Michael Minor

We recently learned that Humana has revised its Medicare Advantage policy for coverage of PNS for chronic pain. While not perfect, we are cautiously optimistic that Humana’s revised Medicare Advantage policy marks a step towards ensuring access to innovative pain treatments for older adults. We will continue to monitor how this policy change unfolds. Learn more: bit.ly/4aghuiB We encourage you to share your experience with PNS payments from Humana directly with NANS (info@neuromodulation.org). Your feedback will help us observe and understand the outcomes of this change.    #neuromodulation #chronicpain #painmanagement #paintreatment #MedicareAdvantageChanges #MedicareAdvantage

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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

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🗣 HealthSherpa's FFM Reintegration The Centers for Medicare & Medicaid Services (CMS) has issued new guidance on correctly integrating FFM accounts with HealthSherpa for Agents. If you haven't received these instructions, please follow the steps below. 👇 1) Ensure you are logged out of the CMS Enterprise portal. https://lnkd.in/et64YmKf 2) Log in to your HealthSherpa for Agents account. https://lnkd.in/ebsnswFv 3)Navigate to your Settings page and select ‘Remove My FFM Account’ (refer to the screenshot below). 4) Reintegrate your FFM account. For more information on how to reintegrate your FFM account with HealthSherpa, visit this help page.https://https://lnkd.in/eQBJxh5R

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Even more alarming, the CDC estimates that 1 in 3 adults with severe Chronic Kidney Disease (CKD) are unaware they have it… With our complimentary Comprehensive Data Analytics, Specialty Care Management can identify potential claimants before they escalate into multimillion-dollar claims, not only protecting the financial integrity of self-insured health plans, but also enhancing member wellbeing and preventing the need for dialysis with proven, clinical intervention. What’s more, our programs can be implemented off-cycle, are TPA agnostic, and carry zero initiation, PEPM, or other ancillary fees, common amongst competitors. Let’s get to work — https://lnkd.in/eF689G5r #ChronicKidneyDisease #RenalDialysis #CostContainment #SpecialtyCM

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Prior authorizations can be a very important tool as a check and balance to ensure that a patient is getting the most appropriate care at any particular time, but it can also be incredibly bureaucratic and burdensome for providers and patients. This adds administrative costs and potentially delays key treatments. There is no doubt the prior authorization process needs to evolve, and eliminating the process for primary care providers is a very logical step. Where do you believe the sweet spot is for maximizing the benefits of prior authorization while minimizing the added burden and costs?

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CVS, Aetna and Humana all announced this week that they foresee membership losses in 2025 as CMS trimmed payments which will cause them to cut back services for seniors. Since the 2025 Final Rule was announced in April, MA insurers have had the tables turned on them for what providers have been experiencing for years; you can’t add more costs, cut reimbursement and have a margin that makes sense. Medicare Advantage turned 21 this year. And this article summed it up quite well…. “MA has been a broken system since the beginning, especially for patients. The business worked only as long as insurers were able to extract large payments from the Medicare fund. The MA model relies on providing as little care as possible in general, with insurers putting care approval behind a wall of delays and denials to save money and leaving patients without necessary treatment. Now that the government is trying to rein in these abuses and seniors are using more health care than before, this model is in serious jeopardy.” Legislators on both sides are introducing bills that certainly puts MA in the spotlight like never before. We need real change, not more regulation. #healthcarefinance #RCM #medicalbilling

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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.

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As policymakers consider changes to the Medicare Advantage (MA) program, it's essential to acknowledge the diversity of D-SNP and MA-PD plans. A one-size-fits-all approach may fail to address the unique needs of these plans and lead to unintended consequences for Medicare beneficiaries. Thoughtful and tailored policy decisions can help ensure that all beneficiaries receive the care and support they desire and deserve. Our new Association for Community Affiliated Plans (ACAP) report shares specific policy recommendations and options for consideration: https://bit.ly/4dHIpWj #MedicareAdvantage #DSNP 

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Four years into implementation, nearly 40% of #MedicareAdvantage plans offer expanded primarily health-related benefits (EPHRB) or Special Supplemental Benefits for the Chronically Ill (#SSBCI). ATI Advisory and LTQA's report, "An Evaluation Framework for Assessing the Progress of Nonmedical Supplemental Benefit Development and Implementation in Medicare Advantage," supported by The SCAN Foundation, dives into the significant growth of these benefits, including in-home support services, food, and transportation to address health-related social needs (#HRSNs). Despite the growth, better data on access, utilization, and outcomes is crucial to understand their true impact on #Medicare beneficiaries' health and wellbeing. As policymakers and stakeholders navigate this evolving landscape, this report is a critical resource for enhancing these essential benefits. Read the full publication: https://lnkd.in/dHChUjF5 ATI Advisory, The SCAN Foundation

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Congratulations to our Humana Healthcare Research team on the publication of their senior-focused primary care study in Health Affairs! In collaboration with Harvard University, this first-of-its-kind study revealed better access to primary care and narrowed racial and socio-economic disparities for seniors receiving care from senior-focused primary care organizations. There is also evidence of better health outcomes. With our long-term investment in integrated senior care services in mind, it is exciting to see this kind of validation that the senior-focused primary care model is working and delivering results. Check out the infographic and news release below to learn more about the findings. https://lnkd.in/g6gGp3iG #HUMEmployee #TeamHumana #SeniorPrimaryCare #HealthcareResearch #ValueBasedCare

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We're proud to announce that our Chief Medical Officer, Michael H Shannon, and Dan Reck, Director of Actuarial Services at MultiCare Health System, have contributed to an important study published in the Journal of Managed Care & Specialty Pharmacy (JMCP). The article, titled "Benefits of Dapagliflozin in Chronic Kidney Disease for US Commercial Payers: A Cost-Offset Analysis," provides valuable insights into the economic and health benefits of dapagliflozin for patients with chronic kidney disease. This research highlights the potential for cost savings and improved patient outcomes—an essential read for healthcare professionals and decision-makers in the industry. 🔗 Read the full article here: https://lnkd.in/gQddbP5H

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Risk adjustment is a risk mitigation tool that attempts to offset the cost of covering enrollees with greater health risk, and in turn, medical spending. This Toolkit includes information on risk adjustment cases since 2009. It also includes information on risk adjustment trends, CMS guidance and updates, Congressional and Agency reports, Corporate Integrity Agreements, and risk adjustment rates. Access the Toolkit: https://lnkd.in/gXi3eQny

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😳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

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A historic and monumental win for #healthcare providers in the battle against big #healthinsurance! On October 14th, providers reached a $2.8 billion #antitrust settlement with Blue Cross Blue Shield (BCBS) entities across the country and Blue Cross Blue Shield Association, to resolve BCBS’s long-standing underpayments and anticompetitive practices.  This includes a $2.8 billion cash payment into a settlement fund, as well as investments by the Blues of hundreds of millions of dollars in system improvements for the benefit of providers. Providers must now decide whether to participate or pursue independent claims. Legal consultation is recommended for providers evaluating their options. Allia Group finances litigation on behalf of providers to recover fair payment and address insurers' unfair business actions. Contact us for a consultation. https://lnkd.in/eH8r-xtd

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#MedicareAdvantage keeps getting more popular among seniors: #MA plans typically offer a range of supplemental benefits (like transportation/#NEMT) that can improve quality of life and health outcomes. But they are facing challenges headed into 2025, including lower star ratings, resistance from some health networks, rising healthcare costs, and a revised CMS payment model. Read our latest blog for a summary of MA changes that will impact health plans, providers, and members in the year ahead. https://hubs.li/Q02XP0700

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HHS finalized its final rule outlining disincentives for hospitals, health systems and clinicians blocking patient information exchange on June 24. Providers knowingly interfering or preventing patients from accessing medical information, EHR use and information exchange will face penalties going forward. Those penalties include: 1. Hospitals, physician groups and clinicians being stripped of meaningful use status for the calendar year of the EHR reporting period when the Office of Inspector General refers its determination to CMS. If one clinician within a group is blocking information, but not the whole group, the penalty will only apply to the offender. 2. Critical access hospitals risk seeing payment reduced to 100% of reasonable costs. 3. Clinicians in ACOs may be ineligible to participate in the ACO for at least one year, and they may not be able to receive revenue earned through the Shared Savings Program. HHS reserved the right to create additional disincentives in the future. The new rules add to existing penalties for IT companies and developers, which face a fine of up to $1 million for information blocking.

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Integrating Medicare & Medicaid for dually eligible individuals is challenging, but critical. Hear how New Jersey & Texas seek to create more person-centered care for this population and improve members’ experiences. Listen now: https://lnkd.in/g7ZEfKQp

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📰 My latest Substack article, diving into Centene's impressive Q2 2024 earnings report. 📈 Despite challenging headwinds, Centene Corporation, under the leadership of Sarah London, has delivered one of its best quarters yet. Here are some key highlights: 💎 Revenue Growth: 5.2% increase through the first half of 2024 to over 80 billion. 💎 EPS Growth: 15% rise compared to Q2 2023, with EPS at $2.42, up from $2.10. 💎 Stock Performance: Almost 9% rally on Friday driven by strong EPS growth and a 34% surge in the ACA/Marketplace membership.. Sarah London's strategic shift away from vertical integration is proving to be a winning move, focusing on core strengths while divesting non-core assets. Here are some major takeaways from the earnings call: 🏥 Medicaid - Addressed acuity misalignment, Centene sees a brighter second half of 2024 as their PMPM rates will move upward. - Significant wins in Florida, Kansas, and Michigan. - Exciting LTSS launch in Arizona, with Oklahoma, Delaware, and North Carolina in launch mode. 👨‍⚕️ ACA/Marketplace - The Ambetter brand is shining as Centene is the largest domestic ACA/Markeplace provider with membership growth of 34%. - Premium subsidies are driving this explosive growth, with total enrollment now at 4.4 million beneficiaries - Premiums revenue hit $8.5 billion in Q2, a 49% increase quarter-over-quarter. 👵 Medicare (Wellcare) - Rebuilding the brand with an eye on growth in 2025/2026. - Focus on the dual-eligible market as a potential growth area. - STAR ratings improvements with the CMS adjustment but must feel good about their meta data for CAHPS/HEDIS -Strong PDP business positioning post-IRA as they feel good about their 2025 bids 💰 Investments/Divestments - Continued share repurchases with $851 million in Q2. - Divesting in non-core businesses like Magellan Rx, PantherRx , Apixio, etc. are now paying off for the company This quarter truly showcased Centene's execution on their longer term strategy. Impressive cause when everyone zigged....They zagged. Full article below: #Healthcare #Medicaid #ACA #Marketplace #Medicare #Centene #Earnings

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