PURPOSE: Using New York City as an example, this research explores reasons for the consistently poor financial performance of three start-up health plans (Health Republic, CareConnect, and Oscar) while other health plans...PURPOSE: Using New York City as an example, this research explores reasons for the consistently poor financial performance of three start-up health plans (Health Republic, CareConnect, and Oscar) while other health plans have performed relatively well in the same market. DESIGN AND METHODS: This study compiles insurer data from financial years 2014 through 2016, submitted to the New York State Department of Financial Services as part of the rate-review process, including premium revenue, claims cost, risk adjustment, administrative costs, net income, and premium. The financial data were used to create a novel metric, adjusted net income, that evaluates the financial performance of an insurer excluding risk adjustment and assuming a market average administrative cost. Descriptive statistics were used to compare the performance of start-up plans, commercial plans, and Medicaid plans in the ACA exchange market. RESULTS: Premiums for start-up plans were within 9% of median silver premiums yet adjusted net income was negative (-$190 PMPM) for all three start-ups while it is positive (+$27 PMPM) for the non-start-ups. The difference in adjusted net incomes shows that poor financial performance of start-ups was due to claims costs, not high administrative costs and poor performance in risk adjustment. CONCLUSION: The consistent financial losses by New York City start-ups is driven by higher-cost provider contracts for the start-ups relative to competitors.
Blue Health Intelligence conducted an analysis of a commercial health plan claims database and adverse events that is designed to paint a fuller, real-world picture of adverse events. The database included patients, ages...Blue Health Intelligence conducted an analysis of a commercial health plan claims database and adverse events that is designed to paint a fuller, real-world picture of adverse events. The database included patients, ages 18-64, admitted to the hospital in 2016 and 2017.
Getting vertical theoretically will allow the new entities to capitalize on efficiencies in care management, total cost of claims, and other programs while creating an all-in-one health care product that provides more se...Getting vertical theoretically will allow the new entities to capitalize on efficiencies in care management, total cost of claims, and other programs while creating an all-in-one health care product that provides more services at less cost. At least that's the spin.
The credibility of cannabis as a source of a legitimate pharmaceutical ingredient in prescription medications took a major step forward in 2018 when the FDA approved Epidiolex (cannabidiol) for two types of severe seizur...The credibility of cannabis as a source of a legitimate pharmaceutical ingredient in prescription medications took a major step forward in 2018 when the FDA approved Epidiolex (cannabidiol) for two types of severe seizures. Epidiolex was a stellar candidate for approval. It reduced convulsive seizures by about 40% and has a good safety profile.
Not that plans won't be taking a close look at some innovative approaches such as addiction recovery medical homes. One model includes bundled payments and performance bonuses, nationally recognized quality metrics, and...Not that plans won't be taking a close look at some innovative approaches such as addiction recovery medical homes. One model includes bundled payments and performance bonuses, nationally recognized quality metrics, and the placement of treatment and recovery providers close to where patients with substance use disorder live.
We'll see what happens to the administration's Part B proposal. Congress is not likely to take bold action, partly because drugmakers are a strong influence on both parties. That leaves the FDA and Administrator Scott Go...We'll see what happens to the administration's Part B proposal. Congress is not likely to take bold action, partly because drugmakers are a strong influence on both parties. That leaves the FDA and Administrator Scott Gottlieb, MD, as major players in efforts to rein in drug prices.
This fall, PricewaterhouseCoopers issued a report on blockchain in health care and outlined six areas where it could have a profound impact: supply chain and inventory management; enrollment and provider data management;...This fall, PricewaterhouseCoopers issued a report on blockchain in health care and outlined six areas where it could have a profound impact: supply chain and inventory management; enrollment and provider data management; back office functions and payments; data management; managing risk and regulatory issues; and research and development.
It's a tight labor market and employer surveys show a modest but steady uptick in employer health benefit spending for the coming year-about 5% on average. Much of that increase will go toward specialty drugs, the benefi...It's a tight labor market and employer surveys show a modest but steady uptick in employer health benefit spending for the coming year-about 5% on average. Much of that increase will go toward specialty drugs, the benefit with the biggest price hikes.
The ACA-and more specifically, the individual ACA exchange market-is doing quite well these days, thank you very much. ACA premium prices have stabilized and even gone down for many plans. In October, CMS announced that...The ACA-and more specifically, the individual ACA exchange market-is doing quite well these days, thank you very much. ACA premium prices have stabilized and even gone down for many plans. In October, CMS announced that the average premium for the second-lowest-cost silver plans for 2019 had decreased by 1.5%.
Is it any wonder that Republican office holders are changing their tune regarding pre-existing conditions? Kaiser Family Foundation polling reports that overwhelming majorities say it is "very important" that the ACA's p...Is it any wonder that Republican office holders are changing their tune regarding pre-existing conditions? Kaiser Family Foundation polling reports that overwhelming majorities say it is "very important" that the ACA's protections for people with pre-existing conditions (75%) remain. Even 58% of Republicans agree.
CMS's Bundled Payments for Care Improvement (BPCI) Advanced program signals a willingness among Medicare providers to redesign care and take on risk. More than 1,500 hospitals and physician groups signed up-north of what...CMS's Bundled Payments for Care Improvement (BPCI) Advanced program signals a willingness among Medicare providers to redesign care and take on risk. More than 1,500 hospitals and physician groups signed up-north of what was expected for a program that includes downside risk from Day 1. Commercial payers are watching closely.
In 2019, a record 36% of Medicare beneficiaries will be getting their benefits in a Medicare Advantage plan. CMS has broadened the services such plans can provide-services that may reduce expensive treatments and injurie...In 2019, a record 36% of Medicare beneficiaries will be getting their benefits in a Medicare Advantage plan. CMS has broadened the services such plans can provide-services that may reduce expensive treatments and injuries. Insurers continue to see the market as a business opportunity. Critics see a slow-motion privatization of the entitlement.
The PBM unit of the health giant CVS decided that any new drug exceeding $100,000 per quality-adjusted life year (QALY) may be excluded from the formularies that are maintained by its clients. Patient groups (with the ba...The PBM unit of the health giant CVS decided that any new drug exceeding $100,000 per quality-adjusted life year (QALY) may be excluded from the formularies that are maintained by its clients. Patient groups (with the backing of pharma) say that the measure is discriminatory.
Britain's National Health Service is taking a good look at how Americans do ACOs. But the move toward accountable care in England has already gotten mired in disputes (and confusion) about what organizational form it sho...Britain's National Health Service is taking a good look at how Americans do ACOs. But the move toward accountable care in England has already gotten mired in disputes (and confusion) about what organizational form it should take and whether current proposals are legal.
It may seem obvious, but people are more likely to remain engaged in an activity if they find it enjoyable-and outcomes back this up. Among the more than 1,000 patients who enrolled in our multiple sclerosis registry, 95...It may seem obvious, but people are more likely to remain engaged in an activity if they find it enjoyable-and outcomes back this up. Among the more than 1,000 patients who enrolled in our multiple sclerosis registry, 95% remained active after one year.
CMS continues to push on measuring and reporting information from the consumer perspective for Medicare Advantage and Part D contracts. Others will follow, and we can expect more emphasis on member-reported outcomes and...CMS continues to push on measuring and reporting information from the consumer perspective for Medicare Advantage and Part D contracts. Others will follow, and we can expect more emphasis on member-reported outcomes and experience measures across all lines of business.
Think of this alternative payment model as a large set of event-driven care packages that get triggered by consumer-patients. Each care package can be priced and adjusted for the individual's medical history. Providers w...Think of this alternative payment model as a large set of event-driven care packages that get triggered by consumer-patients. Each care package can be priced and adjusted for the individual's medical history. Providers who want to bid for the care package can, and what they're offering will be available and comparable to other providers.
Tests for AKI biomarkers would be used more widely if their role were better defined, say their proponents. Researchers are tackling the possibilities from many angles. In addition to detecting kidney injury sooner, AKI...Tests for AKI biomarkers would be used more widely if their role were better defined, say their proponents. Researchers are tackling the possibilities from many angles. In addition to detecting kidney injury sooner, AKI biomarkers might also be used to assess the riskiness of common kidney stressors.
UnitedHealth Group, Humana, Centene, and Anthem have announced billions of dollars of deals to acquire primary care practices, hospice providers, and home health care companies. The insurers' foray into provider territor...UnitedHealth Group, Humana, Centene, and Anthem have announced billions of dollars of deals to acquire primary care practices, hospice providers, and home health care companies. The insurers' foray into provider territory comes as the traditional contours of American health care are in flux.
It may take a little while longer to ferret out whether MIPS is having CMS's self-described effect-to "drive improvement in care processes and health outcomes, increase the use of health care information, and reduce the...It may take a little while longer to ferret out whether MIPS is having CMS's self-described effect-to "drive improvement in care processes and health outcomes, increase the use of health care information, and reduce the cost of care." Already concluding that cost reduction is unlikely, Medpac recommended scraping MIPS altogether.