A new survey finds high satisfaction with Medicare plans, but plenty of concern over costs and future access to benefits.
Though many Medicare beneficiaries are satisfied with their plan, they have trepidation about where the health insurance program is heading, according to a survey by eHealth.
The private health insurance marketplace surveyed 4,567 members with either Medicare Advantage (MA), Medicare Supplement, or Medicare Part D prescription drug plans through eHealth this month to gauge how beneficiaries feel about their coverage.
Nearly nine in 10 respondents (88%) said they are satisfied with their coverage, but 60% believe political leaders who influence Medicare policy aren't listening to their needs.
Costs are the biggest concern, with more beneficiaries saying they are worried about being able to afford out-of-pocket expenses (75%) than their monthly premiums (43%).
The fear of costs is heightened due to the end of the COVID-19 public health emergency, with 62% of members expressing concern about their out-of-pocket expenses for COVID-related care increasing.
Beneficiaries are worried about the future of Medicare, but those concerns differ by income. Lack of access to prescription drugs is the top concern for those with an income over $100,000, while benefits being reduced is foremost for those making between $50,000 and $75,500, and not being able to afford care is front of mind for those making below $25,000.
"As our research demonstrates, there are important nuances in how Medicare beneficiaries feel about their coverage and cost burden," Fran Soistman, CEO of eHealth, said in a statement. "Understandably, uncertainty about future expenses weighs heavily on those living on a fixed income. They want to know that insurance carriers and Medicare policymakers are listening to them.
"As an organization that advocates for transparency in health insurance coverage, it is important for us to shine a light on their concerns."
The survey also revealed that awareness among beneficiaries is low. While 95% of members said it's important to review coverage options at least once per year, only 10% of MA enrollees were aware of the MA enrollment period currently under way.
Lack of awareness is also set to affect Medicaid enrollees. A survey from the Urban Institute found that 64% of adults in a Medicaid-enrolled family have no idea that they may lose coverage with the return to regular Medicaid renewal processes.
Health insurers can do their part by educating their members and guiding those that lose coverage to new plan options.
The major payer will concentrate its focus on its Medicare and Medicaid health plan offerings.
Humana will leave its employer group commercial medical products business to shift its full attention to its core insurance lines, the company announced.
The exit from the market will be phased over the next 18 to 24 months, the health insurer specified, and will include abandoning all fully insured, self-funded, and Federal Employee Health Benefit plans, as well as associated wellness and rewards programs.
Humana stated the decision comes after a strategic review, which determined the "business was no longer positioned to sustainably meet the needs of commercial members over the long term or support the company’s long-term strategic plans."
The payer can now put all of its efforts into its Medicare and Medicaid plans, including its Medicare Advantage (MA) offering. In a recent study by the American Medical Association found that Humana had the second-largest MA market share at 19%, behind only UnitedHealth Group.
"This decision enables Humana to focus resources on our greatest opportunities for growth and where we can deliver industry leading value for our members and customers," Bruce D. Broussard, Humana president and CEO, said in a statement. "It is in line with the company's strategy to focus our health plan offerings primarily on Government-funded programs (Medicare, Medicaid and Military) and Specialty businesses, while advancing our leadership position in integrated value-based care and expanding our CenterWell healthcare services capabilities.
"We are confident in Humana's continued success, and our commitment to improving the health of those we serve is unwavering."
Last year, Humana restructured by splitting into two business units, insurance services and CenterWell, as part of its goal to generate $1 billion of value to pour into its MA and Medicaid businesses.
The announcement came six months after Humana stock fell by 21%, as the payer slashed MA enrollment projections roughly in half.
The federal agency has highlighted areas of improvement to get more facilities complying with the regulation.
CMS is aware more needs to be done to achieve better price transparency compliance by hospitals and plans to take "aggressive additional steps" to make enforcement a priority.
CMS' deputy administrator and director Meena Seshamani and Center for Medicare chief transformation officer Douglas Jacobs detailed next steps for the federal agency and new compliance statistics in a Health Affairs article.
According to CMS, nearly 500 warning notices and over 230 requests for corrective action plans have been issued as of January 2023, with nearly 300 hospitals having addressed the issues to become compliant.
Since the hospital price transparency regulation went into effect on January 1, 2021, hospitals are required to make public their standard charges for items and services through a consumer-friendly display showing at least 300 shoppable services, as well in a machine-readable file.
Hospitals were slow to adapt out of the gates. In an assessment of 235 randomly sampled hospitals conducted by CMS between January and February 2021, 66% met consumer-friendly display criteria, 30% posted a machine-readable file, and 27% did both.
Those figures improved significantly in CMS' second assessment, this time of 600 randomly sampled hospitals between September and November 2022. The analysis found 493 hospitals (82%) posted a consumer-friendly display, 490 (82%) posted a machine-readable file, and 421 (70%) did both.
The second assessment came after CMS increased the penalty for noncompliance, by adjusting the maximum potential penalty from just over $100,000 annually per hospital to over $2 million annually per hospital.
"We believe the multifaceted effort that CMS has undertaken since initially implementing the regulation—including efforts to educate, monitor, and enforce the regulations with increased applicable potential penalty amounts, along with heightened public interest and scrutiny—have driven this improvement," the article stated.
Despite the improvement, that would still leave 30% of hospitals noncompliant with the law. Yet CMS has only taken action against two hospitals to date, issuing fines of $883,180 to Northside Hospital Atlanta and $214,320 to Northside Hospital Cherokee.
In an effort to streamline enforcement going forward, the article said CMS plans to shorten how much time it affords hospitals to come into full compliance. In addition, the federal agency "plans to take aggressive additional steps to identify and prioritize action against hospitals that have failed entirely to post files."
CMS' compliance statistics differ from findings by other groups, including PatientRightsAdvocate.org in its Semi-Annual Hospital Price Transparency Compliance Report. That analysis of 2,000 hospitals from December 10, 2022 through January 26, 2023 revealed that 75.5% of facilities are still noncompliant.
Researchers also found significant variation in data size, which CMS acknowledged as an issue in the Health Affairs article. The agency said it will take steps to standardize both reporting of price transparency information and the machine-readable file.
Finally, CMS stated it will explore ways to make it easier for the public to find the machine-readable files, which could include mandating the centralization of information.
The article concluded: "We believe that, together with members of the public, we can further unlock the collective potential of hospital price transparency and achieve greater competition in the health care system."
The impending renewal process could mean enrollees are left without coverage.
Most adults in a Medicaid-enrolled family lack awareness of the upcoming Medicaid eligibility redetermination, according to analysis from the Urban Institute, funded by the Robert Wood Johnson Foundation.
April 1 is the deadline for states to start redetermining eligibility of Medicaid beneficiaries and the survey by the Urban Institute finds 64.3% of enrollees have heard nothing about the return to regular Medicaid renewal processes as of December 2022.
That's virtually no change when compared to survey results from June 2022, when 62% of beneficiaries reported being unaware of redeterminations.
The most recent survey uncovers that 16% of adults have heard only a little about the return to regular renewal processes, while 13.9% have heard some, and 5.1% have heard a lot.
Regardless of geographical location, awareness remains low. Lack of awareness was 66.5% in the Northeast, 67.6% in the Midwest, 63.4% in the South, and 61.3% in the West.
Whether respondents were in a state that has expanded Medicaid eligibility made no difference either. Lack of awareness was 64.5% in Medicaid expansion states and 63.7% in non-expansion states.
"The end of the public health emergency's continuous coverage requirement means millions of people are at risk of losing continuous coverage in Medicaid, which they have relied upon for nearly three years," Gina R. Hijjawi, senior program officer at the Robert Wood Johnson Foundation, said in a statement.
"States and the federal government must quickly raise awareness that many families will soon need to take steps to maintain or find new health coverage."
As many as 18 million people could lose Medicaid coverage with the COVID-19 public health emergency ending, the Urban Institute states.
States and the federal government can do their part to offset coverage loss by raising awareness that families will have to take steps to maintain or find new coverage on the Affordable Care Act marketplace.
A new report analyses the state of outsourced medical billing and uncovers areas of opportunity.
Nearly two-thirds (65%) of medical billing companies have a positive outlook on the outsourced billing industry, according to a report by digital health operating system company Tebra.
In its 2023 State of the U.S. Medical Billing Industry Report, Tebra surveyed 277 medical billing companies serving independent practices from September 2022 to October 2022 to gauge billing outlooks and trends.
In addition to most respondents saying they have a positive outlook, compared to 9% with a negative outlook, almost half of companies (43%) see outsourcing as a significant opportunity, while 42% see significant opportunities to expand services.
"Even amidst the recent tumult of Covid-19, physician burnout, and consolidation in the medical industry, medical billing companies are still a trusted choice for front-office support to independent practices, and make it easier for physicians to focus on delivering better care to patients," Kevin Marasco, chief marketing officer at Tebra, said in a statement.
"Our new 2023 U.S. Medical Billing Industry report highlights that medical billing companies will continue to thrive in this period of economic uncertainty."
Outsourcing medical billing is a strategy many providers have identified as a way to help cut costs and improve efficiency. A report by Kaufman Hall from October 2022 found that outsourcing revenue cycle functions was the most common area of outsourcing solutions for hospital and health system leaders, pursued by 27% of surveyed respondents.
Automation is part of the appeal for providers outsourcing billing, but many billing companies are still manually handling administrative tasks. According to Tebra's report, only 29% of billing companies use automation, robotic process automation (RPA), HL7 integrations, and outsourcing to manage workflows, leaving plenty of room for improvement to streamline processes.
The companies that have embraced automation have experienced growth, the report states, with more than half (52%) of "high-growth" companies using RPA and 39% using patient collections automation.
Utilizing technology to improve services will be essential in an industry that 46% of companies say has become either more competitive or presents more challenges to finding new customers over the past three years.
The medical billing outsourcing market is expected to keep growing, however, with a study published by Future Market Insights last summer anticipating a compound annual growth rate of 16% from 2022-2032 and a valuation of $55.6 billion by the end of 2032.
Research finds lack of prior authorization as one of the foremost reasons for denials by non-group qualified health plans (QHPSs).
Health insurers on the Affordable Care Act (ACA) marketplace denied an average of 16.6% of in-network claims in 2021, according to a brief by Kaiser Family Foundation (KFF).
Researchers analyzed data released by CMS on claims denials and appeals for QHPs offered on HealthCare.gov for the 2021 plan year and found that denial rates ranged significantly from 2% to 49%. The dataset included 162 QHPs that reported receiving at least 1,000 in-network claims and showed data on claims received and denied.
Of the 291.6 million in-network claims received between the insurers, 48.3 million were denied (16.6%) while 243.3 million (83.4%) were paid. In 2021, 41 insurers had a denial rate of less than 10%, 65 insurers denied between 10% and 19%, 39 insurers denied between 20% and 29%, and 17 insurers denied 30% or more.
Health plans that reported denying one-third or more of claims were Meridian Health Plan of Michigan, Absolute Total Care in South Carolina, Optimum Choice in Virginia, UnitedHealthcare of Arizona, Health Net of Arizona, Buckeye Community Health Plan in Ohio, Celtic Insurance in seven states, and Ambetter Insurance in three states.
Researchers also examined the 44.7 million reasons health plans reported for denying the claims. Lack of prior authorization or referral accounted for 3.6 million (8%), excluded services made up six million (13.5%), medical necessity reasons were 920,000 (2%), and all other reasons accounted for the remaining 34.2 million (76.5%).
Many prior authorization denials occur due to insufficient documentation and an inability to match information that is spread across different systems. Automating the administrative process has become a strategy for revenue cycle leaders, with 78% of respondents in a report by KLAS saying they saw improved financial performance after implementation.
When it comes to ACA data, the KFF brief highlights that CMS does not collect out-of-network claims submitted and out-network enrollee cost sharing and payments.
The researchers state that the lack of required transparency in coverage data reporting by other non-group plans or employer-sponsored plans contributes to hindering improvement with denials.
"The federal government has not expanded or revised transparency data reporting requirements in years and does not appear to conduct any oversight using data that are reported by marketplace plans. As a result, consumers are not provided any information about how reliably marketplace plan options pay claims and plans reporting high claims denial rates do not appear to face any consequences."
The initiative, which changes the holding company's name to The Cigna Group, reflects the corporation's growing portfolio.
Cigna is evolving its brands to be more in line with the company's businesses, the major payer announced.
The rebrand sees the holding company's name change to The Cigna Group, while Cigna Healthcare will be the health benefits provider, and Evernorth Health Services will provide pharmacy, care, and benefits solutions.
"Over the last several years, we’ve built a diverse portfolio of leading capabilities to serve more people across our businesses," Lou Aversano, Cigna's chief brand and marketing officer, said in a statement. "Now, we are evolving our brand architecture to reflect how we are serving the breadth of our relationships today and into the future."
Cigna has maneuvered strategically to better serve its customers and clients, which includes expanding its reach in the Affordable Care Act marketplace. Last summer, the company announced it would branch out to three new states—Indiana, South Carolina, and Texas—as well as 50 new counties in Georgia, Mississippi, and North Carolina.
The payer also announced Medicare Advantage expansion for the fourth consecutive year, growing its offerings to 106 new counties in 2023.
Meanwhile, Cigna's rebranding efforts follow similar initiatives by other payers recently.
In March 2022, Anthem announced it would change its name to Elevance Health to reflect its commitment "to elevating whole health and advancing health beyond healthcare."
Humana also restructured last year, breaking down into two business units: Insurance Services and health services, CenterWell.
Payer giant UnitedHealth Group has operated health benefits under UnitedHealthcare and other services by Optum.
Rebranding is one of the ways companies can get a facelift to grow their presence and appeal.
Organizations will add, enhance, or end services to address employee experiences and benefits.
Almost nine in 10 employers plan to change health and wellbeing vendor partnerships in the next two years, according to a survey from Willis Towers Watson (WTW).
The survey fielded responses from 232 U.S. employers—with three million workers—in November 2022 and found that organizations will adjust their offerings in the near future to address employee needs.
Most respondents (88%) said they are planning to make changes to their vendors either this year or next, which includes adding, enhancing, or ending certain services. Changes may also include working with a different vendor.
"High-performing health and wellbeing vendors are now vital to employers," Courtney Stubblefield, senior director of WTW, stated. "They have become a critical component of competitive benefit and wellbeing programs and strategic to their portfolio."
"However, in an effort to meet the needs of their employees and improve worker health, employers are taking a close look at the value and cost savings their vendors promise. What’s more, they are ready to make changes as needed."
Respondents ranked their top areas of focus for vendor solutions over the next two years, with mental health finishing first, general wellbeing coming in second, and financial wellbeing slotting fifth.
Of those surveyed that provide mental health solutions, 37% said they are planning to make changes to their mental health services in the next two years, including employee assistance programs and other clinical and pharmacy solutions. Nearly a quarter (24%) made changes in 2022.
More than half of the respondents (55%) that offer wellbeing services said they are planning to make changes in the next two years, while 12% already made changes last year.
Just over four in 10 employers (42%) are planning to make changes to their point solutions for clinical conditions like diabetes and musculoskeletal disease over the next two years, with 24% having made changes in 2022.
When it comes to navigation and advocacy programs, 40% of employers are set to make changes to areas such as clinical guidance and expert medical opinion. More than one in 10 respondents made changes in 2022.
Finally, 43% of employers are aiming to change their digital platforms, including digital hubs and health information portals, building on the 7% that already did last year.
"Companies prioritize ROI but need a broader definition of ROI that includes choices based on driving quality, filling the gap in core offerings and lowering cost," said Regina Ihrke, WTW senior director."
"At the same time, they should evaluate if the solution is working, how to optimize current partners and whether they need to embrace innovation in the market. This balanced approach will offer a better experience for their employees."
Plans have experienced exponential growth, but researchers caution that the outdated payment policy has ramifications.
Medicare Advantage (MA) payment policy hasn't kept up with its rapid growth of 337% from 2006 to 2022, according to a study published in Health Affairs.
Researchers from the USC Schaeffer Center analyzed Medicare enrollment data over that time period and found MA added 22.2 million beneficiaries while enrollment in traditional Medicare declined by one million (-2.9%).
MA penetration increased from 16.9% in 2006 to 49.9% nationally in 2022, and 24% of Medicare beneficiaries with Parts A and B lived in a county with adjusted MA penetration equal to greater than 60%.
"The dramatic growth in MA penetration during the past two decades indicates that beneficiaries are reforming Medicare with their feet," the study stated. "Policy discussions about the future of the Medicare program would be well served by recognizing these trends and accounting for the dramatic shifts in the preferences exercised by Medicare beneficiaries in recent years."
With MA enrollment booming, the study highlights that the way plans are paid hasn't evolved to reflect the growth.
Payment to MA plans is based on the average cost per beneficiary in traditional Medicare in each county, but researchers ask what that will mean if only a minority of Medicare enrollees are in traditional Medicare.
"We know that MA plans are getting overpaid relative to the costs of providing care to comparable beneficiaries in traditional Medicare, and this has contributed to the magnitude of extra benefits offered to MA enrollees," study co-author Paul Ginsburg said in a press release. "While this is appealing to consumers, this is increasing federal spending and accelerating the rate at which the Medicare trust fund is being exhausted."
MA plans have come under scrutiny for receiving billions in overpayments, which they will likely have to pay back from 2018 onwards after CMS released its Risk Adjustment Data Validation final rule.
For policymakers wanting to balance the scales and adjust the payment to MA plans, the study suggests not tying payment policy to costs in traditional Medicare, but rather competitive-bidding benchmarks.
"We can't continue to think of Medicare Advantage as an appendage of the traditional Medicare program," Ginsburg said. "We are at a point where the tail is wagging the dog."
New analysis further supports the need for stronger policies to streamline the administrative process.
More than two million prior authorization requests, accounting for six percent of the 35 million total requests, were denied by Medicare Advantage (MA) plans in 2021, according to a report by Kaiser Family Foundation (KFF).
While beneficiaries of traditional Medicare are rarely required to receive prior authorization, nearly all MA members were enrolled in a plan that required prior authorization for some services in 2022, the analysis found.
KFF looked at the data plans must send to CMS for each MA contract that includes the number of prior authorization determinations made during a year and whether the request was approved, and then examined the use of prior authorization in MA during 2021.
The findings reveal that MA plans made over 35 million prior authorization determinations for the year, which equates to 1.5 requests per enrollee on average. Of those, over two million were denied in full or in part, with adverse determinations making up the majority of the denied requests.
The denial rate varied among insurers, ranging from 3% for Anthem and Humana to 12% for CVS (Aetna) and Kaiser Permanente. Insurers that had more prior authorization requests were generally found to deny a lower share of those requests.
While just 11% of denied prior authorization requests were appealed, 82% of appeals resulted in the initial denial being either fully or partially overturned. Only Kaiser Permanente overturned less than half (30%) of appeals of the insurers analyzed.
Researchers stated that the "medical care that was ordered by a health care provider and ultimately deemed necessary was potentially delayed because of the additional step of appealing the initial prior authorization decision, which may have negative effects on beneficiaries' health."
CMS has recognized the problem and proposed a rule in December 2022 to streamline the administrative process by requiring MA plans to implement electronic prior authorization.
Building on that proposed rule, CMS released another proposal to strengthen prior authorization protections for patients, requiring: a granted prior authorization approval remain valid for an enrollee's entire course of treatment; MA plans to annually review utilization management policies; and coverage determinations to be reviewed by professionals with relevant expertise.
KFF's report concluded by highlighting the importance of observing prior authorization practices in MA plans.
Researchers stated: "As the number of Medicare beneficiaries enrolled in Medicare Advantage continues to grow, a better understanding of prior authorization and other processes and programs to contain spending and manage utilization will be important in evaluating the implications of these policies on utilization and quality, including variation across Medicare Advantage plans and compared to traditional Medicare."
