Monday, January 10

Centene integrates pharmacy platform as it prepares for new PBM

Centene executives outlined how they plan to cut costs and improve profitability in 2022, including an update on when they will outsource administrative pharmacy functions.

Centene said yes late last year Seek a Pharmacy Benefits Manager, after settling multiple allegations that the insurer’s PBM overbilled the state Medicaid department for drugs.

Vice-Chair Sarah London said Centene is currently integrating into a pharmacy benefits management platform for its health plans, which will replace the multiple PBM platforms it currently owns. Centene will build an integrated PBM platform to focus on capabilities the company wants to keep in-house, such as member and supplier engagement.

According to London, these components are essential to differentiate the member experience from other insurers.

“Then, to be able to outsource more administrative, commoditized functions to our partners,” she said. Centene plans to start the process of selecting new PBMs this summer.

Other areas of Centene’s “value creation plan” for shareholders include standardizing call center management and reducing the company’s real estate footprint.

While health insurers are increasingly turning to owning healthcare assets, London said Centene tends to partner with outside organisations that provide clinical care. This allows Centene to focus on developing care models and coordinating care, while also partnering with innovative providers and startups, she said.

In some cases, Centene decides to provide care services on its own. Centene completed last week Acquisition of Magellan Health, a managed care company that provides a behavioral health platform and specialty care. According to Centene, Magellan Health will continue to operate independently.

“we believe [the Magellan Health acquisition] Will enhance our ability to provide tailored programs for more specialized and acute behavioral subgroups,” London said. – Jessica King Cohen

Humana CEO addresses Medicare advantage ‘churn’ amid stock slump

Humana President and CEO Bruce Broussard said the for-profit health insurer is “very bullish” on the long-term potential of Medicare Advantage, even though the company recently lowered its forecast for the expected net new MA members this year.

“This is really where the healthcare industry is headed,” Broussard said, citing Medicare Advantage’s focus on value-based care and social determinants of health. “We’re big believers in Medicare Advantage plans.”

Hamana last week cut prospects Expected net new members in Medicare Advantage plans in 2022 range from 325,000 to 375,000 members to a renewed 150,000 to 200,000 members. The company on Thursday attributed the updated forecast to encountering more terminations than expected during this year’s annual election.

Broussard Goldman Sachs meeting on Thursday Citing pricing competition from other insurers as one reason for the higher-than-expected termination rate.

Affected by the news, Humana’s shares fell from $455.83 at Wednesday’s close to $367.52 at Thursday’s close. Shares closed at $385.18 today.

Sales are increasingly being conducted over the phone, Broussard said at a JPMorgan meeting on Monday. Sales over the phone tend to sell by price rather than services, care coordination and other value in the Medicare Advantage plan, he said. In 2022 and 2023, Humana will focus on demonstrating and improving the “value proposition” of its Medicare Advantage plans, Broussard said, citing the insurer’s clinical programs in primary care and home care.

“We do believe that incorporating care into the plan is an important value proposition,” Broussard said. “We found that coordination of care was significantly improved as a result.”

Humana also plans to retain members, which will involve ensuring members participate in the various services available in their plan.

The “churn” that Humana experiences in Medicare Advantage is largely attributable to people who have been in the plan for a year or less.

Humana’s chief financial officer, Susan Diamond, said the insurer plans to review enrollment data on health plans this year to determine where the company should invest.

“Which plans are winning in the market? How do we fight those on the basis of benefit value [and] net worth? “We will also continue to evaluate our marketing and distribution strategies.” ” – Jessica King Cohen

Oak Street CEO shares more DOJ investigation details

Oak Street Health’s chief executive on Monday worked to downplay the Justice Department’s investigation into his company, noting that the program brought in less than 10 percent of new patients.

Chicago Oak Street Disclosure in NovemberThe federal government is working with third-party marketing agents on free transportation from primary care providers to adult Medicare patients to examine possible violations of the False Claims Act.

Oak Steet CEO Mike Pykosz explained in front of a virtual audience at the JPMorgan Healthcare Conference that the investigation involved his company’s relationship with third-party insurance agents and consultants who help seniors choose a Medicare Advantage plan.

He said: “We have hired and compensated a number of agents to help educate seniors on Oak Street and when seniors make requests, they will connect seniors with our team if they are interested in learning more. Get in touch about Oak Street Health.”

Pykosz said it was a relatively small program, bringing in single-digit numbers of patients. It was also only about a year old, he said.

When Oak Street first started, it didn’t have a marketing department and relied on “dream-field marketing methods: ‘If you build it, they’ll come,'” Pykosz said. When that didn’t work, he said the company shifted its focus to educating people about the care Oak Street provides.

Pykosz also highlighted the current and future development of Oak Street in his presentation. Since opening its first center north of Chicago in 2013, the company has expanded into key markets including New York City, Detroit, Philadelphia, Atlanta and Houston. Oak Street added 24 centers in its first five years, but this growth accelerated to 50 new centers by 2021. The company expects to add 70 new centers this year, bringing its total footprint to 199 by the end of 2022.

Oak Street expects its 2021 revenue to hit $1.4 billion, up 61% from a year earlier, according to guidance issued in November. The company has 4,800 employees, including 500 primary care providers.

Oak Street plans its newly acquired Telehealth startup RubiconMDAdjusted earnings before interest, taxes, depreciation and amortization in 2022 will be reduced by $10 million, given the timing of the synergy. Tim Cook, Oak Street’s chief financial officer, said the company expects a deal. – Tara Benno

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97% of Ascension’s revenue is fee-for-service and is expected to remain that way

Ascension’s revenue comes almost entirely from a fee-for-service model, which the health system says will remain above 90 percent for at least the next three years.

The COVID-19 pandemic has exposed pay-for-service flaws, but a vendor presentation at the JPMorgan healthcare conference Monday morning showed that the health system is in very different places in terms of the paradigm shift it has been blamed for enabling today’s runaway healthcare cost.

St. Louis-based Ascension, a sprawling 142-hospital system with more than $25 billion in annual revenue, still derives about 97 percent of its revenue from a fee-for-service model, said Liz Foshage, health system chief financial officer. in the company’s virtual presentation. She said COVID-19 had highlighted the loopholes in providers that depended on fee-for-service revenue, especially when non-emergency procedures were suspended at the start of the crisis.

Ascension is looking to participate in value-based payment models by investing in things like Medicare Advantage and Medicaid Managed Care, Foshage said.

Foshage blames health insurers and the government for her system’s lack of value-based care adoption.

“As we continue to gain these capabilities, we expect to see less reliance on this fee-for-service model and more value-based care,” she said. “But given how government payers pay and how difficult it is to actually get meaningful risk-based payments from commercial and government payers, we expect more than 90% of our revenue to remain fee-for-service for the next 3 years model.”

In contrast, Intermountain Healthcare leaders said in their own virtual presentation that the health system’s revenue from value-based care has exceeded its fee-for-service revenue.

In 2016, Intermountain’s premiums and per capita income accounted for 39% of total revenue. That year, 55% of revenue came from fee-for-service patient services. This compares to 48% for premiums and capitation and 45% for patient services in 2020.

“Fee-for-service has been known to create some perverse incentives,” said Bert Zimmerli, Intermountain’s chief financial officer. “And we’re all evolving in a value-based way.”– Tara Benno

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