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Medicare Advantage in the Hot Seat: Challenges and Opportunities Part 1

Analysis  |  By Laura Beerman  
   June 01, 2023

The first look at a preview of HealthLeaders Payer Week, five days of in-depth coverage and exclusive interviews.

“In quantum mechanics, a particle can exist in multiple states at the same time. Once the particle is observed it ‘picks’ one of these states . . . [and] the results change” — Mindful Leader.

Healthcare is not quantum mechanics. But multiple states do exist simultaneously across the industry, guided by competing groups: providers, pharmaceutical companies, government, tech startups—and payers.

Payers have not “picked” a single state in which to operate. They are also providers, third-party administrators, health services companies, pharmacy benefit managers, data and analytics firms, innovation incubators and investors. The list goes on and it has resulted in a changing healthcare landscape.

Medicare Advantage in the Hot Seat: Challenges and Opportunities

Payer operational diversity will be on display during HealthLeaders Payer Week—five days of in-depth coverage spotlighting the significant roles and contributions of insurers. Our week-long exploration, Medicare Advantage in the Hot Seat: Challenges and Opportunities, will include:

  • Medicare Advantage's tremendous market growth and expansion
  • The sticky business of Medicare Advantage prior authorization and marketing
  • The intersection of benefit design and provider performance
  • Rising drug costs and Medicare Advantage health plan counter-moves
  • The Star Ratings program evolution

Below is some of what you can expect for Payer Week.

Preview 1: Drug cost controls, payer shell games, and market collapse

“Meet the IRA,” writes Dr. Adam Fein, CEO of Drug Channels Institute. It’s an innocent enough introduction to the Inflation Reduction Act, which requires manufacturers to negotiate drug prices with the Medicare program and MA payers.

But Fein believes lower drug prices will come with a high price tag. This includes the potential collapse of the standalone Part D market. The cause? Payers steering members toward plans with combined medical-pharmacy benefits and integrated cost management advantages.

The Payer Week drug pricing brief will include an exclusive interview from CareFirst BlueCross BlueShield VP of pharmacy management, Mandi Poplawksi.

Preview 2: The Star Ratings he said, she said

The performance-benefits mashup isn’t the only marketing strategy that Medicare Advantage payers use. CMS’ Star Ratings are another. And a lucrative one, if you know how to play the game and have a five-star plan you can market year round.

Some believe star ratings genuinely reflect Medicare Advantage plan quality. Others believe the program “harbors an arbitrage game in which CMS consistently overpays MA plans with no demonstratable clinical benefit to patients.”

One fact spans both views: 2023 was a tough year for plans as a trifecta of CMS methodology changes sank Star Ratings.

The Payer Week feature will spotlight winners and losers, why a Medicare oversight group can’t stop ringing Star Rating alarm bells, and top tips from industry experts on how payers can improve performance. 

Preview 3: What you don’t know about the Medicare Value-Based Insurance Design program

Only a few CMS alternative payment models have included Medicare Advantage plans and the value-based insurance design (VBID) program is one of them. From 2017-2023, VBID has grown from eight to 50 states and all U.S. territories and from nine to 50+ MA Organizations as of 2023.

Among value-based care (VBC) models, VBID is less controversial than direct contracting and has maintained a lower profile than the Medicare Shared Savings Program that put ACOs on the map.

Many Medicare Advantage plans have participated since the beginning (or as early as they could) while others—large players like Centene—have just entered. Why? How does VBID compare to home-grown payer models? How do plans balance the demands of multiple VBC programs? And what’s the status of the VBID-X plan design template?

The HealthLeaders Payer Week brief will address and feature an exclusive interview with Healthfirst’s SVP of Medicare, Jen Cohen-Smith.

More special coverage

Outside of Payer Week, HealthLeaders features exclusive leadership profiles for our series The Exec. Recent payer interviews have included:

  • Leading industry voice Dr. Sachin Jain, CEO of SCAN Health Plan and its parent company, The SCAN Group
  • Geisinger Health Plan president Kurt Wrobel, whose plan and parent company Geisinger Health will be acquired by Kaiser Permanente if the deal is approved
  • The president of Care Solutions for Evernorth Health Services, Joan Harvey. The industry veteran shared the top strategic priorities for Cigna’s health services division.
  • Clover Health CTO-turned-president-turned CEO Andrew Toy. Struggling of late, Clover represents a new breed of payers leading with tech and business model innovation.

See HealthLeaders’ companion article for previews of other Payer Week features and briefs on the state of Medicare Advantage expansion, prior authorization, marketing, and benefit design.

Laura Beerman is a contributing writer for HealthLeaders.


As Medicare Advantage enrollment grows, so does scrutiny: Is Medicare Advantage really a better deal for beneficiaries?

Payer Week will shine a light on the program’s hidden and plain-sight hotspots.

These range from prior authorization and drug costs to a possible Part D market collapse and whatever happened to “VBID-X” benefit design.

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