COVID

Since last summer, major health insurers’ reports of unusually high outpatient care utilization have proven to be a thorn in the industry’s side — inflating medical loss ratios and forcing Humana Inc. to significantly downgrade its 2024 earnings outlook. And according to some Wall Street analysts, the trend isn’t likely to go anywhere soon.

With the COVID-19 pandemic winding down, “grandma has been locked in her house for the last three years; she’s ready to go on a cruise and she wants that new hip, she needs that new knee,” Deutsche Bank Managing Director George Hill said during the annual Wall Street Goes to Washington Roundtable on April 8, hosted by the Brookings Institution. That increased demand, he said, “has resulted in a surge in outpatient orthopedic procedures that we’ve seen, particularly among seniors, particularly impacting the Medicare Advantage books of business.”

During a keynote session at the AHIP Medicare, Medicaid, Duals & Commercial Markets Forum, health plan leaders offered sobering assessments about the state of health equity in the U.S. Still, they offered concrete steps their organizations have taken with community partners to address systemic inequalities.

“I would give us a grade of ‘C’ [on health equity]. Probably, before the murder of George Floyd, I would have given us a ‘D,’” said Karen Dale, market president and chief diversity, equity and inclusion officer at AmeriHealth Caritas. Floyd was killed by a white police officer during an arrest made outside a Minneapolis convenience store in May 2020, sparking nationwide protests over police brutality and racial inequality.

Nearly a year into the massive nationwide effort to reverify Medicaid eligibility after a pause in redeterminations during the COVID-19 pandemic, about 40% of renewals have yet to occur. With millions of people estimated to have lost coverage because of administrative or procedural reasons, states have an opportunity to work with managed care organizations and other health care providers to innovate and improve existing processes that aren’t working, according to panelists at a recent session of AHIP’s 2024 Medicare, Medicaid, Duals & Commercial Markets Forum, held March 12 to 14 in Baltimore.

“This is still very much in progress,” and “these next few months are going to be very important,” declared panelist Kate Honsberger, a director with NORC at the University of Chicago. States as of April 1, 2023, were allowed to begin disenrolling people from Medicaid who no longer qualify, but they have 12 months to complete eligibility redeterminations, which may have kicked off at different times depending on the state.

Global spending on medications is expected to hit $2.3 trillion by 2028, as not only more therapies become available but also more people have access to them. That’s one of the findings of the IQVIA Institute for Human Data Science’s recent report titled The Global Use of Medicines 2024: Outlook to 2028. Oncology and obesity, among other therapeutic classes, are expected to be among the top areas in global spending over the next five years, estimated researchers.

Total U.S. health care spending increased by 4.1% in 2022, hitting $4.5 trillion, according to CMS. The growth rate appeared to return to the average annual rate of the 2010s, while the share of the gross domestic product (GDP) devoted to health care (17.3%) also fell to pre-pandemic levels.

The rise in overall health care expenditures reflected faster growth in spending for administration costs, retail prescription drugs and long-term services from 2021 to 2022, which was offset by a decline in federal public health spending, according to an analysis by KFF. As the pandemic entered its third year, public health spending dropped by $33 billion compared to 2020.

Although 2024 seems far removed from the height of the COVID-19 pandemic, the ripple effects associated with that disruptive global crisis are still influencing how this year will turn out for the U.S. health insurance sector, two top credit ratings firms predict.

“We’re calling it the pandemic hangover,” says Brad Ellis, senior director in Fitch Ratings' North American insurance rating group.

“I think this year might be the last year we’re seeing what we call pandemic-related effects on the industry,” adds James Sung, director of insurance ratings at S&P Global.

Medicaid drug spending shows no signs of slowing despite a drop in prescriptions, according to new research from KFF. Net spending on prescription drugs grew 47% to $43.8 billion from fiscal year (FY) 2017 to 2022. The average Medicaid enrollee had 11.4 prescriptions in FY 2017, with a net spend of $39 per prescription. In FY 2022, the number of prescriptions per enrollee dropped to 9.4, while net spending per prescription rose to $58.

Meanwhile, Medicaid enrollment climbed to historic levels amid the COVID-19 pandemic, reaching 96.3 million lives in June 2023, according AIS’s Directory of Health Plans (DHP). With the end of the COVID-era continuous enrollment provision, states are now in the middle of a lengthy — and sometimes controversial — unwinding process. Yet utilization (the overall number of prescriptions) stayed under 2017 levels despite the enrollment boom. That could be because the number of days supplied per prescription has increased, with 90-day supplies becoming more common, in addition to lower utilization overall.

The U.S. Senate Finance Committee seems poised to take up legislation that would make permanent the significant, pandemic-era reforms to Medicare telehealth rules, including rules governing site of care origination and audio-only telehealth encounters, which are otherwise set to expire at the end of next year. Medicare Advantage plan and provider trade groups back the legislation and have pushed for telehealth reforms to be permanent when they were up for renewal in previous legislative cycles.

Emergency reforms to Medicare reimbursement rules were a key reason that the telehealth industry boomed in recent years. Telehealth was the only option for many types of outpatient care during the early parts of the COVID-19 pandemic, and patients, plans and providers became accustomed to using telehealth modalities for a wide variety of low-acuity encounters. Those encounters wouldn’t have been reimbursable if it weren’t for temporary, emergency reforms of Medicare telehealth billing rules passed as parts of COVID relief bills and executive orders by Presidents Donald Trump and Joe Biden.

Almost two years after Paxlovid received emergency authorization as a treatment for acute COVID-19 infection, Pfizer Inc. and the U.S. government are now in the throes of transitioning the drug to the commercial market. That means the drugmaker is, in its own words, “working diligently with payers to achieve the best possible formulary placement” for Paxlovid — but also raising some eyebrows with the list price it set for the antiviral therapy.

Pfizer said in a statement that the commercial list price for Paxlovid (nirmatrelvir/ritonavir) in the U.S. will be $1,390 per five-day treatment course. That’s more than twice what the U.S. government paid for the drug, $529 per five-day course, and significantly higher than the price range of $563-$906 that the Institute for Clinical and Economic Review (ICER) suggested would be most cost effective.

Private insurers paid providers a similar amount for both evaluation and management and mental health therapy services regardless of whether the care was delivered in person or via telehealth in 2021, according to KFF-Peterson Health System Tracker. The analysis noted that while private insurers and employers were paying about the same amounts for in-person and telehealth in 2020, it was initially unclear whether they would continue to do so in 2021.

Telehealth use for mental health therapy surged with the COVID-19 pandemic: In 2021, more than half of mental health services were delivered via telemedicine, compared to only 1% in 2019. Common mental health therapy claims were paid at similar rates for in-person and telehealth care.