AMA: Nearly 70% of payer markets ‘highly concentrated’

http://www.healthcaredive.com/news/ama-nearly-70-of-payer-markets-highly-concentrated/507916/

Dive Brief:

  • A new American Medical Association (AMA) report found that one health insurer has at least a 50% market share in 43% of metropolitan areas. Nearly 90% of markets have at least one insurer with a 30% or greater market share.
  • Anthem, a major Blues payer and one of the largest insurers in the country, had the largest geographic footprint. The payer had the highest market share in 82 metropolitan areas.
  • The report found that 69% of markets are “highly-concentrated.”

Dive Insight:

The AMA study looked at where payer consolidation “may cause anti-competitive harm to consumers and providers of care.”

The authors said market concentration is a “useful indicator of competition and market power” and is an area the U.S. Department of Justice and Federal Trade Commission analyze when evaluating proposed mergers.

The annual report found a further consolidation of markets. The percentage of markets with one dominant insurer increased by 8% over the past two years.

Consolidation of insurers can affect premiums and reimbursements. A recent Health Affairs report found mergers involving hospitals, providers and payers resulted in insurers achieving more bargaining power to reduce provider prices in highly concentrated markets. That report said hospital admission prices were 5% lower in highly consolidated provider and insurer markets compared to those that are not as dense.

The AMA report warned along a similar theme. “We find that the majority of U.S. commercial health insurance markets are highly concentrated. These markets are ripe for the exercise of health insurer market power, which harms consumers and providers of care,” according to the report.

The AMA said major mergers like Anthem-Cigna and Aetna-Humana are reasons why the organization conducts the annual report. Neither merger ultimately happened, but they would have further consolidated the payer market.

The AMA warned about further consolidation. “Our findings should prompt federal and state antitrust authorities to vigorously examine the competitive effects of proposed mergers between health insurers. Given the uncertainty in predicting the competitive effects of consolidation, some mergers that are allowed cause competitive harm,” according to the report.

Anthem’s growing market share comes as the payer is creating policies that attempt to bring down health costs by pushing services away from hospital inpatient settings. Anthem announced this year that it won’t reimburse for emergency department visits deemed unnecessary and will no longer pay for MRIs and CT scans at hospitals in 13 states unless the tests are an emergency.

Given Anthem’s footprint, the payer’s new policies may mean other payers competing in the same markets will follow suit.

Medicare Advantage will have more enrollment, lower premiums in 2018

http://www.healthcaredive.com/news/medicare-advantage-will-have-more-enrollment-lower-premiums-in-2018/506293/

Dive Brief:

  •  The CMS says Medicare Advantage (MA) members will have more choices and lower premiums in 2018. Medicare open enrollment starts on Oct. 15.
  • The average MA monthly premium is expected to decrease by about 6% from $31.91 in 2017 to $30 in 2018. The CMS said 77% of MA enrollees who stay with their current plan will have the same or lower premiums in 2018.
  • MA’s enrollment is expected to increase by 9% to 20.4 million in 2018. The CMS expects that slightly more than one-third of Medicare enrollees will have an MA plan next year.

Dive Insight:

While the CMS has talked negatively about the Affordable Care Act (ACA), CMS Administrator Seema Verma is a big fan of MA. Verma (a candidate for HHS secretary in the wake of Tom Price’s departure) said MA and Medicare Part D “demonstrate what a strong and transparent health market can do — increase quality while lowering costs.”

Payers are enjoying positive financial numbers in the MA market. UnitedHealth Group said recently that it believes eventually half of all Medicare beneficiaries will have an MA plan. Payers are looking at the MA market for growth opportunities. In some cases, payers, such as Humana, are cutting back on ACA plans and investing more in MA.

Despite the CMS’ overall support of MA, the agency still sees one way to improve the program. The CMS wants MA payers to provide current and accurate information about their providers. The CMS found that 45% of MA provider directories had incorrect information, such as listing which providers are taking new patients, or providing the wrong phone numbers and addresses.

Currently, the CMS can only review MA plans’ provider networks when there is a triggering event. This can include when the insurance company starts in MA or extends its coverage, or the CMS receives a complaint about provider network issues. The CMS wants to have more oversight over provider network information, so that it can ensure the information is up to date.

While MA plans have been popular with the CMS, members and payers, there is a concern about a small number of payers monopolizing the market. The Kaiser Family Foundation said UnitedHealth controls nearly one-quarter of the MA market and is a major MA player in 42 states and the District of Columbia. KFF found UnitedHealth, Humana and Blue Cross Blue Shield affiliates make up 57% of MA enrollment and the top eight MA payers comprise three-quarters of the market.

Another issue for MA payers is that federal investigators are concerned about how much MA is paying insurers. The Department of Justice (DOJ) is investigating payments to insurance companies involved with MA.

Two of the bigger cases involve UnitedHealth. The payer is involved in two whistleblower lawsuits that allege MA overpaid the insurer by billions. The DOJ joined the lawsuits, which allege that UnitedHealth changed diagnosis codes to make patients seem sicker, which resulted in higher reimbursements to the insurer.

The CMS estimated that it overpaid $14.1 billion in 2013 to MA organizations. Medicare Advantage payers received about $160 billion in 2014. The CMS estimated about 9.5% of those payments were improper.

Why We Need Medicare for All

This is a pivotal moment in American history. Do we, as a nation, join the rest of the industrialized world and guarantee comprehensive health care to every person as a human right? Or do we maintain a system that is enormously expensive, wasteful and bureaucratic, and is designed to maximize profits for big insurance companies, the pharmaceutical industry, Wall Street and medical equipment suppliers?

We remain the only major country on earth that allows chief executives and stockholders in the health care industry to get incredibly rich, while tens of millions of people suffer because they can’t get the health care they need. This is not what the United States should be about.

All over this country, I have heard from Americans who have shared heartbreaking stories about our dysfunctional system. Doctors have told me about patients who died because they put off their medical visits until it was too late. These were people who had no insurance or could not afford out-of-pocket costs imposed by their insurance plans.

I have heard from older people who have been forced to split their pills in half because they couldn’t pay the outrageously high price of prescription drugs. Oncologists have told me about cancer patients who have been unable to acquire lifesaving treatments because they could not afford them. This should not be happening in the world’s wealthiest country.

Americans should not hesitate about going to the doctor because they do not have enough money. They should not worry that a hospital stay will bankrupt them or leave them deeply in debt. They should be able to go to the doctor they want, not just one in a particular network. They should not have to spend huge amounts of time filling out complicated forms and arguing with insurance companies as to whether or not they have the coverage they expected.

Even though 28 million Americans remain uninsured and even more are underinsured, we spend far more per capita on health care than any other industrialized nation. In 2015, the United States spent almost $10,000 per person for health care; the Canadians, Germans, French and British spent less than half of that, while guaranteeing health care to everyone. Further, these countries have higher life expectancy rates and lower infant mortality rates than we do.

The reason that our health care system is so outrageously expensive is that it is not designed to provide quality care to all in a cost-effective way, but to provide huge profits to the medical-industrial complex. Layers of bureaucracy associated with the administration of hundreds of individual and complicated insurance plans is stunningly wasteful, costing us hundreds of billions of dollars a year. As the only major country not to negotiate drug prices with the pharmaceutical industry, we spend tens of billions more than we should.

The solution to this crisis is not hard to understand. A half-century ago, the United States established Medicare. Guaranteeing comprehensive health benefits to Americans over 65 has proved to be enormously successful, cost-effective and popular. Now is the time to expand and improve Medicare to cover all Americans.

This is not a radical idea. I live 50 miles south of the Canadian border. For decades, every man, woman and child in Canada has been guaranteed health care through a single-payer, publicly funded health care program. This system has not only improved the lives of the Canadian people but has also saved families and businesses an immense amount of money.

On Wednesday I will introduce the Medicare for All Act in the Senate with 15 co-sponsors and support from dozens of grass-roots organizations. Under this legislation, every family in America would receive comprehensive coverage, and middle-class families would save thousands of dollars a year by eliminating their private insurance costs as we move to a publicly funded program.

The transition to the Medicare for All program would take place over four years. In the first year, benefits to older people would be expanded to include dental care, vision coverage and hearing aids, and the eligibility age for Medicare would be lowered to 55. All children under the age of 18 would also be covered. In the second year, the eligibility age would be lowered to 45 and in the third year to 35. By the fourth year, every man, woman and child in the country would be covered by Medicare for All.

Needless to say, there will be huge opposition to this legislation from the powerful special interests that profit from the current wasteful system. The insurance companies, the drug companies and Wall Street will undoubtedly devote a lot of money to lobbying, campaign contributions and television ads to defeat this proposal. But they are on the wrong side of history.

Guaranteeing health care as a right is important to the American people not just from a moral and financial perspective; it also happens to be what the majority of the American people want. According to an April poll by The Economist/YouGov, 60 percent of the American people want to “expand Medicare to provide health insurance to every American,” including 75 percent of Democrats, 58 percent of independents and 46 percent of Republicans.

Now is the time for Congress to stand with the American people and take on the special interests that dominate health care in the United States. Now is the time to extend Medicare to everyone.

Who’s driving health care law – a free market or insurance companies?

http://theconversation.com/republican-health-care-bills-defy-the-partys-own-ideology-80175?utm_medium=email&utm_campaign=Latest%20from%20The%20Conversation%20for%20July%201%202017%20-%2077496134&utm_content=Latest%20from%20The%20Conversation%20for%20July%201%202017%20-%2077496134+CID_7e419ab4ae6962d1afd6f9273e9cc417&utm_source=campaign_monitor_us&utm_term=Republican%20health%20care%20bills%20defy%20the%20partys%20own%20ideology

Image result for insurance company lobbyists health care reform

Does this make economic sense?

Republicans may be too timid or lack the votes to advance structural reform. And they may feel it necessary to prop up insurance companies struggling with the costs of insuring high-risk patients. That’s a fair calculation.

But are they ready to create a health care system that aids every group except the working poor? The wealthy will have their health care and their tax cuts. The middle classes will continue to enjoy expensive, generous insurance that’s indirectly funded through the tax code. And insurance companies will accept whatever assistance the government provides – from tax cuts to coverage penalty periods – to continue increasing their authority over the medical system.

That’s an arrangement that leaves out the very groups that are most desperate for health care reform: lower-income families and the working poor.

Health care fixes miss the mark

http://www.detroitnews.com/story/opinion/2017/04/23/valenti-health-care/100822732/

 

The phrase “repeal and replace Obamacare” might be in the news, but any new legislation regarding it means little for Michiganians.

Obamacare and the Republicans’ fix, the American Health Care Act, are almost entirely focused on the individual insurance market, yet the majority of Americans receive employer-sponsored health insurance coverage. More importantly, more than one million Metro Detroiters are covered by employers who “self-fund” or self-insure their employee health care benefits.

What does self-insure mean? It means your employer pays, right out of its annual budget, 100 percent of employee medical claims. Your card might read Blue Cross Blue Shield or Aetna, but the insurance company is simply the administrator who collects the claims and sends them off to your employer for payment.

Regardless of who is paying, rising health care costs are the No. 1 threat to American prosperity. Health care costs forced General Motors, Chrysler and the city of Detroit into bankruptcy; health care costs are the main reason wages have not grown in 20 years; and, Michigan spends 40 percent (and growing) of its annual budget on health care — crowding out spending on everything else.

But fixing our health care cost problem today doesn’t require a single action from Congress. Instead of marching on Washington and yelling at elected officials, we should be talking to our CEOs and heads of human resources.

Self-insured employers have tremendous power to change health care. Most employers simply outsource health care benefit construction to consultants and brokers — the same people who are compensated to perpetuate our high-cost health care status quo.

When the lame, status quo attempts at cost-control fail, the usual employer response is to cut, cut, cut. They resort to using an axe to prune rose bushes; high deductible health plans are blunt force instruments that do not sustainably control health care costs and will eventually exacerbate our cost problem.

Indeed, a few, truly innovative employers are providing better employee benefits and reducing health care costs 20-50 percent. If everyone followed their lead, it could result in $2,500 to $5,000 annual raises for each of us and immediately pump $2 billion to 4 billion into the Metro Detroit economy every year.

The solution isn’t a secret. In fact, a non-profit/501(c)(3) called the Health Rosetta was formed to publicize the simple fixes. The organization was spurred by a concerned citizen and the former global head of Microsoft’s health care business named Dave Chase.

The Health Rosetta identifies a few, easy to implement, specific improvements, the most important of which focuses on the intake or front-end of the system: primary care. Hence, the Health Rosetta’s foundation is called Value-Based Primary Care or Direct Primary Care. Other improvements are then built on top, such as “Transparent Medical Markets,” where patients receive up-front pricing and even quality guarantees on a range of surgeries and procedures.

These are the kinds of solutions employers should be considering as everyone wrestles with skyrocketing health care costs.

Tom Valenti is the founding partner of Forthright Health.

Obamacare’s Insurers Struggle for Stability Amid Trump Threats

https://www.bloomberg.com/politics/articles/2017-04-17/obamacare-s-insurers-struggle-for-stability-amid-trump-threats

Image result for Obamacare's Insurers Struggle for Stability Amid Trump Threats

Obamacare is stuck in limbo, and insurers and state regulators are struggling to set their plans for what’s increasingly shaping up as a chaotic year for the health-care program.

After the failure of Republicans’ first attempt to repeal and replace the Affordable Care Act and President Donald Trump’s subsequent threats to let the program “explode,” more health insurers are threatening to pull out next year, while others may sharply raise the premiums they charge. They’ll start to declare in the next few weeks whether they’re in or out.

Marguerite Salazar, Colorado’s insurance regulator, said that her state’s carriers, which include Anthem Inc. and Cigna Corp., haven’t said they’re leaving, though they don’t want to commit either.

“That’s my biggest fear, is that we would lose carriers in the individual market,” Salazar said. “We don’t want to set up an environment that would tell them, well, maybe we don’t need to be here.”

In Washington, Insurance Commissioner Mike Kreidler pushed back by a month the date when insurers have to say what they’ll offer. He’s urging them to stay and thinks most will, but “they’re not making commitments right now.”

“They’ve got those cards and they’re holding them close,” said Kreidler, a Democrat. “Right now, there’s so much uncertainty.” The fear is that they’ll follow the lead of Aetna Inc. and Wellmark Inc., which pulled out of Iowa’s Obamacare markets this month.

Trump’s Uncertainty

Much of the uncertainty is thanks to the Trump administration, which will play a key role in deciding whether the health law’s markets collapse or survive. Industry representatives — including company executives and insurance lobby CEO Marilyn Tavenner — are scheduled to meet Tuesday with Seema Verma, the head of the Centers for Medicare and Medicaid Services, the U.S. agency that oversees the law.

Trump’s latest threat has been to stop payments that subsidize co-pays and other upfront costs for lower-income people. Without them, insurers would likely boost their premiums or drop out entirely. The administration has refused to commit to keeping the payments going.

Health insurers see April 30 as a key deadline for a decision on the cost-sharing payments. They’ll start filing with some state regulators in May to say whether or not they’ll stay in the markets.

“Everybody is still in a wait-and-see mode,” said Kristine Grow, a spokeswoman for the industry group America’s Health Insurance Plans. AHIP and other industry groups are pushing the administration to commit to making the cost-sharing payments that Trump has threatened to halt. “Plans really need certainty,” she said.

 

Judge, Citing Harm to Customers, Blocks $48 Billion Anthem-Cigna Merger

Today a federal judge blocked the proposed $48 billion merger of giant health insurers Anthem and Cigna, just two weeks after another federal judge blocked the proposed $37 billion merger between Aetna and Humana. (That judge found Aetna had lied when it said its decision to pull out of Obamacare was triggered by mounting losses; it was triggered by its desire to merge with Humana.)

Both judges agreed with Justice Department that the mergers would violate antitrust laws — giving the combinations too much economic power to raise prices.

Both decisions will almost certainly be appealed by the companies. But Trump’s and Jeff Session’s Justice Department might back down and allow the mergers to proceed.

Which will reveal the underlying choice America faces: Either a private-for profit health insurance system run by a few giant corporations charging as much as possible, or a single-payer system run to keep Americans health at the lowest cost.

What do you think?