Cooperating for better care.

Medicare Advantage

Tag Archives

Geisinger dramatically expanding geographical reach of its insurance


Danville, Pa.-based Geisinger Health System and Bethlehem, Pa.-based St. Luke’s University Health Network have agreed to extend Geisinger health plans to almost 50 Pennsylvania counties.

“The systems will share population and value-based payment model data and create a sponsored Medicare Advantage product to provide recipients access to services not covered under traditional Medicare and Medigap plans. In addition, more than 10,000 St. Luke’s employees will be placed on Geisinger’s health plan, effective Jan. 1,” reported Becker’s Hospital Review.

The development is one of the more dramatic demonstrations of hospital systems expanding insurance offerings to achieve the  cost efficiencies and customer loyalty that some systems see  as needed in the developing value-based world of healthcare.

“When you get to the heart of it, we are two organizations focused on taking the best care of patients and we’re excited to partner with a healthcare system that aligns with our vision and values,” said David Feinberg, M.D., Geisinger president and CEO. “Geisinger is thrilled to expand the scope of our relationship with St. Luke’s to advance population health, improve quality and provide better access to care.”


To read the whole story, please hit this link.

More sculpting of Medicare Advantage value-based program


Modern Healthcare reported:

“The federal government will expand a new Medicare Advantage program to three states in 2018, as part of an effort to change behaviors and cost-sharing for seniors who have chronic diseases.

“In addition, plans that want to join the Medicare Advantage Value-Based Insurance Design model can offer expanded benefits to two new types of chronically ill members {dementia and rheumatoid arthritis}.

“The concept behind VBID is to eliminate the financial barriers sick patients face when they are trying to get certain exams, prescriptions drugs and procedures. If patients with chronic conditions are able to obtain high-quality care that is recommended by doctors for free or at a reduced cost, in theory, they are more likely to get that care and avoid potentially more expensive care down the road. Cost-sharing likewise would increase for services that offer little to no value for patients.”

“Dr. Mark Fendrick, a physician at the University of Michigan and one of the original supporters of VBID, has championed a bill in Congress that would allow all private plans to provide first-dollar coverage for chronically ill people …in a high-deductible policy.

“Starting this January, interested Medicare Advantage insurers will be able to offer enhanced benefits in seven states: Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania and Tennessee. In 2018, the project will expand to Alabama, Michigan and Texas.”

To read the whole article, please hit this link.

UHC pays $148 million to physicians in value-based program


HealthcareDive reports that giant UnitedHealthcare paid more than $148 million last year to primary-care physicians for improving  the medical outcomes for patients in Medicare Advantage plans. The insurer said that nearly 1,900 physicians received bonuses for achieving value-based goals in its PATH program, which encourages physicians to promote prevention, including  monitoring of chronic conditions.

Physicians in the program care for about a million Medicare Advantage members.

The Centers for Medicare & Medicaid Services  is trying to shift 50 percent of Medicare payments to value-based payment models by 2018.

To read the whole HealthcareDive story, please hit this link.

Medicare accepting applications from PCPs for monthly capitation payments

Medscape reports:

“Medicare is now accepting applications from primary-care physicians who want to receive monthly capitation payments for evaluation and management (E/M) services as well as care management apart from office visits — think phone calls, emails, and remote monitoring.

“Selected physicians will participate in a 5-year experimental payment model called Comprehensive Primary Care (CPC) Plus, which is designed for medical homes. The Centers for Medicare & Medicaid Services (CMS) wants to recruit as many as 5000 practices with upwards of 20,000 clinicians to treat 25 million patients, who will not be limited to beneficiaries of traditional Medicare. CMS is partnering with private insurers, state Medicaid programs, and Medicare Advantage plans that agree to adopt the same metrics for payment, data sharing, and quality. As a result, participating physicians won’t have to reorganize their practices just for the sake of patients in traditional Medicare.”

To read the entire article, please hit this link.

CHI getting out of scary insurance business


Englewood, Colo.-based Catholic Health Initiatives has decided to get out of the health-insurance business.

CHI’s insurance subsidiary, QualChoice Health, formerly known as Prominence Health,  has been offering Medicare Advantage and commercial insurance products to members in six states. But, Becker’s Hospital Review reports, the insurance business had a operating loss of almost $97 million in the first nine months of fiscal  2016, which ended March 31. In the like year-earlier period, QualChoice had a nearly $19 million operating loss.

CHI is one of many systems that have launched health plans in recent years, especially since the Affordable Care Act went into effect, but with often disheartening results.

McKinsey & Co.  found that of the 89 hospital-system insurance plans, more than 40 had negative margins in some or all of the past three years. To read the Becker’s story on this, please hit this link.


Coalition’s ideas for boosting care of patients with chronic conditions


The National Coalition on Health Care recommends that to  improve care of patients with chronic conditions in Medicare Advantage, Medicare ACOs and other plans:

  • Congress should pass legislation to encourage health plans and ACOs to invest program dollars in targeted social and long-term services and supports.
  • Integration of mental-health and primary-care settings should be promoted.
  • A Medicaid prospective payment system for community behavioral- health clinics should meet high standards of care and  coordinate and deliver both primary care and behavioral-health services to their patients.
  • That patient-centered care should especially be encouraged when chronic disease evolves into serious or advanced illness.
  • Palliative-care options should always be available  and made known to patients.

For the whole report, hit this link.

Feds fine insurance startup for misleading marketing


Barker at Vermont State Fair, 1941.

Federal regulators have fined Clover Health $106,095 for misleading consumers about their out-of-network benefits.

Clover Health sells Medicare Advantage products in New Jersey. The health- insurance startup provides enrollees with out-of-network benefits and lets them pay nothing for monthly premiums, co-payments and generic prescriptions.

Becker’s Hospital Review reported that CMS says that Clover’s  marketing misled potential enrollees about their ability “to always receive covered services from any out-of-network provider. The regulators said that the materials incorrectly stated that out-of-network providers participating in the Medicare program had  to accept Clover enrollees.”

For the full story from Becker’s Hospital Review, read this link.

The most alluring ACO model

In this HealthAffairs post, the authors argue that today’s most attractive national Accountable Care Organization model is offered by CMS.

They write:

“Fortunately, CMS heard the complaints about early MSSP  {Medicare Shared Savings Program} models and addressed the majority of them through the progressive structure of the Next Gen {of ACOs} model. In fact, the core difference between MSSP Track 1 and the current Next Gen model is that the latter is based upon extensive feedback from health systems regarding their concerns about MSSP Track 1.

“Next Gen is therefore a program that health systems have directly asked for. The model still has room for further improvement — for example, Next Gen ACOs should have access to the full toolkit of benefit- and network-design strategies found in Medicare Advantage and other provider-led offerings. But the CMMI {Center for Medicare & Medicaid Innovation} leadership has pledged to pursue additional features that could take effect in the later years of the Next Gen model, and will continue the virtuous cycle of improvements.”

Centene completes Health Net purchase


Centene has completed its  $6 billlion acquisition of Health Net, creating the largest Medicaid managed-care organization.  California regulators’ approval of the deal paved the way for the transaction to close.

The acquisition expands Centene’s government products to include Medicare Advantage and contracts with Department of Defense and the Veterans Administration,  as well as expanding its role in the health-insurance marketplaces. The integrated company will be insuring more than 10 million members.

The Department of Justice and some state insurance departments are still reviewing Aetna’s acquisition of Humana as well as  Anthem’s  purchase of Cigna.

Deconstructing the slowdown in healthcare costs


Timothy Jost, writing in HealthAffairs about the sixth anniversary of the Affordable Care Act, writes:

A report {by the U.S. Department of Health and Human Services} “does not claim that the ACA was responsible for all of the decrease in spending growth over the past half decade. It recognizes that the slowdown in spending since 2009 has been driven by a number of factors unrelated to the ACA: the slow recovery from the recession, expiring prescription drug patents and a corresponding increase in the use of generic drugs, ongoing shifts in the site of care from inpatient to outpatient settings and to prescription drugs, and a greater emphasis on enrollee cost sharing in private insurance plans. But the report asserts that some credit must be given to the ACA for reductions in Medicare provider payment updates and Medicare Advantage payment rates, purchasing reforms, increase program integrity efforts, state Medicaid cost containment, and shifts in coverage to public programs which have also contributed to slowed expenditure growth.”






Page 2 of 5123...Last

Contact Info

(617) 230-4965

Wellesley, Mass