Scott Waulters

Interesting read from the think tank on federal policy that may positively shape our industry. Examples are: 1. Stop throwing good money after bad and break the cycle of repeatedly expanding Obamacare subsidies to insurance companies despite underwhelming results; 2. Expand high-quality, affordable coverage options by providing health insurance options outside of Obamacare; 3. Give Americans more control by providing them the option to directly receive federal cost-sharing assistance as a deposit into a health savings account; 4. Allow Americans to keep more of their own money for future health expenses by adopting more flexible standards on which insurance plans can be paired with an HSA that allows for tax-free savings; 5. Promote transparency to enable Americans to know prices in advance of receiving care by building on the Trump administration’s groundbreaking price transparency initiative; and 6. Empower medical workers by breaking down the barriers preventing Americans from getting appropriate medical education and those stopping clinicians from practicing to the full extent of their training. #healthcare #transparency #employees #population #individuals #employers #advisors #brokers #carriers #pbms #insurance #providers #nurses #coalition #union #facility #nonprofit

1

1 Comment

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

Great video summary of the resent NYT's Multiplan payor price fixing article. https://lnkd.in/e2wkwKFd

5

Recent projections from Jefferies indicate a significant shake-up for insurers: - Humana: Faces the largest hit, with an expected $2.5 billion reduction in EBITDA and a staggering $16.37 EPS drop, marking an 83% decline compared to 2025 projections. - UnitedHealthcare: Set to lose $1.6 billion in EBITDA, alongside a $1.39 EPS decline (4%). - CVS/Aetna: A relatively modest gain of $100 million in EBITDA and a $0.05 EPS bump (1%). - Elevance: A $100 million reduction in EBITDA with a $0.30 EPS decline (1%). - Centene: A positive outlier, expected to increase EBITDA by $100 million and boost EPS by $0.10 (1%).

7

1 Comment

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?

5

Hey UPMC and UPMC Enterprises are y’all ok? I have some questions. How does one sell #Prodigo to GHX in April of 2023? Which, btw 10/10 M&A “win”.* 😆 Then turn around and have McKinsey & Company lay of 1% of your workforce in May of 2024 (truly inspired work y’all 🙄). * Only then to do those layoffs while on your LEASED PJ!* While you are speaking at GHX’s Summit about… “reducing operational costs, compliance and greater visibility for cash management and forecasting.”* I’m just gonna go ahead and say nah I don’t think you do. Also, did y’all really have the audacity to get up there and talk about that knowing your people were laying folks off of from their LEASED private jet? My word y’all. What is going on here and where did the money go, I mean besides the leased private jets. Can someone get out the big 🖍️’s and talk real slow to help me understand what I’m missing? How is this acceptable behavior? Forget people over profits we are clearly the ones in the wrong, because it’s clearly #pjsoverpeople I guess we should all just eat cake right? 🤷🏼‍♀️ https://lnkd.in/g5fSV__Q https://lnkd.in/g_C8hxBX https://lnkd.in/gjMeH3Et https://lnkd.in/gjDY3qcC

3

2 Comments

Dr. Jain...THANK YOU for this insight and support for the kind of work I do every day! Building complex geriatrics longitudinal care programs is where I cut my value based teeth! These programs - when structured with attention to detail - can create a profoundly positive impact. A fully integrated program that is carefully facilitated, orchestrated, and navigated WITH a patient quite literally changes lives. As a system we have to shift our thinking and embrace the FACT that cookie cutter medicine is NOT effective as well as the notion that precision medicine is not scalable, replicable or sustainable....because it CAN be. Been there, done that (and continue to do it) and have the results to prove it! At Synergy 3C, THESE are the models we build and have a track record of success! We would love to have a conversation with you about HOW these models can and do work! #complexpopulationhealth #complexgeriatrics #medicareadvantage

6

😳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

In 2023 Medicare Advantage was enjoying a long and profitable growth streak, with plans expanding geographically into previously under or unserved areas. With the CMS changes to 'risk adjusting', 2024 became a difficult year. Now in 2025, plans are generally retreating from unprofitable markets, limiting product offerings, and cutting generous benefits for things that Medicare does not cover. It seems that health systems have had enough. As Medicare Advantage plans scrambled to maintain profitability, the administrative burden on providers increased and health systems are saying - enough and exiting participation.

2

🗣 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

3

Feeling overwhelmed by CMS's interoperability and prior authorization rule (CMS-0057)? You're not alone. This regulation brings critical changes for payers, with new compliance deadlines and technical requirements. Ready to tackle CMS-0057? Don't go it alone. Connect with Kendra Obrist or Brian Dwyer for personalized guidance and strategies to ensure your organization has a comprehensive strategy to ensure success. Reach out today to start navigating these changes with confidence!

13

The escalating issue of overall affordability in the healthcare system demands immediate attention. It is alarming that $1.5 trillion is allocated to administrative processes, with a substantial $260 billion attributed to the lack of transparency. Moreover, the fact that 86% of denials are preventable underscores the urgency for prompt action. Rather than the back-and-forth, we can prioritize addressing preventable denials. By leveraging proven behavioral science approaches to behavior modifications and change resistance, adopting an upstream approach, enhancing transparency, and eliminating preventable coding errors, we can potentially achieve positive outcomes and optimize the efficiency of the healthcare system. https://lnkd.in/eRnimbRd #healthcareinnovation ##healthtech #valuebasedcare #affordability #access #comprehensivedenialprevention #codingerrors #denialprevention

5

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

16

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

8

Downside risk for 350K covered members in Pittsburgh including those funded through #MedicareAdvantage, #Medicaid, #ObamaCare exchanges and #Commercial arrangements: #AlleghenyHealthNetwork (the provider) and #Highmark (the insurer) partner for success and show how it's done. Secret Sauce: Invest in #data-sharing tools plus nurturing #collaboration plus attacking the whole system (no baby-steps) plus engaging #patients plus drilling down on #quality. "it’s just another step on a continual journey to high-value, high-quality care. And increasingly, it’s a journey that #insurers and #providers will need to take in tandem as they come together to build a contractual model that doesn’t benefit one party or the other, but the people and communities they serve."

3

A great piece on the battle royale of #lifeinsurance and #financialadvisors and the Biden Administration over misleading #seniors for profit. The similarities here with abuses by #brokers and sales agents for #MedicareAdvantage are clear. “To protect older Americans’ life savings, President Joe Biden pledged in October to crack down on financial advisers who recommend #investments just because they pay higher #commissions. Then the #insurance industry got to work. 
“Lobbying groups representing New York Life Insurance Company, Lincoln Financial Group, Prudential Financial and other companies first pushed back against the newly proposed regulations before suing to topple them entirely. Now the government’s latest attempt to protect retirees is in political and legal limbo, facing the possibility that it may never take effect.
 “It is the latest example of a pervasive pattern: As the Biden administration tries to impose new restrictions on powerful industries, those businesses successfully turn to Congress and the courts for a reprieve. This time, the resulting clash centers on a basic question: Should federal law require more financial professionals to put retirees’ needs above all else — including their own paychecks — when they offer advice about how to invest?” A post-Chevron ruling at the #SupremeCourt seems likely. I expect #healthinsurance sales lobbyists to steal a page from this playbook against tough new MA regulations. https://lnkd.in/ePaBWEsB

11

1 Comment

📉 Elevance Health 3Q Earnings Recap: What Went Wrong? On October 17, Elevance Health reported its Q3 earnings, and the market reaction was swift—a 15% drop. The major culprit? A soaring Medical Loss Ratio (MLR) of 89.5%, up by 270 basis points from Q3 2023. The primary driver: Medicaid reimbursement misalignment, which has burdened payors across the board. The mismanagement of Medicaid redeterminations led to a per-member cost spike, which wasn’t matched by state reimbursement increases, pushing Wall Street into a broad sell-off of the “Big Six Payors.” 📉 Despite these challenges, Elevance’s revenue still grew by 5%, reaching $44.7B. Their membership remains steady at 45.8 million, with ACA and commercial gains offsetting Medicaid losses. Key Takeaways from the Earnings Call and 10-Q: • Medicare Advantage: Conservative bids for open enrollment amid CMS rate cuts. While Elevance improved Medicare Star ratings on 60% of measures, one of their 4-star plans narrowly missed CMS’s cut-off, costing them. • Medicaid: CFO Mark Kaye noted cost-per-member increases as high as 3-5x in some states, driven by a shift to sicker populations post-redeterminations. With half of the state rate adjustments set for January, there’s hope that reimbursement alignment will improve. • Carelon’s Growth: Low 20% growth anticipated as Carelon expands its specialty drug offerings, with recent acquisitions of BioPlus, Paragon, and Kroger Specialty. Their latest acquisition of Carebridge further solidifies Carelon’s role in Elevance’s growth strategy. The specialty drug assets will be driving new value for larger employers they seem to attract. • AI Investments: Elevance is pursuing AI to streamline internal operations and enhance member experiences. This investment is set to mature through 2025, aiming to improve productivity and personalization. While Wall Street’s reaction may seem like an overreaction, the strategic groundwork Elevance has laid—especially in Carelon and specialty pharmacy—positions them for a potential rebound. Expect Carelon to become a key revenue driver as Elevance navigates the current Medicaid headwinds. For a deeper dive into the Elevance Health earnings for Q3 feel free to read and subscribe to my substack! #Healthcare

20

3 Comments

If you click on the link you will see a report called Expense Distribution. I know this report more than you can imagine. It's based on paid claims. It shows that for this plan half the members were essentially self-insured as individuals. If I was the CEO of this company, you can bet I would make sure the rates my employees were paying for their own care were reasonable. If not, I'd be personally liable. #deerhold #ContractRateExplorer #MRFInsights

9

2 Comments