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Health plan costs - misc

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Justice Department Joins Lawsuit Alleging Massive Medicare Fraud by UnitedHealth
"The Justice Department has joined a California whistleblower's lawsuit that accuses insurance giant UnitedHealth Group of fraud in its popular Medicare Advantage health plans.... [The whistleblower] has accused the insurer of 'gaming' the Medicare Advantage payment system by 'making patients look sicker than they are' said his attorney ... [The attorney] said the combined cases could prove to be among the 'larger frauds' ever against Medicare, with damages that he speculates could top $1 billion." (Kaiser Health News)
Insurers Struggle to Plan for Future Amid Health Care Policy Vacuum
"Insurers are most concerned about how the administration and Republicans in Congress plan to treat the ACA's cost-sharing reduction payments, which help subsidize out-of-pocket payments for lower-income enrollees, and whether the Trump administration will enforce the ACA's individual mandate ... Insurers should have until June or July to file their rate requests, an extended timeframe proposed last month by [CMS]. Those requests will offer the first insights into how much they hope to charge consumers for different plans next year." (Morning Consult)
2017 Annual Report to Congress on Self-Insured Group Health Plans (PDF)
17 pages. "Approximately 51,600 health plans filed a Form 5500 for 2014, an increase of nearly 3 percent from the health plans that filed a Form 5500 for 2013. Of health plans filing a 2014 Form 5500, about 21,200 were self-insured and approximately 3,800 mixed self-insurance with insurance ('mixed-insured'). Self-insured plans that filed a Form 5500 covered approximately 3 3 million participants in 2014 and held assets totaling about $87 billion. In 2014 there were nearly 26 million participants covered by mixed-insured group health plans; these mixed-insured group health plans held almost $137 billion in assets." [Appendices also available: Abstract of 2014 Form 5500 Annual Reports Reflecting Statistical Year Filings, and Self-Insured Health Benefit Plans 2017 Based on Filings through Statistical Year 2014.] (Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL])
[Opinion] The Affordable Care Act: Chapter Two
"As we now pivot to Chapter Two for the [ACA], the realities are these: [1] The healthcare system needs improvement. Affordability is the issue one.... [2] The [ACA] has flaws. It successfully increased coverage for 20 million who were uninsured via Medicaid expansion and subsidized coverage for individuals via the marketplaces, but at a hefty price -- $1.1 trillion over 10 years -- and the rules whereby insurers are required to structure and price their plans are problematic.... [3] The strength of our economies--locally and nationally -- is closely tied to the effectiveness of our health system." (Paul Keckley)
More Than Obamacare Repeal, Small Businesses Want Congress to Rein in Costs
"As a bloc, small-business owners have been among the health care law's most vocal opponents.... But every business is uniquely affected by the complex law, and simply demolishing it without putting new guardrails in place is not, for most, the ideal outcome. Small-business owners overwhelmingly say they want Republican and Democratic leaders to quit their partisan bickering, acknowledge that the country's health care economics are fundamentally broken, and work together on fixing the problem." (The New York Times; subscription may be required)
Health Care Cost Challenges Require Employer Innovation
"For the first time, employers reported specialty pharmacy as a top driver of health costs.... [E]mployers may implement pharmacy management techniques, including utilizing specialty tiers within their pharmacy plan designs.... Engaging employees in all aspects of the health insurance program is paramount to controlling benefit costs.... Helping employees understand and navigate their options and costs through coaching and support tools will increase awareness around benefit offerings and deliver on value as well." (Healthcare Trends Institute)
Premium Hikes Largely Caused by Obamacare Regs
"Obamacare caused premiums to rise for various reasons, chief among them being the vast new regulations the law imposed on insurance markets.... [A] chart provides estimates of the average impact that various Obamacare regulations have had on premiums." (The Heritage Foundation)
CBO and JCT Cost Estimate on the American Health Care Act, Incorporating Manager's Amendments 4, 5, 24, and 25
"The provisions dealing with health insurance coverage would reduce deficits, on net, by $883 billion; the noncoverage provisions would increase deficits by $733 billion, mostly by reducing revenues.... [In] 2018, 14 million more people would be uninsured under the legislation than under current law.... In 2026, an estimated 52 million people under age 65 would be uninsured, compared with 28 million who would lack insurance that year under current law.... In 2018 and 2019 ... average premiums for single policyholders in the nongroup market would be 15 percent to 20 percent higher under the legislation than under current law. By 2026, average premiums for single policyholders in the nongroup market would be roughly 10 percent lower than under current law." (Congressional Budget Office [CBO] and Joint Committee on Taxation [JCT])
Impact of Cost Sharing Reductions on Deductibles and Out-of-Pocket Limits
"This note briefly describes the cost-sharing reductions in current law and illustrates their impact by looking at how these provisions affect average deductibles and out-of-pocket maximum limits in benchmark silver plans in 2017 in states using the federally facilitated marketplace." (Henry J. Kaiser Family Foundation)
Wellness Program: 70 Percent of Medical Cost Savings Comes from Employees Using Health Coaches
"Research shows that 70 percent of medical and pharmacy cost savings comes from just 30 percent of employees who enroll in coaching. What's more, those who enrolled in coaching saved an average of $586 on medical costs per year, compared with an average savings of $261 among wellness program participants who do not participate in coaching. This translates to approximately 6 percent more cost savings reaped by those who participate in wellness coaching." (HealthFitness)
2015 Commercial Health Insurance: Overview of Financial Results
"This report provides an overview of health insurer financial results in 2015 and evaluates changes in the health insurance industry's expense structure and enrollment relative to prior years. It also explores impacts to the insurance markets from the insurance marketplaces and the [ACA] 3R programs. In addition, the report reviews marketplace enrollment and associated subsidies from 2014 through 2016 in the context of the aggregate individual health insurance market." (Milliman)
House Passes Small Business Health Fairness Act
"The House of Representatives [on March 22] passed the Small Business Health Fairness Act (H.R. 1101) ... [T]he legislation empowers small businesses to band together though association health plans (AHPs) and negotiate for lower health insurance costs on behalf of their employees. The bill passed by a vote of 236 to 175." (Committee on Education and the Workforce, U.S. House of Representatives)
As Rivals Stand Silent, One Health Insurer Protests GOP Plan
"[Dr. J. Mario Molina] has become one of the few insurance executives publicly criticizing the [AHCA], which he believes could strip away coverage for millions of their clients and cause considerable turmoil for the insurance industry. The major insurers have mostly stayed silent during the debate, supporting some of the Republicans' provisions that promise near-term stability for the insurance exchanges and a repeal of a tax on health insurance." (The New York Times; subscription may be required)
[Opinion] The Reality of CBO's American Health Care Act Coverage Projection
"[T]he 24 million figure for coverage loss is a combination of people who do not want coverage and will choose not to have it if allowed, shaky guesses at employer behavior that have not come to pass previously, people whose coverage could be disrupted but for whom the law provides alternatives, people who do not even have coverage today, but who might possibly gain coverage in an alternate future, as well as about 4 million who may lose their current coverage due to changes to the Medicaid program. A far cry from 24 million people being stripped of their health care." (American Action Forum)
Why Deductibles Would Rise Under the GOP Health Care Plan
"[T]he average deductible for a typical plan in the non-group market under the GOP plan would be about $1,550 higher in 2017 than it would have been under the [ACA] ... Most of the debate has been about what would happen to premiums -- but for consumers, it's total out-of-pocket costs that matter.... The result: premiums may be lower in some cases, but deductibles will go up." (Drew Altman, Kaiser Family Foundation, via Axios)
Health Plan Innovators Focus on Clinical Outcomes
"Consumer-centric innovations such as providing tools to engage members in their own care, enabling providers to better coordinate care, and collaborating with providers to improve members' clinical health outcomes, are gaining momentum. The idea of improved clinical outcomes, something long thought to have been in the purview of health systems and other providers, is now considered to a be a worthy and achievable health plan goal." (America's Health Insurance Plans [AHIP])
As Opioid Epidemic Rages, Worksite Policies Overlook Prescribed Drugs
"Seventy-one percent of U.S. employers say they have been affected in some way by employee misuse of legally prescribed medications, including opioids ... 19 percent of employers feel 'extremely prepared' to deal with prescription drug misuse in the workplace. 81 percent lack a comprehensive drug-free workplace policy. 41 percent of those that drug test employees are not testing for synthetic opioids." (Society for Human Resource Management [SHRM])
Why You Should Share Total Compensation Statements with Your Employees
"Most comp statements will at minimum provide information on the employee's cash compensation and a monetary value for non-cash benefits.... [S]hare compensation reports when it is relevant to the employee: Upon hire, after an increase in pay, or after a promotion." (PayScale)
[Opinion] High-Risk Pools Do Not Serve Consumers Well (PDF)
"Current proposals to subsidize high-risk pools fall far short.... [O]ne recent health reform bill would establish state high-risk pools and allocate $3 billion over three years to fund them. Another recent proposal offered $25 billion over 10 years to fund them.... [It] would cost at least $178 billion a year to adequately fund high-risk pools today[.]" (AARP)
[Opinion] The Economic Effects of Repealing the ACA
"[CBO] recently analyzed the effect of repealing and replacing the [ACA] on federal revenues and the uninsured. There was much hype about their conclusions that 24 million people would be added to the ranks of the uninsured (although about 14 million of those would choose not to buy insurance because they would no longer be forced to). Also, federal deficits would fall by $337 billion over 10 years. However, the CBO did not measure the economic effects of repealing some of the most burdensome aspects of Obamacare, which would create hundreds of thousands of jobs and increase Americans' personal incomes." (National Center for Policy Analysis [NCPA])
[Opinion] What the CBO Gets Wrong About the House GOP's Obamacare Repeal Bill
"CBO's new estimate neglects the behavioral effects that would result from the Republican plan. By dismantling Obamacare, insurance companies would be able to offer a wider variety of plans and people would be more enthusiastic about buying them. CBO states that average premiums would decline after 2020, and this would lead to more enrollment." (Manhattan Institute for Policy Research)
Five Reasons Why Private Exchanges Will Thrive Post-ACA
"[1] With a private exchange, ... [y]ou choose the amount you want to contribute ... [2] A multi-carrier private exchange gives employees access to multiple health plans, so they can select the option that makes the most sense to them.... [3] Private exchanges offer tools to help employees find out which health care providers and prescription drug benefits are associated with each available plan.... [4] Simple administration ... [5] Easy renewal." (Healthcare Trends Institute)
Participation Pay-For-Value High-Need Patients
"[R]esearchers identified 17,443 Blue Cross Blue Shield of Michigan members with two or more chronic diseases, including mental health problems. They compared outcomes for members assigned to a [primary care provider (PCP)] that participated in the insurer's pay-for-performance program for at least four years to outcomes for members assigned to PCPs not in the program. Results were inconsistent.... Sustained involvement by PCPs in pay-for-value programs may be important to improving specific quality and cost outcomes for high-need patients. But PCPs do not have control over overall spending and broader approaches may be needed to improve costs for complex patients." (The Commonwealth Fund)
[Opinion] America's Employers Play a Vital Role in the 'Repeal and Replace' Debate
"Employers are uniquely positioned to help control healthcare spending and promote positive health outcomes. They have long provided the tools employees need to become fiscally responsible insurance consumers, and they are a trusted source of health information and resources. That is why policymakers should view this health reform 'reboot' as an opportunity to partner with American businesses to address the underlying causes of healthcare cost growth.... [L]egislators should reject policies that merely shift costs to private payers or vulnerable consumers. They should push for new policies and regulations that encourage responsible consumer health spending, transparency in healthcare pricing, and use of value-based models." (The Hill)
The Economic Effects of Repealing and Replacing the ACA (PDF)
15 presentation slides. "Repealing ACA and replacing it with the House Plan would by 2027: [1] Increase real GDP by $426 billion, or 1.5%. [2] Increase private sector employment by 940,000, or 0.49%. [3] Increase personal income by $185 billion, or 0.76%. [4] Reduce federal revenue by $132 billion, or 2.51%." (The Beacon Hill Institute, for National Center for Policy Analysis [NCPA])
[Opinion] Obamacare Replacement Debate: Fewer People Will Be Covered and Many Will See Big Cost Increases
"The House Republican plan does a much better job than Obamacare in providing health insurance to the working and middle class. But it does a much worse job in affording access to affordable health insurance to those with low incomes. Obamacare was a massive transfer of wealth from the better off to those with low incomes -- and was very unpopular among the middle class because of that. The House Republican plan is just shifting much of that from the Democratic base back to the Republican base. If it becomes law, we'll just have a different group of people upset." (Bob Laszewski's Health Care Policy and Marketplace Review)
Statement of HHS Secretary Tom Price on CBO Report
"For there to be the reductions in coverage they project in just the first year, they assume five million Americans on Medicaid will drop off of health insurance for which they pay very little, and another nine million will stop participating in the individual and employer markets. These types of assumptions do not translate to the real world, and they do not accurately estimate the effects of this bill. "The CBO report also does not incorporate two-thirds of the healthcare reform plan President Trump has called for -- specifically the regulatory relief HHS can provide and the additional legislative reforms Congress is and will be pursuing." (U.S. Department of Health and Human Services [HHS])
[Opinion] Analyzing the CBO Report on the American Health Care Act
" 'In 2020, CBO and JCT estimate, the average subsidy under the legislation would be about 60 percent of the average subsidy under current law. In addition, the average subsidy would grow more slowly under the legislation than under current law.' ... This is a significant improvement on PPACA in terms of fostering more individual responsibility and keeping deficits under control." (Benefit Revolution)
GOP Health Plan Would Boost Deductibility of Executive Compensation for Health Insurers
"By repealing this $500,000 deduction limit, nonpublic health insurers will be able to fully deduct executive compensation beginning in 2018 and publicly traded health insurers will be treated the same as all other public companies under Section 162(m) of the tax code. That provision generally limits compensation deductions to $1 million for the CEO and the other three highest-paid employees (excluding the CFO) and excludes performance-based pay." (Willis Towers Watson)
[Opinion] Explaining Health Policy to the General Public
"[On] some level every issue discussed in health policy relates to one of the following four fundamental and interrelated questions: How should the health care economy be organized? How should health care be financed? What should govern the availability and pricing of health care services? What should govern the availability and pricing of vehicles used to finance health care (e.g., insurance)?" (The Actuary Magazine)
The Potential Impact of Additional Carrier Exits on the Individual Market
"With plans in 14 states, an Anthem exit would leave nearly 300 counties and about a quarter of a million marketplace enrollees with no carrier, mostly in Georgia, Missouri, and Kentucky. An additional half million consumers residing in 227 other counties would find themselves with only one carrier. In terms of the number of people affected, a Cigna exit would be the second most consequential. Roughly 400,000 enrollees would be left with one or no carrier were Cigna to exit." (Robert Wood Johnson Foundation)
CBO and JCT Cost Estimate for the American Health Care Act (PDF)
37 pages. "CBO and JCT estimate that enacting the legislation would reduce federal deficits by $337 billion over the 2017-2026 period.... CBO and JCT estimate that, in 2018, 14 million more people would be uninsured under the legislation than under current law.... Some of those people would choose not to have insurance because they chose to be covered by insurance under current law only to avoid paying the penalties, and some people would forgo insurance in response to higher premiums.... The legislation would tend to increase average premiums in the nongroup market prior to 2020 and lower average premiums thereafter, relative to projections under current law." (Congressional Budget Office [CBO] and Joint Committee on Taxation [JCT])
[Guidance Overview] HHS Offers States Flexibility to Increase Market Stability and Affordable Choices
"Section 1332 of the [ACA] permits a state to apply for a State Innovation Waiver to pursue innovative strategies for providing its residents with access to high quality, affordable health insurance. The Departments are [hereby] promoting these waivers to give states the opportunity to develop strategies that best suit their individual needs. Through innovative thinking, tailored to specific state circumstances, states can lower premiums for consumers, improve market stability, and increase consumer choice." (U.S. Department of Health and Human Services [HHS])
Examining the House ACA-Repeal Bill's Potential Impact on Employers and Other Sponsors of Group Health Plans
"[American Health Care Act (AHCA) provisions that affect group health plans (GHPs)] and employer- and union-sponsors of GHPs ... include: [1] Repealing of the employer mandate penalty; [2] Delaying the effective date of the Cadillac Tax for five years; [3] Eliminating the health flexible spending account (FSA) employee contribution limits; [4] Expanding health savings account (HSA) availability; [5] Repealing the prohibition of tax-free reimbursements of over-the-counter ('OTC') medications by HSAs and other account-based plans; [6] Removing the limit on employer deductions relating to certain retiree prescription drug plans; and [7] Adding a new refundable, advance tax credit that could be used to pay for certain individual insurance and unsubsidized GHP COBRA coverage, which would replace the current ACA tax credits." (Trucker Huss)
What Employers Should Know about Stop-Loss Insurance
"Including prescription drug coverage under the stop loss coverage is becoming more important as the cost and number of specialty drugs continues to grow; it makes financial sense to cap the employer's cost exposure not only for medical claims, but for prescription claims.... [E]mployers need to understand the details of the stop loss arrangement, including differences in coverages from one carrier to another carrier. It is important to understand if some claims may not be covered under the new policy." (The Alliance)
Unintended Consequences: Out-of-Pocket Costs Changing How Low-Wage Workers Use Healthcare
"Low-wage workers use healthcare differently than their higher-paid counterparts. with a more reactive approach to healthcare. Individuals in the low-wage category used preventive care half as often as their higher paid peers, and notably, were significantly less likely to participate in incentive-based programs to learn about their health. As a result, low-wage workers: Had nearly twice the hospital admission rate; Experienced more than four times the rate of preventable hospitalizations; Had more than three times the rate of emergency department visits." (Conduent)
Corporate Alliance Unveils First Steps Toward Cutting Healthcare Costs
"The blueprint includes group contracts to purchase prescription drugs through units of CVS Health Corp. and UnitedHealth Group Inc.; the creation of specialized doctor networks; and a deal to use International Business Machines Corp.'s Watson software to analyze their health-care data. The nonprofit group, called the Health Transformation Alliance, says combining the negotiating heft of its 38 members allows it to win lower prices than any individual company could alone." (The Wall Street Journal; subscription may be required)
Beyond the ACA, the Affordability of Insurance Has Been Deteriorating Since 2015
"Since 2015, larger shares of people with health insurance say they have a difficult time affording their health care costs: from 27 percent to 37 percent for premiums, 34 percent to 43 percent for deductibles, and from 24 percent to 31 percent for copays and prescription drugs." (Henry J. Kaiser Family Foundation)
Direct-to-Consumer Telehealth May Increase Access to Care But Does Not Decrease Spending
"12 percent of direct-to-consumer telehealth visits replaced visits to other providers, and 88 percent represented new utilization. Net annual spending on acute respiratory illness increased $45 per telehealth user." (Health Affairs)
Verification of ACA Premium Tax Credit Claims During the 2016 Filing Season (PDF)
51 pages. "TIGTA's analysis of approximately 4.9 million tax returns processed by the IRS as of May 1, 2016, found that the IRS accurately determined the amount of allowable PTC on more than 4.7 million (97 percent) returns. For the remaining 154,744 tax returns, either programming errors resulted in an inaccurate PTC computation or high-risk tax returns were not identified as potentially erroneous because the discrepancy amount was below the dollar tolerance for which the IRS will review a claim." (Treasury Inspector General for Tax Administration [TIGTA])
The American Health Care Act: House Energy and Commerce Committee Provisions (PDF)
"The legislation, part of House Republicans' American Health Care Act, ... [1] Creates a Patient and State Stability Fund -- This new and innovative fund give states broad flexibility to design programs that best serve their unique populations. They can also use funds to increase access to preventative services. [2] Responsibly unwinds Obamacare's Medicaid expansion -- By freezing new enrollment after 2 years and grandfathering in current enrollees, we protect patients and offer a stable transition. [3] Strengthens Medicaid -- Using a per capita allotment, our legislation ensures a fair funding formula for states while creating a viable financial future for the program." (Energy and Commerce Committee, U.S. House of Representatives)
The American Health Care Act: Fact Sheet (PDF)
"[T]he primary Committees with jurisdiction over health care -- Ways and Means and Energy and Commerce -- have released the American Health Care Act -- legislation that not only repeals the law, but replaces it with reforms President Trump laid out.... [H]ere's what the American Health Care Act will do: ... [1] Dismantle the Obamacare taxes ... [2] Eliminate the individual and employer mandate penalties ... [3] Prohibit health insurers from denying coverage ... [4] [Allow] dependents to continue staying on their parents' plan until they are 26.... [5] Establish a Patient and State Stability Fund ... [6] Modernize and strengthen Medicaid ... [7] [Expand] Health Savings Accounts (HSAs) -- nearly doubling the amount of money people can contribute and broadening how people can use it.... [8] [Provide] a monthly tax credit -- between $2,000 and $14,000 a year -- for low- and middle-income individuals and families who don't receive insurance through work or a government program." (Committee on Ways and Means, U.S. House of Representatives)
Obamacare Oversight: 112th to 114th Congress (PDF)
45 pages. "Since its passage in 2010, the committee has convened 31 oversight hearings on Obamacare and performed systematic and methodical oversight to examine how the administration implemented the most critical components of Obamacare. In these hearings, 107 witnesses testified before the committee, culminating in hundreds of hours of testimony. Of those witnesses, 38 have been administration officials.... The committee's oversight over the last six years, compiled here in its entirety for the first time, has exposed serious deficiencies in Obamacare that have harmed the American people and wasted taxpayer dollars. These oversight hearings and reports have paved the way to legislation that can repeal this harmful law." (Energy and Commerce Committee, U.S. House of Representatives)
[Opinion] Healthcare is Complicated: Is it Fixable?
"[C]onsumers think healthcare is too complicated for them to understand. Thus, they depend on their caregivers to educate them and are predisposed to be dependent on what they're told. It hasn't changed. In this digital health age, only one in eight consider themselves well-informed and capable of navigating the system. It's too complicated for most Americans and perhaps even more for the GOP lawmakers seeking to transform it in an environment of intense media scrutiny and partisan rancor." (Paul Keckley)
Assessing Premiums, Deductibles, and Plan Competition in's Individual Market (PDF)
17 pages. "Over the 2014-2017 window, [this study] found significant average growth in premiums and cost sharing and a general reduction issuer in between choices. CAHC's previous research shows a major reason for this is that risk pools are seriously unbalanced, with older and sicker enrollees. [These] findings show that the individual market is currently struggling and rapidly deteriorating. [The authors] speculate that in many markets, these pools are in or headed towards a death spiral, but could be saved by intervention to reduce risk and relief from the crushing mandates, restrictions, and rules imposed by current law." (Council for Affordable Health Coverage [CAHC])
Employers Gear Up for Next Fight After Cadillac Tax
"Since World War II, both an employer and employee's contribution to the cost of health insurance have been excluded from federal income and payroll taxes. That's a major incentive for employers to provide insurance. But employers argue that taxing health benefits would require them to scale back on the benefits they offer, pass more costs onto employees, or even quit providing insurance altogether." (Crain's Chicago Business)
Where Does Your Health Insurance Premium Dollar Go?
"Your premium, or how much you pay for your health insurance each month, covers the costs of providing your insurance as well as the medical care you might receive -- everything from prescription drugs and doctors' visits to health improvement programs and customer service. Here is a visual breakdown of where your premium dollar really goes." (America's Health Insurance Plans [AHIP])
This Simple Two-Step Plan Could Lower Healthcare Costs
"A strategy of requiring healthcare providers to publish their rates and offer the same discounts to all health plans could result in more competition and options for consumers[.]" (HealthLeaders Media)
House Education and the Workforce Committee Hearing: Legislative Proposals to Improve Health Care Coverage and Provide Lower Costs for Families
Held March 1, 2017. Page includes links to video webcast, written testimony by invited witnesses, and text of legislative proposals. (Committee on Education and the Workforce, U.S. House of Representatives)
[Opinion] Health Care Can Be Patient-Centered, Accessible and Affordable
"[A] new paradigm of innovative value-based payment and care delivery ... reconciles what many consider competing values: access, affordability and a patient focus.... Value-based care is patient-centered care.... Incentives and accountability create better outcomes for patients.... Realizing the benefits of value-based care requires commitment and investment.... Value-based care works when every stakeholder is engaged.... Value-based care doesn't just benefit patients; it's an economic engine that creates jobs." (Morning Consult)
[Guidance Overview] CMS Issues Proposed Rule to Stabilize the Individual and Small Group Health Insurance Markets
"CMS indicated that they considered maintaining the status quo, but determined that the changes are urgently needed to stabilize health insurance markets, to incentivize insurers to enter or remain in the Exchanges, to ensure premium stability and to increase choices for consumers. However, CMS acknowledges that the net effect of the proposed rule is uncertain and may not have the desired effect on enrollment, premiums or overall healthcare spending. The proposed rule is open to public comment until March 7, 2017." (King & Spalding)
Justice Department Joins Whistleblower Suit Accusing UnitedHealth Group of Overcharging Medicare by 'Hundreds of Millions'
"The suit accuses United of operating an 'up-coding' scheme to receive higher payments under [Medicate Advantage's] risk adjustment program ... The complaint alleges that United fraudulently collected 'hundreds of millions -- and likely billions -- of dollars' by claiming patients were sicker than they really were." (Sheppard Mullin)
Impact of Changing the Age Rating Limit for Health Insurance Premiums (PDF)
"Premiums for adults ages 60 and older would increase by an average of $3,192 per year, from about $14,724 to $17,916. This represents a 22 percent increase. Premiums for adults ages 50-59 would increase by an average of $1,524 per year, from about $11,316 to $12,840. This represents a 13 percent increase." (AARP)
Health Reform: American Businesses Are Critical Partners for Success (PDF)
11 pages. "We are on the cusp of a major transformation in how people access care and how care is delivered.... The potential savings are vast, and would help achieve the important goal of expanding health coverage to more people while preserving the employer-based system that Americans value so highly. [This paper presents] four recommendations to achieve these goals: [1] Address healthcare cost growth and avoid shifting costs to private payers; [2] Maintain favorable tax treatment of employer-sponsored benefits; [3] Update health savings account rules; [4] Create a 'President's Healthcare Leadership Council'." (Marsh & McLennan Companies)
Text of District Court Opinion Enjoining Merger of Anthem and Cigna (PDF)
140 pages. "[T]he merger will be enjoined due to its likely impact on the market for the sale of health insurance to 'national accounts' -- customers with more than 5000 employees, usually spread over at least two states -- within the fourteen states where Anthem operates as the Blue Cross Blue Shield licensee.... This brings us to the elephant in the courtroom. In this case, the Department of Justice is not the only party raising questions about Anthem's characterization of the outcome of the merger: one of the two merging parties is also actively warning against it." [U.S. v. Anthem, No. 16-1493 (D.D.C. Feb. 8, 2017; 12-page order was previously published, this redacted opinion released by the court on Feb. 21, 2017)] (U.S. District Court for the District of Columbia)
Managing Hospital Employee Health Costs Can Help Prepare for Value-Based Care
"As employee health costs continue to rise they have a significant impact on hospital finances.... [H]ospitals already take full risk for the cost of their employees' health. By actively managing the employee health plan a hospital can achieve significant savings that can be used to fund the transformation to accepting risk (population health)." (BDO Center for Healthcare Excellence and Innovation)
When Will Insurers Receive Risk Corridor Payments?
"A number of risk corridor cases are still pending ... While the Lincoln and Health Republic cases were decided on different grounds ... the courts reached contrary conclusions as to whether HHS had an obligation to make annual payments.... The Moda court, however, essentially broke the tie by disagreeing with Lincoln and specifically finding the government liable to Moda.... [In] their recent rate filings, insurers have likely factored in the likelihood of receiving risk corridors payments by raising rates.... [S]ince the risk corridors program expired at the end of 2016, insureds are unlikely to see a significant impact from these cases." (Wolters Kluwer)
Among Low-Income Respondents With Diabetes, High-Deductible Versus No-Deductible Insurance Sharply Reduces Medical Service Use
"Compared with privately insured respondents with diabetes with [no deductible], privately insured lower-income respondents with diabetes with [a low deductible ($1,000/$2,400)] report significant decreases in service use for primary care, checkups, and specialty visits (27%, 39%, and 77% lower, respectively), and respondents with [a high deductible (>$1,000/$2,400) ] decrease use by 42%, 65%, and 86%, respectively." (Diabetes Care)
[Opinion] Insurers, Not Government, Will Lead the Way to Lower Healthcare Costs
"In seeking solutions to the healthcare crisis, politicians have a different focus than insurers. Access is the politician's biggest concern -- how to address the needs of the greatest number of their constituency with the least friction possible.... Health insurance carriers, in contrast, concern themselves most with cost considerations in order to remain competitive in the marketplace.... [A] government-led solution will not work." (Frenkel Benefits)
Top and Bottom Earners Responsible for Most Health Care Spending
"Annual total health care spending was highest among those earning above $70,000, who on average spent $5,074 per patient per year. Those earning $24,000 or less weren't far behind, spending on average $4,835 per patient per year. Middle-wage earners had, on average, less than $4,000 per patient per year in health care spending." (Society for Human Resource Management [SHRM])

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