Acting as the financial coordinator and patient liaison on behalf of thousands of healthcare facilities nationwide, payer organizations stay busy mirroring the moves of their provider counterparts. Here are just a few of the trends currently playing out in this high profile market.
From Payer Provider Acquisition to Hospital Health Plans
Just like insurers courted physician groups in years past, providers continue to bring new competition to the payer market. More and more health systems are making the insurance play as a strategy to accept more risk in value-based contracts with employers, and as a means to better coordinate care, control costs, and move towards population health management.
Ascension Health, Catholic Health Initiatives and Sutter Health are just a few examples of provider organizations making the payer plunge this year. Montefiore Medical Center is also slated to take new insurance offerings to market in 2015. Provider-sponsored Medicare Advantage plans have fared well in CMS quality ratings in recent years and are expected to offer additional appeal via lower rates in 2015, designed to lure more patients into what are typically more narrow networks.
Quality Ratings (and Reimbursement Ramifications?) Loom for Commercial Payers
Inovalon recently shared insights on the new 5 Star Quality Rating System (modeled after the one currently employed by Medicare Advantage) that will be beta tested in the commercial/private payer market in 2015. The Quality Rating System for Qualified Health Plans (QHPs) in the health insurance marketplace (HIM) is currently only slated to bear ratings as a “competitive differentiator and consumer reference point,” but it’s easy to envision a time when there may be more than consumer goodwill driving payers to participate.
The fiscal impact of a reimbursement redistribution model similar to Medicare’s could be pretty staggering in the commercial market. A quick aggregate look at hospital financial statements in the Billian’s HealthDATA Portal places the average portion of patient charges attributed to Medicare at around 11.25% and Medicaid at about 4.3%. “Other” patient charges, which includes cash/self pay and commercial pay charges, on average account for roughly 85% of overall hospital charges. The launch of HIMs has already undoubtedly grown the portion of that “other” revenue that falls under the commercial category. It will be interesting to see how the beta period shakes out and just what else might ensue as things progress.
Payer Data as the Key to Population Health
In other Inovalon news, the company recently released new research examining healthcare outcome variations among more than 98 million de-identified, dual eligible and non-dual eligible Medicare Advantage patients that also took member demographic, socioeconomic, and community characteristics into consideration. “The Impact of Dual Eligible Populations on CMS Five-Star Quality Measures and Member Outcomes in Medicare Advantage Health Plans” is the largest study of its kind, conducted in collaboration with Cigna-HealthSpring, Wellcare, Healthfirst, Gateway Health, Blue Cross Blue Shield Minnesota and Blue Plus, Health Care Services Corporation (HCSC), the SNP Alliance, and Medicaid Health Plans of America (MHPA).
The results validate the integral role that income, race/ethnicity, and gender play on the measures used in CMS’s Five-Star rating system and is a fantastic example of the population health promise in broad-scale payer data sets. It also leaves me pondering just what other ugly truths population health might reveal as more organizations make advancements in putting popHealth analytics to use. You can read more about Inovalon’s Medical Outcomes Research for Effectiveness and Economics Registry (MORE2 Registry®) and study findings here.