Fran Soistman

"CVS Health blamed the declines on higher usage and more costly claims related to its Medicare Advantage policies." More dominos falling... It's simple math Hospital costs keep accelerating Utilization due to sickness keeps increasing Yet rimbursement via government programs is going DOWN! This is business 101 And you don't need a crystal ball to see what's coming... #Healthcare #business #hr #benefits #ceo #insurance #Medicare

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Medicare Advantage is on the rise! Inpatient hospital days for Advantage enrollees grew from 13% to 23% between 2015 and 2022. Nearly half of all Medicare inpatient days are now Advantage-related. Growth is fastest in non-metropolitan areas. #MedicareAdvantage #HealthTrends

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Health equity in healthcare is a critical focus area that has seen greater emphasis in recent years. It's exciting to witness examples of programs and advances emerging to achieve the bold goal of health for all. #HealthEquity #Healthcare #HealthForAll

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Unlocking the full potential of Artificial Intelligence in healthcare means addressing hurdles like physician buy-in, integration into workflows, and cost considerations. Insights from Baptist Health Medical Group's Dr. Oliver shed light on overcoming these challenges to drive value-based care forward. #Healthcare #ValueBasedCare https://buff.ly/3WwXsLY

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Basic “explainer” on Risk Adjustment and a RAF conundrum. This article from The Commonwealth Fund does a good job of providing the basics of risk adjustment. It also calls out one of the major contributors to patient outcomes that isn’t captured in traditional risk models, the Social Determinants of Health (SDoH). They do a great job on this, so I won’t summarize it here. However, I think there is another factor that isn’t captured that I wanted to discuss and would appreciate some different perspectives. I’d love to get some thoughts on the following. Maybe I am simply being pedantic. The issue not mentioned in the article that I think current methodologies of risk adjustment miss is duration and management of disease. A patient with a new diagnosis of diabetes, for example, now has an elevated risk of numerous complications over their lifetime. However, that risk in year 1 after the initial diagnosis is much lower than the risk at year 10. Current risk models don’t take that escalating risk into consideration, keeping the risk adjustment fixed regardless of duration of underlying diagnosis. In addition, there are few scenarios that will impact me differently as the provider: 1) Management of this patient’s diabetes has been poor for the prior 9 years and now my group “inherits” this patient at year 10. 2) My team has helped this patient manage their diabetes very well for the past 9 years. 3) For the past 9 years, this patient’s prior group had managed their diabetes well but they have now switched into my group. As noted above, in scenario 1, that “new” diagnosis of diabetes severely underestimates this patient’s risk of needing expensive resources this upcoming year. I will be adversely impacted from something that is clinically obvious (duration of a disease increases risks) but which is not captured in the current data. To go one step farther, in frameworks 2 and 3, there is a gap between what the patient’s risk would have been without 9 years of great care and what it likely is now. However, there is no recognition of this work. That is to say, if the patient switched to a group that did a terrible job of managing diabetes, they’d receive the same risk adjustment in year 10 as my group would receive after all of our time, effort and resources had been dedicated to keeping this patient healthy. If the patient’s healthcare needs in year 10 are low because of our efforts, shouldn’t we receive more credit than a group that simply gets attribution? And, what about the prior group? How are (were?) their efforts recognized? Please share your thoughts in the comments.

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We received the attached article about the recent conflict between the HCA Hospital System and United Healthcare. The article, titled “HCA and United Healthcare reach agreement before coverage interruption in 4 states” was written by Lynn Varacalli Cavanaugh. If United and HCA hadn’t reached an agreement, policyholders in Texas, Colorado, South Carolina and New Hampshire would not have the same ongoing access and benefits that they had signed up for with United Healthcare. This type of disruption has not been confined to this isolated incident. We have seen this issue raise its head with Cigna and Blue Cross as well recently. In some of those situations, agreements had not been reached, leaving policyholders on the outside looking in. When these conflicts arise, it confirms my belief that this whole medical network structure is really more of a problem I our escalating health costs rather than a solution. How much was spent on lawyers doing the HCA and UHC conflict? If they hadn’t reached this agreement, how disruptive to policyholder’s medical plans could this have been? When agreements aren’t reached, policyholders still have to pay the same premiums every month, even though they don’t have the same access to the same doctors at the same price. Well, I have a suggestion. Why don’t our wonderful political leaders consider legislation that would impose daily fines of let’s say $100,000 to $1,000,000 for every day that policyholders are disrupted. Maybe that would put a stop to whatever practices lead to these conflicts. When they do occur, the carriers still get their premiums; the administrators and lawyers still get paid; the medical providers still get paid; but the policyholders who continue to pay the premiums still have to pay. The inequity in this is mind blowing and it really should get us angry that we, the policyholders, are the one’s most affected. At one point, medical networks may have been a good idea to control costs. However, when you really think about it, networks are nothing more than an artificial, intra-industry, micro version of wage and price controls. They have not been effective in holding costs down. However, they seem to be a factor in driving costs up. In my view, I am quite sure that the United Healthcare stockholders are perfectly happy with these network interferences as long as their bottom line rewards them with dividends and rising stock prices. However, I am certain that policyholders of United Healthcare who are impacted by these conflicts are not quite as happy when these conflicts arise. What do you think?

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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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The #MedicareAdvantage landscape is set for a significant shake-up in 2025 due to a confluence of factors. These changes have led several insurers to pull back, resulting in product closures and market exits that will affect over 1.8 million members. This new #OWHealth article examines the impact on the Medicare Advantage market and explains why it is crucial for insurers to reassess their strategies to ensure long-term viability. Read more here > https://owy.mn/3Y6tjnA

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Let's explore the critical factors shaping the landscape of MA STARs ratings in the upcoming year with a focus on quality and excellence. 🌟💊 🏥 🩺 2025 Medicare Advantage and Part D Star Ratings: Key Metrics for Providers ⭐ 💹 https://lnkd.in/e7aZkZvC Introduction to Star Ratings: -> Star Ratings measure the quality of health and prescription drug services for Medicare enrollees. -> CMS aims to improve the quality of Medicare Advantage (MA) and Part D programs. Significant Metrics for 2025: - Part C Plan All-Cause Readmissions -> Increased weight from 1 to 3, emphasizing the importance of reducing hospital readmissions for comprehensive care. - Tukey Outlier Deletion: -> Applied to improve the accuracy of measure-level cut points used to determine star ratings. -> Aims to minimize the influence of extreme outliers on performance measures. Performance Measurement: -> Contracts rated on up to 40 unique quality measures for MA-PD contracts and 12 for PDP contracts. -> Cut Points: Established thresholds to determine rating (1-5 stars) based on performance. Year-over-Year Rating Trends: -> Changes in measure-level cut points for 2025 reflect a shift towards higher performance standards. Example Metrics: -> Breast Cancer Screening (Part C) -> Average star rating decreased from 3.9 (2022) to 3.4 (2025). -> Colorectal Cancer Screening (Part C) -> Similar downward trend, indicating a need for improvement in preventive care measures. Impact of Contract Experience: -> Contracts with 10+ years in the program tend to achieve higher star ratings, highlighting the importance of experience and stability in delivering quality care. Tax Status Influence: -> Non-profit organizations typically achieve higher ratings (50% earning 4+ stars) compared to for-profit counterparts (36%). Consistency in High Performance: -> Contracts consistently rated with high performance icons (5 stars) maintain strong service delivery, with many having special needs plans (D-SNP). Conclusion: Providers should focus on improving metrics like all-cause readmissions, refining methodologies for accurate performance measurement, and maintaining consistent care quality to achieve higher star ratings in 2025 and beyond.

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Payers move to ditch deductibles The trend of health insurers launching products without traditional deductibles is accelerating, reflecting a broader shift toward consumer-centric healthcare. As member expectations evolve, insurers are increasingly offering plans that emphasize transparency and simplicity. #employeebenefits #newtrends #helpingpeople

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Healthcare providers face immense challenges balancing patient care and administrative tasks, leading to burnout. To address this, we need clinician-led leadership teams, streamlined access to patient data, and robust staffing solutions. Collaboration is key to delivering effective value-based care. #Healthcare #ValueBasedCare https://buff.ly/4d7QdBe

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Top 10 Things we can do to fix health care in the US - #8 Force insurance companies to sell to everyone or no-one. Health insurance companies are allowed to cherry pick the products they sell and the people they choose to sell them to. They can decide to not sell individual plans or not sell on the ACA exchanges. They can decide to not to sell to a certain industry. All of this lowers competition in a market place that is already highly concentrated. Now, I am a free market economist so in most industries this isn't a problem. However, when in comes to something like health insurance you start to get into the area of a public good. Think electric power. This form of discrimination (let's face it, most of the people on the ACA exchanges are lower income individuals) is harmful and it drives up costs and prices. So, here is my idea. If an insurance company wants to sell the profitable business, you know large employer, white collar industries, then they should be forced to also offer to small groups, individuals and on the ACA exchanges. Imagine how we would feel if your local grocery store had a person at the front of the store turning away people because they didn't look very good or if they said we don't want to accept food stamps because we don't like poor people. If someone wants to buy insurance and your company sells insurance then you should have to sell your product to them. This should help create more competition in the insurance market. https://lnkd.in/ecWbB2Fu

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Medicare Advantage unrest, Change Healthcare fallout and more big takeaways from insurers’ Q1 https://lnkd.in/eyg48k7e via Healthcare Dive #MedicareAdvantage #ChangeHealthcare #Cybersecurity #CMS #Medicaid

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I always appreciate Sam’s posts as they are thoughtful and concise. What really upsets me about the letter from these Senators to CMS is how callously the word “brokers” is used in the paragraph below: —- “with more than $6 billion in MA plan spending on commissions and marketing, brokers are under pressure to churn through appointments as quickly as possible. The demand for volume means brokers are under pressure to focus on only a few plans and may not examine the full range of options” —- Let me be clear, the large majority of brokers are NOT under pressure to churn. We do NOT only examine a few plans. The actions being described are that of a call center. And therein lies the problem. The fact that our government officials clearly do not understand the difference between a call center and a broker is a tremendous problem. If we cannot educate our government officials regarding the difference, we are all going to be out of a career. Plain and simple. Pinnacle Financial Services, Inc. Tyler Insurance Group Angela Palo Kevin Shields Nick Palo NABIP Laura Tyler Andrew Horn, MHA Caroline Horn Eric Price, MBA Christopher Raon

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STAR ratings are out. CMS continues to grade on a tough curve by raising the cut points and seeing the average STAR rating decline. The 2026 bid cycle is about to begin and once again MAOs will need to carefully look at benefits and their MLR. We can help with that! Medicare Advantage star ratings dip slightly once again in 2025 (fiercehealthcare.com) #medicareadvantage #Healthworksai #ProductIntel

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The future of Medicare Advantage is evolving fast, with major shifts affecting payers. Demographic changes, regulations, and member preferences are shaping the landscape. Payers need to adapt quickly. Read more in this insightful article. #Medicare #Healthcare

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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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With the healthcare delivery system in the US facing various challenges, the evaluation of healthcare consolidation on Capitol Hill is crucial. The scrutiny reflects good intentions, but there are concerns about whether the underlying issues will be addressed thoughtfully. Partisan politics could impact care delivery and healthcare professionals. It's essential to monitor this trend closely as its implications may be more far-reaching than anticipated. #healthcare #healthcareconsolidation #enterpriseriskmanagement

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