"It's not clear yet what America's health care future will look like, but the continuing impact of the COVID pandemic and debates among policymakers over the future of government programs are shaping consumer experiences and expectations."—eHealth
eHealth, a large health insurance exchange in the U.S., has released its biannual Health Insurance Trends report. Topics range from Medicare, COVID-19, technology, and disparities to insurance coverage selection, costs, billing, and customer experience. The report is based on a survey of more than 6,400 consumers and 15 health plans, and for the first time includes response breakdowns based on racial and ethnic demographics. The results below highlight areas of interest for payers.
Consumer response varies on Medicare benefits, costs, and private sector roles.
Expanding Medicare: 92% want added dental, vision, and hearing benefits for traditional Medicare but only 50% would be willing to pay for them.
Public versus private: A majority believe Medicare should continue to be a public/private program but results vary among Republicans (56%), Independents (56%), and Democrats (51%).
COVID-19 consumer opinions mixed while pandemic impact on health insurers less than expected.
Vaccination status and premiums: 45% of consumers support higher insurance costs for people who are unvaccinated, with 37% opposed.
Modest cost increases: 55% of insurers indicate that COVID has increased member medical costs but most by 10% or less.
Post-pandemic picture: 38% of insurers have reduced, or plan to, their voluntary COVID coverage expansions. Only 12% plan to raise premiums.
Diverse communities see more surprise billing, fewer choices.
Unexpected charges: Compared to 46% of White respondents and 45% of men, many consumers who are Hispanic (60%), Black (56%), or women (54%) have encountered unexpected medical costs.
Coverage doesn't reflect community: Fewer people of color believe that their insurance options meet their specific racial or ethnic medical needs. This includes 41% of Hispanic, 45% of Asian, and 46% of Black respondents compared to white (58%).
Response varies on insurance options and innovation.
Marketplaces: 69% of consumers want additional, private options for marketplace shopping, comparison, and enrollment.
More faith in the private sector: More than half of respondents (52%) believe private enterprise is better at technology and innovation than the government (18%).
"Data gaps and the lack of race data have been a challenge for years. Physicians can't do these kinds of interventions on their own," says BCBS-MA CMO Sandhya Rao.
Lagging, missing, and unstructured data is one kind of healthcare challenge. Some data, however, is hiding in plain sight, waiting to make a difference. One payer, BlueCross Blue Shield of Massachusetts(BCBS-MA), is focusing on existing HEDIS data to reveal multiple racial and ethnic disparities and link solutions to its current value-based purchasing (VBP) model. As reported in September by The Boston Globe, this initiative "will begin paying doctors more money if they close longstanding and pernicious gaps in care for people of color." Although the initiative has just begun, payers can consider what its design is already revealing as they seek to implement similar programs.
Equity begins at home
The initiative is rooted in two ideas and three program elements, according to Sandhya Rao, CMO for BCBS-MA.
"We've been aware of disparities for years and doing a lot to address them. But the events of 2020—including the murder of George Floyd and COVID-19—inspired us to look at our own HEDIS data across groups and to build on being at the forefront of value-based purchasing for more than a decade through our Alternative Quality Contracts (AQC)."
Linking current data, practice leadership, and payment approaches form the programmatic core of the plan's new disparities initiative.
How it will work
BCBS-MA will launch the initiative using publicly reported HEDIS data to identify the most critical gaps in care for members who are Asian, Black, and Hispanic. Early findings from the plan's 2021 Health Equity Report compared disparities in care across ethnic groups in the following areas:
Colorectal screenings: Lower rates for Asian (67.0%), Black (63.8%), and Hispanic members (65.4%) versus non-Hispanic White members (70.8%).
Adolescent well-care: Fewer visits by Black (68.9%) and Hispanic (70.3%) members compared to non-Hispanic White members (80.2%).
Severe maternal morbidity: Rates were more than double for Black members versus White non-Hispanic (2.8% vs. 1.2%).
Antidepressant medication management: Black and Hispanic members were 15%–20% less likely to receive the recommended management than White non-Hispanic members.
BCBS-MA will target these areas first, focusing on commercial members already attributed to its primary-care-focused AQCs, which more than 80% of BCBS-MA's physicians and hospitals participate in. Rao notes that the plan published these findings to “start the conversation” on how existing data can help identify disparities and how to address them.
BCBS-MA will use the AQC model to design incentives for its new equity-based initiative. "This is the part we know the least about now. We always start by sharing data and metrics for a few years to ensure those components are right, then build in incentives over time." This will begin in 2023, according to the plan.
To support providers in this new AQC direction, BCBS-MA is partnering with the Institute for Healthcare Improvement (IHI). The IHI will bring together plan practice leaders who are effective at sharing data to impact disparities and engaging other physicians to close gaps.
Measuring success and applicability for other plans
As to how BCBS-MA will know the initiative is working, Rao says that the plan will "start with the known, provide physicians with ongoing member reports, and refresh and refine the data as often as possible."
Rao says that, based on existing data, the initiative may launch with different metrics for different physician groups and grow from there. "Our general quality strategy is to expand the measure set beyond HEDIS, such as behavioral health where we could use more measures of quality."
Common opportunities and challenges
As is true of many aspects of healthcare, opportunity and challenge are often rooted in the same elements.
"Data gaps and the lack of race data have been a challenge for years," says Rao. The health plan is using multiple approaches to overcome this, including working with providers and employers to collect data, and continuing to ask members to self-identify. The plan will also use imputed data (i.e., data that assumes a member's race based on multiple factors).
Supporting providers is another challenge. "Physicians can't do these kinds of interventions on their own," says Rao. Closely linked to this are BCBS-MA's AQCs, designed so that it "doesn't put all of the burden on the physician."
Paramount to this is whether the current AQC model has worked, given that it will be the chassis for the new program. A Harvard Medical School study published in The New England Journal of Medicine found that BCBS-MA's AQC "slowed the rate of medical spending growth by up to 12% while improving patient care" from 2009–2016 compared to averages nationally and across New England. On the quality and efficiency side, researchers noted that the AQC "has helped change the rates that physicians order tests and some imaging modalities, the rates of emergency department admissions, and the management of chronic conditions."
It is also true that an asterisk can be placed at the end of nearly every VBP result. These include other factors that could contribute to results, including "the presence of Medicare ACOs [accountable care organizations], payment reform among other commercial payers, and state policies," to name a few.
Understanding whether VBP can fully deliver is an ongoing question. Even the IHI's involvement in the new BCBS-MA equity initiative reinforces these challenges. Over the past 20 years, key IHI publications on quality and medical errors have revealed other truths hiding in plain sight: that healthcare was (and still is) struggling to meet its Triple Aim: better cost, outcomes, and customer experience.
Here, Rao cites her colleague Dr. Mark Friedberg, SVP for performance measurement & improvement at BCBS-MA: "We can't just say we want to close these gaps without acknowledging the resource and effort involved."
And also without acknowledging existing data. As payers and other stakeholders look increasingly to alternative data sets from multiple external sources, BCBS-MA is using what it already has to bring into focus a story that was already there.
'The challenge is, how do plans maintain and increase Star scores in the clinical measures for higher-risk members while proactively enhancing the customer experience,' poses one executive.
It has been exactly one month since the Centers for Medicare & Medicaid Services (CMS) published its 2022 Star Ratings for Medicare Advantage plans. One year from now, Star Ratings measures for Patient experience will quadruple in value—a shift in priorities that may disrupt plan ratings and benefits parity. And while some external Stars measures data pose challenges, payers' own data and operational focus can help create a robust, integrated Stars strategy that achieves what CMS' program shift is designed to accomplish.
Star Ratings measures, weights, and methodology change annually to reflect CMS priorities and address parity across measures and plans to ensure continuous performance improvement. For the 2022 MA plan year, Stars Ratings include multiple measures across five categories weighted from one to five: Outcomes, Intermediate outcomes, Patient experience, Access, and Process. Plans that earn 4.0 stars or more qualify for quality bonus payments while plans that achieve 5.0 can market year-round.
The soon-to-be quadrupled weighting of the Patient experience category is no small change. It means that customer experience metrics will represent 57% percent of an individual health contract's overall Star Rating. A prior HealthLeaders article featured this payer call to arms from Amy Amick, president and CEO SPH Analytics, a firm specializing in healthcare analytics and population health: "If you don't want to let be left behind with 2023 Star Ratings, or if you want to continue to use experience as a way to differentiate and outperform, you need to be taking action today." Amick's advice came more than a year ago, a time for plans to begin to act given the challenge of improving customer experience.
Can a focus on customer experience move the needle?
McKinsey notes that while "customer experience measures have been a component of Stars ratings for years, health plans have not been as successful in improving their customer experience compared to other industries." Clearly it is time for a change, and for multiple reasons. For more than a decade, analysts have been citing the Star Ratings "Lake Wobegon" effect, named for a fictional town where "all the children are above average." In 2022, approximately 90% of MA enrollees are in plans rated four stars or higher.
McKinsey further notes that the Stars program has generated $15.1 billion in payer incentives. Despite this, the MA program is not achieving one of its primary objectives: to generate savings for the overall Medicare program while delivering higher quality, coordinated care. This is according to MedPAC, the independent agency that advises Congress on the state of the Medicare program. In its March 2021 report, MedPAC notes that "aggregate MA payments … are about 4 percent higher than expected FFS expenditures." They further add: "The current state of quality reporting in MA is such that the Commission can no longer provide an accurate description of the quality of care in MA."
Similar challenges abide in the Medicare Shared Savings Program (MSSP), which established accountable care organizations (ACO). MedPAC reports have "shown modest success in improving quality" and "modest reductions in spending relative to their benchmarks" compared to FFS." This includes the NextGen ACOs that take on greater risk and which have resulted in no reduction in spending when accounting for shared savings distributed. It's important to note that 43% of MSSP quality measures pertain to patient/caregiver experience.
Implications for payers
While the above data raises questions about Stars and customer experience metrics as a direct path to savings and quality, plans certainly can't go wrong in treating their members well. Amick from SPH Analytics notes that Patient experience can be a payer strategy to "differentiate and outperform"—an especially important one given the current parity in not only Star Ratings but another development leveling the playing field: MA plan supplemental benefits. Randy Strite, director of government programs practice with healthcare consulting firm FluidEdge, notes: "This is not your parents' Medicare. This is a second generation in terms of the rating model and benefits offered.
CMS notes that "[t]he Star Rating system helps Medicare consumers compare the quality of Medicare health and drug plans being offered. As part of this effort, patients are empowered to make health care decisions that are best for them." Improved retention is a possible outcome, given that positive experiences should drive customer loyalty. And while MA members already tend to stick with their plans (85% between 2013-2019), Star Ratings that weight customer experience over clinical outcomes could impact this dynamic.
Embedded challenges
The above-referenced dynamic raises one of the most important questions about the new Stars Ratings weighting, also raised by FluidEdge: "How do plans maintain and increase Star scores in the clinical measures for higher risk members while proactively enhancing the customer experience and ensuring sound operational processes are in place?"
Another challenge is how difficult customer experience is to capture, in general and given the nature of some of the data used to measure it. A portion of Star Ratings Customer Experiences derives from CAHPS. Star Ratings include 21 CAHPS measures across six domains.
Cherié Shortridge, vice president of government programs practice at FluidEdge, highlights the challenges of the data arising from these measures: "CAHPS scores are deidentified so health plans can't nail down the results to specific customers or regions, etc. CAHPS questions are also quite vague and subjective, questioning consumers as to needs versus wants and this is where health plans have trouble. They are tapped into the data but feel they don’t have as much control."
A broader challenge on payers' 2023 Start Ratings is the impact of current baseline scores. Shortridge notes that "[p]lans had artificially inflated scores for this year [2021]; they received the better of the scores from this year and last year due to the impact of COVID-19."
What payers can do
These challenges, and the importance of proprietary intelligence, can inform a payer's readiness for strong 2023 Star Ratings. "This is where health plans need to take a fresh look at their own data," Shortridge notes. "Plans don't have to wait for CAHPS to understand what drives member dissatisfaction. Their own complaints, grievances, and appeals are a window into what needs to be fixed from an experience perspective. This data is also included in the plan operations metrics (e.g., appeals decision timeliness and uphold rates, or how often a plan's original decision stays after appeal and external review), as is the availability of translation services," says Shortridge. "Plans have the operations metrics down because of clear numerators and denominators, and the availability of real-time data."
Plans may also miss opportunities to improve experience by not considering all of their customer-facing departments, including care management, disease management, and call center operations. "These are all points of light as to the root causes of poor customer experience." The balance, then, is between what Strite calls "managing to the metric" where that yields value and a comprehensive view in other areas.
"It's important to take a systems-wide view of contributing factors—what are you successful at, what can you tweak," says Shortridge. Her firm's approach for working with payers includes assessments, road mapping, strategy, intervention, implementation and two analytics tools: a Stars decision engine and score forecasting based on what/if analysis.
"Stars is not a single event"
Despite MedPAC's assertion that Star Ratings quality reporting is insufficient, it is the best mechanism currently available and one that requires a sophisticated, strategic response. "Stars is not an action," says Shortridge. "It's not a single event. It’s a way of operating, of taking care of members and managing customer experience. It is a culture, embedded in everything you do. If you're meeting customer needs with quality, positive Star Ratings will follow."
"Expanding into virtual-first health plans is the next step in providing a convenient and comprehensive care experience," says one health plan executive.
A growing number of regional and national payers are putting telehealth at the center of their care delivery, benefit, and plan designs. With these developments, the virtual visits mothered from pandemic necessity could transform to permanent innovations built on the telehealth foundations that already existed. Implemented well, virtual health could solve multiple problems while paving the way for future virtual therapies that are smartly reimbursed from the start.
Telehealth as care delivery design
Under the care design category, CareFirst has introduced CloseKnit, a "virtual primary care" [model that] … will offer a wide variety of care services, including preventive and urgent care, behavioral and mental health, care coordination, insurance navigation and more." CareFirst will offer CloseKnit to its Maryland commercial enrollees to test this new model. The plan also offers plans in Maryland and the District of Columbia. Larger payers are also taking a pilot approach, while embedding telehealth even more deeply in benefit and plan design.
Telehealth as benefit and plan design
Aetna, Cigna, and UnitedHealth are three national providers announcing their telehealth developments as part of a broader, virtual care strategy. Aetna has called its Virtual Primary Care the "first nationwide virtual primary care solution," while Cigna and UnitedHealth offerings include "virtual-first" health plans. Aetna's Virtual Primary Care, Cigna's MDLive, and UnitedHealth's NavigateNOW all include virtual primary, behavioral, and urgent care, and in some cases dermatology.
Some rollouts are large-scale, others tiered. In contrast to Aetna's national Virtual Primary Care network, Cigna will offer its expanded MDLive services to all employer-group members, with exchange plan members having access to virtual dermatology. This is in addition to a broader "virtual-first" plan option, also for select employers. The plan does not require referrals for in-person, in-network visits and includes $0 copays for "MDLIVE primary care providers, comprehensive chronic condition management and care navigation." UnitedHealth's NavigateNOW offers similar $0 copays and for select employers in nine markets.
Can virtual first deliver on accessible, primary care promises?
In its announcement, CareFirst President and CEO Brian D. Pieninck notes that "[n]early 40% of our members don't have a primary care doctor" and that "CloseKnit helps fill critical gaps for many patients, particularly those who lack a PCP." This raises the question: Can virtual first help achieve what every other coordination model—from HMOs to medical homes to value-based contracting—are often still struggling to produce: cost-effective services rooted in primary care that create better outcomes?
Making convenience a reimbursable commodity rather than "a nice to have" may be the missing ingredient. Along these lines, Pieninck adds: "We created CloseKnit because people deserve an enhanced, modern care experience that meets their expectations, needs and preferences for choice in how they connect and experience care."
Post-pandemic staying power?
What began as a solution for patients in rural areas with limited access to providers could have much broader applications for decades to come. This is particularly true now that commercial telehealth is growing and with the Centers for Medicare & Medicaid Servicers (CMS) permanently expanding telehealth's definition and scope.
And there could be a wraparound effect. Well before the pandemic, consumers were already turning to apps and wearables to put better health at their fingertips. Well after COVID-19 is no longer a public health emergency, it's likely that more prescription digital therapeutics will be reimbursed, ideally via value-based contacts from the start.
Current-state virtual care emerged from unanticipated, systemic disruption that could create planned and permanent systemic innovation. This is not to say that payer and provider virtual capabilities were in 2019 what they are in 2021. Email and text communication, however automated, is not remote monitoring. The question continues to be: Why does it take a crisis to not only drive change but fully implement and reimburse existing solutions?
"Digital Landscape helps payers and other organizations fully understand and navigate barriers of success for any new or existing tech-enabled initiative … They need to know what is going to work," says Trenor Williams, CEO and cofounder of Socially Determined.
Socially Determined, the Washington, D.C.-based technology company that measures the impacts of the social determinants of health (SDOH), has developed Digital Landscape, a new metric for assessing digital equity as an SDOH component. Using Digital Landscape, organizations can assess equity "within a population or community and the impact it has on health outcomes and business performance." The metric is part of Socially Determined's SocialScape analytics platform that helps organizations design, implement, and measure targeted community health initiatives.
Digital Landscape's multiple components are designed to assess whether members can access, afford, and use the technology solutions that payers and other stakeholders are investing so heavily in. "Digital Landscape gives payers the visibility that will be critical to understanding digital equity among their members as reliance on technology grows," says Socially Determined CEO and co-founder Trenor Williams.
Socially Determined reports that "[t]he Digital Landscape metric is unique in its ability to offer an advanced and comprehensive analysis of factors related to [digital equity], … and how they all intersect." These factors include:
Access – Broadband availability plus computer/smartphone ownership and public internet access.
Affordability – Internet access costs, individually and as a function of overall household budget.
Literacy – An individual's technological understanding and skills.
These factors can be measured at a highly granular level. "The Digital Landscape risk metric evaluates the intersection of accessibility, affordability, and digital literacy at a 200-meter level resolution across every community in the United States," says Williams. "This helps ensure that payers and other organizations fully understand and can navigate barriers of success for any new or existing tech-enabled initiative … It's paramount to be as precise and accurate as possible because we live in a world with limited resources. Payers and other organizations need to know what is going to work."
In addition to Digital Landscape, Socially Determined's SocialScape platform includes a range of SDOH data and proprietary risk scores related to food, housing, transportation, and economic security as well as health literacy. The company cites the rise and continued use of telehealth driven by COVID-19 as a factor in "elevating digital equity as a major influencer of business performance for payers and providers, and the overall wellbeing of communities and populations."
"Payers have understood the value prop very quickly: the best fit for the customer is ideally the best fit for the plan," says one executive.
The data scientists will see you now. In fact, they're here to help not only healthcare consumers but payers through a growing number of insurtech platforms. Independent marketplace platforms are one example, offering payers increased customer retention potential through big data, artificial intelligence (AI), and their linkages to risk analysis, plan selection, and broader health and wealth planning. Such marketplace solutions could provide the missing ingredient for consumer-driven healthcare that complements payer efforts via scale, longevity, and positive customer experience.
How data science supports healthcare's "risk-takers"
A recent study from the Irish Journal of Medical Science defines data science as "an interdisciplinary field that extracts knowledge and insights from … big data." Specific to the health industry, the study further states: "Data science provides aid to process, manage, analyze, and assimilate the large quantities of fragmented, structured, and unstructured data created by healthcare systems. This data requires effective management and analysis to acquire factual results" including the "data cleansing, data mining, data preparation, and data analysis used in healthcare applications."
Technology's solutions often create new problems. The importance of data science and AI to fully utilize the big data generated by healthcare systems is but one example, with insurtech emerging as part of the solution subset. Insurtech includes new entrants (often startups) in health plan products, operations, benefits management, and the focus of this article, marketplaces.
Data and the data science that harnesses it have the power to aid payers and startups alike—and even unite them. PitchBook writes: "The growth and increased availability of traditional and nontraditional data sources enable startups to build patient management platforms that provide the risk-takers—including insurers, risk-taking providers, and self-insured employers—with a better understanding of individual healthcare needs."
"Building a better front door"
One such startup is Healthpilot, a new insurtech company using "data science at scale and proprietary decision-support technology to find and match consumers with Medicare plans that match their unique profile." Healthpilot also helps consumers enroll online by transferring their application information to the chosen payer for processing. Plan options include Medicare Advantage (MA), Medicare Supplement, and stand-alone Medicare Prescription Drug Plans (PDP).
Healthpilot's fully online customer engagement and enrollment model combines data collected from customers with diverse, third-party data from multiple sources to create individualized plan recommendations based on the Medicare plans available in the service area. "Our algorithm does two things," says CEO Dave Francis. "It cross-references personal information against larger data sets to create a risk profile and the customer's likely utilization of healthcare resources over the next year." Those larger data sets include aggregated medical claims data from millions of patients nationwide.
"With this information, says Francis, "we can get a pretty good match of who you are from a health utilization perspective, take that score, match it against plans in your ZIP code, and from there match your needs to the best plan for you." Customers indicate their preferences and see the top plan recommendation that fits them best, along with others for easy, transparent comparison. Think of it as Spotifying healthcare, although Francis cites another company, Amazon, as the inspiration for the company’s business model. "It's very forward-looking. This is rooted in data science's ability to bring in instant predictive analytics for the customer’s benefit."
How payers benefit
In addition to a better front door, Healthpilot seeks to offer a back door that stays comfortably shut—i.e., promotes customer retention through continued, personalized support that benefits payers as well. "Post enrollment, we continue to use data and data pathways that help us stay up to date with customers and create ongoing recommendations and targeted communications," says Francis. This data includes individual utilization data and marketplace changes (e.g., benefits, physician networks, pharmacy coverage). Healthpilot has plans to expand beyond Medicare to offer a comprehensive marketplace.
Francis notes that this kind of ongoing engagement "is not mutually exclusive with payer relationships. One of our biggest concerns was that we wouldn't get the time of day with big payers. We were humbled and surprised that they understood the value proposition quickly." That value proposition includes:
Improving risk analysis
Helping plans enroll the best-matched customers
Driving long-lasting relationships
Reducing customer complaints
Improving customer satisfaction
These benefits mirror those that insurtech startups in general can deliver to payers and other stakeholders. The more directly better plan choice can be correlated to better customer health and experience would be a boon to payers and insurtech providers alike. Francis continues: "The best fit for customers is ideally the best fit for the plan. Data science helps us put the customer in that place."
The broader impact could include improvements in how payers communicate and market to customers, including positioning coverage choices as a function of comprehensive health and wealth planning. In a 2021 research brief on value-based care models, The Geneva Association recommends that insurers "capture the opportunities afforded by the convergence of life and health products and solutions."
Data science implications for consumer-driven healthcare
So can data science, insurtech, and decision-support tools combine to deliver customers and carriers that are perfectly matched? A 2020 JAMA Health Forum article notes: "Some health insurance decision aids that incorporate consumer preferences have been experimentally shown to improve decision self-efficacy and confidence in health plan choice. However, … [f]urther research is needed to determine the effect of decision support tools on access to and utilization of desired and high-quality health care services, health outcomes, and financial burden while covered under a plan."
This research and insurtech's rise comes at a time when the industry is wise to examine how technology can aid consumer-driven healthcare. Healthpilot's Francis notes that his company's model is to "service, not sell." That word—service—has become essential to intertwining technology's products with its value message (e.g., data-as-a-service, software-as-a-service, platform-as-a-service). Data-science-as-a service could very well be next in line.
Data science's impact on the value chain
The Irish Journal study cited previously states that data science and big data analytics help build "a comprehensive view of patients, consumers, and clinicians." The ideal solutions will create that view for these stakeholders as well. "Big data is a revolution in the world of health care. The attitude of patients, doctors, and healthcare providers to care delivery has only just begun to transform."
Francis agrees: "There is no reason stakeholders can't be aligned. Data science benefits customers, payers, and providers by delivering better individual capabilities at scale in a way that also addresses the need for personalized, localized solutions."
"Medicare Advantage plans have a unique and growing opportunity to address the needs of socioeconomically vulnerable populations and improve their health," reports America's Health Insurance Plans.
The expansion of supplemental benefits is just one of the strategies Medicare Advantage (MA) plans are using to address social determinants of health (SDOH). More plans for individuals with low incomes, as well as targeted SDOH investments and initiatives, round out carrier approaches.
On the benefits side, offerings such as meals, transportation, and in-home supports are becoming increasingly common across MA plans, including those with a $0 premium (58% in 2022 compared to 53% in 2021). Many of the largest carriers report, in their press releases or through HealthLeaders sourcing, that they have also expanded the number of Dual-Eligible Special Needs Plans (D-SNP) they offer—and in some cases, linking them to added benefits, such as debit cards to help pay for groceries, utilities, and/or covered over-the-counter items.
These moves are in addition to a growing number of MA plans partnering with agencies in high-need communities. In its May 2021 report, America's Health Insurance Plans (AHIP) highlighted initiatives across MA plans to address social isolation, digital literacy, COVID-19, homelessness, disability, and food insecurity. Some of these initiatives are being incentivized.
Carrier highlights
Part 1 of this HealthLeaders' series targeted MA cost design, while Part 2 highlighted Medicare portfolio strategy. In Part 3, highlighting the three next-largest carriers, Kaiser Permanente enrollment data was provided by the company while Centene (Wellcare) and Cigna data were sourced from the Kaiser Family Foundation (KFF).
Kaiser Permanente
The recurring headline with Kaiser Permanente is the company's quality, with MA plans that are consistently rated five stars, allowing the integrated payer-provider and integrated EHR pioneer to market those plans all year long. Andrew Bindman, MD, executive vice president and CMO states: "From the moment our Medicare health plan members choose Kaiser Permanente for their care and coverage, we work diligently to provide an exceptional, coordinated care experience, and this distinction is a reflection of those efforts."
MA enrollment and market share: 1.7 million, 7%.
Footprint: 8 states and the District of Columbia.
$0 premium: Number of plans unavailable at time of publication.
In its 2020 annual report, Kaiser highlights "[t]elehealth's breakout moment" and its "fully integrated telehealth capabilities," which include remote monitoring for diabetes and cardiac conditions with data that links directly to the payer-provider's EHR. The company's Social Health Playbook, which includes screening tools and is promoted as replicable across the industry, focuses on home, food, and social connection resources.
Centene
Centene, with 1.1 million MA enrollees, offered an abbreviated press release for its 2022 portfolio emphasizing largely footprint growth and Wellcare, the company it acquired in 2020 and the umbrella name for its now six MA brands. Michael F. Neidorff, chairman, president and CEO, states: "At a time when many seniors are grappling with the effects of COVID-19, we are committed to expanding choice and access to high-quality, affordable Medicare plans that support our members' health and well-being during the pandemic and beyond."
MA enrollment and market share: 1.1 million, 4%
Footprint: 33 states
$0 premium: Number of plans unavailable at time of publication.
In its financial statements, Centene cites the acquisition as "a key part of our growth as we become one of the nation’s largest sponsors of government health coverage." The company's MA plans have expanded to 327 new counties (a 26% increase) and three additional states (Massachusetts, Nebraska, and Oklahoma) bringing that total to 36 states. Like other carriers, Centene has also increased its PPO offerings, expanding to 10 additional states for 2022.
Cigna
Regarding its 2022 portfolio, Aparna Abburi, President of Cigna Medicare, notes: “Through geographic and product expansion, we’re pleased to be able to provide … customers with the plan that best fits their personal health care needs, including their lifestyle, health and budget. We are committed to making customers’ Medicare options easier to understand and access.” Cigna is the seventh-largest MA company by enrollment in the U.S.
MA enrollment and market share: 0.6 million, 2%.
Footprint: 26 states and the District of Columbia.
$0 premium: 70% of plans with all markets offering at least one such plan.
Cigna's 2022 MA press release highlights the company's geographic expansion, stable premiums, and three specific benefits: its expanded Part D Senior Savings Program; gift card incentives linked to $0 annual, in-network screenings and physical exams; and a new social connection program in select markets to address customer loneliness and support instrumental activities of daily living (e.g., meals, transportation, chores). The company further highlights its transportation, post-hospital meal delivery, and fitness benefits as well as debit card for allowable expenses for select D-SNP customers. Cigna's 30% year-over-year growth continues its geographic expansion of 80% since 2019 with an emphasis on new states and more PPO options. The company will offer PPOs in 152 new counties in 2022.
A unique position?
Noting that many MA beneficiaries "face more socioeconomic risk factors and are more financially vulnerable compared to the traditional FFS Medicare population," AHIP adds that "Medicare Advantage plans have a unique and growing opportunity to address the needs of socioeconomically vulnerable populations and improve their health. The organization recommends multiple policy changes that will allow MA plans more flexibility to offer SDOH-related supplemental benefits, Star Ratings measures, innovation models, and alternative funding. These recommendations will bear watching as MA plans appear, each year, to up the ante for greater market share.
Portfolios are designed to "make care more affordable, accessible and convenient," in the words of one executive.
The ideal value chain for any industry or company is one built for lifelong customer retention and loyalty. One component of such a chain is a portfolio strategy that continues to offer maximum choice and affordability. For insurers in the Medicare market, this equates to a mix of plan designs and standalone prescription drug plans (PDP), group plans, and Medicare Supplement plans.
This spectrum gives insurers the ability to:
Offer options that appeal to every Medicare-eligible beneficiary.
Capture the significant, organic growth represented by the 10,000 baby boomers aging into Medicare daily.
Convert existing, non-Medicare customers to Medicare coverage.
Portability through provider networks and PPOs
The latter may be easier said than done. While some consumers are more passive decision-makers, opting to stick with the brand they know when they become Medicare eligible, the internet has made online plan comparisons and selection navigation, including those offered by a rising group of insurtech startups, easier than ever. Consumers may find that their carrier's Medicare provider network doesn't include their current physicians, cover their prescription drugs, or offer the care choices necessary as medical needs increase.
The importance of provider networks is closely linked to another piece of the strategy puzzle: offering enough PPO plans to maintain provider access. Portability is important not only for consumers but also employers who offer retiree benefits. Being strategically positioned to make conversions also includes the important but rarely discussed factor of whether the umbrella company's subsidiary structure permits the data sharing necessary for payers to target and market to their Medicare eligibles in an efficient, cost-effective way.
Part 1 of this HealthLeaders' series targeted Medicare Advantage (MA) cost design, including the increasing percentage of $0 premium plans and copays while summarizing 2022 offerings from the two largest MA insurers, UnitedHealthcare and Humans. Part 2 will overview plans from the Blue Cross Blue Shield (BCBS) companies and Aetna, the next-largest plans by market share. BCBS enrollment data was sourced from the Kaiser Family Foundation (KFF) and includes its Anthem-branded plans. Aetna provided its enrollment data, which varies only slightly from 2021 KFF statistics.
Blue Cross Blue Shield including Anthem
BCBS, a federation that includes the BCBS Association and 35 independent companies (including Anthem-branded plans), ranks third for MA market share. One of BCBS's stated focus areas is "offering support that goes beyond the four walls of the hospital or doctor's office by addressing social needs that are important to good health for seniors."
MA enrollment and market share: 3.8 million, 14%.
Footprint: 47 states and Puerto Rico
$0 premium: Available in 40 states and Puerto Rico
The impact of multiple chronic conditions is one of several target areas in BCBS plan design. Related benefits include food insecurity and enhanced primary care. Community partnerships are a central part of the strategy. Two BCBS plans partner with community organizations for meal delivery: BCBS of Massachusetts and Independence Blue Cross. The latter has also partnered with Dedicated Senior Medical Centers in Philadelphia to bring primary care closer to low-income neighborhoods and in hopes of reducing ER visits, hospital admissions, and inpatient length of stay. BCBS plans in three states (Rhode Island, Michigan, and New York) also offer "concierge services" to assist members with complex care navigation.
BCBS Anthem plans are offering an Essential Extras package to address "whole health and its many drivers of health." The option, available in seven of the 14 states where Anthem operates, allows members to choose one of nine benefits include allowances for dental, vision, hearing, assistive devices, and groceries; allotted hours for in-home support and personal home helpers; a fitness tracker and fitness program membership; meals and transportation services; and pest control.
Aetna
Aetna, a CVS Health company, is the fourth-largest MA insurer. Christopher Ciano, President, comments that the company wants to maintain its COVID-19 care focus while helping "improve their overall physical and mental health." Ciano reports that the company "expanded our Aetna Medicare Solutions portfolio of products to include more benefits designed to make care more affordable, accessible and convenient."
MA enrollment and market share: 2.9 million, 11%.
Footprint: 46 states and Washington, D.C.
$0 premium: Available to 84% of beneficiaries.
For 2022, Aetna indicates that approximately one-third of its individual MA plan members will see lower out-of-pocket cost maximums for in-network care. The company is also emphasizing its "holistic approach to health," which includes leveraging its CVS Health relationship for expanded over-the-counter (OTC), fall prevention, and smoking cessation solutions as well as lower pharmacy costs. As for additional drug benefit enhancements: "Individual MAPD plans will increase prescription drug day supply to a maximum of 100 days for drugs on tiers 1-4 [where package size allows] … with no increase in copay/coinsurance".
The company's offerings include more dual-eligible special needs plans (D-SNP) and Aetna Medicare Eagle® plans for veterans that pairs with their VA benefits, available in 41 states and with $0 premiums and $0 PCP and lab copays, plus dental, vision, hearing, OTC, and fitness benefits for all plans. Aetna has expanded its hospice benefits and end-of-life support select MA plans in Ohio and Pennsylvania, and its alternative medicine benefits including therapeutic massage for select Northwest region plans. It is one of many plans taking an allowance-based approach for some of its dental benefits.
Additional benefits and up next
As mentioned in Part 1 of this series, many plan benefits have become increasingly standard for MA plans but beyond what traditional Medicare covers. This is true of BCBS and Aetna and includes enhanced dental, vision, and hearing; transportation and post-inpatient-stay meal delivery; OTC and fitness; programs that combat loneliness; and $35-per-month insulin cost caps as part of the Part D Senior Savings Program created by the Centers for Medicare & Medicaid Services (CMS).
Part three of this series will highlight social determinants of health (SDOH) and the next three largest MA carriers: Kaiser Permanente, Centene, and Cigna.
Editor's note: This story was updated on October 25, 2021.
"Medicare consumers overall ... crave stability of benefits and a hassle-free experience that gets them the care and coverage they need at a price they can afford," says one health plan executive.
Health plan marketing has begun for the 2022 Medicare Advantage (MA) season, with the annual enrollment period running from October 15–December 7. This compressed time frame is to MA payers what Black Friday is for retailers: the single-largest opportunity to gain customers and revenue. The analogy is apt given the massive opportunity MA represents for private insurers and the programmatic advantages over traditional Medicare that these companies promote and seek to capitalize on.
This is the first of a three-part series from HealthLeaders that will highlight key themes and spotlight the largest MA insurers in order of market share, including their key differentiators, enrollment totals, and market share. This information was provided by each payer via their national press releases and/or additional data obtained via HealthLeaders' inquiry with the goal of obtaining and reporting as much comparable data as was available at time of publication. Enrollment data differs slightly from the Kaiser Family Foundation's (KFF) analysis of CMS data highlighted in the HealthLeaders look-back of 2021 MA plans.
This week's article will feature UnitedHealthcare (UHC) and Humana. Blue Cross Blue Shield and Aetna (a CVS Health company) will be highlighted in feature two, with week three showcasing plans from Kaiser Permanente, Centene, and Cigna. Collectively, these plans represent 22 million members, with UHC and Humana representing approximately 45% of this number.
Premiums, benefits, and costs
Every MA insurer in the U.S. is looking to capitalize on a rare phenomenon in any industry: significant, organic growth. MedPAC reports that baby boomers "began aging into Medicare in 2011 at a rate of about 10,000 people per day, a rate that will continue until 2030." They further report that "over the next 15 years, Medicare’s enrollment is projected to increase almost 50 percent—rising from 54 million beneficiaries today to more than 80 million beneficiaries in 2030." That is the same year that the MA enrollment is projected to overtake traditional Medicare.
No- to low-cost premiums and cost-sharing is one reason why. Available data show that $0 premiums predominate, representing 65% of all MA plans. This is particularly attractive compared to Medicare Supplement policies. Zero copays also apply to a growing number of services—from provider visits to lab visits. Plans also offer $0 pharmacy deductibles and $0 copays on many tier 1 and tier 2 drugs, especially when filled at preferred retail or mail-order pharmacies.
Benefits that Medicare doesn’t offer or not as fully are another reason for the MA program's growth—from vision, dental, and hearing to home-delivered meals and transportation to services once considered alternative medicine and those identified based on social determinants of health (SDOH). There are also disease-specific savings for diabetes and, since 2020, for COVID-19.
Combine these factors with the overall stability, enhancement, and affordability of increasingly attractive benefit packages. This is the note payer executives consistently strike in their 2022 Medicare portfolio statements. Tim Noel, CEO of UnitedHealthcare Medicare & Retirement, summarizes it this way: that members "crave stability of benefits and a hassle-free experience that gets them the care and coverage they need at a price they can afford."
UnitedHealthcare
UnitedHealthcare is the largest provider of MA benefits in the U.S., with service areas and provider networks that reach 94% of all Medicare-eligible beneficiaries. Noel notes that for 2022, "every expanded benefit, every enhanced program and every investment in a new offering is because we have been listening intently and shaping our plans to deliver on what we hear from consumers." UHC offers Medicare Supplement plans co-branded with AARP, which gives members access to brain health and driving refresher programs with auto insurance premium discount opportunities. UHC also offers standalone prescription drug plans (PDP) co-branded with AARP and Walgreens.
MA enrollment and market share: 7.3 million, 27%.
Footprint: All 50 states, plus Washington, D.C.; includes 276 new counties.
$0 premium: Available to 3 million members.
UHC reports that 98% of its members will have stable or improved benefits in 2022. The company will offer new, lower copays for specialist visits and physical, occupational, and speech therapy. Nearly 90% will have access to comprehensive dental coverage through select plans, with specific coverage for higher-cost services such as crowns, bridges, root canals, and dentures.
Drug cost highlights include more tier 1 covered drugs and gap coverage including more $0 copays and $0 deductibles across plans and delivery options. Among consumers, 70% of UHC's current members and 90% of its eligible beneficiaries will have access to $0 tier 1 retail pharmacy copays with the same copay extending to tier 2 for mail order for most plans.
As part of its customer experience focus, UHC further highlights its expanded HouseCalls program featuring in-home testing for diabetes, hepatitis C, and SDOH factors.
Humana
Humana is the second-largest provider of MA benefits in the U.S. Alan Wheatley, President, Retail, remarks: “After considering the needs of our members and how we could offer them more for 2022, we designed our Medicare plans to address people’s whole-life needs—with a particular focus on their most important health care needs …"
MA enrollment and market share: 4.9 million, 18%.
Footprint: All 50 states, Washington, D.C., and Puerto Rico; includes HMOs in 115 new counties, dual-eligible special needs plans (D-SNP) in 268, and local PPOs (LPPO) in 162.
YOY growth: 72 new plans (42 MAPD non-SNP, 27 SNP, and 3 MA).
$0 premium: 52% of plans.
In its 2022 press release, Humana places less emphasis on $0 premiums, copays, and prescription drug cost-shares than other carriers. It does highlight its D-SNP Prescription Drug Savings Benefit to reduce Part D copays for many of those plan members. Instead, Humana stresses SDOH factors such as food security and transportation access. This includes a Healthy Foods Card for groceries, also for D-SNP members.
The company offers the $0 premium Humana Honor MA plan, which was "designed with U.S. military veterans in mind" and will now be available in 47 states. The plan includes dental benefits and a buy-down feature that reduces Part B premiums. All of Humana's MA plans are USAA endorsed but not co-branded. The company does offer co-branded, stand-alone PDP plans with Walmart that include the retailer's Sam's Club pharmacies.
Humana is the only carrier that HealthLeaders covered that emphasized its sales process, including more personnel available virtually, by phone, and in-person for agents who are fully vaccinated.
Up next
Part two of this series will highlight Medicare portfolio strategy and the next two largest carriers: Blue Cross Blue Shield and Aetna.
"As Medicare Advantage takes on an even larger presence in the Medicare program … [it will] be important to monitor how well beneficiaries are being served in both," notes Kaiser Family Foundation.
Medicare Advantage (MA) marketing launched October 1 in advance of the 2022 Annual Enrollment Period (AEP). Prior to HealthLeaders' survey of 2022 plans publishing next week, we first look back at the 2021 MA season. Using Kaiser Family Foundation's (KFF) summary of the 2021 Centers for Medicare & Medicaid Services (CMS) Medicare Enrollment and Dashboard Files, we explore enrollment, premium, and other trends including the supplemental benefits that distinguish MA from traditional Medicare. This could be changing, however, if dental, vision, and other supplemental benefits are added under the Democrat-proposed, $3.5 trillion Build Back Better plan while MA would see even more growth if eligibility is lowered to age 60.
Enrollment
KFF notes that 2021 MA enrollment totaled 26.4 million people, or 42% of total Medicare beneficiaries (62.7 million). This number has more than doubled since 2000, when MA-PD (prescription drug plan) enrollment was roughly 7 million. This number dipped for a brief period at the turn of the new century (2001–2005) but has more than doubled since then, with roughly one to two million new enrollees joining the program each year between 2007 and 2021. More than half of all Medicare beneficiaries are expected to enroll in an MA plan by 2030.
Most of this enrollment is in individual Medicare Advantage plans versus employer- or union-sponsored (67% compared to 19%). There are eight states, however, where group MA market share is noteworthy: Alaska (100%), Michigan (45%), Maryland (39%), West Virginia (39%), New Jersey (37%), Wyoming (35%), Illinois (32%), and Kentucky (31%).
Special needs plans (SNP) make up an even smaller percentage of MA enrollment, but their numbers have grown as well. Fifteen percent of Medicare beneficiaries, or 3.84 million people, were enrolled in SNPs in 2021. Most of these (88%) are members of dual-eligible special needs plans (D-SNPs), which applies to those also eligible for Medicaid, versus chronic condition (C-SNP) and institutional (I-SNP) plans. Total SNP plan enrollment has more than tripled since 2010.
Geographically, MA enrollment in 25 states plus Puerto Rico represents between 40%–50% of beneficiaries. Among states with penetration rates of 30% or less, Midwestern states predominate with KFF calling out six—Vermont, Maryland, Alaska, and Wyoming—where MA has less than 20% market share.
UnitedHealthcare (UHC) dominates the MA market, representing 7.2 million or 27% of MA enrollments in 2021. KFF adds that UHC growth has exceeded all other plans for five consecutive years. The MA field also includes Humana (4.8 million, 18%), BlueCross BlueShield plans including Anthem (3.8 million, 14%), and CVS Health (2.8 million, 11%). The rest of the field includes Kaiser Permanente, Centene, and Cigna (3.4 million, 13% collectively) with all other insurers representing 17% or 4.5 million enrollees.
Premiums and plan design
In examining the details of MA, KFF's second 2021 analysis focuses on those plans with MA-PD. This model represents 89% of all plans offered, with 90% of enrollees in this plan type.
Of the 17 million enrolled in MA-PD, most (65%) pay no premium. For those who do, premiums range from less than $20 per month to $100+ per month with the average being $21. These already-low premiums for most MA-PD enrollees are also declining. Between 2020 and 2021, monthly premiums declined $4 per month, driven by premium declines for local PPOs.
On average, HMO plans are the lowest priced ($18 per month). This is followed by local PPO plans and regional PPOs ($25 and $48 monthly, respectively). Regional PPOs provide maximum choice, while local PPOs—whose enrollment has scaled notably since 2016—offer the cost benefits of narrow networks. HMO remains the predominant plan design, however, representing 60% of MA-PD enrollments followed by local PPOs at 35% and regional PPOs at 4%.
Cost-sharing and prior authorization
The average maximum out-of-pocket limit for Part A and B services under MA plans was $5,091 for HMO plans and $9,208 for PPOs. This compares to the 2021 federally required limit of $7,550 and $11,300, respectively. Kaiser notes that the "average out-of-pocket limit for in-network services has generally trended down from 2017 but increased slightly between 2020 to 2021."
Moving from cost-sharing to cost control, prior authorization (PA) is a well-established practice in the MA program, applying to 99% of MA enrollees. These range from inpatient hospital and skilled nursing facility stays to diagnostic procedures to select vision, hearing, and dental services. Ninety percent or more of MA enrollees require PA for the services named above as well as for durable medical equipment, part B drugs, non-emergency ambulance services, diabetic supplies and services, and home health. PA can also apply to services one might not consider, such as podiatry (required across 63% of MA plans).
Benefit design
An advantage of MA—one that has built the Medicare private market—is enrollee access to benefits traditional Medicare does not offer. These typically include vision, hearing, dental, and fitness benefits with more than 90% of plans offering these supplemental benefits in 2021. Such benefits may also include over-the-counter products; meal, transportation, and in-home support services; and the telehealth, remote-access, and remote monitoring services that have become critical during the coronavirus pandemic.
KFF notes: "Though these benefits are widely available, the scope of specific services varies … Plans also vary in terms of cost sharing for various services and limits on the number of services covered per year and many impose an annual dollar cap on the amount the plan will pay toward covered services."
As Medicare Advantage continues to expand that scope—with services such as acupuncture, gym membership, and healthy food incentives growing—the program will also grapple with what traditional Medicare expansion might mean. As KFF writes: "As Medicare Advantage takes on an even larger presence in the Medicare program … [it will] be important to monitor how well beneficiaries are being served in both," notes Kaiser Family Foundation. Proposals include lowering Medicare eligibility to age 60 and the addition of vision, hearing, and dental benefits. Simultaneously, however, have been proposals to use Medicare Advantage's private model over a public solution to help achieve Medicare for All.
Health Affairs writes: "Under some proposals, President Joe Biden’s Medicare-like public option would be replaced with private insurance options. Either MA plans would be allowed to compete for non-Medicare business on the insurance exchanges, or insurers would negotiate prepaid contracts with providers, using government funds."
Continuing that "Medicare Advantage may or may not be an ideal policy lever to pull" in light of continued needed analysis on MA's cost, quality, and access landscape compared to traditional Medicare, these are critical questions at the cusp of the 2022 AEP season. Watch for HealthLeaders' upcoming story on how new individual payer offerings compare to 2021 trends.
