until March 19 to make my decision on whom I want to win the GOP nomination. Forgive my delving into non-healthcare issues, but I believe the nation is on

January 11, 2024

January 11, 2024 No Comments

Dysfunction Junction Update: Will Government Shutdown? Faced with an upheaval by the rightists (his very own!) in the House GOP caucus and upended procedural votes, Speaker Mike Johnson, R-LA, met with the Freedom Caucus members to discuss a possible alternative spending bill. This came as a surprise to other leaders. But Johnson could face the same purge that former Speaker McCarthy saw when he tried to do the right thing and comprise to keep government operating. While no one has explicitly said they would call a vote to vacate the speakership, the idea has again been put out there by prominent members of the right-wing fire-setting brigade. Meanwhile, Senate Majority Leader Chuck Schumer, D-NY, has begun drafting a continuing resolution (CR) that extends government while the agreed-upon deal is worked on. Senate Minority Leader Mitch McConnel, R-KY, has said this is needed. Johnson may be softening, but previously ruled out

Major Health Insurers Can Have Differing Profiles and Priorities

January 11, 2024 No Comments

With so much going on in the health insurance world, I thought it would be interesting to profile some of the largest insurers and discuss some of their priorities/activities. I picked the seven largest insurers owned by for-profit publicly traded companies. Collectively, they cover about 200 million people, or 60% of the U.S. population. Collectively, their revenues are over $1.25 trillion annually. While this is not meant to be an exhaustive review of financial information or advice on stock purchases, I combed investor relations filings and sites as well as the internet for this information. As you will see, some are focused a bit on diversification from insurance alone and strengthening services units. Others continue to be more pure-play insurers. A few points: Here goes: United Health Group 2022 Revenue: $324 billion Q3 2023 Membership: Commercial – 27.3 million Medicaid managed care – 8.0 million Medicare Advantage – 7.6 million

January 10, 2024

January 10, 2024 No Comments

Oscar Says It Can Be Profitable in 2024 And May Expand To Other Products Insurtech Oscar says its enrollment will hit 1.3 million members in the Exchanges once open enrollment concludes, a 31% increase year-over-year. It also could see positive margins in 2024, as much as 5%. It could expand into individual coverage health reimbursement arrangements (ICHRA) and Medicare Advantage (MA) in the future. Both Oscar CEO Mark Bertolini (former Aetna CEO) and Centene CEO Sarah London are right that the Affordable Care Act (ACA) is here to stay with over 20 million enrollees. ICHRA is a good Trump-era rule that allows employers to make tax-free contributions toward employees’ individual coverage. Oscar would be well-placed to offer a total ICHRA administrative solution coupled with enrollment in individual Exchange enrollment. Bertolini is a genius on this issue. In other news, Alignment Healthcare touted its Star scores. Additional articles: https://www.fiercehealthcare.com/payers/jpm24-oscar-health-eyes-2024-profitability-and-ichra https://www.fiercehealthcare.com/finance/jpm24-day-3-goodrx-expects-least-749m-revenue-2023

January 9, 2024

January 9, 2024 No Comments

NY Wins Medicaid Waiver Approval New York received an 1115 Medicaid waiver approval from the Centers for Medicare and Medicaid Services (CMS) covering a myriad of innovations, including recruitment and retention of Medicaid providers, eligibility to bill social needs spending, primary care investments, behavioral health investments, and health equity pilots. CMS press release here: https://www.cms.gov/newsroom/press-releases/cms-approves-new-yorks-groundbreaking-section-1115-demonstration-amendment-improve-primary-care #medicaid #cms #waivers #socialneeds #healthequity Link to Article Both Cigna And CVS Say They Are Ready For Changes in PBM World Both Cigna and CVS, owners of two of the three largest traditional Pharmacy Benefits Managers (PBMs) say they are ready for the transformation in the world of PBMS that may be coming. Cigna went as far as to say they welcome unbundling, where plans may hire multiple entities to service them in a transparent way. See my Blog on PBM Transparency from December 14 for the emerging changes in the PBM industry: https://www.healthcarelabyrinth.com/pbm-transparency-and-reform-is-a-big-trend-in-the-american-healthcare-system/ #pbms

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