Sutter Health|Aetna adds Stanford Health Care to network

https://www.healthcarefinancenews.com/news/sutter-healthaetna-adds-stanford-health-care-network?mkt_tok=eyJpIjoiWldGbU16WmxOak00TmprMiIsInQiOiIzeGkycUpwcmtPUk42Z2R0b1k4RHd0NUVoY0k3UmE5TktUSkhMUzVtNVVWOWtWY3BhWkdUbjcrZndNS0tZRnA1cWFSajhWdmlZcUc4VE5DbFB4VEZNNkJyYTkyXC9XK3hxZVMwVzhSaVF2ZjZIdUFjbzZwcnF6aGE0UmowZ2w1eHcifQ%3D%3D

Image result for healthcare market consolidation

The joint venture between provider and payer, which launched last year, has grown to about 50 plan sponsors across 15 counties.

Sutter Health|Aetna has added Stanford Health Care to its network of providers.

Sutter Health|Aetna is the joint venture launched last year between the Sacramento, California-based health system and the national insurer. It offers self-insured preferred provider organization health plans to businesses in the Northern California area.

It has grown to about 50 plan sponsors across 15 counties.

WHY THIS MATTERS

This represents another expanded partnership between a provider and payer, though this is in the commercial space.

Other recent partnerships, such as the one announced between Duke Health and Blue Cross Blue Shield of North Carolina, have capitalized on the Medicare Advantage market.

Stanford Health Care recently launched a Medicare Advantage plan with Lumeris called the Stanford Health Care Advantage, in northern California.

The partnerships allow providers and insurers to expand their reach and get access to population health data to lower costs and improve outcomes.
The addition of Stanford Health Care gives Sutter Health|Aetna’s network members in Northern California access to the network’s more than 1,500 specialists and nearly 200 primary care physicians throughout the San Francisco Bay Area.

THE TREND

With the addition of Stanford Health Care, the Sutter Health|Aetna joint venture features two nationally recognized healthcare systems and access to a Northern California network that includes 33 hospitals, more than 1,700 primary care physicians, more than 9,400 specialists, 74 urgent care locations and 25 walk-in clinics.

ON THE RECORD

“The inclusion of Stanford Health Care, with its physicians from across Stanford Medicine, to our high-quality network will not only expand the provider network for our plan sponsors and members, but also provide access to another highly ranked health care system,” said Steve Wigginton, CEO of Sutter Health|Aetna. “This addition will help us in our goal to create a unique offering for Northern California employers and their employees centered around a superior consumer experience and market-leading value.”

 

 

How Medicare Advantage steers the Silver Tsunami into coordinated, value-based care

https://www.healthcarefinancenews.com/news/how-medicareadvantage-steers-silver-tsunami-coordinated-value-based-care

CMS and other health insurers are using the program to deliver innovative and unique value to customers, both in terms of cost and quality.

Today’s Medicare Advantage plans are flourishing and the Silver Tsunami is among the reasons.

“Over the last four years, Medicare Advantage enrollment increased by more than 30 percent, while the number of people eligible for Medicare grew by about 18 percent,” said Steve Warner, vice president of Medicare Advantage Product for UnitedHealthcare Medicare and Retirement.

Other reasons for the growth: Innovative models from big insurers and upstarts alike that improve care for health plan members and drive revenue for payers as they look beyond fee-for-service.

IT STARTS WITH THE CONSUMER

Consumers are finding unique value in MA, both in terms of the quality of care and in the financial value.

Medicare Advantage, in fact, makes it easier for consumers to navigate the healthcare system and choose providers, in a way that traditional Medicare does not, said those interviewed.

“Actually it’s pretty hard to navigate the healthcare system on your own,” said Tip Kim, chief market development officer at Stanford Health Care. “Most Medicare Advantage plans have some sort of care navigation.”

Warner of UnitedHealth’s Warner added that Medicare Advantage also offers value and simplicity.

“It provides the convenience of combining all your coverage into one plan so you have just one card to carry in your wallet and one company to work with,” Warner said. “Most plans also offer prescription drug coverage and additional benefits and services not available through original Medicare, including dental, vision and fitness.”

REBRANDING FOR THE NEW ERA

MA plans did not emerge out of thin air. By another name, Medicare Advantage is managed care, a term that was the bane of healthcare during the height of HMOs in the 1980s.

“Medicare Advantage has rebranded ‘managed care’ to ‘care coordination,'” said consultant Paul Keckley of The Keckley Report. “Humana and a lot of these folks have done a pretty good job. Coordinating care is a core competence. Managed care seems to be working in this population.”

MA came along at the right time for CMS’s push to value-based care.

“I would suggest on the providers’ side, embracing Medicare Advantage is an opportunity to get off the fee-for-service mill,” said Jeff Carroll, senior vice president of Health Plans for Lumeris, which recently paired with Stanford Health Care on the Medicare Advantage plan, Stanford Health Care Advantage.

“Provider-sponsored Medicare Advantage plans are a way to put teeth into an accountable care organization,” Keckley added. “Medicare Advantage success is a silver tsunami among major tsunamis. Obviously it’s a profitable plan for seniors and profitable for underwriters. The winners in the process will get this to scale.”

MA is an innovative model that is not a government-run system, but a privately-run system essentially funded by the government.

PAYERS IN THE MA GAME

UnitedHealthcare has the largest MA market share of any one insurer.  Twenty-five percent of Medicare Advantage enrollees are in a UnitedHealthcare MA plan, followed by 17 percent in Humana, 13 percent in a Blue Cross Blue Shield and 8 percent in Aetna, according to the Kaiser Family Foundation.

Numerous insurers, in fact, have gotten into the MA market, including Clover Health in San Francisco, a five-year-old startup which has Medicare Advantage as its only business.

Clover is a tech-oriented company that boasts machine learning models that can accurately predict and identify members at risk of hospitalization.

Because Clover focuses only on MA, it can do a better job at problem solving the needs of an older population, said Andrew Toy, president and CTO of Clover Health.

“The problems we face in Medicare Advantage are very different from a younger generation,” Toy said.

Forty percent of the older population is diabetic. Most seniors will be dealing with a chronic disease as they get older.

In other insurance, whether its individual or commercial, the lower cost of the healthier population offsets the cost of the sicker population. MA has no way to offset these costs. Plans can’t cherry-pick consumers or raise premiums for a percentage of the population.

What MA plans can do is design plans that fit the varying needs of the population. A plan can be designed for diabetics. For younger seniors or those not dealing with a chronic disease, a plan can be designed that includes a gym membership.

“All these plans are regulated,” Toy said. “We have the flexibility to move dollars around. We can offer a higher deductible plan, or a nutrition plan. The incentives for us in Medicare Advantage are different than the incentives in Medicare. CMS has explored giving us more leeway for benefits. Consumers have a choice while still having the guarantees of Medicare.”

Toy believes regular Medicare is more expensive because MA offers a more affordable plan based on what an individual needs.

“When you need it, we get more involved in that care,” Toy said, such as “weight control issues for diabetics.”

The drawbacks are narrower networks, though Toy said Clover offers an out-of-network cost sharing that is pretty much in line with being in-network.

UnitedHealthcare’s Medicare Advantage LPPO plans offer out-of-network access to any provider who accepts Medicare, Warner said.

UnitedHealthcare also offers a wide variety of low and even zero-dollar premium Medicare Advantage plans and annual out-of-pocket maximums, Warner said. By contrast, original Medicare generally covers about 80 percent of beneficiaries’ healthcare costs, leaving them to cover the remaining 20 percent out-of-pocket with no annual limit.

“From a consumer value proposition, it makes Medicare Advantage a better deal,” Kim said. “One is Part B, 20 percent of an unknown number. Knowing what the cost will be in a predictable manner is a preferable manner.”

Stanford Health Care launched a Medicare Advantage plan in 2013. Lumeris owned and operated its own plan, Essence Healthcare, for more than eight years. Stanford and Lumeris partnered on Stanford Health Care Advantage in northern California, using Lumeris technology to help manage value-based reimbursementand new approaches to care delivery through artificial intelligence-enabled diagnostic tools and other methods.

“We are not a traditional insurance company,” Kim said. “We’re thinking about benefits from a provider perspective. It’s a different outlook than an insurance company. By definition we’re local.”

MA MARKET STILL HAS ROOM TO GROW

While the Medicare Advantage market is competitive, it is also under-penetrated, Brian Thompson, CEO for UnitedHealthcare Medicare & Retirement, said during a 2018 earnings report.

Currently, about 33 percent of all Medicare beneficiaries are in an MA plan, he added, but UnitedHealth sees a path to over 50 percent market concentration in the next 5-10 years.

It’s a path not so subtly promoted by the Centers for Medicare and Medicaid Services.

As a way to encourage insurers to take risk and get in the market, around 2009, CMS gave MA insurers 114 percent of what it paid for fee-for-service Medicare. The agency began decreasing those payments so that by 2017, traditional Medicare and MA became about even.

MA insurers instead thrive on their ability to tailor benefits toward wellness, coordinate care and contain costs within the confines of capitated payments, the essence of value-based care.

They have received CMS support in recent rate notices that gives them the ability to offer supplemental benefits, such as being able to target care that addresses the social determinants of health. Starting in 2020, telehealth is being added to new flexibility for these plans.

WHAT THE FUTURE MAY HOLD FOR MA

Medicare Advantage plans have expanded and, in so doing, opened innovative new options for plans and their customers alike at the same time that the ranks of people eligible for Medicare continues to swell.

So where is it all going?

Medicare Advantage is changing the way healthcare is paid and delivered to the point that Keckley and Toy agreed the future may not lie in Medicare for All, but in Medicare Advantage for all.

“I think a reasonable place to end, is in some combination where the government is involved in price control, combined with the flexibility of Medicare Advantage,” Toy said. “That’s really powerful.”

 

 

Former Aetna CEO on being a “radical capitalist” and the current state of health care

https://finance.yahoo.com/video/former-aetna-ceo-being-radical-164919638.html?utm_source=Sailthru&utm_medium=email&utm_campaign=Issue:%202019-03-20%20Healthcare%20Dive%20%5Bissue:19979%5D&utm_term=Healthcare%20Dive

Image result for Former Aetna CEO on being a "radical capitalist" and the current state of health care

Former Aetna CEO Mark Bertolini spent 8 years as company head until 2018 when the insurance giant was sold to CVS. He joins Yahoo Finance’s Adam Shapiro, Julie Hyman, and Julia La Roche to discuss his new memoir “Mission-Driving Leadership: My Journey As A Radical Capitalist.”

 

 

 

 

Aetna, Anthem, Health Care Service Corporation, PNC Bank and IBM announce blockchain network

https://www.healthcarefinancenews.com/news/aetna-anthem-health-care-service-corporation-pnc-bank-and-ibm-announce-blockchain-network?mkt_tok=eyJpIjoiT0RJNU16UTNOakl4WlRFNCIsInQiOiJ1WHRTRHREbE5rM1hkZmc1QnRcL3JCSjdxMWdtXC9weGE1OE4yT0tMZ2d0eGVCYnlXbkVDSmVtU09UTzZDaUVSTmE2aVRpT1YzSklCVmVsZ3VaMWVyMDlNa1Z2b25DbXZ2QnpxSUpySWluXC8zSDRoTmkya2JCMU53b1h5YkRQUDlNcyJ9

Network will eventually be open to new members for secure digital sharing of healthcare information.

Aetna, Anthem, IBM, Health Care Service Corporation and PNC Bank have partnered to create a blockchain technology network aimed at improving transparency and interoperability in the healthcare industry. 

The groups intend to use blockchain for more efficient claims and payment processing. Blockchain enables the secure exchange of information. It will also benefit more accurate provider directories.

WHY THIS MATTERS

Collaboration is key in the industry as a more cost-effective alternative to merging to create more competitive and efficient systems.

The current network is expected to add additional health organizations in the coming months, including providers, startups, and technology companies.

Initial members include three of the nation’s largest insurers, Anthem; HCSC,a customer-owned health insurer that includes Blue Cross and Blue Shield plans; Aetna, which is now part of the CVS Health business; IBM, which is a leading blockchain provider; and PNC Bank, which is a member of The PNC Financial Services Group.

Blockchain technology gives health systems an edge because it ideally creates faster, more efficient and secure claims and payment processing.

Insurers are mandated to maintain accurate provider directories, a time consuming and often manual practice involving numerous emails, phone calls and even fax exchanges.

For providers, a new technology that can actually reduce time spent in administrative clicks on a computer is a boon.

THE TREND

Despite major initiatives to digitize healthcare information, improvements in transparency and interoperability are still needed for that data to be shared.

Blockchain is designed to fill that role, reducing administrative errors and costs and ultimately enhancing patient care. The network also enables the companies to build and deploy new solutions.

Walmart last year filed a patent to use blockchain for medical records. A pharmaceutical industry consortium called the MediLedger Project, launched in 2017, is using blockchain to track pills across the supply chain, according to Fortune.

ON THE RECORD

“Through the application of blockchain technology, we’ll work to improve data accuracy for providers, regulators, and other stakeholders, and give our members more control over their own data,” said Claus Jensen, chief technology officer at Aetna

Rajeev Ronanki, Anthem chief digital officer Rajeev Ronanki: “Timely access to medical information has been a stumbling block for creating a seamless consumer experience. With a trusted foundation based on transparency and cryptography, we will provide a faster, safer and more secure way to exchange medical information to transform the  consumer healthcare experience.”

What’s more, blockchain will enable large networks to exchange health data in a transparent and controlled way, according to Lori Steele, general manager for Healthcare and Life Sciences for IBM.

“Using this technology, we can remove friction, duplication, and administrative costs that continue to plague the industry,” added Chris Ward, head of product, PNC Treasury Management.

 

Medicare Advantage industry sees slower growth for 2019

https://www.modernhealthcare.com/article/20190116/NEWS/190119927/medicare-advantage-industry-sees-slower-growth-for-2019

Image result for Medicare Advantage industry sees slower growth for 2019

Medicare Advantage insurers added 1.4 million members to their rosters for 2019 coverage, as they looked to grow membership in a market known for being politically safe and predictably lucrative. But Advantage membership is growing at a slower pace compared with previous years. 

According to the latest federal data showing enrollment as of this month, 22.4 million people are enrolled in Medicare Advantage for 2019 coverage—an alternative to the traditional Medicare program in which private insurers contract with the federal government to administer program benefits. That’s an increase of 6.8% since January 2018. Health insurers, however, managed to grow their Advantage membership base by more than 1.5 million in both 2016 and 2017.

Some industry experts were expecting more. “The formula was there: Health plans were aggressive, they got nice rate increases, the rules around benefit design relaxed a little bit,” explained Jeff Fox, president of Gorman Health Group, which provides technology and other services to Medicare Advantage plans.

Fox expected Advantage enrollment to increase by double-digits over the past year, as health plans invested heavily in marketing and the federal government provided one of the biggest rate increases for the plans in years at 3.4%. The Trump administration also granted Advantage plans the flexibility to provide more supplemental benefits in 2019, such as transportation and in-home care.

But Fox said distraction from the craziness of the November midterm elections may have kept some seniors from enrolling during the annual open enrollment that lasted from Oct. 15 to Dec. 7, 2018. While the CMS data captures some of the sign-ups from open enrollment, figures out next month are likely to be higher.

Despite the slower pace, many Advantage insurers still experienced big enrollment increases as they picked up more market share. About half of all members are covered by just three companies. UnitedHealth held onto the top spot, adding nearly 500,000 Advantage members in the past year for a total 5.7 million. UnitedHealth holds more than a quarter of the total Medicare Advantage market share.

Humana remained the No. 2 Advantage insurer with 3.9 million members, an increase of 10.4% over January 2018. But thanks to its acquisition of Aetna, CVS Health took the No. 3 spot with 2.2 million Advantage enrollees. Kaiser Foundation Health Plan and Anthem rounded out the top five insurers with the most Advantage members.

On a percentage basis, Anthem and Aetna grew membership the fastest. Anthem’s Medicare Advantage membership spiked 53% to 1.1 million members compared with the same time last year. The Indianapolis-based insurer has long focused on serving employers, but recently turned its sights to growing Medicare Advantage rolls through acquisitions and expansions in places where it already operates.

Anthem bought Florida-based Medicare plans HealthSun in December 2017 and America’s 1st Choice in February 2018, together giving Anthem about 170,000 more Advantage members. Anthem CEO Gail Boudreaux told investment analysts in July that the company would focus on selling group Medicare Advantage plans and serving medically complex dual-eligible members in 2019.

CVS Health, meanwhile, grew its Medicare membership by 26.7% in 2018 to 2.2 million through its acquisition of Aetna. The deal is still technically awaiting a federal judge’s approval. In a research note Monday, Barclays equity analyst Steve Valiquette noted that Aetna’s membership growth was driven by its expansion into about 360 new counties. Valiquette wrote that the growth experienced by some public health insurers during the annual enrollment period for 2019 coverage was driven more by market share gains than by industry growth.

Medicare Advantage enrollment is climbing as the baby boomer generation ages rapidly into Medicare. Those seniors are used to employer-sponsored managed-care plans and are choosing Advantage over traditional Medicare more often than previous generations did. Seniors also often get more benefits, including dental care, eyeglasses and gym memberships, with an Advantage plan. 

Medicare Advantage also enjoys support from both political parties and is able to weather swings from one federal administration to the next, whereas insurers that sell plans in the individual market, for example, may have to deal with more volatility.

Moreover, Medicare Advantage margins tend to hover between 4% to 5%, whereas Medicaid margins come in at 2% to 3% and the individual market historically has had even lower margins, S&P analyst Deep Banerjee told Modern Healthcare in August. The group employer business has higher margins, but that market isn’t growing like Medicare Advantage is.

 

 

 

Insurers blame specialty drug costs for rising premiums. This report from California shows why

https://www.fiercehealthcare.com/payer/report-prescription-drug-costs-driving-up-insurance-premiums?mkt_tok=eyJpIjoiWWpZNU4yTTROREExWlRsaSIsInQiOiJjZHh5VGpsWnhSN3RLQjNHbDNsWUROQkg0Y2EzOFZ3OFY2Z0Z1a1dFNVhwNkRXNTE3dTNMK0U2TloxUnFKT1RDU29cL3NEZ0gwMTdJbUptaTFxamFTbFg1cG1PbFRHbTQ2TmQzRHhYZERqcUZXQ1B0YVF1aW1QODBDb2g3aHA1cEwifQ%3D%3D&mrkid=959610&utm_medium=nl&utm_source=internal

Drugs and money sign

Specialty drugs made up about 3% of prescriptions in California in 2017 but accounted for more than half of the prescription drug spending that year, according to new report that compiled drug spending from nine insurers in that state.

According to the first Prescription Drug Cost Transparency Report released by the California Department of Insurance, there were about 270,000 specialty prescriptions compared to about 1.4 million brand-name prescriptions and about 8.9 million generic prescriptions in 2017.

Insurers—including Aetna, Anthem, Cigna, Kaiser Permanente and UnitedHealthcare—reported spending upwards of $606 million on specialty drugs, $271.3 million on brand-name drugs and $172.6 million on generics in 2017.

Among other findings, the report said:

  • In all, insurers reported that per member per month drug spending reached about $81 last year, or about 16.5% of premiums in 2017, comparable to per member per month spending of about $76 or 16.3% in 2016. Total health insurance premiums per member per month were about $491 in 2017, compared to about $470 in 2016.
  • Specialty prescriptions on average cost about $2,361 per prescription compared to about $236 for brand-name prescriptions and $29 for generics. Members typically pay about $113 per specialty prescription while insurers said they pay about $2,248 per specialty drug. They report members pay about $45 per brand-name drug, while insurers pick up $192 of the tab for brand names. And they report members typically pay about $10 for generics on average while insurers pay about $19.
  • The top 25 most frequently prescribed drugs in California represent about 40% of insurers’ overall spending. Specialty drugs make up about 1.3% of the 25 most frequently prescribed drugs and about 20% of insurers’ spending (resulting in a 3.7% impact on health insurance premiums.) In comparison, brand-name drugs make up about 6.8% of the most frequently prescribed drugs and about 11% of insurer spending (and a 1.2% impact on health insurance premiums). Generics represent about 32% of the most frequently prescribed drugs and 4% of the cost to insurers (and about .3% impact on premiums.)

The most frequently prescribed specialty drugs included HIV drug Truvada, immunosuppressant Humira, insulin therapeutic Humalog, diabetes drug Victoza and hormonal agent Androgel.

The most costly specialty drugs by total annual prescription drug spending included Humira, arthritis drug Enbrel, Truvada, psoriasis and psoriatic arthritis drug Stelara and multiple sclerosis drug Copaxone.

 

 

 

California approves CVS, Aetna merger contingent upon premium promise and $240 million investment

https://www.healthcarefinancenews.com/news/california-approves-cvs-and-aetna-merger-contingent-upon-premium-promise-and-240-million?mkt_tok=eyJpIjoiWlRFeU9UTTNaVFV4TkdZMyIsInQiOiJQN0NaY1wvemcra3IwT08wMzYxOVpuSVd4WWE3TTNDRHluT1VHU3Y0SDVuUTJ0WTdZUG9QQVhQUDlNN0FEbFFIWCs1YU5nUDRZKzNUbnUrbkpNSUlCcituNlQ2Uklyem41d0lHaWdnSVd4V0xwNEhHSFRMNFZ1NVk0UlwvRUVZTkt4In0%3D

New York State still needs to clear the $69 billion deal that CVS said it expects to close by Thanksgiving.

A California regulator has cleared the way for CVS Health to acquire Aetna.

Thursday, the California Department of Managed Health Care Director Shelley Rouillard approved the acquisition on the promise that CVS and Aetna agree not to increase premiums as a result of acquisition costs. The agreement states premium rate increases overall would be kept to a minimum.

The plans also agree to invest close to $240 million in California’s healthcare delivery system, according to the press release from the Department of Managed Healthcare.

The money includes $166 million for state healthcare infrastructure and employment, such as building and improving facilities and supporting jobs in Fresno and Walnut Creek.

Another $22.8 million would go to increase the number of healthcare providers in underrepresented communities by funding scholarships and loan repayment programs.

An estimated $22.5 million would support joint ventures and accountable care organizations in the delivery of coordinated and value-based care.

WHY THIS MATTERS

California represents one of the last hurdles for the $69 billion merger that CVS has said it expects to see closed by Thanksgiving.

The New York State Department of Financial Services has yet to issue a decision after holding an October 18 hearing on the application.

THE TREND

The Department of Justice has already said that there are no barriers to the companies completing the merger, once CVS and Aetna sell Aetna’s Medicare Part D plans. Aetna is divesting the prescription drug plans to WellCare.

California held a public meeting on the merger on May 2.

ON THE RECORD

“Our primary focus in reviewing a health plan merger is to ensure compliance with the strong consumer protections and financial solvency requirements in state law,” Rouillard said. “The department thoroughly examined this merger and determined enrollees will have continued access to appropriate healthcare services and also imposed conditions that will help increase access and quality of care, remove barriers to care and improve health outcomes.”