How Genomics Helps Payers Balance MLR & Improve Member Care

HOME / BLOG / Payers Balance MLR


Payers Balance MLR

How Genomics Helps Payers Balance MLR & Improve Member Care 

From large, well-established companies to relative newcomers, health insurance companies found it difficult to be profitable in 2015. However, companies with the insight to invest in genomics can begin to reap the rewards now and are setting themselves up for long-term benefits. 

Many losses suffered by insurance companies occurred on the Affordable Care Act (ACA) exchanges. Blue Cross Blue Shield drained more than 650 million dollars from its reserves and United Health Group lost more than 720 million dollars. Even the heavily touted startup Oscar Health Insurance lost over 100 million dollars last year.

Through the exchanges, these companies were inundated with new members who were sicker than expected and drove healthcare costs up. Many payers were not prepared to cover these high costs because their medical loss ratio (MLR) was off. The ACA’s MLR rule states that at least 80 percent of member premiums must be spent on health care claims and quality improvements.

The question is: how can insurance companies balance their MLR by driving down costs while continuing to focus on the health and wellbeing of their members?

Balancing MLR 

“Right now payers and providers are throwing away some really fundamental information,” said Dr. Rao Kotamarti, CEO of Quibble Genomics. “Most insurance companies base the premiums they charge on last year’s data and demographics. By combining DNA profile information with age, gender, and other demographic information, payers will be able to make clearer predictions as to what the budget should be in the upcoming year.” 

Quibble provides a wealth of information to payers and members through its GeneClues® application. This easy-to-use app uses 3-D models of DNA to convey information and is constantly being updated with the latest scientific discoveries. 

“The important thing to see here is that Quibble doesn’t just address one subject in the equation,” said Dr. Kotamarti. “Quibble provides a way for a payer to get genomics testing started as economically as possible. At the same time, Quibble provides a dynamic means for that DNA information to stay up to date. With Quibble, there’s never an ‘old’ DNA test, because a person’s information is continually updated with the latest findings. No other company today is facilitating the ease and the tools that Quibble is proving.” 

Member Health and Wellbeing 

Genomics is already changing the way we think about healthcare and medicine. Oncology is utilizing targeted genetic treatments to personalize cancer treatments, and diagnostic testing and medications for disease states like diabetes, Alzheimer’s, and Parkinson’s are rapidly evolving. 

“I think you are looking at a more proactive lifestyle all around. Individuals who have had their genome read will find that the entire healthcare system is geared up to alert them, to bring them in for early check-ups and so forth,” said Dr. Kotamarti. “Even when expensive procedures are required, they won’t be a surprise. And that's going to be a great benefit to everyone.” 

Most health insurance programs already have a health management program. Adding genomics is a natural evolution that will benefit all involved: payer, provider, and member. 

“Here’s how one scenario will work,” said Dr. Kotamarti. “An insurance company will work with Quibble to provide a joint offering to a corporation that delivers a competitive and comprehensive plan for employees who are ready to get genotyped. Those employees would download our GeneClues® app and use it to get their genotype ordered. Employees are able to view their information on our HIPPA compliant app and, when they willingly share their Genotype information, the insurance company can identify the employees most likely to have complications. The provider network is then able to provide better, more proactive services for those employees. It’s Quibble, ACOs, corporations, and insurance companies working together to lower costs by improving the health and wellness of members.” 

Genomics is revolutionizing medicine. To see how genomics can help balance MLR and improve members’ lives, click here.