Pathwell integrates Cigna and Evernorth capabilities to create personalized health journeys for biologics and musculoskeletal (MSK) customers.
Cigna's 2020 launch of Evernorth, its health services division, has generated multiple new products, services, and acquisitions. The newest is Pathwell, which targets high-cost specialty pharmacy and MSK conditions by linking the health plan's benefit designs and national provider networks with Evernorth's "analytics, clinical expertise, treatment planning, and personalized digital solutions."
In a press release for the announcement, Cigna SVP for U.S. solutions Heather Dlugolenski noted: "Our clients and customers are exhausted by the fragmented health care system. They want one place to go to get a personalized experience for their entire health care journey."
Touting the benefits for employer cost-control as well, Dlugolenski added: "Cigna Pathwell connects customers with the providers and therapies that are best suited to their unique health conditions and, through our unparalleled data and expertise, can help anticipate their future needs to help them recover faster."
Here are three things to know about the new Pathwell suite.
The new suite includes two products with plans to expand to new markets and conditions.
Pathwell Specialty is for patients with complex or rare conditions that require infusions or injectable medicines. Pathwell Bone & Joint targets customers with "wear and tear" MSK conditions. Cigna plans to expand the products to more U.S. commercial clients throughout 2023. The suite will continue to evolve based on this navigating a range of complex health conditions based on a "flexible blueprint for innovation to support the needs of health plans and patients."
Pathwell Specialty uses a concierge approach to coordinate medical and pharmacy benefits while reducing cost of care for patients and the plan.
"Biologic medicines can be life-changing for patients, but only if they can afford them," Dr. Ajani Nimmagadda, Cigna Pharmacy CMO, said in the Pathwell announcement, adding that they "account for 65 percent of drug spending even though only four percent of Cigna customers need them."
To address these issues, Pathwell Specialty will offer concierge care management services that will link patients to the quality, affordable infusion options in a variety of settings. This will include home infusions or injections that providers order for patients via the Cigna Pathwell Specialty network.
The Pathwell Specialty expansion will include behavioral, wellness and nutritional services; telehealth visits; and extended support via the Cigna Caregiver Bridge Program.
Pathwell Bone & Joint addresses less acute MSK conditions to prevent high-cost surgeries.
A recent study from the Evernorth Research Institute found the following:
Nearly 25% of people seek care for strains and sprains.
These injuries represent nearly 66% of MSK utilization and spend.
Better approaches to intervention and care coordination can reduce that spend up to 40%.
Like Pathwell Specialty, Pathwell Bone & Joint combines Cigna provider networks and plans with Evernorth's tech capabilities—specifically its digital navigation and advanced predictive analytics capabilities to predict surgery risk and prevent it if possible. If surgery is required, Cigna benefits include "low or zero cost for surgery from admission through discharge."
That can anticipate a surgery up to a year in advance, create a holistic, integrated musculoskeletal solution that will improve health outcomes while reducing unnecessary surgeries which can lead to increased costs.
"The ability to access multiple care modalities through a single vendor is extremely attractive to plans," says one health tech leader.
Payers are included in three of the five business models that digital health companies need to build and scale, according to McKinsey—whether the focus is health plans, employers, or new products like digital therapeutics.
HealthLeaders asked multiple health plans and tech companies about why today, the payer is a new kind of customer and how that impacts purchasing decisions, scale, and value delivery.
The executive soundbites below include a behind-the-scenes discussion from HealthLeaders' recent roundtable. The event report, A One-Of-A-Kind Discussion On Healthcare's Platform-Industrial Complex, is available as a free download.
Making purchasing decisions
Buy versus build is just one aspect of payer tech decision-making. Once a payer decides to partner, their digital health offerings must deliver on multiple aspects of ROI.
Debra Williams, chief sales and marketing officer for BlueCross BlueShield of Massachusetts, told HealthLeaders: "There are two lanes by which health plans will evaluate these offerings: insured and self-insured targets. For the former, plans need the health tech to show ROI—whether that's bending cost trend, increasing access, connecting dots for the consumer, or helping with better health outcomes. For self-insured clients, health techs need to help them with all of the above and support their war on talent."
Katie DiPerna Cook, senior vice president of Partnerships for Headspace Health, agrees. Headspace Health uses science-backed tools to support meditation, sleep, stress, and mindfulness.
"Health plans understand that ROI won't happen overnight and that a long-term investment in mental health and well-being can greatly impact the total cost of care and outcomes over time … And while the health plan business can have a longer sales cycle, health tech companies need to be able to demonstrate immediate value to the plan and their members through initial sign-ups, greater engagement, and clinical outcomes."
The following is a behind-the-scenes, real-time section of HealthLeaders' recent platforms roundtable, focused on the vendor-to-payer pitch and capabilities demonstration.
Jesse Horowitz, chief product officer, Oscar Health: "One thing that may not be new but that we're certainly seeing a lot of is this idea of pilot and try before you buy. I don't think it's new, but a continuation. A prospect journey might start with an executive level alignment, but then you start having business unit owners who say no way. It's almost the hunt for the thing that won't work. Why is the executive desire not matching the team leader desire?"
Alex Zavgorodni, VP of enterprise architecture, Healthfirst: "If you want to know if a new investment will work, the fastest way to answer that question is to do a proof of concept [POC]—especially if you're really zeroing in on time-to-value."
Leah Silver, director of business solutions, Zelis: "The decision-making process from a partner perspective is now longer and more complex. We're going into deep due diligence and nearly implementation during a sales process as an advanced demonstration of our capabilities. There are also multiple stakeholders."
Zavgorodni: "The thing that's always been more challenging is the human dynamic and navigating decisions. Being able to have those discussions is more of an art than science but it needs to be had."
Achieving scale
"Payers hold the key to unlock scale," notes Aaron Gani, founder and CEO of BehaVR, a digital therapeutics (DTx) company applying "the neurological power of VR" to curb anxiety disorders and chronic disease at scale.
"In a D2C model, you need to convince one person at a time that your solution is effective, safe, and affordable. Just getting their attention can be incredibly costly. Working with organizations that have a financial stake in member or employee health can streamline that process. Health plans aren't going to promote or reimburse for something that's not proven or trusted."
Williams agrees: "When you put yourself in the shoes of the health techs, it's much better to sell in bulk versus try to get share of wallet from consumers one by one."
As an example, she cites Hinge, which offers virtual physical therapy for musculoskeletal conditions such as back and joint pain. Hinge understands this as well. BCBS-MA is one of the many health plans and vendors that form the "ecosystem relationships" that Hinge uses to tout its advantages to employers including a simple contracting process, established data and billing integrations.
Delivering value
For tech vendors to link into the payer value chain, they must address workflows, reimbursement, and long-term health and economic outcomes to name a few.
Melissa Sherry, vice president of social care integration for Unite Us, notes: "For payers, you must understand their unique priorities—things like benefit design and understanding business requirements at the individual and population health levels. Payers don't want to have to drastically change how they work today or make their reporting more difficult; however, it is also important that they do not medicalize community-based organizations in an effort to use existing systems."
Buy versus build decisions have a direct impact on results, including how long it takes for value capture.
Says Gani: "Payers are looking for companies that can do more than just one thing. Vendors need to meet a range of needs, rather than just point solutions, to help payers streamline their own evaluation and purchasing processes, but also potentially to meet a range of co-morbidities within individual members."
DiPerna Cook adds: "Plans like Cigna, and Blue Shield of California, among others, come to us as a digital mental health provider because of our comprehensive solutions. The ability to access multiple care modalities through a single vendor is extremely attractive to plans … There's immense value in being able to provide step-care to plan members, triaging a member up to a higher level of care or down as needed based on need."
Choosing and pivoting the best business model
As McKinsey writes, health tech companies must have the right business model to address customer need.
A vendor's business model must often be as agile as the product itself so roadblocks to implementation can be overcome with strategic pivots. With payers at the core of multiple business models, it has never been more important for health tech companies to understand how health insurers and employers make product decisions.
Judge Carl Nichols, who formerly served in the Department of Justice (DOJ), greenlights deal but requires key claims system divestiture.
Only three times in Senate history has the nuclear option—a 51 versus 60 vote confirmation—been used. One of those was the confirmation of Carl Nichols, the judge for the U.S. District Court for the District of Columbia, who has ruled against the DOJ in its attempt to block the merger of UnitedHealth Group (UHG) and Change Healthcare.
It's interesting to speculate what the outcome might have been with another judge at the helm, but the most concrete trajectory will come from two sources: the DOJ's response and the full ruling details. Jonathan Kanter, Assistant Attorney General of the Antitrust Division, has said that the department is "reviewing the opinion closely to evaluate next steps" in what Reuters calls "a blow to the U.S. administration's tougher enforcement of antitrust issues."
Judge Nichols complete opinion will be unsealed this week.
Ruling details
If Judge Nichols' ruling stands, the nearly $13 billion merger between UHG and Change—which will join the OptumInsight division—would become final December 31, 2022.
While the overall ruling may have been a surprise, Nichols' stipulation regarding Change's ClaimsXten software was not. As part of the merger, UHG will be required to divest that portion of the business to TPG capital—a $2.2 billion deal that United announced in April 2022, two months after the DOJ's lawsuit, which was joined by the Attorneys General of Minnesota and New York.
As HealthLeaders reported in February 2022, the complaint alleged that the merger would raise costs and harm competition in not only health insurance markets, but also technology used by health insurers to process insurance claims and reduce healthcare costs.
Continued opposition
While UHG and Change statements express pleasure with the decision, the same cannot be said of an early response from the National Community Pharmacists Association (NCPA).
CEO B. Douglas Hoey pulled no punches in expressing the association's disappointment, stating: "With its insurance business, its pharmacy benefit manager business, and its mail-order pharmacy business, UnitedHealthcare is already a three-headed dragon and one of the worst actors in the market."
The NCPA was one of several organizations to oppose the merger, including the American Hospital Association (AHA).
Judge Nichols' divesture ruling on Change's ClaimsXten business addresses only a portion of the merger opposition. The original DOJ suit cited the frequency with which UHG, UnitedHealthcare, and Optum senior executives move frequently across the companies and engage in "enterprise-wide planning."
The AHA's ongoing opposition included the ClaimsXten advantage among its multiple antitrust concerns, echoed by the NCPA's Hoey: "The acquisition of … Change Healthcare will give [UHG] a massive advantage over its competitors, and it will create an irresistible incentive for the insurance company to use patient data to steer business to its own pharmacy, and away from local, small-business pharmacies."
Aetna is set to offer national scale, measures reporting, and plan complexity perspectives.
Digital health and value-based care (VBC) transformation both require digital quality measurement (dQM). The NCQA's Digital Quality Solutions pilot will culminate in the conversion of the organization's printed quality measures manual to a software solution that supports dQM.
Aetna, a CVS Health Company, and Health Care Service Corporation were the two payers chosen to "inform, test, and provide feedback on NCQA's initial Digital Quality Solutions product offering." Also noted in the pilot description, participants will be considered Digital Quality Solutions Trailblazers with the opportunity to be featured in case studies.
Dr. Sonja Hughes, Aetna VP of strategy and service excellence, shared her plan's motivation and qualifications for joining the pilot.
HealthLeaders: How do you see the current state of healthcare quality measurement and why is the NCQA pilot important?
Hughes: The COVID-19 pandemic accelerated the adoption of virtual care services and tools, including the importance of technology in facilitating caring for members. The NCQA Digital Quality Solutions pilot is designed to facilitate a way to explore how health plans can provide the information members and providers need—and want—through digital means and how they can exchange this information.
I was a physician for 22 years before transitioning to managed care and quality outcomes. In my early years as an MD, everything had to be written down by hand, then transcribed. I've experienced and witnessed angst from different generations of physicians regarding the transition to EHRs. Flash forward to now, we have robust data that we can access and work with electronically.
As someone who has been in the trenches of these processes, digital tools like the NCQA software will make care timelier and leave less room for errors. These tools can relieve burdens across the healthcare system—ultimately leading to better health outcomes.
HL: Why do you believe Aetna was one of the payers chosen for the pilot?
Hughes: Aetna has a long-standing relationship with NCQA and was able to provide a diverse team with broad experience that makes us well positioned to be a trailblazer in digital quality. The end product of the pilot should be something that can be leveraged across the industry, and Aetna provides insight into the complexities based on our national member base and the data we can leverage.
HL: Why did you want to participate? What do you want to achieve? What unique role/perspectives does the payer contribute to the pilot compared to the others in the group?
Hughes: Our primary motivation for participating was ensuring that we foster better health outcomes and provide real-time education for the communities we serve. As an industry, we're on the right path to operability, but digital tools can increase access to care and address the unmet needs of patients. Through our participation, we want to ensure that the industry as a whole has the tools and resources necessary to make digital equality a reality.
Aetna aims to contribute several unique perspectives to the program. First, we wanted to provide our perspective as a large, national plan. Considering the complexities of large national plans allows for the end product to be applicable to and leveraged by organizations, payers and companies across the board, regardless of size. We also wanted to provide our unique skill set with measures reporting. As a large payer, we possess rich digital data that can help inform a more connected and robust end product. Lastly, like other more extensive national health plans, we understand the complexities of having more than a single or multi-state plan. Leveraging that data is crucial for the success of the pilot. We're proud to be able to provide that.
HL: How will Aetna apply lessons learned from the pilot to its own initiatives?
Hughes: The Aetna team will analyze, inform, and provide feedback on NCQA's initial product offering. In addition, the participation will provide us with insight into what process changes may be impacted by digital measure solutions.
The entire healthcare industry recognizes a shift towards adopting more digital tools and services, and health plans, in particular, are aware that electronic measures are becoming increasingly important. Many health plans have begun the necessary infrastructure changes and investments needed to accommodate digital solutions. It is also an iterative process involving internal discussions where participating organizations provide NCQA feedback to inform the appropriate implementation of these solutions.
HL: Do you agree that payers can now expect more from providers in terms of outcomes?
Hughes: From a provider and payer perspective, I've been thinking about all that NCQA has done over the past decades, bringing together and measuring different aspects of healthcare for better outcomes. This program, and the solutions and framework that it aims to build, certainly have the ability to impact provider behavior.
From my point of view, I reflect on what I would have or could have done differently if more digital information had been available when I was practicing. Even as advancements are made, it is imperative to consider the providers and recognize that we must be very thoughtful of how changes will impact their care of patients. In the end, the patient is the focus. Having the ability to access information that impacts better health outcomes is the ultimate goal.
Read the previous articles in the series, including HealthLeaders' interviews with NCQA chief product officer Dr. Brad Ryan and from pilot participant 1upHealth's leaders CEO Joe Gagnon and chief strategy officer Don Rucker.
With few exceptions, highlights from KFF's review reveal much parity between the programs.
In a review of 62 studies comparing original Medicare and Medicare Advantage (MA), Kaiser Family Foundation (KFF) found "few big differences…on a variety of measures." These measures included beneficiary experience, affordability, service utilization, and quality. KFF noted that these results were based on "strong evidence or [findings that] have been replicated across multiple studies."
The review, summarized in a KFF press release, included studies published since 2016. Among the following findings, KFF noted that "relatively few studies specifically examine … population subgroups," including people of color, rural residents, and dual eligibles.
No real difference—across all quality measures.
It's one thing to have parity, or differences, on more detailed program components. But perhaps the most notable KFF finding was neither MA nor original Medicare outperformed on quality as a whole. In select measures for heart disease and diabetes management, quality was also similar for blood sugar control, insulin use, receipt of diabetes blood tests, and receipt of "guideline-recommended" heart disease therapies in outpatient settings.
The differences: More MA enrollees received "guideline-recommended therapies" for inpatient heart disease care and performed better on select diabetes care metrics.
A similar result for multiple patient experience measures.
KFF's analyses found no differences between original Medicare and MA on four beneficiary experience metrics: wait times, trouble finding a general doctor, and being told that their health insurance was not accepted or that they would not be able to join as a new patient.
The differences: MA enrollees were more likely to have a usual source of care and to receive needed prescription drugs as well as care transition instructions.
Equal affordability for select patient groups.
Three of the 62 studies KFF reviewed examined affordability for high-need beneficiaries, including those with diabetes or a mental illness.
The differences: Fewer original Medicare enrollees with supplemental coverage reported affordability challenges compared to MA, but these results were flipped for Medicare beneficiaries without the added benefits.
Hospital performance parity.
Across the 62 studies there were "generally no differences" in hospital days or average length of stay for more common admissions.
The differences: Findings were mixed for Hospital Services utilization, with one cluster of studies finding fewer hospital stays for MA members and two other studies finding no real distinction. Similarly, MA members had lower overall hospital admission rates, but no difference in a cluster of studies focused on a single hospital or procedure. MA hospital readmission rates were higher for heart attack, CHF, and pneumonia.
The agency embeds equity in quality benchmark payments as part of a "zero-sum game" to support the underserved.
Health equity is the lynchpin that will enable CMS' ACO REACH program to introduce upside and downside incentives, even for participants who enter the model at lower risk thresholds.
The goal? Rewarding providers for serving more vulnerable populations and addressing their social determinants of health (SDOH)—a component that largely has been missing from value-based reimbursement.
In a Q&A with Ashley Perry, chief strategy and solutions officer for Socially Determined, she highlighted how the model can help speed health equity data collection, analysis, and use. Socially Determined is a healthcare analytics company that delivers Social Risk Intelligence to organizations committed to addressing SDOH.
HealthLeaders: What's new about ACO REACH's quality benchmark approach and why is it important?
Perry: This is the first time that CMS has intentionally embedded within the economic incentives of a model an effort to adjust for providers that are disproportionately serving more vulnerable populations. I think it's an important signal in terms of what the agency is doing, both within the innovation center models [Center for Medicare & Medicaid Innovation, or CMMI] as well as potentially more broadly.
HL: What are the components of how these new incentives will work?
Perry: So broadly with ACO REACH, CMS is not only creating incentives within the program for providers to address beneficiaries' social needs but adjusting the way that they're calculating the benchmark and the risk adjustment methodology itself to financially incentivize providers to do that work.
The first component is in the post-baseline adjustments to how reimbursement is calculated. The calculation will now include the Area Deprivation Index (ADI), which is a measure of deprivation driven by a number of community-level factors that exists at a group level across the entire country.
For CMS, the idea here was we're going to adjust a benchmark for this program [ACO REACH] based on a combination of a census block group ADI and an extra bump if the beneficiary is dual eligible.
In doing so, the post-baseline health equity adjustments are taking into account the vulnerability of the community in which the providers are serving as well as the individual beneficiary. This is based on data CMS already has and doesn't require any data collection effort on the part of program participants.
HL: What is the other component that's changed?
Perry: The other is the 2% quality measure withhold that participants have the opportunity earn back by hitting their quality targets. There is up to a 10% opportunity to get a bonus or to earn back that 2% withhold by collecting [SDOH-related] demographic data.
HL: What is the significance of this?
Perry: It's the first time we've seen the introduction of a zero-sum game, health-equity-driven adjustments to the benchmark. Some providers are going to see a bonus and others are going to see a reduction, and that is tied to the vulnerability of the population that they're serving. So it's the first explicit incentive that we've seen to try and encourage providers to serve more of those kinds of beneficiaries.
It's also a signal that participants—not only in this program but really in all CMS programs—should start to expect that they're going to be asked by the agency to collect demographic and SDOH data. And that they should be prepared to apply the data collection and risk analytics methodologies that they're using on the clinical side to manage performance on the social side.
HL: How do stakeholder bridge the gap between the now-clear understanding that 80% of health outcomes are not based on clinical care and actually changing those outcomes?
Perry: There is clear evidence that the vast majority of healthcare utilization costs and outcomes are driven by factors that happen outside the four walls of a clinic or hospital. We see that every day. The more interesting question is, what do you do about that?
Socially Determined's view is that we need to think more holistically about the data and analytic insights that exist outside of enterprise healthcare data systems that we've used to date.
Part of the solution here is being able to open the aperture around the data that we're using—to be more proactive about identifying subsets of populations that are in need, but may not exist in our datasets today, and then proactively engage those individuals before they show up in your ED or get readmitted to the hospital.
Recent news from eHealth and the Purchaser Business Group on Health reinforce employer frustration with rising coverage costs as they foot the bill.
In the 1976 film Network, anchor Howard Beale—frustrated with society's ills—famously exclaims on air: "I'm as mad as hell, and I'm not going to take this anymore!"
While today's employers—frustrated with rising healthcare costs—might not word it that way publicly, they are clearly looking for options beyond traditional group coverage and even TPA-administered self-insurance.
"Some big employers are getting upset with the current system," says Ken Janda, a consultant, adjunct professor at the University of Houston College of Medicine, and 40-year insurance industry veteran.
Two announcements within the past two weeks reinforce that they are turning to new solutions.
eHealth and PBGH announcements signal growing trends
In late August, online private health exchange eHealth announced it would offer employers "ICHRA health insurance products and services." Through Individual Health Coverage Reimbursement Arrangements, introduced in 2020, employers make defined contributions to employees to purchase their own insurance and subsidize premium and other costs.
On September 12, the Purchaser Business Group on Health (PBGH) debuted new strategic goals to "redirect" member spend and purchasing toward affordable, whole-person, equitable care. PBGH, which includes nearly 40 large public and private employers, will also launch a Public Purchaser Advisory Committee to "elevate the needs of public members and help further integrate the work of public and private purchasers."
Indeed. The PBGH press release noted that its members are "frustrated by uneven quality and out-of-control spending" and that some 90% of large corporate executives "believe the cost of providing health benefits will become unsustainable" within five to 10 years. This from an April 2021 survey from PBGH, the Kaiser Family Foundation and West Health Institute. Some 85% "expect the government will be required to intervene to provide coverage and contain costs."
EVP for Health Policy, Larry Levitt, notes: "Any efforts to expand public coverage options or restrain prices will be met with strong opposition from the health care industry. Employers … could be a powerful counterweight."
Two sets of golden handcuffs
One could argue that health benefits have become "golden handcuffs" for employees and employers alike—binding people to unhappy jobs to maintain coverage and turning employers into healthcare's predominant payer as a way to attract and retain talent.
"In what remains a tight labor market, employers are absorbing most of the health care cost increases," said Debbie Ashford, North America chief actuary for health solutions at Aon. In August, the company projected a 6.5% rise in 2023 per-employee healthcare costs. Based on data from 700 employers, the increase is more than double than what employers paid from 2021 to 2022.
Defined contribution on the rise
Upticks like these need the counterweights that KFF's Levitt mentioned. ICHRA is one of them. The arrangement represents the kind of "defined contribution versus defined benefit" disruption that The Innovator's Prescription called for more than a decade ago.
And while the prediction that vehicles like Health Savings Accounts paired with high-deductible plans would account for 90% of the private health plan market by 2016 has not yet materialized, an eHealth spokesperson indicated ICHRA interest has been notable and emerged before the company had launched its dedicated website to promote it.
Willis Towers Watson (WTW) also reports a rise in defined contribution:
41% of employers currently use the strategy with another 11% "planning or considering doing so in the next two years."
These contributions often differ by employee tier.
More than 28% of companies band defined contributions based on employee wage or job class with 13% more likely to join by 2025.
This data comes from the WTW 2022 Best Practices in Health Care Survey, which included nearly 450 U.S. companies and their collective 8.2 million employees.
Employers ready to choose their adventure
It will take a while for defined contribution and strategies like direct contracting to predominate.
"Right now, employers will continue to look to self-insurance with insurance companies to support them. But some will demand lower prices, and be willing to look at different network configurations," says Janda, adding that defined contribution is likely to drive more rapid change.
If employers are indeed mad as hell like Network's Howard Beale, new coverage options will help them follow a new maxim: don't just get mad, get even.
"The ratings are a way for consumers to hold the industry accountable and for families to choose plans based on their individual needs," said NCQA's Andy Reynolds.
The National Committee for Quality Assurance (NCQA) has published its 2022 Health Plan Ratings, which evaluate "commercial, Medicare and Medicaid health plans based on the quality of patient care, how happy patients are with their care and health plans' efforts to keep improving."
Eligible plans—those that report Healthcare Effectiveness Data and Information Set (HEDIS) results to NCQA—receive a 0–5-star rating. For calendar year 2021, this included 1,048 health plans.
"With open enrollment for health plans beginning in November, the NCQA 2022 Health Plan Ratings provide timely insight to help consumers and businesses make informed decisions about their health care," said NCQA President Margaret E. O'Kane in the agency's ratings press release.
In interview with HealthLeaders, Andy Reynolds, the organization's assistant VP of external relations, added: "The health plan ratings are a culmination of NCQA values, including measurement and transparency. They are a way for consumers to hold the industry accountable and for families to choose plans based on their individual needs."
Sarah Shih, NCQA's assistant VP of research and analysis, also detailed plan rating methodology, which includes:
Patient Experience – Self reported by patients, measured by eight questions from the Consumer Assessment of Healthcare Providers and Systems (CAHPS).
Clinical – The proportion of eligible members receiving preventive services (prevention measures) and recommended care for select conditions (treatment measures).
Accreditation – Plans that are NCQA accredited (including full or provisional status receive an added 0.5 bonus points as part of their rating.
The NCQA website details complete results, measures, and methodology. Key findings from the 2022 Health Plan Ratings include:
Six plans achieved five-star ratings, including Kaiser Foundation Health Plan (KFHP) which achieved a top rating across all three lines of business.
Specifically, KFHP of the Mid-Atlantic States, Inc. received five stars in its commercial, Medicaid, and MA plans (counted as three distinct plans). The payer's MA plan in Colorado also earned five stars, with other top-rated Medicare Advantage plans including: Medical Associates Clinic Health Plan of Wisconsin; and Medical Associates Health Plan, Inc.
The NCQA ratings represent a significant proportion of U.S. health plans.
Up to 203 million Americans are represented by NCQA-accredited plans, a number that "has never been higher," said NCQA's Reynolds. More than 70% of the people enrolled in a commercial, Medicaid, or MA plan are members of an NCQA-accredited plan. Note: NCQA does not rate ACA Marketplace plans.
Patient experience is paramount, despite a decline in adult care satisfaction.
"The clear signal we all want to put forward is that patient experience matters," said NCQA's Shih. "Roughly 22-27% of overall rating weight is patient experience, which is close to CMS MA Star Ratings." The ratings did reflect, however, that adult patients' overall healthcare ratings of their plans dropped year over year for both commercial (4.2%) and Medicaid (2.2%) plans.
Patient experience will only become more important. Shin noted that there is an intent to develop additional experience measures, which could be added to CAHPS, represent entirely new types of metrics, or both.
Quality improved for Heart Disease and Diabetes Care.
Controlling high blood pressure improved the most: 6.9% for commercial plans, 7.6% for MA, and 2.7% for Medicaid. Plans improved on two diabetes-related measures: Controlling blood pressure (with an average increase of 5.5%, 2.5%, and 2.1%, respectively for commercial, MA, and Medicaid Plans) and Controlling Hemoglobin A1c (performance improved on average 4.1%, 3.2%, and 3.3% for those same categories).
Both Heart Disease and Diabetes Care had declined the prior measurement year (2019–2020).
Immunization rates show children on Medicaid more at risk.
While immunization rates were up 2.2% for commercially insured children, they declined 3% for those enrolled in Medicaid plans. In its ratings press release, the NCQA noted: "This >5-point divergence suggests a growing gap in preventive care that puts America's most vulnerable children at disproportionate risk for disease."
The immunization disparity highlights the continued importance of health equity.
Speaking on the healthcare disparities that the pandemic laid bare, Reynolds stated: "Everyone gets it: we have a problem. From there, there are a variety of responses and readiness to respond." Reynolds added that while some states are out front and others are just getting started, "there stepwise ways to get better" no matter where a state or plan currently sits.
One surprise: The number of plans not meeting reporting benchmarks.
As part of NCQA's methodology, 40% of plans must be able to report a measure for it to be used in the ratings. The organization reports that two Medicaid measures (Rating of Specialist, Care Coordination) and one Commercial measure (Claims Processing) failed to meet the threshold and were excluded from the 2022 ratings. All three are CAHPS patient experience measures.
"We're trying to understand the why of this," said Shih. "It could be continued impacts from the pandemic, that the public is just feeling over surveyed, or other reasons."
The development represented what Reynolds termed "a tale of two cities" in this year's ratings: "the reduction of plans not meeting reporting thresholds but at the same time, an unprecedented expansion" of U.S. health plan members represented.
"Particularly for payers now, you need to show economic outcomes and savings," says one company founder.
Until fairly recently, digital therapeutics (DTx) simply weren't on healthcare's shelf.
These products "deliver medical interventions directly to patients using evidence-based, clinically evaluated software to treat, manage, and prevent a broad spectrum of diseases and disorders" alongside medication. Examples include mental health applications from BehaVR (virtual reality focus) as well as Big Health, which also targets insomnia, and Pear Therapeutics, which offers additional products for substance abuse and severe persistent mental illnesses such as schizophrenia.
The epidemic nature of mental illness in the U.S. puts these and other DTx companies well on their way to addressing the Holy Grail of product fit: TAM-SAM-SOM, or the available, serviceable, and obtainable markets for new offerings.
But market demand comes in two forms: those who need your product and those who will pay for it. They may not be the same party.
Insurers, employers, and PBMs are the B2B segments that DTx companies need to grow with scale. As Big Health co-founder Peter Hames notes: the customer is "whoever economically benefits from … [an] individual being healthy as quickly as possible. That customer is, therefore, whoever pays their healthcare costs."
An innovation in search of its SKU
As HealthLeaders covered in December, Big Health is one of several companies pioneering DTx coverage and payment. This is especially important for prescription digital therapeutics (PDT), those DTx interventions that a clinician must order and that have received FDA clearance or approval.
Healthcare codes are an important part of the equation, for prescription and non-prescription DTx alike. These include CPT (Current Procedure Terminology) and HCPCS (Healthcare Common Procedure Coding System). Just as product SKUs revolutionized both early supply chain management and modern e-commerce, diagnosis and billing codes are needed to unlock DTx uptake. And while a limited number exist, there is a lack standardization—and manufacturers would argue variety—to scale DTx use.
To be fair, DTx traction is about more than product classification. It's about product efficacy. Where is the proof that 'x' not only works but is cost-effective? As Aaron Gani, former Humana CTO and now founder and CEO of BehaVR, noted in a recent interview with HealthLeaders: "Randomized controlled trials (RCT)—which are really just tables takes to demonstrate safety and efficacy—are not necessarily enough to convince the key decision makers, whether it's clinicians or payers, that your program should be adopted.
Gani said: "You have to go beyond that to real-world evidence of clinical effectiveness. And, particularly for payers now, you need to show economic outcomes and savings," adding: "It's one thing to prove some set of endpoints in an RCT. But what about outcomes over six or 12 months? Does your solution really change lives in a way that's persistent?"
Coverage categories and novel interpretation are the next frontier
Beyond efficacy, however, DTx will also succeed on its ability to be workflowed. And while progress has been made, Health Affairs notes that next-level adoption will require CMS action: "[C] considering alternative regulatory pathways in the design of future payment rails may lay the groundwork for a path to federal coverage for digital therapeutics."
The current state of DTx coverage and reimbursement could be described as limited, one-off, even creative as payers—mostly self-insured employers—strike individual DTx contracts using a patchwork of codes. These include new CPT and HCPCS PDT-related codes added in 2022.
While these additions are a step forward, Health Affairs notes that "PDT manufacturers … have long pushed for a transition to claims-based reimbursement as a more scalable and repeatable method for selling and distributing these products."
This would require "either a new Medicare benefit category or a revised interpretation of existing benefit categories to incorporate digital health technologies," both tied to evidence standards with the Health Affairs article concluding: "CMS can take advantage of infrequently utilized regulatory pathways to both supplement the evidence base for PDTs and help guide the development of a fair, cost-effective fee schedule for these products in line with the level of clinical value they provide to patients."
"Extras have become table stakes in this competitive environment," says the payvider's chief Medicare officer, Britta Orr.
Focus on national Medicare Advantage (MA) headlines and you might miss some intriguing local dynamics—like what it means for a state to transition from Cost Plans to MA and how Allina Health | Aetna has become a leader in a market that didn't exist five years ago.
A great place to get those insights is from Britta Orr, Allina Health | Aetna's chief Medicare officer. Orr is responsible for driving Medicare strategy, directing functional areas for the provider-payer joint venture, and managing regulatory compliance.
Minnesota's shift from Cost Plan to MA market
If you hadn't thought about Medicare Cost Plans for a while, you can be forgiven. Until 2019, MA plan presence was limited in Minnesota. Original Medicare and Cost Plans ruled, causing what Allina Health | Aetna's CMO calls "an acute shift" in market dynamics.
Per a Congressional update in contract year (CY) 2016, service areas "where two or more competing local or regional Medicare Advantage (MA) coordinated care plans meet minimum enrollment requirements" must terminate their Cost Plan offerings over the course of the entire prior contract year. Cost Plans, now available in only a handful of states, offer Part A and Part B coverage with both offering the option to add drug coverage.
Orr states that $0 premium MA plans in Allina Health | Aetna's service area have seen 130% state growth since the shift from Cost Plans in 2019, the same year that Allina Health | Aetna launched its plan and introduced what Orr calls "positive disruption" in the form of MA's low premiums, added benefits, and out-of-pocket limits.
The MA planning cycle
Given that its MA planning cycles run two to three years, it's still early days for Allina Health | Aetna's MA strategy. In addition to the recurring bid process every MA plan grinds through, the payvider's annual cycle includes spring product planning based on consumer market signals, benefit choices, innovation, and unmet need.
Per Orr, the plan also looks out "years ahead of current bids from benefit design, marketing, training, selling, and serving"—including trends like the young Boomer social media use that helps define consumer communication strategy.
All this in addition to pricing.
"Pricing as close to the pin as possible"
During the 2022 MA Annual Enrollment Period (AEP), Humana's stock price plummeted after the payer adjusted its enrollment projections. Only in a market as organically hot as MA can notable, albeit lower-than-expected, growth be seen as a negative. Analysts believed Humana had priced too conservatively.
When asked about this and the role pricing would play in 2023 MA dynamics, Orr answered: "With benefits and pricing, our goal is to get to as close to the pin as possible. This is extremely important from a bid perspective," adding: "We want to avoid consumer cost volatility. We don't want to underprice and surprise with higher premiums later. Allina Health | Aetna has kept a stable portfolio year over year in the face of new entrants and enhanced benefits."
Leveraging national resources
About those enhanced MA benefits, Orr notes: "The extras have become table stakes in this competitive environment."
In delivering those extras, Allina Health | Aetna has access to something few state plans do: the national resources of CVS Health, Aetna's parent company.
"We have a Goliath in our corner," says Orr.
"We can reach into CVS and leverage technology, data, and analytics for targeted care," she adds, also noting the retailer's enhanced services HealthHUB Hub model, its Resources for Living service ("an Angi's list for health"), and OTC benefits.
As part of a "whole-person health" approach, Orr also named her plan's wraparound services, including post-discharge meals and a $100-per-quarter benefit card that can be used for medical copays and other out-of-pocket cost shares."
Consumerism comes in many forms
"I am always wearing the consumer hat. Our sales motto is the best benefit with no surprises," says Orr.
Noting that Allina Health | Aetna's very first MA Star Rating was a 4.5, Orr adds: "To compete on benefits, you must compete on high quality, provider partnership, and other collaborations, especially for high-need populations."
Orr also stresses the importance of the omnichannel, "Amazon-like experience" that healthcare consumers are looking for. For Allina | Aetna, that means meeting people where they're at and communicating with them in the ways they want. Plan engagement ranges from online portals to brick-and-mortar, storefront sites with local member advocates.
Orr sees Allina | Aetna's payvider model as another consumer benefit.
"It's an exciting model to be in close provider partnership," says Orr.