Health Plan Weekly

A recent report from Morgan Health, JP Morgan Chase & Co.’s health care venture fund and consultancy, documents troubling disparities for health care access and outcomes among Black, Asian American and Hispanic employer-sponsored insurance plan members; lesbian, gay and bisexual (LGB) plan members; and ESI members with low incomes. Experts tell AIS Health, a division of MMIT, that plan sponsors and insurers must consider plan design and provider incentives, among other strategies, to close health disparity gaps.

Plan sponsors and insurers can take proactive steps to reduce health disparities among their plan members, experts say — and they add that there are clear business incentives for doing so.

In the latest round of health insurer executive compensation data collected by AIS Health, there were once again intriguing stories to tell — such as why an insurtech CEO appeared to outearn the heads of the industry’s largest insurers, or what led a Blue Cross Blue Shield affiliate to nearly double its CEO’s compensation year over year.

However, finance experts who spoke to AIS Health, a division of MMIT, say that the biggest story might just be a recent court decision involving none other than Tesla, Inc. CEO Elon Musk, as the ruling could influence how all types of companies — including health insurers — determine their chief executives’ compensation going forward.

Fixes for the beleaguered arbitration process set up as part of the No Surprises Act (NSA) have begun to circulate in recent months as the health care sector grapples with a daunting backlog of unresolved Independent Dispute Resolution (IDR) cases. Policy experts say that modest tweaks should fix most problems, despite denouncements of IDR from providers and some members of Congress, and they point out that the NSA seems to have achieved its primary goal of protecting patients from exorbitant, unexpected bills for out-of-network emergency care.

Still, there are problems with IDR in its current form, which is made clear by the large and growing backlog of undecided cases. According to a December report from the Government Accountability Office (GAO), parties submitted nearly 490,000 disputes between April 2022 and June 2023, closing only 38.6% of those cases. That means about 300,000 cases are still unresolved.

Most states have authority to review premium rates for comprehensive, Affordable Care Act-compliant health plans in the individual and small group markets, while only a few have such authority in the large group market, according to an analysis published by the Georgetown University Center on Health Insurance Reforms. Additionally, the analysis found that while a “healthy minority of states” have the authority to question the rates that insurers negotiate with providers and suppliers, many struggle to actually do so.

The ACA, enacted in 2010, established the health insurance rate review program that requires the review and disclosure of “unreasonable” rate increases. As of August 2023, 43 states have authority to review and require changes to or disapprove proposed rates in the individual market, whereas only 26 states had such authority in 2010. Eight states — Arizona, California, Idaho, Indiana, Missouri, Montana, Texas and Wisconsin — have authority to require insurers to review proposed rates in the individual market, but they cannot require changes or disapprove the rates. Thirty-eight states currently have prior authority over rates in the small group market.

CVS Health Corp. on Feb. 7 lowered its earnings per share (EPS) guidance for 2024, citing high Medicare Advantage cost trends. Wall Street analysts expected the announcement because other insurers, such as UnitedHealth Group and Humana Inc., previously mentioned MA costs as a potential drag on their profits. Meanwhile, The Cigna Group, reporting its fourth-quarter and full-year 2023 results on Feb. 2., increased its EPS guidance for this year and received favorable views from analysts.

CVS projects an adjusted EPS of at least $8.30 this year, down from its previous guidance of at least $8.50 that the company disclosed during its investor day on Dec. 5. The company had an adjusted EPS of $8.74 in 2023.

Here’s how major health insurers’ stock performed in January 2024. UnitedHealth Group had the highest closing stock price among major commercial insurers as of Jan. 31, 2024, at $511.74. Humana Inc. had the highest closing stock price among major Medicare insurers at $378.06.

Although a “healthy minority” of states have the authority to conduct enhanced reviews of proposed premium rates — in which they evaluate the rates that health insurers negotiate with providers — just a small handful are doing so, according to a new analysis.

A variety of barriers are preventing state regulators from fully flexing their rate-review muscles, including industry opposition, according to one of the researchers who produced the analysis. And although that opposition historically has included insurers, there’s an argument to be made that the sector should change its tune.

“I think the health plans should embrace this kind of regulation, because when you look at the hospital sector and how increasingly consolidated it is, and how so many hospitals and health systems are using their market power to demand ever-higher reimbursement rates in the commercial market…health plans are really powerless to push back, because these hospitals are must-have participating providers” in health plan networks, says Sabrina Corlette, co-director of Georgetown University’s Center on Health Insurance Reforms (CHIR).

Centene Corp.’s results for the fourth quarter of 2023 were largely positive, earning mild praise from Wall Street analysts. While Centene was the latest health insurer to face higher-than-expected Medicare Advantage utilization, executives claimed that the firm’s MA performance was far less worrisome than that of its peers — an argument that analysts seemed to accept.

Centene’s Medicare medical loss ratio (MLR) for the quarter was an eye-popping 95.3%, up from 87.5% in the fourth quarter of 2022, an increase of 780 basis points (bps). According to Jefferies analyst David Windley, that figure was 510 bps above Wall Street consensus projection for Centene’s Medicare book of business. However, during a Feb. 6 earnings call, Centene CEO Sarah London and Chief Financial Officer Drew Asher both insisted that the high MLR figure was not a reason for concern, was not caused by the same factors that drove high MLRs for MA peer firms like Humana Inc., and was accounted for in 2024 guidance.

As of Feb. 1, at least 16.4 million Medicaid enrollees had been disenrolled from coverage since last April, representing about one-third of people who had applied to have their coverage renewed, according to KFF. KFF said the number of people disenrolled is likely higher “due to varying lags for when states report data.” Of the people who had been disenrolled, 71% were terminated for procedural reasons, meaning they did not complete the renewal process in time. The disenrollment rates ranged from 13% in Maine to 61% in Texas. Overall, states and Washington, D.C., have reported renewal outcomes for 52% of people enrolled in Medicaid, while the remaining 48% of people were awaiting decisions as of Feb. 1.

Dirk McMahon, UnitedHealth Group’s president and chief operating officer, plans on retiring, effective April 1. McMahon joined UnitedHealth in 2003 and has been president and COO since February 2021. UnitedHealth has not named a replacement for McMahon, whose previous roles at the company included CEO of UnitedHealthcare and president and COO of Optum.

As health care costs continue to rise, Congress may take up site-neutral payment reform or other cost control measures in coming years, if a Jan. 31 House of Representatives hearing is any indication. The House recently passed a bill, the Lower Costs, More Transparency Act (LCMTA), that includes limited site neutrality and PBM reforms, but some Congress members floated more aggressive cost-control interventions in the health care system — including tougher scrutiny on Medicare Advantage plans.

During the Jan. 31 hearing, the leaders of the House Energy & Commerce’s Health subcommittee — chairman Rep. Brett Guthrie (R-Ky.) and ranking member Rep. Anna Eshoo (D-Calif.) — both said that the LCMTA didn’t go far enough to control costs.