The Center for Medicare & Medicaid Innovation (CMMI) will break its own rules to test new models.
New alternative payment models (APM) underperformed during CMMI's first decade. CMMI hopes that a focus on primary-specialty care integration will improve outcomes during its next 10 years.
CMMI's new report includes progress made across five strategic categories and a roadmap to continue advancing each one:
Drive Accountable Care
Advance Health Equity
Support Innovation
Address Affordability
Partner to Achieve System Transformation
Prioritizing integration is a highlight of the CMMI report, which—in addition to PCP-specialist coordination—signals a greater focus on behavioral and maternal health, person-centered innovation, and multi-payer APM designs.
Connected care models for better outcomes
In its report, CMMI states: "Moving forward, the Innovation Center will consider providing ACOs with tools to better engage specialists, test ways to better link primary and specialty care upstream in the patient journey, and continue to incentivize better management of inpatient admissions and transitions back to the community for patients."
This could include the use of e-consults, an example of "the data, supports, and tools needed to connect advanced primary and specialty care—before, during, and after acute episodes."
Other CMMI priorities to strengthen PCP-specialty care coordination include recruiting more safety net and Medicaid providers and the new Initiative to Strengthen Primary Health Care to increase federal support.
Healthcare's pre-existing conditions
Referrals are an abiding operational obstacle within the healthcare delivery system—a kind of "pre-existing condition" that impacts how referrals are made, to whom, and how close to real-time they can begin connecting a patient to their next needed level of care.
These challenges impact both the daily practice of medicine and broader imperatives, such as value-based care, and what is healthcare's now quintuple aim: patient experience, population health, and cost, plus a new emphasis on health equity and workforce demands.
Faster, slower
Government healthcare agencies have been busy this fall, updating their approach to reflect these factors. CMS launched its strategic vision and priorities in September, with CMMI announcing a strategy refresh less than a month ago after finding that only six of its 50 APMs have generated Medicare savings in the past decade.
Ten years is a long time for what's broken to stay broken. Conversely, what's broken is so deeply entrenched, it cannot be fixed overnight. For these reasons, CMMI states it will depart from its typical rules to allow more time to test new advanced primary care models and achieve results.
The agency may take this approach with other models as well, noting the importance of "longitudinal accountable care" as a focus area as well as " testing mechanisms to deliver integrated-whole person care, especially by increasing access to coordinated and high-value specialty care; and supporting providers on the value-based care journey by driving meaningful multi-payer alignment and providing data to support patients at the point of care, and across settings."
"Bringing pre-authorization to the point of care" reduces burden across stakeholders, notes one Regence executive.
Regence—a Blue Cross Blue Shield Association plan offering commercial, exchange, and Medicare Advantage (MA) plans across Idaho, Oregon, Utah, and Washington—has launched a partnership with ACO MultiCare to speed prior authorization (PA) using the FHIR PA Support Standard.
The new standard "will provide an interoperable method for providers to submit prior authorization requests directly from electronic health records at the point of care," said Regence in its press release.
In the release, Regence VP CTO Kirk Anderson states: "Bringing pre-authorization to the point of care reduces the burden on health systems managing patient data and promotes timely, evidence-based care and a more seamless experience for our members."
MultiCare's AVP of population health and value-based care, Anna Taylor, adds: "Embedding pre-authorization in our native EHR system is a gamechanger … Not only will we ease the administrative complexity of health care, but the ability to receive transparent and actionable data at the point of service accelerates care delivery and increases adherence."
PA automation
Other health plans are automating the PA process. But Regence reports that it is the first health plan to do so using a FHIR Application Programming Interface, or API, that will "enable faster determinations, reduced administrative burden and costs, and better outcomes for patients."
PA automation is one of several operational improvements possible by FHIR, definition including APIs. Two others include API-enabled patient data access and provider directory standards, required by CMS' Interoperability and Patient Access final rule. Payers offering MA, Medicaid, or CHIP plans were required to comply with the provider directory rule effective July 2021.
And while X-enabled PAs are not yet required—CMS' Interoperability and Prior Authorization rule was proposed in December 2020 but is not yet final—the Regence-MultiCare implementation reflects stakeholder understanding that FHIR-driven APIs are a key tool for making meaningful digital healthcare transformation a reality.
PA under fire
Health plans use PA to manage health service delivery. Ideally, PA prevents improper utilization and encourages appropriate, evidence-based care. Providers and patients alike, however, see PA's true intent as cost control that restricts access to needed services. Providers site the cumbersome PA process, one that often requires dedicated staff to manage, as a key contributor to the burnout worsened by the pandemic.
Congress agrees. In September, the House passed the Improving Seniors' Timely Access to Care Act, which requires MA plans to report their PA utilization rates to CMS, including resulting approvals and denials. The bill, also supported by the Senate, requires HHS to establish a "real-time" PA decision process facilitated by automation.
And while it only applies to MA plans, the bill—combined with CMS' proposed interoperability rule—would create a path to PA progress that stakeholders have been calling for.
The Justice Department is intervening in a whistleblower lawsuit, first filed in 2017.
Medicare Advantage (MA) plans have long been accused of upcoding, defined as "systematically assessing enrollees as having more health conditions and being sicker on average than is actually the case." Upcoding results in more patients assessed as higher risk, which draws higher payments from Medicare.
The Department of Justice (DOJ) has now made these claims against Cigna, filing a civil fraud lawsuit on October 17 and joining an existing whistleblower suit first filed in 2017.
In a statement for the suit, the DOJ writes: "The lawsuit seeks damages and penalties under the False Claims Act for CIGNA's submissions to the Government of false and invalid patient diagnosis codes to artificially inflate the payments CIGNA received for providing insurance coverage to its Medicare Advantage plan members."
The 360 assessment
At the center of the suit is the in-home version of Cigna's "360 comprehensive assessment program," an annual member assessment completed by contracted Vendor Health Care Providers (Vendor HCPs)—generally nurse practitioners and, according to the suit, "on occasion by other nonphysician healthcare providers such as registered nurses and physician assistants."
The suit details that the Vendor HCPs would use a "360 form" with a multi-page checklist to document medical conditions that could not be corroborated by other provider documentation during the same year. In addition, the suit alleges, the Vendor HCPs completing the forms "did not perform or order the testing or imaging that would have been necessary to reliably diagnose the serious, complex conditions reported and were prohibited by CIGNA from providing any treatment during the home visit for the medical conditions they purportedly found."
The dollar details
In the DOJ's statement regarding the suit, U.S. Attorney Damian Williams said: "As alleged, CIGNA obtained tens of millions of dollars in Medicare funding by submitting to the Government false and invalid diagnoses for its Medicare Advantage plan members.
The full DOJ suit states that "Cigna carefully tracked the return on investment ('ROI') from the 360 home visits by comparing the total amounts paid to vendors to perform the in-home visits to the additional PMPM payments generated by the resulting increased risk scores for Plan members."
Two examples cited include a projected profit of $61.8 million on 2014 home visits costing $18.8 million and a $38.8 million projected profit versus an $8.7 million spend for the first eight months of 2015.
The suit continues: "Tellingly, the ROI calculations included as a cost only the payments to vendors for conducting home visits—but did not incorporate any additional costs for actually treating the additional medical conditions that the Vendor HCPs had purportedly diagnosed."
The DOJ detailed seven specific instances among the "tens of thousands of false and invalid diagnosis codes" included in the suit.
Three highlights from a future rule that would preserve a focus on approval speed and inter-agency collaboration.
Regulating innovation is a tough gig. Just ask CMS.
The agency withdrew a proposed rule that would have granted four years of automatic Medicare coverage for medical devices approved via the Food and Drug Administration's (FDA) Breakthrough Devices Program for innovative technologies. To be eligible for breakthrough submission, a device must provide more effective treatment and meet one of four additional criteria focused on innovation, advantage, and patient interest.
It was an aggressive proposal that CMS looks to replace in 2023 following stakeholder concerns for patient safety, sufficient evidence including for longer-term outcomes, and that approvals were tied to a more limited population that is covered by Medicare.
The new rule will be informed by existing stakeholder feedback and a September 2022 draft report on evidence-based coverage decisions from the Agency for Healthcare Research and Quality. In an article for the Internal Medicine publication of the Journal of the American Medical Association, CMS officials announced that its new proposed rule will reflect four principles and may include three additional components.
Participation is voluntary and the scope is limited.
Manufacturers are not required to participate and only medical devices that fall within Medicare statute will be included.
The review process will maintain a federal focus on speed and collaboration.
CMS may conduct an early evidence review—before FDA marketing authorization and at the manufacturer's request. This proactive approach would maintain CMS and FDA's intent to work in parallel for faster approvals. It would also alert manufacturers to the "best Medicare coverage pathway" based on the evidence presented and whether stronger evidence might be required.
In its article, the agency added: "If CMS determines that further evidence development is the best coverage pathway, the agency would explore how to reduce the burden on manufacturers, clinicians, and patients while maintaining rigorous evidence requirements."
Possible additional components.
Where evidence is required, other elements of CMS's proposed rule could include:
Clear decision timelines
Whether the device is reasonable, necessary, and improves overall health
Whether its easy for patients and providers to choose a new device
Summing up its intent, the agency writes: "The CMS believes that a rule guided by these principles would strike a balance between promoting access to emerging medical technologies and maintaining the protections and rigorous evidence standards that are essential to the welfare of Medicare beneficiaries."
"At the end of the day, data is the currency of healthcare—being able to understand and show how healthcare actually happens in communities," says one health tech executive.
HealthLeaders interviewed the governing body of one of those CCOs and its technology partner, Activate Care, to learn how the two are working toward a focus on preventive social care that helps individuals and families build generational strength.
How one rural Oregon COO operates
The Columbia Gorge Health Council (The Gorge) is the governing body of PacificSource Community Solutions – Columbia Gorge Region, one of 16 Oregon CCOs which includes Pacific Source Health Plans as its Medicaid MCO partners. CCOs were not only one of the first Medicaid ACO models in the U.S. but also one of the first ACO models of any kind.
For its CCO, The Gorge—a 501(c)3 non-profit serving an area of rural Oregon just outside of Portland—acts as a community advisory council, a role that former senior project manager Suzanne Cross notes "has a lot of power and voice in the governing of the CCOs. They determine how money is spent, advocate for access to services to improve."
The Gorge uses its power as a convenor to target regional need. It hosts a large cross-sector collaborative program that uses 17 community health workers employed at agencies across the region as its workforce. The goal is to assess regional needs, break down barriers, connect clients to medical and non-medical resources, and close gaps. The initiative serves people in Medicaid, Medicare, and those who are uninsured.
"Many health workers are trusted members of the community," Cross emphasizes. "They speak the language as a client that they work with. Our community health workers will tell us, 'They listened to me because they know I'm in.' And so that's really important for primary care providers."
Especially when there are non-medical reasons why a patient isn't following their care plan. In addition to lacking resources, Cross notes: "Maybe they also didn't really understand the instructions that were given … So having a trusted member of the community to learn from is really crucial."
The Gorge's technology partner, Activate Care, agrees, with founder and CEO Ted Quinn adding how important tech skills are as community-based workforces stand up their programs.
Creating a hyperlocal, community care record
A tech-trained workforce is just the beginning.
"Our focus is creating what we refer to as a community care record," says Quinn. "It's a technology and a platform which enables stakeholders that work within a community from different types of organizations and perspectives to really coordinate and drive care around specific individuals and populations."
Quinn adds: "The work The Gorge is doing is where it all really comes together, into a hyper-localized approach. I think this is why MCOs and Medicaid are trending to more holistic care, because they recognize that it's got to be done at that level."
Noting that Activate acts as a "technology convener so stakeholders can work together," Quinn emphasizes: "At the end of the day, data is the currency of healthcare—being able to understand and show how healthcare actually happens in communities across different organizations, and how they work together to measure, report, and show the impact of their programs."
Cross adds: "With cross-sector collaboration, there are HIPAA requirements and how to collectively share our work when you've got somebody at the housing authority, somebody in a primary care clinic, and somebody else working in a public health clinic. All of that involves breaking down the rules and creating contracts that allow us to work together, not duplicate services, and lean on each other's strengths."
"Activate allows us to understand the households that we work with, understand their needs, and understand how to navigate them."
Evolving the Medicaid MCO model
With Medicaid MCOs playing a central role in Oregon CCOs, Quinn and Cross discussed how important it is for traditional health plan models to evolve toward SDOH and for funding that ensures sustainability.
"If you think about the MCO business model, they have an established value proposition of how they deliver care," says Quinn. "They have resources they allocate out to the provider and delivery system to support their members. They have processes for how they track and report measurements back to the state or federal government and they have a set profit formula."
Quinn continues: "What we've seen over the last few years is that they're being pushed to incorporate the social determinants into their model to care. And that's really hard to do."
Cross agrees on the difficulty.
"We're trying to figure out how equity plays in, how to really be creative in addressing the social determinants of health when looking at Medicaid members. If you don't have a roof over your head or can no longer afford gas prices to get to work, you're not even going to think about going to the dentist or a mental health provider," she says.
The need for creativity applies not only to solving problems but how solutions are funded and reimbursed.
"It's really crucial to continue to be creative and to look at new programs that are successful. If something is not funded through state or federal sources, keeping services available is not sustainable."
Preventative social care
Despite the difficulty, the new expectations are clear, says Quinn—showing up in State Medicaid MCO procurements as well as federal initiatives.
"So here we sit—hopefully on the backside of the pandemic—and if you just follow the funds from CMS, you see that things have fundamentally changed," he says, adding: "It's hard to believe you'll be able to pull these things back."
Quinn continues: "On the community side, we've spent a lot of time and effort focused on reactive social care, but where we haven't spent a lot of time is on the preventative social care. When COVID hit and as we are headed into an economic downturn, the needs are going through the roof and the supply to meet that need is often not well understood. Through the work of the past couple of years, we're collecting that data that helps tell the story of the community."
"That," the Activate CEO notes, "is going to help us build the evidence base to say, 'How do we think about preventative care? How do you get further upstream so that when someone's life goes sideways, they know where to go?'"
Cross agrees: "Once someone has the resources that are available to them, how do we use the data to get more resources and address system gaps?"
Returning to a different kind of sustainability, Cross emphasizes the need for generational support.
"How do you start to build savings and what does that mean? How do we also help the next generation have a better opportunity?"
While noting declines in the percentage of people covered by their employers, the AAF panel asked multiple questions about the model's future and opportunities for reform.
Holtz-Eakin framed the ESI discussion politically—between the "government-sponsored single-payer healthcare" that the Left prefers and, by the Right, as an "accident of history…[that is] not taken seriously as market phenomenon" that would be typically defended.
Following these contrasts, Mulligan framed ESI's value proposition:
People stick to the model, even when the price increases.
As distinct from individual health insurance…you're not alone. You're buying with groups of people.
The group insurance structure offers concentrates innovation and ease.
There is a lack of competition, with employers able to get better deals than individual buyers.
Lack of insurance leads to more government-subsidized healthcare.
Impact of subsidies
Schaefer highlighted how the ACA changed the ESI policy landscape while focusing on efforts to fix the model's deficiencies. The Heritage Foundation executive highlighted the unique challenges of small businesses and how less advantaged subsets of employers impact the role of the ACA marketplace.
Schaefer discussed the subsidy firewalls put in place "to prevent erosion of employer-based coverage," noting that the loosening of these firewalls "have created a deterrent where people are going to say, 'We're just going to flood out of the employer market.'"
Moderator Holtz-Eakin posed how expanded and increased subsidies—in 2021 and then extended through 2025 via the Inflation Reduction Act—"reorganized the deck chairs, moving a lot of people out of ESI and into the ACA."
Despite clear marketplace growth, Mulligan described "Obamacare" as "an incredibly bad brand," with Schaefer reiterating ESI's value proposition as "the brand you know" and a more desirable opportunity with employer resources for benefits navigation versus 1-800-number support from the federal government.
"As people are faced with more and more of these tradeoffs, even with the 'financial benefit,' they'll still want to gravitate" toward ESI.
ESI flexibility
Schaefer highlighted another ESI value: how quickly employers shifted their health benefits in response to the pandemic, such as telehealth, and how much faster this occurred than in areas such as Medicare. The Heritage Foundation Director noted the ability to pivot faster in general as an advantage of ESI.
Mulligan added to this, stressing the importance of innovation to the U.S. economy and healthcare in particular. The economist noted that companies are better at innovation in general than not only the government, but individuals and their capacity to get the same results. "A group like employers are perfect for that," he concluded. "In an innovative world, the employer system has a lot going for it."
Biggest threats to ESI
When asked by Holtz-Eakin what ESI's biggest threats were, Shaefer noted "the incremental attempts to supplant it"—citing continued subsidies, State caps, and other "strategic and small" regulatory moves. She added that left-leaning politicians are more likely to succeed with this approach than the universal healthcare and "Medicare for All" messages attempted.
Mulligan believes, however, that Medicare for All still has more legs. With this, Mulligan highlighted a kind of conflicting groupthink in which it's difficult for individuals to achieve innovation individually or navigate massive changes, yet when they do, they find a collective approach "seductive."
AAF's president agreed with Mulligan, stating: "If you say insurance companies are pushing back on it [Medicare for All], that's proof it's a good idea."
Policy levers to strengthen ESI
For people who fall between the cracks of government-subsidized care and ESI, Schaefer suggested different approaches to grouping individuals. "While it's still a work model and its focused on where you are employed, where we see a mobile workforce and a changing workforce of people patched together … are there ways we can mimic ESI?"
Schafer also suggested further scaling the benefit flexibility employers have come to expect as a result of the pandemic. Mulligan predicted that the intersection of technology and drugs will aid ESI.
The panelists' concluding comments focused on how employers could be innovative leaders in the area of gene-based healthcare services.
The insurer, which just filed suit in California's State Superior Court, was one of four to appeal the state's recent Medicaid awards.
Deadlines. Documents. Designates.
These are three of the reasons cited by Blue Shield of California for its new lawsuit against the California Department of Health Care Services (DHCS), the agency that administers Medi-Cal, the state's Medicaid program. The lawsuit is in addition to the insurer's original appeal and rebuttal following DHCS's recent Medicaid MCO award announcement.
In August, DHCS chose three insurers—Blue Cross of California Partnership Plan, Inc., Molina Healthcare of California, Inc., and Health Net Community Solutions, Inc.—to serve Medi-Cal enrollees across 21 counties. In all counties but seven, these plans were chosen as the sole Medicaid managed care organization (MCO).
1. Documents
In a press release announcing the suit, Blue Shield alleges that DHCS did not produce all of the documents its requested as part of its appeal related to "crucial information about their scoring process, methodology, and their communications about the bid."
2. Deadlines
Blue Shield also requested additional time "so that each party to the appeal has the opportunity to review all documents related to the request for proposals." The request was denied by the state-appointed hearing officer, who Blue Shield appears to object to in its press release.
Regarding the delayed documents and denial of the request for more time, Blue Shield president and CEO Kristen Cerf stated: "We have waited in good faith and the Department of Health Care Services is refusing to provide the public information we are requesting or to provide a reasonable amount of time for the appeal process."
Cerf added: "We believe that the Department of Health Care Services has a duty to get this right and not just rubber stamp its original decision."
Philip Heinrich of DHCS was appointed the Hearing Officer by Department Director Michelle Baass. Regarding his selection, Blue Shield further noted that "the state assigned an employee from its Information Management Division as the hearing officer in this matter; this means an IT professional is responsible for reviewing all appeal materials and making the final decision as to which health plans will be available to millions of Medi-Cal beneficiaries."
Blue Shield's press release notes its nonprofit status and calls attention to the "national, for-profit companies beholden to Wall Street" that DHCS chose to serve state Medi-Cal enrollees. It further noted the separate, statewide, no-bid contract DHCS awarded Kaiser Permanente earlier in 2022—labeled as a sweetheart deal by critics.
These actions follow a six-month procurement process in which DHCS selected three plans to begin or continue service Medi-Cal members effective 2024 for the state's multiple Medicaid MCO models.
The Request for Proposal (RFP) was to select commercial health plans for the two-plan, Geographic Managed Care, and Regional models. The RFP did not apply to the State's County Organized Health System (COHS), Local Initiative Plan, or single plan (in non-COHS counties) models.
Across 14 counties, Blue Shield was joined in its appeals by Aetna Better Health of California, Inc. and/or Health Net appealed in 14 counties, with CHG Foundation d/b/a Community Health Group Partnership Plan appealing in San Diego County. There were no appeals in the remaining six counties, where Blue Cross was either the sole or joint awardee.
As of October 10, none of the non-awarded plans has extended its appeal to legal action.
"The ultimate goal is to make sure that fragmented systems begin to come together to serve our communities," says one program executive.
Since 2019, North Carolina has launched a statewide referral network, begun implementing and expanding a novel 1115 waiver demonstration, transitioned its Medicaid program to managed care, and added an innovative social care payments platform—all in the middle of COVID-19.
HealthLeaders interviewed LaQuana Palmer, program director at NCCARE360, who was previously the Healthy Opportunities program manager, putting her on the front row of North Carolina's health equity transformation.
Says Palmer: "The ultimate goal is to make sure that fragmented systems begin to come together to serve our communities. I think that was the biggest thing that that came out of this work that we were all doing together."
Three interlinked initiatives
Healthy Opportunities is a statewide framework and infrastructure that can support innovation in the private sector and promote opportunities for health for all North Carolinians. Under this umbrella are the Healthy Opportunity Pilots, a comprehensive program to test and evaluate the impact of providing select evidence-based, non-medical interventions to high-needs Medicaid enrollees as part of the state's newest 1115 demonstration waiver.
NCCARE360 puts into place the statewide infrastructure for all payers and providers—including providers in at-risk contracts—to address the social drivers of health that account for almost 80% of health outcomes. Its building blocks include:
A robust statewide resource directory.
A resource team that includes dedicated navigators.
A shared technology platform that enables providers to assess for and identify unmet social needs, and then send and receive secure electronic referrals and track outcomes.
A community engagement team working with community-based organizations (CBOs), social service agencies, health systems, independent providers, and more to create a statewide, coordinated care network.
Within NCCARE360 for the Healthy Opportunities Pilots are Advance Pilot Functionalities with invoicing mechanisms that facilitate Medicaid payment to CBOs.
This payment is for providing social services to Medicaid beneficiaries who meet the eligibility criteria to qualify for the Healthy Opportunities Pilots.
"The strategy that was taken was to look at Healthy Opportunities, to ensure that we were looking at whole-person health, and how NCCARE360 fits into that. It is the infrastructure and the network that helps with linking a fragmented system."
How NCCARE360 grew
As of July 2022, NCCARE360 had served more than 98,000 clients for a full variety of non-clinical needs supported by:
2,863 organizations in-network
7,130 individual programs
47,311 network users
Palmer detailed how NCCARE360 and its broader work started with "the nuts and bolts of resource repositories and getting all of the directories together into a network that links different providers so there is a No Wrong Door approach."
She adds: "We were building the NCCARE360 network in the midst of responding to COVID. During this time, a number of the organizations were using the newly developed NCCARE360 network and wanted to be a part of the Healthy Opportunities Pilot work but were also recovering from the economic effects of the pandemic.
The approach was careful and incremental.
When the Healthy Opportunities Network Leads were identified, the organizations worked with the North Carolina Department of Health and Human Services to build their capacity—staff, organizational, and program development.
"There was a lot of work that went on ahead of time to make sure that we were prepared when we went live," says Palmer. "We rolled organizations on with a couple of weeks in between to ensure we had the staff to answer questions.
"At the end of 2020 was when we really began to look at rolling on each of our payers, onboarding them to ensure they are using what we've built and that there was an understanding of the workflows of the organizations that use NCCARE360."
These payers are the state's seven Local Management Entities/Managed Care Organizations are responsible for public mental health, intellectual and developmental disabilities, and substance use disorder services for people who are uninsured or are covered by Medicaid.
The role of technology and public-private partnership
To function as designed, NCCARE360 required technology and financial connectors between consumers, traditional providers, CBOs, and other organizations.
It also includes two technology partners. Expound Decision Systems has created a data repository model to manage state social determinants of health resources. Unite Us, an enterprise technology company connecting health and social care, supports both NCCARE360 and the Healthy Opportunities Pilot, the latter as of Q1 2022 through Social Care Payments.
Unite Us describes Social Care Payments as the first integrated social care payments platform "designed to bridge the gap between healthcare funders and [CBOs]" and "the only end-to-end solution for social care that streamlines the implementation and management of paid social care programs."
Says Palmer: "We were looking for an organization that could come in and not only look at how we are linking to services but could combine both technology and engagement. We were able to do that by linking with our partners at Unite Us and United Way of North Carolina and Expound decision making as well."
She adds: "The key takeaway from NCCARE360 and the work we're doing that advances the Health Opportunity work … is the public-private partnership [FHLI]. Many states have never seen this before—the fact that folks from the public sector, nonprofits, and private sector will be able to say, 'We've got an ultimate goal all in mind. We know we all have different systems and needs, but this is an opportunity for us to all come together to make sure that our communities are being served.'"
The path ahead
HealthLeaders also interviewed NCCARE360 VP Darrell Deaton about current obstacles and next steps.
"One of the challenges is to make sure that we have platform interoperability—that's why we are working with Unite Us and an Electronic Health Record (EHR) vendor to integrate information so that when a patient gets a referral from the NCCARE360 platform, the clinicians know they don't have to go different places."
Deaton adds: "We're hoping to pilot the interoperability of the Unite Us platform with a leading EHR platform at a health system in North Carolina. That is a primary function that health systems across the country are asking for to improve their staff workflows and have a patient's social and medical records consolidated in the medical record."
A look back at 2022 growth dynamics as a handful of exchange plans announce their 2023 plans.
The 2022 plan year saw record growth: per CMS, nearly 14.5 million enrollees with close to 3 million being first-time exchange customers. Aetna, a CVS Health company, re-entered the exchange for the first time since 2018, and nearly all of incumbent and startup plans alike expanded per the Robert Wood Johnson Foundation's (RWFJ) 2022 analysis.
Among startup plans:
Bright HealthCare — Entered five new states (California, Illinois, Texas, Utah, and Virginia) for a total of 16, with expanded service areas in North Carolina and Tennessee.
Friday Health Plans — Tripled their enrollment to more than 300,000 members by entering Georgia, North Carolina, and Oklahoma for a total of seven states.
Oscar Health — Expanded into three new states as a standalone brand (Arkansas, Illinois, and Nebraska) and three additional states as part of co-branded Cigna+Oscar plans (Kansas, Missouri, and Tennessee).
Among traditional plans:
Centene — Entered four states including New Jersey, which RWJF reported "hadn't had a new insurer since Oscar returned to their market in 2018."
Cigna — Added two new states (Georgia and Pennsylvania) for a 2022 total of 13.
UnitedHealthcare — Entered seven new states (Alabama, Florida, Georgia, Illinois, Louisiana, Michigan, and Texas), bringing its 2022 state footprint to 18.
Slow and steady wins the race
Even with enrollment and market expansion, RWJF assessed that plan growth was less rapid in 2022, with author Katherine Hempstead noting: "This year [2022], we see more robust growth in enrollment, but some moderation in issuer participation trends. To support, Hempstead added: "While the total number of plan offerings increased about one third in 2021 (from 10,289 to 13,596), this year's increase to 15,638 constitutes growth of about 15%."
Two additional observations for slower-paced growth concerned Aetna's re-entry, other plans that expanded modestly or not at all, and those that left states in 2022.
RWJF noted that Aetna took "a comparatively modest foray into a little more than 300 counties" in rejoining the marketplace" and in a total of eight states — adding that this "is consistent with the pattern exhibited by United Health Group, when they recently returned to the marketplace in a very slimmed down form."
In 2022, Molina "made modest entries into Idaho, Illinois, and Kentucky" while Anthem, now known as Elevance Health, did not expand at all.
What we know about 2023
It remains to be seen what combination of enrollment growth and plan market pacing will emerge for 2023. Among the plans that have announced their new exchange offerings, there is a mix of expansion and contraction:
Bright HealthCare announced it will exit six states in 2023 — New Mexico, Oklahoma, South Carolina, Illinois, Utah, and Virginia — leaving the latter three after just one year.
In a communication to brokers, the plan stated: "Bright Health is taking steps to refine and optimize our strategy to ensure we are best positioned to enhance the health care experience for consumers and Care Partners and deliver the highest quality, affordable care. In 2023, we will deepen our presence in those markets where we can have the greatest impact, achieve long-term success and drive differentiated value with our Fully Aligned system of care.
Oscar Health will also be exiting states in 2023 (Arkansas and Colorado) while expanding in others.
Cigna will continue to expand in 2023, entering Texas, Indiana, and 50 additional counties in Georgia, Mississippi, and North Carolina. In its press release, Cigna's president of U.S. government business Charles Berg noted the plan's consistent marketplace presence since 2014 and the potential for it to reach nearly 730,000 new customers through its 2023 expansion.
Returning full circle to the theme of health plan paced growth, Aetna's second year back on the exchange will see it enter select counties in four more states — California, Delaware, Illinois, and New Jersey — plus county expansion in the eight states it entered in 2022.
Several large insurers have yet to announce their 2023 plans, including UnitedHealthcare and Elevance.
A study reveals disparities across multiple dimensions.
A new analysis finds deep inequities among U.S. children who lack health insurance by race, income, geography, and age at both the national and state levels. The study, conducted by the State Health Access Data Assistance Center (SHADAC) and funded by the Robert Wood Johnson Foundation (RWJF), is based on a national five-year data set.
In a press release, Colin Planalp, the report's lead author and SHADAC senior research fellow, noted: "Our study found clear inequities in health insurance coverage within all states." Planalp added: "Plenty of work is still needed to achieve goals of ensuring children have equitable access to health insurance and healthcare, but the high coverage rates among some groups prove that progress is possible."
Uninsured rates for U.S. children differ based on age but hover on average around 5%.
The state data analysis showed that approximately 3.6 million children lacked health coverage between 2016 and 2020. Older children (ages 12 to 17) experienced the highest rate at 5.8%, followed by kids six to 11 (4.8%), and those younger than five (4.3%).
Based on race, American Indian and Alaska Native, Latino, Native Hawaiian and Pacific Islander children fare worst.
Among these groups, the average uninsured rate is in some case more than 10% higher than for other races. The uninsured rate for American Indian and Alaska Native children (14.1%) is significantly higher than for children who are Black (4.2%), White (3.9%) or Asian (3.6%). Higher uninsured rates were also seen for children who are Latino (7.8%) and Native Hawaiian and Pacific Islander (6.0%).
Children in the West were more likely to lack coverage than those in the Northeast, as were rural kids.
Six states rank highest for uninsured children, including: Texas (10.6%); Wyoming (9.3%); Alaska (8.4%); Arizona (8.2%); and Oklahoma and North Dakota (7.9%). Lack of coverage improved traveling East, with the lowest rates appearing in six states and the District of Columbia: Massachusetts (1.3%), Vermont (1.3%), DC (1.9%), Rhode Island (2.2%), and at 2.5% each, New York, West Virginia, and Iowa. More broadly, the uninsurance rate was 6.2% for kids in non-metro areas compared to 4.7% for those living in cities.
Andrea Ducas, senior program officer at RWJF, added: "Disparities in children's health insurance exacerbate inequities among populations that are often already disadvantaged. The data point to the need for more policy solutions at the state and national levels."
