Cigna and Trinity Health sign off on multiyear deal after months of negotiations and a disruption of coverage.
Cigna and Trinity Health of New England have struck a multiyear deal after months of contentious negotiations that left patients out of network.
Cigna’s original contract with Trinity that covered Mount Sinai Rehabilitation Hospital, St. Francis Hospital, and Trinity Health of New England Medical Group providers in Connecticut expired on January 1.
The new deal, which started March 1, applies to those facilities as well as St. Mary’s Hospital in Waterbury and Johnson Memorial Hospital in Stafford, which have agreements that do not expire until April 30, according to a report from the Harvard Business Journal.
While full details of the agreement were not released, this new deal will extend coverage to all of Trinity Health’s facilities in Connecticut.
Why It Matters
Payer and provider negotiations have become more contentious as providers face rising health costs. Providers are pushing back against payers to cover these costs as payers are feeling the pressure to curtail premiums.
And, as in this case, this can mean a disruption in coverage for patients while the two parties work on an agreement.
“We worked diligently to negotiate an agreement that covers the true cost of the care we provide—which is critical to ensuring our Regional Health Ministry can continue to invest in the medical staff, care innovations, and health programs our community expects and deserves, because Health Comes First,” Trinity said in an announcement.
“While we wish this agreement could have come without going out of network with Cigna, we look forward to continuing our partnership.”
Trinity’s announcement addressed the two-month-long disruption of coverage for their patients and encouraged them to contact the number on the back of their Cigna insurance card to ensure they will be covered at in-network rates as they resume scheduling appointments.
As more payers and providers continue to battle, we may see more providers going out of network temporarily, or permanently, as a way to even the playing field.
Trinity’s Push For More Data
In January Trinity Health also struck a multiyear deal with Anthem Blue Cross Blue Shield of Connecticut. This agreement mentions that the two would collaborate on several initiatives “including advanced data connectivity and value-based care models designed to improve health outcomes and better control costs for Trinity Health patients covered by Anthem health plans.”
The announcement on Trinity’s website stated that the two organizations will incorporate the Epic Payer Platform into regular operations that will work to streamline patient data flow, among several other operational efficiency goals.
“Our shared focus on simplifying the healthcare ecosystem, removing barriers to care, and overcoming administrative hurdles for doctors and clinicians is a particularly rewarding aspect of our relationship with Trinity Health,” said Anthem Vice President of Networks Jordan Vidor.
Trinity Health’s newest deal with Cigna did not include collaborative goals such as these. Harvard Business Journal reported that Kaitlin Rocheleau, a spokeswoman for Trinity Health, said the new agreement with Cigna "does not yet include collaboration on data connectivity and value-based care models, but we intend to continue those discussions."
Healthcare C-suite execs flocked to ViVE this week in Los Angeles.
The 2024 ViVE conference in Los Angeles is sparking innovative conversations. AI and cybersecurity were among some of the big topics, and health leaders are looking for more action and ROI in these spaces. Nursing was also top of mind, with healthcare executives talking about how they can improve workflows, reduce stress, and boost patient care
The recent proposed MA rate cuts could cut into payers’ profits, and payers are fighting back.
Medicare Advantage (MA) has long been a favorite of payers, often doubling their profits. But will potential rate cuts send payers fleeing out of the program?
Originally, CMS expected MA rate cuts to drop about 0.16%. But a recent study from the payer lobbying group Better Medicine Alliance, which represents payers in Medicare, found that if the proposed rates are approved, next year MA cuts could drop by 1% per month per beneficiary.
Payers are arguing that CMS didn’t consider higher utilization, which has increased considerably among seniors.
So where did the CMS go wrong?
The Growth Factor
Insurers are saying CMS failed to take the growth factor—and how the growth rate is affecting payers’ spending—into consideration when calculating the proposed rates.
With increased costs at play, the growth factor is vital in calculating the overall MA reimbursement rate. For 2025, regulators calculated a growth factor of 2.4%, but realistically, it’s leaning more towards 4-6%, according to the Berkeley Research Group analysis.
This change is likely to affect premiums and supplemental benefits for members. Since the second quarter of last year, MA saw an uptick in care utilization, especially in outpatient care such as hip and knee surgeries/replacements. With this trend continuing, payers are seeing a dip in their profits from premiums.
The Lobbing Effort
Now, payers are urging regulators and administration officials to pressure CMS to change the proposed cuts before the finalization goes through on April 1.
Although this may not spur the lobbying efforts we saw by payers last year, it will however still most likely include a digital ad strategy to oppose the newest cuts. American seniors have already taken to organizing meetings on Capitol Hill to protest the changes, saying that they don’t want their coverage to change.
The Earnings Outlook
For payers who lean hard into the MA market, the proposed cuts could ruffle some feathers.
Humana, which brings in a large portion of its revenue from Medicare, brought forward an internal analysis that said the cuts would cause its funding to drop by 1.6%. Cetene (also a MA-heavy insurer) complained the cuts would drop its rates by 1.3%.
The cuts will certainly have effects, but probably not as intensely as payers are anticipating. The fact is that only two insurers, CVS Health and Humana, are actually looking at a cut in their 2024 earnings outlook coming into this fiscal year, citing higher medical costs.
But these cuts are not exactly spelling doom for payers in the MA market, CMS says.
CMS stated that from 2024 to 2025 MA payments from the government to MA plans are expected to increase on average by 3.7%, or over $16 billion.
MA may not be the cash cow for payers that it used to be. Although the proposed rates will likely be lowered, payers are still likely to intensify their coding practices, up premiums, and drop some benefits, hurting beneficiaries who are comfortable in their current plan.
If it stands, the final rule could send payers exiting what they consider an underperforming market.
Will the dip in profits cause some payers to jump the MA ship altogether?
Comments on the matter are due March 1, so we’ll check back in April.
Employers are seeking claims data, but payers are refusing.
Employers are at odds with payers over their cost and claims data.
Claiming that insurers consistently block access to this data, employers are saying it is increasingly difficult or even impossible to understand what they are being charged in their health plans. Despite a federal mandate that restricts health plans from limiting access to this valuable data, employers are still struggling to obtain it from insurers, turning to lawsuits as a last resort.
In 2021 The Consolidated Appropriations Act (H.R. 133) required employer sponsored health plans and health insurance companies to affirm by the end of 2023 that their contracts don’t contain “gag clauses” that would restrict the handover of information about the cost or quality of medical services.
But it hasn’t been that simple.
What’s happening?
As employers begin to use hospital and health plan data to compare prices and create well-structured plans, some questions are rising, and payers aren’t answering. Much of the time, employers and plan sponsors say that insurers are refusing to hand over their claims data, leading to federal investigations.
This dynamic has led to a push from Congress and some states to stiffen the legal requirements to ensure health plans have access to their cost and claims data.
The argument employers, and specifically member benefits directors, are making is that their plans need to access their claims data to check that payments made to medical providers are accurate, which can sometimes far exceed the actual billed amounts.
Some insurers are arguing that they do provide information about their plans, but only when specifically authorized by the state.
According to an article by Bloomberg, Health Care Service Corporation (HCSC) discussed the possibility of allowing a data warehouse to provide the information to employers, but that would be accompanied by a whopping $20,000 price tag. That’s not the answer employers are looking for.
In June of last year Kraft Heinz filed a complaint that Aetna “breached its fiduciary duties and engaged in prohibited transactions” through permitting undisclosed fees and processing medical and dental claims without human review. Aetna never commented on the complaint, and the matter was moved to arbitration.
Do unresolved complaints turn into lawsuits?
In December, labor unions that were contracted with Elevance Health sued the insurer, claiming the giant did not allow employers access to their own claims data and then charged the plans higher rates than what it negotiated with hospitals.
Employers are fed up with paying the higher fees. Studies show that when employers do have access to this data, they are able to significantly reduce their costs.
What does this mean for hospital and health system leaders?
And as we know in healthcare, reducing those benefit costs are important to hospital and health system leaders. As labor costs in general are weighing heavy on CFOs, they are now playing a bigger role in healthcare benefit decisions.
The breadth of information they consider in making health plan design and purchasing decisions has expanded well beyond monthly premiums and cost sharing, and claims data access could play an important part in that decision making.
In fact, a study by NIH that examined employers' access to claims data stated: “Employee health claims data offer a unique opportunity for employers to yield additional savings in the long run through implementation of wellness and other targeted programs and have a lasting, positive impact on their employees.”
As the struggle continues, the payer landscape could see more lawsuits like the Kraft/Aetna case in the future; and maybe even with a hospital or health system. Will the action and complaints from employers be enough to get insurers to loosen their grip on their data?
Gold Carding is expanding across the country with several states already implementing the legislature in some way.
The states are fighting back against prior authorization woes. In Janaury, the Biden adminstration announced new rules to help streamline the PA process, but states are taking it even further with Gold Carding legislation. Studies have shown that prior authorization has been a big pain point for health systems, and is contributing to things like worker burnout and higher costs.
Check out the infographic below to see how prior authorization delays and denials are affecting health systems, as well as what this legislation means for payers.
How do you balance financial priorities with quality patient care?
Private equity accounts for over 30% of all hospitals in rural areas, which can make a big difference in how an organization operates. How do you balance financial priorities with quality patient care? For one CEO, it’s a no-brainer.
David Schreiner is the CEO of Katherine Shaw Bethea Hospital in Dixon, Illinois, and he sees the friction here. But he also knows that quality patient care is not an item he will compromise on.
“We're an independent rural hospital. We have no ownership, no one is receiving dividends or investment returns from our organization,” he said in an interview with HealthLeaders.
This is the second setback in what would be a $2.5B sale.
Less than 12 hours before regulatory hearings were set to take place, Blue Cross halted the sale to Elevance, for the second time this year. Citing regulatory and stakeholder concerns, BCBS has paused the sale for what would have been the biggest healthcare deal in the state’s history. BCBS operates in all 50 states and their Louisiana operation is the state’s largest insurer with 1.9 million members.
"It is clear that our stakeholders need more time and information to understand the benefits of the changes we have proposed," Blue Cross said in a statement. "This is why we have decided to again pause the process in our proposed transaction with Elevance Health.”
For the sale to go through BCBS would have to reorganize itself as a for-profit entity, which isn’t sitting well with state regulators. Worried the deal could present anti-competitive issues and raise premiums, state regulators also question how the proceeds would be split amongst policyholders.
BCBS proposed a reorganization plan back in December last year, but was unsuccessful in swaying stakeholders.
“I’m glad it was shelved,” Senate Insurance Committee Chairman Kirk Talbot, R-River Ridge said. “That process had a lot of problems.”
BCBS has argued for the deal, stating that it would be the best way to navigate a rapidly changing healthcare landscape. The payer says the deal could allow more financial resources and flexibility to operate and expand in Louisiana, and would better member experience and benefits.
In order to go through, the deal would require approval from Louisiana’s insurance commissioner and two-thirds of BCBSLA policyholders.
The sale was also largely unpopular amongst healthcare and physicians’ groups, the state medical society even sending an open letter to policyholders urging a “no” on the deal.
Meanwhile, Elevance says it is supportive of BCBS’s decision to withdraw the plan at this time. "We will continue to meaningfully engage community members who are truly interested in better health outcomes and more affordable health care," Elevance officials said. "We remain committed to this partnership.”
Indiana-based Elevance, which operates BCBS plans in 14 states, is one of the largest insurers in the country. With its own telehealth platforms, pharmacy benefits manager and specialty physician practices, BCBS was hoping these items would help it provide better services to its Louisiana members.
If the sale is completely scraped, Elevance could scope out other potential partners.
However, during two legislative hearings about the acquisition several questions were raised concerning Elevance. Concerns over whether or not Elevance would be able to retain the 2,500 Louisiana based employees, as well as confusion over which policy holders were allowed to vote on the sale were two major pain points.
Stakeholders that have been closely following the controversial deal seemed divided on whether or not BCBS would come back with another revised plan.
The deal has been controversial from the beginning, but will it be able to gain the lawmaker support it needs to proceed in the future?
Federally qualified health centers (FQHCs) are using digital health tools to improve patient experience and care coordination.
FQHCs, RHCs (rural health centers) and CHCs (community health clinics) serve millions of Americans as their sole form of healthcare access. Through Telehealth and digital health tools, providers are addressing care issues that typically end up creating higher costs and poorer patient outcomes. The tech is ultimately helping providers improve chronic care management and address social determinants of health.
For example, the Massachusetts League of Community Health Centers, which serves 52 CHCs, 300 sites and 1 million patients, is using an RSA grant to implement a technology that keeps track of when and where patients receive care. The platform, developed by Bamboo Health, sends real-time notifications to care teams when a patient visits another provider outside of the system. This then enables the care team to access admission, discharge and data transfers.
Since the pandemic unions and general workforce unrest have been rising.
CEOs must be prepared to deal with components in their organization that can spark unionization. Some top reasons for union formation are burnout, administrative burden, and understaffing. Union or no union, CEOs must know where their organizations' vulnerabilities lie, how they can approach the issues that are present, and where and how they can be flexible in their solutions.
A number of states are looking to Medicaid for coverage.
As of March 2023 16.9M people were disenrolled from Medicaid, and rates for disenrollment have varied widely across each state. Meanwhile, more states are pushing for Medicaid expansion. Florida, Georgia, North Carolina and Texas have recently made some moves in this space to acquire coverage.