Performance was higher in Medicare Advantage (MA) health maintenance organizations (HMOs) and preferred provider organizations (PPOs).
Enrollees utilize Medicare Advantage at a lower rate than traditional Medicare, but the former has higher clinical quality performance, according to a study published in Health Affairs.
In a comparison of quality and utilization measures in MA and traditional Medicare in 2010 and 2017, researchers found clinical quality performance was higher in MA HMOs and PPOs in nearly all measures in both years.
Clinical quality performance was based on CMS Healthcare Effectiveness Data and Information Set (HEDIS) measures.
MA HMOs outperformed traditional Medicare in all nine measures in both years, aside from osteoporosis in 2010. In 2017, MA HMOs improved on nearly all seven measures and outperformed traditional Medicare on five of them.
MA PPOs, meanwhile, either kept pace or outpaced traditional Medicare on all but one patient-reported quality measure in both years.
In terms of utilization, MA HMOs experienced 30% fewer emergency department visits, approximately 10% fewer elective hip and knee replacements, and almost 30% fewer back surgeries than traditional Medicare in 2017. The differences were less noticeable with MA PPOs, but the utilization trends held true.
As MA continues to grow at a rapid pace, adding a record 2.7 million members this year, it is notable that the study suggests MA does deliver higher quality of care.
However, MA plans have been under scrutiny for receiving billions of dollars in overpayments, in large part due to incentivized upcoding. CMS has released its Medicare Advantage Risk Adjustment Data Validation final rule to recoup the overpayments, which payer groups claim will have the unintended effect of harming patients.
The study concluded: "As policymakers consider alternatives to address potential overpayments in Medicare Advantage, they should also consider the evidence that MA plans provide fewer services while also achieving equal or better quality performance relative to traditional Medicare on a broad array of measures."
A report examines changes in marketplace premiums and insurer participation between 2022 and 2023.
Health insurer competition, as well as economic growth and inflationary pressures, contributed to the Affordable Care Act (ACA) benchmark premium rising 3.4% in 2023, according to analysis by the Urban Institute.
The research, which looks at data from Healthcare.gov and state-based marketplace websites, analyzed marketplace premiums and insurer participation in each state and tracked changes between 2022 and 2023.
After average annual premium reductions of 2.2% from 2019 to 2022, the report found that the marketplace benchmark premium increased nationally by an average of 3.4% in 2023.
The increase is likely due to the strong economy and rising inflation, with the latter contributing to labor costs in the healthcare industry, the researchers stated.
"There may also be expectations that the risk pool will improve following the end of the COVID-19 public health emergency," the report said. "Individuals losing Medicaid and becoming eligible for Marketplace coverage are likely to be low-income workers and healthier than those who remain unemployed or out of the labor force."
The variation in premiums across states is also attributable to insurer competition, with premiums lower in areas with a large number of insurers.
In the report, 12 states had monthly benchmarks above $500: Alabama, Alaska, Connecticut, Delaware, Louisiana, Nebraska, New York, North Carolina, South Dakota, Vermont, West Virginia, and Wyoming. Many of these states have one or two insurers in most rating regions and higher concentration of hospitals.
Meanwhile, 10 states had premiums below $400: Colorado, Indiana, Maryland, Michigan, Minnesota, Nevada, new Hampshire, Rhode Island, Virginia, and Washington. Most of these states have strong competition, a Medicaid insurer, or both.
The analysis revealed that for 2023, if only one insurer was in the market, premiums were higher by $128 relative to a market with five or more insurers. When there were two insurers in the market, the benchmark premiums were higher by $119.
"Premiums have been kept low in part because insurers have developed narrow network plans with providers willing to accept lower payment rates," the researchers wrote. "Narrow networks are not necessarily a problem. But the looming issue is whether the low premiums that have been achieved are also associated with provider networks that are in some ways inadequate."
Lastly, the report examined changes in insurer participation and found that the number of payers grew from 227 in 2022 to 232 in 2023. The modest rise came after a large growth between 2020 and 2022, when insurers expanded from 185 to 227.
Researchers posited if introducing a public option plan into the marketplace would significantly affect premiums. While a public option wouldn't change much in markets with relatively low premiums because most of the feasible savings are already captured, it could theoretically bring down benchmark premiums in markets with little competition, they said.
"But the public option is likely to face the same problems existing insurers face. That is, it is difficult to negotiate provider payment rates because the number of providers is limited," the researchers concluded. "The risk of providers refusing to participate is great and the political power of these providers is considerable."
Understanding negotiated rates between insurers and providers is easier said than done due to the sheer volume of data.
Price transparency regulations have the potential to aid the shift to value-based care, but parsing the data currently available remains a challenge.
Uncovering total cost of care not only benefits patients, but it allows providers and payers to negotiate with one another based on the volume and quality of care delivered.
However, price transparency compliance continues to lag on the hospital side, with a recent report by PatientRightsAdvocate.org finding that 75.5% of hospitals are still not adhering to the rule.
On the payer side, there's been no shortage of data since the law went into effect on July 1, 2022, with Turquoise Health recently reporting that it amassed 630 terabytes of insurer price transparency data. Despite the overwhelming volume, payers have yet to figure out the best way to display all that information, as payer-machine readable files have varied 50-100 times in size, according to Turquoise Health.
In a previous interview with HealthLeaders, Turquoise Health CEO Chris Severn spoke to the price transparency rules' long-term impact on the healthcare system, when done right.
Severn said: "As the adoption of the current rules and laws continues to increase, we believe that data will inspire positive changes, such as transparent contracting and less variability in pricing. Both of those would in turn help move the needle closer to fair prices of services, but those positive effects take time."
To make sense of the data that is available right now, companies like Turquoise Health are developing platformsthat allow for the comparison of providers, payers, and costs of services.
Trilliant Health has released its own health plan price transparency analytics tool that can shed light on negotiated rates for services rendered, the company announced.
Ultimately, Trilliant CEO Hal Andrews said, "health plan price transparency data will enable value-based competition, revealing the best value for any service in any market under fee-for-service arrangements."
The new ruling applies to task force recommendations issued on or after the Affordable Care Act (ACA) was signed into law.
The American Medical Association (AMA) expressed concern and disappointment over the recent ACA ruling on preventive care, while AHIP emphasized coverage won't be immediately affected.
U.S. District Judge Reed O'Connor struck down enforcement of preventive care mandates under the ACA, determining that health insurers are not required to cover services such as cancer and heart screenings.
The decision applies to recommendations made by the U.S. Preventive Services Task Force on or after March 23, 2010, when the ACA became a law.
The Biden administration filed a notice of appeal two days after the ruling was made.
AMA president Jack Resneck Jr. said in a statement that the physician association "is alarmed by today’s deeply flawed court ruling in Texas" and decried the decision.
"Providing insurance coverage for screenings and interventions that prevent disease saves lives—period," Resneck said. "Invalidating this provision jeopardizes tools physicians use every day to improve the health of our patients."
Meanwhile, AHIP president Matt Eyles stated that patients will continue to have preventive services covered as the appeal process plays out.
"Every American deserves access to high-quality affordable coverage and health care, including affordable access to preventive care and services that help avoid illnesses and other health problems," Eyles said in a statement. "As we review the decision and its potential impact with regard to the preventive services recommended by the United States Preventive Services Task Force, we want to be clear: Americans should have peace of mind there will be no immediate disruption in care or coverage."
Loss of coverage for preventive care could have serious consequences, according to a recent survey by Morning Consult.
The business intelligence company polled a sample of 2,199 Americans and found that at least two in five respondents are not willing to pay for 11 of the 12 preventive services. Cancer screenings are the service respondents said they would most likely pay out of pocket for.
If O'Connor's ruling holds up, it could result in patients skipping or delaying necessary care.
The payer giant will reduce codes in the summer with the aim of easing the administrative process.
UnitedHealthcare is responding to concerns over prior authorization's potential to delay care and create burden by introducing code reductions this summer, the company announced.
The nation's largest health insurer said it will eliminate nearly 20% of current prior authorizations beginning in the third quarter for most commercial, Medicare Advantage, and Medicaid businesses.
The move is "part of a comprehensive effort to simplify the health care experience for consumers and providers."
Additionally, the insurer stated that it will also implement a national Gold Card program for provider groups in early 2024, which will get rid of prior authorization requirements for most procedures.
"Prior authorizations help ensure member safety and lower the total cost of care, but we understand they can be a pain point for providers and members," Dr. Anne Docimo, chief medical officer of UnitedHealthcare, said in the press release.
"We need to continue to make sure the system works better for everyone, and we will continue to evaluate prior authorization codes and look for opportunities to limit or remove them while improving our systems and infrastructure. We hope other health plans will make similar changes."
UnitedHealthcare's efforts to scale back on prior authorization are a step in the right direction, but more still needs to be done to ensure the process isn't harming patients and overwhelming providers.
In a recent poll of practicing physicians by the American Medical Association, 89% of respondents said prior authorization has had a negative impact on patient clinical outcomes, with 94% saying it delayed access to necessary care.
Furthermore, 86% of physicians reported that prior authorization requirements sometimes, often, or always led to higher overall utilization.
Regulations are on the way for insurers that are expected to streamline the process by requiring certain payers to implement electronic prior authorization.
Medicare Advantage (MA) growth was led by United and Humana, while nonprofit insurers lagged behind.
MA experienced record enrollment for the 2023 plan year as for-profit payers continued to grab a greater market share, according to analysis by The Chartis Group.
The healthcare consulting firm examined MA and Medicare data from CMS between January 2019 and January 2023 and found that MA grew 9.5% this year. The addition of 2.7 million beneficiaries brings MA enrollment to 30.7 million in total.
When Chartis originally released the report in February, the findings showed MA growth of 1.5 million members for 2023, representing a slowdown from previous years. However, after accounting for new CMS MA enrollment data, the updated research illustrates that MA is growing faster than ever.
While MA enrollment continues to rise, traditional Medicare remains on the downslope. The report revealed traditional Medicare lost 1.3 million members this year and has contracted by four million since 2019, all while Medicare as a whole has grown by 5.1 million beneficiaries.
"This shift has meaningful implications for health plans and organizations that serve seniors," the authors wrote. "The 'where' and the 'how' of generating enrollment by aligning with growth markets become increasingly important and nuanced."
Much of the MA growth this year was spurred by for-profit insurers, which accounted for 84% of the rise in enrollment. Nearly two in three enrollees came from United (44%) and Humana (21%).
Collectively, the 10 largest for-profit insurers make up 70.6% of MA enrollment nationally, with the top five payers accounting for 67.1%, the analysis found.
While nonprofit Blues plans earned a market share gain of 0.1 percentage point, the remaining nonprofit plans experienced a 1.1 percentage point share decline to continue a pattern from previous years.
"The competitive shift here is stark and will have implications for health plans looking to both enter and grow in this space, for organizations that partner with Medicare Advantage plans, and for healthcare providers that participate in their networks," the authors stated.
As MA commands more and more attention and eventually surges past traditional Medicare in terms of market share, the industry will follow to support its needs.
The insurtech is shaking up its leadership group, with co-founder and current CEO Mario Schlosser transitioning to President of Technology.
Oscar Health is handing the CEO reins to veteran healthcare leader Mark Bertolini as it continues to shore up its strategy for profitability, the company announced today.
Bertolini, who was formerly CEO of Aetna, will take over the role on April 3, with co-founder and current CEO Mark Schlosser moving to President of Technology, where he will lead product and engineering, focusing on Oscar's tech platform +Oscar.
Schlosser will continue as a member of the board, which will expand to include Bertolini.
"Oscar Health is an established challenger brand in the healthcare industry, pushing the boundaries of how insurance operates and delivers for members," Bertolini said in the press release. "I am proud to join the company at this pivotal time, and excited to cement Oscar's future as a leader in the industry."
During his tenure at Aetna, Bertolini established a reputation as a healthcare thought leader and led the payer from 2011 through its sale to CVS for $69 billion in 2018.
Most recently, Bertolini served as co-CEO of asset management firm Bridgewater Associates and in an advisory role to Oscar.
"I have worked closely with Mark in his role as a strategic advisor to Oscar for the past 18 months and it's become clear that we share a vision for the future of healthcare," Schlosser said. "By pairing my passion in tech with Mark's extensive expertise in building and scaling companies, we are well-positioned to continue to execute our strategy for profitability, set Oscar up for continued growth, and deliver enhanced value for our members and shareholders."
Oscar is hoping the hiring of Bertolini will accelerate it towards profitability, which has so far eluded the insurtech.
The company announced it suffered a net loss of $610 million for 2022 in its recent fourth quarter and full year earnings report, with revenue being offset by operating expenses.
Last year also saw Oscar lose a significant customer for +Oscar and the payer saying it will pause any new +Oscar deals through early 2024.
Insurtechs as a whole have struggled to achieve financial stability and 2023 could be telling for the future of several companies in the space.
Research reveals the financial discrepancies between Medicare Advantage (MA) and Medicare Supplement beneficiaries.
Most MA enrollees are satisfied with their plan coverage, but are more financially challenged than Medicare Supplement (Medigap) beneficiaries, according to an eHealth report.
The research surveyed 3,880 Medicare enrollees who purchased their coverage through eHealth in February 2023 to highlight how MA and Medicare Supplement beneficiaries differ in financial profile.
While both MA and Medicare Supplement enrollees are largely satisfied with their coverage, to the tune of 89% and 87%, respectively, MA beneficiaries are more vulnerable to higher premiums and other costs.
Of those surveyed, 73% of MA enrollees live on less than $50,000 per year, with 39% living on less than $25,000. In comparison, 50% of those on Medicare Supplement live on more than $50,000, with 31% living on $75,000 or more.
Income level contributes to 52% of MA beneficiaries saying they cannot afford any monthly premiums, with an additional 18% saying they cannot afford one of more than $25.
When it comes to out-of-pocket costs, only 37% of MA enrollees say they have enough savings to pay for hospitalization, versus 61% for Medicare Supplement beneficiaries.
Respondents have different worries for the future, depending on what plan they're on. For MA members, the biggest worry is not being able to afford their medical care in the future (chosen by 39%), while Medicare Supplement enrollees are most concerned with seeing their Medicare benefits reduced (selected by 32%).
"The challenges that lie ahead for Medicare Advantage underscore the importance of highlighting the financial vulnerabilities of millions of beneficiaries who depend on the program," said eHealth CEO Fran Soistman.
"We'll continue to advocate on their behalf with our carrier partners to ensure that enrollees' need for both affordable premiums and affordable out-of-pocket costs are given the attention they deserve."
As MA continues to grow exponentially, it will be important for benefits of an expanding membership group to be protected.
A survey reveals patients' experiences with challenging a bill with their physician, hospital, or insurance company.
Patients don't usually contend medical bills, but when they do their chances of getting charges removed or reduced are high, according to a YouGov survey commissioned by revenue cycle firm AKASA.
Over 2,000 Americans were polled between March 9-14, 2022, including 179 adults with employer-sponsored high-deductible health plans, to gauge patient experience with disputed medical bills.
Nearly two-thirds of respondents (64%) reported having never challenged the validity or accuracy of a bill with their physician, hospital, or health insurance company. That figure shot up to 78% for uninsured individuals, while those with high-deductible health plans (45%) and Medicare Advantage (43%) were more likely to contend bills.
"Despite all the negative experiences many patients have with getting surprise bills, we've been conditioned not to question or challenge medical bills we receive," said Amy Raymond, VP of revenue cycle operations at AKASA.
"While providers need to take a close look at their revenue cycle department to prevent those billing mistakes in the first place, we also need to drive awareness among consumers that they can indeed push back on a bill that is simply incorrect."
Of the respondents who had challenged a bill, 78% reported getting charges reduced or removed.
However, the time it took to resolve the disputed bill varied, sometimes taking longer than half a year. More than a quarter of respondents (27%) said it took one to three months, while 18% said it took three to six months and 16% said it took more than six months.
For providers and revenue cycle departments, ensuring the billing experience is as smooth as possible for patients can pay dividends.
According to a recent survey of 1,000 patients by RevSpring, 56% of respondents said they would likely switch providers if they had a poor billing experiencing, which was especially true for patients aged 18 to 26 (74%).
Patients value personalization and consistency, which means getting the bill right the first time.
Research into directories of UnitedHealth, Elevance, Cigna, Aetna, and Humana uncovers inaccuracies that can lead to surprise billing and delays in care.
Five of the largest health insurers have inconsistencies in 81% of their physician directory entries, according to a study published in JAMA Open Network.
Researchers from the University of Colorado School of Medicine and HiLabs searched physician information in the Medicare Provider Enrollment, Chain, and Ownership System database in online physician directories of UnitedHealth, Elevance, Cigna, Aetna, and Humana, based on physician name and zip code in September 2022.
The analysis considered a physician's information as consistent if it was the same among all locations or specialties across all directories in which the physician was found. Physician information was deemed inconsistent if the physician address or specialty was different across directories or if a physician was found in a directory without an address or specialty that was found in another directory.
Of the 634,914 unique physicians in the database, 449,282 were found in multiple directories, with just 19.4% of those having consistent address and specialty information across all directories they were found in.
Over a quarter (27.9%) of physicians had consistent practice location addresses, while over a third (67.8%) had consistent specialty information.
Among physicians who had only one practice location listed, consistency was 58.6% for address and specialty information, 84.8% for practice address, and 68.6% for specialty information.
"These results were driven by inconsistencies in addresses among physicians listed as practicing at multiple locations, which is concordant with prior research suggesting that most address errors stem from group practices reporting all physicians at all practice locations to insurers, irrespective of each individual physician's practice locations," researchers wrote.
The study highlights the unintended consequences of inaccurate physician directories, which includes but is not limited to surprise billing.
"Beyond surprise billing, inaccurate physician directories can lead to delays in care due to difficulty finding the correct physician, challenges in regulators assessing health insurer network adequacy, and misrepresentation of network depth and breadth as consumers select health plans," researchers stated.
The No Surprise Act requires health plans to maintain accurate provider directories, but the report notes how lack of standardization is making that a challenge.
When the administrative burden to inform and send updates to insurers falls on providers, the collective cost is $2.76 billion annually, according to a report by CAQH.
"This study's findings highlight the need for unified technology-enabled solutions, such as that proposed by the Centers for Medicare & Medicaid Services, which is seeking to create a single, centralized physician directory using modern interoperable formats," the authors concluded.
