Tyler Benware

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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Check out our latest blog on Talking CAHPS, more specifically on the Health Outcomes Survey which measures patients experience.

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United HealthGroup reported their earnings yesterday and their earnings call was chock full of interesting tidbits Tim Noel , the CEO of Medicare for UHG was on the call again, what he said probably left a lot of distributors wondering what he means “we continue to believe that there's opportunities to improve the distribution environment in Medicare Advantage and have been in a dialog with CMS for several years on how to do that. Some of the elements of the final notice that were published recently are directly in line with some of our recommendations and some of them are relatively consistent, but not totally as we had conceived them”  “it's a little bit early to comment on how this might rebalance some of the channel mix, as still some questions on how some of the key elements of that will be rolled out.” Pretty aggressive wording about how much influence they have with CMS The Change Healthcare hack was the first thing mentioned after a couple of quarters where Medicare Advantage led things off on the earnings calls Andrew Witty, the CEO was strident in his defense of Medicare Advantage as a better deal for seniors financially as well as with care outcomes. Interesting to see how strong he was here considering UHG’s market leadership in Medsupp as well Their commercial business had its largest quarterly gain in years, likely driven by some recent marker exits by Humana and Aetna, although UHG said it was mostly from their innovative products. Individual exchange business was also mentioned as a growth driver MLR on Medicare Advantage went down from the 85% in Q4 to 84.3% and that is inflated by 40 basis points due to suspension or care management plus an additional $800 Million due to claims reserves related to the cyberattack AJ Rice from UBS asked about the $800 Million and they basically said the actual claims costs will be more than 0 but less than $800 million, so MLR is down at least a full point and maybe more in reality Jared Strock also posted some great analysis diving into the numbers, check it out!

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This is something that cou;d mean some significant effect in the market all over the country, however the reinsurance progream in the state of Minnespta also puts another wrinkle in this! Stay tuned! #thinkingdifferently #cfoinsights #ceoinsights #hr #hrbenefits #employee experience #ESOPCG

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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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The ongoing financial impact of Covid on healthcare organizations is a reality worth considering. This article from Modern Healthcare sheds light on the challenges faced due to supply chain disruptions. Understanding this dynamic risk factor is crucial, and HUB International's EPS strategy offers specific tools and data points to navigate these complexities effectively. #healthcare #riskmanagement #logistics

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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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Five years from now, it will be clear that the perfect storm of pain coming to the Medicare industry in a few months catalyzed some big winners and losers. New businesses will be created in the next six months that will have a huge tailwind from the chaos and many current companies in the space will not exist or be struggling mightily. Unfortunately, many seniors will be on the losing side of the coin. They have become accustomed to not pay any premiums and get decent medical service with an increasing array of supplemental benefits. Taking away any entitlements is very hard to do, doing it after several years of high inflation impacting those on a fixed income is going to feel a lot more harsh. The Medsupp market will have tons of its own disruption, is already struggling with profitability and will come under increasing pressure to do more guaranteed issue business at the exact time that its claims will get worse. The healthcare ecosystem was never designed, it always evolved, with modest "design" tweaks coming from the market and regulators every few years. The regulations are generally tinkering at the margins and it keeps plodding along while predictions of its demise pop up every couple of years. Chaos means meaningful opportunity for those who can find the alpha in the pain. Solving challenges that seniors will face will create meaningful economics for the winners. Most incumbents of scale will have a really hard time inventing the future, creative destruction is hard enough when you are fat and happy, it's almost impossible when you are fighting for survival. If anyone is working on an idea that could capture alpha from solving the pain, please hit me up, we are always interested!

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Everyone in the Medicare space should absolutely take a moment to read this article. It is an incredibly well written article from Sachin H. Jain, MD, MBA, explaining the confusing landscape of STAR Ratings and the need for reform regarding this particular CMS model. Well done Sachin!

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Brad Paulis, ASA, MAAA, and Partner at Continuing Care Actuaries will be participating in the LeadingAge / Ziegler CCRC CFO Conference Brad’s session will be on Thursday, April 25 at 11:00 AM CT HCBS Pivot – A Closer Look into Continuing Care at Home This year’s HCBS discussion will pivot to the topic of Continuing Care at Home (CCaH). As organizations look to diversify revenues and service lines, expanding the continuum into people’s homes will take a fresh look in this year’s session. Objectives: 1. Overview of services that are provided for Continuing Care at Home and payor arrangements for CCaH 2. Overview of trends related to this emerging area of care 3. Deep dive into case studies exploring the “Look of CCaH”

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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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It is a big day in the pharmacy benefits/drug pricing space. After much anticipation, we have the first round a price negotiations between manufacturers and #Medicare (see chart in comments). Here are my quick thoughts. 💵 This is for Medicare. The impact on commercial plans is to be determined. Will these become the new WAC prices, or will pricing continue to rise for others as a response to having to shave prices for Medicare? 💵 A 60-70% discount sounds great, however they are comparing to list price not NET price. The 2023 price should be shown as net to really get the impact, unless #rebates are going to stay the same with new prices (doubt it!) 💵 As a #pharmacist, I think nine of these drugs don't have to be relevant as brands come 2026. I understand this is a long process, and hopefully it will get quicker, but nine either have or will have a direct generic/biosimilar come 2026 or there are other great options in the class that do/will. Good formulary management will have taken care of these prices. 💵 Imbruvica is an agent with relevance come 2026. It has the lowest discount at 38%. (This lowest savings amount most likely speaks to point 2 as it isn't very well rebated currently). #Pharmacists #Pharmacybenefits #PBM #Pricing

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In this episode, the discussion revolves around the challenges inherent in the American healthcare system, as Butch Zemar critiques its structure and operations. The conversation touches upon various issues, including rising costs, affordability, and fraudulent billing practices, shedding light on the systemic flaws perpetuating these problems. The impact of the Affordable Care Act (ACA) is attributed to increased costs and reduced commissions for health insurance providers due to its implementation. He argues that while consumer demand plays a role, systemic issues such as abuse and neglect within the healthcare system significantly contribute to the unaffordable costs that consumers and providers bear. A key theme throughout the health insurance is the lack of transparency and accountability in healthcare billing practices. Butch discusses how providers often maximize charges, leading to unexpectedly high bills for patients, while also highlighting instances of billing mistakes and hidden fees encountered in personal experiences and interactions with clients. The discussion extends to strategies for small businesses to mitigate healthcare costs and increase revenue. It is important to learn the healthcare process, asking questions, and negotiating with providers to achieve cost savings. This podcast includes actionable advice tailored to businesses of varying sizes, urging employers to evaluate loyalty to insurers and brokers to ensure they are providing leverage to control costs effectively. In essence, the episode serves as a call to action for stakeholders within the healthcare system to prioritize transparency, accountability, and fair practices. By challenging assumptions, advocating for fair fees, and exploring alternative cost-saving strategies, Butch Zemar offers a roadmap for navigating the complex seas of healthcare in America, ultimately aiming to empower employers to take control of their healthcare expenses and improve the financial well-being of their businesses. For more information, please contact us at EliteBenefits.net or call 708-535-3006.

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As we head into Long-Term Care Insurance Awareness Month here are some staggering stats to consider. #protectingwhatmatters https://lnkd.in/gyXZyDFg

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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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Join me at Aon’s Midwest Region Healthcare Symposium for a two-day discussion on navigating the complexities of commercial risk in healthcare. Industry leaders, innovators, and experts will share their insights, experiences, and best practices. DM me for registration/hotel details and about the Navy Pier cruise outing. #Aon #AonBetterDecisions #Healthcare #MedicalMalpractice #CyberClaims #LegalUpdates #ParametricSolutions #ERM #RiskManagement #terrorism #networking #healthcareprofessionalliability #constructioninsurance #clinicaltrials

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The Midwest Business Group on Health released new survey results from their members. Their members are saying what most employers are- 🎯 "The most significant threats to the affordability of employer-provided care are drug prices (98%)..." 🎯 "...half said that they are considering changing their PBM vendor in the next 1-3 years due to concerns about #cost and #transparency" Employers shouldn't have to figure out better drug prices or changing #PBM vendors alone. That is where Innovative Rx Strategies and our pharmacists and account executives come in. This is the perfect time to start planning on assessments and changes for the future! Reach out today to talk more! #PharmacyBenefits #Pharmacists https://lnkd.in/geQ8Ydb4

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A recent study by OneAmerica highlights the growing need for long-term care planning as costs surge and consumer confidence remains low. With 74% of respondents believing they will require long-term care, only 33% feel adequately prepared, underscoring the importance of early and informed planning to safeguard finances and ease family burdens. There are several ways to plan for the future costs and burdens of aging, from traditional partnership-certified policies to hybrid policies combining life insurance or annuities with a qualified rider for long-term care to even short-term cash indemnity policies. Having a plan is essential to ensure access to quality care, protect income and assets, and reduce the burdens on those you love. The best time to plan is before you retire. Get free and accurate quotes from all the top companies from one trusted source - www.mccannltc.net Discover the cost of care where you live at https://lnkd.in/gHqTMyrD If your loved one needs quality care now, use the LTC NEWS Caregiver Directory -www.ltcnews.com/care If you're a Long-Term Care Insurance professional seeking a home, consider joining forces with Platinum LTC Solutions. Insurance agents, CPAs, lawyers, and financial planners, let's collaborate to assist your clients nationwide. Contact for more information — https://lnkd.in/gAhJgmjg https://lnkd.in/gBJ7vEzf

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