AIS Blogs | AIS Health

Will Contraceptive Mandate Impact Health Insurers?

By Jonathan Block - February 22, 2012 - Comments

Somewhat lost in the recent hubbub over the health reform law’s mandate that contraceptives be covered in health plans for employees of religious organizations is the impact it will have on health insurers. By and large, insurers have been publicly mum on the topic, though a spokesman for trade group America’s Health Insurance Plans did say, “We are concerned about the precedent this proposed rule would set.” Read more

Pharma, Providers Bear the Brunt of 2013 Budget Cuts

By Jill Brown - February 14, 2012 - Comments

When the White House said its proposed 2013 budget calls for more than $350 billion in cuts to HHS over 10 years, health insurers could be excused for assuming the worst, after getting a major hit in fees via the health reform law. But perhaps payers have suffered enough already. In the 2013 budget, “Pain is felt by pharma, providers, states and the ‘rich,’” say equity analysts Tom Carroll and Mark Kelly at Stifel Nicolaus. Read more

The End of Health Insurance Companies?

By Jonathan Block - February 6, 2012 - Comments

That was the headline of a blog opinion piece posted on The New York Times website on Jan. 30. With a title like that, how could the piece not be interesting? And although I personally disagree with some of their arguments, the authors, Ezekiel J. Emanuel and Jeffrey B. Liebman, both former advisors under President Obama, do make some valid points worth discussing. Read more

Aetna Goes For New Look, Focus in Quest to Enhance Consumer Appeal

By Jonathan Block - January 24, 2012 - Comments

“Madison Avenue” is not a term you might expect to be associated with health insurers, but an increasing number of carriers have boosted their marketing and advertising efforts lately. Just last week, Aetna launched a new look, rebranding its logo into all lowercase, purple letters with an eye toward being known not as an insurer but as a “health solutions company.” The aim of the campaign, according to Aetna, is to be known as a consumer-friendly brand. Read more

Are Insurers Prepared to Battle ACO Competitors?

By Jill Brown - January 18, 2012 - Comments

Speaking today at a webinar sponsored by AIS, Morningstar, Inc. analyst Matthew Coffina points to Steward Health Care System in Massachusetts as an example of the type of "increasingly powerful and well‐organized Accountable Care Organizations [that will] compete directly with insurers." Steward got its start in Massachusetts through the November 2010 acquisition of the six-hospital Caritas Christi chain. It now operates 10 hospitals in Massachusetts and is seeking regulatory approval to... Read more

CMS Report Shows Paltry Growth in Health Care Spending

By Jonathan Block - January 10, 2012 - Comments

If you are a health insurance executive, then the release Monday of a report by CMS on 2010 health spending was probably a good way to start your week. The annual report on national health expenditures (NHE) found that the increase in health spending was just 3.9% in 2010, the second-smallest increase in the growth rate since the NHE first was compiled in 1960. The smallest increase, 3.8%, was in 2009. Read more

What’s in a Name?

By Jennifer Lubell - February 15, 2012 - Comments

If folks in the health care industry continue on their hesitant path to use the term “Accountable Care Organization” in describing the latest agreement or venture to coordinate patient care, I may just have to change the name of my monthly newsletter. So long, ACO Business News. Hello…Clinical Integration Monthly? Or how about Health Care Delivery Innovation News? That has a ring to it. Read more

Final Exchange Regulations Are Expected This Month

By Steve Davis - February 10, 2012 - Comments

In the February issue of Inside Health Insurance Exchanges, I interview Joel Ario, who headed HHS’s Office of Health Insurance Exchanges until last September. Last month, he joined Manatt Health Solutions — a division of the law firm Manatt, Phelps & Phillips, LLP — as a managing director. This was his first in-depth interview on exchanges, and he had quite a bit to say on the topic. When it comes to insurance exchanges, by far the biggest complaint I hear is related to the snail-like pace... Read more

ACO Models Are Eyeing the Pediatric Population

By Jennifer Lubell - January 30, 2012 - Comments

We’ve all read about the quest to cover Medicare populations in accountable care, but as of late, I’ve been seeing more news items about kids being the focus of ACO-type models. Several efforts are under way in the private sector and at the state level to apply this concept to pediatric care. The Children’s Mercy Hospital (CMH) in Kansas City, Mo., recently sold its Medicaid HMO to fund a new payment and care delivery model called an Integrated Pediatric Network (IPN) that will assume global... Read more

HHS Will Certify Exchanges Next Year….but What Does That Mean, Exactly?

By Steve Davis - January 24, 2012 - Comments

The White House last week hailed 28 states — led by both Republican and Democratic governors — that “are on their way toward establishing” a health insurance exchange. So far, HHS has issued three rounds of establishment grants, collectively worth up to $729 million. But states might run out of time long before they run out of money. In less than a year, HHS must certify state insurance exchanges, which will begin enrolling members 10 months later and become operational on Jan. 1, 2014. Read more

Dearth of ACOs

By Jennifer Lubell - January 17, 2012 - Comments

As the “accountable care boom” strides on in certain parts of the country, no soil is being tilled at all, it seems, in other areas to grow these new models of care. A recent story in ACO Business News highlighted a white paper by Leavitt Partners’ Center for ACO Intelligence, which tracks national and regional trends related to ACOs and other emerging care delivery systems. As the white paper noted, some regions of the United States seem to be devoid of ACOs. “While ACO growth is extensive in... Read more

Allowing States to Choose Essential Benefits Could Push Exchange Development

By Steve Davis - January 12, 2012 - Comments

In a follow-up to a blog I posted last month, I thought I’d look into whether allowing states to define essential health benefits themselves, rather than having the feds create a national standard, could inspire some states to move forward on the development of an insurance exchange. A 13-page “bulletin,” issued by CMS’s Center for Consumer Information and Insurance Oversight on Dec. Read more

MA 'Flavor of the Week' Is Duals

By James Gutman - February 17, 2012 - Comments

Each year, there seems to be one issue that dominates presentations and questions during Medicare Advantage plan sponsors' quarterly earnings calls. In 2012 so far, this issue clearly is new initiatives to manage care and costs of Medicare-Medicaid dual eligibles. The interest is understandable, of course, since there are 9 million duals and only about 10% of them are in any form of managed care. Read more

The MA PPO Members That Nobody Wants

By James Gutman - February 10, 2012 - Comments

If there is a "hot potato" that Medicare Advantage plans want to avoid catching, it might just be non-HMO beneficiaries in Northern California. And if one leading securities analyst is right, Health Net, Inc. may have to take a bite out of that hot potato in 2012. The history began, as securities analyst Carl McDonald of Citigroup Global Markets writes in a Feb. Read more

How to Make a Prediction Come True by Really Trying

By James Gutman - February 3, 2012 - Comments

CMS might have done some creative thinking for its presentation of the Medicare Advantage 2012 Annual Election Period (AEP) results on Feb. 1. Back on Sept. 15, 2011, the agency had forecast, based on information it said was obtained from MA sponsors, that MA plan enrollment would climb 10% for 2012 from the 2011 level, a figure higher than predictions of industry analysts. But the AEP got off to a slow start, partly because of the new earlier time frame compared with in prior years, and even a... Read more

Here We Go Again on MA Pay — and at a Bad Time

By James Gutman - January 27, 2012 - Comments

The report issued by the Government Accountability Office (GAO) Jan. 26 on Medicare Advantage plan payment levels is a big problem for MA plans not only because of what it says but also when it comes. The report, requested by House Democrats, finds Medicare's methodology for paying MA organizations is flawed since beneficiary risk scores are much higher than they would be if the same beneficiaries were enrolled in fee-for-service. Read more

Wall Street Punishes Insurer for Deal That Would Improve It

By James Gutman - January 13, 2012 - Comments

Only in the alternate universe that is Wall Street would something like this make sense. Medicare Advantage insurer Universal American Corp. announced Jan. 11 a planned acquisition of APS Healthcare, Inc. that figures to help it substantially in competing for the coming huge contracts for Medicare-Medicaid dual eligibles as well as help boost its CMS star ratings. The purchase price of $227.5 million was a little bit on the high side but not out of range given recent transactions. Read more

Give CMS a Gold Star for Stars Transparency

By James Gutman - January 6, 2012 - Comments

Whatever else Medicare Advantage plans think about CMS, they will have to give the agency credit for one thing — being increasingly transparent about its regulatory initiatives. Just as it did in the past two years with scoring criteria for MA plans' Quality Improvement Projects and Chronic Care Improvement Programs, CMS late last month laid out what it is planning to do on star ratings for 2013 and beyond. Read more

By Angela Maas - February 9, 2012 - Comments

The FDA today issued three draft guidance documents on biosimilar development. Scientific Considerations in Demonstrating Biosimilarity to a Reference Product describes how the FDA will determine biosimilarity through a stepwise approach to evaluating evidence. Read more

The Footnote Heard ’Round the World

By Lauren Flynn Kelly - February 2, 2012 - Comments

The comment period for responses to HHS’s Dec. 16 bulletin on essential health benefits packages has just closed, and a variety of stakeholders have expressed concerns over the agency’s intent to give states “flexibility” in choosing an existing health plan to define the benefits that must be included in individual and small-group plans in 2014. Read more

Addressing the Disparity Between the Medical and the Pharmacy Benefit

By Angela Maas - January 27, 2012 - Comments

With specialty drugs being adjudicated under both the pharmacy benefit and the medical benefit, health plans can run the risk of incentivizing members to choose a drug based on their out-of-pocket cost share. According to data from The Zitter Group, 35% of 40 payers that have a cost-sharing level disparity between the two benefits said they were doing nothing to address that disparity. And of the 65 payers with a disparity in the prior-authorization application between the two benefits, 48%... Read more

Are Copay Cards as Bad as Everyone Says They Are?

By Lauren Flynn Kelly - January 19, 2012 - Comments

Last month Drug Benefit News ran a story on PBM and insurer tactics to combat the growing use of copay cards among members. As you may already know, these copay offset programs are loathed by PBMs for their potential to undermine tiered benefit designs and increase overall cost share. Read more

FTC Investigation Leads to Consent Order for CVS Caremark

By Angela Maas - January 12, 2012 - Comments

The FTC has concluded its investigation of a CVS Caremark Corp. subsidiary’s actions related to the Medicare Part D prescription drug program. The PBM will enter a consent order that requires it to pay $5 million into a fund intended for compensation to consumers who purchased coverage from Rx America for the 2008 plan year. Read more

2012 Outlook: Plans, PBMs Talk Pharmacy Trends in New DBN

By Lauren Flynn Kelly - January 5, 2012 - Comments

For our first issue of the New Year, Drug Benefit News surveyed a range of PBM executives, health plan pharmacy directors and consultants to get an idea of what’s on trend, where companies are putting their investment dollars and what’s keeping them up at night. You can find their answers in a series of “Outlook 2012” stories in tomorrow’s issue. One of the topics I had anticipated would stir up the most conversation is the trend of limited pharmacy networks, which was getting a lot of buzz... Read more

ICD-10 Delay May be Mixed Bag

By Nina Youngstrom - February 17, 2012 - Comments

By now, most people probably know that HHS has delayed the October 2013 implementation date of ICD-10 diagnosis and procedure codes. While HHS apparently responded to concerns raised by some sectors of the industry, the jury is still out on whether the delay will serve providers well. On the one hand, the transition to ICD-10 can be overwhelming, and the delay helps providers ease into it. Read more

Physicians Put on Notice

By Francie Fernald - February 9, 2012 - Comments

Physicians received two important notices recently, one from CMS issued Feb. 3, and the other from the HHS Office of Inspector General, issued Feb. 8. The CMS notice is Trans. 2407, which takes effect on April 1. It establishes a new national policy for assignment of place of service (POS) codes. In essence, the POS is where the patient receives the face-to-face service. Read more

Link Gets Stronger Between Payment and Quality

By Nina Youngstrom - February 1, 2012 - Comments

About five years ago, CMS started down the road toward penalizing hospitals for less-than-optimal patient outcomes with potential DRG cuts for hospital-acquired conditions (HACs). But as CMS implements new quality-related programs, such as value-based purchasing, readmission reductions and HACs for Medicaid, and sharpens its knives under existing programs (e.g., the worst HAC offenders will face bigger MS-DRG losses), hospitals will start to really feel the connection between quality and... Read more

Medicare Quarterly Provider Compliance Newsletter Published

By Francie Fernald - January 26, 2012 - Comments

CMS has released its second FY 2012 issue of the Medicare Quarterly Provider Compliance Newsletter (Vol. 2, Issue 2, January 2012). This issue of the newsletter highlights major findings identified by RACs in audits of inpatient hospitals and DME suppliers. It is a good heads-up for providers on hot compliance issues and provides some guidance and resources to help tackle the problem. If you are trying to identify topics for training sessions, this is a good place to start. Read more

OIG Unveils More Stark, Kickback-Related Civil Monetary Penalty Settlements

By Nina Youngstrom - January 20, 2012 - Comments

There’s been no shortage of hospital civil monetary penalty (CMP) settlements for alleged Stark and kickback violations, most of them stemming from self-disclosures. The HHS Office of Inspector General rolled out a number of them in late December, and the settlement amounts aren’t small potatoes. For example, Westfields Hospital in Wisconsin agreed to pay $204,150 to resolve allegations that it violated the CMP law in connection with providing space, services and supplies to four physician... Read more

How About an Appreciate Compliance Officers Day?

By Francie Fernald - January 11, 2012 - Comments

While this probably is not news to compliance officers, the results of a recent survey conducted by the Society of Corporate Compliance and Ethics and the Health Care Compliance Association indicate that their jobs are unusually stressful. Read more