Category Archives: America’s Health Insurance Plans (AHIP)

The Fox Guards the Hen House – Translating AHIP’s Commitments to Streamlining Prior Authorization

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, America's Health Insurance Plans (AHIP), Electronic Pre Authorization, Health Insurance Industry, Health Insurance Pre Authorization, Lobbyist, Medicare Advantage, Medicare Advantage Denials, Prior Authorization, Unnecessary Pre Authorizations • Tagged , , , , • Leave a comment
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“We urge the Administration to consider the timing of these policies in the context of the broader scope of requirements and challenges facing the industry that require significant system changes.”

  • AHIP, March 13, 2023 (in a letter to CMS Administrator Chiquita Brooks-LaSure responding to CMS’s proposed rule on Advancing Interoperability and Improving Prior Authorization Processes, proposed Final Rule, CMS-0057-P)

“Health insurance plans today announced a series of commitments to streamline, simplify and reduce prior authorization – a critical safeguard to ensure their members’ care is safe, effective, evidence-based and affordable.”

  • AHIP, June 23, 2025 (press release announcing voluntary prior authorization reforms)

What a difference two years make.

After lobbying aggressively to delay implementation of the PA reforms proposed by the previous administration (successfully delayed one year and counting), AHIP, the big PR and lobbying group for health insurers, now claims the mantle of reformer, announcing a set of voluntary commitments to streamline prior authorization.

So naturally, the industry’s “commitments” deserve closer scrutiny. Let’s unpack them. As a former health insurance industry executive, I speak their language, so allow me to translate. AHIP, which has no enforcement power, by the way, claims that 48 large insurers will:

  1. Develop and implement standards for electronic prior authorization using Fast Healthcare Interoperability Resources Application Programming Interfaces (FHIR APIs).Translation: CMS is already requiring all insurers to do this by 2027. We might as well take credit preemptively.
  2. Reduce the volume of in-network medical authorizations. Translation: We already demand hundreds of millions of unnecessary prior authorizations for thousands of procedures and services, so cutting a few (who knows how many?) should be a layup and won’t cut into profits.
  3. Enhance continuity of care when patients change health plans by honoring a PA decision for a 90-day transition period starting in 2026.Translation: We’re already required to do this in Medicare Advantage. And since we delayed implementation of e-authorization until 2027, we’re in the clear until then anyway.
  4. Improve communications by providing members with clear explanations for authorization determinations and support for appeals. Translation: We’re already required by state and federal law to do this. We’ll double-check our materials.
  5. Ensure 80% of prior authorizations are processed in real time and expand new API standards to all lines of business. Translation: We had to promise to hold ourselves accountable to at least one measurable goal. We will set the denominator – we’ll decide which procedures and medications require PA – so we’ll hit this goal, no problem, and we might even use more non-human AI algorithms to do it.
  6. 6. Ensuring medical review of non-approved requests. Translation: People will be relieved we’re not using robots. And we’ll avoid having Congress insist that reviews must be done by a same-specialty physician, as proposed in the Reducing Medically Unnecessary Delays in Care Act of 2025 (H.R. 2433).

Of course, I wasn’t in the room when AHIP drafted these commitments, so take my translations with a grain of salt. But let’s be honest: These promises are thin on specifics, short on accountability, and devoid of measurable impact.

They also follow a familiar script, blaming physicians for cost escalation by “deviating from evidence-based care” and the “latest research”, while positioning PA as a necessary safeguard to protect patients from “unsafe or inappropriate care.” And largely ignoring how PA routinely delays necessary treatment and harms patients.

It’s also rich coming from an industry still reliant on something called the X12 transaction standard – technology that is now over 40 years old – to process prior authorization requests, while simultaneously pointing the finger at providers for outdated technology and being slow to adopt modern systems. Many insurers did not start accepting electronic submissions of prior authorization until roughly 2019, nearly 20 years after clinicians started using online portals such as MyChart in their regular practice. The claim that providers are the ones behind on technology is another ploy by insurers to dodge scrutiny for their schemes.

We shouldn’t settle for incremental fixes when the system itself is the problem. Nor should we allow the industry that created this problem – and perpetuates it in its own self-interest – to dictate the pace or terms of reforming it.

As we argued in our recent piece, Congress should act to significantly curtail the use of prior authorization, limiting it to a narrow, evidence-based set of high-risk use cases. Insurers should also be required to rapidly adopt smarter, lower-friction cost-control methods, like gold-carding trusted clinicians (if it can be implemented with integrity and fairness), without compromising patient access or clinical autonomy.

Letting the fox design the hen house’s security perimeter won’t protect the hens. It’s time for Congress to build a better fence.

Healthcare’s Three Big Tents have Much in Common

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Healthcare’s Three Big Tents have Much in Common

Arguably, three trade groups have emerged at the center of healthcare system transformation efforts in the U.S.: the American Hospital Association (AHA), America’s Health Insurance Plans (AHIP) and the Pharmaceutical Research and Manufacturers of America (PhRMA). Others weigh in—the American Medical Association, AdvaMed, the American Public Health Association and others—but this trio is widely regarded as the Big Tents under which policy changes are pursued.

Each plays a unique advocacy role in the system, protecting their members’ turf from unwelcome regulation while fighting against restrictions that might limit their growth opportunities. Their focus is their members:

 AHAAHIPPhRMA
Members5000 hospitals & 43,000 individual members125 Health Insurers31 Manufacturers
Board Composition26 (10 female)33 (5 female)25 (3 female) 
Revenues (’22)$138.8 Mil$78.6 Mil$568.3 Mil
Revenue chg. ’22 v. ‘21+7.7%-7.1%-6.7
Margin (’22) $6.6 Mil$4.7 Mil$-0.1%
Exec Comp % of ’22 Rev8.4%9.6%3.9%
CEO (Tenure)Richard J. Pollack (since 2015, with AHA 37 yrs.).Mike Tuffin (since Jan 2024)Prior: SVP UHG, APCOStephen J. Ubl (since 2015)Prior: CEO AdvaMed, FAH
Direct Lobbying ‘23$30.2 MilNA$27.6 Mil
Total Industry Lobbying 2023 (includes all sources)$133.3 Mil$129.3 Mil$383.7 Mil

Sources:*Nonprofit Explorer – ProPublicaIndustries IRS Form 990 for 2022, the latest year available • OpenSecrets based on year-end 2023.

Ironically, these Big Tents have much in common:

  • All three serve diverse memberships and are highly protective of their Big Tents. But each faces growing intramural pressure from member cohorts that seek special attention–especially their large and highly profitable members vs. the rest.
  • All three struggle with the notions of affordability, price transparency, profit, executive compensation and value. These terms appear frequently in their white papers and comment letters but each tent defines them differently.
  • All three depend on physicians to fund member revenues: they’re gatekeepers to member patients, referrals and prescriptions. Each Big Tent is focused on advocacy that enables physician interactions upon which member revenues can be sustainable and service disruption minimal.  Thus, physician well-being is a concern to the Big Tents.
  • All blame factors outside their control for health costs escalation. The health habits of population, over-regulation and U.S. monetary policy are frequent targets. Projections by the CBO of annual health spending of 5.6% through 2032 are justified by the Big Tents as the net result of increased demand and flaws in the system’s incentives, legals protections and funding mechanisms. Each Big Tent is on the defensive about how they address costs and waste, and how their prices enable increased affordability.
  • All three spend heavily to influence lawmakers to avoid unwelcome regulation. Their spending for direct lobbying is multiplied by formal coalitions with friendly trade groups, political action committees, high net worth contributors and corporations. Coalition building is a major function in each Big Tent used against swings in public opinion of concern or against pending legislation that threaten member interests.
  • All three serve memberships that operate primarily with business-to-business (B2B) business models primarily. Each subordinates ‘consumerism’ to ‘patients, enrollees, and communities’ served by their members. Maximizing consumer (voter) good will and counter-messaging against hostile media coverage are core functions in each Big Tent.
  • All three favor incremental changes to the status quo over transformational reform of the system top to bottom. Wholesale change is unwelcome though the majority of U.S. adults say it’s fundamentally flawed and needs a fresh start.

In each campaign cycle, the Big Tents create playbooks based on possible election outcomes and potential issues they’ll confront. Each identifies possible political appointees to key government posts, committee appointments and legislative staff that with whom they’ll deal. Each reaches out to friendly think-tanks, ex-pats from previous government roles and research organizations to create favorable thought leadership for the talking heads they trust. And each lines up outside lobbyists to augment their staff.

The Boards of the Big Tent trio weigh in, but senior staff in each of the Big Tents drive the organization’s strategy. They’re experienced in advocacy, well-paid and often heavy-handed in dealing with critics.  

Operationally, the 3 Big Tents have much in common. Strategically, they’re far apart and the gap appears to be widening. Each blames the other for medical inflation and unnecessary cost. Each alleges the others use unfair business practices to gain market advantages. And each thinks their vision for the future of the U.S. health system is accurate, complete and in the best interest of the public good.

And none of the three has put-forth a vision for the long-term future of the U.S. health system.  Protecting the immediate interests of their members against unwelcome regulatory changes is their focus.

P.S. It can be argued that the American Medical Association is the Fourth Big Tent. However, fewer than a fourth of the million active practitioners are AMA members contrasted to the other Big Tents. Like the trio, AMA’s primary advocacy focus is its members: protecting against encroachment by non-physicians, maintenance of clinical autonomy, restrictions on the use of artificial intelligence in patient care and Medicare reimbursement rate changes are major concerns. And, akin to the others, the wider set of issues facing the system i.e. structure, funding, ownership, price transparency, workforce modernization et al. has gotten less attention.

AMA report: U.S. has “highly concentrated” payer markets that stifle competition  

Posted on by • Posted in ACA, America's Health Insurance Plans (AHIP), American Medical Association (AMA), Competition, Federal Trade Commission (FTC), Health Insurance Coverage Adequacy, Health Insurance Industry, Health Policy, High Deductible Health Plans, High Drug Prices, High Premiums, High Prices, Market Consolidation, Market Failure, Market Power, Market Share, Market Trends, Mergers & Acquisitions, Monopoly, Monopoly Behavior, Out of Network, Out of Pocket Expenses, Surprise Bills • Leave a comment

https://medcitynews.com/2021/10/ama-report-u-s-has-highly-concentrated-payer-markets-that-stifle-competition/?utm_campaign=MCN%20Daily%20Top%20Stories&utm_medium=email&hsmi=166812730&_hsenc=p2ANqtz–Z_7y9-ZOPkhC7HI4RXSwuM5xDzd2B0uZi9sApeW1J89hQBktG-rqujxpBFiXmxEEnaK77vlq-7vHhr-qK8mxRgBmwA&utm_content=166812730&utm_source=hs_email

About 73% of health insurance markets are highly concentrated, and in 46% of markets, one insurer had a share of 50% or more, a new report from the American Medical Association shows. The report comes a few months after President Joe Biden directed federal agencies to ramp up oversight of healthcare consolidation.

The majority of health insurance markets in the U.S. are highly concentrated, curbing competition, according to a report released by the American Medical Association.

For the report, researchers reviewed market share and market concentration data for the 50 states and District of Columbia, and each of the 384 metropolitan statistical areas in the country.

They found that 73% of the metropolitan statistical area-level payer markets were highly concentrated in 2020. In 91% of markets, at least one insurer had a market share of 30%, and in 46% of markets, one insurer had a share of 50% or more.

Further, the share of markets that are highly concentrated rose from 71% in 2014 to 73% last year. Of those markets that were not highly concentrated in 2014, 26% experienced an increase large enough to enter the category by 2020.

In terms of national-level market shares of the 10 largest U.S. health insurers, UnitedHealth Group comes out on top with the largest market share in both 2014 and 2020, reporting 16% and 15% market share, respectively. Anthem comes in second with shares of 13% in 2014 and 12% in 2020.

But the picture looks different when it comes to the market share of health insurers participating in the Affordable Care Act individual exchanges. In 2014, Anthem held the largest market share among the top 10 insurers on the exchanges, with a share of 14%. By 2020, Centene had taken the top spot, with a share of 18%, while Anthem had slipped to fifth place, with a share of just 4%.

Another key entrant into the top 10 list in 2020 was insurance technology company Oscar Health, with 3% of the market share in the exchanges at the national level.

“These [concentrated] markets are ripe for the exercise of health insurer market power, which harms consumers and providers of care,” the report authors wrote. “Our findings should prompt federal and state antitrust authorities to vigorously examine the competitive effects of proposed mergers involving health insurers.”

The payer industry hit back. In a statement provided to MedCity News, America’s Health Insurance Plans, a national payer association, said that Americans have many affordable choices for their coverage, pointing to the fact that CMS announced average premiums for Medicare Advantage plans will drop to $19 per month in 2022 from $21.22 this year.

“Health insurance providers are an advocate for Americans, fighting for lower prices and more choices for them,” said Kristine Grow, senior vice president of communications at America’s Health Insurance Plans, in an email. “We negotiate lower prices with doctors, hospitals and drug companies, and consumers benefit from lower premiums as a result.”

Further, the report does not mention the provider consolidation that also contributes to higher healthcare prices. Mergers and acquisitions among hospitals and health systems have continued steadily over the past decade, remaining relatively impervious to even the Covid-19 pandemic.

Scrutiny around consolidation in the healthcare industry may grow. In July, President Joe Biden issued an executive order urging federal agencies to review and revise their merger guidelines through the lens of preventing patient harm.

The Federal Trade Commission has already said that healthcare businesses will be one of its priority targets for antitrust enforcement actions.

Hospital, insurer and employer groups band together in bid to achieve universal coverage

Posted on by • Posted in ACA, America's Health Insurance Plans (AHIP), American Academy of Family Physicians, American Hospital Association (AHA), American Medical Association (AMA), Employer-Based Health Insurance, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, Medicare for All, Preexisting Conditions, Public Option, Underinsured, Uninsured, Universal Coverage, Universal Healthcare System • Leave a comment

https://www.healthcarefinancenews.com/news/hospital-insurer-and-employer-groups-band-together-bid-achieve-universal-coverage

Image result for univeral health coverage

The groups said that Americans “deserve a stable healthcare market that provides access to high-quality care and affordable coverage for all.”

This week, a coalition of healthcare and employer groups called for achieving universal health coverage by expanding financial assistance to consumers, bolstering enrollment and outreach efforts, and taking additional steps to protect those who have lost or are at risk of losing employer-based coverage because of the economic downturn caused by the COVID-19 pandemic.

The Affordable Coverage Coalition encompasses groups representing the nation’s doctors, hospitals, employers and insurers. They include America’s Health Insurance Plans, American Hospital Association, American Medical Association, American Academy of Family Physicians, Blue Cross Blue Shield Association, Federation of American Hospitals and the American Benefits Council.

They have banded together to advocate for achieving universal coverage via expansion of the Affordable Care Act, which is supported by President Biden. Biden also intends to achieve universal coverage through a Medicare-like public option — a government-run health plan that would compete with private insurers.

WHAT’S THE IMPACT

Despite a lot of pre-election talk about universal healthcare coverage from elected officials and those vying for public office, achieving this has remained an elusive goal in the U.S. In a joint statement of principles, the groups said that Americans “deserve a stable healthcare market that provides access to high-quality care and affordable coverage for all.”

“Achieving universal coverage is particularly critical as we strive to contain the COVID-19 pandemic and work to address long-standing inequities in healthcare access and outcomes,” the groups wrote.

The organizations support a number of steps to make health coverage more accessible and affordable, including protecting Americans who have lost or are at risk of losing employer-provided health coverage from becoming uninsured.

They also want to make Affordable Care Act premium tax credits and cost-sharing reductions more generous, and expand eligibility for them, as well as establish an insurance affordability fund to support any unexpected high costs for caring for those with serious health conditions, or to otherwise lower premiums or cost-sharing for ACA marketplace enrollees.

Also on the group’s to-do list: Restoring federal funding for outreach and enrollment programs; automatically enrolling and renewing those eligible for Medicaid and premium-free ACA marketplace plans; and providing incentives for additional states to expand Medicaid in order to close the low-income coverage gap.

THE LARGER TREND

The concept of universal coverage is gaining traction among patients thanks in large part to the COVID-19 pandemic. In fact, A Morning Consult poll taken in the pandemic’s early days showed about 41% of Americans say they’re more likely to support universal healthcare proposals. Twenty-six percent of U.S. adults say they’re “much more likely” to support such policy initiatives, while 15% say they’re somewhat more likely.

As expected, Democrats were the most favorable to the idea, with 59% saying they were either much more likely or somewhat more likely to support a universal healthcare proposal. Just 21% of Republicans said the same. Independents were somewhere in the middle, with 34% warming up to the idea of blanket coverage.

More than 21% of Republicans said they were less likely to support universal care in the wake of the COVID-19 crisis. Seven percent of independents reported the same, while for Democrats the number was statistically insignificant.

During his campaign, President Joe Biden said he supported a public option for healthcare coverage. He also pledged to strengthen the Affordable Care Act. By executive order, Biden opened a new ACA enrollment period for those left uninsured. It begins February 15 and goes through May 15.

Medical groups implore Congress to extend moratorium on sequester cuts as COVID-19 ramps up

Posted on by • Posted in America's Health Insurance Plans (AHIP), American Medical Association (AMA), Economic Crisis, Economic Recovery, Economic Stimulus, Federation of American Hospitals, Health System, Hospital, Hospital Industry, Medicare, Medicare Sequestration, Pandemic, The CARES Act • Leave a comment
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Congress building

A collection of provider and payer groups are imploring Congress to continue a moratorium on Medicare payment cuts instituted under the sequester.

The letter (PDF), sent Friday by more than 20 groups to congressional leaders, is concerned that the moratorium installed under the CARES Act expires on Jan. 1. The groups want the moratorium to extend through the COVID-19 public health emergency, which has been renewed by the federal government several times.

The groups said that the moratorium needs to be extended as healthcare facilities are under massive financial stress with new surges of COVID-19.

The surge has impacted the “financial health of medical professionals and facilities, including increased cost of labor to ensure adequate staffing, procurement of personal protective equipment, significant reductions in patient volume resulting from orders to cancel non-emergent procedures and the high cost of caring for COVID patients,” the letter said.

Some of the groups signing on to the letter include the American Medical Association, America’s Health Insurance Plans, Federation of American Hospitals and American College of Physicians.

The groups said that the moratorium on the sequester cuts installed as part of the CARES Act was an acknowledgment from Congress over the important role that Medicare reimbursement plays in “the financial well being of our healthcare system.”

The sequestration cut Medicare payments by 2% across the board to all Medicare providers back in 2013.

The letter comes as Congress is pondering another relief package for COVID-19 during the lame-duck period. Senate Majority Leader Mitch McConnell said after the presidential election that he was open to restarting talks on a new relief package and added that hospitals will need some additional relief.

But McConnell said earlier this week that the same issues that have held up a deal with House Speaker Nancy Pelosi are still there.

“I don’t think the current situation demands a multi-trillion dollar package,” McConnell told reporters. “I think it should be highly targeted.”

But Pelosi has endorsed a larger package. The House passed the HEROES Act, a $3 trillion relief bill, several months ago.

Short-term ‘junk’ plans widely discriminate against those with pre-existing conditions, House probe finds

Posted on by • Posted in 2020 Election Issues, ACA, America's Health Insurance Plans (AHIP), Discrimination, Essential Health Benefits, Health Insurance Broker Commissions, Health Insurance Coverage Adequacy, Health Insurance Industry, Health Policy, Medical Loss Ratio (MLR), Out of Pocket Expenses, Preexisting Conditions, Short Term Health Insurance, Supreme Court • Leave a comment

https://www.healthcaredive.com/news/short-term-junk-plans-widely-discriminate-against-those-with-pre-existing/580556/

U.S. Rep. Castor's Statement Following a Federal Judge's Ruling on ...

Dive Brief:

  • A yearlong probe by the House Committee on Energy and Commerce into bare-bones insurance plans encouraged by the Trump administration found widespread discrimination against people with pre-existing conditions, even as a growing number are enrolled.
  • Top congressional Democrats investigated eight insurers selling short-term, limited duration plans, finding they all denied medical care claims if they found a consumer had a pre-existing condition. Some refused to pay for medical claims for no discernable reason, processing them only after consumers sued or complained to state regulators. Most rescinded coverage if they determined a member had a pre-existing condition or developed one later.
  • An HHS spokesperson defended the coverage as an affordable option to pricier Affordable Care Act plans, telling Healthcare Dive, “We’ve been abundantly clear that these plans aren’t for everyone.” America’s Health Insurance Plans made similar points, with spokesperson David Allen noting: “For Americans with pre-existing conditions, they may not be protected at all.”

 

Dive Insight:

The investigation looked at 14 companies that sell or market the plans, including eight insurers such as market giants Anthem and UnitedHealth Group, and six brokers.

It found insurers frequently turned down consumers with pre-existing conditions and discriminated against women, turning down applicants who were pregnant or planning to become pregnant and charging women more than men for the same coverage.

The plans had significant coverage limitations. Some excluded routine care like basic preventive visits and pelvic exams. Some plans had hard coverage cutoffs that left consumers with massive medical bills.

In one case, a consumer was billed a whopping $280,000 and lost coverage after being treated for an infection. The insurer said the patient previously had gotten an ultrasound that was “suspicious for deep venous thrombosis.”

AHIP spokesman Allen said it is not surprising given the plans are not intended to replace comprehensive coverage.

“They often do not cover the care and treatments that patients need throughout the year — preventive care, prescription drugs, mental health care or treatments for chronic health conditions — or if they do, they may limit or cap the benefits,” he acknowledged.

On average, short-term plans spend less than half of premium dollars collected from consumers on medical care: only 48%, the investigation found. That’s in stark contrast to plans in the ACA’s individual market, which are required to shell out at least 80% of all premium dollars on claims and benefits.

Short-term insurance represents a significant and growing share of the individual healthcare market. Roughly 3 million consumers bought the plans in 2019, a 27% growth from 2018, the investigation launched in March last year found.

The growth came after the Trump administration, in a controversial move, extended the maximum duration of the plans. The skimpy coverage, which isn’t required to cover the 10 essential benefits under the ACA, was originally designed as cheap safety net coverage for three months.

But in August 2018, HHS expanded the plans to 12 months, with a three year renewal period, and opened them up to all consumers, not just for those who can’t afford other coverage.

ACA supporters and patient advocates blasted the move, which sparked an ongoing legal challenge from safety net providers. Reports of consumers purchasing the coverage, believing it was comprehensive, then being shocked by balance bills prompted the House investigation.

The report also found brokers are paid up to 10 times more compensation for peddling short-term plans than ACA-compliant coverage. The average commission rate for short-term plans compared to ACA plans was 23% versus 2%, respectively.

Currently, 24 states ban or restrict the sale of short-term plans. Some states, including California, Massachusetts, New Jersey and New York, prohibit their sale entirely, while others like Colorado, Connecticut, New Mexico and Rhode Island have such strict regulations that no plans are sold.

Democratic leaders unveiled a bill on Wednesday to bolster the ACA and rescind the administration’s expansion of the plans and expand subsidies, allowing more people to qualify for coverage.

The effort has zero chance of moving this year with Republicans in control of the Senate, but both it and the probe are likely to play into the looming 2020 presidential and congressional elections.

“The heavy-handed tactics uncovered in this investigation demonstrate why Congress must reverse the Trump Administration’s expansion of these junk plans,” E&C Chairman Frank Pallone, D-N.J., Health Subcommittee Chairwoman Anna Eshoo, D-Calif., and Oversight and Investigations Subcommittee Chair Diana DeGette, D-Colo., wrote in a joint statement. “It also shows how dangerous a post-ACA world would be if Republican Attorneys General and the Trump Administration are successful in striking down the law and its protections.”

That lawsuit, led by 18 red states, argues the ACA, which expanded insurance to some 20 million people, is unconstitutional because a tax bill passed in 2017 zeroed out the penalty for its individual mandate. It’s currently pending before the U.S. Supreme Court.

President Donald Trump and his health officials have repeatedly promised people with pre-existing conditions will be protected if the ACA is struck down, but neither the administration nor Republicans in Congress have said specifically how.

 

 

 

 

 

Gladwell: COVID-19 should push healthcare to consider its ‘weak links’

Posted on by • Posted in America's Health Insurance Plans (AHIP), Health Insurance Industry, Health System, Hospital, Hospital Industry, Investment, Investments, Leadership, Social Determinants of Health, Strategy, Strong Link Approach, Supply Chain, Weak Link Approach • Leave a comment

https://www.fiercehealthcare.com/payer/malcolm-gladwell-covid-19-should-push-healthcare-to-consider-its-weak-links?mkt_tok=eyJpIjoiWlRJMk9UYzVZVFl4Tm1VMSIsInQiOiJ0aElzSllzTkpISWNIcU13ZXErNVdPSzU3K05cLzRVY2FEWFMycDNHZTZcLzlTYUo3UVNNQXd3ZjlwZXlFbVA3c3NQTHI0NFhqcjhFNk1VUXc4aVlnYW9aSnFVOVIydEFqWG5weWdEc2Viall1elwvK0RIRWtEajhPWGw3TEFTNDlkUCJ9&mrkid=959610

Gladwell: COVID-19 should push healthcare to consider its 'weak ...

The coronavirus pandemic has shown the healthcare industry that it needs to decide whether it’s playing basketball or soccer, journalist and author Malcolm Gladwell said. 

Gladwell, the opening keynote speaker at America’s Health Insurance Plans’ annual Institute & Expo, said the two sports exemplify the differences in thinking when one tackles problems using a “strong link” approach versus a “weak link” approach.

In basketball, he said, the team is as strong as its strongest, most high-profile players. In soccer, by contrast, the team is only as strong as its weakest players.

For healthcare organizations, that means making investments in the “weakest links”—such as harried clinicians who may need more training and low-income communities that cannot afford or access coverage—rather than the stronger links, like building out teaching hospitals and physician specializations.

“In healthcare, this is a chance for us to turn the ship around and say we can benefit far more from making health insurance more plentiful and more affordable,” Gladwell said. 

Gladwell emphasized that healthcare is far from the only industry to largely follow a “strong link” approach to improvement. In higher education, for example, much of the investment and funding goes to Ivy League institutions and other wealthy, top-performing universities.

Meanwhile, the education system could see significant benefits if it invested in the “weak links” like community colleges and bringing down tuition, Gladwell said. 

It’s a similar story in national security—and that “strong link” thinking led to two of the largest security breaches in American history, Gladwell said. Both Edward Snowden and Chelsea Manning were relatively low-ranking people within the security apparatus, but they were able to access critical files and release them.

“I would argue that ‘strong link’ paradigm has dominated every part of American society,” Gladwell said. “We have really put our chips down on the ‘strong link’ paradigm.” 

How could a “weak link” approach have impacted the response to the COVID-19 pandemic? Gladwell argues that, for instance, widespread testing is hampered by a lack of supplies like nasal swabs. Investment in the supply chain could have mitigated that challenge, he said.

The virus also disproportionately impacts people with certain conditions, notably diabetes. A broader focus on preventing and treating obesity could have had a large impact on how the pandemic played out, he said. 

“With this particular pandemic, I think we’re having a wake-up call,” Gladwell said.

 

 

 

COVID-19 could cost insurers up to $547B through 2021: report

Posted on by • Posted in America's Health Insurance Plans (AHIP), Coronavirus, Deferred Healthcare, Health Insurance Industry, Health Insurance Premiums, High Deductible Health Plans, High Premiums, High Prices, Infection Control, Infection Control Plan, Infectious Virus, Mortality, Pandemic, Public Health, Public Safety, Quarantine, Social Distancing • Leave a comment

https://www.fiercehealthcare.com/payer/report-covid-19-could-cost-insurers-up-to-546b-over-next-two-years?mkt_tok=eyJpIjoiWlRnNU16RmxOemM1WXpWaSIsInQiOiJ0TFFnRkR2OUVoQjY5SXArbjU0ZXVmcjJaMFdNWXZ6cXBHOGQxVzZ1dkxhMHJVK0t3dmRtcUVicFIrVDdlMUJPY3doWlQzeVN0VVZxakdnUFBHY2w2a0VVQ0s2WFI1anhqR2xvSFBtMDZZcVlaYVwvK2xlRWdcL01uQmFRVTA0VGtMIn0%3D&mrkid=959610

COVID-19 could cost insurers up to $547B through 2021: report ...

The estimated costs for treating COVID-19 could add up as much as $547 billion for private insurers from 2020 to 2021 depending on the rate of infection, an updated report found.

The report, released Monday from consulting firm Wakely and commissioned by insurance lobbying group America’s Health Insurance Plans (AHIP), looks at the utilization of medical services associated with a COVID-19 infection and the costs for such services. The analysis is restricted to insurers operating in commercial, Medicare Advantage and Medicaid managed care markets.

Wakely estimates that the pandemic could cost insurers between $30 billion and $547 billion.

The report explores the costs of COVID-19 based on a series of potential infection rates, which represent the total population infected. The study modeled infection rates based on 10%, 20% and 60%, while acknowledging that the true infection rate could be far lower.

Wakely then looked at the total costs the plan is liable to cover based on each infection rate.

A 10% rate would lead to a total cost of $30 billion to $92 billion from 2020 to 2021, and a rate of 20% would be $60 billion to $182 billion.

But an infection rate of 60% would cost insurers the greatest, with a range of $180 billion to $547 billion.

“We assume that a higher volume of COVID related services will be incurred in 2020 and lower volume in 2021, distributing approximately 75% of the total services to 2020 and 25% to 2021,” the study said.

Wakely notes it did not model any long-term costs for treating people recovering from COVID-19 infections.

The firm also didn’t factor in vaccine mitigation in 2021 nor a scenario in which large-scale infections occur throughout 2021.

While private insurers have waived cost-sharing for COVID-19 treatments, it remains unclear how long the waivers will last. Anthem and Molina announced Monday they will extend their cost-sharing waivers through the rest of 2020.

The report is an update to an earlier one distributed by Wakely back in March at the onset of the pandemic. That report pegged the total COVID-19 costs between $56 billion and $556 billion.

The main reason for the decline is Wakely factored in deferred care due to the pandemic.

Wakely also reduced the overall assumed rate of hospitalizations for COVID-19-infected individuals to align with more recent studies. But the estimated unit cost for a hospital admission also increased, based on survey data from AHIP members.

People have been putting off necessary care for fear of going to a doctor’s office, and hospital systems have canceled or postponed elective surgical procedures for months.

Hospitals have slowly started to resume elective procedures, but only after installing stringent requirements on cleaning and testing.

Insurers are bracing for a wave of healthcare utilization some time later this year or in 2021 to deal with this pent-up demand.

The deferred care costs would differ based on the infection rate of the virus.

“We assumed, particularly for higher infection rate scenarios, that there may be limited capacity to make up care in 2021,” the report said.

 

 

 

 

Insurers face uncertainty in setting 2021 premiums

Posted on by • Posted in ACA, America's Health Insurance Plans (AHIP), Coronavirus, Elective Procedures, Elective Surgery, Health Insurance Industry, Health Insurance Premiums, Health Insurance Refunds, Market Uncertainty, Medical Loss Ratio (MLR), Uncertainty • Leave a comment

https://www.healthcarefinancenews.com/news/insurers-face-uncertainty-setting-2021-premiums?mkt_tok=eyJpIjoiTldabE9UTTFZbU16TkRneSIsInQiOiI1djBwUWV6SVpzNlJtRUJEdXBEcEM1UkdGZWtvYTZpdkZ5V1NkTHhpNVFnVFwvR2FJSGlDTVVDcE5lTGtmTDhHY0hWQ05XU1NQNWt3UjRRYUtCOVZtS1ZoNG9SN2wxNU1xYmJVT1k5YWptY2hYVVBObCszNVhiREVFSERNT1hxRkMifQ%3D%3D

What To Do When Faced With Career Uncertainty

Insurers need to project the future cost of delayed elective procedures and total expenses of COVID-19 care.

While health insurers have saved money by the cancellation of elective surgeries and many are currently refunding excess revenue under the Medical Loss Ratio, premiums for the 2021 plan year are still in question.

There is a lot of uncertainty, America’s Health Insurance Plans said. Without comprehensive data, insurers are working to estimate 2021 healthcare costs and must base their rates on projected costs, AHIP explained in an infographic.

It is too soon to know what the real healthcare costs of COVID-19 will be. Also, delayed elective and non-urgent care will likely be delivered – and paid for – later.

That care could be more complex and costly because it was delayed, AHIP said.

WHY THIS MATTERS

Insurers are working to meet state deadlines to file 2021 premiums in the individual market.

THE LARGER TREND

Federal law requires insurers to spend 80-85 cents of every premium dollar on medical services and care. The rest, under the Medical Loss Ratio, may go towards administrative expenses, regulatory costs, federal and state taxes, customer service and other expenses.

The COVID-19 pandemic’s postponement of elective surgeries and regular care has created a surplus in revenue for insurers due to lower spending, which many are refunding now.

ON THE RECORD

“COVID-19 has had a very real impact on the economic, physical, and mental health of millions of Americans,” said Jeanette Thornton, senior vice president of Product, Employer, and Commercial Policy at AHIP.  “Our members are working through this uncertainty to strengthen access to affordable care as the fight against the coronavirus continues. COVID-19 dramatically changed the healthcare landscape–in 2020 and for years to come.

 

 

 

 

AHIP to insurers: Extend approvals for surgeries postponed by COVID-19

Posted on by • Posted in America's Health Insurance Plans (AHIP), Elective Procedures, Elective Surgery, Health Insurance Industry, Health System, Hospital, Hospital Industry • Leave a comment

https://www.beckershospitalreview.com/payer-issues/ahip-to-insurers-extend-approvals-for-surgeries-postponed-by-covid-19.html?utm_medium=email

New AHIP chief: Insurers are watching single-payer proposals closely

America’s Health Insurance Plans, the national trade association for health insurers, is telling members to extend prior authorizations for elective surgeries and procedures that were postponed due to COVID-19.

Some payers, like Anthem and UnitedHealthcare, have already extended prior authorizations for procedures that were delayed to curb COVID-19 exposure and to conserve medical resources for patients with the virus. AHIP’s board of directors is encouraging more health insurers to extend approvals for surgeries and procedures that were authorized before the national emergency declaration March 13.

“These grace periods will enable surgeries and procedures to be scheduled and performed without having to be re-authorized,” AHIP said. “Because circumstances will vary significantly by geography based on the incidence of COVID-19 and the availability of clinical resources, we encourage approvals to be valid for at least 90 days or until local backlogs are cleared.”