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

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

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Major Health Insurers Can Have Differing Profiles and Priorities

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

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January 9, 2024

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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January 8, 2024

Aetna Turnaround On Stars And Enrollment Is Amazing At the JP Morgan conference, CVS President and CEO Karen Lynch was taking a well-deserved victory lap.  With all that is going on at CVS, the Aetna turnaround on enrollment and Stars in Medicare Advantage (MA) is amazing.  It is no small feat given competitiveness in the MA world and the major changes in Star for 2024.  #cvsaetna #cvshealth #aetna #medicareadvantage Link to Article Clover Touting Clover Assistant Clover Health also deserves credit for its work creating the Clover Assistant.  It has been shown to promote better outcomes, especially in the tough pharmacy adherence area. With prior authorization to take a back seat, data analytics and member and provider engagement are key to reducing and controlling medical expense at health plans. #clover #dataanalytics #engagement #caremanagement Link to Article Alignment Healthcare Bullish On Membership And Positive Margin Alignment Healthcare John Kao expects major

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Inflation Reduction Act’s Medicare Price Negotiations Should Have Small Impact On Innovation But Positive Impact On American Lives And What We Pay

If you have read my book, The Healthcare Labyrinth (available at this website), you know I am a proponent of negotiating drug prices nationally as well as the Medicare drug price provisions of the Inflation Reduction Act (IRA) more specifically. In my book, I argue a few fundamentals about drug prices in America: I am a Republican and I hold atypical views on drug pricing for my party – at least compared with most House and Senate GOP lawmakers. But the truth is, the last president and current president have proposed similar reforms on drug pricing. Respected think tanks with bipartisan representation support change, too. Polls also show support across parties for drastic changes to lower drug prices. I also don’t believe that if you support drug price negotiations and other reforms that somehow you are anti-free market. Negotiations and contractual agreements are a cornerstone of the free market. But

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January 5, 2024

FDA Approves Florida Drug Importation The Food and Drug Administration (FDA) has approved Florida to import prescription drugs from Canada via bulk purchasing.  This would mean Florida residents would have access to Canadian wholesale prices, which are far lower than in the United States.  Brand drug makers immediately attacked the waiver as reckless and claimed it could endanger health.  Nonsense.  Canada is a developed country with a great safety record. The waiver also has strict quality control measures in it. This is yet another stunt by Big Pharma to maintain its high prices in the United States. It likely will sue to stop it. Canada, too, could disrupt the plan if it results in shortages there.  Although the targeted drugs right now look like they are in reasonable supply, look out for a “manufactured” crisis to emerge. This is a feather in the cap of presidential candidate and Fl. Gov.

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January 4, 2024

Hospitals, Payers Have Better Compliance With Transparency Requirements Hospitals and payers seem to be complying more with required price transparency postings.  As well, the Centers for Medicare and Medicaid Services (CMS) has ramped up enforcement.  New rules went into effect 1/1 and Congress wants to codify the rules and enhance them. Additional article here: https://www.medpagetoday.com/special-reports/features/108126 #transparency #pricetransparency #healthplans #hospitals #cms Link to Article Physician and Hospital Groups Object To Info-Blocking Penalties In Proposed Interoperability Rule Provider and hospital groups dislike proposed penalties for info-blocking under a new proposed interoperability rule.  Penalties include a change in meaningful-use status in federal programs and reductions in payments. Additional article here: https://insidehealthpolicy.com/daily-news/stakeholders-seek-less-severe-penalties-potential-info-blocking-claims (Some articles may require a subscription.) #interoperability #infoblocking #hospitals #providers Link to Article Lawmakers Miss Medicare Advantage’s Benefits Lawmakers at a symposium on Medicare drug pricing complained that healthcare inflation is impacting Medicare provider payments and hurting access for Medicare beneficiaries. They

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Risk Adjustment Basics and The Controversy Over Medicare RADV

A few readers have sent me messages and asked me to detail some basics of risk adjustment (RA) — how it works, its benefits, and its challenges — and the controversy surrounding risk adjustment data validation (RADV) in Medicare Advantage (MA) specifically. RA is a complex world, but here is my best effort to keep the overview simple and then move to the coming RADV conflagration. While not practiced in the employer world because of the penetration of self-insured funds under the Employee Retirement Income Security Act (ERISA, where the employer shoulders the entire burden of costs and insurers are not at risk), risk adjustment has become an important and common practice in MA, Medicaid managed care, and Exchange managed care. Quite simply, risk adjustment is critical to ensuring that health plans are compensated fairly to cover the costs of a given individual as well as the population as a

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