What Every Provider and Innovator Must Know Going into 2025:

The health insurance industry is facing a perfect storm characterized by rising healthcare costs, increased patient demand, and intense scrutiny from lawmakers. As we move into 2025, the challenges confronting Medicare Advantage plans, once considered the crown jewel of insurer profitability, are becoming increasingly apparent.

Industry giants like Humana and UnitedHealth are grappling with significant pressures that could redefine managed care. However, amidst this turmoil, there are opportunities for healthcare providers and entrepreneurs to innovate and adapt. By focusing on high-cost patient areas and exploring innovative contracts, stakeholders can position themselves to thrive in this evolving landscape.

This episode delves into the tumultuous state of the health insurance industry as it faces unprecedented challenges heading into 2025. Rising healthcare costs, increased patient demand, and government scrutiny are converging to create a 'perfect storm' for insurers, particularly in the Medicare Advantage sector. This segment highlights how traditional revenue models are being tested as utilization rates rebound post-COVID, with many patients returning for procedures they deferred during the pandemic.

Insurers are grappling with higher medical loss ratios (MLR), which are squeezing their profit margins and forcing a reevaluation of their operational strategies. Industry giants like Humana and UnitedHealth Group are highlighted as they navigate this challenging landscape, revealing how their dependence on Medicare Advantage has made them particularly vulnerable amidst shifting policies and scrutiny from lawmakers.

The discussion emphasizes the urgent need for healthcare providers and entrepreneurs to identify innovative solutions that can not only alleviate cost pressures but also enhance patient care, suggesting that these turbulent times may present new opportunities for growth and transformation within the industry.

Takeaways:

• The health insurance industry is facing significant challenges due to rising costs and increased scrutiny.
• Medicare Advantage plans are experiencing financial strain from surging patient demand and utilization rates.
• As healthcare providers, understanding your patient population is crucial for identifying high-cost areas.
• The medical loss ratio is a key metric that impacts insurers' profitability and operational strategies.
• Entrepreneurs should focus on innovative solutions that reduce waste and improve healthcare delivery efficiency.
• The evolving healthcare landscape presents opportunities for proactive adaptation and strategic partnerships.

Companies mentioned in this episode:

• Humana
• UnitedHealth
• CVS
• Aetna
• Morgan Stanley

Research Links:

• There's uncertainty ahead for the health insurance industry in 2025
• Hearing: Hacking America’s Health Care: Assessing the Change Healthcare Cyber Attack and What’s Next | The United States Senate Committee on Finance
• Potential Health Policy Administrative Actions in the Second Trump Administration | KFF
• UnitedHealthcare Profits Less About Denials, More About The Pandemic
• Higher and Faster Growing Spending Per Medicare Advantage Enrollee Adds to Medicare's Solvency and Affordability Challenges | KFF
• Humana stock declines on Medicare Advantage star rating struggle | STAT

Welcome to this eye-opening episode of the VBCA Podcast, where we tackle one of the most pressing yet underreported issues in healthcare: hidden fees, surprise bills, and the alleged cartel controlling out-of-network reimbursements.

In this episode, host Alex Yarijanian breaks down the allegations against MultiPlan, a third-party repricing company accused of working with major insurers like UnitedHealthcare, Cigna, and Aetna to suppress out-of-network payments. We explore:

• How MultiPlan's practices impact patients, providers, and employers.
• The AMA’s antitrust lawsuit accusing MultiPlan of operating a cartel.
• Real stories, like that of Kelsey Toney, a behavioral therapist forced to turn away patients due to unsustainable payment rates.
• The staggering $19 billion providers lose annually to these practices.

If you’ve ever wondered why your healthcare bills are so high or why your provider suddenly stopped taking your insurance, this is the episode for you.

Key Topics Discussed:

• What are in-network vs. out-of-network providers?
• How does MultiPlan determine reimbursement rates?
• The human cost of suppressed reimbursements for providers and patients.
• Legal implications of the AMA and ISMS lawsuit against MultiPlan.
• The broader impact on value-based care and healthcare transparency.

Takeaways:

• Hidden fees in healthcare create a sense of unpredictability and financial anxiety for patients.
• MultiPlan's involvement in processing out-of-network claims often leads to underpayment for healthcare providers.
• Out-of-network providers typically charge fees that reflect their true cost of delivering services.
• Patients frequently find themselves responsible for covering the difference in reimbursement rates from insurers.
• Real-life patient stories underscore the profound human impact of rising healthcare costs and surprise bills.
• The current healthcare system often prioritizes profit margins over genuine patient care and outcomes.

Companies mentioned in this episode:

• MultiPlan
• UnitedHealthcare
• Cigna
• Aetna

Research Links:

• Legal Complaint (PDF): AMA v. MultiPlan Full Complaint - Filed in the United States District Court for the Northern District of Illinois involves the American Medical Association (AMA) and the Illinois State Medical Society (ISMS) as plaintiffs, suing MultiPlan, Inc. for alleged antitrust violations.
• Community Health Systems adds another antitrust lawsuit to MultiPlan's collection - Community Health Systems is the latest health system to allege that MultiPlan’s data-driven claims repricing business meets the bar for antitrust violation.
• AMA lawsuit targets collusion in health care pricing
• Insurers Reap Hidden Fees by Slashing Payments. You May Get the Bill. - A little-known data firm helps health insurers make more when less of an out-of-network claim gets paid.
• New York Times Investigation: Health Insurers' Lucrative, Little-Known Alliance - How a private-equity-backed firm called MultiPlan has helped drive down payments to medical providers and drive up patients' bills, while earning billions.
• AMA Press Release - The American Medical Association’s press release discussing the antitrust lawsuit against MultiPlan.

This episode explores the rising tide of healthcare startups pursuing value-based care (VBC) with ambitious visions to improve patient outcomes and lower costs. However, without a robust patient acquisition strategy, many founders find themselves struggling to meet volume requirements, maintain contracts, and deliver quality care. Through candid dialogue and practical insights, host Alex Yarijanian addresses these pain points and offers actionable advice for navigating the competitive healthcare market.

Startup Realities in Value-Based Care

• Analogy to Streaming Service Overload: Alex compares the influx of VBC startups to the crowded streaming industry, highlighting how many of these startups lack a practical strategy, assuming that contracts with big payers alone will drive patient volume.
• Importance of Patient Acquisition: Building meaningful connections and community engagement is critical for driving patient volume—something often overlooked by startup founders. Alex discusses tactics like forming referral networks and partnering with local organizations to build a sustainable patient base.

Key Strategies for Healthcare Startups

• Understanding Payer Volume Thresholds: Alex underscores the need for startups to grasp the minimum patient volumes required by payers to maintain contracts.
• Patient Engagement & Marketing: Effective marketing and visibility are as essential as clinical quality. Engaging patients through tailored messaging and demonstrating value within local communities can solidify a startup's presence and relevance in the healthcare landscape.

New Segment: 'Tough Calls in Healthcare'

• This episode introduces a new segment, where Alex addresses real-world negotiation dilemmas faced by healthcare professionals. In this installment, he discusses:
• Negotiating Reimbursement Rates: Tips on understanding local market rates and using data to strengthen negotiation positions with payers.
• Handling Contract Amendments: Strategies for managing unilateral changes imposed by payers and knowing when to push back or walk away.

• Beyond Business Models: For startups, having a robust business model isn’t enough—securing patient volume is essential.
• Value-Based Contracts: These can be highly advantageous, but they require a substantial patient base to fulfill the value equation.
• Community Connection: Building credibility and visibility within the local healthcare ecosystem is crucial.
• Balancing Act: Startups must balance patient volume and care quality to sustain payer relationships.
• Negotiation Essentials: Effective contract negotiation includes knowing market benchmarks and maintaining flexibility.

Companies Discussed:

• UnitedHealthcare
• Cigna

Listeners can expect a blend of in-depth analysis, actionable advice, and fresh perspectives on how to navigate the complexities of launching and sustaining a healthcare startup focused on value-based care.

• Hospital ER fees: They’ve been secret. We’re uncovering them. | Vox
• ER bills: A baby was treated with a nap. His parents got an $18,000 bill. | Vox
• Cigna hit with class action alleging it used an algorithm to reject claims

This podcast episode dives deep into the complexities of mental health parity and the implications of the Mental Health Parity Act. The conversation emphasizes the necessity for behavioral health services to be treated with the same level of care and coverage as physical health services, addressing the ongoing disparities in treatment and reimbursement practices.

Alex Yarijanian and Dr. Chris Esguerra discuss the challenges providers face when navigating insurance plans and the barriers to accessing equitable care for patients.

Dr. Esguerra is board certified in both Psychiatry and Health Care and Quality Management and is a Fellow of the American Psychiatric Association and the American Board of Quality Assurance and Utilization Review Physicians.

Dr. Esguerra’s extensive payer-side executive experience includes:

• Senior Medical Director, Blue Shield of California
• Senior Medical Director, Magellan Health
• Deputy Chief Medical Officer, Health Plan Of San Mateo

They highlight the critical role employers play in advocating for better mental health coverage and how they can leverage their purchasing power to ensure compliance with parity laws. Ultimately, the episode aims to empower providers with the knowledge and tools necessary to advocate effectively for their patients and promote a more integrated and equitable healthcare system.

A significant focus of the episode is on the role of providers in identifying and addressing parity violations. The speakers guide listeners through the necessary steps for raising concerns regarding unequal treatment, emphasizing the importance of gathering evidence and understanding insurance policies.

This segment is particularly valuable for behavioral health providers who may face obstacles in securing appropriate coverage for their patients. The discussion also touches upon the regulatory landscape, explaining how self-insured plans differ from traditional insurance plans and the implications this has for parity enforcement.

Additionally, the episode discusses the importance of employers in advocating for better mental health coverage, encouraging providers to leverage their relationships with these entities to push for systemic changes that prioritize mental health equity.

Takeaways:

• The Mental Health Parity Act requires equal coverage for both physical and behavioral health services, ensuring that patients receive the same level of care.
• Providers should gather evidence of parity violations and present it to state regulators to advocate for fair treatment.
• Behavioral health is lagging behind primary care in integration and reimbursement models, highlighting the need for systemic reform.
• Employers play a crucial role in advocating for mental health parity by demanding better coverage from their insurance plans.
• Effective communication and partnerships between providers and health plans can lead to better patient outcomes and innovative care models.
• Tracking outcomes and demonstrating quality of care is essential for providers to negotiate better contracts with health plans.

Companies mentioned in this episode:

• Blue Shield of California
• Magellan
• Kaiser Permanente
• Google
• Apple
• Anthem
• Centene
• United
• Cigna
• Aetna
• Humana
• CalPERS
• Pacific Business Group on Health
• National Business Group on Health

Chris Esguerra MD MBA

This episode is also available as a blog post: https://healthcare-wiki.com/2022/03/12/changing-demographics-value-based-care/

The system used to pay for health care today does not encourage the integration of health care and social care, nor can it adequately adapt to the trending shift toward value-based payments for care — paying for better quality and better health outcomes. New financing approaches are needed to enable the health care sector to engage in activities that strengthen social care and community resource.

This episode is also available as a blog post: https://healthcare-wiki.com/2021/07/21/paying-for-biopsychosocial-care/

No two states are alike in how telehealth is defined and regulated. While there are some similarities in language, perhaps indicating states may have utilized existing verbiage from other states, noticeable differences exist.

These differences are to be expected, given that each state defines its Medicaid policy parameters, but it also creates a confusing environment for telehealth participants to navigate, particularly when a health system or practitioner provides health care services in multiple states. In most cases, states have moved away from duplicating Medicare’s restrictive telehealth policy, with some reimbursing a wide range of practitioners and services, with little to no restrictions.

One of the most common trends with live video reimbursement was the addition of eligible services to the list of telehealth eligible services, with applied behavioral analysis being the most common service addition mentioned in Medicaid manuals.

Additionally, in the wake of the COVID-19 pandemic, some states do seem to be adopting the Center for Medicare and Medicaid Services (CMS) communication technology-based services (CTBS) codes, including the virtual check-in and remote evaluation of prerecorded information, audio-only service codes and remote physiologic monitoring.

All fifty states and the District of Columbia have a definition in law, regulation, or their Medicaid program for telehealth, telemedicine, or both. Additionally, because of the allowance in most states to utilize telephone as a form of telehealth during COVID-19, some states are taking steps to broaden its permanent definitions of telehealth or telemedicine by removing the explicit exclusion of telephone or including audio-only services within the definition itself.

One of the states with the most significant changes to their telehealth policy was Massachusetts which passed a comprehensive telehealth law to require reimbursement for both Medicaid and private payers if the services are covered in-person and it is appropriately delivered through telehealth. The law contained some unique elements including specifying that the rate of payment for telehealth services provided via interactive audio-video technology and audio-only telephone may be greater than the rate of payment for the same services delivered by other telehealth modalities. It also provided payment parity for in-network providers of behavioral health services delivered via interactive audio-video technology or audio-only telephone only.

Read: https://healthcare-wiki.com/2021/08/01/telehealth-landscape-overview-50-states-dc/

During the 2019 legislative session, Florida passed Chapter 2019-137, Laws of Florida, which establishes standards of practice for telehealth services, including patient evaluations, record-keeping, and controlled substances prescribing. The law also authorizes out-of-state health care practitioners to perform telehealth services for patients in Florida. Signed by the Governor on June 25, 2019, this law became effective on July 1, 2019.

Out-of-state health care practitioners must be registered with the Florida Department of Health to perform telehealth services for patients in Florida.

Providers must also use two-way, interactive communication tools, such as live video, instead of email or audio-only communication. If you use Medicaid, your telehealth provider must be registered with the Florida Medicaid program to receive reimbursement for telehealth services. Florida doesn’t require private insurers to cover telehealth, so check with your insurance company to determine if you’re eligible for the service. Some of these regulations may be altered during the COVID-19 pandemic.

In Florida, telehealth providers are permitted to prescribe medications if the medications aren’t listed as controlled substances.

However, there is one important exception to this rule: If you need a controlled substance to manage a mental health condition, your telehealth provider is allowed to prescribe it.

Before prescribing medication, your telehealth provider must conduct an evaluation and explain the risks and benefits of the medication to you.

Filling out a questionnaire before your telehealth appointment isn’t enough to satisfy the evaluation requirement, so you should expect the provider to ask multiple questions about your symptoms and health history.

This episode is also available as a blog post: https://healthcare-wiki.com/2021/06/22/florida-market-telehealth-rule/

A Carenodes Production.

California Governor Gavin Newsom on September 25 signed Senate Bill 855, Health coverage: mental health or substance use disorders, into law. The law increases health and disability insurers' coverage obligations for mental health and addiction diagnosis, prevention, and treatment in the state.