A new customer experience survey fills in the blank; and why health plan members trust AI and digital health tools more.
Trust.
It tends to get undermined when expensive health benefits don't yield affordable health care, the kind that meets people where they are.
"Health plans looking to build deeper relationships with their members need to start by building back trust," saysWalter Jin, chair at CEO at Pager HealthSM.
Jin's company supports its position based on a new customer experience survey conducted with The Harris Poll. Pager Health is a connected health platform for payers and their members. The Harris Poll is one of the longest-running surveys of U.S. public opinion, motivations, and social sentiment.
Their joint findings show that while Americans tend not to trust their health plans, they would if the relationship delivered. Personalized AI plus digital health and well-being apps already do and health plans must bridge the gap.
Health plans must support well-being
"Insured Americans expect their health plans to deliver the type of highly personalized, easily accessible and seamlessly integrated experience that is now routine in every other business sector," notes Rita Sharma, Pager Health's Chief Product Officer.
Pager's survey of nearly 2,000 of those Americans found that:
74% — are interested in health plan wellbeing recommendations, right after and relevant to their medical appointments.
79% — reported that 24/7 online nurse access would enhance their wellbeing and peace of mind.
77% — want health plan wellbeing apps and services that also facilitate follow-up, like appointment scheduling.
"The insights revealed by this survey lay out a clear strategic road map for forward-thinking health plans," adds Sharma.
That road map includes artificial intelligence and digital health.
Health plans must leverage AI
In the Pager Health/Harris Poll survey, respondents expressed a "higher-than-expected comfort level" in using artificial intelligence to improve health plan interactions. Among insured adults:
75% — trust AI to find available, in-network doctors and schedule an appointment.
67% — trust an AI copilot to help them navigate health plan benefits and resources.
66% — believe AI creates digital health experiences that are accurate, personal, customized and occur in real-time.
What AI delivers must be highly personalized, easily accessible and seamlessly integrated, insureds say.
Sharma adds: "Only health plans that fully leverage the power of AI to analyze the wealth of health data available will be able to meet this demand and, in the process, boost member engagement and satisfaction."
Health plans must deliver
Some 41% of insured Americans report health plan recommendations are non-specific, automated and/or impersonal, with 17% reporting they receive no recommendations at all.
When their health plan does provide recommendations, insureds want them to be personalized, contextual, data-driven and in real-time. Some 45% said they would be more likely to follow such recommendations. Another 34% report they would encourage use of health plan wellness programs to meet their goals.
Per Pager Health's head exec Jin, these challenges present opportunities.
"The Pager Health survey reveals a major opportunity for health plans to transform how — and when — they engage with their members."
"It also points to a willingness from members to engage more proactively with their health plan throughout the plan lifecycle, not just when they need care."
Find Pager Health's full report and recommendations here.
"Informed negotiations always lead to fairer terms," says the president and CEO.
Employers face tremendous pressure to offer affordable, quality healthcare for their employees. This is particularly true for self-insured employers who pay their own healthcare claims.
No one defines these problem and their solutions better than Elizabeth Mitchell. As president and CEO of Purchaser Business Group on Health (PBGH), Mitchell leads a nonprofit coalition representing 40 private employers and public entities that collectively have $350 billion in annual health care buying power.
“For most employers, healthcare benefits are their second-largest expense. It’s in the interest of employers — and for their employees — that they be good fiduciaries and eliminate wasteful spending.”
“But in order to do so, they need access to data from the other relevant parties: insurers, providers, insurance brokers, Pharmacy Benefit Managers [PBMs]. Simply put, the commercial health care market is not functional because buyers do not have access to needed information to make informed purchasing decisions.”
In other words, healthcare is not only broken but expensive — and lack of transparency is a big reason why. The Consolidated Appropriations Act of 2021 (CAA) clarified that employers are entitled to data from their health plans and providers to gain this transparency.
In this exclusive with HealthLeaders, Mitchell details the pressures employers face, why transparency is essential, and the initiatives PBGH has launched to help employers take control of their destinies.
HealthLeaders: Explain the new pressures on employers as health care plan fiduciaries, including the risks of employee lawsuits.
Elizabeth Mitchell, President and CEO of PBGH: First, it's important to point out that 46% of Americans, nearly half, get their health care coverage from employer-sponsored insurance. Under the CAA, employers are legally accountable as fiduciaries for their health plans, meaning they are required to provide their employees with the best health care benefits for the best price.
Traditionally they have relied on their health plans to do this, but it is increasingly clear they have not acted in employers’ best interest. Self-insured employers as the accountable fiduciary — [those who pay for their own healthcare claims] — need to take on a significantly larger role in selecting and managing health care vendors and partners.
To fulfill that responsibility and to be good stewards of their own resources, employers need access to information about health plan and provider prices, claims data, care quality, patient outcomes and more.
Without this data, employers are operating in the dark. With no visibility into varying prices or quality, it makes it difficult, if not impossible, for employers to negotiate for the best possible care and terms.
This is an impossible position and leaves employers vulnerable to lawsuits from employees unhappy with the cost and of health care. There have been several high-profile lawsuits filed recently by employees against their employers alleging that they failed their fiduciary responsibilities by overpaying for prescription drugs and other services. We expect those lawsuits to continue.
HealthLeaders: Why are price and quality transparency essential for lowering costs and improving care outcomes?
Mitchell: When employers have that transparency, they are in a much better position to select the best provider partners, negotiate rates and coverage, and direct their covered members to the providers and facilities with the best outcomes.
Imagine trying to buy a car with no information on safety, gas mileage, or even the actual price of the car? Informed negotiations always lead to fairer terms.
Transparency has the systemic effect of creating competition on cost and quality — something that does not currently exist in health care. That helps not only employers, but the overall economy because, let’s face it, the insurmountable cost of health care in America makes its way into just about everything we buy and consume.
HealthLeaders: What is the status of CAA compliance and what story does the data tell so far?
Mitchell: Now that insurers and hospitals are required to disclose their prices and arrangements, employers are getting their first look into what was previously hidden. What they’re finding isn’t pretty: Conflicts of interest between brokers and providers, between insurers and providers, overpricing of health care services, and more.
What data is available shows that the exact same service — like an MRI — may cost 5x as much at a neighboring facility with no difference in quality.
Many health plans and providers are still not fully compliant with CAA and continue to withhold key information — on outpatient care, for example. But PBGH members are using what they can access.
HealthLeaders: What specific actions does PBGH recommend for employer CAA compliance?
Mitchell: We work closely with PBGH members on how to be effective fiduciaries. [Here, Mitchell identified three PBGH initiatives.]
New CAA Data Demonstration Project. A first initiative of its kind, combining CAA hospital and payer datasets with provider quality metrics as well as specific employer demographic and claims data from five employers in 10 geographic markets. With this project, PBGH will:
Create fair-cost commercial benchmarks to help PBGH members assess whether what they are paying is fair and appropriate.
Analyze cost variations so employer members can compare — for the first time — whether it’s the best “deal” by hospital, by network, and by carrier from “actual” price at the service code level (versus self-report aggregated carrier data).
Correlate price variation data with provider quality data to understand value.
Contracting standards for PBGH members. These standards — which are for PBMs, Advanced Primary Care and maternal health — enable purchasers to get the optimal value for their health care spend but require significant expertise to develop and then enforce. Performance measures are also included in these contracting standards, leveraging PBGH’s technical expertise and decades of work on quality and cost measurement.
Direct contracting. We just launched a very untraditional Advanced Primary Care health plan in Puget Sound with Boeing and eBay . . . By directly contracting with top primary care and specialty providers, thousands of employees and their dependents can access primary care that meets PBGH’s quality standards.
Zooming back out to healthcare affordability at large, Mitchell adds: “We’ve been talking about this crisis for a long time. Employers find themselves in an untenable position with a nonfunctioning commercial marketplace and lack of support to meet their obligations under the Consolidated Appropriations Act.
“Through thoughtful collaboration and bold innovation, we can reshape the system to better serve all Americans.”
So what is? Part 2 of our interview with Ann Somers Hogg of The Christensen Institute proposes solutions.
It's been three weeks since UnitedHealthcare CEO Brian Thompson was murdered. As is well known, the responses have ranged from tone-deaf — by both the public and UnitedHealth Group's CEO — to "Now What?," the nonviolent path needed to finally fix healthcare.
"The current national conversation brings into focus that the status quo of insured health care is not a viable path forward."
This from Ann Somers Hogg, the director of health care research at The Christensen Institute: and author of its new report: Zero-Inflation Health Care: A national strategy for unlocking and scaling insurance innovation.
In part 1 of this HealthLeaders series, Hogg defined the status quo: the "complex, four-party system — insurers, sponsors [employers], providers, and consumers — that disrupts normal market dynamics. This system is why premiums keep rising, leaving individuals, families, and businesses struggling."
In part 2, she and her report expand on the problem.
Quoting entrepreneur-turned-investor Ernest Ludy on the four-party's system two supply chains — member-provider and sponsor-insurer — the report adds that the "additional involvement of the sponsor and insurer disintermediates the traditional supply-demand relationship that could otherwise exist between the consumer and the provider."
In response, the report proposes a two-part solution:
Innovate — and prove the viability of — an Optimal Care Business Model (OCBM)
Scale this new health insurance model through a new value network
"This approach gets to the root of the problem and avoids the missteps of past attempts to disrupt the industry," says Hogg.
To understand how and why, a brief summary of disruptive innovation and business model theory are helpful.
The role of disruptive innovation and business models
The Christensen Institute report disruptive innovations as those that "make products and services more affordable and accessible to more people" — versus just making good products better. This process often takes years to unfold and includes three components:
The enabling technology that increases affordability and accessibility.
An innovative business model that targets non-consumers or those overserved by current products and services.
A new value network where the four-party system and its partners are better off with disruptive innovation than with the status quo.
The report notes that "business models determine an organization's capabilities and its priorities" — adding that while they solidify over time and become resistant to change," a new value network that changes existing incentives can make all the difference."
The report outlines what innovators, government and self-insured employers must do to effect change.
5 recommendations and calls to action
The Christensen Institute report concludes with what innovators and government must do.
Entrepreneurs solve systemic healthcare inflation through business model innovation.
The Christensen Institute defines healthcare's current business model as Cost-Plus. Its value proposition? "Good enough care at high and rising costs." The "good enough" is designed to maximize margins and limit provider profit sharing and must be replaced, per the Institute, by a new Optimal Care Business Model (OCBM). Its four components include:
Value Proposition: The best care at the best cost, every time.
Resources and Platforms: Leaders who understand healthcare's four-party economics and enterprise-wide platforms that is driven by actuarial engineering and AI, and that drives supply chain transparency.
Profit Formula: Quality dividends for meeting the value proposition paid across stakeholder groups (described below).
OCBM requires two other key capabilities (intelligence and risk mitigation) and one key outcome (quality-based cost reduction).
As Institute report notes, the OCBM's profit formula hinges on quality dividends paid to providers (financial incentives), members (added benefits), and sponsors (lower premiums). These dividends require that poor/suboptimal care be identified and eliminated for a person-centered, quality-driven margin growth.
Providers are critical.
For OCBM to be successful, "innovators must support provider partners in altering their business models as well" notes the report.
Innovators must bring OCBM to market or partner with scaled entity(ies).
Catalyzing change at scale is needed for health insurance market transformation in healthcare's complex system. Innovators and entrepreneurs can attempt disruption if they can overcome the need for scale, but market conditions make this less likely.
The federal government — via agencies such as CMS — has the scale to bring Optimal Care to market to reduce systemic inflation and stabilize premiums.
"Many entities can bring Optimal Care to market," says Hogg. "But only the U.S. government, as the largest payer, has the scale to create new value networks, drive premium stabilization, and transform the industry."
But its tremendous size also makes it slow-moving.
The Institute suggests that state governments could bring OCBM to market first for multiple reasons and outcomes:
State governments can often move faster.
States have more near-term budgetary demands, which encourages health plan cost reduction.
A large state health plan has the scale to prove OCBM viability.
The Institute report notes, however: "CMS would ultimately need to adopt the OC[BM] approach to create the new value network and transform the industry. One state on its own doesn't
have the scale required to achieve those outcomes."
To further grow market and scale, OCBM must target more customers.
Self-insured employers — the sponsors in healthcare's complex and problematic four-party system — are these customers.
The Institute notes that as OCBM reaches more customers, "more and more stakeholders will exit the incumbent value network and enter the new one characterized by Optimal Care."
Why past attempts have failed
Value-based care and its alternative payment models have yet to yield the expected results. The Center for Medicare & Medicaid Innovation (CMMI) found that since 2011, only six out more than 50 of these models created statistically significant savings for Medicare. The results are similar on the commercial side, and for the same reason: it is notoriously difficult to improve cost and quality simultaneously and nearly impossible to do so with our current reimbursement system.
Why have prior attempts at disruptive innovation failed? The Christensen Institute report outlines the reasons:
"The value-based care mistake" — Expecting old business models to deliver new value propositions that expand beyond good enough care that grows profit margins.
Fee-for-service and value-based contracts without new business models perpetuate these incentives.
Incumbent commercial insurers benefit from these incentives and have no reason to change them.
Hogg adds two more reasons.
"New entrants often go after an incumbent's best customers. That is a losing battle."
She reiterates that "new entrants don't have scale to succeed."
The Christensen Institute report concludes: "With the budgetary incentives to reduce costs and provide higher-value care, coupled with being the largest payer in the nation, this opportunity [a scaled and innovative OCBM] can't be ignored."
Is the murder of a healthcare executive enough to finally change our broken healthcare system?
Hope is not a plan. Neither is anger, retribution or grief. And all too often, it takes a crisis to motivate both immediate action and the kind of sticky commitment needed for long-term change.
Just as COVID re-surfaced the long-standing disparities hiding in plain sight in the U.S. healthcare system, the murder of UnitedHealthcare CEO Brian Thompson has surfaced the collective anger of the American public with that system.
Jamie Towey, vice president of Advocacy for Aging with Dignity, captures this sentiment and the why in his AWD newsletter post "Humans Come First": "There is an underlying reason for [this] anger . . . most Americans don't trust health insurance companies. Gallup polls consistently show that a majority of people view health insurance companies negatively, a percentage that has steadily increased and that stands in stark contrast to the public's perception of physicians and hospitals."
Towey adds: "Healthcare is an immensely complex system with many more players and variables than just health insurance providers."
Ann Somers Hogg, director of health care research at The Christensen Institute, agrees and that our current system must change — despite and because of that complexity.
Part one of this series will detail the problem part of the roadmap, and part two the solution.
1. Understand the root cause of the healthcare inflation problem
In a Dec. 13 New York Times op-ed, Andrew Witty — CEO of UnitedHealth Group, parent company of UnitedHealthcare — wrote: "We know the health system does not work as well as it should, and we understand people's frustrations with it. No one would design a system like the one we have. And no one did. It's a patchwork built over decades."
Witty's history lesson on why healthcare is broken was as misguided as the cruel responses to Brian Thompson's murder. Not that Witty is wrong, but payers and other industry players have also exploited that patchwork with actions that too often put profits before people.
Hogg notes that in 2022, the U.S. spent $4.5 trillion on health care "thanks to a complex, four-party system — insurers, sponsors [employers], providers, and consumers — that disrupts normal market dynamics."
"This system is why premiums keep rising, leaving individuals, families, and businesses struggling."
2. Acknowledge the three systemic consequences that innovators must address
"Even though the problem is systemic, we don't suggest changing the four-party system as a first step," says Hogg. "Instead, innovators must tackle the consequences of that system."
Per her report, those consequences are:
The cost-plus business model of incumbent insurers
Weak market forces that limit competition and innovation
No supply chain visibility to see and correct waste
Hogg adds detail to each of these, starting with the cost-plus model that has yet to be disrupted and that includes four dimensions:
Value Proposition: Good enough care at high and rising costs.
Resources: Used in part to incentivize leaders to maximize margins. This is in addition to the resource of enterprise data/transaction platforms.
Processes: Risk estimation without attempts to change it, and limited data sharing resulting in no supply chain visibility.
Profit Formula: A traditional fee-for-service model that creates inflation, yet limited profit sharing with providers participating in value-based care contracts.
"A systemic problem requires systemic solutions."
A combination of perverse incentives, waste and greed is grifting an industry whose primary product is — or should be — human health.
The Christensen Institute offers a two-part solution: 1) innovate the business model, and 2) build a new value network, with the U.S. government leading the charge as the largest payer.
"This approach gets to the root of the problem and avoids the missteps of past attempts to disrupt the industry," she adds.
Part 2 of this series will detail this solution, including an Optimal Care Business Model — the counterpoint to the current payer cost-plus approach.
Without data on Social Drivers of Health, there can be no intervention, measurement or improvement.
In 1624, poet John Donne wrote that gold bullion must be “coined into current money” to be of use. Four hundred years later, data is the gold that health plans must coin — extract, collect, store, share, analyze and apply — to achieve results.
Some of the most difficult gold to coin is data, specifically related to Social Drivers of Health (SDoH) data. A new qualitative study published in Health Affairs details health plans’ top three SDoH data challenges and possible solutions.
Progress and pitfalls as SDoH measure application grows
SDoH are the non-clinical factors — food insecurity, housing instability, transportation needs, difficulty paying utilities, interpersonal safety — that contribute to 80% of clinical outcomes. Healthcare has made SDoH progress. Quality measures for five SDOH domains are included or proposed in 21 federal programs, initiatives, or guidance documents:
There is also far to go. As noted in the Health Affairs study: “The ability of SDOH quality measures to improve care is predicated on health plans and other entities being able to collect and report these data.” Not only collect and report but analyze and implement. Not only improve care but make it more affordable and equitable — all in a way that is both standardized and patient centric.
The study adds: “Widespread implementation of SDOH quality measures is therefore dependent on an array of factors related to a health plan’s data system, including what SDOH-related fields are collected, how they are coded and stored, and interoperability.”
Data challenges persist as SDoH domains and measures grow. The Health Affairs study included two domains being developed by the National Committee for Quality Assurance (NCQA) — utility insecurity and social connection — and a third new measure — Social Need Screening and Intervention (SNS-E), which addresses unmet food, housing, and transportation needs.
The study included eight health plans that serve between 100,000-47 million government program members across the U.S. The findings produced three SDoH data barriers with mixed results across plans: 1) Health plan coding; 2) Health plan storage, extraction, and mapping; and 3) Systemwide considerations
Barrier 1: Health plan variable coding capabilities
To receive NCQA accreditation, health plans must submit HEDIS measures (Health Effectiveness Information Data Set). To collect and report on SDoH via HEDIS, health plans must be able to submit data via one of three standardized code sets: LOINC, SNOMED or CPT (hereafter “Code Sets). [1]
In the Health Affairs study, plans differed in their ability to extract these Code Sets:
Only 37.5% (3 of 8) could access LOINC codes, which are associated with health observations and measurement.
Of these 3 plans, only 2 could also pull SNOMED or CPT codes, used collectively for clinical terminology, interventions, services, and procedures.
Most health plans could also report Z Codes, used for SDoH screenings and interventions), but they are currently not allowed by HEDIS.
Health plans reported that financial incentives could help standardize coding practices.
Barrier 2: Health plan data storage, extraction, and mapping
Health plans’ ability to map SDoH data from EHRs was also mixed. Again, only 37.5% had automation capabilities to map while four plans mapped manually. Other results pertained to the SNS-E measure. Using SNS-E, most plans could report screening indicators but not interventions. However, it was difficult to map the two or link intervention with follow-up because the SDoH data came from multiple databases and lacked the needed time stamps.
Barrier 3: Systemwide need for improvement
The above-referenced link between screenings and interventions requires standardizing screening tools, intervention definitions, and data terminology. This requires the following improvements:
operationalizing SDOH data queries.
strengthening interoperability between health plans and providers.
facilitating referrals between health plans and community resources.
This is a systemwide opportunity. Health plans, as well as healthcare systems and community partners, must be able to align — with one another and with national measurement initiatives as they expand and change.
The plans also support federal policies that help facilitate, standardize and incentivize SDoH data practices. Current CMS policies designed to achieve this and updated in 2024 include:
The Interoperability and Prior Authorization Final Rule: Requires government health plans (Medicare Advantage, Medicaid, CHIP, marketplace) to establish and maintain a provider access API for claims and encounter data sharing. The hope is that this rule, which plans must comply with by Jan. 1, 2027, will facilitate the tracking of SDOH screening and interventions, and the coding time stamps needed to link the two and support follow-up care.
Physician Fee Schedule: Incentivizes the use of specific codes for SDOH risk assessments and to improve documentation. The study notes that these codes are “an incremental step toward collecting standardized SDOH data while interoperability continues to develop.”
Collectively these three barriers and opportunities for improvement deliver early lessons in how to integrate SDoH measures into practice. The Health Affairs study concludes: “Further research is needed to explore additional codes, mechanisms for collecting SDOH data in a patient-centric manner, and ensuring that health plans, health care systems, and community partners can align with national measurement initiatives. Standardizing these data will be key to improving outcomes for all.
[1] LOINC: Logical Observation Identifiers, Names, and Codes. SNOMED: Systematized Nomenclature of Medicine, used for clinical terminology. CPT: Current Procedural Terminology, used for interventions, services, and procedures.
A new Commonwealth Fund survey explores the intersection of finances and healthcare among older adults, including differences between Medicare and Medicare Advantage beneficiaries.
High cost-sharing is making it hard for many older U.S. adults to afford needed healthcare. This is compared to other countries and despite having Medicare or Medicare Advantage (MA) coverage. The result is skipped and delayed care — from recommended tests to treatment to follow-up.
U.S. cost share is not only higher but rising and with broad implications.
“Rising costs are forcing many older Americans to pay more out of pocket, leading to delayed care, poorer health, and higher long-term spending.” So notes Commonwealth Fund Vice President of Medicare, Gretchen Jacobson.
Her colleague — Munira Z. Gunja, Senior Researcher for International Health Policy and Practice Innovations — notes: “In some countries, almost no older adults are skipping or delaying care because of the cost.”
The research goes on to spotlight key findings and possible solutions.
Key findings: High OOP leads to skipped, delayed care
The Commonwealth Fund survey compared older adults in the U.S. with those in nine other high-income nations — Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, and the United Kingdom — with the following results:
High out-of-pocket costs: Over the past year, nearly 25% of U.S. adults spent at least $2,000 in out-of-pocket healthcare costs.
America leads in skipped/delayed care: The U.S. had the highest rates among surveyed countries.
Dental, drugs reflect the largest disparities: Some 20% skipped need dental care in the U.S., Australia, and Canada, while 2x in the U.S. alone skipped doses of prescription drug or never filled them.
These findings are particularly concerning given that one-third of older U.S. adults with cost-related access challenges reported fair or poor health. These challenges included one of the following during the prior 12 months:
not visiting a doctor despite a medical issue
skipping a recommended medical test, treatment, or follow-up
not filling a prescription or skipping medication doses
Spotlight: Mental health
Mental health care was a bright spot in the survey results. The Commonwealth Fund notes that
“few beneficiaries across countries report skipping this type of care because of costs” — less than 5% of residents across all countries.
Access in the U.S., however, remains challenging due to the difficulty of finding mental health providers who accept Medicare or MA plans. Again, The Commonwealth Fund notes: “Policymakers and researchers should monitor how these access barriers may lead to beneficiaries paying out-of-pocket for mental health care.”
Solutions, at home and abroad
When older Americans can’t afford needed healthcare, it impacts the entire delivery system. Sick patients get sicker and federal Medicare spending increases long term.
The Commonwealth Fund’s Gunja recommends that the U.S. look abroad for solutions, “such as capping out-of-pocket expenses and fully covering hospital and physician services.”
Conversely, home-grown solutions have focused on prescription drug costs. The Inflation Reduction Act includes multiple initiatives in various stages of implementation, including:
limiting Part D expenses
expanding low-income subsidies
capping insulin copayments
negotiating drug prices with manufacturers
These actions impact Medicare and MA beneficiaries in particular. While The Commonwealth Fund survey found no significant affordability differences between the two, the organization notes that MA plans limit enrollees’ maximum out-of-pocket medical expenses, offer lower cost-sharing opportunities, and typically include at least some dental coverage.
Still, and compared to other countries, Medicare and MA can do better.
“Even though nearly all older adults in the United States are covered by Medicare, this study highlights areas where the program has room to improve,” adds Gunja.
“Medicare was created to ensure older Americans can get the care they need and afford to stay healthy, and it’s critical that we uphold that promise to them.”
"We have this superpower of connecting with each other," noted the industry leader at the NCQA's recent Health Innovation Summit.
The NCQA Health Innovation Summit (HIS) connects diverse industry leaders and innovators around a common purpose: advancing healthcare quality through data solutions. Held earlier this month, the 2024 summit addressed value-based care, health equity, digital quality solutions and behavioral health, and how they can enhance comprehensive healthcare quality.
One summit panel, Women in Quality, addressed these topics from the perspective of five female healthcare leaders:
Guzman moderated the panel discussion, which emphasized the importance of community, leadership, and personal growth, and three key themes: the significance of integrity, the power of trust, and the impact of personal stories.
As leader of NCQA, O'Kane's insights accredit not only health plans but patient-centered medical homes with an emphasis on quality and health equity.
Embodying leadership and integrity
The panel began with a pivotal question and this response from NCQA's O'Kane.
Vanessa Guzman, CEO & President-SmartRise Health: You're all seen as leaders, as experts. You're all CEOs or in senior-level positions within your organizations. How do you embody that? What does that even feel like? How do you express it on a day-to-day basis?
Peggy O'Kane, CEO-NQCA: It's a really hard question, but I think I show up. That's it, pretty much. I have been on this job for 34 years, showing up.
Five insights from the rest of the panel included:
Remember that every day is a job interview
Act with integrity even when no one is watching
Lean into personal traits and let them influence your leadership style
Lead with purpose, curiosity and integrity
Balance your personal and professional roles
Using your "kitchen table"
The next topic was the concept of the "kitchen table," the people in our support networks who share our core values — family, friends, colleagues, mentors — and how important it is to nurture these connections.
Guzman: What does the kitchen table look like for you? And how does that kitchen table support your core values?
O'Kane: I actually think women have this superpower of connecting with each other, and it's a big deal. There's an emotional attribute in the dedication to quality.
Harris was speaking about pregnant women who get gestational diabetes. She showed that many of them never received continuous glucose monitoring. CGM helps reduce the onset of Type Two Diabetes after the pregnancy is over. Harris went to bat for these women with data—and within months, she's made this amazing change. I could just feel her resonating with love for these patients.
"That is a source of incredible motivation for all of us. I see young women who work for me or work elsewhere who are not so sure of themselves. And I just say ‘It's not it's not about you. It's about this thing that you're channeling, something that's bigger than we are.' I think that's a way to kind of forget your own ego a little bit, at least for the moment, and not make yourself too crazy about getting everything perfect."
Creating a strong culture while overcoming imposter syndrome
In discussing how intimidating it can be to build and lead a culture of quality, equity and trust, an important subtopic emerged: imposter syndrome. Women in particular often struggle with it, which can keep them from taking on leadership roles.
Moderator Guzman asked each panelist if they'd encountered imposter syndrome and how they've overcome it. In addition to the collective "Yes," the responses ranged from leveraging one's unique perspectives and value to creating peer mentoring groups. The discussion came full circle with the importance of trust in building culture, a point O'Kane emphasized.
O'Kane: This subject of trust is very interesting. I think we're going through a time when people are afraid to trust. It's so massive in our society . . . It's really horrible to be facing this kind of contemptuous distrust that's out there. I don't have an answer for this. I know all of us do try to be trustworthy, but there's just something that's out there that we've got to be the antidote to in some way—in our personal lives, in our communities, and in our organizations. That's not happening overnight but it's a big deal.
The panel's parting thoughts
The NCQA HIS session ended with key takeaways for the audience:
Do your homework and ask specific questions when seeking mentorship
Embrace your power and pay it forward by creating paths for others
Be conscious of living in your truth and the impact of simple acts of kindness
These takeaways emerged from the panel's final question, which O'Kane answered powerfully.
Guzman: What is your greatest wish, and would be one recommendation you would give in terms of opening the door for someone else?
O'Kane: I just want us all to live in every dimension of our lives and not only about work. I'm really obsessed about the political situation. We kind of all are. I like the idea of somehow finding a way, knowing that there's a huge business model out there that divides us. So, what are we going to do? We can't just do what we've always done.
Special Needs Plans are surprisingly (and highly) profitable. That's good for payers — but what about members?
For private payers, Medicare Advantage (MA) has been a lucrative business.
"Plans have had strong incentives to enter the MA market: relatively stable, higher payments and higher gross margins compared to other lines of business," says Jeannie Fuglesten Biniek, Associate Director-Program on Medicare Policy at Kaiser Family Foundation (KFF).
It's even more lucrative when it comes to Special Needs Plans (SNP) — in particular D-SNPs, or plans for people dually eligible for Medicaid and Medicare.
In contrast to SNP, the 2025 MA market has seen "unprecedented challenges with a redesigned Part D benefit, MA revenue pressures, and rising healthcare trends . . . [with] fewer plans, fewer carriers, and a significant uptick in plan terminations " (Milliman). This after many years of Medicare plans being a "huge driver of profits for insurance companies" (Wall Street Journal; Kaiser Family Foundation-KFF).
SNP's explosive growth makes it a bad time for the broader "Medicare Gold Rush" to be slowing:
MA market exits put SNP's growing members (particularly D-SNP) in the hands of fewer private payers.
This increases payer power with D-SNP members, who are already vulnerable — medically and socioeconomically (the social drivers of health, or SDoH)
Per KFF, "Medicare Advantage [already] enrolls a disproportionate share of people of color."
All of this casts insurers in a somewhat negative light. Like Big Tech — which corrects over hires with mass layoffs — MA payers were all in when times were flush but headed for the exits when market pressures hit.
Milliman notes that in 2026, "we will again see significant changes to stakeholders in Medicare Advantage." With more SNP growth guaranteed, the market has more questions to answer.
Big questions remain — before 2030 and after
What are the Medicaid implications?
Here, D-SNPs are a push-pull:
Redeterminations cut Medicaid members from the rolls who would have been dual-eligible.
Conversely, the market is not fully tapped, with 1.2 million current Medicaid members eligible for D-SNPs but enrolled in other plans (KFF).
Finally, D-SNP enrollment benefits states, who can lean on MA payers to provide extra benefits (i.e., "Medicare maximization").
Are there implications for value-based care (VBC)?
By 2030, CMS wants 100% of traditional Medicare beneficiaries to be in value-based arrangements. But it must also lean on MA plans to deliver VBC.
CMS continues to over-incentivize MA plans despite mixed results.
All of this could make SNPs a great proving ground for VBC demonstrations that get results. SNPs are already growing and strive for the kind of integrated, coordinated care that CMS models target.
The agency is clearly willing to try more complex VBC models (e.g., Innovations in Behavioral Health, which targets dual-enrollees with severe mental health and substance use disorders.
How much more will SNPs grow and for whom?
The CBO projects that MA penetration will reach 64% by 2030 (a 10% increase). As the fastest-growing plan type, SNPs — and the payers that offer them — are poised to capture a healthy percentage of this growth.
In 2023, UnitedHealthcare and Humana held 52% of D-SNP enrollment. Expect those numbers to grow and include other payers. In 2025, UHC, Aetna and Devoted Health grew their D-SNP plan counts by double-digits" (Milliman).
A modified Medicare Gold Rush?
Milliman predicts another challenging year for MA at large in 2026. Meanwhile, expect SNP plans to continue growing in a market that's not fully tapped.
Will some payers decide to focus more exclusively on SNPs? Possibly, particularly smaller MA carriers.
Could more SNP members in the hands of fewer payers be a good thing? Possibly, if they continue to fine-tune the kind of integrated services and specialized care coordination that SNPs were created to deliver.
As KFF's Associate Director-Program on Medicare Policy Jeannie Fuglesten Biniek has noted: "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."
All of this spells a Medicare Gold Rush that's not entirely over — just modified, with a SNP twist.
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!
