The Behavioral Health Tech (BHT) Conference just keeps getting bigger and better.
The Behavioral Health Tech (BHT) Conference just keeps getting bigger and better — and has quickly become the must-see / must-be-at for mental health (MH) tech and telehealth insights.
Held this year Nov. 5-7 in Phoenix, AZ, BHT “is the largest conference focused on expanding access to mental health and substance use care through technology, health equity and innovation.”
In addition, BHT “convenes health plans, employers, behavioral health providers, digital health companies, investors, and policy makers to connect for the purposes of advancing access to behavioral healthcare for all.”
This multi-stakeholder focus was evident not only across the conference, but within BHT’s more than 45 panel discussions. BHT’s more than 225 speakers include “experts, innovators, those with lived experiences, advocates, and industry disruptors.”
From this representation, many key conference themes have emerged. Many are expected: what’s next for mental health policy, value-based care and innovative payment models. Others have become more nuanced, including:
health equity through the lens of behavioral health, neurodiversity, and the needs of younger populations;
treatment innovation via not only technology and AI but psychedelic and mindfulness alternatives;
a growing number of public-private partnerships sharpened by defining Whys;
substance use disorder (SUD) treatment and recovery strengthened through peer support; and
specialized care that requires includes safety, wellness, and workforce development frameworks.
While it’s impossible to summarize every session, these bullets emerged from panels that emphasized collaboration, funding, and meeting people where they are.
Panel Spotlight 1: Costly, Ineffective OCD Care Has Met Its Match — Through Gold-Standard, Specialty Telehealth Treatment With Significant Payer Savings
While 1 in 4 people will experience Obsessive-Compulsive Disorder in their lifetimes, it can take more than a decade to receive an accurate diagnosis. In the meantime, people suffer co-occurring anxiety, depression and other symptoms that can leave them homebound while spending tens of thousands of dollars on the wrong treatment.
This panel focused on the partnerships of two distinct health organizations — HCSC and Cigna-subsidiary Evernorth Health Services — with NOCD, whose telehealth-based OCD specialty treatment and community-driven therapy approach are driving significant per-member per-month savings for health plans and rapid time-to-improvement times for members.
Panel Spotlight 2: Federal Funding for Digital Behavioral Health: Strategies, Partnerships, and Real-World Wins
Every healthcare stakeholder recognizes the importance of partnership, in theory if not in practice. This includes nonprofits that rely on government funding such as Vibrant Health, a key partner in the national 988 Suicide & Crisis Lifeline. On the BHT panel, Vibrant was represented by new CEO Cara McNulty, who emphasized one of her key messages — being fierce behind your Why — while emphasizing what that sometimes means: understanding what you do best and relying on partners to protect your resources, ability to scale, and get collaborative results.
Panel Spotlight 3: Innovating Substance Use Disorder Treatment: New Approaches and Breakthroughs
This was the first of two panels that HealthLeaders moderated at the BHT conference. The SUD innovation discussion began with the dismal state of SUD treatment and how healthcare has failed to meet the needs of the population. It continued with better access; engagement; and care that is personalized, community-based, and peer-supported.
The panelists described a kind of captive hope in serving and supporting those with SUD and the importance of meeting people where they are. That theme continued in the next panel . . .
Panel Spotlight 4: From Crisis to Wellness: How Specialized Care Can Drive Outcomes
Delivering care to everyone who needs it was a shared objective in this specialized care panel, also moderated by HealthLeaders. For example, panelist and CEO Colin LeClair noted that even though his organization, Connections Health Solutions, is focused on emergency psychiatric care, that CHS attempts to triage patients to care they don’t provide.
Care for people with MH/SUD conditions includes non-clinical needs and social drivers of health (SDoH). Brooke Parish, Executive Medical Director of Behavioral Health at HCSC, described programs where the health plan has provided camping equipment for patients who are unhoused and do not take advantage of or can’t access other housing options. Amy Hawthorne, Director of Mental Health & Wellness from Canyon Ranch also noted the importance and effectiveness of alternative treatments based on whole-person, even spiritually-based care.
The panel’s two other experts — AJ Patel, President & CEO of TeleMed2U, and Lorena Roth, Senior Director, National Mental Health and Wellness at Kaiser Permanente — put a spotlight on the how their organizations address one of healthcare’s biggest challenges, particularly in MH/SUD: workforce shortages and their impact.
With the largest turnout since Behavioral Health Tech launched, expect attendees to apply multiple takeaways from this year’s BHT panelists and for next year’s conference to attract even more leaders and innovators in the MH/SUD space.
The fastest-growing MA plans and what's behind the 2x growth in enrollment and profit margin.
It’s no secret that Medicare Advantage payers are facing multiple market pressures: rising costs, higher utilization and the CMS payment model changes that HealthLeaders recently analyzed.
Amidst these pressures, one type of MA plan is doing just fine: Special Needs Plans, or SNPs.
These plans “restrict enrollment to specific types of beneficiaries with significant or relatively specialized care needs, or who qualify because they are eligible for both Medicare and Medicaid.”
In 2024, 6.64 million members were enrolled in SNPs (Kaiser Family Foundation-KFF). That number alone might not warrant a headline. But 88% of SNP enrollees are in D-SNPs, plans for members who are dually enrolled in both Medicare and Medicaid. KFF notes that these plans “have increasingly become the main source of Medicare Advantage coverage for dual-eligible individuals,” with nearly 30% enrolled in D-SNPs.
SNPs are the fastest-growing plans
There are three main MA categories: individual plans, employer/union-sponsored group plans and SNPs. Individual plans are still the largest segment of MA — 20.5 million, or nearly two-thirds of all enrollees in 2024. But they have declined as a share of total MA enrollment (71%) since 2010 (KFF).
SNPs are now the fastest-growing category, with enrollment growing:
more than 2x since 2019
16% between 2023 and 2024
to 20% of total MA enrollment in 2024
This trend continues. Among 2025 plan offerings, D-SNPs have grown 8% and C-SNPs by 21% — with United, Aetna and Devoted Health “all growing their D-SNP plan counts by double-digits” (Milliman).
How D-SNPs are doubling growth — and profit margins
More dual-eligibles with greater access to more plans with attractive benefits is driving D-SNP growth.
“Insurers use public CMS Medicare enrollment data to identify where there are dual-eligible beneficiaries but low D-SNP plan penetration,” says Jeannie Fuglesten Biniek, KFF’s Associate Director-Program on Medicare Policy. “They can capitalize with relatively low start-up costs.”
“This benefits members but can also make choosing a plan harder,” she adds. “A person may not need 43 plans to choose from but may need more than one or two to get the kind of targeted benefits that will attract them.”
All of these factors affect MA payer strategies and market decisions (e.g., changing benefit design to anticipate higher utilization). KFF looks for these “sticky levers,” says Fuglesten Biniek — as well as market exits — when analyzing MA plan offerings.
This includes D-SNPs, which are attractive to payers for two reasons:
Coding risk adjustments work in their favor. D-SNP members tend to have more health conditions, giving payers more opportunities to increase coding intensity. So, while CMS’s payment formula updates hurt other MA plan types, not so with D-SNPs.
It’s not more expensive to administer SNPs. This is true despite their added benefits (e.g., OTC, meals, transportation).
The last reason seems counter-intuitive. Given how difficult it is to keep healthcare efficient and cost-effective, how could this be easier for members with special needs? Fuglesten Biniek weighs in.
“It’s an open question whether plans are actually better at managing these populations or if the payment is so generous that it gives plans more room financially.”
“Yes, the risk model includes indicators for people with dual-eligible status which can increase payments beyond costs,” she adds. “Conversely, there is evidence that even people with more complex health status who enroll in Medicare Advantage are lower utilizers than similar people in traditional Medicare and for a variety of reasons” (e.g., the impact of referrals, prior authorizations).
The result is lower plan costs with bigger profit margins. Fuglesten Biniek notes that SNP margins are often double those of other plan types: 7.5% for D-SNPs compared to 3.6% on average for MA plans overall (2022 data; MedPAC’s March 2024 Report to Congress).
This is great news for payers but what about members?
While multiple sources have flagged D-SNP growth among MA trends, few have explored what happens when a growing and vulnerable SNP population is increasingly in the hands of fewer MA payers.
We’ll explore the far-reaching implications in our final article of this series. Stay tuned!
It's already an active season and we're just getting started.
CMS payment model changes, rising costs and higher utilization. In addition to these Medicare Advantage (MA) stories, which have dominated 2024, the past few weeks have been a cornucopia of new headlines. Their alternate versions might read:
Will they or won’t they? The Cigna-Humana deal appears back on the table. Since merger rumors swirled last year, Cigna’s stock price has boomed while Humana’s continues to drop.
The best $3.3 billion they ever spent. In January, HCSC signed a definitive agreement to acquire Cigna’s Medicare business (MA, Med-Supp, Part D and CareAllies). The deal is set to close Q1 2025 and will then be in regulators’ hands.
Medicare = Medicare Advantage = United HealthCare? If 54% of Medicare beneficiaries are enrolled in MA, and nearly 30% of that number is in the hands of a single private payer (UnitedHealthcare), what exactly is in the cards for Medicare, this "government" program?
AEP will curate these headlines further. In the meantime, HealthLeaders got a sneak peek from Kaiser Family Foundation (KFF) and its Associate Director-Program on Medicare Policy, Jeannie Fuglesten Biniek.
The conversation starts with a look-back to CMS’s risk adjustment changes. It ends with the one MA plan type that’s not only weathering market changes but growing in spite of them — and why that could be a problem.
The impact of the MA payment formula updates
Annually, CMS recalibrates its MA payment models through the lens of new data (e.g., how much it costs to treat diabetes now versus a few years ago, and for original Medicare beneficiaries compared to MA members).
Occasionally, those changes are much bigger and deserve the attention they get — representing changes CMS can make without involvement from Congress and because of their impact on health plan financials.
"Every couple of years, CMS updates these models in a more significant way, updating the actual payment formulas, including for associated disease categories," notes Fuglesten Biniek. "This is so health plans don’t just pick healthy people who cost less as members. The plans get higher payments for people who are sicker."
With its April 2024 payment rule update, CMS changed the algorithm that assigns diagnostic codes to address coding variability across MA payers. Depending on new data and analysis — including demographics like age and gender — payments for conditions like heart disease might be higher or lower (overall and compared to MA).
"This variability is less about changes in the conditions themselves and more about how plans code, are paid by CMS, and thus pay providers."
Coding manipulation to increase reimbursement from CMS is a private payer strategy. There is an entire sub-industry dedicated to helping health plans "upcode," which Fuglesten Biniek describes as plans receiving "higher payments than are justified and from a payment system that is set up to incentivize this because CMS pays more for people who are sicker."
Under pressure, stable or mixed?
About the payment formula changes, Fuglesten Biniek comments that "CMS could have gone further with its adjustments and is also phasing these changes in over three years to minimize impact."
You could have fooled MA payers. For much of 2024, the sky has been falling due to the aforementioned headwinds. Plans have sounded the alarm all year that there would be MA market impacts, and there have been — or as the new Milliman analysis put it: "Fewer plans, fewer carriers, and significant uptick in plan terminations."
Milliman recapped AEP 2025, noting that:
CVS and Centene "were drivers of the plan offering decreases, both cutting over 60 plans from their overall offerings."
Service area reductions also increased, again led by CVS (24%) and Humana (55%).
Cigna and Aetna also made significant market exits.
Six carriers exited the MA market entirely: Premera Blue Cross, Blue Cross and Blue Shield of Kansas City, Health Partners Unity Point Health, Care N’ Care, Moda Partners, and Western Health Advantage.
Premium and deductible changes are mixed, with some plans increasing one or both and others decreasing.
On the other hand, KFF notes a relatively stable market in its 2025 preview, with Fuglesten Biniek adding for HealthLeaders: "We’re still digging into 2025, but initial indications are that…exits seem mixed."
Meanwhile, one MA plan type is doing just fine
Since the end of 2023, industry-watchers have suggested that the Medicare "Gold Rush" is slowing down. While the CBO projects that MA penetration will reach 57% in 2025 and 64% by 2030, the percentage of individual and employer/union-sponsored group plans in the MA market has been slowing.
In fact, KFF notes that "individual plans have declined as a share of total Medicare Advantage enrollment since 2010 (71%)."
Meanwhile, enrollment in Special Needs Plans (SNP) has more than doubled since 2019, from 2.92 million to 6.64 million in 2024. SNPs "restrict enrollment to specific types of beneficiaries with significant or relatively specialized care needs." They include plans for those with chronic illness (C-SNP), who live in nursing homes or institutions (I-SNP), and those dually eligible for both Medicare and Medicaid (D-SNP).
While this is still a small percentage of overall MA enrollment, it is more than significant.
KFF adds that SNP enrollment increased by 16% alone between 2023 and 2024, and now accounts for 20% of MA enrollment overall. D-SNPs are driving this growth. In 2010, MA dual-eligible enrollment was just over 11%; in 2024, it was 29%.
The speed with which SNPs are growing leads us to one of Medicare Advantage’s biggest hidden headlines: A vulnerable population in the hands of an increasingly smaller number of dominant insurers as market pressures force others to the sidelines or entirely out.
HealthLeaders will explore this subject in our Medicare Advantage analysis.
Blue Shield of California CFO and endurance athlete Mike Stuart shares new requirements for today's financial leaders.
If being a CFO is a marathon not a sprint, then being a new kind of CFO might just be an ultra-marathon.
Mike Stuart would know. The Blue Shield of California CFO is an ultra-athlete who loves a challenge, intellectual and physical. He’s completed multiple long-distance and endurance races in his years as a financial officer. When the pandemic shut races down, Stuart created his own: running every street in his hometown and organizing an unofficial two-person marathon to raise money for a local food bank.
“People have asked me ‘Why do you do these things? They seem hard.’ It’s because the lessons apply not just to personal growth but professional. When you do hard things, you learn more about what you can do.”
In this exclusive interview with HealthLeaders, Stuart shares the skill set and the mindset that today’s healthcare CFOs must demonstrate.
The Triathlon: Three skills for CFO strategic thought leadership
“More than ever, a key part of the Chief Financial Officer role is being a highly effective strategic thought partner for the senior leadership team,” says Stuart. “I think it’s become more of the expectation for a high-performing CFO.”
Stuart has had time to think about this during his many triathlons, including Ironman Lake Tahoe 2015, Ironman Sacramento 2023, Escape from Alcatraz Triathlon, and Wildflower. He’s not sure at what point along those swims, bikes, and runs that the need for a new kind of CFO emerged, but he’s well-versed in what it requires.
“I’d say probably for the last 10 years there’s been more dialog and discussion around the emerging role of CFO. It’s well beyond managing the finances and reporting on the numbers. It’s understanding the business and effectively calling out the opportunities, the risks — and most importantly, what we do about them.”
Like the three legs of a triathlon, Stuart has identified three skills CFOs need to lean into their strategic leadership role:
Integrated planning
Collaboration
Communication
“Establishing and maintaining a truly integrated planning process is critical: Strategic, financial and operational,” notes Stuart, adding:
“All too often, there can be disconnects between the different handoffs. The CFO and their function play a key, coordinating role because the CFO team tends to have interactions with all parts of the company. It’s important to ensure things are connected — all the way from a strategy formation perspective so you can hit the milestones and hit the outcomes.”
Also critical is understanding your business partners and their operations, or as Stuart describes it: “really leaning in and getting curious as to what it takes for them to be successful.”
“When we're at a table together trying to take a different path forward, it isn't a one-way dialog — it’s what do we need to do to be successful together, to really make an impact for our members and patients.”
Stuart adds: “This requires a level of communication that I’ve found to be really fascinating.”
“As a finance professional, being a highly effective communicator is more important than ever. Health plans are a complex business. Never assume that everyone understands all of the nuances. Taking the time to set context and educate people is really, really important.”
The Marathon/Ultra: How CFOs meet healthcare’s biggest challenges
In addition to triathlons, Mike Stuart has run multiple long-distance races: Los Angeles Marathon (his first at age 22), San Franciso Marathon, North Face San Franciso Endurance Challenge 50k and Marathon, and several Way Too Cool 50ks.
Ultra-race performance may not be quite the same as health plan CFO performance, but both require a shift in perspective:
Knowing the status quo: “It’s really hard to change how the industry is structured. It’s inherently flawed, and there are misaligned incentives. The trajectory, from a cost or affordability perspective, is unsustainable.”
Challenging the status quo: “Getting that to shift is going to require a lot of collaboration with all sectors of the industry. We’re at that inflection point. It needs to change and it needs to change now.”
Changing the status quo: “You’re going to need to take some risks, to assess and select the right opportunities — whether it’s new ventures or partnerships. Making significant investments in more innovative, transformational initiatives is going to be critical.”
The Adventure: How to become a CFO strategic thought partner
Beyond triathlons, marathons and ultras, even Stuart’s favorite hikes are epic: from the Grand Canyon Rim-to-Rim run and bikepacking the Lake Tahoe Rim Trail to the GORUCK Tough Challenge and 29029 Everesting.
Stuart may not be able to choose every adventure, but he has great advice for other strategically minded CFOs:
Thought: “Be a continuous learner, not just within the Finance domain. Really understand the business.”
Action: “Have a strong bias toward action” — This goes back to Finance teams seeing a lot and doing something about what you’re seeing, whether at risk or opportunity, is critical and needed.”
Intention: “Work beyond your job description. If you see an opportunity, pursue it. That gets noticed. It adds value.”
Stuart adds: “Finance teams see a lot of data and information. They tend to know where the risks are, where the opportunities are. There’s a great need for the Finance team, the CFO, to communicate them back to the organization — not just sharing information but really having insights into what to do with it and in a way that can be absorbed, digested and acted upon.
The Results: Being a CFO at Blue Shield
As a strategic partner, Stuart applies thought, action and intention to key efforts at his plan, Blue Shield of California:
Know the Score (KTS): Described as “the fastest 30 minutes at Blue Shield,” the KTS monthly call makes teams aware of plan performance, how the business works, and how their work connects to sustainable outcomes.
2% Pledge: As a nonprofit, Blue Shield caps its income at 2% of revenue.
A Different Kind of Value: “‘What does it mean to be a finance professional in a nonprofit? We're not publicly traded. Rather than measuring shareholder value, are we driving and increasing member value? Are we making access to high-quality healthcare more affordable? You can quantify that, and it really helps us prioritize.”
“It’s all a challenge, but it’s also really rewarding work because making things more affordable impacts everybody. That’s top of mind for me.”
Relating these professional goals to his personal ones, Stuart adds a final piece of advice for emerging CFOs: “You’re building a muscle and confidence. You go from ‘Wow, this is really uncomfortable’ to ‘This is exciting.’”
“Just do a few reps. You’re going to figure it out and get to the end of the project or the race and come out stronger for having grown.”
For everything from GLP-1 and cancer costs to provider networks, one employer association has strategies — and they don't involve the major carriers.
In a press release for its 2024 Best Practices in Healthcare Survey, WTW notes: "To navigate the current healthcare environment, companies need to proactively address cost challenges and implement effective risk management strategies…By doing so, they can mitigate financial risks, support the wellbeing of their workforce and achieve long-term sustainability."
How do they do it and what could it mean for employers? Learn more from ACHRM's Nine-Pronged Strategy and HealthLeaders' exclusive interview with AHCRM CEO Bill Lacy.
Helping self-funded employers rethink their self-funding methodologies
Self-funded employers pay for their employees' health insurance claims, contracting with a third-party administrator — usually one operated by a big national carrier — to handle things like billing and claims.
AHCRM promotes "the benefits of engaging an independent non-insurance carrier …[and] pharmacy benefit managers (PBM)." The goal for employers is "rethinking your firm's self-funding methodology [to] benefit your bottom line, employees, but also medical professionals."
As mentioned in Part 1 of this series, ACHRM has introduced its 2024-25 Strategic Plan to help employers achieve these goals and comply with the Consolidated Appropriations Act (CAA). This 2021 act requires employers to act in the best interests of their employees and offer quality, affordable group health coverage.
ACHRM's strategies include but are not limited to:
Reigning in GLP-1 costs
Targeting cancer costs
Developing employer-provider partnerships
Here are the details . . .
Strategy: Target GLP-1 costs
A single class of drugs is responsible for a tipping point in prescription drug coverage and cost management: GLP-1s for weight-loss.
As WTW noted in its survey: "Employers are still contending with the continued demand for high-cost weight loss medications. While most employers are maintaining coverage for obesity medications with some restrictions, those not offering coverage today state cost and safety as the biggest barriers."
WTW adds that employers "are eager to consider safe and effective lower-cost alternatives."
This includes the employers that belong to ACHRM, says association CEO Bill Lacy.
"There's pandemonium in the marketplace as consumers are bombarded with weight-loss drug advertisements generating a tidal wave of inquiries to their employers regarding accessing these newer medications. If employers cover these medications, weight-loss drugs are quickly becoming one of their top drug spends."
In line with ACHRM's independent TPA/PBM approach, Lacy adds: "Unfortunately, employers are not receiving any guidance from the manufacturers or Big Four PBMs (CVS/Caremark, ExpressScripts, Optum). ACHRM's Pilot is to develop and test ‘guardrails,' such as lead-in and exit strategies, weight-loss and behavioral management programs, and strategies for side effects, compounding, PBM rebate manipulation, among other issues."
Strategy: Rethink PBMs — And just about everything related to prescription costs
ACHRM's approach is well-timed. The WTW study noted that employers have "strong interest in alternative drug channels and pricing":
27% would consider a smaller PBM with alternate pricing models
17% expect to have acquisition cost PBM contract structures
73% plan to gradually carve out pharmacy benefits from medical
21% may use drug discount cards or direct-to-consumer prescription delivery
18% may also allow employees to buy prescriptions from retail or "cost plus" outlets
Prescription drugs are just one of the high-cost areas employers contend with. Cancer treatment is another.
Strategy: Partner with independent oncology providers
Lacy notes that cancer is the most expensive condition for employers to target.
"Employers can manage cost-savings in multiple ways, but then cancer costs hit them hard. The pandemic delayed screenings, so now cancer claims have become significant after flat periods. Employers are now seeing million-dollar claims for cancer and 10-20% cost increases, even with an independent TPA strategy."
ACHRM is developing pilots that stress prevention and direct contracting between employers and oncologists.
"We need to be more forward-thinking on prevention, like screenings, and focus on ineffective treatments with high costs," says Lacy, adding that AHCRM already has pilots in New Jersey and Arkansas. "It's still costly but much less. Payments are faster, more direct and represent a partnership."
Strategy: The importance of including the medical community
Employer-provider partnerships take us full circle to a key from Part 1 of this series and the WTW survey data.
More employers want to take control of provider networks from their contracted health plans and third-party administrators. In the WTW survey:
30% of employers are exploring narrow networks
25% are also exploring centers of excellence
43% of employers plan to require re-bids from their health plans and vendors
The objective of all of these strategies is cost control. Again, ACHRM recommends employers consider more flexible and affordable alternatives: Contracting with non-insurance-carrier-based TPAs and PBMs and direct contracting with providers.
"For their TPAs, self-funded employers traditionally contract with BUCA [BlueCross plans, UnitedHealthcare, Cigna, Aetna]," says Lacy. "Most markets are dominated by a big payer and PBM. These middlemen are expensive and, in many ways, unnecessary."
The ACHRM CEO adds: "There are hundreds of challenged markets across the country that need this thinking to make this model successful." This includes what Lacy calls "rural, monopolistic markets [where] 30-50% of revenues go to these intermediaries [BUCA and their PBMs]."
ACHRM's proposal is to "replace both of them — to take the intermediaries out and bring employers and the medical community together. It's a win-win."
A win-win that more self-insured employers may be ready for.
You've seen the WTW stats: Employer health costs are rising exponentially. But have you seen the surprising solutions? Including how one unique employer association is meeting the moment.
Get ready to add more "What It Means" slides to your next employer healthcare cost strategy deck.
At a time when Medicare Advantage plans are responding to higher costs and utilization by pulling back, American's employers are choosing a different path.
"To tackle high prices and other causes driving increased spending, companies are pursuing initiatives that are beyond cost-shifting," says Tim Stawicki, WTW's Chief Actuary of Health & Benefits.
WTW's 2024 Best Practices in Healthcare Survey shows that while nearly half of employers believe that healthcare costs will exceed budget projections, more than half will respond with better plan/network design and other strategies designed to better support their workforce. The June-July WTW survey included 417 companies that employ 6 million employees.
In addition to more WTW survey highlights, this HealthLeaders feature follows the thread of employer cost-control strategies and the unique efforts of one collective — the Association for Corporate Health Risk Management (ACHRM) — to help self-funded employers rethink their funding methodologies.
Employer Strategy 1: Providers over premiums, design over deductibles
Employers project a 7.7% increase in their healthcare costs in 2025 — up from 6.9% in 2024 and 6.5% in 2023. Given these statistics, it's no surprise that 52% of employers from the WTW survey plan to implement cost-control programs. But how they plan to do it is.
The WTW press release notes that "employers are embracing different approaches to safeguard program affordability for their companies as well as for their employees. While focusing on more competitive, cost-effective plan designs to control costs, they are seeking to maintain employee wellbeing." In the WTW employer survey:
51% say they'll "adopt plan design and network strategies that steer to lower-cost, higher-quality providers and sites of care"
Only 34% plan to shift costs by increasing employee premiums
Just 20% will promote high-deductible health plans (HDHP)
This is an about face from what we've been taught about healthcare cost control, namely that cost increases must be passed to the consumer, whose utilization choices will be guided by high-deductible plans. They often are, but adversely.
As described in We've Got You Covered: Rebooting American Health Care: "The idea is to give patients a bit of ‘skin in the game' so they don't immediately race to the doctor every time they have a sniffle. Or cancer."
"With cost increases reaching a post-pandemic high, companies are concerned about the burden it's putting on their workforces, especially since it affects decisions about insurance coverage and care," WTW's Stawicki notes.
Employer Strategy 2: More direct contracting please
Not that delivering lower-cost, higher-quality care is easy. If it was, healthcare would be solved.
Rather, these steering strategies signal that more employers want to take control of provider networks from their contracted health plans and third-party administrators. In the WTW survey 30% of employers indicate they are exploring narrow networks and another 25% centers of excellence.
Employer direct contracting should put health plans on notice. In fact, 43% of employers plan to require re-bids from their health plans and vendors in their "proactive efforts to control costs over the next two years."
Enter ACHRM, "the only National Employer-Based Association, Think Tank offering alternatives to traditional health insurance carrier health risk management strategies."
The organization is in the midst of its Nine-Pronged 2024-25 Strategic Plan, which includes provider approaches. For example, Strategy 5 calls out the negative impact of hospital consolidation, especially in rural communities. ACHRM's solution is to "launch and advance employer-medical professional partnerships in monopolistic, rural and underserved pilots to improve access to high quality care at lower costs."
Addressing the "multiple layers between physician and patient," including employees and their employers is another ACHRM strategy.
Strategy Spotlight 3: Care for key conditions
A focus on key health conditions is another strategy employers plan to use, including these from the WTW survey:
obesity and weight management (40%)
cancer and oncology (34%)
cardiovascular health (28%)
women's health (27%) including fertility services
These are but a few of the conditions and strategies employers will focus on to "support affordability and employee wellbeing."
Part 2 of this employer deep dive will focus on GLP-1s, other WTW findings — plus an exclusive interview with ACHRM's CEO Bill Lacy on how self-insured employers can rethink their funding methodologies. Stay tuned!
The new CEO of Vibrant Emotional Health and former leader at CVS Health shares a masterclass in executive decision-making.
In July, Cara McNulty became CEO of Vibrant Emotional Health after serving as President of Behavioral Health and Mental Well-Being at CVS Health. It was a big change but met all of McNulty's leadership Whys.
In recognition of National Suicide Prevention Month and following 988 Day on Sept. 8, Cara McNulty spoke with HealthLeaders about how she makes the big decisions — for publicly traded payers and nonprofits alike.
From local to nationwide crisis lines
Two years before Cara McNulty took the helm at Vibrant, the National Suicide Prevention Line transitioned from a 10-digit crisis line number to the three-digit 988 Lifeline. 988 is overseen by lead federal agency SAMHSA, which has entrusted Vibrant to be a part of the network of providers supporting 988, offering essential administrative services to those seeking help.
For more than 50 years, Vibrant Emotional Health has run multiple crisis lines — from the local NYC 988 to the NFL Life Line. Its role now includes 988, an expansion McNulty is proud of as Vibrant's new CEO.
"It took decades to develop 911. For 988's development, Vibrant used best practices plus its tremendous experience. As a broad-based organization, we had a lot to offer."
Those offerings include the infrastructure for 988's technology platforms and the more than 213 mental health centers that Vibrant contracts with across the U.S. for call routing.
"We make the experience seamless for the end user," says McNulty, adding. "Vibrant is really embedded, understanding the community so we can meet the needs of the community."
This includes those with unique needs — veterans, the LGBTQ+ population — and what is most important to meet them in moments of crisis. It's an approach McNulty describes as "Not about me without me" and one that illustrates the importance of "knowing your Why."
"What's your Why? Start with that," she advises. "If you're not fierce behind your why, you're not going to be your best."
For McNulty, this principle applies personally and professionally — and is the first of many she deploys in her executive decision-making.
Executive Playbook: How to choose the right leadership role
McNulty knew her Why when she joined Vibrant: The opportunity to be a population health leader in an entirely new way. Three of her decision factors were:
Optimal reach: "I thought about the healthcare ecosystem, where I've been and what more I could do. I always want to have population-level impact — doing the most for people I may never meet."
Optimal environments: "I also thought about ‘How do we create psychological safety in our work environments.'"
Optimal place: "I asked myself: ‘Where is all this happening and most needed: A startup? A tech-forward company that supports mental health?'"
McNulty concluded: "All roads kept leading me back to an area where I haven't been, kept leading me here to Vibrant. It was a really neat process."
Executive Playbook: How to transition to nonprofit leadership
Still, leaving CVS Health wasn't an easy decision.
"I learned more there professionally and personally due to the organizational size, the infrastructure, the total impact you could have. What a powerful experience. I've never had a harder role — ever," says McNulty, noting that it began just one year before COVID.
McNulty's new role involves another big shift. CVS Health is a publicly-traded, for-profit company. Vibrant Emotional Health is a nonprofit.
"There are a ton of similarities — mainly because most people in the mental health ecosystem know their Why."
She adds, however, that many things are different: "Probably the biggest change for me is that I'm used to a lot of form and function. [At a nonprofit, y]ou don't have five financial systems to choose from; you have one, and we have to make sure we have the right things in place."
For McNulty, those right things include:
Deep work over decks — "Another difference is that people have less time to spend on the basics, like developing decks. There's just too much work to get done. We can't fall prey to perfection and use time we could spend on strategy and innovation."
"The muscle of fiscal accountability" — On the importance of this key skill, McNulty notes: "My past experience has brought financial rigor and understanding the importance of partners."
"Not just good . . . Exceptional" — McNulty prizes this in a leadership team, stressing the importance of accountability, curiosity, advance thinking and being driven by measures and outcomes.
She adds that nonprofits can "move faster and have some agility."
This is critical for McNulty's charge: to lead Vibrant through its stage of scaling and growth.
Executive Playbook: How to scale, smartly
In the coming years, Vibrant will continue to scale 988 and offer broader services beyond its crisis line and programs. This includes policy, advocacy, support, and community engagement.
"We are assessing where Vibrant is best across the mental health ecosystem and where we can leverage our skills to expand." Those skills include:
Keeping it simple: "It's really easy in complex mental healthcare systems to make it complicated for the people who need care and support and their loved ones. There is so much noise. I don't want to create more."
Collaborating across the industry: "I want us to collaborate and partner with the ecosystem so every organization is working at the top of its ability, not tripping over each other."
Maintaining focus: "Where do we add the most value and why? What are our sweet spots and where should we back away because others do it better?"
McNulty notes that some of Vibrant's programs will probably remain only in New York because they are population specific. Those that will scale are relevant to many populations and scenarios (e.g., young adults, providing upstream support before someone is in crisis).
Keeping the main thing, the main thing
Cara McNulty's executive playbook ends where it began: The importance of Why.
"I know exactly why I get up every day to do this job. I don't want people to suffer in silence, to think that they're less than and not worthy. Everyone brings value."
"It takes all of us. I have learned how easy it is for us to point fingers at one or two partners. It can be easy to do that when the system is complicated. But no one can do it by themselves."
She adds: "We all play a role, and I just feel so fortunate to be here."
A memorable healthcare debate moment in an election year focused largely on other issues.
A new federal regulation went into effect Sept. 1, 2024, that once again limits the coverage term of short-term limited-duration insurance (STLDI).
If Sept. 1 came and went without you noticing, you're probably not alone. If you did notice — and watched Tuesday's Presidential debate — you might wonder if Donald Trump's "concepts of a plan" to improve the ACA could once again include STLDI if there is an Executive branch party change come November.
The "concepts of a plan" remark came after ABC News co-moderator Linsey Davis asked Trump about his plans for an alternative to the ACA, with the former president adding: "If we can come up with a plan that's going to cost our people, our population, less money and be better health care than Obamacare, then I would absolutely do it . . . But until then I'd run it as good as it can be run."
When STLDI was part of the plan
In its recap of the exchange, The New York Times noted that "the congressional plans he [Trump] later endorsed as president would have decreased insurance coverage overall, cut funding to states, and erased protections for many Americans with pre-existing conditions" — adding that "Congressional Republican leaders . . . have shown little appetite for advancing such bills again."
It's worth noting that expanding STLDI coverage was a plan that Trump executed during his Administration. While STLDI plans are designed to provide a stop-gap when individuals lose their health insurance (e.g., after a job loss), the Administration's 2018 rule expanded coverage from six months to three years, a term that the Biden Administration has reduced again, this time to four months.
The ACA's awkward years
The ACA was at first "broadly unpopular". This includes the Marketplace — from its early years, when premiums were higher and many large insurers had temporarily exited the Exchanges, to as recently as 2020.
But even in this climate, STLDI never took off as an ACA alternative. Earlier this year, HealthLeaders explored this proposition in a two-partseries. Our coverage noted that STLDI:
lacks the federal coverage mandates of Marketplace plans: 10 Essential Health Benefits, out-of-pocket maximums (MOOP), free preventive services, and no denials for pre-existing conditions;
is also often much cheaper and the benefits it may exclude aren't benefits that younger, healthier, childless individuals may need; and
lack of data makes it difficult to demonstrate its real costs and value, although it is widely viewed as "junk insurance" when used as a form of comprehensive coverage.
And now, times have very much changed. The American Rescue Plan Act of 2021 (COVID-19 relief) increased and expanded Marketplace subsidies. As The Times noted: "Almost 50 million Americans have signed up for plans through the Affordable Care Act's marketplaces since 2014 . . . [while m]illions of lower-income Americans now have Medicaid coverage in states that expanded the program" through the ACA.
Past is prologue
Forbes'coverage of the Presidential debate noted that Harris's plan would be to "maintain and grow the Affordable Care Act" while continuing to support Medicare and Medicaid. The Times coverage, meanwhile, quoted a Trump campaign spokesperson that POTUS 45's "overall position on health care remains the same: bring down costs and increase the quality of care by improving competition in the marketplace."
A Harris Administration's would surely maintain and grow, not change, the new STLDI coverage term limits. And it's far more likely that a Trump Administration would improve competition in the marketplace by improving competition with it. If past is prologue, that could once again include enrollment options for longer-term STLDI plans — just not at critical mass.
Coverage for substance use disorder varies but the view from 2024 looks so much brighter.
Created by SAMHSA in 1989, the goal of September’s National Recovery Month is “to promote and support new evidence-based treatment and recovery practices, the nation’s strong and proud recovery community, and the dedication of service providers and communities who make recovery in all its forms possible” (Substance Abuse and Mental Health Services Administration, a branch of HHS).
In recognition of National Recovery Month, HealthLeaders examines where substance use disorder (SUD) coverage has been, recent changes, and the additional factors that influence access, outcomes and long-term recovery.
A little history: Treatment, parity and coverage
SAMHSA defines recovery as “a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential.” Since 2000, recovery-oriented systems of care (ROSC) have been a growing focus of substance use disorder (SUD) treatment.
Treatment
In terms of SUD treatment, ROSC represents a shift — from the long-standing acute-care model to one that views SUD like other chronic illnesses (e.g., diabetes, asthma; McLellan et al. 2000) with multiple focus points including: engagement and assessment; service integration, planning, options, and duration; and long-term maintenance with the help of a broader personal, professional, and community network (Slaying the Dragon: The History of U.S. Addiction Treatment And Recovery in America, William L. White).
Coverage
In Slaying the Dragon, White cites the role of payers in the development of ROSC, “who were tiring of paying for multiple treatments without measurable recovery outcomes.”
But it got worse before it got better. The Recovery Research Institute notes that “the advent of managed care in the 1990s . . . greatly reduced access to formal addiction treatment by tightening insurance reimbursement for care.” This began to change with the Mental Health Parity Act of 1996 (MHPA), which mandated that large group health plans could not limit mental health benefits differently than medical/surgical benefits (annual or lifetime dollar limits; CMS).
Parity
While the MHPA was a first step, it did not include SUD benefits. It wasn’t until 2008 that Congress added SUD to parity legislation (MHPAEA, or The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008). And it wasn’t until 2010 that the ACA required that health plans provide SUD/MH coverage if they wanted to participate in the Marketplace.
But what is the current state of SUD coverage across multiple payers — and how is it evolving?
Medicare SUD coverage is limited but expanding
Data from 2020 shows that approximately 3% of Medicare beneficiaries had a past-year SUD (1.7 of 61.5 million) — but that only 11% sought treatment due to insufficient coverage and high cost of care.
Current Coverage: Historically, Medicare has only covered hospital- or outpatient-based SUD treatment.
Developing: CMS has added some coverage for intensive outpatient (IOP, or treatment beyond traditional OP services), and new legislation would grant access to residential SUD care in non-hospital settings (Residential Recovery for Seniors Act, introduced just last month).
Medicare Advantage coverage varies
With MA growing as a percentage of overall Medicare enrollment (54% in 2024), it’s important to look at this subset related to SUD.
Current Coverage: The Kaiser Family Foundation notes that despite this growth, “not much is known about the scope of mental health and substance use disorder benefits covered by these plans” — including OOP limits, the use of prior authorization and resulting care delays/denials — as well as SUD provider network access. What was known as of 2022:
Inpatient: MA must cover what Medicare does (Part A) but only 12% of plans offered extra SUD/MH benefits
Outpatient: Again, MA matches Medicare (Part B) but plans required and varied in their cost-sharing.
Out-of-network: 60% of plans offered no SUD/MH coverage.
Developing: The traditional Medicare IOP additions should cascade to MA plans as part of Part B coverage. Beyond this, SUD coverage is at the discretion of MA plans.
Medicaid MCOs are in the driver’s seat
Medicaid MCOs cover the majority of Medicaid enrollees, who have a higher prevalence of SUD (more than 20%) compared to 16% of commercial enrollees; KFF).
Current Coverage: Despite prevalence and major progress, including enhanced access/services, half of states do not require full SUD coverage via their contracted MCOs. A July 2024 Health Affairsstudy of 33 states and Washington, DC found that while most required that MCOs cover common SUD treatments without annual maximum out-of-pockets and cost sharing:
Many states leave SUD coverage requirements entirely to MCO discretion
Less than one-third of states kept MCOs from applying prior authorization to services
This increased to less than two-thirds of states for medication PAs (drug testing, step therapy)
Developing: New York state is an exception — adding “teeth” to parity law by fining Medicaid MCOs for denials and unpaid specialty care. While these fines applied to MH claims, it’s not a far stretch to expect SUD-related fines and that other states may follow suit. In addition, At least three state Medicaid programs (AL, AR and CA) operate under 1115 waivers that specifically address SUD.
Commercial payer coverage: Workplace versus Marketplace
Collectively, SUD among commercial enrollees is 16% (KFF).
As mentioned, 2008 legislation applied SUD parity to large group health plans (e.g., employers with more than 50 employees) and to other insurers that offer SUD/MH benefits.
Workplace: While it is difficult to quantify employer SUD coverage, one thing is certain: It is costing companies and their health plans a lot, and they are struggling to ensure sufficient provider networks. A 2023 JAMA study found:
1.4% of employer plan members had an SUD diagnosis (2.3 of 162 million).
Annual attributable medical expenditures were nearly $16,000 per enrollee
Across the entire population, these costs were $35.3 billion.
Despite this prevalence and cost, a 2023 KFF annual Employer Health Benefits Survey showed that only 59% of employers offering coverage believe there are enough in-network SUD providers to provide timely access and care.
Marketplace: The ACA brought parity to Marketplace plans by defining SUD (and MH) as one of 10 essential benefits that payers must provide. While SUD is an essential benefit, states can nuance coverage via the benchmark plans they must submit to CMS. In addition, in its 2025 Marketplace rule, CMS has defined SUD cost-sharing ranges for the new standardized Marketplace plans:
Inpatient hospital SUD: $350 to 50%
Outpatient SUD office visit: $0-50
Progress, not perfection
There cannot be parity without coverage but there cannot be care without provider access or service use. The 50% coinsurance for inpatient treatment shows that even when legislation mandates coverage, costs may prohibit care:
Medicare: The previously cited 2020 data showed that only 11% of the 1.7 million beneficiaries with an SUD sought treatment.
Medicaid: ACA expansion increased SUD coverage but multiplestudies have shown that access did not increase treatment rates.
Reasons varied. Medicare beneficiaries cited still-insufficient SUD coverage and high cost of care. The Medicaid studies cited lack of accessible treatment, particularly in rural areas. Of note, CMS did not extend provider network adequacy standards (time and distance) to SUD providers in its 2025 Marketplace plans rule.
SAMHSA cites access to affordable, high-quality SUD coverage and treatment as one of several policy recommendations to support recovery. Legislation and regulations have expanded coverage and parity.
Engagement, innovation, reimbursement, equity and integration will advance the SUD field even further. About alcohol use disorder specifically, the Recovery Research Institute writes: “In the past century there have been dramatic socio-cultural, scientific, and political shifts in how alcohol use disorder is perceived, understood, and treated . . . At the same time, stigma has reduced” as perceptions about SUD shift from the moral to the medical.
Many SUD challenges remain, but so do the opportunities. If we in recovery can sustain not only our sobriety but our hope and capacity for transformation, the healthcare industry can too.
Medicare Advantage makes up 54% of overall Medicare enrollment, with 64% penetration estimated by 2033. But will 10% growth over the next nine years be enough for today's market leaders? Plan executives at Aetna, Centene and Humana have either already announced or anticipate MA market exits and/or membership declines for the upcoming enrollment year.
MA now enrolls more than half with more growth projected through 2033
We've known for some time that Medicare Advantage enrollment would and has eclipsed original Medicare. But how much growth is left in the tank?
MA as a percentage of total enrollment eclipsed 50% in 2023 when its market share was 51%. This is up from just 19% in 2007. Since then, MA penetration has grown from 1-3% annually and was at its highest, 4%, from 2020 to 2021.
In 2024, MA penetration reached 54, and the Congressional Budget Office projects it to be 64% by 2033. The last Baby Boomers will age into Medicare by 2030. That equates to essentially 1% growth per year, the lowest annual rate since 2014-2016.
This and other factors — lower payments from CMS, slower growth from MA leaders, and market consolidation — led The Wall Street Journal to note last year that the "Medicare Gold Rush" was slowing down. Add to this higher payer costs due to higher post-pandemic member utilization — and increased government scrutiny over MA prior authorization, marketing, and brokers — and the path to 2033 looks shakier indeed.
Despite rumors of its demise, the Medicare gold rush is still very much on in select markets
For the time being, the MA market share is already higher than the national percentage in select states and counties.
While MA's share of the Medicare pie is as low as 2% in some states, it is 60% or more in seven states — AL, CT, MI, HI, ME, FL, RI — and in Puerto Rico. This is compared to just three states in 2023.
The proportion of counties with MA enrollment at 60% or more is even higher — 37% in 2024. While 8% of beneficiaries live in a county where MA enrollment is less than one third, the other end of the spectrum shows MA penetration at 80% or more in counties in Florida (80% in Miami-Dad), New York (82% in Monroe) and Texas (81% in Starr).
As KFF notes, this variation reflects "several factors, such as differences in firm strategy, urbanicity of the county, Medicare payment rates, number of Medicare beneficiaries, health care use patterns, and historical Medicare Advantage market penetration."
Two payers control nearly half of MA enrollment; three control more than 60%
Two names have dominated MA since 2010: UnitedHealthcare and Humana. In those 14 years, United's market share has grown (20% to 29%) while Humana's has stayed relatively consistent (16% to 18%), including since 2017. By the numbers, United's MA enrollment was nearly 9.4 million in March 2024; Humana's was just over 6 million.
CVS Health/Aetna has also been in growth mode since 2010 (from 6% to 12% market share). The payer had the largest growth year over year, more than 758,000 members between March 2023-March 2024.
Every other major MA player has declined:
BlueCross BlueShield: 15% to 14%
Kaiser Permanente: 9% to 6%
Centene: 6% to 3%
Cigna has exited MA altogether. With a market share that was already low and declining — from 3% in 2010 to 2% in 2024 — the commercial payer sold its MA business to Blues-affiliated HCSC in 2024.
All other MA insurers combined account for 16% of the market — just over 5.1 million members and a decline from 24% in 2010
Most MA members have individual plans but that percentage is decreasing
Some 62% of MA enrollment comes from individual plans, but that percentage is steadily declining.
Since 2010, individual plans as a percentage of enrollment have shrunk by 9% — from 71% in 2010, with declines in every year but one.
Meanwhile, enrollment in Special Needs Plans (SNPs) as a percentage of overall MA has grown significantly, from 12% in 2010 to 20% in 2024. SNPs are available to beneficiaries who are dually eligible for Medicare due to age and Medicaid due to lower income (D-SNPs). They are available to individuals with chronic illness (C-SNP) and those who live in institutions such as nursing homes (I-SNP).
Last year, SNPs overtook group plan penetration, whose enrollment has resembled a bell curve over the past 10 years (cresting from 17% to 20% before declining back to 17%). SNP enrollment has more than doubled — from 2.92 million to 6.64 million — since 2019 alone.
D-SNP makes up 88% of SNP enrollment, C-SNP 10%, and I-SNP 2%.
KFF attributes this growth to "the increasing number of SNP plans available on average and more dual eligible individuals having access to these plans" — supply and demand.
The 2025 Annual Enrollment Period
In addition to rapid SNP growth, KFF notes that "Medicare Advantage enrolls a disproportionate share of people of color in Medicare" and that Medicare "pays more to private Medicare Advantage plans for enrollees than their costs would be in traditional Medicare" — 122% or an estimated $83 billion in 2024.
While overall MA growth may be slowing compared to recent years and payer projections, these and other factors will make AEP 2025 worth watching.
