1115 waiver approved | Pricing driving market share | Hilary Haycock

There was some big news over the weekend with the approval of Medi-Cal’s 1115 waiver, and the fact that no news was made by technology failures in insurance exchanges across the country – and California – as the third Open Enrollment period launched.

These and other topics are what we’re watching this month – and what we’ll be talking about this Friday at our 2015 Southern California State of Reform Health Policy Conference.

DJ 5 Things Signature


1. CMS approves narrowed 1115 waiver

CMS and California’s Department of Health Care Services reached agreement on California’s recently submitted 1115 waiver.  It provides $6.2 billion in federal funds over five years to support 6 core areas of work, ranging from a global payment methodology to independent assessments of network adequacy in Medi-Cal managed care.  The state formally asked for “15 to 20 billion in Federal funds” down from its original scope of $25bn. I think it’s hard to see a grant of $6.2bn as a let down, but with sights set so much higher, some may well see it that way.

At our conference this week, this will be one of the primary topics of discussion.  We have multiple panels lined up, and even a keynote on Medi-Cal if you’re interested in learning about what this means for California. 


2. Video: Hilary Haycock, Harbage Consulting

Hilary Haycock, President and CEO of Harbage Consulting, offered a few of her thoughts on California’s waiver request when we sat down with her a few weeks ago.  So, we thought it appropriate to feature some of her comments about the state of California health care, and listen in on what trends she’s watching in the market today.

As always, you can check out our complete “What They’re Watching” series for commentary from other thought leaders in California health care — and up and down the west coast. This series has become a unique collection of what senior leaders in health care are tracking today, organized concisely in a way you won’t find anywhere else.

Moss Adams conference

3. Exclusive: Mark Baum, CEO Imprimis Pharmaceuticals

You may have seen Imprimis Pharmaceuticals in the news lately for its challenge to Turig’s five thousand percent price increase of the drug Daraprim. In fact, the rising cost of pharmaceuticals seems to be a bit of a hot issue for everyone lately. In an exclusive interview with State of Reform, Mark Baum offers his insights on some innovative and potentially disruptive solutions. 

Mark Baum is one of our list of speakers lined up to join us at our conference this Friday.  He’ll be on the 1:45 panel “Dialog on System-level Disruption” with Providence Ventures Senior Associate Christina Pluta and Prof. Walter Zelman, Chair of the School of Public Health at Cal State University Los Angeles.  It’s the kind of cross-silo dialog that we love to feature (and sit in on!) – at our events.

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4. New NAIC network adequacy draft

The National Association of Insurance Commissioners (NAIC) is set to adopt a model law in November which will offer provisions for accurate provider directories, balance billing, and continuity of care in the states. The draft bill is the first update in nearly a decade and will serve as a model for all states to use during their 2016 legislative sessions. It will also guide HHS standards for 2017 plans.

The guidance may fuel what is already a strong dialog in the state on network transparency. Back in September, CAPG wrote a letter to DMHC proposing that the department enforce an All-Payer Claims Database and Multiplan Provider Directory. DMHC Director Shelley Rouillard enacted proposed undertakings in her Oct. 8 approval of the Blue Shield and Care 1st merger, the same day SB 137 was signed into law. But groups like the California Hospital Association have raised concerns that the penalties suggested in the bill may go too far.

5. Pricing to re-align commercial market share

A quick look at the preliminary rates reveals that in Los Angeles (region 15) Blue Shield PPO holds the second lowest Silver position with a monthly premium of $192. Last year, this spot belonged to Anthem. In LA (region 16), Health Net captures the second lowest Silver position at $200, a spot that Molina held in 2015. Blue Shield also holds the second Silver position in Orange County. But the new kid on the block, Oscar Health Plan, is a wild card offering plans in OC and partial LA counties.

This pricing realignment should lead to some shifting of enrollment in the commercial marketplace.  Organizations like these will be with us this Friday, and will be talking through what shifts like these mean for the commercial payer marketplace in California.