Topic: Medicaid

PBMs are the Health Plan Industry’s Achilles Heel

John Gorman

In this Golden Age of government programs, the health plan industry has never had more exposure to the generally poor performance of pharmacy benefit managers (PBMs).  Performance metrics in Medicare, Medicaid and ObamaCare are directly tied to PBM execution, and the recent track record of these companies means they are the Achille’s Heel of insurers.

Read more

Leave a comment | Share | |

Tuesday Night’s Primary Elections Were Huge. Here’s What They Mean for Our Industry.

John Gorman

House Majority Leader, Eric Cantor (R-VA) is toast.  Trounced in his Richmond district by a nobody Tea Bagger Tuesday night. Cantor gave up his leadership position yesterday. Depending on where you sit politically, either the unthinkable or the inevitable happened.  In fact, a Majority Leader hasn’t lost incumbency since the office was created in 1899.   “The defeat of the second-ranking Republican in the House by an ill-funded, little-known tea party-backed candidate ranks as the biggest congressional upset in modern memory and will immediately generate a series of political and policy-related shock waves in Washington,” wrote Chris Cilizza of WaPo.

Read more

Leave a comment | Share | |

The Status of Medicaid Expansion, and Why It Will Keep Getting Better

John Gorman

Medicaid is already the largest insurer on the planet, and the Affordable Care Act (ACA) is driving enrollment faster than anyone imagined.  But there are headwinds in covering more Americans through Medicaid, some political, some operational.  Here’s why it will continue to improve and drive expanded coverage for the uninsured — and why all insurers need to participate to remain relevant to the new American healthcare landscape.

Read more

Leave a comment | Share | |

What’s Gained and Lost with an HHS Secretary Burwell

John Gorman

My old Clinton Administration colleague Sylvia Mathews Burwell sailed through a confirmation hearing last week.  What was expected to result in serious anti-ObamaCare fireworks and soundbite fodder for midterm campaigns ended with a whimper.  Her second confirmation hearing was yesterday, and it’s a “Washington dog isn’t barking” story.  It’s now looking like she’ll cruise through and we’ll have an unexpectedly rapid successor to the embattled Kathleen Sebelius.

Read more

Leave a comment | Share | |

Follow the Leader: United Health Group’s Outlook on Government Health Programs

John Gorman

Ralph Giacobbe at Credit Suisse is a leading health industry analyst and is doing the best work of his career.  Today he produced a fantastic recap of his discussion with United Health Group CEO Steve Hemsley and several of his top executives.  It included some fascinating insights into the market leader’s strategy for government health programs:

Read more

Leave a comment | Share | |

POTUS Spikes the Football, but the ObamaCare War-Game Isn’t Over

John Gorman

Last week as health insurance exchange open enrollment ended, President Obama spiked the football, announcing that 8 million people had signed up, and that the Obamacare debate is “over.”  He put an exclamation point on it: that millions more had gained coverage through Medicaid expansion and new mandates on employers.  Now, any further discussion of repealing ObamaCare was about taking coverage away from those millions of Americans.

Read more

Leave a comment | Share | |

Member Engagement and Experience are the New Risk Adjustment

John Gorman

In this new era of Star Ratings in Medicare Advantage and Part D, where a 4+ score is now do-or-die, health plan survival comes down to two things: member engagement and the member experience.  They’re the new risk adjustment when rates in 2014-2015 will be at their lowest levels in more than a decade, and a low-quality rating is a kiss of death in government programs.  Plans that can’t evolve into kinder, gentler, more coordinated and Member-Centric service providers are already beginning to disappear.

Read more

Leave a comment | Share | |