Mostafa Kamal

I always appreciate Sam’s posts as they are thoughtful and concise. What really upsets me about the letter from these Senators to CMS is how callously the word “brokers” is used in the paragraph below: —- “with more than $6 billion in MA plan spending on commissions and marketing, brokers are under pressure to churn through appointments as quickly as possible. The demand for volume means brokers are under pressure to focus on only a few plans and may not examine the full range of options” —- Let me be clear, the large majority of brokers are NOT under pressure to churn. We do NOT only examine a few plans. The actions being described are that of a call center. And therein lies the problem. The fact that our government officials clearly do not understand the difference between a call center and a broker is a tremendous problem. If we cannot educate our government officials regarding the difference, we are all going to be out of a career. Plain and simple. Pinnacle Financial Services, Inc. Tyler Insurance Group Angela Palo Kevin Shields Nick Palo NABIP Laura Tyler Andrew Horn, MHA Caroline Horn Eric Price, MBA Christopher Raon

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RECENT CMS MEDICARE ADVANTAGE COMPENSATION RULE: "LIMITED TO INDEPENDENT AGENTS AND BROKERS AND DO NOT EXTEND TO TPMO'S (FMO'S) MORE GENERALLY" "CURRENT POLICY DOES NOT EXTEND TO PLACING LIMITATIONS ON PAYMENTS FROM AN MAO TO A TPMO" SEEMS CLEAR THAT A CHANGE IN THE FMO RELATED COMPENSATION & STRUCTURE IS NOT REQUIRED BY THE RECENT CMS RULE. https://buff.ly/3VkNxdf

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We recently sat down with Insurance Business America to share our insights into the increasing cost of specialty drugs and its impacts on payers and risk managers. Our senior sales associates, Mike Gold and James Hughes, discuss how predictive analytics can be a solution to this rising industry problem. “Predictive analytics not only allows us to price for the known risks, but by virtue of looking at quantitative and qualitative data surrounding each person within a population, we are able to predict that risk with our emerging flags.” ➡ Read the full article here: https://lnkd.in/g-bhBahk

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Basic “explainer” on Risk Adjustment and a RAF conundrum. This article from The Commonwealth Fund does a good job of providing the basics of risk adjustment. It also calls out one of the major contributors to patient outcomes that isn’t captured in traditional risk models, the Social Determinants of Health (SDoH). They do a great job on this, so I won’t summarize it here. However, I think there is another factor that isn’t captured that I wanted to discuss and would appreciate some different perspectives. I’d love to get some thoughts on the following. Maybe I am simply being pedantic. The issue not mentioned in the article that I think current methodologies of risk adjustment miss is duration and management of disease. A patient with a new diagnosis of diabetes, for example, now has an elevated risk of numerous complications over their lifetime. However, that risk in year 1 after the initial diagnosis is much lower than the risk at year 10. Current risk models don’t take that escalating risk into consideration, keeping the risk adjustment fixed regardless of duration of underlying diagnosis. In addition, there are few scenarios that will impact me differently as the provider: 1) Management of this patient’s diabetes has been poor for the prior 9 years and now my group “inherits” this patient at year 10. 2) My team has helped this patient manage their diabetes very well for the past 9 years. 3) For the past 9 years, this patient’s prior group had managed their diabetes well but they have now switched into my group. As noted above, in scenario 1, that “new” diagnosis of diabetes severely underestimates this patient’s risk of needing expensive resources this upcoming year. I will be adversely impacted from something that is clinically obvious (duration of a disease increases risks) but which is not captured in the current data. To go one step farther, in frameworks 2 and 3, there is a gap between what the patient’s risk would have been without 9 years of great care and what it likely is now. However, there is no recognition of this work. That is to say, if the patient switched to a group that did a terrible job of managing diabetes, they’d receive the same risk adjustment in year 10 as my group would receive after all of our time, effort and resources had been dedicated to keeping this patient healthy. If the patient’s healthcare needs in year 10 are low because of our efforts, shouldn’t we receive more credit than a group that simply gets attribution? And, what about the prior group? How are (were?) their efforts recognized? Please share your thoughts in the comments.

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So after a hiatus from the news headlines since the passage of the ACA and several failed attempts to repeal it, it seems that recent events (one horribly tragic) have pushed the macro industry back into the forefront of the news and politics. The issue is, obviously, complicated and intertwined with many other facets of our U.S. society. Health care delivery and the business of health insurance are different sides of the same coin. I worry that the debate about it due to the news will unnecessarily blur the lines between the two. Providers and healthcare organizations alike need to take a strategic and enterprise-wide view on the matter in order to navigate the waters in the coming 3-5 years. #healthcare #riskmanagement #ERM #healthinsurance

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Have you heard insurers & PBMs restructuring? The latest? CVS Health is intensifying its cost-cutting efforts with a new $2 billion initiative, adding to a previous plan to reduce costs by hundreds of millions. Aetna President fired based on earnings failure. Now, CVS is planning a multiyear program aimed at saving $2 billion by leveraging AI, automation, and streamlining operations, according to company presentation materials cited by Bloomberg reported prior to CVS' scheduled earnings call Aug. 7. #employeebenefits #employers #healthcare

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Open enrollment is approaching, which means major #insurers have shared their 2025 Medicare plans. 📆 To stay in the loop, this article from Becker's Payer Issues does a nice job summarizing some of the main takeaways from big names such as: - UnitedHealthcare - Humana - Aetna - Elevance Health - Centene A common thread? Numerous new plan options and extended access for new states across the U.S. #Payers #Insurance #PharmaNews #Medicare

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Andrew Toy, President of Clover Health, talks about how the US healthcare system being almost exclusively provided through a health insurance model can change the dynamics of the market versus other countries. That can create complications, but can also create opportunities for an insurer to make change, like Clover is working to do. Watch the clip at https://lnkd.in/eVJFHTiq and catch the full episode at https://lnkd.in/eQbhWN6E #insurtech #insurance #futureofinsurance #innovation

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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 evolving landscape of GLP-1s for weight management is prompting employers to reassess their obesity strategies. M3's Connie Perry explains that considering drug insurance coverage for obesity drugs involves balancing potential health advantages and financial considerations. #m3ins

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CVS Health appoints Steve Nelson, former head of insurance at UnitedHealth, to lead Aetna as the company grapples with rising medical costs and investor pressure. This leadership change comes in the wake of CVS's Q3 earnings miss, with Aetna's unexpected healthcare spending causing a significant drop in profits. As CVS focuses on streamlining operations and improving profitability, Nelson’s experience in healthcare could be key to navigating these challenges. With investor optimism and strategic leadership updates, CVS is positioning itself for a strong future. Read more: https://lnkd.in/egBXXQhm #NKDAdvisory #CVSHealth #Aetna #Leadership #Healthcare #CostManagement #ExecutiveChanges #CVSNews #HealthcareIndustry #Investors #BusinessStrategy #HealthInsurance #Profitability

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What does the Medicare FMO market look like if the 4 lawsuits against CMS do not prevail and the new law goes into effect with a more onerous final reading and CMS does clarify that overrides are problematic? I can see a few changes coming that will reshape things. The best FMO's are value-add to their agents, providing real technology, know-how, back office support, plan education, certification help, marketing and sales education, leads etc.. Some of the things FMO's provide are cheaper to generate when you have scale. An FMO can buy leads at scale and across geographies cheaper than individual agents can. They can provide access to SunFire, CSG Actuarial, LLC, ConnectureDRX, and others. But their value-add is not distributed evenly across all of the agents they work with, some lean on them heavily and others rarely use them. There are other FMO's that do not provide much support at all and some at the bottom of the barrel actually detract value by tying up agent with contracts with no release without providing any support. Meanwhile, if the final rule puts the extra $100 in agents pockets and does not allow overrides, the agents will have some more money available to spend on buying these services one by one. Top agents who got their start with the help of FMO's won't need them as much, and would look to buy what they need and keep the extra dollars. Not really fair for FMO's who invested in getting them started, but that's life, markets change and they need to adopt to the new realities. The big carriers do not seem to have settled on their interpretations yet, but behind closed doors some believe that FMO's are less necessary than when they were looking for growth at all costs and given their financial pressures, they have not been aggressive in advocating for the FMO structure to continue with business as usual. I am guessing a SAAS type of model might emerge for some, with the best FMO's probably focused on how they can help agents grow their business in the new reality by investing more in marketing, charging more for leads and finding other back-office services they can provide. There are definitely accounting, software, marketing and other services that FMO's could do better at scale than individual agents. Affiliates owned by Integrity and Amerilife might find themselves competing little more than they have been, which might drive them to move towards more full integration. Likely, a new W2 model will also emerge where FMO's employ their agents more formally, which can get them around the 1 to 1 marketing rules since leads can be shared without restriction inside a single corporation and there are more tools available to handle compensation through salary and avoid some of the issues. The need for education across plans might be more important than ever with the market exits, plan design changes, PDP and Part D shifts, is that a new business that will pop up as a SAAS model? What do you think happens if the rule sticks?

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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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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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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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