Christopher Merkel

Price Transparency in Indiana for 2 Large Health Systems: IU Health & Parkview Focus is ER visits comparing Anthem PPO and UHC PPO contracted rates benchmarking to Medicare Adjusted Rates CPT 99283 Anthem Range % of Medicare: 366%-520% UHC Range % of Medicare: 410%-1,119% CPT 99284 Anthem Range % of Medicare: 639%-794% UHC Range % of Medicare: 631%-1,011% CPT 99285 Anthem Range % of Medicare: 440%-551% UHC Range % of Medicare: 490%-727% Additional Insight: CPT codes 99285, 99284, and 9923 generated $339,301,095 in billed charges through July 2024 YTD for IU Health System All three CPT codes were in the top 13 of utilization and generated the most in billed charges #employeebenefits #pricetransparency

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📰 White paper release: Stars in Retrograde – Decoding the 2025 Decline The 2025 Medicare Advantage Star Ratings brought significant changes to the quality landscape, challenging health plans to rethink their strategies. Our latest Milliman white paper authored by Hayley Rogers and Matthew Smith dives into key factors affecting this year’s decline, including: ⭐ Sharp decline in Quality Bonus Payments (QBP): The member-weighted average fell below 3.5% for the first time, impacting revenue. See Figure 1 for number of contracts by change, with more contracts negatively impacted. ⭐ Rising impact of Social Risk Factors (SRFs): Plans with high SRFs saw more substantial rating drops, highlighting the need for targeted quality improvements. ⭐ Legal landscape: Multiple Medicare Advantage organizations are challenging the Star Rating methodology, including issues with transparency and data reliability. ⭐ Market restructuring: Fewer new entrants and increased contract consolidations may signal further Star Rating declines, with profound implications for future quality initiatives. Learn more about these industry-wide shifts and what they mean for healthcare policy and strategy. 📄 Read the full white paper to prepare your organization for what's next. Link in comments

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At Freightliner of Grand Rapids, finding the best health plan for employees while minimizing out-of-pocket expenses is a top priority. By partnering with Sympl Benefits, the company has achieved significant savings without compromising on quality. Want to learn more about how Freightliner of Grand Rapids is improving their healthcare approach and prioritizing employee well-being? Watch the full video to discover the impact of Sympl Benefits' solutions and see how your organization can benefit from a similar strategy. https://lnkd.in/gVJbyRY9 #EmployeeHealthcare #CostSavings #InnovativeSolutions #SymplBenefits

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Since when did health insurance companies received thier “MD’s”? This is a long article but a fascinating read. We wonder why healthcare costs continue to escalate and premiums are unaffordable? Well, when you have insurance companies being able to add diagnosis’s and conditions to a members healthcare record which allows them to receive more money for treatment - oh and by the way these members don’t have these illnesses…rocket science not needed here! While this seems like its a “Medicare” problem - it’s happening everywhere. In your commercial and group health plan too. Providers trying to charge patients for negotiated discounts, millions of dollars in fake billings, pharmacy rebates being used to increase insurance company profits versus going back to the companies footing these bills or the patients using the drugs. Insurance companies and the organizations that own physician groups and hospitals have figured out how to game the system to increase profits - not deliver better health outcomes. I do believe that there are a lot of great professionals in the medical field that honestly want to improve the lives of people that they treat - they unfortunately now mostly work for companies that don’t really care much about that.

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Who: Ben Krambeck Where: West Des Moines, IA What: A 60 Minutes-style Interview Why: To share the powerful story of ClaimDOC We hope you enjoy this journalistic look at how ClaimDOC came to be. #rbp #referencebased #medicalpricing #medicalbilling #healthinsurance #insurance #claimdoc #selffunded

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This week's Medicare Market Insights deep dive looked at the shift in Stars, Premiums, Drug Deductibles and MOOPs. For plans that are renewing in 2025, how are these components changing? Here's a summary. -Star Rating Down -Premiums Level/Down -Drug Deductibles Up -MOOP Mixed, though largely up Go here for the full deep dive -> https://lnkd.in/gs_wURZG __ P.S.- don't forget to subscribe!

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Use case on cost variability within the LA market. Below is the Average PPO Rate for an MRI of your low back. This is comparing 7 LA hospitals contracted/allowed amount average PPO rates across Aetna, Anthem, Cigna, and UHC with Medicare as the benchmark. Huge variances over Medicare and displays why employers need to gain access to this information and take action to steer members away from hospitals that are not a fair market price. Unfortunately, LA is not a unique city as there is cost and quality variability by facility, by provider, by procedure code across all states and all networks. Good news is that there are proven solutions to reduce cost, improve quality of care, decrease or eliminate members out-of-pocket cost, and enhance benefit offerings. If you do what you’ve always done, you’ll get what you’ve always gotten.

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The discussion surrounding weight loss management and obesity is constantly evolving with an increased focus on prescription drugs. In this SOA podcast, Jackie Lee and I discuss GLP-1s and why actuaries and other healthcare professionals need to continuously monitor their growth.

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This piece by Modern Healthcare is spot on (link in comments), and well worth the quick read for any stakeholder in the #medicareadvantage space to ensure you are considering the risks new membership may bring. 📉 We know that many of the national #medicareadvantage organizations pulled out of markets for 2025. They likely were doing so because the areas were under performing or because they didn’t see a path to profitability. 💲 In service areas where MAOs retained plans, many nationals are also not paying commissions in some form or another – and the reason for that is after seeing what competitors are offering, they are worried the membership they may attract will be “poor risks” or that they will be unable to manage these members in the long-term. 👵 For smaller, regional, health insurers who remain in these service areas, they have an unprecedented opportunity to expand market share due to the nationals plan terminations or SARs. ❓ However, smaller, regional, MAOs should stop to question – what does this really mean for us? It will be critically important to understand the new membership MAOs are taking on in 2025 – the characteristics each member brings and if your organization is prepared to manage those members. This may or may not have been something #medicareadvantage organizations planned for in their 2025 bid – but as you are going into 2026 bids, it will be especially important to measure and adjust your 2024 population baseline (used in the 2026 bids) for the new membership you have taken on. If you have any questions on better understanding this dynamic, please do not hesitate to reach out!

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A case for the value of Medicare Advantage. Key takeaways from the study: 1) Low Value Services (LVS) provide little or no benefits to patients, and in some cases, may even cause harm. 2) In a study of 6M Medicare beneficiaries, it was found that Medicare Advantage enrollees experience fewer unnecessary medical services compared to traditional Medicare enrollees. https://lnkd.in/eVFZss7r As the 2025 Medicare AEP rapidly comes to a close, it's important to recognize the value of the plan you recommend to your client. At Priority Health we always focus on value-based care to ensure our members receive the best care to lead to better health outcomes. This is something you can count on when you enroll your clients with a Priority Health Medicare Advantage plan. Good luck closing out a busy AEP! #medicareadvantage

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With the struggles that many health plans are facing in Medicare Advantage, understanding care management and where the best place to focus resources and hit the gas is of utmost importance. With that in mind, I'll be brushing up on this oldie but goodie from the SOA in the early 2000s and will be sharing my thoughts as I go. https://lnkd.in/eZWnVS8q #Medicare #CareManagement #Wakely

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GLP-1's and Medicare. This week's Medicare Market Insights deep dive by Andrew Ryba takes a look at GLP-1s. What are they? Why are they always in the news? How does Medicare currently handle them? Don't miss out. Read the deep dive here -> https://lnkd.in/gipRAVSG P.S. -> don't forget to subscribe!

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We recently posted our view that medical networks are more of an interference and barrier to needed medical services than a means to reduce costs to employer sponsored group health plans. Evidently, this extends beyond group plans and reaches into the ACA market plans as much, if not more. We recently received an article from an online information source titled, “Size of physician networks varies widely among ACA Marketplace plans, study finds” written by Alan Goforth. The gist of the article reported that these network-based plans only have policyholders access to a modest percentage of doctors in their respective communities. The article reported that “on average, more than one quarter of actively practicing physicians were not included in any marketplace plan network.” The question I raise is WHY NOT? People buy medical insurance to have a pathway to healthcare when needed. How have we allowed ourselves to evolve to a system whereby when we buy insurance, it operates like an exclusive boys and girls club of practicing doctors? How did we evolve to this point whereby we have ceded control of our medical funding resources to third parties who decide not only what we can have with our money, but who we are allowed to get what we need from? It seems to me that the more gimmicks that third parties conceive and market to the public as the latest and greatest cost control devise; the more expensive health care becomes and the narrower the choices as to where we can go to get it are becoming. We continue to advocate that groups have to take back control of the funding that represents claims reserves and be in stronger positions to determine what you can have and where you can go. Whomever controls the money, controls the system. In our view, employers must flip the equation as to who controls the funding for claims. When we give up control of our funds, the system controls us! When we take control of these funds, we control the system! Our groups control their claims reserves in order to minimize the above-mentioned problems. Let us show you how! To learn more, contact us. The Ecchic Group 314-997-8865 www.ecchic.com 11704 Lackland Industrial Drive St. Louis, MO 63146 Article: https://lnkd.in/g-qnSrpA

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The new ACO PC Flex program offers some potentially substantial financial upsides for MSSP ACOs. We discuss five key takeaways in a new paper: https://lnkd.in/gQeeJY8X

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📣 📣 📣 Centers for Medicare & Medicaid Services dropped the CY 2025 landscape files! 📣 📣 📣 https://lnkd.in/gMhye24W ❓ What questions does this answer? Post below so we can share learnings!

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Im sitting in the airport on my way back home from a whirlwind of a week and reflecting more on this care management paper series. One additional takeaway that i want to add from paper 4 is that many programs and interventions may promise significant savings based on clinical research or a focus group. While these results may be valid, it’s important to consider that there are decreasing marginal returns as you expand a program to a larger population. It’s critical to understand at what point expanding the program is no longer providing the desired returns. This is something that Wakely can help with. Check out our care management practice page or reach out to me with questions - https://lnkd.in/eqkUFkeA #Wakely #CareManagement

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Health care affordability is cited as a top concern by employees earning less than $100K. Nationally, salary-based contributions for health plan offerings is a growing strategy employers are using to help employees keep more of their paychecks. But our benefits benchmarking survey found only 9% of Midwest employers are offering this option. Download our Employee Health & Benefits Benchmarking report for insights on where your own benefits are leading – or lagging. #HealthCare #EmployeeBenefits

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This week we talk to Brad Johnson, and he shares insights from the Rand Hospital Study, which compares hospital payments from private insurers vs. Medicare. The study reveals a widening gap, with private plans paying an average of 2.5 times more than Medicare. This differential varies by state, with Iowa having one of the lowest at 1.84 times Medicare rates, while Georgia has the highest at 3.45 times. As hospital contracts come up for renegotiation post-COVID, medical inflation (currently around 8-8.5%) is expected to rise further. This raises concerns about the sustainability of the current system and the impact on employer health plans. Join the conversation: How do you think this growing payment gap can be addressed? #HealthcareEconomics #MedicareVsPrivateInsurance #HospitalPayments #EmployerHealthPlans Brad Johnson Chris Boling - PPACA

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This week we talk to Brad Johnson, and he shares insights from the Rand Hospital Study, which compares hospital payments from private insurers vs. Medicare. The study reveals a widening gap, with private plans paying an average of 2.5 times more than Medicare. This differential varies by state, with Iowa having one of the lowest at 1.84 times Medicare rates, while Georgia has the highest at 3.45 times. As hospital contracts come up for renegotiation post-COVID, medical inflation (currently around 8-8.5%) is expected to rise further. This raises concerns about the sustainability of the current system and the impact on employer health plans. Join the conversation: How do you think this growing payment gap can be addressed? #HealthcareEconomics #MedicareVsPrivateInsurance #HospitalPayments #EmployerHealthPlans

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