ISQua EEA’s Post

CMS To Recalculate MA Quality Ratings For This Year Reuters (6/14, Roy) reported CMS “said it will recalculate this year’s quality ratings of Medicare Advantage plans for people aged 65 years and above, which would likely increase the bonus payments for insurers.” CMS “notified insurers of its decision to recalculate the Star Ratings in a memo on Thursday, which determine the reimbursement levels and can sway enrollees in choosing their plans.” Increased “bonus payments would be a relief to health insurers who are already struggling with high medical costs and lower-than-expected rates for next year.” The decision to recalculate the ratings “comes after two lawsuits over the Star Ratings, filed by insurers SCAN Health Plan and Elevance Health. Both insurers won their challenges.” https://buff.ly/4enlrp9

𝐓𝐡𝐞 𝐔𝐒 𝐡𝐞𝐚𝐥𝐭𝐡 𝐩𝐚𝐲𝐞𝐫𝐬 𝐚𝐫𝐞 𝐟𝐚𝐜𝐢𝐧𝐠 𝐚 𝐦𝐚𝐫𝐠𝐢𝐧 𝐜𝐫𝐢𝐬𝐢𝐬. 𝐓𝐡𝐞 𝐪𝐮𝐞𝐬𝐭𝐢𝐨𝐧 𝐢𝐬: 𝐖𝐡𝐚𝐭’𝐬 𝐧𝐞𝐱𝐭 𝐟𝐨𝐫 𝐩𝐚𝐲𝐞𝐫𝐬? Despite vertical integration efforts and cost-control strategies, the systemic pressures on health insurers continue to intensify. Declining underwriting revenues, rising medical costs, and an aging population are reshaping the landscape.  𝐇𝐞𝐫𝐞 𝐚𝐫𝐞 𝟓 𝐜𝐫𝐢𝐭𝐢𝐜𝐚𝐥 𝐭𝐫𝐞𝐧𝐝𝐬 𝐫𝐞𝐬𝐡𝐚𝐩𝐢𝐧𝐠 𝐭𝐡𝐞 𝐩𝐚𝐲𝐞𝐫 𝐥𝐚𝐧𝐝𝐬𝐜𝐚𝐩𝐞: 1️⃣ Government & self-insured dominance – 72% of lives bypass insurers. 2️⃣ Declining underwriting revenues – Profits contribute <30% to revenue streams. 3️⃣ Provider networks commoditized – Employers seek direct, transparent partnerships. 4️⃣ Vertical integration struggles – Margins for top payers average ~2.5%. 5️⃣ Systemic pressures escalating – Costs outpacing inflation; chronic care demand rising. 🔍 𝐓𝐡𝐞 𝐁𝐨𝐭𝐭𝐨𝐦 𝐋𝐢𝐧𝐞? Payers need a bold strategy to redefine their role in healthcare. This isn’t just about cost control anymore—it’s about creating value, trust, and sustainability in a system under immense pressure. 𝑾𝒉𝒂𝒕 𝒔𝒕𝒆𝒑𝒔 𝒅𝒐 𝒚𝒐𝒖 𝒕𝒉𝒊𝒏𝒌 𝒑𝒂𝒚𝒆𝒓𝒔 𝒔𝒉𝒐𝒖𝒍𝒅 𝒕𝒂𝒌𝒆 𝒕𝒐 𝒔𝒕𝒂𝒚 𝒓𝒆𝒍𝒆𝒗𝒂𝒏𝒕 𝒂𝒏𝒅 𝒑𝒓𝒐𝒇𝒊𝒕𝒂𝒃𝒍𝒆 𝒊𝒏 𝒕𝒉𝒊𝒔 𝒆𝒗𝒐𝒍𝒗𝒊𝒏𝒈 𝒍𝒂𝒏𝒅𝒔𝒄𝒂𝒑𝒆? 🔗 Read more detail here: https://lnkd.in/gZwaJVyS #Healthcare #HealthInsurance #Innovation #Payers Rohan Kulkarni Melissa O'Brien Elena Christopher Ashish Chaturvedi Saurabh Gupta Reetika Fleming

Healthcare is the prevention, diagnosis, treatment, and cure of physical and mental health issues. It can also refer to the organizations and personnel that provide healthcare. Healthcare is a vital industry that employs many people and is important to the health and well-being of individuals, populations, and economies. Here are some things to know about healthcare: Healthcare professionals include doctors, dentists, nurses, and other healthcare professionals. Healthcare services include medical, dental, and nursing services. Technology is improving healthcare in many ways, such as helping doctors identify strokes and provide better care. Healthcare costs can be high, and the number of uninsured people can increase if healthcare continues to become more expensive. India's healthcare industry is growing rapidly, and includes hospitals, medical devices, telemedicine, and health insurance.

Transforming Healthcare: The National Health Claim Exchange (NHCX) The Health Ministry and IRDAI are set to revolutionize healthcare with the NHCX, a digital platform aimed at enhancing access to quality healthcare while reducing out-of-pocket expenses. Here's a glimpse of what to expect: Key Points: -The NHCX will facilitate seamless exchange of health claims data, streamlining interactions between hospitals and insurers. -Cashless claims will be processed within three hours, ensuring swift and efficient claim settlement for patients. -The NHCX platform already has over 30 insurance companies onboard, with efforts underway to bring in hospitals. -Financial incentives under the Digital Health Incentive Scheme will encourage digital health transactions and digitization of patient health records. Addressing Challenges: -The NHCX seeks to standardize and streamline health claims, reducing operational costs and fostering predictability and transparency in healthcare pricing. -Challenges such as discharge delays and miscommunication between hospitals and insurers will be addressed through the NHCX portal, leading to more efficient services and smoother operations within the healthcare space. -The NHCX is set to revolutionize the healthcare ecosystem, bringing efficiency, transparency, and enhanced patient care to the forefront. Source- https://lnkd.in/d--AKwst #NHCX #HealthcareRevolution #DigitalHealthcare #InsuranceInnovation #InsuranceBrokers #InsuranceAdvisors #HealthPolicy

CMS To Recalculate MA Quality Ratings For This Year Reuters (6/14, Roy) reported CMS “said it will recalculate this year’s quality ratings of Medicare Advantage plans for people aged 65 years and above, which would likely increase the bonus payments for insurers.” CMS “notified insurers of its decision to recalculate the Star Ratings in a memo on Thursday, which determine the reimbursement levels and can sway enrollees in choosing their plans.” Increased “bonus payments would be a relief to health insurers who are already struggling with high medical costs and lower-than-expected rates for next year.” The decision to recalculate the ratings “comes after two lawsuits over the Star Ratings, filed by insurers SCAN Health Plan and Elevance Health. Both insurers won their challenges.” https://buff.ly/4enlrp9

CMS To Recalculate MA Quality Ratings For This Year Reuters (6/14, Roy) reported CMS “said it will recalculate this year’s quality ratings of Medicare Advantage plans for people aged 65 years and above, which would likely increase the bonus payments for insurers.” CMS “notified insurers of its decision to recalculate the Star Ratings in a memo on Thursday, which determine the reimbursement levels and can sway enrollees in choosing their plans.” Increased “bonus payments would be a relief to health insurers who are already struggling with high medical costs and lower-than-expected rates for next year.” The decision to recalculate the ratings “comes after two lawsuits over the Star Ratings, filed by insurers SCAN Health Plan and Elevance Health. Both insurers won their challenges.” https://buff.ly/4enlrp9

“Medicare Advantage are private plans that are typically more profitable than other segments of the health-insurance market. They have grown in popularity in recent years, and large insurers have rushed into the market to take advantage of the growing opportunity.” How about focusing on an opportunity to provide good medical care instead of expanding profit margins? If these companies did that, we might actually have a healthcare system that works!

There’s simply no evidence that diminished FFS (fee for service) reimbursement to Physicians is improving VBC #valuebasedcare in America. In Bismarck Healthcare Nations like Germany, Switzerland, Netherlands and Japan there’s access for all citizens to private insured private FFS manufactured medical care with better outcomes and costs (value) than in America and lower costs, and, rhete are more private insurers and hospitals competing capitalistically per Capita than in America. This value based fee-for-service (#FFS) care is achieved simply by making health insurers profit-neutralized UTILITIES instead of luxuries as they are in America. #MedicareAdvantage, #Medicaid, #ObamaCare #Commercial #AlleghenyHealthNetwork #Highmark #data #collaboration #patients #quality. #insurers #providers Read about Bismarck Model HC here;

This is an excellent explanation as to why the concept of health insurance using its buying power to lower costs is completely invalid. To be clear this was happening long before the ACA but the ACA’s fixing of loss ratios did throw gasoline on the fire…MK PS - next Right to Health Care video posts tomorrow.

https://lnkd.in/dNApDugZ #Buddycare has developed a technology-driven platform powered by artificial intelligence that is set to transform health insurance for both payers and providers, marking a significant advancement in the industry. #plugandplay solution for insurers, designed to streamline the integration of healthcare services with insurance offerings. Key features include: #PrepolicyIssuance Services: Facilitates the initial steps for insurers to issue policies efficiently. #RealtimeRiskQuantification. Provides insurers with immediate insights into potential risks associated with policyholders. Seamless #PostpolicyServiceDelivery: Ensures smooth healthcare delivery after policy issuance. The platform utilizes advanced #riskmanagementframeworks and fraud-resilient OPD systems, enhancing operational transparency and minimizing financial risks for insurers. This integration fosters a unified ecosystem, promoting cashless healthcare access across India