Deana Bell

The Milliman Medical Index (MMI) estimates annual healthcare costs for people covered by a typical employer-sponsored health plan.

Approximately 42% of the U.S. population has obesity, and the demand for weight-loss solutions has never been higher. The glucagon-like peptide-1 (GLP-1) receptor agonist drug class, used to manage type 2 diabetes, is also proving to be highly effective for the treatment of obesity and has the potential to meet this growing need. Approved medications include Wegovy, which is a higher strength version of diabetes drug Ozempic. To properly manage opportunities and challenges surrounding these… Show more

Approximately 42% of the U.S. population has obesity, and the demand for weight-loss solutions has never been higher. The glucagon-like peptide-1 (GLP-1) receptor agonist drug class, used to manage type 2 diabetes, is also proving to be highly effective for the treatment of obesity and has the potential to meet this growing need. Approved medications include Wegovy, which is a higher strength version of diabetes drug Ozempic. To properly manage opportunities and challenges surrounding these drugs, payers should take some key actions related to the coverage of GLP-1 prescriptions for weight loss. This paper provides a thoughtful care management framework with robust medication counseling and education, which are both considered essential for payers and relevant healthcare stakeholders if they choose to cover these medications.

Our discussion includes the following topics:

Current medications available
Clinical distinction
Media attention and market demand
Current coverage status by U.S. market segment
Importance of medication adherence and persistency
Potential for prescription benefit spend waste
Utilization and care management impact
Strategies for payers Show less

Gennev recently commissioned Milliman to conduct an analysis to quantify the medical and pharmacy costs and utilization of U.S. women aged 45 to 54 who have employer-sponsored health insurance and have been diagnosed with or are being treated for menopause or perimenopause. The report is intended to identify the healthcare economic profiles of women in menopause who have used specific types of therapy, including hormone-replacement therapy, nonhormonal therapy, or no therapy at all for their… Show more

Gennev recently commissioned Milliman to conduct an analysis to quantify the medical and pharmacy costs and utilization of U.S. women aged 45 to 54 who have employer-sponsored health insurance and have been diagnosed with or are being treated for menopause or perimenopause. The report is intended to identify the healthcare economic profiles of women in menopause who have used specific types of therapy, including hormone-replacement therapy, nonhormonal therapy, or no therapy at all for their menopause symptoms. Administrative healthcare claims data was summarized from Milliman’s nationwide commercial data set for calendar year 2021 across seven populations. Show less

Each year, the Milliman Medical Index analyzes insurance claims to estimate how much money families—and their employers—can expect to spend annually on healthcare.

Considerations for applying Medicare pharmacy price concessions at the point of sale

As part of the Trump administration’s effort to reduce drug prices, HHS and CMS each published potentially significant rules that focus on drug costs in Medicare Part B and Part D.

We modeled the impact on risk scores if services are avoided during a code capture period.

The need for access to new information, emerging standards of practice and diverse and intellectual discourse remains. Read about how this content was delivered virtually to participants.

As the United States continues to struggle and question the high cost of health care, the fact that drug manufacturers issue rebates to prescription benefit managers (PBMs) and health plans (payers) has moved from industry-insider information to the public spotlight. In light of this, payers have considered sharing their rebates with the consumer at the point of sale (POS). The Society of Actuaries’ (SOA’s) Initiative 18|11 is exploring all areas of the U.S. health care system to find ways to… Show more

As the United States continues to struggle and question the high cost of health care, the fact that drug manufacturers issue rebates to prescription benefit managers (PBMs) and health plans (payers) has moved from industry-insider information to the public spotlight. In light of this, payers have considered sharing their rebates with the consumer at the point of sale (POS). The Society of Actuaries’ (SOA’s) Initiative 18|11 is exploring all areas of the U.S. health care system to find ways to control spending. One of these areas is prescription drug rebates. This article examines how rebates at the POS might affect the consumer. Show less

The employer-sponsored drug benefit landscape includes a wide range of plan designs; high-deductible health plans (HDHPs) as well as copay and/or coinsurance plans are among available benefit options. While a creative array of plan designs offers flexibility to members, it creates new challenges for plan sponsors.

Ambulance rides are a necessary and important service for patients in emergency situations, but as most people who have taken an ambulance can attest, it is a costly service even with insurance coverage. As the public discourse continues to focus on the high cost of healthcare, an increasing number of payers and healthcare organizations are turning to ride-sharing services such as Uber or Lyft for non-emergency medical transportation.

On February 6, 2019, the Trump Administration published a proposed rule to remove the safe harbor for drug manufacturer rebates under the federal Anti-Kickback Statute. This proposed rule may be effective as soon as 2020, and would have major and broad impacts to federally funded prescription drug programs, especially Medicare Part D.

In 2017, many changes came to Medicare Advantage (MA) risk adjustment as the transition continued from Risk Adjustment Processing System data to Encounter Data System data. Based on the Advance Notice Part I from the Centers for Medicare and Medicaid Services, released at the end of December 2017, the payment year 2019 will also see complexity and challenges to MA organizations.

Direct and indirect remuneration (DIR) has grown to be an important provision which Medicare Part D plan sponsors use to reduce their claim liabilities and thus member premiums. As DIR continues to increase, it is important for Part D sponsors to consider the effect of potential regulatory changes on plans’ bottom lines and operations.

The Medicare Advantage market is currently in the middle of a multi-year transition from the existing Risk Adjustment Processing System (RAPS) to the new Encounter Data System (EDS) for calculating risk scores. CMS has stated that ultimately EDS will be the sole diagnosis data source for Medicare Advantage organizations' risk scores and revenue. Dave Dillon, FSA, MAAA, interviews Deana Bell, FSA, MAAA, on the topic and they discuss how the transition has shown to have a financial impact on… Show more

The Medicare Advantage market is currently in the middle of a multi-year transition from the existing Risk Adjustment Processing System (RAPS) to the new Encounter Data System (EDS) for calculating risk scores. CMS has stated that ultimately EDS will be the sole diagnosis data source for Medicare Advantage organizations' risk scores and revenue. Dave Dillon, FSA, MAAA, interviews Deana Bell, FSA, MAAA, on the topic and they discuss how the transition has shown to have a financial impact on Medicare Advantage revenue and how actuaries are well equipped to help. Show less

Transition from RAPS to EDS as the source of data for Medicare Advantage risk scores.

Milliman completed a study of how the transition from Risk Adjustment Processing System (RAPS) data to Encounter Data System (EDS) data is affecting the payment year (PY) 2016 risk scores and revenue for Medicare Advantage (MA), also known as Medicare Part C. Fifteen Medicare Advantage organizations (MAOs) participated in the study, reflecting a cross-section of small and medium size organizations and representing over 900,000 members in 154 plans. The study relied on the revised EDS MAO-004… Show more

Milliman completed a study of how the transition from Risk Adjustment Processing System (RAPS) data to Encounter Data System (EDS) data is affecting the payment year (PY) 2016 risk scores and revenue for Medicare Advantage (MA), also known as Medicare Part C. Fifteen Medicare Advantage organizations (MAOs) participated in the study, reflecting a cross-section of small and medium size organizations and representing over 900,000 members in 154 plans. The study relied on the revised EDS MAO-004 files that the Centers for Medicare and Medicaid Services (CMS) released late in October 2016. Show less

During the transition to using Encounter Data System (EDS) data files, Medicare Advantage organizations must be knowledgeable about EDS, understand the impact of the transition on revenue, and monitor and review EDS submissions closely to ensure their revenue will not be negatively affected.