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November 21, 2023

Out For Blood Is Right: Great Example of Outrageous Prices And The Need For Reform Kaiser Health News, the healthcare news aggregator, also does tremendous original news stories. One of its series is “Bill of the Month,” where it features one person’s heartache related to a recent healthcare bill. In this article, KFF intervened to get the patient’s bill cancelled, but she is among the lucky ones. It is also important to remember that not all surprise bills you receive will suddenly go away under the No Surprises Act. This surprise bill was from an in-network provider (hospital), which was charging outrageous lab fees on everyday tests. The health plan negotiated a poor discount and the patient’s plan had the insured covering a percentage of allowable costs. The article touches upon the need for site neutral payments to lower costs in the system and protect consumer’s from high costs. Why

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Medicare Advantage Will Have Huge Challenges Ahead

Medicare Advantage (MA) has been known as the most profitable sector of any health plan. With high premiums, a lucrative Star quality bonus, and chance to reduce medical expenses compared to the traditional fee-for-service program, plans have been able to register higher percentage and overall dollar margins in MA as compared with commercial and Medicaid. But as we have seen throughout the last few years, MA is not without its challenges and that will continue into the future. Surprisingly, at least one major player could be shopping its Medicare Advantage portfolio and getting out of the business. Here are the top challenges I see and areas MA plans need to keep an eye on. The collapse of the insurtechs Just a few years ago, the insurtechs were the darlings of investors. Investors believed that the insurtechs would leverage technology to transform healthcare, reduce costs, and drive quality. The investors also

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2024 Star Ratings Turmoil Creates Huge Vulnerability for Medicare Advantage Plans

While the Medicare Advantage (MA) Star Program has always made it difficult for plans to achieve and maintain high Star scores, the Star roller coaster ride has been much more profound over the past several years.  We now have had two years of pretty bad news, which puts a blemish on the program (fair or not). What’s more, the percentage of high-scoring contracts and the percentage of enrollment in them are now below pre-COVID years.  To refresh a bit on this, during the COVID pandemic, the Centers for Medicare and Medicaid Services (CMS) created fairly major calculation allowances for both Star 2021 (2019 and 2020 data) and 2022 (2020 and 2021 data). These allowances had the effect of boosting Star scores. We saw a surge in Star scores in 2022, including for plans that historically did not have a great track record of consistently hitting 4 Stars and above.  However,

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November 14, 2023

Health Tech Still Growing Despite some notable failures in the health tech world and tightness in equity markets, deals and mergers continue. Two notable examples in this article. #digitalhealth #healthtech Link to Article Kaiser Sees Deep Drop in Star Scores Kaiser Permanente saw deep drops in its Medicare Advantage Star scores for 2024, with four of its seven plans losing out on bonus payments (dropped below 4 Star). The CMO of Kaiser discusses this in the article below. Plans big and small suffered the past two years (2023 and 2024 Star Years). While achieving and maintaining high scores has always been a challenge, that a strong integrated system’s plans was a victim speaks volumes. You could always count on most Kaiser plans to be 5 Stars. Weighting, statistical changes, and new complex measures are catching plans by surprise. Based on the Stars road map, this will continue. Plans need data-driven

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