"This is a whole new ballgame," notes one academic consultant—an observation about marketplace exchanges that also applies to every aspect of healthcare next year.
Pandemic year three is at hand and will continue to affect everything from cost-sharing and telehealth to data disruption and tech innovation. Expect multiple disruptions aimed at improving patient experience and outcomes, including, social determinants of health (SDOH); exchange and Medicare Advantage (MA) plan growth; and advanced digitization. Payers will continue to grapple with the forces of consolidation and value-based care (VBC) as COVID concern runs tandem with delivery system progress.
Finally, the full story of patient health
The pandemic laid bare healthcare's disparities. Healthcare, especially payers, have the data to do something about it. To a degree that they always have, but alternative data integrated from multiple sources and activated by artificial intelligence will be even bigger game changers.
Big payers will continue to cozy-up the exchanges
Federal subsidies, a special enrollment period, and change of administration have breathed new life into the ACA marketplace. As of August 2021, the Kaiser Family Foundation (KFF) reported that a record 12.2 million people were enrolled in exchange plans. And while KFF was cautious as to current Open Enrollment projections, others are more optimistic. "This is a whole new ballgame," says consultant and adjunct professor Katie Keith of Georgetown University Law School.
In addition to 32 new insurers, larger payers have reestablished themselves. Bill Melville, principal analyst of Market Access Insights with Clarivate notes: “Exchanges have drawn back major insurers who left them, notably Aetna in eight new markets and UnitedHealth Group in seven. The risk is much lower for participation now, as payers have learned how to price for exchanges."
Expect more Medicare Advantage disruptions
MA plans will continue to see enrollment growth through expansion and collaboration. Cigna has expanded its small-group partnership with insurance startup Oscar while more established players like Blue Cross Blue Shield (BCBS) either expanded or entered new markets (CareFirst's group entry).
Two additional MA disruptions loom with Humana at the crux of both: Star Rating changes with quadruple-weighted customer experience measures as of plan year 2023 and a larger shift to VBC rooted in home health. "Humana has invested heavily in home-based health services for its Medicare Advantage members," says Paula Wade, also a Market Access Insights principal analyst with Clarivate. Her colleague Melville adds: “The company plans to have 50% of its MA lives in value-based home-health models within five years," noting that "Humana’s strength in MA could lead the entire segment into a value-based shift.”
VBC will expand within its limits
That an MA payer's shift into VBC could lead others to follow says a lot about how original Medicare's VBC demonstrations are faring. Quality has improved and costs decreased—or not—depending on the source. All eyes will be CMS' strategy refresh and Global and Professional Direct Contracting (GPDC) Model, which welcomes new entrants January 1, 2022, and "opens capitation for both new and experienced groups" per industry consultant Jennifer Bresnick.
This is against a payer VBC backdrop that will continue to be marked by expansion and constraint in 2022: the former as VBC is applied to novel drug treatments and digital therapeutic services, and the latter as the industry seeks more degrees of separation from its fee-for-service chassis. But this will be just the beginning. Speaking at a Health Plan of the Future webinar, Jake Sattelmair, co-founder and CEO of Wellframe, notes: "Provider payment is no longer the primary vector for influencing risk," with co-presenter Marcia Macphearson, Partner, Oliver Wyman, adding: "Alignment of reimbursement structures is only a first step … If payers stop there, they will not get the results."
Digitization growth through a consumer focus
Macphearson and Sattelmair highlight that the next step for VBC is identical to that for healthcare's digital transformation: putting consumers first. The two are intertwined, as reflected in AI Multiple's definition of digital transformation as "the use of the latest technologies to enhance existing processes and offer new and improved services and products to customers. It aims to create value by changing how businesses operate and how they deliver value." In 2022, and over the next decade, payer digitization efforts will accelerate beyond core business with the help of startup supporters and payers' own innovation ventures.
Payers will continue to get a little closer
How will payers achieve this? Consolidation and integration, the disruptive forces that show no signs of stopping. Clarivate's Wade notes: "So many hospital systems have morphed into huge regional Integrated Delivery Networks (IDN), and that has inhibited carriers' ability to dictate contract terms and pricing. It also allows the more advanced IDNs to contract directly for care with local employer groups. Often, the payers' best solution is to design a co-branded regional plan." Reflecting IDN power, payer advocacy group America's Health Insurance Plans even rebranded itself in 2021. The new "just AHIP" reflects a "P" that increasingly stands for "payvider."
As these arrangements grow, Wade adds that "big insurers will continue to develop and integrate their own healthcare delivery assets: from the large-scale buyups by UnitedHealth … to Humana's network of owned clinics and home health operations." Melville adds another example, the increased CVS Health-Aetna integration that is tying more CVS MinuteClinic and HealthHUBs to Aetna plan designs.
Wait and see on BBB
Finally, there is the grab bag known as the Build Back Better bill (BBB): its items have been picked through and who knows what the leftover goodies are worth? The BBB is already a shell of its former self but does—if it passes—retain in-home care funding and coverage subsidies for the Medicaid program, drug-price negotiation levers, and hearing benefits for original Medicare but not the lower age-in threshold that would have expanded care. Still, any major healthcare reform proposal is a step forward. It remains to be seen whether that step will happen in 2022.
Laura Beerman is a contributing writer for HealthLeaders.