Tuesday Night's Primary Elections Were Huge. Here's What They Mean for Our Industry.
House Majority Leader, Eric Cantor (R-VA) is toast. Trounced in his Richmond district by a nobody Tea Bagger Tuesday night. Cantor gave up his leadership position yesterday. Depending on where you sit politically, either the unthinkable or the inevitable happened. In fact, a Majority Leader hasn't lost incumbency since the office was created in 1899. "The defeat of the second-ranking Republican in the House by an ill-funded, little-known tea party-backed candidate ranks as the biggest congressional upset in modern memory and will immediately generate a series of political and policy-related shock waves in Washington," wrote Chris Cilizza of WaPo.
What it means for our industry is that legislatively speaking, President Obama's second term is already over. The House will seize up like a bag of concrete in a toilet. The most unproductive Congress in history is about to continue and worsen that record as an epic Republican leadership battle ensues.
That means Obama is left chasing his agenda through administrative action, Executive Orders, regulations and enforcement. With brand-new and surprisingly popular HHS Secretary Sylvia Mathews Burwell on the job, expect her department to flex its muscles in ways we haven't seen, especially given the number of oversight hearings she's about to be subjected to:
- There will be tough new rules for all government-sponsored health programs: Medicare, Medicaid and implementation of the Affordable Care Act. The contentious new Part D rules are just the beginning.
- There will be increasing activism in network adequacy and rate reviews of insurers in Medicare Advantage, Part D and the exchanges;
- CMS will take a hard line on Medicare plans lagging in Star ratings and/or compliance records. The second term of a Democratic administration is always when scores are settled; the renewed Congressional scrutiny on our favorite agency will make the paper tiger grow some claws;
- CMS and the HHS Inspector General (IG) will finally put the pedal down on dreaded RADV audits with the promise of hundreds of millions in recoveries.
- With wingnuts like House Oversight Chairman Darryl Issa (R-CA) salivating for domestic Benghazis, the HHS IG will likely deliver a few surprises of its own.
Every time there's a major electoral event in Washington like this, elected and appointed officials alike will usually settle back on the motherhood and apple pie of health care politics: kicking the crap out of the insurance industry and other monied interests like pharmaceutical manufacturers and PBMs. If you're not wearing them already, it's time to pull on the kevlar boxers and the asbestos Spanx.
The Status of Medicaid Expansion, and Why It Will Keep Getting Better
Medicaid is already the largest insurer on the planet, and the Affordable Care Act (ACA) is driving enrollment faster than anyone imagined. But there are headwinds in covering more Americans through Medicaid, some political, some operational. Here's why it will continue to improve and drive expanded coverage for the uninsured -- and why all insurers need to participate to remain relevant to the new American healthcare landscape.
Twenty-six states have expanded eligibility under the ACA to everyone with incomes under 138% of the federal poverty level, or about $16,100 for an individual. April's Medicaid enrollment report from CMS showed a year-over-year increase of over 6 million, a 10.3% increase. Much of this is due to the "woodwork effect" -- folks heard about ObamaCare, applied through the exchanges, and found they were Medicaid eligible. It doesn't count nearly a million Americans who gained coverage under the ACA's "early option" or a waiver.
Predictably, enrollment has grown much faster in Medicaid expansion states (mostly Blue) than in states that have not expanded Medicaid (all Red): 15.3% in expansion states, but only 3.3% in non-expansion states.
Nine out of 24 states that had Medicaid expansions in effect in April experienced an enrollment increase of 25%. Ironically, many states with the largest Medicaid enrollment growth also had the most dysfunctional exchanges: Oregon at 49.4%; Nevada at 41.1%, and Maryland, at 29.7% growth.
The problem has been that between exchange dysfunction, weak infrastructure, and a culture in many state Medicaid agencies of creating barriers to enrollment rather than the ACA's policy of "no wrong door", more than 1.7 million are still waiting for their applications to be processed — with some stuck in limbo for as long as eight months. The scope of the issue varies widely: California accounts for 900,000 applications pending as of early June; Illinois has 283,000 cases pending, while New York has no backlog at all. All three states have implemented the ACA's expansion of Medicaid. Even some big Red states that chose not to expand have enrollment pileups, including North Carolina (170,000 applications pending), Georgia (100,000), and South Carolina (62,000).
Matt Salo, executive director of the National Association of Medicaid Directors, thinks the worst is over. He said the computerized handoffs from the federal exchange are occurring more quickly and states are getting more data to approve or deny applicants. "I don't want to say it's been solved," he said, "but it's definitely getting a lot better." One measure: Publicly-traded health plan Medicaid revenue grew 19% in the first quarter of 2014, demonstrating the enormous economic opportunity from the expansion and the woodwork effect.
So if the backlog is largely resolved by the next open enrollment period this fall, the next big question is what about the 24 holdout Red states, the ones whose governors like Rick Perry (TX) and Bobby Jindal (LA) seem hell-bent on throwing a middle finger at the White House while thousands of their constituents literally die because of inaction. Speculation is that a growing number of Red states will fold and take the Medicaid expansion money -- but not until after the midterm elections. Here's why:
- Funding: the Feds are funding 100% of Medicaid expansion through 2016, scaling down to 90% in 2020+. While the initial ACA backlash may have provided cover for states not to expand, it will be increasingly difficult to continue to defend not taking the federal money to insure a significant population group. Remember, Red states have the highest rates of uninsurance per capita, largely due to their historically stingy Medicaid programs.
- Access: most states that choose not to expand created a significant coverage gap. This happens because subsidies on the exchange are available from 100%-400% of the Federal poverty limit, but not below that, leaving a low-income population paying significantly more for healthcare coverage.
- "You're Still Paying for It": The ACA funds Medicaid expansion largely from tax revenue. States like Texas and Florida are among the highest contributors to general tax revenue and have the highest number of uninsured population. They are helping to fund Medicaid expansion for other states via higher income taxes, yet not receiving any of the benefits for their own population. Medicaid accounted for about two-thirds of all federal funding to states in 2014, up from 43 percent two years ago.
- Hospitals: hospitals traded in insufficient DSH funding and bad debt for Medicaid or exchange coverage in the ACA. Hospitals in Red states that didn't expand Medicaid are now reporting they can't even issue bonds for capital projects, and are dying on the vine as the DSH funds are taken away without a substitute. Considering hospitals are often the largest employers in their communities, and especially in rural Red states, their lobbying might is expected to break anti-ObamaCare partisanship after the elections are over.
I'm not as optimistic as some on Wall Street that all RedGovs will fold in the face of these arguments, but suspect that several more will as we head into 2015. And given the central and growing role Medicaid plays in healthcare financing, health insurers are awakening to the fact that if they're not in it, they won't be around long.
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Medicaid health plans must be able to navigate through State and Federal regulations and work well with State agencies. GHG can help, find out how >>
What's Gained and Lost with an HHS Secretary Burwell
My old Clinton Administration colleague Sylvia Mathews Burwell sailed through a confirmation hearing last week. What was expected to result in serious anti-ObamaCare fireworks and soundbite fodder for midterm campaigns ended with a whimper. Her second confirmation hearing was yesterday, and it's a "Washington dog isn't barking" story. It's now looking like she'll cruise through and we'll have an unexpectedly rapid successor to the embattled Kathleen Sebelius.
Mathews is unquestionably qualified for the job, but there are both positives and negatives of her succeeding the former Governor and Insurance Commissioner of Kansas as Secretary of Health and Human Services at the most critical juncture since Medicare and Medicaid were launched in the 60's.
Here's what's gained: bipartisan support. Sebelius had become the face of last fall's ObamaCare meltdown and needed her own parking spot on the Hill for all the oversight hearings she had to endure. The GOP majority in the House had especially come to revile her, but Mathews is known on the Hill as a skilled technocrat with none of Sebelius' baggage, quiet, non-ideological, and effective. It also helps that with the 7 million enrollee target easily met in the first ObamaCare open enrollment period and at a lower cost than expected, Republicans are turning away from their "repeal and replace" mantra of the last 4 years.
Mathews' proven management skills are also critically important as ObamaCare sails into Year 2. The initative's turnaround this winter was nothing short of incredible, but there's still ample opportunity for health insurers to cause a crackup with the less-visible "back end" problems that persist. Details matter now more than ever. Remember Mark McClellan's impact on Medicare Part D. A massive implementation of government-sponsored insurance needs an operator to see it through.
But here's what's lost: Burwell, locked in the bowels of the Office of Management and Budget for much of her career, enjoys none of the relationships with governors, state Medicaid directors, insurance commissioners or insurance executives Sebelius does, especially those in hostile red states where coverage expansion is needed most. And that could hurt post-midterm chances of getting RedGovs to roll over on the Affordable Care Act's Medicaid expansion and hostile insurance commissioners like Georgia's to back off. She will need to build trust as the face of ObamaCare with politicians in the deep south and west. She will also need a "meet-and-greet" tour of insurance executives, and must demonstrate her ability to hear their concerns and implement fixes quickly in CMS in the runup to open enrollment Round Two.
This isn't to say Burwell will completely avoid controversy and that the Health Secretary's impossible job got much easier. She should continue to pull on her asbestos Spanx every time she sets foot outside her new office in this political environment. But it will give her some breathing room to hit the job hard, get some wins early, and build the trust that's necessary to see ObamaCare through from partisan lightning-rod to established and popular entitlement program.
Follow the Leader: United Health Group's Outlook on Government Health Programs
Ralph Giacobbe at Credit Suisse is a leading health industry analyst and is doing the best work of his career. Today he produced a fantastic recap of his discussion with United Health Group CEO Steve Hemsley and several of his top executives. It included some fascinating insights into the market leader's strategy for government health programs:
â– 2015 Earnings Growth: Management reiterated its focus on growing operating earnings in 2015. While Medicare rate pressures remain (-3 to -3.5%), the company is optimistic of better MA enrollment in 2015 as it does not expect the same level of market disruptions with more limited network reconfigurations...Medicaid is expected to remain a positive contributor. Additionally, UNH has $90B in medical costs and $20B in administrative costs from which to drive savings, which was stressed by management during the meetings...cost creep has backfilled previous administrative cost savings. Management is now "acutely focused" on applying more rigorous standards to general reinvestments in the organization.
â– Medicare Star Ratings and Renewed Focus on Performance: While the management team noted that performance as a whole has been "good", there was clearly a sentiment that performance needs to improve. Hemsley noted that too many of UnitedHealthcare's recent issues have been "self-inflicted," especially Medicare Stars. As a result, UNH is in the process of narrowing its networks to steer patients to high performing providers in an effort to improve quality. Additionally, a greater focus will be placed on leveraging data to stratify members in order to quickly identify and place high acuity members in appropriate care management programs. As the largest player in the market, UNH has several metrics under its control and is expected to perform at high levels. According to management, it took UHC too long to figure out that STAR ratings place significant emphasis on serving both the healthcare and social needs of members. While corrective steps are encouraging the improvement in STAR rating won't be evident until 2017 at the earliest given the lag time in measuring criteria.
â– Network Reconfigurations Continue: As a result of MA rate pressures, UNH significantly adjusted its networks during the 2014 annual enrollment period for which it received scrutiny. Management reiterated that network reconfigurations will continue, but will be guided by insights gained during 2014. Last year UNH narrowed its Medicare networks by 10-15% and management expects some continuation into 2015, although changes will be made more on a continuous basis vs. occurring all at once and therefore should be less disruptive. Overall, network configuration remains a significant component of managing trend and should not be underestimated as narrowing networks to higher performing facilities/providers can save on medical costs. MA rate pressures for 2015 were evident when management reiterated that the final rate came in below their expectation of flat. UNH sizes the impact in the range of -3% to -3.5%. We would expect network reconfigurations to be an ongoing process, as management believes it is only in the 2nd or 3rd inning, but again, don't expect big disruption like 2014.
â– Reform Update: While UNH's exchange participation in 2014 was limited, it is inclined to increase its involvement in 2015. UNH is currently in the process of evaluating markets, products, regulations, and first year pricing. While it continues to appear that the company is likely to increase its exchange exposure in 2015, it has until September to finalize its decisions.
â– Medicaid: Expansion also appears to be tracking well, as management now expects Medicaid growth to exceed the high end of guidance (+350-450K lives). While the dust has yet to settle, expectations were to see 65% of expansion enrollment 1Q, followed by more moderate enrollment in the middle of the year and a reacceleration around year end. It is still early, but at this point UNH has not seen anything alarming in terms of utilization and feels comfortable about its ability to effectively manage new Medicaid members. Additionally, UNH is getting paid appropriately higher rates for Medicaid expansion members.
â– Optum: Management's new goals are "8 by '16" (8% operating margins, 10 new large relationships, double digit top and bottom line growth, and doubling 2013 op earnings of $2.3B). With a backlog of $7.2B, Optum has an abundance of opportunities at its fingertips...Optum's role as a system integrator for HealthCare.gov was an important building block in establishing its reputation. Management also conveyed a new level of confidence that scrutiny around Optum's association with UNH has subsided, as payors and healthcare systems appear to have gained comfort that the appropriate firewalls are in place for Optum to maintain its independence from UNH.
Resources
On May 7, Gorman Health Group Executive Vice President and former regulator Steve Balcerzak joined Vice President of Provider Network Management Craig Lyon for a deep dive into CMS expectations. Attendees got their their take on what to expect and how to prepare. Access the webinar recording here >>
From ACO-type incentives to bundled payments and contract capitation, to full professional and global capitation — where the potential is promising, we can help design and implement these arrangements. Contact us for more information >>
POTUS Spikes the Football, but the ObamaCare War-Game Isn't Over
Last week as health insurance exchange open enrollment ended, President Obama spiked the football, announcing that 8 million people had signed up, and that the Obamacare debate is "over." He put an exclamation point on it: that millions more had gained coverage through Medicaid expansion and new mandates on employers. Now, any further discussion of repealing ObamaCare was about taking coverage away from those millions of Americans.
Republicans, sickened by a blinding case of ObamaCare Derangement Syndrome (ODS -- it's in DSM-4, check it out ;)), predictably wailed. "The Debate Will Be Over When the American People Say It's Over," The Weekly Standard‘s Jeffery A. Anderson blogged the next morning.
POTUS is right. This train has left the station. ObamaCare, like Medicare Part D in 2006, is now a part of the firmament of the American health system, and can't be dismantled without a Republican in the White House. And as far as the American public goes, they're done with this repeal nonsense too. Last month, the Kaiser Family Foundation released its monthly polling and found approval of the law rising, especially among the uninsured. 53% of Americans are "tired of hearing about the debate over the ACA and want the country to focus more on other issues." Can we get an amen? Look, it ain't popular -- yet, remember it took the Medicare drug benefit 2 years before opinion turned -- but it's not going away.
But that doesn't mean the repeal fight ends. Oh no. Two things guarantee that: the tax on the wealthy that funds a big piece of ObamaCare, and the Citizens United and McCutcheon cases in the Supreme Court. The New York Times‘ explains: Under the Affordable Care Act, the Medicare payroll tax increased by 0.9% in 2013, but only for couples earning $250,000+ and unmarried taxpayers earning $200,000+. That tax hits just 2% of taxpayers, but helps to explain the spread of ODS among Republicans.
Combine that with virtually unlimited funding for campaign-style ads and events under the Citizens United and McCutcheon decisions, which enable a small number of families to donate more in one election cycle than most Americans will earn in their whole life, and we're looking at a virtually endless ObamaCare war of dead-ender fundraising, attack ads, and futile repeal attempts.
What's more, it seems increasingly likely that Republicans will regain control of the US Senate in the 2014 midterms, putting Congress entirely under GOP control. I wouldn't be surprised to see articles of impeachment filed early in 2015 as ObamaCare Derangement Syndrome sweeps over Capitol Hill. It will be an ugly conclusion to the Obama Administration, but it won't end in repeal, that much is certain. Republicans will just pretend like it could.
Resources
Exchange enrollment is a multi-pronged strategy with member outreach and connection embedded within. Find out more about how GHG can help you with your strategy >>
Member Engagement and Experience are the New Risk Adjustment
In this new era of Star Ratings in Medicare Advantage and Part D, where a 4+ score is now do-or-die, health plan survival comes down to two things: member engagement and the member experience. They're the new risk adjustment when rates in 2014-2015 will be at their lowest levels in more than a decade, and a low-quality rating is a kiss of death in government programs. Plans that can't evolve into kinder, gentler, more coordinated and Member-Centric service providers are already beginning to disappear.
Here's why: the vast majority of the Star Ratings performance measures, especially those that are triple-weighted, are utterly dependent on an engaged member. Example: breast cancer screening. All women hate mammograms, and this measure doesn't move unless the member shows up. Another: Diabetes Care -- Blood Sugar Controlled. "Controlled" is a clinical outcome. And you can't get there with daily testing and insulin treatment without a member who's paying attention every day. Less than 20% of seniors engage in all screenings and tests required in Stars.
Similarly, the patient's experience measures and surveys now comprise fully a third of the Star Rating and are all 1.5 weighted, which means they count 500 basis points more than simple process measures. Getting appointments and care quickly, handling of complaints and coverage disputes, interpreter availability -- just a couple examples, all 1.5 weighted and instrumental to getting or keeping those all-important 4 Stars. The Consumer Assessment of Health Plan Survey (CAHPS) and the Health of Seniors Survey (HOS) are enormous determinants of ratings, both conducted by government surveyors, and both strike fear in the hearts of health plans. "Has your health improved in the last two years you've been enrolled, and who do you attribute it to?" are two of the most critical questions facing our industry. You have no hope of a positive answer to these questions from your members if they don't know who you are and what you're doing for them.
Most of the tasks involved in the Stars measures are actually pretty simple, like getting a flu shot. And behavioral economics show us that simple tasks are susceptible to contingent, or "if-then" rewards. So plans need to have the ability to track member progress on health-related tasks and administer appropriate incentives when they are completed. And all of the patient's experience measures necessitate a responsive, proactive service model that could be lifted from some of the leaders of e-commerce.
So the more we thought about it, the more we realized we needed to offer our clients a platform that can help them execute better on Stars tasks, while ensuring dramatically better member engagement and a much more positive consumer experience. And that's where our new partnership with Novu comes in. Novu is a unique platform which creates a deep ongoing relationship between your plan and your members, and gives you the "stickiness" that keeps them around. Members engage in a fun, easy to use, and rewarding health engagement tool that has a proven record of getting people to actively participate in their health: 76% of members return to the site 2 or more times per week, and stay on the site almost 10 minutes per visit.
We're thrilled to offer this first-of-its-kind engagement platform specifically tailored to the needs of Medicare, Medicaid and ObamaCare exchange members with Novu. Check out the product on the GHG website: https://www.ghgadvisors.com/who-we-are/our-partners/novu
Resources
New Webinar with John Gorman: Join him on April 2 for this complimentary presentation. "Member-centricity is more than a catch-phrase. How enhancing member engagement impacts the top AND bottom lines." Register now.
Learn more about the GHG-Novu partnership by reading our press release.
Join John Gorman, Novu's Tom Wicka, and dozens more industry thought leaders at the 2014 GHG Forum. Full agenda just released.
Lighting the Path in the Golden Age of Government-Sponsored Health Programs: Join Us for the GHG Client Forum
More than 300 guests will convene on May 1-2 at the Red Rock Casino in Las Vegas for the 2014 Gorman Health Group Forum, our annual strategic retreat for leaders in government-sponsored health programs. This year's gathering promises to be the most actionable, content-packed conference you could attend on how to succeed in this new Golden Age of government business. And when the learning and planning is done for the day, we will celebrate this unique moment in health care history as only GHG can in Vegas. Here's what's happening this year and why you've got to join us:
- The event features 27 content-charged sessions, including multiple presentations on Star Ratings tactics, quality improvement, risk adjustment, and compliance challenges unique to Medicare Advantage and Part D, Medicaid, and the ObamaCare exchanges
- A keynote presentation from CMS leadership
- An expert roster of presenters from Gorman Health Group and leading health plans in government-sponsored programs. No fluff, no sales pitches, no history lessons -- it's all about what to do NOW
- Approved for up to 12 continuing education credits from the Compliance Certification Board
- The perfect off-the-strip venue to minimize distractions during the day, but close enough to the action to make plenty of bad decisions in the evenings. ;)
Based on feedback from last year's Forum, I'm speaking in three separate sessions on overall strategy and implementation planning for government programs. If you've heard my "state of the industry" presentation before, you may think you know what to expect from me on stage. Think again. This is my favorite gathering of the year, and I'm building three brand-spankin' new presentations that are focused on specific steps and mileposts your organization needs to reach this year in care management innovation, risk adjustment, Star Ratings, and operational performance improvement. In each session I'll drill down to specific steps, and we'll leave you with a self-assessment tool in our closing session to help track your progress.
Many of our clients use the Forum as an offsite retreat for their government programs executive teams, and so we offer huge group discounts to encourage it. It's a unique opportunity for team-building and action-oriented planning and budgeting.
If government-sponsored health programs are central to your company's future, do yourself a favor and join us in Vegas. You'll come back tired, happy, and ready to win in this crazy new environment of health reform.
Don't believe me? Hear what last year's attendees thought about the event, and why they keep coming back for more.
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Register today for The Annual GHG Forum held May 1-2 at the Red Rock Casino and Resort in Las Vegas. This two day event is designed to provide best practices for the decision makers of organizations serving Medicare members, Exchange beneficiaries, and the Dual eligible population.
On April 11, Bill MacBain and Jean LeMasurier will be back, and this time joined by John Gorman, Executive Chairman of GHG, to offer insight on the Final Rate Announcement from CMS. You will walk away from this session with critical to-do items and issues to tackle in order to ensure your success in 2015 and beyond. Register now >>
ObamaCare's Winners and Losers -- Consumer Edition
I got my start in DC some 23 years ago as a reporter, and the profession's credo is always to "afflict the comfortable and comfort the afflicted." ObamaCare is the story of a lifetime for enterprising journalists, and the really poignant anecdotes that can shape and move public opinion -- and therefore politics -- are just beginning. Small stories will go viral in the echo chamber of 24-hour news cycles and social media in the coming weeks as enrollment and coverage begins in earnest. Here's how these very personal stories of what ObamaCare means to consumers will break down.
University of Michigan professor and senior Brookings fellow Justin Wolfers created a chart depicting the "winners and losers" under the Affordable Care Act, sourced to a Ryan Lizza article that used estimates from M.I.T. economist Jon Gruber, a former adviser to Mitt Romney.
The chart shows how the GOP and ObamaCare dead-enders have pumped up media coverage of the relatively small number of Americans whose substandard individual market plans were cancelled. It also shows how many Americans are unaffected by health reform. But it's not without its problems and does manage to oversimplify things, but as a visual processor, I appreciate this stuff.
You could say the biggest losers under ObamaCare are patients with expensive medical conditions who don't qualify for the just-extended state high risk pools and whose current plans have been canceled, and who are having trouble getting through HealthCare.Gov to purchase coverage by Dec. 23 -- the deadline for buying insurance that begins January 1. WaPo had a good piece with some gut-punching anecdotes here: ObamaCare losers who have given up hope. The best you can hope for in first quarter of 2014 is that vulnerable patients don't die because of an administrative screw-up or lapse in coverage. Those are the kinds of anecdotes that could become serious liabilities for the President, and it'd only take a few to shatter what little public or political confidence in ObamaCare still exists.
Other losers include those with lower incomes who live in states that decided not to expand their Medicaid programs. The Advisory Board looked at which states will have the most uninsured in 2016. Being uninsured but too poor for exchange subsidies in a state that refuses to expand Medicaid, or being an undocumented immigrant and ineligible for ObamaCare benefits, means you lose out.
ObamaCare's consumer winners thus far include the "bro's" and young invincibles who can now remain on their parents' health plans until age 26; consumers with serious pre-existing conditions who have been denied health insurance; and residents of states that opted to expand their Medicaid programs up to 138% of the federal poverty level. Anecdotes abound here too, from across the country, like these from Nebraska:
Obamacare will benefit retired Windstream Manager John Gapp, who now pays $1,375 a month for a plan available through his former employer that covers him and his wife. The premium is high because he pays both company and employee shares. Gapp, who isn't yet 65 and eligible for Medicare, wasn't able to get less expensive private health insurance last year because of a pre-existing condition -- a mild heart attack in 2012. He hasn't signed up for an ACA policy yet, but he has done some online window shopping. Because Gapp's income is less than 400 percent above the federal poverty level, he will qualify for some subsidy and likely will pay $580 to $800 less per month, depending on the plan he chooses. Without the subsidy, his insurance premiums under ACA plans would be similar to what he's now paying, $100 less for one plan and $125 more for a so-called Cadillac plan that has better benefits than the one he has now.
Lori Schwartz will pay $200 less a month for a better insurance plan under Obamacare, because insurers no longer can charge people more or deny coverage because of pre-existing conditions. Schwartz, who has diabetes, has been buying insurance under a state program for people who couldn't get health insurance on the private market. She was paying more than $750 for a policy with a $5,000 deductible. Her husband, Mark, recently signed her up online for an ACA-approved plan that will cost $526 a month, even with no tax subsidy. And it is a much better plan, with a $1,500 deductible, she says.
There will be plenty of ammunition in the coming weeks for both sides of ObamaCare. The trick for issuers is to ensure you're not the one plastered across your hometown paper or Twitter by a wipeout in your enrollment department this month.
Resources
Every health care organization is looking for improved outcomes, better compliance and enhanced process efficiency when it comes to managing membership and premium payments. GHG's Valencia was designed specifically to meet those needs.
Aaron Eaton, Chief Development Officer at Gorman Health Group, discusses the latest announcement from CMS related to payment process changes for the Health Insurance Marketplace. Access the podcast >>
In this recorded presentation Gorman Health Group strategy and data analysis experts discuss actual case studies that show how plans can mine data for precious insight that can help improve performance.
There is no cheat sheet for 2014.
Now is the time of year when we all have 12 things to do in the next 30 minutes, plus we are budgeting and we need to write our strategic approach for 2014. We have to learn how to prioritize and focus on what is truly important to our success. Unfortunately, there is no cheat sheet, no best practices for all things healthcare, and we cannot succeed if we have too many strategies. Let's compare five areas:
- Administrative excellence and compliance
- Clinical innovations around case, disease, and utilization management
- Provider Engagement
- Risk Adjustment
- High-risk member management
Recently, Gorman Health Group asked the attendees of Medicaid Health Plan Association, "What are the most important strategies in 2014?" The answers and ranking are below:
- High-risk member management
- Provider engagement and innovative reimbursement models
- Risk Adjustment
I imagine that this may be that cheat sheet for all of us.
Although Michael Porter shares, "strategy is about making choices, trade-offs; it's about deliberately choosing to be different." There are some strategies that every business has to do well to survive, and we all need to be ready to succeed at those mentioned above in 2014.
Resources:
Decision-makers from Health Plans and Provider Organizations are invited to join GHG for a free webinar on November 19th: "The future of the Government sponsored health care." Register for this free event now >>
Medicaid health plans must be able to navigate through State and Federal regulations and work well with State agencies.
GHG solutions-based consulting drives results to your Medicaid health plan, visit our website to learn how >>
The Shutdown Will Become the Siege of the ObamaCare Teahadists
If you're paying any attention to the worsening drama here in DC, dig in because the calendar is not our friend. With the stalemate over the government shutdown ossifying, the Congress just backed into the debt ceiling, which we'll hit in less than two weeks. Now we're going to need a big deal both reopening the government and raising the debt ceiling to get out of this mess, at the very moment postions are hardening. A few days ago, I thought a shutdown would go on for about a week...now I'm thinking it might be a month, or even longer. And that could have big implications for ObamaCare, Medicare and Medicaid.
The supreme irony of this week has been watching right-wing House Republicans shutdown the government over ObamaCare, on the very day ObamaCare launches and almost crashes because so many Americans want it. There is no clearer evidence of the lunacy of the anti-ObamaCare dead-enders. This shutdown and manufactured budget crisis never had a chance of stopping ObamaCare. It's doubly ironic because as the exchanges launch and stumble, its harshest critics are now trying to figure out what they want.
Compounding failures in stopping ObamaCare, resoundingly negative public opinion, and legislative charades like a string of piecemeal "reopen this favorite monument and federal agency that I voted to close" are strengthening the right's resolve, but for what? One of them, conservative Representative Marlin Stutzman (R-IN) summed it up today: "We're not going to be disrespected. We have to get something out of this. And I don't know what that even is." The fight has become a zero-sum game -- if the Democrats win, Republicans lose -- and it's taken on a life of its own. A moderate Republican, Rep. Michael Grimm (R-NY), said "This is not just about ObamaCare anymore."
Head. Banging.
As the extremists -- let's call them the ObamaCare Teahadists -- about 40 in the House and 15 in the Senate -- move the goalposts, we're backing into the Oct. 17 deadline to raise the $16.7 trillion national debt ceiling. Cold reality set in here in DC today that the shutdown and debt ceiling are now intertwined...and the President has been rock-solid that he will not negotiate on the latter. Preparations are being made to dig in for a long siege. And that has implications for our favorite government-sponsored health programs.
The launch of the ObamaCare exchanges this week were predictably messy. The big story has been the astounding level of interest -- over 7 million unique visitors nationally in three days, more than Southwest Airlines' website gets in a month, over 100,000 phone consultations. Several state-based exchanges like Maryland had to delay full openings. California overestimated its volume, literally, by 900%. New York and a handful of states had isolated reports of right-wing bloggers and commentators urging their followers to clog phone lines and ping exchange websites, literally waging electronic warfare against ObamaCare.
The Department of Health and Human Services furloughed over half its workforce this week but hundreds of CMS staffers are soldiering on, unpaid, trying to get this plane off the ground. Tech glitches with the CMS data hub and holes in healthcare.gov made raw by the volume prevented more than a few thousand applications from being accreted this week. Several former colleagues of mine in the agency acknowledged that eligibility and enrollment vendors signed just weeks ago weren't ready to go, but that there was no moving the start date. "It's going to be weeks of crises and workarounds trying to make this work by January 1, all while we're getting bombed by the Taliban on the Hill," one said.
By next week media attention will turn from high interest to insufficient results of open enrollment, and HHS Secretary Kathleen Sebelius will be forced to play a shell game with her department's budget to reinforce the exchange staff in the middle of a shutdown. One casualty already: the Centers for Disease Control's annual flu vaccination campaign got iced, right on the brink of flu season, with direct implications for Medicare and Medicaid plans. All of this will put more fire in the Teahadists' bellies, entrenching positions further: longer shutdown, longer debt crisis. To whit, as House Speaker John Boehner (R-OH) just said: "With Obamacare proving to be a train wreck, the president's insistence on steamrolling ahead with this flawed program is irresponsible. It's time for the President and Senate Democrats to come to the negotiating table and drop their my-way-or-the-highway approach that gave us this shutdown."
Wooooo-sahhhhh.
This doesn't start to get too ugly for Medicare Advantage, Part D, or Medicaid plans unless this nonsense stretches longer than 30 days. But if we're still at impasse heading into Thanksgiving -- and that is very much a possibility now -- we could be looking at the winter of our discontent in government-sponsored health programs. With a side of Tea.
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