Each Medicare Advantage (MA) plan has an associated “value
added,” which is defined as the value of benefits provided to a specific plan’s
beneficiaries beyond traditional Medicare that are not funded through member
premiums. This metric accounts for the value of non-Medicare-covered benefits,
reductions in cost sharing to traditional Medicare, any buy-down of the Part B
premium, and any additional premium the member if responsible for. Therefore,
two plans with identical benefits will have different value added amounts if
their premiums vary.
This report by Milliman actuaries highlights changes in the MA value added from 2016 to 2020. The authors focus their analyses on general enrollment and dual-eligible special needs plan types nationwide, excluding any U.S. territories.
Milliman today released the 2020 edition of its triennial report on the estimated costs of U.S. organ and tissue transplants. The report summarizes average annual costs per member per month (PMPM), including utilization and billed charges, related to the 30 days prior through 180 days after transplant admission for organ and tissue transplants. This includes single-organ transplants such as heart, intestine, kidney, liver, lung, and pancreas, and a number of multiple-organ transplants; tissue transplants include bone marrow and cornea.
While the findings vary greatly by transplant and
population type, the study found that for all combined organ and tissue
transplants, per member costs based on billed charges saw an average annual
increase of 11% for those under age 65, and 10.5% for those age 65 and over when
compared to the 2017 report. The analysis also examined trends in hospital
lengths of stay, average waiting times for organs, and changes in survival rates
between our 2017 and 2020 reports, with results varying by transplant.
New this year, the report also explores emerging
innovations and issues in the areas of organ viability and availability, such
as the use of bioengineering, xenotransplantation, and anti-Hepatitis C drugs
to combat shortages and growing waitlists.
There are a number of scientific and policy initiatives geared at improving the availability of and access to much-needed organ and tissue transplants. As new technologies emerge, Milliman’s research will continue to be an important tool for physicians, insurers, and the public to better understand the utilization, billed charges, and related trends associated with this vital healthcare service.
To view the complete report, click here.
On January 30, the Centers for Medicare and Medicaid
Services (CMS) introduced guidance describing the new Healthy Adult Opportunity
(HAO) 1115 waiver option. This option outlines conditions under which a state
might convert open-ended matching funding for expansion adults into a block
grant or per capita program.
The HAO offers states new flexibilities for their Medicaid
programs in return for assuming the financial risk of block grants. State
program directors face many complex considerations as they evaluate these
options. While the HAO will clearly appeal to states that have previously
considered requesting a block grant, the range of policy options made available
under this initiative may bear considerations for states across the country.
In this paper, Milliman’s consultants discuss 10 key considerations for states evaluating the HAO.
Health insurance, like most insurance, can be
priced using risk ratings, where premiums are set based on the relative risk of
insured lives and the propensity to claim. This may result in unaffordable health
insurance for the most high-risk members of society. As a result, many
governments restrict the use of risk ratings in health insurance markets in
favour of “community rating.”
In a community-rated system where all consumers
are charged the same premium, many high-risk consumers are protected from
paying unaffordable premiums. Other consumers, such as healthier or younger
individuals, will generally pay a higher premium to subsidise sicker and often
older individuals. Consequently, premium revenue collected by insurers or other
risk-bearing entities may no longer truly reflect the underlying risk
associated with their insured populations.
In many healthcare systems and health insurance markets around the world where risk rating is not allowed, risk equalisation is used to enhance consumer protection and market stability. Its aim is to compensate for the risk profiles of different groups of the population such that the additional medical expenses associated with high-risk members are shared amongst healthcare providers or insurance companies.
In this paper, Milliman consultants have set out a “how-to” guide to risk equalisation, or risk adjustment. They use illustrative examples from around the world to explain the challenges and practicalities that should be considered in the design and management of a risk equalisation program.
At the end of 2018, the Centers for Medicare and Medicaid
Services published the Pathways to Success final rule for the Medicare Shared
Savings Program (MSSP) giving accountable care organizations (ACOs) renewing
July 1, 2019, or later the option to select between prospective and
retrospective assignment of patients.
Under prospective assignment, beneficiaries are assigned to
an ACO based on services occurring prior to the performance year. Under
retrospective assignment, beneficiaries are assigned to an ACO based on
services occurring during the performance year. Averages for
assignment-eligible fee-for-service beneficiaries can help provide understanding
of how the two assignment methodologies affect results.
Retrospective and prospective assignment have significantly
different effects on the characteristics of the assigned populations for
beneficiaries assigned to primary care physicians and specialists. Prospective
and retrospective assignment will ultimately affect the population that is
assigned to the ACO because some beneficiaries who are assigned under
prospective assignment are not assigned under retrospective and vice versa. The
choice between these assignment methodologies can have subtle effects on the
ACO’s overall benchmark, risk score, and performance year costs.
In this brief, Milliman’s Sam Shellabarger, Charlie Mills, and Lance Anderson explore in more detail the potential effects of prospective and retrospective assignment on key ACO metrics under the MSSP.
Many social determinants of health have important effects on
behavioral health and can apply to all members of a family. Some research has
found that having a family member with a mental illness decreases family
functioning and is a general stressor for families. With that in mind, payers
and providers may find that the diagnosis of a behavioral health condition in
one family member could signal that it may be worth screening for circumstances
that might affect the entire household. This could provide an opportunity for
earlier diagnosis and intervention with other household members who may be at
heightened risk for similar behavioral health concerns.
In order to shed more light on how behavioral health conditions affect families, Milliman analyzed the prevalence of several conditions among family members in a national, commercially insured population in 2017. In this paper, Milliman’s Stoddard Davenport and Marissa North expand on existing research by analyzing the prevalence of behavioral conditions in parents of children with behavioral conditions versus those without as well as children of parents with behavioral conditions versus those without.