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The Digital-First Health Insurance Startup Changing Healthcare in Nigeria | Femi Kuti, RelianceHMO

By JESSICA DaMASSA, WTF HEALTH

RelianceHMO is a Nigerian-based health insurance startup that aims to turn the traditional health insurance world upside-down. CEO Femi Kuti delves into how his company is using mobile phones, telemedicine, data science, and even underwriting (!) to make health insurance cheaper — and more accessible. With more than 1800 hospital partners across Nigeria, RelianceHMO is making a name for itself, but how does it plan to scale throughout Africa? And, what can payers around the world learn from their approach as they seek to make health insurance easy and affordable for Nigeria’s 190M uninsured? We love talking about disrupting payment models in healthcare and after hearing Femi’s story, you’ll understand why.

Filmed at Bayer G4A Signing Day in Berlin, Germany, October 2019.

Asinine, Backasswards Colonoscopy Insurance Rules Make Patients Decline Medically Necessary Testing

By HANS DUVEFELT, MD

I’ve had several telephone calls in the last two weeks from a 40-year-old woman with abdominal pain and changed bowel habits. She obviously needs a colonoscopy, which is what I told her when I saw her.

If she needed an MRI to rule out a brain tumor I think she would accept that there would be co-pays or deductibles, because the seriousness of our concern for her symptoms would make her want the testing.

But because in the inscrutable wisdom of the Obama Affordable Care Act, it was decided that screening colonoscopies done on people with no symptoms whatsoever are a freebie, whereas colonoscopies done when patients have symptoms of colon cancer are subject to severe financial penalties.

So, because there’s so much talk about free screening colonoscopies, patients who have symptoms and need a diagnostic colonoscopy are often frustrated, confused and downright angry that they have to pay out-of-pocket to get what other people get for free when they don’t even represent a high risk for life-threatening disease.

But, a free screening colonoscopy turns into an expensive diagnostic one if it shows you have a polyp and the doctor does a biopsy – that’s how the law was written. If that polyp turns out to be benign, or hyperplastic, there is no increased cancer risk associated with it, but you still have to pay your part of a diagnostic colonoscopy bill because they found something.

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Health in 2 Point 00, Episode 103 | ACA Ruling, Sutter Health Settlement, & Bright Health

Today, I’m closing out the year of Health in 2 Point 00 from the ski slopes. In Episode 103, Jess asks me about the ACA ruling that the individual mandate is unconstitutional, whether Sutter Health got what they deserved after the $575 million settlement, health insurer Bright Health raising a huge $635 million round, and a rumor about a $250M Softbank investment coming next week. Wishing you all a very happy 2020! —Matthew Holt

Will Your Health Plan Tell You That It Can Save Your Life?

By MICHAEL MILLENSON

At kitchen tables everywhere, ordinary Americans have been grappling with the arcane language of deductibles and co-pays as they’ve struggled to select a health insurance plan during “open enrollment” season.

Unfortunately, critical information that could literally spell the difference between life and death is conspicuously absent from the glossy brochures and eye-catching websites.

Which plan will arrange a consultation with top-tier oncologists if I’m diagnosed with a complex cancer? Which might alert my doctor that I urgently need heart bypass surgery? And which plan will tell me important information such as doctor-specific breast cancer screening rates?

According to Matt Eyles, president and chief executive officer of America’s Health Insurance Plans (AHIP), insurers over the last decade have made a “dramatic shift” to focus more on consumers.  That shift, however, has yet to include giving members the kind of detailed information available to corporate human resources managers and benefits consultants (one of my past jobs).

What’s at stake could be seen at a recent AHIP-sponsored meeting in Chicago on consumerism. Rajeev Ronaki, chief digital officer for Anthem, Inc., explained how the giant insurer is using artificial intelligence to predict a long list of medical conditions, including the need for heart bypass surgery. Information on individual patients is passed on to clinicians.

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Lower Health Insurance Premiums Sound Like Great News – But It’s Only Part Of the Story

By A. MARK FENDRICK, MD

It’s great news to read headlines that the average health-insurance premium will drop by 4% next year in the 38 states using federal Obamacare exchanges. As millions of Americans entered open enrollment this year to choose their health insurance plans, it is important to remember that premiums are only one of the ways that we pay for our medical coverage. 

In many plans lower premiums (paid by everyone) often mean a higher deductible — or paying more out-of-pocket before insurance coverage kicks in. This burden is paid only by those who use medical care services.

Deductibles are rising, and so is the number of Americans enrolled in so-called high-deductible health plans (HDHPs). Thus, more people with health insurance are being asked to pay full price for all their care, regardless of its clinical value. Although it may be better for many people with significant medical needs (and less disposable income) to avoid plans with high deductibles, more and more people who receive health insurance through their employer no longer have a choice except to choose a plan with hefty costs in addition to premiums.

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Improving the Affordable Care Act Markets (Part 2)

By JONATHAN HALVORSON

In a previous post, I described how some features of the Affordable Care Act, despite the best intentions, have made it harder or even impossible for many plans to compete against dominant players in the individual and small employer markets. This has undermined aspects of the ACA designed to improve competition, like the insurance exchanges, and exacerbated a long term trend toward consolidation and reduced choice, and there is evidence it is resulting in higher costs. I focused on the ACA’s risk adjustment program and its impact on the small group market where the damage has been greatest.

The goal of risk adjustment is commendable: to create stability and fairness by removing the ability of plans to profit by “cherry picking” healthier enrollees, so that plans instead compete on innovative services, disease management, administrative efficiency, and customer support. But in the attempt to find stability, the playing field was tilted in favor of plans with long-tenured enrollment and sophisticated operations to identify all scorable health risks. The next generation of risk adjustment should truly even out the playing field by retaining the current program’s elimination of an incentive to avoid the sick, while also eliminating its bias towards incumbency and other unintended effects.

One important distinction concerns when to use risk adjustment to balance out differences that arise from consumer preferences. For example, high deductible plans tend to attract healthier enrollees, and without risk adjustment these plans would become even cheaper than they already are, while more comprehensive plans that attract sicker members would get disproportionately more expensive, setting off a race to the bottom that pushes more and more people into the plans that have the least benefits, while the sickest stay behind in more generous plans whose premium cost spirals upward. Using risk adjustment to counteract this effect has been widely beneficial in the individual market, along with other features like community rating and guaranteed issue.

However, in other cases where risk levels between plans differ due to consumer preferences it may not be helpful. For example, it has been documented that older and sicker members have a greater aversion to change (changing plans to something less familiar) and to constraints intended to lower cost even if they do not undermine benefit levels or quality of care, like narrow networks. These aversions tend to make newer plans and small network plans score as healthier. Risk adjustment would then force those plans to pay a penalty that in turn forces enrollees in the plans to pay for the preferences of others.

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Why the Health Care System Is Incapable of Reducing Its Own Costs: A Brief Structural System Analysis

By JOE FLOWER

Leading lights of the health insurance industry are crying that Medicare For All or any kind of universal health reform would “crash the system” and “destroy healthcare as we know it.”

They say that like it’s a bad thing.

They say we should trust them and their cost-cutting efforts to bring all Americans more affordable health care.

We should not trust them, because the system as it is currently structured economically is incapable of reducing costs.

Why? Let’s do a quick structural analysis. This is how health care actually works.

Health care, in the neatly packaged phrase of Nick Soman, CEO of Decent.com, is a “system designed to create reimbursable events.” For all that we talk of being “patient-centered” and “accountable,” the fee-for-service, incident-oriented system is simply not designed to march toward those lofty goals.

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Private Health Insurance Organizations Shouldn’t Dictate Quality of Care

By LYNLY JEANLOUIS

Health insurance companies are standing in the way of many patients receiving affordable, quality healthcare. Insurance companies have been denying patient claims for medical care, all while increasing monthly premiums for most Americans. Many of the nation’s largest healthcare payers are private “for-profit” companies that are focused on generating profits through the healthcare system. Through a rigorous approval/denial system, health insurance companies can dictate the type care patients receive. In some cases, this has resulted in patients foregoing life-saving treatments or procedures.  

In 2014, Aetna, one of the nation’s leading healthcare companies, denied coverage to Oklahoma native Orrana Cunningham, who had stage 4 nasopharyngeal cancer near her brain stem.  Her doctors suggested she undergo proton beam therapy, which is a targeted form of radiation that can pinpoint tumor cells, resulting in a decrease risk of potential blindness and other radiation side effects. Aetna found the study too experimental and denied coverage, which resulted in Orrana’s death. Aetna was forced to pay the Cunningham family $25.5 million.  

In December of 2007, Cigna Healthcare, the largest healthcare payer in Philadelphia, denied coverage for Nataline Sarkisyan’s liver transplant. Natalie was diagnosed with leukemia and had recently received a bone marrow transplant from her brother, which caused complications to her liver. A specialist at UCLA requested she undergo a liver transplant, which is an expensive procedure that would result in a lengthy inpatient hospital stay for recovery. Cigna denied the procedure as they felt it was “too experimental and outside the scope of coverage”. They later reversed the decision, but Nataline passed away hours later at the University of California, Los Angeles Medical Center.

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The Next Frontier: Clinically Driven, Employer-Customized Care

Health systems and employers are bypassing insurers to deliver higher-quality, more affordable care

By MICHAEL J. ALKIRE

Employee health plan premiums are rising along with the total healthcare spending tab, spurring employers to rethink their benefits design strategy. Footing the tab, employers are becoming a more active and forceful driver in managing wellness, seeking healthcare partners that can keep their workforce healthy through affordable, convenient care.

Likewise, as health systems assume accountability for the health of their communities, a market has been born that is ripe for new partnerships between local health systems and national employers in their community to resourcefully and effectively manage wellness and overall healthcare costs. Together, they are bypassing traditional third-party payers to pursue a new type of healthcare financing and delivery model.

While just 3 percent of self-insured employers are contracting directly with health systems today, dodging third parties to redesign employee benefit and care plans is becoming increasingly popular. AdventHealth in Florida announced a partnership with Disney in 2018 to provide health benefits to Disney employees at a lower cost in exchange for taking on some risk, and Henry Ford Health System has a multi-year, risk-based contract with General Motors.

The notion of bypassing payers is attractive for employers, especially on the back of consecutive cost increases they and their employees have swallowed over the last several years. Payers have traditionally offered employers rigid, fee-for-service plans that not only provide little room for customization, but often exacerbate issues with care coordination and lead to suboptimal health outcomes for both employees and their families. Adding to this frustration for employers is the need to manage complex benefits packages and their corresponding administrative burdens.

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Failing Healthcare’s ‘Free Market’ Experiment in US: Single Payer to the Rescue?

By KHURRAM NASIR MD, MPH, MSc 

In the industrialized world and especially in United States, health care expenditures per capita has has significantly outgrown per capita income in the last few decades. The projected national expenditures growth at 6.2%/year from 2015 onwards with an estimated in 20% of entire national spending in 2022 on healthcare, has resulted in passionate deliberation on the enormous consequences in US political and policy circles. In US, the ongoing public healthcare reform discussions have gained traction especially with the recent efforts by the Senate to repeal national government intervention with Affordable Care Act (ACA).

In this never ending debate the role of government interventions has been vehemently opposed by conservative stakeholders who strongly favor the neoclassical economic tradition of allowing “invisible hands” of the free market without minimal (or any) government regulations to achieve the desired economic efficiency (Pareto optimality).

A central tenet of this argument is that perfect competition will weed out inefficiency by permitting only competent producers to survive in the market as well as benefit consumer to gain more “value for their money” through lower prices and wider choices.

Restrained by limited societal resources, in US to make our health market ‘efficient’ we need to aim for enhancing production of health services provision at optimal per unit cost that can match consumers maximum utility (satisfaction) given income/budget restraints.

Keeping asides the discussion on whether a competitive market solution for healthcare is even desirable as adversely impact the policy objective of ‘equity”, however from a pure ‘efficiency’ perspective it is worthwhile to focus on the core issue whether conditions in healthcare market align with the prototypical, traditional competitive model for efficient allocation of resources.

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