Jonathan Har-Even

Recently invited to share information on how provider contract discussions are approached. These conversations are generally kept private because we almost always reach an agreement, and we don’t want to cause unnecessary stress or confusion for our members. Please take a moment to view the video and review our latest provider contract updates at https://bit.ly/3XnkxRE

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The whole notion of “public trust” has become an oxymoronic notion, at least when it comes to issues surrounding Connecticut’s health insurance exchange Access Health Connecticut. A recent audit discovers numerous failures in leadership, administration and accountability that puts the privacy of participants at risk. “The audit, which studied the Exchange between the years of 2020 and 2021, found that the Exchange suffered 51 data breaches of clients’ personal information, one of which exposed 160 clients’ information, and three of which they failed to disclose to the Auditors and State Comptroller. These breaches occurred both through the Exchange itself, as well as five of its contractors, one of which incurred 14 data breaches. The audit noted that the Exchange is statutorily required to notify both the Auditors and State Comptroller of any security breaches, to which the Exchange pleaded ignorance.” In addition: “The audit found no list of Navigator program employees, who have access to client’s personal information, that had completed criminal background checks.” Further: ““A lack of internal controls increases the risk that clients receive improper health insurance coverage or are enrolled in programs they are not eligible for,” read the audit.” The piece goes on to describe a lack of accountability for expenditures and ineligible employee credit card expenditures. This is shameful behavior that potentially puts vulnerable citizens at risk. Taxpayers deserve and demand better. #accountability #ConnecticutGovernment #healthcare

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Learn more about the Medicare environment in 2024 from my FTI Consulting Healthcare Risk Management & Advisory colleagues Wayne Gibson, Anne Winter, and Krunal Patel during an Association for Community Affiliated Plans (ACAP) webinar on April 16. Insights will focus on considerations for entering the D-SNP market, impact of the Health Equity Index, impact to Model of Care, and Stars performance. Register here: https://lnkd.in/eEBUxANU #FTIHealthcare

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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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In the face of challenges in the insurance and pharmacy sector, CVS is taking decisive actions to navigate these hurdles, including store closures, leadership changes, and significant cost-cutting measures totaling $2 billion. Furthermore, CVS is innovating by testing new pharmacy designs that incorporate Oak Street Health primary-care centers for seniors, showcasing a commitment to adapting to evolving market dynamics. #InsuranceSector #PharmacyIndustry #CVSHealth

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Vertical integration in the health insurance industry pledges to streamline operations, yet when it comes to drug costs, the outcomes warrant closer scrutiny. The reality is third-party payers may not be capitalizing on potential savings. Major PBMs tout cost reduction and streamlined care; however, the opacity of pricing models raises questions. A candid discussion is essential on the real impact these integrations have on drug affordability, not just for consumers but for employers as well. #DrugCostTransparency #PharmacyBenefits #HealthcareEconomics

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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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Could this be a sign that vertical integration in healthcare will start to reverse course? The likes of UnitedHealth Group Aetna, a CVS Health Company and Cigna Healthcare have amassed hundreds of subsidiary companies over the past decade in their quest to dominate control of the #patientjourney. In doing so, they’ve also created massive value, for example, Optum is now a top #Fortune brand on its own (if sold). Could those strategies be tested and are investors looking for a #breakup of these #conglomerates as #regulations against #PBMs and other #healthcare middlemen come under new scrutiny? If so a windfall of #value could be unlocked, but this would signifcantly transform the healthcare delivery landscape and be the start of a new era for the #businessofhealthcare. It’s possible more reviews like this may be coming given the growing uncertainty regarding future healthcare policy from both political parties.

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I really enjoyed participating in this podcast with Capital Rx ‘s Justin Venneri . We talk about how important it is for employer’s to use their voice NOW to get what they need to manage their plans appropriately. So many employers complain about the fact that they can’t get data from their health plan partners and that their brokers refuse to disclose compensation. Both of these issues are solvable NOW whilst in the middle of renewal negotiations. We also talk about how important it is for employers to get credible data about their groups and to have access to data platforms like Judi that give plan fiduciaries direction and accountability around their drug spend. Now is the time to spend quality time doing fiduciary PBM procurement to discover whether or not your employer PBM partner is extruding value from your plan members. Most are. In addition, now is the time to take action on other big cost drivers especially including hospital costs. Employers who embrace this task yield huge value for their plan members and act in their interests. Hope you listen to our discussion! #pharmacy #PBM #compliance #healthplans #healthcare #transparency #procurement #healthdata #healthanalytics #healthinnovation #healthleadership #hospitals #healthcarecosts #fiduciary #fiduciaryduty Christine Arnold Steve Schutzer, MD Lisa Trumble Peter Hayes Chris Deacon Darren Fogarty Patrick Long Al Lewis 🇺🇦 Moving to Value Alliance Kerry Wood Wyatt Bosworth Dean Jargo Tim Denman Raju Kattumenu Josh Spivak John Bass Christopher Gormley Les Wilkinson Michael Brouthers 🎙Spencer Smith, CSFS® Doug Aldeen Jamie Greenleaf AIF, CBFA, C(k)P Julie Selesnick Dave Chase, Health Rosetta-discovering archaeologist Derek Moore Kevin Joyce Jay Silverstein Justin Leader

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📈 CVS Health just released their Q3 earnings this morning and the market seems to love that they beat on top line revenue despite being aware of the elevated medical benefits ratio. MBR rose to 95.2% from 85.7% in Q3 of last year (WOW). 🚀 Despite the high MBR, the stock is up 7% in premarket as expectations were low headed into the earnings call. I will take a deeper dive in my substack over the weekend but below are the CVS Health Q3 Earnings Highlights: 👑 New Leadership: Steve Nelson former UnitedHealth Group executive, now leads Aetna, aiming to address financial challenges in CVS’s insurance unit. Prem Shah, Chief Pharmacy Officer, has also been promoted to President. 💰Financial Performance: • Adjusted Q3 profit was $1.09 per share, a drop from $2.21 per share last year. • The company took a $1.1 billion charge related to anticipated losses in its insurance business for Q4. 📈💰Revenue Growth: Revenue in the healthcare benefits unit rose by 25.5% to $33 billion, supported by Medicare and commercial insurance growth Aetna, a CVS Health Company •. Health Services down to 44 billion in the quarter which is down from 49 billion in Q3 of 2023 due to the loss of the Centene Corporation PBM contract at Caremark. 🙌 Strategic Focus: Glenview Capital met with the leadership team a month ago demanding leadership changes leading to the departure of CEO Karen Lynch. Overall changes are expected to drive CVS’s cost management efforts and bolster Aetna, a CVS Health Company as they weather the storm in Medicare Advantage while integrating some of their recent M&A assets. #healthcare https://lnkd.in/gUXieZm6

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Proud to partner with Brown & Brown Insurance & Eric Kasen on this piece for BenefitsPRO about the future of #ICHRA for large groups. At SureCo we're building the first private enterprise health marketplace, and ICHRA is the first step. As more people and companies adopt this model, it will create more demand for carriers to create products specifically for this cohort and price them competitively. For the first time, the health coverage system will work as it should—in service of the employee.   https://lnkd.in/gtmr5_fn

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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.

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Health insurance isn’t really insurance - at least not in the way we think of typically think of insurance. In its most basic form, insurance is the pooling of premium dollars to create a fund which can be accessed by those who file claims with the assumption that not all will file claims. Those who don’t file claims subsidize those who do. For instance, only about 40% of homeowners ever file a homeowner’s claim in their lifetime, so the 60% who never file a claim help pay the claims of those who do. Same percentages with auto insurance. Fewer than 10% of workers ever file a disability claim, so the 90% who never file a claim underwrite those who are disabled. You get the idea. Health insurance is very different. No matter how many jumping jacks you do or how many carrots you eat or how robust your genes may be, eventually we will all have medical claims. Health insurance should actually be called 'pre-paid medical'. Most people incur 80% of their lifetime medical spend after age 40. 50% of lifetime spend after age 65. And 30% of lifetime spend in the final year of life. Unlike other forms of insurance, with medical claims, it’s when, not if. Since use of healthcare services is inevitable for everyone, our best aim must be using those services in the most efficient way to achieve the healthiest and longest lives possible. Understandably, most people have no idea how to do that. Garner does. www.getgarner.com

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If your organization is struggling with what to do with GLP-1 drugs, read this insightful article from my colleagues.

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Higher utilization in Medicare Advantage will force payers to further reduce reimbursements to providers through rate cuts, increased denials, downcoding, benefit reductions (more bad debt) and excessive administrative hassles. Now is the time to increase Medicare Advantage reimbursements for 2025! We are working with our clients to issue MA RFP’s to payers to strategically align with 1 or 2 MA plans next year and address declining MA yields. We can help you develop and execute your MA strategy to improve overall reimbursements. Let us show you how! Learn more about how to optimize your Medicare Advantage Contracts👉 https://lnkd.in/gRB3rMw3 #EllsworthConsulting #HealthcareInnovation #ConsultingServices #HealthcareLeadership #PayerNegotiations #HealthcareConsulting #HealthcareManagement #ContractNegotiation #HealthcareContracts #ContractStrategies #ContractSolutions #NegotiationSuccess

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This is the “Stars For Dummies” piece you’ve been looking for. When some brokers say all plans are the same, on the surface, I can see why - benefit grids are boringly similar. But that’s where the comparisons take a dramatic shift. Quality of care is the key differentiator, and where higher-rated plans do their best work. How can lower rated plans have “richer” benefits than those rated higher (SCAN 4.5 Stars!)? Because we are here when actual healthcare is the patient’s (and broker’s) priority. We approve your referrals, pay claims, and work with our members to stay healthy and independent. Broker question - If your parents were looking for a health plan, do Stars influence your selling decision? Assuming your truthful answer is yes, then why do you sell the others? If higher quarterly grocery benefits is the answer, there are lots of things you should reconsider.

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