Benefit Design

During UnitedHealth Group’s annual Investor Day, analysts focused largely on looming challenges for the firm’s Medicare Advantage business. Yet the company’s executives also revealed some intriguing details about new benefit designs gaining traction in the company’s commercial insurance book of business.

In reviewing the updated 2024 financial estimates that UnitedHealth released before its Nov. 29 Investor Day, Wells Fargo analyst Stephen Baxter advised investors that “we see higher-than-expected MLR [medical loss ratio] and more modest MA membership growth as items to pick at.”

Fewer people with employment-based health plans visited primary care practices, while more have turned to telemedicine and urgent care clinics since the COVID-19 pandemic, according to a report published by the Employee Benefit Research Institute.

Using claims data from 2013 to 2021, researchers found that primary care office visits at a family/general practice, internal medicine practice or with a medical doctor dropped during that time. The share of visits with a nurse practitioner, however, increased significantly, from 4% in 2013 to 16% in 2021.

A new report from the Employee Benefit Research Institute (EBRI) confirms that primary care for commercially insured patients is in the midst of a significant transformation. In a study of claims data from 2013 to 2021, EBRI found that fewer patients have a primary care practitioner (PCP), more non-physician practitioners deliver primary care than ever, and sites of care are changing. And the author of the report says he believes the COVID-19 pandemic accelerated the shift.

EBRI’s findings are a mixed bag for payers. On the one hand, the report confirms that the size of the workforce able to deliver primary care is likely growing, and more patients may have better access to a variety of primary care options: 95-97% of all primary care visits were in an office setting prior to 2020, but that share declined to 86% in 2020. Seven to eight percent of primary care visits went to telemedicine that year and 3-4% went to urgent care clinics. However, the report also found that primary care costs have not gone down despite broader access.

Deep within two new proposed health insurance regulations are provisions that would alter how Medicare Advantage and Affordable Care Act exchanges cover prescription drugs — and some of them are garnering praise from patient advocates.

For example, the HIV+Hepatitis Policy Institute welcomed two of the proposals in the 2025 Notice of Benefit and Payment Parameters (NBPP), the annual regulation governing the ACA marketplaces, which CMS released on Nov. 15.

One of those provisions would codify existing policies surrounding how health plans treat prescription drugs that aren’t part of a given state’s essential health benefits (EHB) benchmark plan. Under the ACA, individual market plans must cover items and services in 10 core benefit categories, including prescription drugs, and each state is responsible for defining which drugs make the must-cover list.

Depending on whom you ask, a new “cost-plus pharmacy pricing” option from The Cigna Group’s Express Scripts is either a half-hearted attempt to compete with true market innovation or an offering that simplicity-seeking PBM clients are likely to embrace. However, industry experts agree on one thing: The model was clearly inspired by Mark Cuban Cost Plus Drug Co.

“I’m not surprised to hear that Express Scripts is rolling this out. The Mark Cuban company set the pathway for this to happen; their business is growing pretty quickly,” says Marc Guieb, Pharm.D., a consulting pharmacist at Milliman. He notes that Blue Shield of California in August awarded a contract to Cost Plus Drugs to manage retail pharmacy pricing and payment for the insurer’s members, as part of an “unbundling” of Blue Shield’s current PBM contract with CVS Health Corp.

In the 2025 version of the government’s annual mega-regulation governing the Affordable Care Act exchanges, multiple proposals appear to be aimed at ensuring state-based marketplaces are adhering to the same standards that apply to the federal marketplace, HealthCare.gov. One health policy expert says it’s probably not a coincidence that the proposed policy changes would take effect the same year that conservative-leaning Georgia is slated to launch its own state-based exchange.

“I see some proposals in here that are trying to safeguard against efforts to reduce the quality of exchange operations or run an exchange on the cheap,” says Sabrina Corlette, co-director of Georgetown University’s Center on Health Insurance Reforms.

The ulcerative colitis (UC) space has seen multiple new approvals recently that could focus payer management even more on the condition. Payers already take an aggressive approach toward managing branded agents within the class, according to a Zitter Insights survey.

While no cure exists for the inflammatory bowel disease, the FDA has approved numerous agents to treat signs and symptoms of the condition. In addition to the nine biosimilars of AbbVie Inc.’s Humira (adalimumab) that have launched in the U.S. in 2023, a handful of other therapies have been approved by the agency since late September. All of the agents offer maintenance dosing either through an oral or subcutaneous route of administration.

Since the FDA approved the first biosimilar — Zarxio (filgrastim-sndz) from Sandoz, then a division of Novartis Pharmaceuticals Corp. — on March 6, 2015, the agency has approved more than 40 additional agents via the 351(k) pathway established under the Biologics Price Competition and Innovation Act (BPCIA), itself part of the Affordable Care Act (ACA). This past year has been especially busy in the space, with highlights including the launch of nine biosimilars of AbbVie Inc.’s Humira (adalimumab) and approvals of the first biosimilars of three different biologics: Biogen’s Tysabri (natalizumab), Actemra (tocilizumab) from Genentech USA, Inc., a member of the Roche Group and Stelara (ustekinumab) from the Janssen Pharmaceutical Companies of Johnson & Johnson. As the FDA approves more biosimilars, uptake of these agents will continue to increase, say industry experts.

“2023 was a banner year for the biosimilar market,” contends Andy Szczotka, Pharm.D., chief pharmacy officer at AscellaHealth. “The availability of biosimilars across multiple therapeutic areas provides opportunities for physicians, patients and payers to have additional clinical and cost-saving treatment choices.”

Major payer coverage policies across select categories often met fair access criteria for cost sharing, clinical eligibility, step therapy and provider restrictions, according to the third annual “Barriers to Fair Access” assessment published by the Institute for Clinical and Economic Review (ICER).

The analysis examined coverage policies for 18 drugs across 10 commercial formularies, eight Affordable Care Act exchange plans and the Veterans Health Administration national formulary, representing 42 million enrollees in total. ICER asked the payers for coverage policy information and leveraged the MMIT Analytics Market Access Database for additional information. (MMIT is the parent company of AIS Health, which maintains journalistic independence and did not play a role in producing the report.)

Rising utilization in Medicare Advantage caught the attention of investors earlier this year after UnitedHealth Group disclosed an increase in outpatient care utilization in June, followed by Humana Inc.’s revelation that it was also seeing elevated medical costs due to an increased use of services. When reporting second-quarter 2023 earnings this summer, several insurers indicated that they were able to factor such trends into their bids for the 2024 plan year. Now, it appears that insurers’ rich supplemental benefit offerings continue to drive costs, as both CVS Health Corp. and Humana attributed elevated medical loss ratios (MLRs) in the third quarter to higher-than-normal uptake of benefits such as dental and flexible spending cards.