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Vermont Abandons Single Payer, for Now

"Three years after Vermont's legislature passed Act 48 creating a roadmap for a state-financed single payer system called Green Mountain Care, Governor Peter Shumlin has abandoned the idea ... A team within the Shumlin Administration had drafted a financing proposal to fund Green Mountain Care, a public healthcare plan envisioned to cover 94 percent of healthcare costs for all Vermonters except those enrolled in Medicaid or Tricare. The proposal called for an 11.5 percent payroll tax on all businesses, as well as a 9.5 percent assessment on individuals earning over 400 percent of the poverty level, with a lower, sliding scale tax for those earning under 400 percent FPL."

New Health Models Drive Payer Outsourcing Boom

"Over the last year, the traditional [business processing outsourcing (BPO)] services rose only 13 percent, even as 7.2 million new members enrolled in ACA plans and millions more gained coverage through Medicaid managed care.... At the same time, contracting has nearly doubled for ... 'inventive and unchartered administrative services' -- analytics, new plan design, claims modernization and alternative payment services. This kind of spending by commercial insurers, government payers, ACOs and provider-sponsored plans is increasing the payer BPO market from estimated $5 billion in 2014 to an expected $8 billion in 2016[.]"

The Rise of Healthcare Provider-Sponsored Health Insurance

"With the ACA's mandate to control healthcare costs, increasingly high deductibles and growing enrollment in ACA exchange plans, Medicaid managed care and Medicare Advantage, the insurance market is beckoning health systems. They might be able to offer a strong value proposition -- lower premiums, easier access, expanded primary care and more affordable medical bills.... Given the shift of healthcare resources to primary and preventive care, there are real, long-standing problems with the health insurance model that could be solved uniquely when the payer is owned by the provider business getting paid."

Four Factors Shaping Higher 2015 Healthcare Premiums

"The following four considerations will factor into insurers' 2015 pricing: [1] The risk pool may differ somewhat.... [2] The risk mitigation program -- risk adjustment, reinsurance and risk corridor -- continues but at lower funding in 2015.... [3] Narrow provider networks were a key reason 2014 exchange rates ended up lower than most had predicted, and will continue in 2015.... [4] Insurer positioning next to the lowest rates is an important strategy to be competitive."

CEO of eHealth.com to Obama: 'Let Us Take Over' Healthcare.gov

"In a letter to President Obama, [eHealth] CEO Gary Lauer [asked] for the administration to 'allow eHealth to take over enrollment' for the federal marketplace. 'We are ready to help you get this program back on track promptly, with the cooperation of the federal exchange, if you allow us to take over the shopping and enrollment process in all 36 federal exchange states -- without cost to the taxpayer. While your staff is working hard to repair Healthcare.gov, with your support, we can be the stopgap that is needed,' Lauer wrote."

Aetna Devised Quick Fixes for Early Exchange Mess

"Mired deep in early problems it didn't expect with the exchanges, Aetna turned to tools from its previous large enrollment experiences to get operations on track.... The hard fought experiences brought a silver lining of significant collaboration among major payers in an alpha group, along with the CMS team for Healthcare.gov and state-based marketplaces, and others [who were] brought in ... for 'unraveling complex issues and noodling creative solutions'[.]"

'Pay and Chase' Fades as Insurers Seek Revenue Integrity

"Healthcare cost inflation is a national problem, shared by everyone in the industry and those being served by it, patients and consumers ... But incorrect payments are largely confined to insurers, who suffer the consequences of lost revenue by paying claims that, say, should have been covered by auto insurance, or by losing Medicare Advantage reimbursement due to erroneous eligibility information with the CMS' mandatory insurer reporting (or section 111) files. With provider upcoding and demand for healthcare services bound to continue ... payment integrity is one area where insurers can start to make a large difference."

CMS Threatens Fines as Industry Struggles to Maintain Accurate Provider Directories

"While healthcare provider directories have always been hard to maintain, new [CMS] regulations can mean costly fines if insurers fail to keep accurate, up-to-date information on the physicians who are in their health plans.... [The new regulations levy] fines against insurers of up to $25,000 per beneficiary for errors in Medicare Advantage plan directories and up to $100 per beneficiary for errors in plans sold on the federally run insurance exchanges in 37 states. Payers found in violation of the CMS rules can also be banned from new enrollment and marketing."

Five Tactics to Fight Pill Mills, Opiates Abuse

"Illegitimate use of prescription drugs, especially of opiates, is a complex and deadly problem in healthcare, and expensive for insurers that pay the claims through their health plans and Part D Medicare prescription drug plans.... For every $1 the payer spent on an opiate, it spent $40 for the facility fee, typically the emergency room visit for the member to get the script."

Insurers, Providers Could Save $8 Billion by Automating HIPAA Transactions

"Despite increasing use of electronic transactions for eligibility and benefit verifications and claim status inquiries, the industry continues to handle high volumes of these transactions manually. Healthcare providers alone could save more than $5 billion annually by using automated processes to check patients' eligibility and benefits ... On average, ... each manual transaction cost providers and plans $2 more than automated electronic transactions."