Ten new industry developments challenge health plans and other payers to remain relevant and competitive. For forward-thinking plans and payers, the developments offer strategic guidance to assist them with redesigning their business models in response to transformative industry wide changes like price transparency and population health.

Health Insurance Exchanges

CMS says medical costs incurred by enrollees in public exchange health plans stable

The Centers for Medicare & Medicaid released figures that show that enrollees in health plans sold over state and federal health insurance exchanges last year were no more costly than the enrollees in 2014. “Available evidence indicates that the slow ACA individual market cost growth resulted at least in part from a broader, healthier risk pool,” CMS said. Specifically, the CMS said per member per month claims paid by exchange plans fell by 0.1 percent from 2014 to 2015 compared with a 3 to 6 percent increase in the overall health insurance market over the same period.

Employers show limited interest in shifting employee health coverage to private exchange plans

Only 4 percent of large employers surveyed by the National Business Group on Health said they moved active workers this year to health plans sold over private health insurance exchanges. None of the 133 employers polled by the NGBH said they planned to do so in 2017. Only 10 percent said they will consider shifting employees to private exchange plans in 2018 and 2019. “Respondents continue to have little confidence in the ability of private exchanges to outperform employer efforts to control health care costs, assist employees with questions/problems and engage employees in better health care decision-making,” the NBGH said.

Enrollee Engagement

Out-of-pocket cost calculator tops ranking of tech features enrollees want from health plans

A survey by Strategy&, the global strategy consulting practice at PricewaterhouseCoopers, asked 500 consumers to rank 15 different technology-enabled functions they want from health plans via mobile applications, computers or other devices. The top-five most-preferred functions were: 1) out-of-pocket cost estimator; 2) simple online and mobile access to electronic medical records; 3) mobile post-care instructions and follow-up notifications; 4) online appointment scheduling with in-network providers; and 5) central payment portal to both health plan and to providers. 

More than a third of millennials say their knowledge of health insurance options is lacking

According to the Millennial Survey: Young Adults' Healthcare Reality from the Transamerica Center for Health Studies, about 1,200 millennial adults born between 1980 and 1997 found that 35 percent of the respondents described themselves as being “not very informed” or “not at all informed” about the health insurance coverage options available to them. Further, 41 percent described the process of choosing a health plan as “difficult” or “very difficult” with 63 percent saying they've never comparison shopped for health plan coverage.

Population Health

Diabetes tops list of maladies targeted by chronic disease management programs

A survey of nearly 200 health care executives conducted by HIMSS Analytics reports that 75.9 percent of the respondents cited diabetes as the top focus of their chronic disease management efforts followed by congestive heart failure (58.6 percent), chronic obstructive pulmonary disease (41.4 percent), heart disease (27.6 percent), stroke (20.7 percent) and high blood pressure (20.7 percent).

CDC says cancer surpassing heart disease as leading cause of death in nearly half states

From 2000 to 2014, cancer overtook cardiovascular disease as the leading cause of death in 20 states, according to a data brief released by the Centers for Disease Control and Prevention's National Center for Health Statistics. That brings to 22 the number of states where cancer is the leading cause of death. With deaths from heart disease decreasing and deaths from cancer increasing, cancer was thought to replace heart disease as the leading cause of death nationally as soon as five years ago. But an uptick in heart disease deaths has kept it in the top spot, the agency said. In 2014, 614,348 people died from heart disease compared with 591,699 from cancer.

Price and Performance Transparency

Feds approve 15 organizations for disseminating analyzed claims data to providers, employers

The Centers for Medicare & Medicaid Services issued final rules that allow certain “qualified entities” to share or sell analyses of aggregated claims data from Medicare and private health plans to providers, employers and others to support quality-improvements efforts. The regulations expand the Qualified Entity Certification Program for Medicare data, which permits qualified entities like health plans to obtain Medicare data to evaluate provider performance. Now, qualified entities can obtain the Medicare claims data, mix it with their own claims data and generate analytical reports that are “representative of how providers and suppliers are performing across multiple payers,” CMS said. The agency said 15 organizations to date have applied and received approval to become quality entities under the new regulations.

Reference pricing combined with transparent tool lower expenditures on common lab tests

A new study in JAMA Internal Medicine found that the use of “reference pricing” for common diagnostic laboratory tests can cut employers' health care expenses and employees' out-of-pocket costs for those tests. Under reference pricing, a health plan or employer sets a maximum reimbursable dollar amount for a medical service. Enrollees who select a service at or below that amount pay the usual deductible or co-payment, and those that select a service above that amount pay the difference. The study looked at effects of reference pricing by a large grocery organization. The reference pricing applied to 285 common diagnostic lab tests for non-urgent medical needs. The percentage of employees who used higher-priced labs dropped to 15.6 percent by 2013 from 45.6 percent in 2010, and the company and its employees saved an estimated $2.6 million on common lab tests from 2011 through 2013

Value-Based Reimbursement

Medicare invites 57 health plans to participate in new Comprehensive Primary Care Plus demo

The Centers for Medicare & Medicaid Services selected 14 regions where the agency will test its new Comprehensive Primary Care Plus, or CPC+, value-based reimbursement program, and it's invited 57 health plans serving those regions to join Medicare as its private-sector partner in the five-year initiative. Under the program, which CMS says will attract as many as 5,000 primary-care practices, Medicare will pay doctors additional per beneficiary per month fees based on how well they perform on five functions: access and continuity of care; care management; comprehensiveness and coordination; patient and caregiver engagement; and planned care and population health. Eligible practices have until Sept. 15 to apply for the program.

Health plans have yet to adopt value frameworks for making drug coverage determinations

None of 11 major health plans surveyed by Avalere Health are using any of four publicly available value frameworks to make prescription drug coverage decisions. Value frameworks are formulas that assess the value of prescription drugs based on a number of variables, including clinical benefits, side effects, improvements in patients' quality of life and cost. In a new report, the consulting firm said it interviewed medical and pharmacy directors at the 11 health plans. All of the interviewees said they were aware of the availability of the value frameworks, yet none said their health plans were using them, and most said they have no plans of using them a year from now. Directors considered value frameworks to still be “early in their development,” and their health plans “would like to see the provider community embrace these frameworks before formally adopting them in their decision-making process.”

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