steptherapy

Part 1: My Courageous Daughter Is Having Brain Surgery!

This is one of a number of blogs that will appear on my daughter.  I call her Kitty.  She is a wonderfully talented, bright, and empathetic individual in her late ‘20s.  She and I agreed I would write this series to impart how important health coverage is. Not only is her decision to have surgery courageous, but so is her decision to share her journey through me. The principal reason to share the journey is because we both want to explain what many average Americans go through financially when they have major operations and do not have the best insurance or no insurance at all.  My daughter is privileged to come from a well-off family and to have consistent and robust insurance.  This will mean that she will pay a tiny amount for a surgery with a sticker price in the hundreds of thousands of dollars.  But for uninsured and

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Value-Based Care Payments And Arrangements Explained

A few readers have written in and asked if I could explain the various value-based-care (VBC) payment and arrangement frameworks. Specifically, they asked about my references to global and partial risk funds for providers.  Here is my best effort to explain what I see as the two overall types of VBC payments/arrangements we see in the marketplace today. Purpose VBC payments are meant to move from the fee-for-service (FFS) transactional payment system to one driven by efficiency and quality.  What do I mean by transaction payments? For the past many decades, most payments in our healthcare system were made as a fee for each service transacted in the healthcare system.  That can be the case when we go to the primary care physician (PCP), where he or she will be paid a fee by the insurer for the visit as well as other services provided. Similarly, a specialist may be

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2025 Rates for Medicare Advantage Plans Look Tight

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

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With Boom Over, Will Medicare Advantage Collapse Or Adjust?

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

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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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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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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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