HHS-CMS Share Marketplace Projections and Nine Open Enrollment Strategies

By Clive Riddle, October 21, 2016

Earlier this Week, HHS Secretary Sylvia M. Burwell “announced that she expects 13.8 million individuals to sign up for coverage through the Marketplaces during the upcoming Open Enrollment.” In conjunction with her announcement, the HHS Office of the Assistant Secretary for Planning and Evaluation released a report detailing these 2017 enrollment projections for 2017, telling us:

  • The projected enrollment of 13.8 million would represent an increase of 1.1 million from 12.7 million plan selections at the end of 2016’s Open Enrollment.
  • They estimate this will net down to monthly effectuated enrollment averaging 11.4 million people during 2017.
  • 10.7 million uninsured Americans are eligible for Marketplace coverage. Among them, 85% are potentially income eligible for financial assistance,  and 60% have incomes that would also qualify them for cost-sharing reductions in addition to tax credits
  • 40% of the eligible uninsured are 18-34 years old
  • 5.1 million eligible for the Marketplace currently purchase off-Marketplace coverage. Of this group, they estimates 2.5 million people could be eligible for financial assistance via Open Enrollment signups for Marketplace coverage

So how are they going to increase the open enrollment signups to 13.8 million? Last week, CMS shared their open enrollment marketing strategies, noting that “nearly half of uninsured adults are unaware of the financial assistance available to help pay for health insurance, even though about 85 percent of Marketplace-eligible uninsured Americans could qualify for financial help.” Their marketing plan includes:

  1. Increasing direct mail pieces from 800,000 last year to 10 million this year, targeted to “people who were recently uninsured, recently lost coverage, or sought coverage in the past through or a state Medicaid program,” including “people who started to sign up at last year, but didn’t complete the process”; “consumers who lost eligibility for Medicaid or CHIP coverage last year, or who applied for Medicaid or CHIP but had incomes too high to qualify.”
  2. The IRS “will conduct new outreach to uninsured people who paid the penalty or claimed an exemption, letting them know that tax credits are available for Marketplace coverage and providing information about their health coverage options.”
  3. E-Mail marketing will be expanded, as “’s email list has grown by over 30 percent” to 20 million+ people
  4. notes they “learned that simply reminding a consumer about their eligibility for financial assistance in an email increased enrollment rates by 17 percent compared to emails that did not include that information,” and that “emails informing returning consumers of increased costs in their current plan and encouraging them to review their options by shopping increased active renewal rates by 279 percent.”
  5. also learned merely mentioning a deadline in an email increased enrollment by 14 percent compared to emails that did not mention deadlines.
  6. will remind consumers about the a penalty for not having coverage, and cite a study in which “consumers who received an email with additional language referencing the penalty were 13 percent more likely to enroll,” and a test that “found that more prominently displaying penalty information with the deadline (for example, in the email subject line) produced a larger lift in enrollment, 97 percent,” and a “message that gave higher-income people information about the higher penalty levels likely to apply to them increased enrollment by 18 percent.”
  7. Outreach is being expanded to mobile and streaming platforms, and gaming platforms in order to reach younger audiences. cites a partnership with gaming platform Twitch, and notes that they will run ads and sponsor content on YouTube, Instagram and Facebook
  8. will emphasis optimized search efforts and cite that “CMS increased overall search conversion rates by 24 percent compared to the previous year.”
  9.  will “double the number of impressions a consumer sees (“Gross Rating Points”) on TV in the week leading up to December 15th compared to the same week last year.”

Will Anyone Notice?

By Kim Bellard October 13, 2016

There's an interesting verbal battle going on between two prominent tech venture capitalists over the future of AI in health care. Marc Andreessen asserted that Vinod Khosla "has written all these stories about how doctors are going to go away...And I think he is completely wrong."  Mr. Khosla was quick to respond:  "Maybe Mr. Andreessen should read what I think before assuming what I said about doctors going away."

It turns out that Mr. Khosla believes that AI will take away 80% of physicians' work, but not necessarily 80% of their jobs, leaving them more time to focus on the "human aspects of medical practice such as empathy and ethical choices."  That is not necessarily much different than Mr. Andreessen's prediction that "the job of a doctor shifts and becomes a higher-level, more important job that pays better as the doctor becomes augmented by smarter computers."

When AIs start replacing physicians, will we notice -- or care?

Personally, I think it is naive to expect that only 20% of physicians' jobs are at risk from AI, or that AI will lead to physicians being paid even more.  The future may be closer than we realize, and "virtual visits" -- telehealth -- may illustrate why.

Recently, Fortune reported that over half of Kaiser Permanente's patient visits were done virtually, via smartphones, videoconferencing, kiosks, etc.  That's over 50 million such visits annually.  

Sherpaa, a health start-up that is trying to replace fee-for-service, in-person doctor visits with virtual visits.  Available with a $40 monthly membership fee, the visits are delivered via their app, tests or emails.  Their physicians can order lab work, prescribe, and make referrals if needed.

How many people would notice if virtual visits were with an AI, not an actual physician?  

Companies in every industry are racing to create chatbots, using AI to provide human-like interactions without humans.  And health care bots are on the way.

Not everyone is convinced we're there yet.  A new study did a direct comparison of human physicians versus 23 commonly used symptom checkers to test diagnostic accuracy, and found that the latter's performance was "clearly inferior."  The symptom checkers listed the correct diagnosis in their top 3 possibilities 51% of the time, versus 84% for humans.  

However, consider the symptom-checkers may be the most commonly used, but may not have been the most state-of-the-art.  And the real test is how the best of those trackers did against the average human physician. Humans still got the diagnosis wrong is at least 16% of the cases.  They're not likely to get much better (at least, not without AI assistance).  AIs, on the other hand, are only going to get better.  

It used to be that physicians were sure that their patients would always rather wait in order to see them in their offices, until retail clinics proved them wrong.  It used to be that physicians were sure patients would always rather see them in person rather than use a virtual visit (possibly with another physician), until telehealth proved them wrong.  And it still is true that most physicians are sure that patients prefer them to AI, but they may soon be proved wrong about that too.

AI is going to play a major role in health care.  Rather using physicians to focus more on empathy and ethical issues, as Mr.  Khosla suggested (or paying them more for it, as Mr. Andreessen suggested), we might be better off using nurses and ethicists, respectively, for those purposes.  So what will physicians do?

The hardest part of using AI in health care may not be developing the AI, but in figuring out what the uniquely human role in providing health care is.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting


It’s Complicated – Navigating Health Care Integrated Delivery Networks

By Claire Thayer, October 7, 2016

Integrated delivery networks (IDNs) are vast and complex. In the U.S. alone, there are more the 626 IDNs operating at 44,000 sites, employing over 412,000 health care providers.  Some IDNs are groups of hospitals, some are regional, some have facilities scattered throughout the country and even internationally – think Kaiser Permanente and the Mayo Clinic – both long standing traditional IDNs. More and more health systems are taking on risk management for their patient populations and in doing so, are looking for ways to collaborate with health plans and providers and related entities to align efficiencies in overall patient care management.  In the not to distant future, expect to see most provider organizations involved at some level with an IDN. 

Navigating IDNs and understanding the scope of their reach is the focus of a recent MCOL infographoid, co-sponsored by LexisNexis Health Care, highlighted below:

MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more here.


Opportunities With Consumer Angst About ACA Exchanges and Out of Pocket Costs

By Clive Riddle, October 7, 2016

GfK has just released updated survey results on consumer health insurance purchasing which found that “one-third of consumers who purchased on ACA exchanges do not expect that their present insurer (33%) – or any other carrier (34%) – will offer insurance through their exchange in 2017. And 32% do not think they will find options on the exchange that meet their needs.”

Additional findings they report include:

  • 13% of consumers purchasing through ACA exchanges plan to revert to becoming uninsured if their current coverage was not offered.
  • For ACA exchange consumers earning less than $25,000 a year, 34% plan on becoming uninsured if current coverage isn’t available
  • 43% of exchange users say they would seek new options through the exchanges – with levels highest among 50 to 64 year olds.
  • 35% of exchange users would go directly to an insurer or agent for solutions if their coverage lapses
  • 66% say they would choose the best option to meet their needs, regardless of the insurance company
  • Only 12% would make a point of staying with their current carrier
  • 20% say they would explore coverage through a different insurer

Liz Reyer, GfK Vice President and health insurance lead concludes that “as a ’brand,’ the ACA has taken some hits in 2016. While most observers expected insurance companies to reassess their offerings on the exchanges now and then, the outright defections we have seen have quickly limited consumers’ choices and eroded confidence that the ACA will find ways to meet their needs. We need to see a high-profile campaign making clear the options that consumers still have – so no one goes without insurance unnecessarily – and stronger collaboration between the insurance industry and the government in keeping the ACA viable.”

Health Plans remaining on the ACA exchanges certainly have a market opportunity to mop up the mess left by large national plans exiting the exchanges. Outside the ACA exchanges, plans active in individual markets, and applicable private exchanges have a major opportunity to gain ground with consumers not eligible for subsidies (which are only available through the ACA exchanges.)

Meanwhile, Navicure, in conjunction with Porter Research has just released provider survey results from a study on how healthcare organizations are responding to patient engagement and consumerism, with a focus on consumer concerns about price transparency, financial responsibility and payment options. The survey included hospitals (19%) and medical groups ranging in size (33% in practices with ten providers or less and 21% with 100 providers or more.)

Of the most common questions patients ask about their financial responsibility, provider respondents said “58 percent inquire about payment plans, and 56 percent ask about total treatment cost. Other top questions include asking what balance is due (53%) and what payment options are available (43%).”

67% of provider respondents say patients do not understand their payment responsibility versus their insurance provider’s responsibility, and 42% of providers find that attempting to estimate prices for services is a major problem.

The study found that most healthcare organizations aren’t using available tools to help with consumer confusion over out of pocket costs, with 33% of providers using patient bill estimation tools, 26% sending patients electronic statements, and 25% securely store debit or credit card information on file.

In this era of ever increasing consumer cost sharing, a major market opportunity exists for providers and health plans that can easily answer patient questions on what their out of pocket will be, and offer a range of options for how patients can pay for them.


Prescription Drug Costs on the Public’s Mind – Reductions in the Uninsured Not So Much

By Clive Riddle, September 30, 2016

The just released current Kaiser Family Foundation Tracking Poll finds that while the public continues to be deeply divided on the Affordable Care Act, they are fairly united in backing policy changes to rein in prescription drug costs. The level of bipartisan public support – powered by recent EpiPen pricing headlines among other Rx cost woes in the news -  would seem to offer a prescription paving the way for a rare event these days– legislation that has a chance of being enacted into law when the new Congress convenes next session.

There is widespread agreement on five policy points:

  1. 86% support requiring drug companies to release information to the public on how they set drug prices
  2. 82% favor allowing the federal government to negotiate with drug companies to get a lower price on medications for people on Medicare
  3. 78% approve of limiting the amount drug companies can charge for high-cost drugs for illnesses like hepatitis or cancer
  4. 71% like allowing Americans to buy prescription drugs imported from Canada
  5. 66% want an independent group that oversees the pricing of prescription drugs

Here’s a graphic Kaiser Family Foundation provided regarding the poll results:

The survey finds that “a large majority (77%) perceive drug costs as unreasonable, while one in five (21%) say they are reasonable. The share who say drug costs are unreasonable is up somewhat from 72 percent a year ago in August 2015.”  The Survey also finds that “about half (55%) of the public report currently taking prescription drugs, and the vast majority (73%) of them say paying for their medications is easy; far fewer (26% of those taking prescription drugs, or 14% of the total population) say it is difficult to pay for their drugs.”

The September tracking poll continues to reflect the deep partisan divide in views on the ACA, which spill over to recognition of a significant drop in the level of the uninsured:

  • 47 percent have an unfavorable view of the ACA while 44 percent have a favorable one. 
  • 48% say the marketplace in their own state is working well, while 43 percent say it is not working well, but 49% say they are not working well nationally vs. 44% that say they are working well.
  • “When asked whether the uninsured rate is at an all-time low or all-time high, a quarter (26%) are aware that it is at an all-time low, while a fifth (21%) say that it is at an all-time high. Democrats and those with a favorable view of the health reform law are more likely to be aware of this; Republicans and those with an unfavorable view are less likely to be aware.”


With regard to the current level of the uninsured, HHS this week released a report indicating “the uninsured rate fell by around 40 percent for Americans in all income groups for 2010 through 2015, including individuals with incomes above 400 percent of the federal poverty level (FPL).”
Here’s the levels of reduction in the rate of uninsured they found during this time period by income levels and age:

  • Less than 100% FPL: 39% reduction
  • 100-125% FPL: 48% reduction
  • 125-250% FPL: 41% reduction
  • 250-400% FPL: 37% reduction
  • 400% FPL and higher: 42% reduction
  • 18-25 year olds: 52% reduction
  • 26-34 year olds: 36% reduction
  • 35-54 year olds: 39% reduction
  • 55-64 year olds: 40% reduction