By now we should all know the insurers are looking at ways to keep the cost of healthcare down and now it’s coming down to pretty much an “algorithm stick” for the doctors to deal with.  This new company, interestingly enough is being headed from a former White House Executive, Dr. Julian Harris.  He’s the former OMB Associate Director for Health.  The revolving door between insurers and US Healthcare never stops.image

Seriously, now when you look at one insurers page you get the same rhetoric about empowering and motivating physicians, same text different insurance carrier and I bet the doctors are a bit tired of the quantitated madness they deal with today as it’s not doing much for them.  Just like Optum it’s a bunch of algorithmic formulas (and hey maybe they licensed some of those algos from Optum) to “score” and cut costs and access.  Here’s what happened one time a while back when Cigna and most all other health insurers licensed United Healthcare (Ingenix, now named Optum) algorithms, lawsuits.

Cigna Legal Case With Ingenix Flawed Formulas for Out of Network Payments Allowed to Proceed Under ERISA, Can’t Avoid the Claims…

Our CMS is being run today by Quant mind sets and there’s like no changing it as they “think” all this quantitation is going to save the day.  It will deny access and drugs at times though.  As a matter of fact, Cigna is still on the hot seat for quality issues and currently can’t sell any Medicare Part D plans as CMS has them sanctioned.

I think there’s more that than the book cover myself as there’s this big merger with Anthem trying to take place as well and when you buy a Cigna plan now, you get another insurer, United Healthcare, under their OptumRX subsidiary to be your pharmacy benefit manager.  image

CMS Sanctions Cigna-No More Selling Any New Medicare Advantage Policies Until Algo Problems Denying Medical Coverage and Prescription Denials Are Fixed

Cigna was one of the first companies that started using software to analyze and determine your current state of mind over the phone with their customer service centers and they just about do that now, so be aware when you use the call centers for customer service, that your state of mind is being actively scored and maybe that data gets sold to some behavioral business too.

Insurers Certainly Like Consumer/Business Healthcare Apps: Subsidiary of Blue Cross Rolls & Couple Others Out $20 Additional Million in Funding to Audax First Backed by Cigna & Cardinal Health

A few years ago Cigna increased their Medicare HMO business by purchasing another HMO called Spring.

Cigna Buys HealthSpring Inc For $3.8 Billion, Who Bought Bravo Medicare HMO Who Had Profits of a Billion in 2010-Subsidiary Watch

It’s going to be interesting to see how the insurance mergers and all these “managed care” algorithms all come into play and you can look forward to more flawed data as they have built massive data lakes and the bigger the lakes, the more errors you get. I addressed that a couple years ago. 

Health Insurance Business Is Driving Itself Off a Cliff & Doesn’t Know When to Stop With Collecting, Analyzing and Processing Non Relevant Data With Little Or No Impact On Giving Good Care..

It is also interesting to note that HHS Healthcare.Gov CEO is also touting Cigna as expanding their ACA insurance polices for sale, this of course since United Healthcare is pulling out of all but 3 states.  Keven Coulihan from Healthcare.Gov was also a former Cigna Healthcare executive, so more cronyism there as well.  I’ve kind of laughed at wondering when the co-marketing with Cigna and United Healthcare might begin on ACA and maybe even other policies as if Cigna gets the sale, then United Healthcare shares in the money as the pharmacy benefit manager.  By the way, you should look and see that United Healthcare/OptumRX revenue stream is making more money than their 3 insurance revenue streams and appears to be going back to their roots with making a lot of money with drug companies, how the company got started in the late 70s.  United sold the PBM a drug company who sold it to to Express Scripts (who I’m sure still uses Optum Algos today) a year later.  So co-marketing now so OptumRX can make even more money on pharmacy benefit management?  BD

United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups

BLOOMFIELD, Conn.--(BUSINESS WIRE)--The nation’s health care system is moving from volume to value, yet it remains fragmented and complex. Health care providers are facing increased pressure to move from fee-for-service to value-based payment, yet current market solutions to accelerate this journey have been criticized as too rigid to meet complex provider needs. Cigna (NYSE: CI) has partnered with health care providers for many years to help them align their financial incentives with patient health outcomes, resulting in joint success through shared risk.

The new company, CareAllies, Inc., will deliver the systems, capabilities and management services that providers need to be successful under a variety of value-based and risk-sharing models across the value-based reimbursement spectrum. CareAlliesimage will offer services to help ease providers’ administrative burden across payers and can even help providers launch and manage their own health plans.

The new CareAllies will combine assets from Cigna, Cigna-HealthSpring’s management services division for independent physician associations (IPAs), and QualCare Alliance Networks, Inc. (QANI), which Cigna acquired in 2015. It will leverage these companies’ extensive histories of successful and innovative provider collaborations. Dr. Julian Harris has been named president of CareAllies, Inc., which will operate as a wholly-owned subsidiary of Cigna.

CareAllies is similar to UnitedHealth Group Inc.'s health care services subsidiary, Optum Inc., said Vishnu Lekraj, senior equity analyst at Morningstar Inc. in Chicago.


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