ZorroCard Round Up (11/7/24)

Hey all,

Happy Thursday! In today’s rundown I was especially surprised by MA Plans being a scam for taxpayers and veterans…oh wait, no I wasn’t. I hope the next administration will reform Medicare Advantage. Enjoy the rundown!

Jacob Brody (Co-Founder & CEO, ZorroCard)

Medicare Advantage Plans Collected $1B for Veteran Enrollees Not Using Services (Beckers Payer)

A recent study highlights that Medicare Advantage (MA) plans received over $1 billion in payments for veteran enrollees who didn’t use any Medicare-covered services, as many veterans primarily rely on VA benefits. This funding structure stems from CMS’s per-enrollee payment model, which doesn’t account for actual service usage and allows MA plans to receive payments even when veterans exclusively use VA care. With nearly one-third of Medicare-enrolled veterans opting for MA, this raises questions about efficiency and potential policy adjustments to prevent taxpayer-funded duplications. Full Article.

Pulse of the Purchaser Fall 2024 (National Alliance of Healthcare Purchaser Coalitions)

This survey reveals that employers prioritize controlling healthcare costs amid rising expenses, often leading to employee cost-shifting and wage trade-offs. Employers are focused on controlling healthcare costs, identifying drug prices, high-cost claims, and hospital fees as top threats to affordability. Women’s health benefits are expanding, with rising support for maternity, menopause, and mental health resources. Obesity management is also a priority, with increased coverage of lifestyle programs, bariatric surgery, and interest in GLP-1 medications under selective conditions. Many employers plan to reassess PBM contracts for greater transparency and control, and strategies for managing high-cost claims include direct contracting, pharmacy procurement, and hospital price audits. Full Document.

Niche Health Insurance Concepts Explained (Out Of Pocket) 

Nikhil Krishnan delves into obscure health insurance concepts, particularly “intercompany eliminations,” where insurers like UnitedHealth profit by paying their subsidiaries for services and counting these payments toward their regulated medical loss ratio (MLR). Through vertical integration, insurance giants can pay their own subsidiaries for care or drug services, thereby maximizing revenue streams under MLR caps. While insurers argue this setup streamlines patient care and controls costs, critics contend it enables larger companies to crowd out smaller providers. The article humorously unpacks these dynamics and promotes a claims data course. Full Article.