"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.
"If I was a payer right now, security and ransomware would be keeping me up at night," says one HIPAA legal expert.
Quantum computing derives its name from quantum physics, in which particles can operate in two states at the same time. Quantum computing's potential is to "tackle certain types of problems—especially those involving a daunting number of variables and potential outcomes, like simulations or optimization questions—much faster than any classical computer." The difference is the quantum bit or qubit, the equivalent of the transistor, which has itself advanced exponentially since its creation more than 60 years ago.
Just as the number of transistors per microchip increases processing power, so theoretically does the qubit, with the added phenomenon that multiple computing realities are present at once. The question is how payers and other healthcare stakeholders can apply such technology. The potential for quantum computing in healthcare includes what it can be used for and what it may protect organizations from.
Quantum computing's healthcare applications
A commonly cited quantum computing application in the for column is drug discovery speed and effectiveness for manufacturers and process optimization for payers and providers. CB Insights writes: "Optimization problems are notoriously difficult for classical computers to solve due to the overwhelming number of variables and possible combinations involved. Quantum computers, however, are well suited to this type of task as different options can be sifted through at the same time."
To a question of when, the future appears to be soon. For the first time, IBM will install its quantum computers at an off-site private business: Cleveland Clinic. Planned applications include gene, infectious disease, and public health studies. National payer Anthem is entering the space, having joined IBM's Q Network Hub to explore how quantum computing "may help in developing more accurate and personalized treatment options and improving the prediction of health conditions."
Additional quantum computing applications for payers and providers include:
Improving diagnostic imaging quality, analysis, and processes
Advancing precision medicine
Optimizing pricing and perfecting risk analysis
All of these could be possible through quantum computing's ability to process multiple, interdependent data sources concurrently (e.g., clinical, social, economic, environmental). That same data, however, is where quantum computing poses a real threat that regulators and tech developers alike are seeking to solve.
Cybersecurity and emerging standards
To understand why, in part, we need to look at the algorithms that industry uses to collect, manage, and harness big data for business and consumer applications. IBM notes that "[q]uantum-enhanced machine learning algorithms are particularly relevant to the [healthcare] sector." But current algorithms also represent a threat, including to payers. CB Insights writes: "Cybersecurity could be upended by quantum computing. … Powerful quantum computers threaten to break cryptography techniques like RSA encryption that are commonly used today to keep sensitive data and electronic communications secure."
The potential threat has prompted the National Institute of Standards and Technology (NIST) to draft new guidelines. Congress established NIST at the turn of the 20th century to help build the national infrastructure needed for global competition. Two decades into the 21st century, NIST is developing new cryptographic standards with finalization expected in 2022. In an August 2021 white paper titled Migration to Post-Quantum Cryptography, NIST states that this requires identifying, prioritizing, and migrating the "vulnerable algorithms" that underpin current cryptography to "quantum-resistant" ones via five planned discovery scenarios. One of these scenarios will address healthcare algorithms in both "enterprise data center environments … [including] on-premises data center and hybrid cloud deployment hosted by a third-party data center or a public cloud provider."
The National Cybersecurity Center of Excellence (NCCoE) will also be "developing white papers, playbooks, and proof-of-concept implementations … [and] forming a Cryptographic Applications community of interest ... [to] provide recommended practices to prepare for a smooth cryptographic migration" from quantum-vulnerable to quantum-resistant encryption algorithms. Quantum key distribution (QKD), another strategy, will help transfer encryption keys and detect their interception. "Done right," CB Insights writes, "this means that even quantum computer-equipped hackers would have a hard time stealing information."
HIPAA is not enough
These efforts are right on time as current standards alone will not fully protect health plans and other HIPAA-covered entities as an increasing number of corporate ransomware attacks make headlines. National HIPAA expert Roy Wyman, a partner with the legal firm Nelson Mullins and chair of the its Privacy & Security Industry Group, notes: "If I was a payer right now, security and ransomware would be keeping me up at night. Simply complying with HIPAA is not enough. New technology like quantum computing will make it more difficult to stop hackers, especially state actors."
In a 2020 paper, Wyman notes that HIPAA "has mostly been locked in amber since 2009,” despite regulatory updates. Even a "second wave" of privacy and security requirements marked by the EU's 2018 General Data Protection Regulation (GDPR) guidance and stateside via legislation in California, Colorado, and Virginia have not fundamentally altered HIPAA. Noting that none of these state statutes goes beyond simply requiring "reasonable" security measures, Wyman adds: "There must be a much more nuanced approach than just complying with HIPAA."
Solutions through payer collaboration
From a tactical perspective, Wyman offered one solution for health plans: banding together to create security cooperatives to share resources, group data where appropriate, and segment it where critical firewalls are needed. This could be accomplished via joint venture, one of healthcare's favorite ways to turn competitors into collaborators, that is funded by participating payers. "Quantum computing is becoming more common but very expensive. Individual players may not be able to afford their own individually but collectively could fund a quantum shell for protection," he says.
CB Insights notes that while quantum computing "faces a number of hurdles, … the payoff may still be worth it. Some think that quantum computing represents the next big paradigm shift for computing—akin to the emergence of the internet or the PC. Businesses would be right to be concerned about missing out."
Wyman cautions, however, against technology's ability to solve everything that ails healthcare data privacy and security. "There is a perspective with tech that it's always the answer. There are places where it doesn't help. We're not systematically weighting benefits and costs." He recommends a similar systematic approach to revising the regulations that go hand in hand with tech development. "We either need to revise HIPAA to put more resources behind it or, even better, take a step back to reassess privacy and security, and how we deal with them."
"Some of the findings may sound crazy, but in 2021, it's not far from reality in the insurance industry," says one insurtech source.
As we navigate year two of the coronavirus, privacy in the time of COVID-19 continues to shine a light on the permanence and proliferation of personal data and preferences regarding it. Some of the statistics, including those from a recent Breeze survey, may surprise you but the implications likely won't—nor the seriousness given that the first major company in the U.S. has announced it will raise individual premiums based on employee vaccination status data.
Employers and payers alike are increasingly using big data and from a variety of sources to design predictive analytics and assess insured risk. Breeze is one of those companies, an insurtech startup that offers health coverage related to disability, critical illness, and other wraparound benefits. In its August 2021 survey of 1,000 U.S. adults, 56% overall replied that insurance companies should not be allowed to price policies based on big data. Notably, that figure jumped to 83% for those 55 and older. Following this first question, however, the results changed radically when payer use of that data impacted consumer pocketbooks. In exchange for more affordable premiums:
55% would wear a health-plan-mandated biometric tracker (e.g., Fitbit)
51% would be comfortable with payer prescription drug use monitoring
42% would also agree to a health plan tracking their consumer activity and purchases
"The story here is not only the groundbreaking technology that's changing the industry, but also the privacy concerns and public sentiment on big data in insurance," says Breeze's Director of Communications Mike Brown.
Other noteworthy results included consumer response on insurance companies analyzing their DNA, installing home cameras to monitor daily habits, and tracking online/social media activity. These were at far lower approval rates, however.
Noting that in the past seven to 10 years, Big Data has altered insurance underwriting forever, Breeze CEO Colin Nabity adds, "Insurtechs are trying to figure out how do we get more creative with all of this data that has not been traditionally used. The more data available from more sources, the greater the predictive analytics and the better the opportunity to assess risk and drive down costs."
As the survey results indicate, incentives help. But for health plan members, do carrots or sticks work best? And how are stakeholders proceeding? We know the answer when it comes to Delta Airlines. Following the FDA's full approval of the Pfizer vaccine, the company announced in late August that "unvaccinated employees enrolled in Delta's account-based healthcare plan will be subject to a $200 monthly surcharge." Delta is self-insured with UnitedHealthcare acting as its third-party administrator. The airline declined a HealthLeaders interview request regarding the legal and compliance complexities of their decision-making process but did indicate that more than 60,000 employees (75% of their workforce) have been vaccinated.
As to the decision, one health law expert speculates that Delta will levy the surcharge as part of a wellness program, allowable under the Health Insurance Portability and Accountability Act (HIPAA) and that will not change under now-frozen wellness program rules. This perspective comes from Lindsay Wiley with the American University Washington College of Law. Wiley notes that a HIPAA exception "allows group health plans (employment-based plans) to establish premium discounts or rebates or modify copayments or deductibles as an incentive for employees who adhere to 'programs of health promotion and disease prevention'— better known as 'wellness programs' ".
This is an effective strategy for employers and payers alike as more consider vaccine mandates tied to financial consequences and data monitoring. Another August 2021 survey, this one from Willis Towers Watson, finds that 59% of the responding 961 employers track employee vaccination status with 19% more planning to do so. Seventeen percent offer vaccine incentives and 14% are planning or considering to do so. Another 18% are considering incentives, penalties, or both—with only 2% of respondents currently imposing surcharges.
These results come as requiring vaccination status is cited, incorrectly, as a HIPAA violation. While the HIPAA Privacy Rule may see a change in 2021, the proposed changes did not pertain to COVID-19. The U.S. Department of Health and Human Services Office of Civil Rights (OCR) has issued the most recent federal COVID guidance on topics ranging from online vaccine scheduling to PHI public health disclosures tied to health information exchanges.
In addition, President Biden signed an executive order requiring that all federal employee and government contracts get the COVID-19 vaccine. The Administration also announced its six-point plan for containing coronavirus spread, including in schools and at work.
Slow or fast, Big Data keeps up as the Delta variant continues to surge and payers, employers, and other stakeholders seek tools that balance privacy and legality, economic concerns, and public safety.
"The consumer behavior aspect is a bit unrealized," says one group executive.
There aren't too many holy grails in healthcare, probably none. But there are many hopefuls and consumer-directed health plans (CDHP) are one.
CDHPs were created to bend the cost curve and they remain popular with fully and self-insured employers alike (FI and SI). But results from the 2022 Business Group on Health employer survey indicate that CDHP dynamics are changing. This article explores the reasons for this shift in the second of two articles on the Business Group's annual findings.
CDHP relevance among business group members
CDHPs remain the plan design of choice among large, SI employers. The Business Group reports that median CDHP enrollment was 50% in 2021 and that CDHPs "continue to be the highest enrolled plan for a majority of employers” at 53%.
But paired with this popularity is a decline in CDHPs as the sole coverage option. The Business Group findings show that "the last several years have seen a move away from full replacement." The primary reason for this is the 2019 repeal of the Affordable Care Act (ACA) excise tax, designed to discourage employers from offering high-cost Cadillac plans. CDHPs offered employers an alternative and their uptake predictably grew. Among the Business Group employers, CDHP full replacement increased from 17% in 2012 to a high of 39% in 2018. A steady decline with the tax repeal will result in only 14% of the Business Group members expecting to offer CDHP as their only option in 2022.
"Employees who might have swung the pendulum further toward CDHP now have more choice," says Ellen Kelsay, Business Group on Health's President and CEO. PPOs now rank a relatively close second in plan design, representing 41% of large, SI employer enrollment.
The broader landscape is comparable but not equal
In 2020, 64% the Business Group's large, SI employers offered only CDHPs. This year is called out to compare those survey results to the most recent findings from the Kaiser Family Foundation (KFF). In that survey, which includes all employer types (small, large, SI and FI), 68% offered CDHPs as their sole option.
The comparison is important to gauge benefit design popularity across the landscape, how SI trends influence other employers and payers, and vice versa. Kelsay notes, "When you are a large innovative employer that makes some change, other employers are keen to learn from that—especially smaller employers. Health plans watch, too," she adds. "There seems to be an interest in not only plan design, but vendor choice. Plans pay attention for when it makes sense for them to pivot."
HSA a vital part of the strategy
Health Savings Accounts (HSA) are an important part of CDHP plan design, with these related findings from the Business Group survey.
HSA dominates HRA in CDHP pairings. Among responding employers, 97% offered HSAs in 2021, compared to 22% for HRAs. HSAs dominate in the KFF 2020 survey as well (20% versus 8%) but overall employers that offer either option is lower (26%).
Employer HSA contribution. The median 2021 contribution was $600 for employees, $500 for spouses/partners among the Business Group respondents. KFF 2020 results, again across all employer types, averaged $550 and $1,018.
Contribution strategy. Some 57% of the Business Group 2021 respondents make predefined HSA contributions that may be wage-based, matched, or seeded. Of those contributions, 26% were based on employee health improvement program participation. The 2020 KFF survey did not contain this information.
The latter is important, as consumer engagement is a critical aspect of overall CDHP success—and one that has been mixed.
If you build it they will come, sort of
Consumers play a vital role in CDHP actual outcomes versus plan design potential. In 2008 and pre-ACA, The Innovator's Prescription identified the combination of HSAs with high-deductible health plans as "one of the most important reforms to be made in health care . . . a necessary element of the new disruptive value network that major employers will need to orchestrate." The authors predicted 90% CDHP substitution by 2016, which has not clearly come to pass. Consumer behavior is a significant component.
"The consumer behavior aspect is a bit unrealized," observes Kelsay. "There was a lot of optimism about CDHP. The hope was that it would create more informed healthcare consumers who, because of the high deductible, would think twice about using the ER, getting a scan, or choosing brand over generic. But there are the practicalities of how we use services, the urgency of choice. In these scenarios, lining up the information to make good decisions isn't necessarily the answer. This plus the impact of high-deductible plans on people who live paycheck to paycheck and the unintended consequences of delayed care has made things hard."
But it's more than consumer behavior. It's system behavior. Jason Hwang, MD, one of The Innovator's Prescription's authors, commented in 2019:
“While HSA adoption has increased a lot, it hasn’t quite been exponential. . . the reluctance of the system to move beyond a volume-based fee for service model (the tyranny of the visit!) has precluded value and outcomes-based offerings that are ideal for HSAs and informed consumers."
Health Affairs had a similar prognosis in 2020, noting that today's innovators, "Walmart, Amazon, and Google, are hardly the streamlined outsiders evoked in the Innovators Prescription. If their services and products appear cheap, it’s because customers are paying with their data as well as with their dollars". Amazon, along with Berkshire Hathaway and JPMorgan Chase, was one of the employer behemoths that formed Haven to deliver better, more affordable care to employees. Three years after it launched, Haven is no more with Harvard Business Review author John S. Toussaint citing "insufficient market power…[the healthcare system's] perverse incentives, [and] poor timing [COVID]" as the primary factors.
Toussaint advocates a public option and notes, "If large corporations want to self-insure, they would still be able to do so but at a substantially higher cost." Like so many healthcare reform discussions, the role of self-insured employers, CDHP, and the broader implications of benefit design ends where it began—with concerns over cost, quality, and access.
More than 90% of employers are concerned about COVID's long-term impact on deferred care and employee mental health.
In the era of COVID, the term site of care has multiple implications. This includes not only where care is delivered but the physiological conditions that are now within telehealth's reach and employers' ability to impact. HealthLeaders has identified this site of care takeaway from the 2022 Business Group on Health employer survey and recent online press conference. Site of care's influence can be seen among the top five large employer concerns from this year's Business Group on Health survey, including:
COVID's impact horizon
Expanded social determinants of health (SDOH) benefit design, including financial programs
Mental health care, access, cost, and quality as well as stigma awareness.
Reimagined roles for, and the future of, worksite clinics
Anticipated cost upticks after a mixed spending year
Key highlights from each area are outlined below. The survey reflects responses from the Business Group's members, including 136 employers—mostly large and self-insured from diverse industries—that cover more than 8 million people.
COVID'S LONG REACH
More than 90% of employers are concerned about COVID's long-term impact on deferred care (particularly related to cancer diagnosis and treatment) and employee mental health. While health and well-being are either integral to or a consideration in workforce strategy for 87% of employers, this represents a surprising decrease from 2020 (94%).
And while the key reason is not surprising (e.g., COVID response overtook existing strategies), how employers dialed back is. The Business Group reports that 15% of respondents reduced value-based health and well-being efforts, such as participation in accountable care organizations (ACO), high-performance provider networks, and provider centers of excellence. Given that COVID is the equivalent of a dumpster fire for healthcare data trending and business intelligence decisions, however, these value-based program shifts may prove well-advised for the short term.
WHY SDOH MATTER EVEN MORE
With the U.S. workforce still largely remote and the Delta variant curbing activity, site of care continues to align with site of live, work, and play. This makes SDOH's impact on health and well-being even more important and for more people, with self-insured employers challenged to address these intersections.
Emerging SDOH concerns include employee finances/income and racism, with 60% and 55% of employers respectively implementing benefits and programs to address them. Health inequities related to fertility/material care are another key focus, with 82% of employers creating solutions to target high-risk pregnancies, post-partum depression, fertility, prenatal care, C-section rates, and doula services by 2022. Transgender health needs and neurodiversity (e.g., spectrum disorders, ADHD) are two additional areas with 75% or more of employers reporting that they are addressing.
MENTAL HEALTH: A NEW FOCUS ON STIGMA
COVID has amplified another U.S. epidemic: mental health. Now, more employers are targeting a significant reason why many people do not seek care: stigma. "The year 2022 will mark the first time that a majority of employers will have an anti-stigma campaign, according to the survey," says Ellen Kelsay, Business Group on Health's President and CEO, who spoke at the organization's August 25 press conference. While mental health service access is still the prevailing focus for 76% of employers, 57% named stigma as one of their top three areas of concern for employee well-being.
A growing number of mental health tech solutions are also helping, moving site of care as close as a smartphone app or wearable and expanding the reach of companies' Employee Assistance Programs (EAP). "Health tech is a major way employers are increasing employee access to mental health," says Business Group on Health Vice President Brenna Shebel, another conference speaker. For more traditional mental health services like counseling, 75% of employers intend to offer no- or low-cost telehealth options in 2022—a significant increase compared to the 54% that currently do.
ON-SITE OR ONLINE?
Workplace clinics aren't going anywhere anytime soon. Yes, employers report that the number of on- or near-site clinics declined in 2020 and 2021—with a return to pre-pandemic numbers not expected until 2024. But those sites have and may continue to play a role with COVID testing and vaccination, particularly if more employees are required to return to the office fully inoculated and face fees if they don't. "Employers are exploring surcharges for non-vaccinated employees. This is a hot employer topic. There are compliance and legal concerns, as well as bad PR," notes Shebel. The day after the Business Group's press conference, Delta Airlines announced that it would charge unvaccinated staff a $200 monthly insurance fee effective November 1, 2021.
Still, on-site may be the better place for the urgent and chronic, with virtual visits an ideal solution for acute and maintenance care. The Business Group reports that 76% of employers plan to maintain their telehealth expansion efforts in areas ranging from the traditional to the surprising. Among this latter group, fertility, musculoskeletal, cardiac, and kidney care are expected to see a minimum 20% increase in the number of employers planning telehealth offerings by 2023/2024.
THE FUTURE OF HEALTHCARE SPENDING
In 2020, the coronavirus accomplished what the healthcare industry has not: bending the cost curve. Reduced spending from deferred care appears to have offset the costs associated with COVID-related care for large, self-insured employers. The Business Group reports that a spend trend ranging from -12% to +10% resulted in a net-zero overall increase.
No one expects that to continue. A 6% increase is expected in 2021, with some mitigation through benefit design in 2021. Consumer-directed health plans (CDHP), however, may not be part of that strategy. In a follow-up article, HealthLeaders will explore the Business Group's findings specific to CDHPs, which fewer employers are offering as a full replacement in lieu of other coverage options—one of many areas in which the group offers rich data.
"The Business Group's annual survey is a unique window into how large employers plan to evolve their benefit strategies and offerings in the coming year," said Kelsay. “Employers seek information about their peers' strategies, and survey findings offer collective guidance for companies to best support their workforces."
Editor's note: This story was updated on August 30, 2021, at 5:01 p.m.
