Anita Bachmann

Major Changes Coming For The KC Market 📢 Blue KC to Exit Medicare Advantage Market by 2025 Due to Regulatory Demands 📢 Blue Cross and Blue Shield of Kansas City (Blue KC) has announced its departure from the Medicare Advantage (MA) market by the end of 2024, citing increased regulatory demands and financial pressures as primary reasons for the decision. The company will shift its focus to employer-sponsored health plans, Medicare supplement plans, and Affordable Care Act plans while ensuring uninterrupted, quality service to current MA members through 2024. With a smaller MA membership base, Blue KC finds it challenging to compete economically at scale, leading to the difficult but necessary market exit. In a statement, Blue KC's President and CEO, Erin Stucky, expressed disappointment, saying, “We explored every alternative path for our MA members and are disappointed we must exit this line of business.” This move aligns with industry trends, as other insurers, like Oscar Health, have also exited the MA market due to similar challenges, including the impact of regulatory changes such as the CMS's benchmark payment adjustments on the profitability of MA plans for smaller insurers. #Healthcare #MedicareAdvantage #BlueKC #RegulatoryChallenges #InsuranceIndustry #HealthPlans #CMS #MarketExit

3

1 Comment

Full Medicaid expansion needed to retain Georgia’s physicians Georgia was ranked 5th worst place to practice in a recent Medscape article (“Best and Worst Places to Practice 2024”), using five criteria: physician compensation, cost of living, malpractice premiums, the health of the state’s residents, and physician burnout levels. As current and future physicians and health advocates, this column will add context by detailing our experiences practicing in Georgia. It is no surprise that three of the five worst-ranked states for practicing are among those that have not expanded Medicaid. In Georgia, refusal to expand Medicaid means that nearly 12 percent of residents (well over a million people) are uninsured, significantly limiting their access to healthcare. Only in Texas is coverage worse. Due solely to political concerns, Georgia chose to submit a Medicaid waiver and develop its own Medicaid expansion program, Pathways to Coverage. The governor’s office projected that the program would cover an additional 100,000 Georgians in its first year. But it has been an utter failure, with fewer than 3,500 covered at a cost to taxpayers of $26 million. Full Medicaid expansion would have added over 350,000 Georgians while cutting state spending by $710 million. These three states that refused to expand Medicaid are not surprisingly red. It is also unsurprising that the states with the greatest percentage of unhealthy residents are red. Hopefully, Georgia who thought they had a better way of expanding access to care with their own plan that squandered $26 million to cover 3,500 residents will realize that retaining physicians requires a more sensible approach to expanding access to care. #expandinghealthacess, #accesstocare, #limitingcoveragetoresidents https://lnkd.in/eefqH-9Y

7

Modern Healthcare highlights the potential benefits for Florida's health systems as they embrace Medicaid reimbursement for hospital-at-home services. This move aligns with the trend of states adopting this innovative care model, with approximately 330 hospitals in 37 states already offering at-home acute care. The shift towards home-based hospital care presents numerous advantages, from promoting health equity to enhancing patient satisfaction. By backing Medicaid reimbursement for these services, we can drive improved healthcare outcomes and optimize resource utilization. It's crucial for more states to acknowledge the value of hospital-at-home programs and consider following suit. #HealthcareInnovation #Medicaid #HospitalAtHome #HealthEquity

13

2 Comments

Exciting times at 4C Digital Health! Wilmington, Delaware - 4C Digital Health (4C), the preeminent organization delivering independent financial oversight and control solutions for self-funded employee health plans, recently announced the strategic expansion of its services into the Commonwealth of Kentucky. In late 2023, 4C successfully competed for an initial award issued by Kentucky’s Department of Employee Insurance, and Kentucky has since extended the initial contract to allow 4C to continue its important work on behalf of the Commonwealth, its employees, and its taxpayers. The Kentucky Employee Health Plan (KEHP) serves more than 288,000 members, which amounts to 1 in 16 Kentuckians. In addition, KEHP spends over $1.8 billion dollars in total healthcare benefits on behalf of its members per year and covers over 8.2 million claims per year. KEHP objectives include “improving employee health and well-being” and “providing state-of-the-art benefits while maintaining reasonable premiums.” Recognizing its important fiduciary responsibilities to its employees and its state health plan, the Commonwealth of Kentucky enacted Senate Bill 42 (2023) introduced by Senator Stephen Meredith for the purpose of ensuring that critical health plan dollars are being spent properly on behalf of state employees. The legislation requires that 4C analyze 100% of medical claims submitted for payment to KEHP; identify erroneous overpayments; and identify inappropriate or erroneous fees imposed by KEHP’s third-party administrator. Ron Templeton CEO of 4C Digital Health stated: “4C Digital Health is grateful to the Commonwealth of Kentucky for recognizing the fiduciary responsibility that state and local governments have to their employee health plans and for the opportunity to provide our services in support of this mission. We appreciate Kentucky’s goal of using 4C’s expertise and innovative solutions to improve healthcare outcomes and reduce healthcare costs for the Commonwealth, its employees, and its taxpayers.” About 4C Digital Health: 4C Digital Health (https://lnkd.in/eB-fJg4X) is a healthcare data analytics company that was founded for the purpose of developing a disruptive technology targeted at bringing transparency and honesty to the healthcare marketplace.

15

3 Comments

"The panel discussion highlighted the tension between state regulation of PBMs and Employee Retirement Income Security Act (ERISA) preemption, emphasizing the need for reforms that balance the interests of self-insured employers, who benefit from ERISA's uniformity, and the need to address harmful PBM practices, with potential incremental progress at the state level leading to broader federal reforms." #ERISA is a fascinating and challenging issue for major #PBM reform, and also impacts value-based #oncology reform. This was a great panel at the Community Oncology Alliance #PayerExchangeSummit. https://lnkd.in/evKbxaj3

10

On this episode Joseph Webb, D.Sc, MSHA, FACHE, Nashville General Hospital CEO and author of the hub and spoke health equity model, discusses the science of healthcare delivery. “This evidence-based approach to care is statistically, scientifically, and empirically proven to produce desired outcomes.” Webb shares how Nashville General is putting evidence-based models to work to remove barriers to care and improve outcomes in the populations it serves. #TheAvaneerSpark https://lnkd.in/euQPiNq2

2

In her upcoming webinar, Healthcare Advisory Practice Leader and Principal Valerie F. Barckhoff, MBA will equip healthcare leaders with strategies to protect their revenue cycles from cyber threats. Gain fresh insights that could transform your approach— register for this session hosted by the Georgia Hospital Association on September 12 at 11 a.m. Email education@gha.org for registration questions! #healthcare #webinar #healthcaredata #datasecurity #financialdata

11

1 Comment

New for 2025, CMS is rolling out a geographically based targeting option for Medicare Advantage organizations based on an Area Deprivation Index. If these orgs get things right, this could mean opportunities with new enrollees (especially in Midwest and Southern states) with potential rewards, incentives, and reduced cost sharing. This is in addition to CMS’ 2025 proposal to draw from ACO REACH and its geographic adjustments (which saw some big winners). If finalized, savvy ACOs would have additional capabilities through prepaid shared savings. tl;dr, CMS continues to push geographic considerations for beneficiaries. #sdoh #healthequity #medicare #medicaid .Variate Health

8

The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey is the first national, standardized, publicly reported survey of patients' perspectives of hospital care. 👉 30% of hospitals’ Medicare reimbursement based on patient satisfaction survey scores. 👉 In 2019, $1.9 billion in value-based payments was available to hospitals for inpatient care. 👉 Those that had the highest HCAHPS scores — across the domains of clinical outcomes, safety, person and community engagement, efficiency, and cost reduction — received the most financial support, while those with exceptionally low scores received financial penalties. ⭐ Across all domains of HCAHPS, organizations using Get Well score higher than non-Get Well customers.

13

On Veteran's Day we honor the brave men and women who have served our country with honor. Thank you for your service. More than 700,000 veterans call Florida home. Older veterans many not know that a Florida Blue Medicare Advantage plan can complement your VA benefits, providing additional coverage and flexibility. Read the blog post here to find out the three reasons why you should consider a Medicare Advantage plan. https://lnkd.in/en-fhZD7

35

Should be an interesting conversation about where we are today on 50% of the healthcare costs, are these costs fair from a sustainability standpoint, does price influence quality or access? We know the price paid does not equal the cost to deliver a service, so do we have the price right? Shouldn’t we move upstream to better support/incent care earlier to prevent and mitigate some of these higher costs in the primary care setting? How do we make that happen?

24

1 Comment

😳Humana faces a significant challenge following the release of preliminary 2025 Medicare Advantage (MA) Star Ratings data from CMS. Only 25% of its MA members are now enrolled in plans rated 4 stars or higher, a steep decline from 94% in 2024. 👉🏻The drop was driven primarily by the performance of contract H5216, which covers nearly half of Humana’s MA members, including over 90% of its Group MA plans, and saw its rating fall from 4.5 to 3.5 stars. 💴This will impact quality bonus payments in 2026. Humana is actively appealing some results and working to improve operating discipline to regain its industry-leading position. 🧘Key initiatives will focus on member engagement, customer experience, and technology enhancements to drive long-term value. Medicare Advantage open enrollment kicks off 10/15 and goes until 12/7. STAR ratings expected to be released to the public around 10/10! 📉Down 22% in premarket! https://lnkd.in/gUTT84tR

41

1 Comment

Does your health system's compliance program contain these 7 essential elements of an effective program?

12

1 Comment

My Friday good news celebrates the heroes of value-based care: primary care physicians and teams. The most successful #Medicare ACOs, those delivering value for Medicare and Medicare beneficiaries and sharing in that value, are primary care-centric #ACOs. We know how they do it; the playbook often includes support from enablers like Aledade, Inc.. Dr. Menard and his colleagues didn't give up when success wasn't immediate. How do we grow more primary care-centric ACOs and generate more value for Medicare and more access and quality care for beneficiaries? There are some health system ACOs investing in primary care and integrated teams. But it might take more forceful nudges from Medicare to get big health systems participating in total cost-of-care risk models. Or, we might need payment policies to give primary care more independence to practice comprehensive care. Congress could also consider restructuring the APM bonus to reward primary care "centricity". #primarycare #valuebasedcare Primary Care Collaborative David Raths David Muhlestein AAFP Foundation Thomas Culhane, MD, MMM, MS Darrin Menard, M.D. Stacey Richter https://lnkd.in/dThMvJrQ

11

1 Comment

This is a unique meeting of healthcare executives who share strategies and use cases for innovative technologies (AI and cybersecurity)and operations. I highly recommend this meeting as an opportunity to meet some transformational leaders in healthcare. https://lnkd.in/gfffn2aH

6

Interested in the CMS Medicare Shared Savings Program (MSSP), but not sure where to start? Check out this Sg2 expert blog post on how MSSP provides a structure for intentional strategic exploration and learnings, even for systems not fully committed to value-based care.

3

This upcoming Better Care Playbook webinar on 11/20, 12–1:15pm ET, will spotlight three state Medicaid agencies (CA, IA, and TN) that participated in the Medicare Academy — an initiative providing training for Medicaid agencies building Medicare knowledge needed to successfully advance integration goals. The state panelists will discuss how they are developing Medicare capacity. It will also feature a dually eligible enrollee who will share considerations for improving Medicare and Medicaid coordination to help individuals navigating these programs. https://bit.ly/40yJwF7 The SCAN Foundation, Arnold Ventures, The Commonwealth Fund, California Department of Health Care Services, Iowa Department of Health and Human Services, TennCare

4

From a healthcare provider perspective, the issue with Medicare Advantage is that CMS has squeezed reimbursement while providing significant premium increases to health plans. Plans have been printing money and expanding until 2024. Providers now expect further reimbursement pressure and tighter prior auth and claims payment when there is no margin in the services.

3