Mike Costa

Medicare Advantage unrest, Change Healthcare fallout and more big takeaways from insurers’ Q1 https://lnkd.in/eyg48k7e via Healthcare Dive #MedicareAdvantage #ChangeHealthcare #Cybersecurity #CMS #Medicaid

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The Great Reckoning in Medicare Advantage: Collaboration or Division? The landscape of Medicare Advantage is facing its biggest shift in two decades, according to McKinsey, which is presenting new challenges for payers and providers alike. As pressures mount, the vital question emerges: “How can health systems avoid getting the smallest slice of the remaining pie?” In a recent panel of payer and health system executives hosted by Strategy Catalyst, executives from both sectors discussed the future. The consensus? Those positioned to thrive in the impending Medicare Advantage "great reckoning" will be the innovators who foster collaborative efforts to optimize each other's cost structures. What might this entail? • Payers could seek to reduce their own cost-regulating denials and prior authorizations by trying to work collaboratively, focusing on efficient data sharing and solution-driven dialogues with providers. • Providers could streamline contracts to only work with those seeking mutual value, guided by well-defined principles for selecting partners and governing contract performance. Potential collaborative areas: • Jointly deciding on supplemental benefits that will be high impact of the population and promoting their utilization through the health system's medical group. • Establishing joint quality measures that would allow movement to prospective payment systems. • Exploring evidence-based care guidelines that could be agreed upon jointly to reduce administrative burdens, like unnecessary prior authorizations. Join the conversation and let us know your thoughts. For more detailed insights, ask for our two-pager on the future of Medicare Advantage.

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The growth of the health insurance marketplace is picking up steam, fuelled by Medicaid disenrollment. https://ow.ly/N1vW50Tafsq MMIT’s Erin Trompeter explains what these large-scale changes mean for providers, manufacturers, payers and health IT vendors. Get the insights by clicking the link in this post. #HealthInsuranceMarketplace #HealthInsurance #Medicaid

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Recent data from eHealth and Retirable’s report shows that the top financial concern of retirees is healthcare costs. Dive into the latest insights from this report at Medical Economics. https://bit.ly/4aUbdKj

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The era of splashing the market with flashy supplemental benefits is in the rearview as CMS, MA plans, and downstream risk-bearing providers are collectively challenged to "do more with less."   CMS' heightened data collection requirements will slowly but surely drive an emphasis on cost-saving, impact-driving supplemental benefits rather than those that simply attract members.   This shift could serve risk-bearing providers well, as overly generous and unmanageable supplemental benefit allowances have often driven MLR headwinds in recent years.

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Access to care in rural communities continues to shrink. Utilizing a digital care platform like Actuvi can allow specialties, primary care, RHCs and FQHCs to expand their geographic constraints and increase access to care. Additionally, Actuvi allows them to deploy preventative health measures like RTM and RPM along with other digital care services. #prevenativehealthcare #healthtech #digitalcare

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With over 2 million members displaced by major healthcare players exiting underperforming Medicare Advantage markets, regional insurers face both a challenge and an opportunity. This influx of high-cost members demands innovative solutions to manage chronic conditions like diabetes and heart failure effectively. At Circadian Health, we’re helping regional insurers navigate this disruption with virtual-first specialty care, reducing costs and improving outcomes for the most complex members. This market shake-up isn’t just a challenge—it’s a chance to redefine care delivery. Discover how regional insurers can transform disruption into opportunity—read more on our blog. #MedicareAdvantage #HealthcareInnovation #VirtualCare #CircadianHealth #ValueBasedCare #HealthEquity

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Despite recent challenges, Medicare Advantage, or MA, now accounts for more than half of all Medicare beneficiaries—a patient population that every healthcare organization must engage. In a new article Joyjit Saha Choudhury, John Poziemski and Webster Macomber explore possible scenarios for the future of MA—and the potential impact on providers and payers—amid rising uncertainty. #payerproviders #medicare #healthcaremanagement https://lnkd.in/gB_GTZU4

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Cigna Healthcare and Humana have reportedly reignited #merger talks after stalled discussions last year. If successful, the merger could shake up the healthcare industry, potentially creating a #powerhouse in the #Medicare #Advantage #space. However, with increased scrutiny from the FTC, navigating regulatory hurdles will be key. The sector is watching closely for further developments. #HealthcareNews #Cigna #Humana #MergerTalks #MedicareAdvantage #HealthInsurance #FTC #IndustryUpdate

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Let's explore the critical factors shaping the landscape of MA STARs ratings in the upcoming year with a focus on quality and excellence. 🌟💊 🏥 🩺 2025 Medicare Advantage and Part D Star Ratings: Key Metrics for Providers ⭐ 💹 https://lnkd.in/e7aZkZvC Introduction to Star Ratings: -> Star Ratings measure the quality of health and prescription drug services for Medicare enrollees. -> CMS aims to improve the quality of Medicare Advantage (MA) and Part D programs. Significant Metrics for 2025: - Part C Plan All-Cause Readmissions -> Increased weight from 1 to 3, emphasizing the importance of reducing hospital readmissions for comprehensive care. - Tukey Outlier Deletion: -> Applied to improve the accuracy of measure-level cut points used to determine star ratings. -> Aims to minimize the influence of extreme outliers on performance measures. Performance Measurement: -> Contracts rated on up to 40 unique quality measures for MA-PD contracts and 12 for PDP contracts. -> Cut Points: Established thresholds to determine rating (1-5 stars) based on performance. Year-over-Year Rating Trends: -> Changes in measure-level cut points for 2025 reflect a shift towards higher performance standards. Example Metrics: -> Breast Cancer Screening (Part C) -> Average star rating decreased from 3.9 (2022) to 3.4 (2025). -> Colorectal Cancer Screening (Part C) -> Similar downward trend, indicating a need for improvement in preventive care measures. Impact of Contract Experience: -> Contracts with 10+ years in the program tend to achieve higher star ratings, highlighting the importance of experience and stability in delivering quality care. Tax Status Influence: -> Non-profit organizations typically achieve higher ratings (50% earning 4+ stars) compared to for-profit counterparts (36%). Consistency in High Performance: -> Contracts consistently rated with high performance icons (5 stars) maintain strong service delivery, with many having special needs plans (D-SNP). Conclusion: Providers should focus on improving metrics like all-cause readmissions, refining methodologies for accurate performance measurement, and maintaining consistent care quality to achieve higher star ratings in 2025 and beyond.

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Drex DeFord Advises Simplifying Healthcare for Vendor Risk Reduction: https://lnkd.in/dDvhYsDF First Health Strategic Advisory Board Member & Healthcare Strategist Drex DeFord dives into pressing concerns around the increasingly complex, difficult to manage, and frequently targeted healthcare environment. Drex’s conversations with This Week Health fuel meaningful conversations to spur the change necessary for improving health sector resilience. We’re proud to have such a dedicated member of the healthcare cybersecurity space advising our leaders and ensuring First Health is at the forefront of digital health security innovation. For more insight into First Health’s leadership and board members, visit https://lnkd.in/gQUx5BzD or contact First Health at [email protected]. #CISO #CIO #CTO #CDO #Compliance #HIPAA #HealthcareIT #HealthcareSecurity #CyberRisk #ThirdPartyRisk #RiskAssessment #Cybersecurity #HTM #DigitalHealth #PatientSafety

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📉 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

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For all of those plans thinking about VBIDs, here is a big update.

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