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New study on Medicaid health plan margins from SOA

The Society of Actuaries has a new study out on Medicaid health plan margins. Its a comprehensive look at how health plans perform in the space, and a must read for anyone working in Medicaid finance.

Here’s the summary (full report is attached)

Medicaid Managed Care Organizations: Considerations in Calculating Margin in Rate Setting

The Society of Actuaries Health Section Research Committee is pleased to make available a research report that describes the components of margin for calculating capitation rates in a Medicaid context along with a description of practical issues that may be encountered by MCO’s. The report includes observations from interviews with MCO executives as well as financial results analysis of MCOs nationwide. The material was authored by Sara Teppema, Jeff Goldman, Luke Smith, and Steve Tutewohl from Valence Health.




You can also check out more on this report (including an appendix / data file in excel) here –


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Guest Post: How Asking the Wrong Questions Impacts Medicaid Health Plans

This post is provided by one of our Medicaid Star Search panelists. Be sure to check out Forecast Health on the April 3rd show. Sign up here if you haven’t already. 



If asking the right questions is everything, why are so many Medicaid plans asking the wrong ones?


Today, plans and providers dedicate time and resources to identifying high risk patients — those who are more likely to experience a readmission, post-operative complication, higher costs, or other adverse event.  To do this, they rely on a variety of popular analytics platforms that are only marginally better than clinical judgment (or making educated guesses, frankly) at predicting a patient/member’s risk.


For organizations charged with reducing and managing risk, not just measuring it, merely answering questions about a person’s future risk is wasteful.  We believe answering the question about future risk is wasteful even if the prediction is perfect.


Why?  Many predicted high-risk people, and rising risk people, are not impactable.  Or if they are, the plan or provider doesn’t know which type of intervention is likely to have the biggest impact.  Or, perhaps the provider or plan does not offer services that would make a difference in preventing the adverse event.


A more useful way to look at the data is to focus on the subset of high-risk patients who are impactable.  By identifying this subgroup, Medicaid plans and providers can focus resources in ways that will make a difference.


So exactly what could this mean to a Medicaid plan? Consider one procedure with among the highest costs and risks for a Medicaid population:  joint replacements.  An organization that oversees approximately 3,000 joint replacements annually asked us to evaluate their decisions regarding post-acute care and managing risk. Using a combination of machine-learning predictive analytics and evaluation analytics with social determinants of health (SDH) data to predict risk and impactability, they were able to:


  • More accurately identify joint replacement patients at high-risk for unplanned readmission in the 90-day post-discharge period
  • Identify the 14% of patients who were discharged from the hospital to a skilled nursing facility, but could have safely been discharged home.
  • Identify the 7% of patients who were discharged home, but would have had better outcomes and lower costs if they had been initially discharged to a SNF (the costs of the more expensive SNF were offset by the reduced emergency readmissions).
  • Identify patients’ individual risk drivers—prior to admission—in order to better inform the care team of potential issues with affordability, caregiver support, medication non-adherence, transportation, material deprivation, and health behaviors.  This information provides opportunities for care managers to spend more time addressing the needs of the patients versus trying to discover exactly what those needs might be via intake questioning and exhaustive chart review.


Together, these analytics can save on average over $800 per joint replacement patient, or $2.5 million annually based on 3,000 joint replacement patients.

The bottom line is this:  Asking the right question isn’t just an academic exercise.  By moving from just predicting risk to identifying who is impactable, and how, an organization can measurably impact costs and patient outcomes.  For more information, please contact Sandy Shroyer at

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Menges Group 5 Slides Series for Jan and Feb 2017

The Menges Group puts out these great analyses and insights each month. And is kind enough to let us repost them for the MM audience. Check out to learn more about the work they do. 

The January edition tabulates the distribution of Medicaid pharmacy costs by unit price cohort.  Explosive growth in the share of Medicaid prescriptions among drugs costing more than $1,000 per prescription (pre-rebate) continues to occur.  These drugs now represent 40% of all Medicaid pre-rebate prescription drug expenditures.

The February edition tabulates overall health care expenditures from 2006-2016, and shows the progression of Medicaid, Medicare, and private health spending.  A key observation from these tabulations is that health costs haven’t grown all that rapidly across the past decade – annual per capita cost increases have averaged 3.7% for the entire US population, 2.3% in Medicare, 3.2% in Medicaid, and 4.0% in the rest of the population.


Health Expenditures Progression 2006 – 2016 Feb. 2017


Price Per Script Categories Jan. 2017 (1)

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Obamacare / Trumpcare: Let the arguments begin


by Len Kirschner, MD, MPH

Dear Editor, The Affordable Care Act (aka Obamacare) became law almost seven years ago in March, 2010. The battles for and against the law have continued since Day #1. There have been many ups and downs. Trips to the Supreme Court, the initial failure of and the rancorous rhetoric in the 2016 Presidential campaign have poisoned the debate.

The positives are impressive. We now have the lowest number of people without health insurance in the history of this country. Close to 200,000 Arizonans have coverage under the Exchange and over 700,000 have received coverage under our Medicaid program better known as AHCCCS.

In Washington the debate is raging about “Repeal and Replace” with no obvious resolution to the issue. A total repeal would be damaging to Arizona and a huge hit to the state budget. Hundreds of thousands of people would lose coverage and the entire population would be impacted. Much of the debate centers on the Exchange but Medicare would also be impacted. Closing the prescription drug “doughnut hole” would be canceled and the million Arizonans on Medicare would see costs increase. Hospitals would see a rise in uncompensated care and emergency department use would increase.

The House of Representatives has voted 60 times to repeal Obamacare. It was symbolic since the bill was going nowhere. Now they have the political strength to act and truly repeal Obamacare. They look like the dog who kept chasing the car and finally caught it. What do they do now?

Change is coming and the new system will be called Trumpcare. Let the arguments begin.



Len has done so much in the healthcare space its impossible to do it justice in a simple footer. Highlights include being State President of AARP of Arizona, the former Medicaid Director for Arizona, and 22 years of active duty in the United States Air Force. He is also a physician and regular on the Medicaid conference circuit. To learn more about Len, check out this bio and this bio.

This article originally appeared in a local newspaper. Reprinted with kind permission from the author.

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Truth and “Entitlements”

Dave Mosley

by Dave Mosley

For the minority of Americans that are judicious in attempting to access and digest the news relating to our economy, there is a term that is often frustrating and misleading: entitlement.

One often hears that entitlements are dooming our economy and that spending must be curbed.

However, one also hears the argument that individuals have paid into Social Security and Medicare, so, in fact, they are not entitlements, unlike Medicaid, for which those receiving the benefit, paid nothing directly toward the benefit.

Regarding Social Security each person who receives benefits has contributed to that fund throughout their working life. Moreover, if a person is self-employed the annual contribution is doubled. Thus, to classify such a program as an “entitlement” is false. Yes, there is a right to benefits specified by law, but individuals have paid for their benefits. The average person comes very close to paying for (while working) his/her Social Security benefits (while retired).

Medicare benefits are different, in that the average individual, retiring this year will likely receive more than 3x the total dollars in benefits than he/she has paid into the program. For this reason, one might argue that Medicare is an entitlement. The government receives approximately 1/3 of the amount from an individual that the government will pay out on behalf of said individual.

For Medicaid, there is zero correlation between what an individual pays in to the program, versus the benefits one receives. Yes, various taxes are used to create the funding sources from which the Federal, state, and even local governments pay for Medicaid. However, again, there is no correlation between payment and benefit. In fact, the majority of individuals on Medicaid have never paid taxes at all.

Also worth noting is the fact that across our Nation individuals believe that Medicare, Medicaid, and commercial insurance are very similar health insurance platforms. Many presume that the primary difference between these payers is that the Feds pay for old folks, employers pay for working folks, and Medicaid pays for poor folks.

In fact, while Medicaid was created as a parallel program to Medicare – – addressing care based upon medical necessity and sufficiency criteria – – nearly one-half of all Medicaid payments are made for services that Medicare does not cover and never has covered.

Medicaid’s benefit package, in every state, far exceeds the benefits available through commercial, Medicare, VA, TRICARE and any other type of health insurance. Nearly one-half of Medicaid services provided to beneficiaries are neither curative nor restorative. Unlimited nursing home days (or home-based care), occupational therapy, hearing aids, eye glasses, orthodontics, and a plethora of other services are all covered by Medicaid and only Medicaid.

As the next budget cycle comes around, let’s not only listen to those crafting and adopting both Federal and state budgets, let’s listen in an informed manner.

Perhaps it would be beneficial if neither elected officials, nor the media, endeavored to paint all “entitlements”, or all health insurance, with the same brush?

It is disingenuous, at best, when the 24/7 news lumps Medicaid coverage in with any other coverage available in the Nation. Medicaid is far more than “health insurance”. We, as a Nation, can certainly afford to care for the most fragile members of our society; however, let’s do so through in a manner that affords transparency and clarity.

Dave Mosley is a Managing Director and the State Practice Leader for Navigant’s Government Healthcare Solutions (GHS). He assists Medicaid, human services, and elected leaders to navigate regulatory channels and to apply best practices to improve organizational performance. He is a recognized public speaker, has been published in trade journals, and is frequently called upon as a resource to elected officials at the state and Federal levels.


For more about Dave, check out his LinkedIn profile.


Article reprinted with kind permission from author.

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The Fairness of Medicaid Expansion Under the ACA

Ted Calvert

by Ted Calvert


As Congress and the new administration try to figure out what to do with the Affordable Care Act (ACA), it’s important to highlight one particularly impactful provision that’s often overlooked: Medicaid expansion. Keeping kids on their parents plans until they are 26 is also terrific, but it’s insignificant in comparison.

Of the approximately 25 million individuals who gained insurance coverage due to the ACA, almost half have been through Medicaid expansion. Those are, of course, individuals in the 29 states that decided to expand – an easy choice for many states since it meant billions of dollars in federal spending with comparatively small state outlays. Although Medicaid eligibility rules remain far too complex, the ACA brought some simplicity, elegance, and I think fairness to at least part of the criteria: all individuals below the poverty line are now eligible. It has always been more politically acceptable to provide government sponsored health care to poor children and their mothers, or even fathers in low-income families, but the pre-ACA rules excluded the poor who were not eligible in some other categorical way. As a result of the ACA, many more childless adults (most of them men) are now eligible for free health care. It always struck me as unfair that they were not previously eligible, and apparently the authors of the ACA agreed.

With the future of the ACA uncertain at best, I worry most about this group of individuals who earn less than $16,390 per year losing their health care coverage. In California, that’s almost three million people that are now covered due to the ACA, double the approximately 1.4 million that gained coverage through the Covered California plans. It’s not cheap – roughly $5,000 per person or $50 billion in federal spending nationwide, but we probably should have been doing it all along, at least if we believed in subsidized health care for the poor. If we don’t have the money, let’s reduce the spending in some other way, but let’s do it in a way that more evenly impacts all low-income individuals.

Ted Calvert is the owner of Ted Calvert Consulting (TCC). Ted has more than 30 years experience in the healthcare industry, and assists clients with program management, analytics, large-scale IT system oversight and standards adoption. Learn more about TCC by visiting Learn more about Ted by checking out his LinkedIn profile.

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Make Medicaid Great Again

I have had clients and readers ask my thoughts on what President-elect Donald Trump’s shocking (gasp!) victory means for Medicaid. I have intentionally waited a few weeks for the dust to begin to settle. At first the punditocracy was silent, then the fear-mongering began about 2 days after election day. And now there is a deluge of mostly panic pieces, with some general fluff crystal-balling out there.

Here’s a few thoughts:

1) The sky is not falling, but there is rain in the forecast. Although you wouldn’t know it as the 4th estate continues their delusional narrative with headlines like these: “Millions could lose coverage under Trump plan,” “Trump victory worries KY Medicaid advocates,” and “Gov. Edwards hopes Medicaid Expansion isn’t at risk under a Trump presidency”. Medicaid will change, as it always does (I have a chart showing major changes in Medicaid over 50 years and its full). And we likely will see a rebalancing towards cost control as opposed to the spending orgy of the past 20 years (but its free federal money! They print the stuff!). The go-to answer of spend more money, like Death-Star-construction-budget amounts of money, probably is weakening. And that’s a good thing. We need to think harder and come up with additional strategies besides additional spending.

Which brings me to my next assessment-

2) Reducing or beginning to limit Medicaid spending growth will force states to prioritize like never before. It will change the current highly conceptual “value-based care” paradigm to one in which there are real winners and losers based on risk ultimately tied to performance (not just symbolic tiny percentages based on who had the best data, marketing or lobbyist). This is what those of us who love Medicaid because it helps those in the most need truly want. Medicaid has had fundamental and terrible issues for decades. We need disruption in Medicaid. But we are all so accustomed to looking the other way on the waste and fraud- which is way bigger than anyone thinks, just read the fraud follies each week- and that’s just what I happen to find in the press – that we are almost entirely unequipped to look at Medicaid in an honest, constructive way. We don’t even have the words to criticize it in our language- Medicaid is the great untouchable policy idol in our lives. We are so practiced in defending it with sometimes ridiculous theories that we end up with nothing but weak defenses that just get us through the next budget cycle. And Medicaid always grows in those state level budget discussions, even when education and roads and parks and other things do not (we just robbed the AL coast of BP oil-spill money here to fund one more ride on the Medicaid carousel next year). We do this (fight for more Medicaid funding) because we care about the populations, but we have become intellectually lazy as we swim in oceans of money. We can do better.

It may well be that, after finally forced to do so, all of us actually with some ability to fix it (consultants, health plan management, providers, agency officials), may be motivated to do just that.


But lest you be encouraged, here’s number 3-

3): The foggy delusion that more money is the answer will likely continue, and most in our Medicaid world will not rise to the challenge. Instead we will dig in our heels and look for ways to resist the change. We will wait and only react to whatever is “done to Medicaid” by that mean-ole’ GOP. Perhaps the best opportunity to really improve outcomes for Medicaid members to come our way in 50 years will be met with fierce opposition disguised as virtuous panic. So what will be done with Medicaid, the reason you have read all these words to this point (and either loved me more for them or decided to finally set aside the RoundUp after all those years of reading in secret guilt) is the subject of number 4-

4): A very large Pause Button is being pressed. In February it will be a pause on all the late comers to expansion. Between now and late January, it will be the Fast Forward button on any of those waivers seeking to trim back expansion (hurry up and deny them, like CMS did with NH’s request a few weeks back). When the Pause is over (likely around Q3 2017), we will see Medicaid transformation as part of federal repeal and replace efforts. Expect block grants or something like them. Expect it to be a fight, and expect there to be some sort of compromise but not 50-50.

Regardless of what 2017 brings for our Medicaid world, I can safely predict this will be the most exciting time to be in Medicaid in the history of the program. For those afraid, find the fire in your gut to fight whatever you perceive as the danger. For those able to peek past the fear, pursue the opportunity to improve this critical program like never before.

Onward and Upward!


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Government had ACA Costs Wrong

Dave Mosley


by Dave Mosley



The Feds had expected, in their estimates, that the newly insured population would behave in a manner commensurate with the previously insured population.  They have not.  In addition to a backlog of health needs that were addressed subsequent to obtaining insurance, the new population was comprised largely of individuals inexperience with acting in manner similar to those who were previously insured.


Are they taking advantage of primary care instead of using emergency rooms, as insured folks do?  No, not really.


Are they compliant with physician guidance?  No, not really.


Are they adopting new behaviors that lead to improved health and wellness?  Again, not so much.


A significant percentage of the increased cost per beneficiary is also attributable to the failure of well, young individuals to sign-up.


I have heard from several young people…”no, I am not signing up and I am claiming more deductions than necessary so that I never get a refund….and the refund is the only way the Feds can get a penalty from me.”  OR, “there are no pre-existing exclusions, so I will wait until I am very sick and I will sign-up then.”


The Feds calculations for per member cost included a huge wave of young, healthy folks signing up and this hasn’t happened.


Dave Mosley is a Managing Director and the State Practice Leader for Navigant’s Government Healthcare Solutions (GHS). He assists Medicaid, human services, and elected leaders to navigate regulatory channels and to apply best practices to improve organizational performance. He is a recognized public speaker, has been published in trade journals, and is frequently called upon as a resource to elected officials at the state and Federal levels.


For more about Dave, check out his LinkedIn profile.


Article reprinted with kind permission from author.