Consumer Engagement

CMS on Nov. 6 released a proposed rule that aims to address multiple parts of the Medicare Advantage program that recently have been the target of criticism — including broker compensation, access to behavioral health care, and the use of supplemental benefits and prior authorization. However, a major trade group for health insurance brokers and agents says the part of regulation targeting their industry is both misguided and potentially disastrous.

Should the rule be implemented as proposed, “I think that the MA distribution [system], which is the agents and brokers, will collapse,” says John Greene, senior vice president of government affairs at the National Association of Benefits and Insurance Professionals (NABIP).

Despite declines in the average overall Star Rating for Medicare Advantage Prescription Drug plans and the number of MA-PD contracts earning 4 stars or higher, the 2024 Star Ratings data released by CMS last month indicates that about two-thirds of performers held onto their 5-star rating from the previous year. For our annual series on the success stories of highly rated MA plans, leadership at several repeat 5-star performers touted comprehensive, integrated and localized approaches to continually delivering quality care.

For Quartz Health Plan, simplifying the member journey and working closely with its provider owners have been two areas of focus, according to Christina Ott, chief growth officer. Formed by the 2017 combination of Gundersen Health Plan, UnityPoint Health and Physicians Plus Insurance Corp., and then rebranded as Quartz, the insurer’s MA-PD contract serving enrollees in select counties of Minnesota has earned 5 stars for the 16th time, according to Ott. Quartz also has MA membership in Illinois, Iowa and Wisconsin; Advocate Aurora Health joined as a minority owner in 2021. While Quartz is focused on selling its products where its provider owners can best serve seniors and “has a narrower network than most,” it does have other providers in the network and it “aligns with providers in ways that work for the individual,” she tells AIS Health, a division of MMIT.

The latest Medicare Part C and Part D Star Ratings data show that it’s getting harder for payers to achieve the bonus payment level of 4 stars or higher, in part due to cut point changes driven by the new Turkey outlier deletion methodology. As CMS continues to alter the way it calculates the Star Ratings, including lowering the weight of Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures for 2026, plans should deploy a top-down, cross-departmental government structure to incentivize quality performance across all functions, according to global management and technology consulting firm AArete.

To learn more about this and other characteristics of a 5-star MA plan, AIS Health, a division of MMIT, spoke with Darren Ghanayem, managing director with the health care payer group at AArete. The firm works with payers across the MA, Medicaid and commercial markets, advising them on everything from systems migrations and provider network strategy to maximizing revenue and optimizing administrative costs. Ghanayem previously served as chief information officer with WellCare Health Plans, prior to its acquisition by Centene Corp., and at Anthem, Inc. (now Elevance Health, Inc.).

The stand-alone Prescription Drug Plan (PDP) market — which was already in decline — is poised to take even more hits due to regulatory and legislative changes that are taking effect in 2024 and beyond, according to industry observers. Indeed, one expert who analyzed data from CMS’s 2024 Medicare Advantage and Part D “landscape files” predicts that “a lot of people are faced with pretty significant premium increases” next year.

There’s a complicated calculus driving that trend, explains Tom Kornfield, a senior consultant at Avalere Health. But both he and equities analyst George Hill agree that the Inflation Reduction Act of 2022 (IRA) is a major factor.

“Wheel of deceit.” “Sleazy, private sector scoundrels.” The transfer of personal information “from one moneygrubbing hand to another.” These are just a few of the verbal gems dropped by Sen. Ron Wyden (D-Ore.) when, during a recent hearing on Capitol Hill, he described the billion-dollar third-party Medicare marketing machine that has been under increased scrutiny by Congress, consumer advocates and researchers.

But beyond Wyden’s descriptive remarks, the Senate Finance Committee chair and other lawmakers queried stakeholders about real solutions to rein in misleading marketing practices and improve seniors’ shopping experiences. Suggestions that came up on multiple occasions included prohibiting the transfer of beneficiary information from one lead generator to another, putting additional limits on the fees brokers earn for enrolling MA members, penalizing MA insurers for the actions of third-party marketers, and increasing transparency around the full cost associated with enrolling in an MA plan.

States are struggling to complete Medicaid redeterminations: CMS has said that there are potentially millions of Medicaid and Children’s Health Insurance Program members who were improperly disenrolled due to administrative problems. Some in the managed care industry believe that text messaging could drastically reduce the amount of procedural disenrollments, but a managed care trade group says that regulatory and operational struggles stand in the way of texting’s full potential.

State-led verification of Medicaid eligibility restarted earlier this year after being paused for several years as part of the federal response to the COVID-19 pandemic. According to KFF, “at least” 7.87 million people have been disenrolled through Oct. 2 — a figure that is almost certainly an “undercount” due to reporting lags of state data. KFF also found that 73% of people disenrolled from Medicaid lost coverage for “procedural reasons.”

J.D. Power & Co., in the latest edition of its annual survey of consumer satisfaction with telehealth brands, gave UnitedHealthcare, the managed care arm of UnitedHealth Group, the highest marks of any insurer. The company beat out second place Kaiser Permanente and third place Humana Inc. for the top spot.

Insurers have invested heavily in telehealth since the beginning of the COVID-19 pandemic. Starting in 2020, due to pandemic lockdown orders, telehealth became a key care modality in a way that it never had been before. UnitedHealthcare, according to a press release touting the J.D. Power results, offers telehealth products such as 24-hour virtual urgent care without cost sharing and virtual primary care. The health care giant in June made 24-hour virtual care available to 5 million of its fully insured members without cost sharing.

Findings from a study jointly conducted by AllianceRx Walgreens Pharmacy and Walgreen Co. reveal the importance of adherence to non-infused biologics for the treatment of rheumatoid arthritis (RA). Specifically, researchers found a connection between adherence and lower medical costs, rates of hospitalization and length of stay (LOS).

Researchers presented the findings on Sept. 20 at the National Association of Specialty Pharmacy (NASP) Annual Meeting & Expo, which was held Sept. 18-21.

The study used data from 2019-2020 in the MarketScan Commercial Claims and Encounters databases for patients with commercial coverage, and Supplemental or Coordination of Benefits databases for Medicare beneficiaries. It also used the reporting metric of proportion of days covered (PDC) from the Pharmacy Quality Alliance (PQA), an independent non-profit organization focused on improving safety, adherence and appropriate use of medications.

The stand-alone Prescription Drug Plan (PDP) market — which was already in decline — is poised to take even more hits due to regulatory and legislative changes that are taking effect in 2024 and beyond, according to industry observers. Indeed, one expert who analyzed data from CMS’s 2024 Medicare Advantage and Part D “landscape files” predicts that “a lot of people are faced with pretty significant premium increases” next year.

There’s a complicated calculus driving that trend, explains Tom Kornfield, a senior consultant at Avalere Health. But both he and equities analyst George Hill agree that the Inflation Reduction Act of 2022 (IRA) is a major factor.

Mark Cuban Cost Plus Drug Co. and Select Health, the managed care arm of Utah-based nonprofit health system Intermountain Health, on Sept. 19 struck a deal to provide Select Health members with what a press release called “direct access” to Cost Plus’ online generics pharmacy. Select Health tells AIS Health, a division of MMIT, that members’ level of access to Cost Plus depends on their plan design and plan sponsor: Some members may be able to count any purchases made through Cost Plus toward their annual deductible and out-of-pocket maximum.

Intermountain, which owns its own PBM, Scripius, is just the latest notable regional player to partner with Cost Plus on generics. The deal comes shortly after the much discussed move by Blue Shield of California to unbundle its PBM contracts. (As part of Blue Shield’s new strategy, Cost Plus will manage retail pharmacy pricing and payment for the insurer.)