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Hysteria over Aetna’s partial ACA evacuation needs to be cooled


Jon Kingsdale argues in Health Affairs that news coverage of Aetna’s plan to exit from 11 of the 15 states where it now offers insurance on Affordable Care Act insurance exchanges, and similar actions by some other big insurers, such as Humana and United Healthcare, has contained much hyperbole and that in fact the exits are no big deal.

He writes:

Critics of the ACA are citing these departures as evidence of the law’s fatally flawed design. Even supporters worry about how to staunch the outflow. And the news reverberated in presidential politics, on both sides. What’s really going on here? Are these big insurers bailing because Obamacare is just too risky? Will more such desertions cripple the marketplaces?”

He answers himself: “Not all health insurance companies are the same, nor do they necessarily serve the same customer segments. In fact, most medical insurance companies, unlike Aetna and United, are regional non-profits, such as the state (or smaller) Blue Cross Blue Shield plans, Kaiser Permanente and HIP. These ‘regional’ plans and Medicaid managed care organizations (MCOs) are generally better positioned to compete on the new marketplaces than ‘national’ insurers.”

“By contrast, national firms such as Aetna, United and CIGNA are far better positioned to serve national employers and other large, self-insured groups than to compete for individual households.”

“The vast majority of purchasers on the ACA marketplace are low-to-moderate income households, who are searching for low-priced health plans. As extremely ‘price-sensitive’ buyers, most seem willing to trade access to a broader network in return for lower premiums. Regional health plans and Medicaid MCOs are generally more successful than national ones in negotiating the lowest payment rates with local doctors and hospitals. As a result, the Blue Cross Blue Shield and other regional plans generally—not always—enjoy a cost and premium advantage over national plans and tend to dominate their marketplaces.”

“In fact, United and Aetna, despite their deep penetration of the large-group insurance market, together serve only 15 percent of marketplace enrollees, and their retrenchment will impact only about 10 percent.

“They are leaving many marketplaces, but staying in those where they think they can compete. This is clearly not the same as rejecting ACA marketplaces wholesale because of some fundamental flaw in the law. Presumably, they are being selective about their participation as they see how price-disciplined the marketplaces are and where they enjoy a competitive advantage.”

To read Mr. Kingsdale’s Health Affairs 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.

Fighting back against the insurers


P.J. Cloud-Moulds writes in Medical Economics:

“An article posted on reports that the North Carolina Medical Society (NCMS), after 12 years of litigation, has finally won a lawsuit against United Healthcare for $11.5 million. I wholeheartedly applaud NCMS for sticking to their goals and not giving up, particularly after so many years! The lawsuit was not intended to make financial payments to providers, as much as it was to upgrade UHC’s provider self-service technology systems. Quite frankly, I’m not sure why they are not already required to maintain and upgrade their data platform, especially being a medical business entity of their size. Regardless, the lawsuit is over, and the little guys won.

“This is just one of many {such} lawsuits going on right now. …Patients are tired of being lied to by these insurance companies, and they’re supporting these lawsuits, as well. The lawsuits vary from allegedly violating anti-trust laws, to creating plans under the Affordable Care Act that do not have any physicians in their networks — forcing patients to pay more out-of-pocket expenses, and fighting wrongfully denied claims.

“Whatever the reasons, it’s clear that those being wronged by these large insurance payers are fighting back, and it’s about time.”

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