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July 3, 2019
Oxford qualifies for $132 million risk-adjustment award in small-group market
The Affordable Care Act's risk adjustment program has once again made winners and losers out of New York's health insurers, with UnitedHealthcare's Oxford continuing to reap the biggest bounty.
Based on the risk of members last year, Oxford is set to receive $132 million from its competitors in the small-group market out of the $165.3 million that is being transferred among the state's insurers.
The program transfers money to health plans that had members who were sicker on average from plans with healthier members. It is intended to discourage insurers from cherry-picking younger, healthier people to enroll.
EmblemHealth is making the largest payment into the small-group pool, $35.2 million, and upstate Excellus BlueCross BlueShield is paying in $31.5 million. Oscar owes $29.3 million into the pool.
A spokeswoman for Oscar said the size of the payment was in line with its projections.
One of the main consequences in New York's insurance market for small businesses has been a flow of money to Oxford, which controls more than half of the small-group market. The federal government calculated a $216 million transfer to Oxford in the previous round of awards.
Northwell Health's CareConnect, which didn't sell new plans last year but wrapped up existing business, is on the hook for $14.9 million for its small-group plans. Northwell cited the risk adjustment program as one of the driving factors behind its closure after it was required to pay more than $100 million to competitors in consecutive years.
Oxford might not receive the full $132 million. The state Department of Financial Services has previously made adjustments to the transfers, reducing the amount of money flowing between insurers. Last year the agency lowered the payments for the 2017 plan year by 18%.
Oxford's parent, UnitedHealthcare, sued the agency last year to block the state from lowering its award, but DFS prevailed.
"It is not unconstitutional for the superintendent to require insurance companies to pay into a risk-adjustment pool to ensure the proper functioning of the health insurance market in the state," U.S. District Judge John Koeltl wrote when he dismissed the case in August.
Asked about such an adjustment this year, a spokesman for DFS said it was reviewing the awards.
In the individual market, Empire BlueCross BlueShield is to receive $64.9 million for the individual market while upstate Excellus was awarded $26.1 million and UnitedHealthcare qualified for $18 million.
Centene's Fidelis Care owes the largest payment in the individual market, $80.5 million, followed by Oscar with $45.6 million and NYC Health + Hospitals' MetroPlus with $11.8 million.
Nursing schools bank federal dollars to create workforce pipeline
Three nursing schools in the state have been awarded about $8.3 million in federal money to create a nurse pipeline for areas of need through 2023.
The schools are the Binghamton University Decker School of Nursing, the Hofstra Northwell School of Graduate Nursing and Physician Assistant Studies, and the College of Nursing at SUNY Upstate Medical University. Each has been awarded between $670,000 and $700,000 a year for four years, the Health Resources and Services Administration said.
The monies will be used to prepare primary care and advanced practice nurses to work in rural and underserved communities. Specifically the funding is focused on nurses' contributions to integrated and value-based care.
"Nurse practitioners play a vital role in the health care delivery system, as evidenced by the growing demand for their services due to an aging population and a shortage of primary care physicians," said Kathleen Gallo, a registered nurse and dean of the Hofstra Northwell School of Graduate Nursing and Physician Assistant Studies, in a statement.
Prior advanced nursing education grants awarded to the school from the Health Resources and Services Administration were an award of $1.6 million in 2016 for creating a nurse practitioner student transition to primary care practice model and an award of $750,000 last year for a sexual assault nurse examiner program.
Nationwide, the administration awarded the latest round of grants Monday to some 63 institutions.
What went wrong for Crystal Run's insurance company?
Crystal Run Health Plan's failure to enroll enough members to support its high administrative costs doomed the startup insurer's chances of surviving, according to an analysis by Adam Block, an assistant professor of health policy and management at New York Medical College.
The insurer was created by Crystal Run Healthcare, a Middletown-based medical group with more than 400 providers in the Hudson Valley and lower Catskill region, and began selling health plans in 2015 in Orange and Sullivan counties. In March, Crystal Run said it would close the health plan at the end of the year.
Crystal Run blamed the Affordable Care Act's risk adjustment program, which shifted money from plans with healthier members to those with sicker ones, for creating a financial burden it couldn't overcome. This was a similar rationale cited by other short-lived startup insurers CareConnect and Health Republic.
But Block wrote in Managed Care that below-market premiums in the individual market were a greater culprit in Crystal Run's financial losses. In the small-group market, the health plan managed medical costs well, but it had administrative costs that were three times that of its competitors.
For its small-business product, it paid out nearly one-third of its premiums into the risk adjustment pool. Block concluded that its 6,400 members weren't enough to sustain the administrative costs of breaking into New York's competitive market.
"They were simply unable to get the scale they needed," Block said.
Mount Sinai physicians develop guide to better transgender care
A review by Mount Sinai physicians published Monday in the Annals of Internal Medicine is designed to help primary care providers better care for transgender patients.
Prior research points to a lack of knowledgeable providers as the most significant barrier to health care reported by transgender individuals, Mount Sinai said. That contributes to health disparities, such as higher rates of cancer, substance abuse, mental health concerns and chronic diseases.
To address those disparities and help physicians determine where more research is needed, Mount Sinai physicians developed a series of recommendations for providers.
The recommendations include prescribing and managing hormone therapy with guidance from endocrinologists as well as understanding surgical options for transgender individuals and the postoperative concerns associated with those options, Mount Sinai said. They also include updating electronic medical records to correctly record relevant medical and social details for transgender individuals as well as integrating medical care within relevant specialty training.
"The hope is that, as education initiatives improve, providers will become more comfortable caring for gender- minority patients, who with improved access to care will no longer always need to seek subspecialists in transgender services," said Dr. Joshua Safer, lead author of the review and executive director of the Mount Sinai Center for Transgender Medicine and Surgery, in a statement.
Last week Mount Sinai said it had added talent at the center. Dr. Miroslav Djordjevic, a surgeon and expert on surgery for transgender individuals, joined as a urogenital reconstructive surgeon from the Belgrade Center for Genital Reconstructive Surgery in Serbia. He'll also serve as a professor at the Icahn School of Medicine.
AT A GLANCE
HOLIDAY: Health Pulse will not publish on July 4 and July 5 in observance of Independence Day. We will resume our normal schedule on Monday, July 8.
OSCAR RESPONDS: A spokeswoman for health insurer Oscar addressed criticism of the company from health policy researcher David Anderson that was cited in Tuesday's Health Pulse. The company said Anderson used outdated projections when he charged that Oscar had badly miscalculated what it would owe in the risk-adjustment program in Tennessee. Updated projections were within 0.5% of what it is required to pay in risk adjustment, she said. Oscar CEO Mario Schlosser sparred with Anderson over his analysis in the comments section of Anderson's post.
WHO'S NEWS: Alice Wang McKenney is the new deputy chief of the state Department of Financial Services' Health Bureau in New York City, where she will will oversee the financial solvency and compliance of health insurers. Before joining DFS in 2017, McKenney was a vice president on the private wealth global management team of Goldman Sachs.
Chad Shearer has been named senior vice president for policy and program at United Hospital Fund. He previously served as vice president for policy and director of the Medicaid Institute. Prior to joining the fund in 2014, Shearer served as deputy director of the Robert Wood Johnson Foundation's State Health Reform Assistance Network, based at the Woodrow Wilson School of Public & International Affairs at Princeton University.
Bill Kelty is now vice president and chief information officer at St. John's Episcopal Hospital in Far Rockaway, Queens. Kelty previously was information systems site director at Advocate Christ Medical Center in Chicago.
UNNECESSARY OPIOIDS: Geoffrey Berman, the U.S. Attorney for the Southern District of New York, said Tuesday that Ernesto Lopez, a New York-licensed doctor who wrote thousands of unnecessary prescriptions for oxycodone and fentanyl, was sentenced in federal court to five years in prison. Lopez was found guilty in February of distribution of narcotics.