TexHealth

Value-Based Care Advances Despite Financial, Data, and Engagement Challenges

At the recent NAACOS conference, healthcare leaders explored the ongoing shift to value-based care, which emphasizes patient outcomes and cost reduction. Leaders like Dr. Geoffrey Nicholson and Dr. Jamie Reedy noted that while this approach improves care quality, challenges remain in data integration, financial sustainability, and specialist engagement. Although private insurers have made strides with value-based agreements, aligning these models with specialty care remains complex. The COVID-19 pandemic highlighted the need for flexible payment structures, as many health systems rely on commercial payers to support government-funded programs. Moving forward, better data integration, patient education, and collaborative partnerships are essential for making value-based care successful and sustainable.

Comments from our CEO James (Jim) Rodriguez, FACHE:
“Having been through the advent of HMOs and the wars they created decades ago I know the hurtles that confront any change initiative, especially in healthcare delivery. However, value-based care is not unlike what has been done in the recent and not-so-recent past. But switching the risk from payor to provider has been especially prickly for some. The old adage thrown at payors of withholding care to save on cost will begin being used in the delivery field and many providers know that and dread that possibility. None, I’m sure would ever even consider that, but the dollar has a mesmerizing pull that even the most stalwart may fall victim to. Given these temptations there must be a way to share the risk so not one party (payor or provider) are left holding the proverbial bag. Sharing risk among the best and brightest minds will be fertile ground for gains in health and finances.”

Read the full article by Hayden E. Klein by clicking the link below.

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Rising Insurance Premiums in 2025 Trace Back to Affordable Care Act's Unintended Consequences

Health insurance premiums are set to jump 7% in 2025, continuing a trend of rising costs that has frustrated consumers. Surprisingly, the roots of today’s escalating premiums can be traced back to the Affordable Care Act (ACA) of 2010. Despite its original goal of lowering healthcare expenses, the ACA triggered a wave of market consolidation, leading to fewer competitors and higher prices. Major insurers and healthcare systems have merged into powerful entities, making it easier to raise costs. To reverse this trend, the article by Forbes calls for a transparent, competitive healthcare model that ties pricing to quality outcomes.

Comments from our CEO James (Jim) Rodriguez, FACHE:

This is a very interesting article. I was surprised to read its claim that the ACA has to take responsibility for the high rate of health insurance and healthcare in general. I would like to say it’s not true because of the successes of the ACA but when I think about it, I see where the author is coming from. In the small group market in Texas there are only 2 fully insured small group carriers! (I wrote about this recently). They are United Healthcare and Blue Cross Blue Shield. Luckily in Central Texas there is also Baylor Scott & White and other regions have similar small players like them. Humana dropped out of small group, Cigna and Aetna don’t want small group and there is no ACA SHOP plans available in Texas. So, with so little competition it’s no wonder the rates are going so high. Combine that with the easily attainable cost sharing federal subsidies for individual coverage on the exchange, it’s no wonder rates are going up. While cost-sharing subsidies have helped many people afford coverage, they can also contribute to higher premiums. As insurers anticipate receiving more subsidy payments, they may increase premiums accordingly.

To read the full article by Forbes, check out the link below.
https://lnkd.in/e7V_iF73

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⚡️Breaking News in the Health Insurance Industry ⚡️
4 nonprofit health systems have launched new health plan, Longitude Health

Comments from our CEO James (Jim) Rodriguez, FACHE:

Ok health insurance carriers…pay attention! Four (count them, FOUR) health systems have banded together to offer a new health plan called Longitude Health. The four owners, investors, operators are Baylor Scott & White Health, Memorial Hermann Health System, Novant Health and Providence. It appears that these delivery systems decided to take the plunge because of the carrier turmoil in their respective regions. For example, in Central Texas there are now only 2 major small group carriers with any real gravitas. They are United Healthcare and Blue Cross Blue Shield with Baylor Scott & White health plan trying to make inroads. And while the literature is shouting that rate increases for 2025 are going to be in the mid-single-digits we are seeing double digits across the board. This new entre may not bode well for the majors.

To read the full article by Modern Healthcare, visit the link below.
https://lnkd.in/g3EPYn5Y

Here we are at another Legislative Session and we are going great guns! Our goal is to modify the statute that created TexHealth so that TexHealth does not have to have County Commissioners Court approval. When TexHealth was first created as a health plan for small business it made some sense for the County Commissioners to be involved in oversight. Now however, it is not needed and TexHealth should be available statewide to those who need the help paying for their health insurance premiums. We have proposed language to modify the original statute and we just need the Legislators to approve it. This will take visits to many offices to explain the rationale. If we are successful in getting the change we will also need more funding to go statewide. That is in the works too! Keep your fingers crossed.

https://www.beckershospitalreview.com/payer-issues/metros-with-the-highest-uninsured-rates-by-state.html?origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newsletter&oly_enc_id=7443D9880812F1R

Metros with the highest uninsured rates, by state The McAllen-Edinburg-Mission metro area in Texas has the highest uninsured rate at 35.7 percent when compared to other metro areas in the U.S., according to a ranking from 24/7 Wall St.

https://www.informnny.com/abc50-now/lidocaine-solution-sold-in-the-u-s-recalled-could-lead-to-serious-complications/

Lidocaine solution sold in the U.S. recalled, could lead to serious complications UNITED STATES (WWTI) — Teligent Pharma, Inc. is voluntarily recalling one lot of Lidocaine HCl Topical Solution 4%, 50 milliliters which was sold in a screw cap glass bottle at the user level. The …

https://www.beckershospitalreview.com/pharmacy/10-most-expensive-drugs-in-the-us-3.html?origin=CFOE&utm_source=CFOE&utm_medium=email&utm_content=newsletter&oly_enc_id=7443D9880812F1R

10 most expensive drugs in the US Spinal muscular atrophy treatment Zolgensma is the most expensive drug in the U.S., with a 12-month supply costing $2.1 million.

https://www.beckershospitalreview.com/lab/owner-of-texas-lab-company-pleads-guilty-to-73m-medicare-fraud-scheme.html?origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newsletter&oly_enc_id=7443D9880812F1R

Owner of Texas lab company pleads guilty to $73M Medicare fraud scheme Leonel Palatnik, 42, co-owner of Dallas-based Panda Conservation Group, a medical lab company, pleaded guilty Aug. 31 for his role in a $73 million Medicare kickback conspiracy, according to a Justice Department news release. Mr. Palatnik paid kickbacks to a telehealth company in exchange for orders...

https://www.beckershospitalreview.com/rankings-and-ratings/50-states-ranked-from-healthiest-to-unhealthiest-090221.html?origin=CFOE&utm_source=CFOE&utm_medium=email&utm_content=newsletter&oly_enc_id=7443D9880812F1R

50 states ranked from healthiest to unhealthiest Massachusetts is the healthiest state in the U. S. , according to the most recent annual ranking from Sharecare, a digital health company, and the Boston University School of Public Health.

https://www.beckershospitalreview.com/pharmacy/5-recent-drug-device-recalls-4.html?origin=PharmacyE&utm_source=PharmacyE&utm_medium=email&utm_content=newsletter&oly_enc_id=7443D9880812F1R

5 recent drug, device recalls Medical device and drug recalls, whether voluntary or mandated by the FDA, ensure patient safety. Here are five reported to the FDA in August:

https://www.beckershospitalreview.com/finance/illinois-governor-signs-bill-requiring-hospitals-to-provide-cheaper-care-to-uninsured.html?origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newsletter&oly_enc_id=7443D9880812F1R

Illinois governor signs bill requiring hospitals to provide cheaper care to uninsured Illinois Gov. J.B. Pritzker on Aug. 25 signed a bill that will require hospitals in the state to provide cheaper care to those who are uninsured.

AI Blood Test Proves Useful in Lung Cancer Detection

https://www.medpagetoday.com/pulmonology/lungcancer/94210?xid=nl_mpt_DHE_2021-08-26&eun=g1326083d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%20Top%20Cat%20HeC%20%202021-08-26&utm_term=NL_Daily_DHE_dual-gmail-definition

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https://www.beckershospitalreview.com/payer-issues/cms-urges-medicare-advantage-plans-to-relax-some-prior-authorization-requirements.html?origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newsletter&oly_enc_id=7443D9880812F1R

CMS urges Medicare Advantage plans to relax some prior authorization requirements CMS is encouraging all Medicare Advantage organizations and Medicare-Medicaid plans to waive or relax certain prior authorization requirements amid the COVID-19 surge.

More and More U.S. Kids Being Diagnosed With Diabetes

https://www.medpagetoday.com/primarycare/diabetes/94183?xid=nl_mpt_SRCardiology_2021-08-24&eun=g1326083d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=CardioUpdate_082421&utm_term=NL_Spec_Cardiology_Update_Active

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Mom's Obesity During Pregnancy Linked to Colon Cancer in Offspring

https://www.medpagetoday.com/obgyn/pregnancy/94179?xid=nl_covidupdate_2021-08-24&eun=g1326083d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=DailyUpdate_082421&utm_term=NL_Gen_Int_Daily_News_Update_active

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https://www.medpagetoday.com/infectiousdisease/vaccines/94059?xid=nl_mpt_DHE_2021-08-22&eun=g1326083d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=Weekly%20Review%202021-08-22&utm_term=NL_DHE_Weekly_Active

First Tick-Borne Encephalitis Vax Approved in the U.S.

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Herbal Weight-Loss Supplement Tied to Severe Liver Damage

https://www.medpagetoday.com/gastroenterology/generalhepatology/94075?xid=nl_mpt_SR_specialty_update_2021-08-19&eun=g1326083d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=SpecialtyUpdate_Cardiology_08192021_%7BOpt:0064z000024XxhQAAS%7D&utm_term=NL_Spec_Cardiology_Update_Active

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Fertility and Fatherhood: Don't Wait Too Long

https://www.medpagetoday.com/urology/urology/94080?xid=nl_covidupdate_2021-08-18&eun=g1326083d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=DailyUpdate_081821&utm_term=NL_Gen_Int_Daily_News_Update_active

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