Category: Health plans

How does COVID-19 change Medicare Advantage?

published date
June 29th, 2020 by

Medicare eligible Americans have borne the brunt of coronavirus. Some of the immediate impact on Medicare Advantage plans is obvious. They are covering telehealth and paying for acute hospital stays.

But there are longer term implications, too. Their risk adjustment scores are thrown off by the lack of visits. Certain supplemental benefits (think gym membership!) no longer sound so healthy, while others (meal delivery) become super valuable.

In this episode of #CareTalk, CareCentrix CEO John Driscoll and I lay it all out,

Interoperability for health plans. Interview with WK’s Karen Kobelski

published date
June 5th, 2020 by
kobelski
Karen Kobelski of Wolters Kluwer Health

The 21st Century Cures Act (signed by President Obama in 2016) set out to make healthcare more patient-centric and increase patient access to medical records held by health plans. Implementation is occurring this year and health insurers need to improve interoperability in order to meet the requirements.

In this podcast interview, Karen Kobelski, who runs Wolters Kluwer Health’s Clinical Surveillance, Compliance & Data Solutions business unit explains what plans are doing and how her organization is helping.

Here are some of the topics we covered:

  • What are some of the key challenges health plans face in gathering and managing data?
  • There has been talk of interoperability for many years —but seemingly little progress. What does interoperability mean in the context of health plans?
  • The 21st Century Cures Act addressed interoperability. What was the aim? How are the rules being implemented?
  • COVID-19 is affecting everything in healthcare and in society more broadly. How does the interoperability imperative for payers change when viewed through the lens of the pandemic?
  • What role does Wolters Kluwer Health play in interoperability for health plans? Can you give me an example of a client success story?

By healthcare business consultant David E. Williams, president of Health Business Group.

Why is UnitedHealth rebating insurance premiums?

published date
May 11th, 2020 by
twenty percent off 1424812 1280
Tell me something good!

It’s no surprise why auto insurers like State Farm and Geico are sending rebates to customers this spring and summer. No one’s driving, so accident claims are way down and insurers are paying out very little. No one expects drivers to make up for lost time by crashing their cars more often once they return to the roads. That means a dollar saved now on claims is a dollar saved forever. Insurance companies and state insurance commissioners realize this, too and that’s why the rebates are coming.

But you might be surprised that health insurers, starting with UnitedHealth are beginning to do the same thing. United is offering a 5 to 20 percent credit on June billing statements, which is the same order of magnitude as the auto insurers.

So the questions are:

  1. Aren’t insurers spending a fortune on the surge of COVID-19 patients as they overwhelm the medical system?
  2. What about the coming surge of deferred elective surgeries and the ‘train wrecks’ with acute or chronic conditions that have stayed away from the emergency room and doctor’s office? Won’t insurers need the money to pay for those when they return?

And the answers?

Insurers are spending a lot on some COVID-19 patients. Big bills are rolling in for hospitalized patients, especially those that land in the ICU and are on ventilators for weeks. But even though a lot of people are sick, it’s only the hospitalized patients that incur expenses. With no costly outpatient or drug treatments, overall COVID-19 costs are not so high. Also, many of these patients are older (Medicare) or poorer (Medicaid), not in United’s commercial markets, where the rebates are focused.

Other than COVID-19, the medical system is eerily quiet. Essentially the only other bills are for telemedicine, some cancer treatments, and medications for chronic illness.

We do hear about a coming ‘second wave’ of non-COVID-19 patients later this year as hospitals reschedule elective surgeries, people who have been avoiding the emergency room come back in worse shape, and chronic care patients incur more intensive treatments after declining.

These assumptions are driven by a combination of what seems like common sense, clinician desires to help patients, and wishful thinking by hospital financial chiefs.

But UnitedHealth knows something that others don’t: utilization and costs are not going to rise as fast as people assume. So insurers are getting out ahead of it before regulators, the ACA medical loss ratio requirements, and public opinion force their hand.

Here are some thoughts I shared a week ago.

After the surge: Hospitals prep to bring back regular patients while virus cases linger describes how hospitals are gearing up to work through the backlog of canceled appointments and procedures. Hospitals assume that there will be tremendous, pent up demand for their services. They are looking forward to getting back to normal with cases that pay the bills.

 They will be in for a rude surprise, however, because many people will continue to stay away. Instead patients will use telemedicine, pursue less aggressive treatments, or just wait for time to heal what ails them. For years, healthcare experts and insurers have known that hospital care is over-utilized and sometimes dangerous. Now  COVID-19 has done what co-pays, deductibles and hospital safety reports never could –keep patients away.

 It’s no surprise that elective procedures and routine visits have plummeted. After all, hospitals canceled them. Surprisingly, the use of emergency rooms in Boston for strokes, heart attacks and appendicitis has also dropped by half during the emergency.  Many emergency patients will return, but those with common issues like back pain and rashes will think twice or three times before coming in. Patients who are due for colonoscopies or mammograms will put them off even longer than usual.


By healthcare business consultant David E. Williams, president of Health Business Group.

How to get Noom for free

published date
March 31st, 2020 by

Noom combines an app with human coaching to help people lose weight and keep it off. The company’s typical user loses 7.5% of body weight over the course of a four month program.  Customers are joining like crazy, and revenue quadrupled last year.

After hearing about Noom on NPR late last year I signed up, paying $44.99 per month. To put it in perspective, that’s almost twice what I pay for my gym. Plus, my health insurer, Blue Cross Blue Shield of Massachusetts actually reimburses me for three months of gym membership.

And that got me thinking, if Blue Cross pays for me to stay fit at the gym, maybe they would pay for my weight loss program as well. After all, trimmer people cost insurers less money. So I called Blue Cross and they told me they actually do cover weight loss plans, the same way they cover gym memberships.

Once I found out about the benefit, it was incredibly simple to get reimbursed. I typed in some basic information online, uploaded my Noom receipt –and today I received a check for the full amount of my Noom membership. No co-pays, no deductibles, no negotiated discount!

Screenshot 2020 03 30 23.35.25
Online form

It wasn’t easy to find, though, so I’m writing this post to give others a heads up. Here’s where I had to go on the Blue Cross site to find the benefit:

  • Login> My plans> Plan Details> Plan Benefits> Benefit Details> Routine Adult Physical Exams Covered By Your Plan
Screenshot 2020 03 30 23.45.06
Where’s Weight Loss?

Buried at the bottom of a run-on paragraph with no line breaks, I found the following run-on section with weird punctuation and a typo:

Weight Loss Benefit – you and your covered family members can be reimbursed for up to 3 months of participation fees paid to a weight loss program that is hospital-based; or one that is non-hospital-based program focused on eating and physical activity habits, and behavioral/lifestyle counseling with certified health professionals (in-person, by phone, or online). You can request this reimbursement once each calendar year; requests must be submitted by March 31 of the following year.

Bingo! (Although can someone explain why on earth this would be in the physical exams benefit?)

Noom isn’t specifically mentioned, but when I called Blue Cross they assured me the company was on the list. They also told me my call was being recorded in case I was denied and wanted to complain later! That was comforting.

Anyway, the moral of this story is to check with your health plan to see if they’ll pay for Noom. You might be pleasantly surprised. And who couldn’t use a little break during these tough financial times?


Don’t worry, be happy with your health plan!

published date
November 21st, 2019 by
i like 432493 1280
The Likes have it

Joe Biden said in a recent debate, “one hundred sixty million people like their private insurance.” I agree with Biden’s assessment that it’s foolish to advocate scrapping insurance companies as his rivals Elizabeth Warren and Bernie Sanders want. It’s stupid politically to take such an extreme view and it’s also worth noting that other countries with nationalized health insurance (like the UK and Germany) have private insurers, too.

Still, what does it mean to say people like their private health insurance? I suppose I would be counted in that number. And, by and large I would say I do “like” my insurance, which is with Blue Cross Blue Shield of Massachusetts. They cover the doctors and hospitals I want to use and the drugs my family takes. Their customer service is good. Their website is ok. They’re flexible in their approach to enforcing policies.

The problem is the cost, which soared to about $2800 per month for family coverage, even for a high-deductible plan. At a colleague’s suggestion, I switched to an even higher deductible plan –which is also one where you have to pay for your own prescription drugs within that deductible instead of the first-dollar coverage I had previously. So while the premium dropped by several hundred dollars a month, I ended up with a co-pay on a generic drug of over $1000 –which would have been $100 before.

And did I mention that since it’s an HMO I needed to buy separate insurance for a dependent who’s at school out of state? And that the out-of-state insurance doesn’t cover expenses arising from participation in college sports? So I had to buy a third policy.

I don’t really blame my health insurer for the high and rising premiums. The main driver is the price of healthcare procedures, which continue to go up. I’ve been healthy, but still routinely see bills for my care in the thousands of dollars that would cost hundreds at most in other places. Some of that cost is attributable to the paperwork burdens imposed by the plans.

Warren and Sanders have a point about problems with health insurers and the lack of universal coverage. But in my view, the real way to address problems in the US healthcare system is to build on Obamacare, focusing not just on coverage (which Obamacare provides, especially if Medicaid expansion is fully implemented), but also on the cost, efficiency, and appropriateness of the care provided.

By healthcare business consultant David E. Williams, president of Health Business Group.