Joel Kempner

Interesting trends in the insurance industry

3

2 Comments

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

The cost of healthcare is on the rise, and so are the types of ailments. With increasing pollution, stressful lifestyles, and the popularity of junk food, diseases like diabetes, cholesterol, kidney and liver issues, and cardiac disorders are rampant. Surgeries, organ transplants, chemotherapy, and other medical procedures can leave a massive dent in your pocket. Medical emergencies can strike at any moment! Are you sufficiently equipped to meet the expenses? Visit Bay Area Health Insurance at LocalBizNetwork’s business page, the one-stop platform for all your insurance needs. https://lnkd.in/gy5yKXA . . . #HealthIsWealth #HealthAndWellness #HealthyHabits #HealthyChoices #HealthyLiving #HealthFreak #BeSafeEveryone #Covered #StudentHealthInsurancePlans #HealthInsuranceForInternationalStudents #InsuranceAgentLife #InsuranceAgentinUSA #InsuranceAgentByDay #InsuranceAgentLifestyle #HealthInsuranceMarketplace

1

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

Uninsured Rate Rises To 8.2% Healthcare Dive (8/7, Pifer) reports, “The percentage of Americans without health insurance grew to 8.2% in the first quarter of this year as states culling their Medicaid rolls reversed a once-record low uninsurance rate, according to new Centers for Disease Control and Prevention data.” Specifically, “an additional 1.6 million people lost coverage from January through March, bringing total Americans without insurance to 27.1 million, the CDC said.” Many Americans who are losing coverage “have turned to the Affordable Care Act exchanges for insurance, causing enrollment in the plans to swell to historic highs this year.” The rate of uninsured Americans “could hit 8.9% over the next decade because of Medicaid unwinding and the loss of the subsidies, according to recent projections from the Congressional Budget Office.” #cdc #uninsured #medicaid

2

The California Office of Health Care Affordability has recently approved a requirement that all healthcare providers report their annual operating expenses. If those expenses increase more than 3.5% (eventually lowering to 3%) in a year, that provider will be fined, ironically increasing their expenses. The state claims this regulation is aimed at protecting consumers from high healthcare costs. This is the same State of California that recently raised all healthcare workers' minimum wage to $25 per hour (up from $15.50).  For our health system, that results in a $30 million annual cost increase and a 7.5% increase in our salary costs. This is also the same state that passed an unfunded mandate that requires our system to spend about $1 billion to replace a hospital building that they feel is at risk from damage in an earthquake. And it’s also the same state that increased the cap on medical malpractice lawsuits…and has authorized utility companies to raise their rates 15% per year.  So, with all of these unfunded requirements and policies that dramatically increase providers' costs beyond their control, how exactly does the state suggest that we limit our expense growth to 3% per year?  Healthcare cost inflation has already been running at more than 5% before any of these new requirements took effect. Perhaps if California wants to get serious about reducing the cost of healthcare they might look at the managed care plans. The most recent data I could find from the California Health Care Foundation indicates that California managed care companies made $222 billion in 2020. What direct value did these companies provide to the health of our communities? Meanwhile, hospitals and physicians are providing direct patient care and struggling to survive- especially systems like Kaweah Health that serve a high percentage of Medi-Cal (Medicaid) and Medicare patients.  On a side note, the governor did sign a new managed care organization tax into law this year, which was promised to increase Medi-Cal reimbursements to providers, but all signs suggest that he now intends to use those proceeds (nearly $7 billion) to fill holes in his budget's general fund deficit and will not be providing Medi-Cal rate increases. I would humbly suggest that if the state is genuinely concerned about its residents' cost of living, they might look at the state income tax (highest in the country), its gas prices (highest in the country), the essentially unaffordable housing costs, or countless other factors that will have a larger impact on individuals' pockets than beating up healthcare providers with laws that don't make any sense. #hospitals #california #healthcare

106

19 Comments

"Medicare continues evolving." A recent article highlights upcoming changes to the Medicare Advantage program. As one who has witnessed dramatic shifts firsthand, I have perspective to share. Healthcare is progressively moving off fee-for-service. Insurers innovating new care models will dominate future markets. 🏥 Focus on wellness, not just sickness. Those improving outcomes while lowering costs gain clear competitive edge. Regulatory winds blow innovation. New pilots test expanded benefits nationally. But local knowledge keys territorial success. 🧭 Partnerships unlocking community resources strengthen tailored solutions. Personal touch augments high-tech care. What's your strategic view? How does your vision align with trends? Change happens fast - stay cognizant of customer need. Your ability to adapt will determine disruptor or disrupted. How might we construct tomorrow's more accessible, preventative-focused healthcare...together? Collaborating on solutions better serves patients during this transition. I'm all ears to new perspectives... #ThomasGraceBizSolutions #StrategicConsulting #BusinessOptimization #GrowthStrategies #OperationalExcellence #LeadershipDevelopment #InnovationSolutions #PerformanceImprovement #StrategicAdvisory #BusinessSuccess #ManagementConsulting #CustomConsulting #ExpertAdvice #BusinessTransformation #SolutionsDriven

1

1 Comment

State of Medicare Advantage 2024 Report was released by Better Medicare Alliance. The #MedicareAdvantage population is increasingly diverse and more complex. Today’s #MedicareAdvantage beneficiaries have higher rates of #clinical and #socialriskfactors than those in Fee-for-Service Medicare. More beneficiaries in Medicare Advantage are #lowincome, identify as a #racial and #ethnic #minority, and have more #chronicconditions. #Socialdeterminantsofhealth is here to stay. For a long time. We need to continue to get better to solve and provide solutions that help address SDOH. One day at a time. 1. #MedicareAdvantage enrollment has doubled over the last decade. 2. 33.8 million seniors and people with disabilities choose #MedicareAdvantage, or 55% of the #Medicare population 3. Enrollment in #SpecialNeedsPlans increased 14% between 2023 and 2024 4. 40% of all eligible #Medicare beneficiaries in rural counties are enrolled in #MedicareAdvantage, almost four times the share in 2010 5. 30.6% of #MedicareAdvantage beneficiaries identify as Black, Latino, or Asian, compared to 18.4% in #FeeforService #Medicare 6. #MedicareAdvantage access is nearly universal, with 99.7% of #Medicare beneficiaries having access to a #MedicareAdvantage plan 7. Over 98% of #MedicareAdvantage beneficiaries are enrolled in an #MAPD plan, which is a #MedicareAdvantage plan that includes #prescriptiondrugcoverage 8. 99% of beneficiaries have access to a $0 premium MA-PD plan 9. 99% of #MedicareAdvantage plans offer at least one #supplementalbenefit 10. #MedicareAdvantage beneficiaries report spending on average $2,541 less on out-of-pocket costs and #premiums annually than those in #FeeforService #Medicare 11. The average #MedicareAdvantage monthly premium is $18.50 in 2024 12. #MedicareAdvantage provides $59.9 billion annually in additional value to beneficiaries and the federal government 13. #MedicareAdvantage beneficiaries with certain #chronicconditions, including #diabetes, #hyperlipidemia, and #hypertension, have lower rates of inpatient utilization and emergency room visits compared to Fee-for-Service beneficiaries 14. #MedicareAdvantage beneficiaries with #prediabetes who develop #type2diabetes are diagnosed nearly 5 months earlier on average than similar Fee-for-Service beneficiaries 15. #MedicareAdvantage beneficiaries with #chronicdiabetes are more likely than Fee-for-Service beneficiaries to receive #preventativecare 16. 95% of #MedicareAdvantage beneficiaries report being satisfied with their health care quality Centers for Medicare & Medicaid Services Better Medicare Alliance

27

3 Comments

🎬 Providence vs. Aetna: The Battle Over Reimbursement 💥 Another health system is locked in a dispute with an insurance carrier. But is this battle justified? 📰 According to The Seattle Times, nearly 35,000 Providence patients with Aetna insurance may lose coverage after contract disputes escalated. Providence’s CFO pointed out that rising costs in labor, supplies, and drugs are making their multi-year contract unsustainable. But what do the numbers say? 💡 Using Payerset’s Rate Explorer, we dove into Aetna's price transparency data—specifically focusing on hospitals in King, Snohomish, and Pierce counties. Let’s break it down: ✅ Providence ranks 7th in reimbursement across 152 DRGs—just ahead of UW, Overlake, and Government hospitals. ✅ Swedish tops the list in reimbursement rates in the region. ✅ Providence’s argument for higher rates seems valid. Check out the video where I take you through the analysis! 📊🔍 #pricetransparency #hospitalreimbursement #Providence #Aetna #Payerset #RateExplorer

5

1 Comment

Awesome work Payerset, it's amazing to see the immediate insights from diving into the available data. Like everything in healthcare It's a slow evolution, but we're starting to see the veil lift on the underlying costs buried in the system that impact all of us. With the demand for transparency throughout the system, the spotlight on PBMs and Rx contract rates this space is just starting to heat up.

1

This analyzes and illustrates what I mention in a recent post regarding physician pay cuts each year. One of the few industries that cannot increase its charges to effectively combat inflation/erosion.

1

In cased you missed it, check out our webinar highlighting many of the biggest considerations when planning for healthcare in retirement. Many people are asking the same questions: When do I need to sign up for Medicare? What are the various Medicare provisions? What are the differences between Parts A, B, C, D, and even G? Watch to see if some of your questions are answered! #healthcareinretirement #medicare #retirementplanning #healthcare https://ow.ly/Cxkw50SB2W0

3

📉 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

Today’s healthcare insurance news: 📅 New Limits on Short-Term Health Insurance Plans Coming Sept. 1 ⏳ Starting Sept. 1, a new federal rule will limit short-term health insurance plans to just four months (including renewals). This change is a significant shift from the current duration limits, affecting many consumers nationwide. Here's what you need to know: 1.    New Duration Limits: The rule caps initial terms at 3 months, with a total duration of 4 months, including renewals. After the policy expires, you can’t purchase another short-term plan from the same #insurer for 12 months. This is a big change from the previous 36-month limit. 2.    State-Specific Impact: While the rule is stricter than current limits in most states, it won’t affect states like Delaware, Maryland, Oregon, and 14 others where short-term plans are either banned or already limited. However, states like Florida, Texas, and Pennsylvania will see significant changes. 3.    Plan Ahead: If you're currently on a short-term plan, or planning to enroll, you can still buy a plan before Sept. 1 and potentially keep it through the end of the year. Be sure to prepare for the upcoming Open Enrollment period starting Nov. 1, to transition to an ACA-compliant plan for 2025. This new rule is designed to ensure short-term plans are used for brief coverage gaps, but it’s crucial to plan ahead to avoid any coverage gaps. 🛡️ #HealthInsurance #InsuranceChanges #HealthcareReform #OpenEnrollment #HealthCoverage #ShortTermPlans #InsuranceTips #ACA #Healthcare #SBMU #MCG #SBM101 https://lnkd.in/ekCy4Brx

3

The 8/15 Healthcare Labyrinth Blog is now live. Click below to read. There was a great deal of health plan news the past month, so I decided to do an insurer news roundup blog. Of course, you can find all the details on these topics in my newsfeeds, blogs, and podcasts on my website. #healthcare #healthcarereform #healthinsurance The Healthcare Labyrinth Marc S. Ryan 🇺🇦 https://lnkd.in/gcDdbmAm

1

Great Report by Kodiak. As we continue to navigate the complexities of healthcare payments, it's clear that we need to address the growing challenge of initial Request for Information (RFI) claim denials. These denials are becoming more frequent, and they’re costing both providers and payers more time and money than ever before. Since 2023, there has been a steady increase in these denials, which require providers to submit additional information before claims can even be reviewed. What does that mean in layman terms? RFI Claim Denial Rate: The rate of initial RFI claim denials rose from 3.51% in 2022 to 3.82% by May 2024. Administrative Costs: The cost of responding to these denials reached nearly $2 billion in the first five months of 2024, which, if extrapolated, could total around $4.6 billion for the year. Inpatient vs. Outpatient: Inpatient care is hit hardest, with denial rates climbing to 4.54% for inpatient services in early 2024, compared to 2.96% for outpatient. Key Offenders: Traditional Medicaid and commercial payors are the main drivers of these denials, with initial denial rates of 9.23% and 8.14%, respectively, for inpatient claims. | Metric                                | 2022| 2023 | 2024-May) | | RFI Claim Denial Rate       | 3.51%  | 3.68%| 3.82% | | Administrative Cost         | $1.5B    | $1.7B | $1.9B| | Inpatient Denial Rate        | 4.20%  | 4.33%| 4.54%| | Outpatient Denial Rate     | 2.69%  | 2.90%| 2.96%| | Medicaid Denial (IP)                                   | 9.23%| | Commercial Denial (IP)                                | 8.14%| These stats highlight the critical need for implementing advanced payment integrity software. By adopting next-generation tools that can accurately identify which claims need review, with probability of successful outcomes in advance (DRG, IBR's Coding) and why, we can significantly reduce the administrative burden and keep our focus on what truly matters—providing quality care without unnecessary delays. AMS (Advanced Medical Strategies)David Cardelle RPh John-Michael Loke https://lnkd.in/eBhVD3Fu

11

3 Comments

😳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

Navigating health insurance shouldn't be a maze. Christine Cooper, CEO, aequum was featured in @MedicalEconomics discussing how Transparent Explanations of Benefits (EOBs) are key to reducing patient confusion and improving the provider experience. With the No Surprises Act and Advanced EOBs, we're moving towards clarity, enabling better patient-provider discussions and trust. Let's advocate for clearer health coverage processes and a more equitable system for all. Read the full article here: https://bit.ly/3SrwK6w #HealthInsurance #PatientCare #EOBTransparency #HealthcareTransparency #InsuranceEducation #PatientAdvocacy #MedicalBilling #HealthcareReform #HealthEquity #NoSurprisesAct #HealthcareCommunication #HealthLiteracy #PatientExperience

1