Holding Insurers Accountable for Parity in Coverage of Mental Health Treatment.

Despite a series of federal laws aimed at ensuring parity in insurance coverage of treatment for mental health and general health conditions, patients with mental disorders continue to face discrimination by insurers. This inequity is often due to overly restrictive utilization review criteria that fail to conform to accepted professional standards. A recent class action challenge to the practices of the largest U.S. health insurer may represent an important step forward in judicial enforcement of parity laws. Rejecting the insurer's guidelines for coverage determinations as inconsistent with usual practices, the court enunciated eight principles that defined accepted standards of care.

The 2018 risk-adjustment reform in the Czech Republic: Introducing Pharmacy-based Cost Groups and strengthening reinsurance.

BACKGROUND: Risk-adjustment in resource allocation is commonly used for regional redistribution or for eliminating risk selection motives of multiple statutory health insurers. In the Czech Republic, revenue redistribution between health insurers takes place since the 1990's. Since 2018, the risk-adjustment mechanism includes an adjustment for insured with chronic diseases using Pharmacy-based Cost Group (PCG) classification. In addition, retrospective compensation for very high cost patients has been strengthened. AIM: To provide an internationally relevant overview of the Czech risk-adjustment system. To assess the implication of the 2018 reform for health insurers and for the development of chronic care. METHOD: The framework of the Health Reform Monitor is used to analyse the policy process. Data from Czech health insurers and Czech Ministry of Health are used to assess likely impact of the reform. RESULTS: The reform increases coverage of predictable individual health risks and combines prospective risk-rating with strengthened retrospective risk-sharing among insurers. The reform results in moderate changes in risk-adjusted allocations of individual insurers. CONCLUSION: The Czech experience with risk-adjustment reforms is relevant for countries with multiple health insurers as well as for countries with risk-adjusted regional redistribution mechanisms. Combining prospective risk factors of age, sex, and PCGs with retrospective compensation of expensive cases limits potential losses to a manageable level, also for small risk-pools. It reduces incentives for cream skimming based on health status, enables higher use of risk-sharing contracts, and incentivizes the development of disease management programs in the Czech Republic.

Individual market health plan affordability after cost-sharing reduction subsidy cuts.

OBJECTIVE: To investigate how changes in insurer participation and composition as well as state policies affect health plan affordability for individual market enrollees. DATA SOURCES: 2014-2019 Qualified Health Plan Landscape Files augmented with supplementary insurer-level information. STUDY DESIGN: We measured plan affordability for subsidized enrollees using premium spreads, the difference between the benchmark plan and the lowest cost plan, and premium levels for unsubsidized enrollees. We estimated how premium spreads and levels varied with insurer participation, insurer composition, and state policies using log-linear models for 15 222 county-years. PRINCIPAL FINDINGS: Increased insurer participation reduces premium levels, which is beneficial for unsubsidized enrollees. However, it also reduces premium spreads, leading to lower plan affordability for subsidized enrollees. States responding to cost-sharing reduction subsidy payment cuts by increasing only silver plans' premiums increase premium spreads, particularly when premium increases are restricted to on-Marketplace silver plans. The latter approach also protects unsubsidized, off-Marketplace enrollees from experiencing premium shocks. CONCLUSIONS: Insurer participation and insurer composition affect subsidized and unsubsidized enrollees' health plan affordability in different ways. Decisions by state regulators regarding health plan pricing can significantly affect health plan affordability for each enrollee segment.

Emerging role of the Australian private health insurance sector in providing chronic disease management programs: current activities, challenges and constraints.

Objective This study explored the current activities of a sample of Australian private health insurance (PHI) funds to support the care of people living with chronic conditions, following changes to PHI legislation in 2007 permitting funds to cover a broader range of chronic disease management (CDM) services. Methods A qualitative research design was used to gather perspectives from PHI sector representatives via semistructured interviews with eight participants. The interview data were analysed systematically using the framework analysis method. Results Three main types of activities were most commonly identified: (1) healthcare navigation; (2) structured disease management and health coaching programs; and (3) care coordination services. These activities were primarily conducted via telephone by a combination of in-house and third-party health professionals. PHI funds seem to be taking a pragmatic approach to the type of CDM activities currently offered, guided by available data and identified member need. Activities are focused on people with diagnosed chronic conditions exiting hospital, rather than the broader population at-risk of developing a chronic condition. Conclusions Despite legislation permitting PHI funds to pay benefits for CDM services being in place for more than 10 years, insurers are still in an early stage of implementation and evaluation of CDM activities. Primarily due to the regulated scope of PHI coverage in Australia, participants reported several challenges in providing CDM services, including identifying target groups, evaluating service outcomes and collaborating with other healthcare providers. The effectiveness of the approach of PHI funds to CDM in terms of the groups targeted and outcomes of services provided still needs to be established because evidence suggests that population-level interventions that target a larger number of people with lower levels of risks are likely to have greater benefit than targeting a small number of high-risk cases. What is known about the topic? Since 2007, PHI funds in Australia have been able to pay benefits for a range of out-of-hospital services, focused on CDM. Although a small number of program evaluations has been published, there is little information on the scope of activities and the factors influencing the design and implementation of CDM programs. What does this paper add? This paper presents the findings of a qualitative study reporting on the CDM activities offered by a sample of PHI funds, their approach to delivery and the challenges and constraints in designing and implementing CDM activities, given the PHI sector's role as a supplementary health insurer in the Australian health system. What are the implications for practitioners? Current CDM activities offered by insurers focus on health navigation advice, structured, time-limited CDM programs and care coordination services for people following a hospital admission. There is currently little integration of these programs with the care provided by other health professionals for a person accessing these services. Although the role of insurers is currently small, the movement of insurers into service provision raises considerations for managing potential conflicts in having a dual role as an insurer and provider, including the effectiveness and value of services offered, and how these programs complement other types of health care being received.

Patient Protection and Affordable Care Act; Adoption of the Methodology for the HHS-Operated Permanent Risk Adjustment Program for the 2018 Benefit Year Final Rule. Final rule.

This final rule adopts the HHS-operated risk adjustment methodology for the 2018 benefit year. In February 2018, a district court vacated the use of statewide average premium in the HHS-operated risk adjustment methodology for the 2014 through 2018 benefit years. Following review of all submitted comments to the proposed rule, HHS is adopting for the 2018 benefit year an HHS-operated risk adjustment methodology that utilizes the statewide average premium and is operated in a budget-neutral manner, as established in the final rules published in the March 23, 2012 and the December 22, 2016 editions of the Federal Register.

China's Insurance Regulatory Reform, Corporate Governance Behavior and Insurers' Governance Effectiveness.

External regulation is an important mechanism to improve corporate behavior in emerging markets. China's insurance governance regulation, which began to supervise and guide insurance corporate governance behavior in 2006, has experienced a complex process of reform. This study tested our hypotheses with a sample of 85 firms during 2010-2011, which was obtained by providing a questionnaire to all of China's shareholding insurance companies. The empirical study results generally show that China's insurance governance effectiveness has significantly improved through strict regulation. Insurance corporate governance can improve business acumen and risk-control ability, but no significant evidence was found to prove its influence on profitability, as a result of focusing less attention on governance than on management. State ownership is associated with higher corporate governance effectiveness than non-state ownership. Listed companies tend to outperform non-listed firms, and life insurance corporate governance is more effective than that of property insurers. This study not only contributes to the comprehensive understanding of corporate governance effectiveness but also to the literature by highlighting the effect of corporate governance regulation in China's insurance industry and other emerging economies of the financial sector.

Building Better Policies.

Balances left on medical bills and unwarranted changes to medication: Those are just two of the ways in which health insurers can and do make life difficult for patients and physicians throughout Texas. Two bills that TMA backed in the 85th Texas legislative session - and that earned Gov. Greg Abbott's signature - won't eradicate those problems in Texas. But they should create some relief from the headaches that those two issues have caused throughout the years.

Risk Adjustment, Reinsurance Improved Financial Outcomes For Individual Market Insurers With The Highest Claims.

The Affordable Care Act (ACA) reformed the individual health insurance market. Because insurers can no longer vary their offers of coverage based on applicants' health status, the ACA established a risk adjustment program to equalize health-related cost differences across plans. The ACA also established a temporary reinsurance program to subsidize high-cost claims. To assess the impact of these programs, we compared revenues to claims costs for insurers in the individual market during the first two years of ACA implementation (2014 and 2015), before and after the inclusion of risk adjustment and reinsurance payments. Before these payments were included, for the 30 percent of insurers with the highest claims costs, claims (not including administrative expenses) exceeded premium revenues by $90-$397 per enrollee per month. The effect was reversed after these payments were included, with revenues exceeding claims costs by $0-$49 per month. The risk adjustment and reinsurance programs were relatively well targeted in the first two years. While there is ongoing discussion regarding the future of the ACA, our findings can shed light on how risk-sharing programs can address risk selection among insurers-a pervasive issue in all health insurance markets.

Anthem sees Trump's DOJ as its wingman.

It reads like an ugly divorce. Court records show two former partners accusing each other of lies and sabotage.

ACA risk programs level the playing field for insurers.

Small insurers have complained that the ACA's risk-adjustment program favors big payers, but one study found that the risk-adjustment and reinsurance program adequately compensate insurers.