This is Jacob Emerson with the Becker payer
issues podcast.
Here's your bi weekly industry news briefing for
June fifth.
The nation's largest health insurers have signaled significant
headwind in recent months across their Medicare Advantage
and Medicaid businesses as costs rise and the
effect, of of rude determinations takes hold.
On May 20 ninth, United Health Group Ceo,
Andrew Witty told analyst, the company is closely
watching its Medicaid business. The Said we've come
through this prolonged red determination cycle in Medicaid,
making sure the utilization and the rate and
everything else stay in perfect. Sync
during a multi quarter cycle, there's probably going
to be some disturbance around that.
In April 20 23, states began the process,
of dis enrolling Medicaid beneficiaries for the first
time since the Covid Public health emergency was
declared, which prevented state agencies from removing individuals
from there in Medicaid rules.
As of June fourth, at least 22700000.0
people have lost Medicaid coverage, a direct hit
to private insurers, enrollments. If Mc continue to
lose members, but the enroll they retain use
health care at to high rate, profits could
suffer. Cent Ceo, Sarah London said may 30
first. They are seeing pressure in their Medicaid
book of business in April results, and that's
largely due to the impact of the determination
process, the we've been going through for more
than a year now and the shift in
acuity of the underlying population that remains after
red
nations. Health system owned insurers with Medicaid contracts
have also been reporting significant losses to their
enrollments,
Texas Children's health plan in Houston laid off
a few hundred employees after it lost 30
percent of its members during red determinations. On
the Medicare Advantage front, major carriers such as
Cvs Health and Human have said they are
looking to shrink enrollments and exit markets in
20 25
as the industry faces lower margins and rising
Utilization rates among older adults. On May t,
Bc cbs of Kansas city said it is
leaving the M market at the end of
20 24,
citing increasing regulatory requirements and financial headwind.
Notably, United Health said it is not planning
Any major shake up to its Medicare business
in 20 25,
citing a long term strategy to adjust to
industry pressures.
Mister Witty told analysts inquiring about M competitors
that right now, trying to pin the tail
on the donkey of who gets what next
year, if there's probably not much mileage in
that.
Well scan health plan has won its lawsuit
against Cms that claimed the agency improperly calculated
the payers 20 24 Met a Care Advantage
star rating.
Scan filed that soon in December after its
star rating decreased from 4 and a half
to 3 and a half stars, the A
move that could have led to about 250000000
dollars in missed quality bonus payments for the
health plan and at the heart of why
the company filed the lawsuits.
According to its Ceo, doctor sac and Jai.
Doctor Jane told backers that this decision reaffirm
that star ratings actually matter. When there are
these changes to the rules and how they're
implemented, real people are affected by that. In
this case, Medicare
beneficiaries.
In the June third ruling from the Us
district court for Washington Dc.
Judge Carl Nichols said Cms violated the rate
of procedure act when it calculated scans 20
24 rating using new methodology changes. A decision
that could have sweeping industry consequence rate.
Scan said the agency did not follow the
correct rule making process when implementing the methodology
changes and that it should have been given
an overall star rating of at least for
storm.
M plans must receive star ratings of 4
or higher to earn quality bonus payments from
Cms, which can then be used to improve
member benefits.
Judge Nichols ordered that scans 3 and a
half star rating be set aside and prohibited
Cms from utilizing the original store
score to calculate quality bonus payments. Other m
carriers such as el Health and Z Health
have filed similar lawsuits alleging that unlawful methodology
changes that led to miss bonus payments,
or terminated Medicare
contracts.
In March, Cms did increase the ratings of
4 of El Medicare
contracts, a move the company estimates,
will lead to a hundred and 90000000 dollars
and bonuses for payment year 20 25.
Ina United Health Group says it is running
around 500 use case applications for Ai across
the organization.
Ceo, Andrew Witty said some of the company's
Ai efforts are, quote, low hanging opportunity entities
aimed at speeding up administrative processes.
He said it's not Einstein opportunities. These are
relatively
straightforward. Some of them are already underway. It
they play out in areas like speed, allowing
call handlers to deal with issues faster than
they used to. Opt Ceo, Heather C and
F told investors that Opt Ai efforts, they
are focused in 2 areas. 1 is administrative
support particularly for clinicians and giving them time
back at home more in the office,
The second area is identifying disease progression or
emergency
emerging disease faster.
United Health executives previously said that Ai additions
to their customer service offerings helped boost the
company's net promoter scores, a measure of customer
satisfaction.
Their Well a former Astra
executive is facing federal cyber stocking charges, poor
allegedly sending violent threats to executives at Cvs
Health Ae, following issues with personal claims reimbursement.
That's according to a criminal complaint filed May
eighth in a Delaware federal court.
The individual was arrested on May eighth and
charged with cyber stocking after more than a
year of allegedly sending court traffic threats over
email, facts, and mail to former and current
president, along with Cbs Ceo Karen Lynch and
other Ae employees. Traffic along with employees at
Astra.
The issue first began in November of 20
22 when the individual sent a threatening letter
to Ae former president
regarding claims and appeals challenges related to his
Crohn's disease treatments.
Those threats continued through January of 20 23.
Ae then noted the pharmaceutical company about the
communications and the individual allegedly sending the letters
was. Terminated.
Executives that at and Astra though continued to
receive graphically violent threatening letters from March 20
is 23 to April of this year, which
included threats to their minor aged children.
The Fbi executed a search warrant at the
individual's residence in Maryland in May where he
was arrested. His arrangement is scheduled for June
thirteenth.
A possible dives buyer has backed out of
a deal with United Health group and A
that aim to make a proposed acquisition of
the home health company more palatable to regulators.
Of In May, the... It was reported that
the q companies offered to sell 100 clinics
to a private equity buyer and that United
Health is still seeking a single purchaser of
those facilities.
Opt intends to acquire a medi in a
3300000000.0
dollar deal. It approved
a it would... It got approved by shareholders
in September, but the proposal is under review
by the justice department. Lawmakers have also urged
careful scrutiny of that proposal.
Ci Ever North Care group plans to cut
specific specialty service and consolidate certain Arizona care
locations in the next few months. Those reductions
will result in the termination of 261
employees.
In Phoenix.
The decision comes as Ever North, Care group
works to adapt to market conditions and evolve
its strategy to meet patient and community needs
in Employees affected by those layoffs will be
provided a severance package, including transitional services.
News of those workforce cuts comes out after
Ever north sold 7 Phoenix based outpatient
imaging centers to Rad, a diagnostic imaging provider
in late January for an undisclosed amount.
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