utilizationmanagement

NOTE: This blog is co-published with Lilac Software. See the end of the blog for more information on Lilac’s Stars platform and agentic AI solutions. The skinny on Star changes in the future and how tough it may be, especially for Special Needs Plans. On November 13, I did a blog (see it here: https://www.healthcarelabyrinth.com/cms-likely-to-remake-star-ratings/ ) that said the Centers for Medicare and Medicaid Services (CMS) plans on remaking the Medicare Advantage (MA) Stars program by eliminating easy-to-hit operational measures and replacing them with tougher clinical measures. Sure enough, CMS acted on this on November 25, publishing a draft MA and Part D rule for 2027 that would make sweeping Star changes. The CMS Stars announcement Beginning primarily in Measure Year (MY) 2027 or Star Year (SY) 2029, CMS proposes to remove 12 (really 14 based on duplication in Parts C and D) measures, largely focused on operational/administrative processes or

A quick blog to tell you about enrollment growth in Medicare Advantage (MA) in both October and November 2025. The October data was delayed due to the government shutdown. Recently, both the October and November data were posted. Due to the financial meltdown of health insurers in general and in the MA line specifically, many of the biggest plans have sought to restrain growth. But growth has continued throughout the year because of some strong benefit packages still out there and the better value in MA compared with traditional fee-for-service (FFS) Medicare. We are now in open enrollment for 2026 so we will continue to see growth in Q4 2025 because of some enrollees who are able to switch early (before January 2026) with special enrollment periods.   What do the latest statistics show? Growth from January 2024 to February 2025 was 4.39% or 1.468 million. (I used February 2025

Weight-loss drug concessions are positive, but not seminal reform. The Trump administration announced yet another major development on the drug pricing front. In an October 9 blog, I told you about a set of initial drug price concessions President Donald Trump got from a few Big Pharma companies. On November 3, I discussed a related topic on the drug front – Cigna’s pharmacy benefits manager, Express Scripts, announcing a slow migration away from gross and rebate pricing to a net basis. You can go to the blog tab and those dates to read more. Now, Trump announced drug price concession deals with two GLP-1 weight-loss brand drug makers – American firm Eli Lilly and Danish firm Novo Nordisk. What are GLP-1s? The two leading types of GLP-1 weight-loss drugs are semaglutide (sold by Novo Nordisk as either Ozempic or Wegovy) and tirzepatide (sold by Eli Lilly as either Mounjaro or

Annual announcement updating Medicare beneficary payments reminds us how antiquated Medicare fee-for-service (FFS) really is. It is on life support. The Centers for Medicare and Medicaid Services (CMS) released its annual updates for traditional Medicare Part A and B premiums deductibles, and cost-sharing. There was a huge surge in Part B premiums monthly by 10%. The Social Security cost-of-living increase was just 2.8% or about $56 per month on average. The Part B premium increase will eat up $18 of that. When this comes out, I reflect on a few things. How antiquated traditional Medicare fee-for-service (FFS) really is. It is stuck back in the 1950s/1960s and the 80-20 indemnity world. While CMS champions how many providers are now in a value-based reimbursement program, there is nothing stunning there — true savings (if any) is a rounding error in the $1 trillion plus behemoth. Traditional Medicare is on life support.

NOTE: This blog is co-published with Lilac Software. See the end of the blog for more information on Lilac’s Stars platform and agentic AI solutions. As low as Stars are right now, reaching higher in the future could be tougher A bit of a bombshell from Health Payer Specialist (link at the end of the blog) — well, yes and no. Officials at the Centers for Medicare and Medicaid Services (CMS) told the publication that changes likely are coming to the Medicare Advantage (MA) and Part D Star rating program. And this could make Star achievement even more difficult in a current environment where ratings are already in the doldrums. As I have said in the past, CMS and the White House have prominent conservative policy advisors, including from Brian Blase’s Paragon Health Institute. The think tank holds great sway in both the Trump administration and Congress. I have noted

UnitedHealthcare study may mean Congress takes up vertical integration reform A recent study published by Health Affairs about what UnitedHealthcare pays its sister providers compared with other network providers could ignite renewed scrutiny of vertical integration. It could also lead to a fresh look at what some call the gaming of the minimum medical loss ratio (MLR) mandate that touches virtually all insurance product types out there except self-insured employer coverage. The study finds that UnitedHealthcare pays its owned providers at sister company Optum 17% more than those it does not own. And if United controls 25% or more of a market, that percentage increases to 61%. Again, researchers said the results suggest the company may be sidestepping government rules regarding calculation of medical expenses against premiums. If those rules are not met, rebates need to be sent to the government, employers, or individuals depending on the type of coverage.

Huge utilization and medical expense still a factor in insurer recovery Given the fiscal crisis happening in the health plan industry, I thought a quick blog summarizing Q3 2025 financial reports made sense. As well, a few more updates on Medicare Advantage (MA) contraction. One of my biggest observations is that medical loss ratios (MLRs), the way health plans measure the percentage of medical costs against premiums, remains at record levels. This appears to be across all lines of business – government programs and commercial/employer coverage. When MLRs are at 90 or well into the 90s (with the exception of commercial-only Cigna), you know things are upside down financially. And while plans continue to recover financially, there is little sign that high utilization, inflation, and costs will temper anytime soon. Further, developments in Medicaid and Exchanges as well as to some degree in MA could further complicate the medical cost

Express Scripts’ announcement about drug rebates is a step forward, but not earth-shattering change In an October 9, 2025 blog, I applauded President Donald Trump’s efforts to redefine drug price in America. At the same time, I questioned whether some of the deals he has announced with brand drug manufacturers (aka Big Pharma) were truly game changers for drug price in America. I urged the president not to settle for these deals but to continue to push forward on true price reform. Along comes Cigna’s Express Scripts’ announcement that it would begin the process of migrating in part from the current gross price and rebate model to net drug pricing. This upends both its brand drug contracts with drug makers but also with insurers and employer groups. In part the announcement was precipitated by the Trump administration’s own demands that pharmacy benefits managers (PBMs) like Express Scripts abandon the rebate

It is not just about high costs in America for healthcare, it is about quality too Back on September 17, I did a quick blog on the Peterson-KFF Health System Tracker Chart Collection comparing U.S. healthcare prices and utilization against those in other developed nations. I like these periodic looks at prices and utilization throughout the developed world because it reveals at least one of the biggest reasons our healthcare system is in crisis or at least tumbling toward it – the highest prices in the developed world. A few key Peterson-KFF  findings as I related in the blog, which can be found here ( https://www.healthcarelabyrinth.com/u-s-healthcare-prices-compared-with-other-developed-nations/ ): Now, Peterson-KFF has released a new analysis and charts related to how America compares to the rest of the developed world in terms of quality outcomes and healthcare system performance. This is a bit like what The Commonwealth Fund does every three years

The bad Exchange replacement nightmare keeps coming back Say it isn’t so. More talk of an ACA replacement? Just as 2026 midterm fundraising is heating up, Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz dropped a bombshell recently when he told NBC News that President Donald Trump may have a plan to overhaul and replace the Affordable Care Act (ACA). I emphasize “may.” Dr. Oz referred to the potential hidden plan as he was declaring his opposition to extending the current enhanced Exchange premium subsidies due to expire at the end of this year. “I fully believe the president has a plan,” Oz said. “We’ve been talking about it quite a lot.” He added there is a “full plan,” but Democrats are “hold[ing] the entire country hostage by shutting the government down … the folks who would help this system evolve into a mature model aren’t at