Substance Abuse and Behavioral Health – Front Line Intel Helping Drive Better Decisions

JibeHealth (

Treatment facilities that can work with winning insurers and adopt new business practices will position their businesses to increase their market share, during this changing environment.

Very few treatment owners are taking a conscious and proactive look at the approaching storm clouds on the horizon. Things such as compliant client acquisition, documentation of processes and scalability are taking a back seat to business as usual. It is estimated that less than 15% of treatment facilities nationally have adapted to the new health care business model. That is an astounding 85% that potentially won’t make it.  In many cases, these vanishing businesses are ignoring basic business principles out of pure ignorance, but many of them simply have a myopic view of their businesses as it relates to the overall market landscape.

Health insurance distributors and health insurers are also not exempt from business life cycles. In fact, since the healthcare overhaul occurred in our country with the enactment of PPACA 2010 (Patient Affordability Care Act; AKA “Obamacare”), dozens of insurers have called it quits.

Some of the losers like Assurant, saw an early demise, while others like United Health Care are seeing are showing signs of weakness.  On the flip side, winners like Anthem, Kaiser Permanente, Tenet Healthcare and new comers like Oscar are capitalizing and gaining rapid momentum.

Private hospital owners have been some of the biggest winners. As a result they have seen a 24% increase in profits in 2015. Mainly due to rebalancing of their business models to accommodate a wider range of insurance policies.

Although most insurers have had the advantage of being subsidized by the federal government, a level playing field has not been the cure for all insurance companies.  Insurance carriers have medical loss ratios that must be maintained at a lower proportion than premiums coming in from policyholders.  Like with any business when expenses (loss ratios / claims) accelerate revenues (premiums), cut backs are inevitable.

Since the Affordable Care Act took effect in 2010, insurers have had to deal with claims deprived of empirical data.  United Health Care has decided to stop selling individual insurance coverage through the exchanges resulting from these losses.  It is no mystery why the decision by UHC was made to only allow verification of benefits to be controlled by the policyholders, insurance agents or billing companies.  When losses are up, companies get creative and implement new procedures to help mitigate losses.  For UHC, it happens to be, becoming their own gatekeeper.

In the insurance company’s defense, they had no way of calculating this new risk. Think about it from a practical standpoint.  If your business started to see unexpected losses resulting from a vendor payment that was a large new item on your balance sheet, would you question it, or at least get in the weeds to get a better assessment of the loss? Most businesses would. As PPACA continues to integrate into our new healthcare system, every business related to health care is forced to rethink, reassess and reengineer their business models in order to stay in the game.

Another example, Highmark Inc. BCBS of Pennsylvania, recently filed a law suit against the federal government on May 17, 2016.  The company and some of its subsidiaries and affiliates are seeking to recover damages they believe are owed by the federal government’s failure to honor its contractual obligations relating its participation in the health care exchanges.  Highmark Inc. BCBS of Pennsylvania claims the federal government is refusing to pay the full amount that the risk corridor program for the calendar year 2014 (“CY 2014”) implies in the statute, regulation, and contracts which induced Highmark insurers to participate in the ACA marketplace.  The lawsuit states that Highmark is owed nearly $223 million, less any prorated amounts actually paid by the government, which was reported to be only $27.3 million by Centers for Medicare and Medicaid Services (CMS).  Reading between the lines, Highmark BCBS of Pennsylvania are seeing a bit higher medical loss ratios then what they anticipated.

Anthem on the other hand, has reported earnings better than expected and added 1 million new customers since the end of last year, many of which were Obamacare enrollees.  Earnings for Anthem came higher than expected.  They beat estimates by more than 10 cents per share, coming in at $3.46 for the first quarter.  The company expects revenues for 2016 to range from $81 billion to $82 billion, up from its previous estimate of $80 billion to $81 billion.  In addition, Anthem plans to finalize its merger with Cigna in the second half of this year.  The story seems a quite different than UHC, Assurant and Highmark, Inc. BCBS of Pennsylvania.

Insurance is simply “a promise to pay”.  A policy is nothing more than a contract between an insured and an insurer.  The business structure of insurance is a collection of more policies and premiums than actual payouts.  When the market rules change, courtesy of the federal government, insurers without question have to adjust their promises.

Questions We Must Ask Ourselves

As these promises (insurance contracts) continue to evolve over the next 2-4 years, will your business parallel these changes?

As insurance companies modify their revenue models and continue to balance out their medical loss ratios in the new environment, will your business modify its revenue model to adapt?

So what is the solution for treatment facilities?  Change is never comfortable, no matter how big or small your business is.  Adopting new business practices and processes such as upgrading customer and lead management tools, auto dialer software, insurance rebalancing, state rebalancing and spreading levels of care will result in a different outcome.  As the saying goes; “The definition of insanity is doing the same thing over and over and expecting a different result”.

Historically, disruption is found in every single US business sector since WWII. Profitability and growth proceeding the disruptive era has always been far greater then all prior time periods leading to disruption. Why? Simply because the market has not gone away rather the number of players shrunk, leaving more profits for fewer players.

Now is the chance for treatment providers to take full advantage of the opportunity laid in their path.

Actionable Recommendations (we are closely monitoring these insurers medical loss ratios in the coming months)


  • Anthem, MLR Balance Stable (Gaining traction and playing a big part in the carrier consolidation. Have remained healthy in terms of market share. Reports show a stable MLR balance.
  • Aetna, MLR Balance Stable (Merged with Coventry and Humana in 2015. Reports show a stable MRL balance.)
  • Cigna, MLR Balance Stable (With the likely Anthem merger and with all the adjustments made last year, Cigna is starting to see more stability. Reports show a stable MRL balance.)Not all treatment centers have been eliminated.)


  • UHC, MLR Balance Unsustainable (reported losses and unbalanced MLR, more changes expected in 2016.)
  • Highmark BCBS of Pennsylvania, Delaware and West Virginia, MLR Balance Unsustainable

(Seeing unbalanced MLR, and in litigation with the federal government.)


  • No current data to support negative outlook on a specific insurer or state as of the writing of this report.
 JibeHealth (

Deadline Extended Healthcare – Sign up by Dec 17 for Jan 1 Coverage (

December 15th 2015

Santa has delivered an early gift to millions of Americans by extending the deadline to get coverage for January 1st. Obamacare officials extended the deadline by 48 hours late Tuesday night as a result of “unprecedented demand” during the current 2015 open enrollment.


The December deadline includes 38 states and California, the largest state run exchange. Officials have not indicated that an extension will be granted for the broader deadline of January 31st.

Get covered by January 1 and avoid the tax penalty of $695 or up to $2085+ per household.

A special number has been setup to fast track your application.


Avoid any wait times. Must call in the next 48 hours!

Millions of Americans Have Unclaimed Health Care Money

The 2010 passage of the Affordable Care Act extended a variety of health care benefits to different socioeconomic groups. Specifically, Obamacare sought to deliver reliable insurance coverage to lower-income, often uninsured groups. Subsidies, which are a part of the ACA, help to offset the costs of health insurance for individuals and families who meet specific income standards. Unfortunately, many people are unaware of the intricacies of Obamacare, including the access to subsidies, which results in billions of dollars of health subsidy money left untouched.

Health Subsidy Requirements

The annually established federal poverty level, or FPL, is the standard by which subsidies are assessed and distributed — for health insurance and beyond. The federal poverty level is set for a variety of family sizes, from individuals and married couples to families with one or many children. What percentage of income an individual, couple, or family brings in as it relates to the FPL determines what, if any subsidies, that they are eligible for. For example, the Affordable Care Act gives states the opportunity to offer Medicaid coverage to anyone who qualifies under 138% of the FPL. Those with incomes of up to 400% of the FPL may also have access to insurance coverage with lower deductibles and copayments, which can result in significant savings every month. In between those extremes, other subsidies exist as well.


One of the primary tenets of the Affordable Care Act was to give the uninsured access to affordable health care. Thus, the purpose of these subsidies is to help extend health coverage to those people who need it but cannot afford it. Individuals and families living at low and moderate income levels might struggle to piece together the money to secure health insurance. These subsidies make both health coverage and health care services more affordable, with a goal of increasing the number of insured individuals in the U.S. If you haven’t looked into your eligibility for subsidies, now is the time.

Recouping Your Subsidies

Determining whether you are eligible for subsidies begins with comparing your household income to the federal poverty level. Don’t be put off by this simple formula. Instead, visit the Jibe Health platform, where you can determine your subsidy eligibility in as little as 60 seconds. Just imagine in one minute, you might tap into unclaimed money that you deserve in accordance to the Affordable Care Act. We understand that researching these subsidies and assessing your eligibility might be confusing, especially for novices with health insurance. At Jibe Health, we are well versed in the many intricacies of the Affordable Care Act’s subsidies, and we can quickly assess whether your income level qualifies you for these reduced rates.

The federal government is sitting on billions of dollars in subsidies that have gone unused. Don’t let these potential savings go to waste another day. If you think that your family might be eligible for a subsidy, let help you minimize your health care expenses today. You’re just a few clicks away from increased savings and improved access to health care.

Why Your Generic Prescription Could Be Killing You

Opting for a generic prescription might seem like the smart choice. After all, you seem to be getting the same drug, only at a fraction of the price. However, generic drugs aren’t always what they seem. You could be putting your health at risk by choosing the more inexpensive option. Discover here why generic drugs could be a dangerous choice, one that can have serious and long-term consequences.

Bioequivalence: Not an Exact Science

While the U.S. Food and Drug Administration oversees the production of generic drugs and ultimately approves their usage, the FDA also acknowledges that reproducing a brand-name drug isn’t always an easy undertaking. As a result, when you choose the generic option, you’re opting for a drug that is not the biologic equivalent of the brand-name drug.

Here’s how the creation of generic drugs works. The generic drug manufacturer, by law, is mandated to use the same active ingredient in the brand-name drug. However, the FDA gives some leeway regarding just how precise the use of that active ingredient must be. Rather than precisely replicating the makeup of the drug’s components, the FDA allows generic drug manufacturers to create a drug that contains up to 20% less of the active ingredient in the brand-name drug. As a result, your generic drug just might be 20% less effective than the brand name.

Furthermore, Katherine Eban of Fortune Magazine, reports that the FDA’s rules surrounding the drugs other ingredients are far more lax. So, while the generic drug you choose may have some portion of the same active ingredient in the name brand, it also may include other ingredients not found in the pricier prescription. Logic tells you that if you’re paying less for this drug, the ingredients are probably of a lesser quality.

The Impact of Generic Drugs

Simply put, the generic drug you pick up at your pharmacy probably isn’t the same makeup as the brand-name drug. As a result, the switch from a brand-name drug to a generic one can dramatically impact your health. For example, even when the brand-name drug and generic drug have the same amount of active ingredient, the rate at which this active ingredient is released into your body may vary. You might notice unexpected side effects and reduced efficacy of the drug as a result. Moreover, the less-regulated excipients, or other ingredients, may contribute to a host of side effects as well. In one startling example, individuals who took the brand-name antidepressant Wellbutrin XL reported extreme depression and suicidal thoughts when they switched to the generic drug, according to ABC News.

Choosing Health Insurance with Prescriptions in Mind

Your health insurance should give you the freedom to choose brand-name pharmaceuticals. While Tier 1 and Tier 2 generic prescriptions might result in a lower copay, they also might be less effective, bring with them more side effects, or, in a worst-case scenario, negatively impact your health. matches individuals with health insurance plans based on their needs.  JibeHealth will match you with the right tier and identify health plans that meet your exact needs.  Tier 4 prescriptions include higher-priced, brand-name drugs. When choosing a health insurance plan, look closely at the prescription coverage to make sure you aren’t forced into opting for questionable generic alternatives. Maximize your health, and get matched with a plan that provides you access to Tier 4 brand-name drugs.