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Insurer-Driven Price Negotiation Makes Dent in Cancer Care Cost Growth

"The concept of paying for value in the cancer care space has gained steam of late with health insurers, as major companies including Anthem, UnitedHealth, Aetna and Highmark have all debuted value-based oncology payment models aimed at reducing costs and improving quality. And when it comes to paying for all types of drugs, insurers are increasingly pushing manufacturers toward outcomes-based pricing deals."  MORE >>

Texas Insurer's 60% Premium Hike Request Spurs New Worries About ACA Plans

"In an effort to make up for more than $1 billion in losses over the past two years, Blue Cross Blue Shield of Texas is seeking a premium increase of nearly 60 percent on [ACA] plans ... BCBS of Texas lost $592 million in 2015 on top of $416 million in 2014[.]"  MORE >>

Missouri to Ban Small-Group Products of Resulting Firm If Aetna and Humana Merge

"In a preliminary order, Missouri Department of Insurance Director John Huff writes that if Aetna and Humana's deal eventually closes, the company and its subsidiaries must 'cease and desist' from doing business throughout the state in the comprehensive individual, comprehensive small-group and group Medicare Advantage markets. In the individual MA market, Aetna-Humana would have to stop doing business in certain counties in Missouri that the state has determined would be adversely affected by competition."  MORE >>

Health Insurers Not Responsible for Rising Premiums, Exec Says

"Physicians and hospitals account for 55 percent of health costs, while pharmaceuticals represent 22 percent -- up 6 percent in the last year alone, writes John D. Bennett, M.D., president and CEO of Capital District Physicians' Health Plan. Meanwhile, the percentage going to plan administration has hit a historic low."  MORE >>

How UnitedHealth Group Grew Into a Healthcare Industry Behemoth

"UnitedHealth sold its [pharmacy benefit manager (PBM) unit] in 1994 for $1.65 billion, which provided the capital buy up regional insurers and emerge as a national payer. Four years after the company sold the PBM, UnitedHealth split into five units that focused on small to midsize employers; national employers; Medicare; technology; and health and wellness services."  MORE >>

Oscar Among Insurers Seeking Steep Premium Increases

"Health insurance startup Oscar is asking for premium increases as high as 30 percent in New York ... another sign the [ACA] exchanges are headed for a market correction ... Last year, New York regulators approved Oscar's request for an average rate hike of just 4.54 percent."  MORE >>

Cigna's Disclosure Signals Trouble Ahead for Insurer Mergers

"Cigna executives are probably looking with increasing nervousness at the feds' recent spate of antitrust victories ... [F]ederal regulators' treatment of hospital and physician group deals speaks to their increasing concern about the healthcare industry's consolidation arms race.... It all adds up to a regulatory landscape that perhaps isn't quite what Cigna bargained for."  MORE >>

Some Cost-Sharing Measures Rise Significantly in ACA Marketplace Plans

"Out-of-pocket limits rose by 7 percent, general annual deductibles climbed 10 percent and copayments for nonpreferred drugs rose 14 percent [from 2015 to 2016 among the 40 million Americans who aren't eligible for cost-sharing reductions]. In contrast, copayments for generic drugs decreased by 3 percent. Deductibles ... increased by 10 percent for bronze plans and by 5 percent for silver and gold plans, while platinum plans had a 16 percent decrease in deductibles[.]"  MORE >>

CMS Administrator, GOP Lawmakers Spar Over Reinsurance Payments

"Rep. Tim Murphy (R-Pa.) took issue with the [CMS] decision to prioritize reinsurance payments to insurance companies rather than the U.S. Treasury.... CMS Acting Administrator Andy Slavitt defended the decision ... arguing that the agency used its standard rulemaking procedure -- including requests for comments -- to implement modifications to the program that were intended to 'maximize the financial effect of the transitional reinsurance program.' "  MORE >>

As Drug Costs Rise, a Few Bright Spots Appear for Payers

"Overall, total spending on prescription drugs in the U.S. reached $424.8 billion in 2015, an increase of 12.2 percent from 2014 ... Spending adjusted for net prices reached $309.5 billion, an increase of 8.5 percent over 2014. Yet ... the average net price for brands already in the market is estimated to have increased by just 2.8 percent in 2015, down from a 5.1 percent rise in 2014 and 'significantly lower' than seen in prior years."  MORE >>

Employer-Sponsored Health Plans Find Solace in Private Exchanges

"Data security and wellness programs were a primary focus for lawmakers, insurers and business representatives during a Senate subcommittee hearing [April 14] on employer-sponsored health plans that are reaping the benefits of switching to a private exchange."  MORE >>

Reluctance to Cover Obesity Treatment Could Cost Health Insurers

"Routine policy exclusions for obesity care could cost insurance companies more than they bargained for ... [T]he move to a value-based system will help promote coverage for obesity care because it will make sense to pay for services with proven outcomes. The challenge ... comes from having to convince major employers with self-funded plans that obesity care is worth it."  MORE >>

Beyond Workout Apps: The ROI of Well-Crafted Wellness Programs

"Both health insurers and employers have a stake in driving down healthcare costs for their member populations -- especially among patients with expensive-to-treat chronic conditions. Increasingly, businesses are turning to payers to design wellness programs to aid in the effort. But it's not as simple as handing out activity trackers or launching a member wellness portal. Every company is different, and there are many ways to measure success."  MORE >>

Employer-Based Health Insurance: Should It Stay or Should It Go?

"[If] the system is so broken, why haven't employers yet gotten out of managing health benefits? ... Over the last several years, employers have moved from a defined benefit to a defined contribution ... [One author believes that] employer-based coverage will continue to exist, but as consumers become more educated and are forced to shoulder more of the cost burden, 'we will see more interest in looking at other options, including being able to navigate independently in a national marketplace.' "

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Failed CO-OP Sues Feds Over Risk Corridor Shortfall

"[CMS] announced last fall that it would be able to pay insurers only 12.6 percent of what they were owed through the risk corridor program, as payments into the program from insurers came up short.... The shortfall hits smaller insurers and CO-OPS especially hard, including Health Republic in Oregon, which took a $20 million hit ... [W]hile it has ceased operating, Health Republic wants to use its experience to help other insurers recoup what they're owed through the risk corridor program ... Thus, it is trying to make its complaint into a class-action suit."

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Aetna Exec: Why We Were Able to Finally Come Up with Core Quality Measures

"[CMS], America's Health Insurance Plans [AHIP] and the National Quality Forum took a unique approach to developing the measures ... The group began the process by creating measures that served as a starting point, then in stages brought in representatives from the provider community, followed by purchasers and consumers, all of which contributed to designing the final sets of measures."

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CMS, AHIP Release New Quality Measures for Physicians

"The Core Quality Measures represent a collaborative effort to design and implement a standard set of metrics across payers, according to AHIP. Providers who have been forced to report different quality metrics on a payer-by-payer basis should see a reduced administrative burden as CMS and private payers move to the common system."

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Medical Costs for BCBS Individual Plans Outpaced Premiums in 2015

"BCBS plans spent $20.7 billion on medical claims during the first three quarters, but took in just $20.4 billion in premiums, a sharp contrast from 2014 earnings in which premiums outpaced medical costs."

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Feds Want Healthcare.gov to Become an Active Purchaser

"The proposed reforms, tucked into the 2017 Notice of Benefit and Payment Parameters released by [CMS] late last year, suggest that CMS wants to trade a wide array of plan choices on the federal exchange for more tailored options.... These standardized options for bronze, silver and gold plans would include a single provider tier, a fixed in-network deductible, a fixed annual limitation on cost sharing, and standardized copayments and coinsurance for a key set of essential health benefits ... Insurers would not be required to offer standardize options in 2017 and 'would retain flexibility to offer non-standardized plans.' "

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Health Insurer Mergers Could Affect Credit Ratings

"The three health insurers planning to acquire another insurer -- Anthem, Aetna and Centene -- have each raised a large amount of debt in order to finance their deals with Cigna, Humana and HealthNet, respectively ... S&P could lower Anthem-Cigna's ratings by up to two notches, and it could lower Aetna's ratings by one notch. S&P could raise its ratings on Humana by up to two notches -- capped by its rating on Aetna -- and does not plan any ratings actions on HealthNet or Centene related to their pending merger."

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