Humana, UnitedHealth Utilization Disclosures Put MA Powerhouses in Hot Seat

Not long after UnitedHealth Group sparked an insurer-stock selloff by revealing that it is seeing higher-than-usual outpatient care utilization, Humana Inc. disclosed that it, too, is seeing elevated medical costs due to an increased use of services.

“At this point it appears that there may be a new trend brewing with a rise in utilization and claims, particularly in the Medicare Advantage segment,” A.M. Best Senior Director Sally Rosen remarked in a new video released by the insurance-focused credit rating firm.

And that’s significant for the managed care industry writ large, Rosen tells AIS Health, a division of MMIT. “Medicare Advantage comprised more than one-third of the industry’s underwriting income in 2022, and while the dollar amount has fluctuated, the percentage of underwriting income coming from Medicare Advantage has made up about one third for each of the past three years,” she says.


Insurer Stocks Take Hit After UnitedHealth Says Seniors Are Using More Outpatient Care

UnitedHealth Group’s stock took a nosedive on June 13 after Chief Financial Officer John Rex said elevated outpatient care utilization might push the insurer’s 2023 medical loss ratio (MLR) higher than it originally expected. Since UnitedHealth is the bellwether of the managed care sector, other insurers’ stock traded down in the wake of Rex’s comments. However, equities analysts suggested that the highly diversified UnitedHealth isn’t in any danger of taking a major earnings hit.

During the Goldman Sachs Global Healthcare Conference, Rex said UnitedHealth has seen higher levels of outpatient care activity since the first quarter of 2023, and looking at data from the second quarter, the trend doesn’t appear to be going away. He cited hip and knee replacements as well as cardiovascular care — all “very localized in [the] Medicare business” — as the areas where UnitedHealth is seeing higher utilization.


HHS Urges States to Avoid Unnecessary Coverage Loss, Threatens Enforcement

Starting April 1, states were once again allowed to start disenrolling people from Medicaid who no longer qualify. But after early indications that people are getting kicked off the roles for procedural reasons, the federal government this week offered a stern warning to states that may have been too quick to begin disenrollments.

Eligibility redeterminations were suspended during the COVID-19 public health emergency as a condition of states receiving higher federal funding. In that time, more than 20 million people joined Medicaid rolls nationwide, with enrollment soaring to 95.9 million lives as of May 2023, according to the latest update to AIS’s Directory of Health Plans (DHP). With millions of people standing to lose coverage with the resumed redeterminations, many in the health care industry feared lack of beneficiary knowledge about the renewal process could cause mass procedural disenrollments among those who are still eligible for coverage.


Report Examines Utilization, Spending Growth of U.S. Health Care Services

By the end of the third year of the COVID-19 pandemic, health services utilization had returned to their pre-pandemic levels overall, but some shifts have occurred. That’s just one of the findings of the IQVIA Institute for Human Data Science’s The Use of Medicines in the U.S. 2023: Usage and Spending Trends and Outlook to 2027 recently released report. And while spending on medications will continue to grow, driven by new oncology drugs, traditional areas of growth such as immunology and diabetes will instead help to slow that growth.

Since the beginning of the COVID-19 pandemic, the institute has tracked patient visits, including both telehealth and in-person ones; screening and diagnostic tests; elective procedures; and new prescriptions for its IQVIA Health Services Utilization Index. Speaking at a May 18 webinar on the report’s findings, Michael Kleinrock, research director for the IQVIA Institute for Human Data Science, explained that overall, those services have returned to 100% of pre-pandemic levels as of the fourth quarter of 2022. However, some shifts among the four elements have occurred.


Retail Clinic Volume Boomed During Pandemic — and Could Stay High

According to a new report, retail clinic claims have boomed since the onset of the COVID-19 pandemic — and heavy utilization seems like it’s here to stay. Experts tell AIS Health, a division of MMIT, that retail clinics can help improve access and convenience for patients, but they also caution that retail clinics aren’t a substitute for high-quality primary care and could induce demand for low-value encounters.

The report, prepared by health care consultancy Definitive Healthcare LLC, found that retail clinic claim volume increased by 200% between 2017 and 2022, according to information sourced from the firm’s proprietary all-payer claims database. During the same period, urgent care claims increased by 70%, emergency room claims decreased by 1%, and primary care physician claims decreased by 13%.


News Briefs: Senate Panel Advances PBM Reform Bill

Following a hearing on insulin costs in which senators from both political parties grilled PBM executives, the Senate Health, Education, Labor and Pensions (HELP) Committee approved the Pharmacy Benefit Manager Reform Act of 2023 (S. 1339). The legislation would ban spread pricing, introduce a host of transparency requirements, and compel PBMs to pass on rebates and fees they collect to their health plan clients, Pink Sheet reported. However, HELP Committee Chairman Bernie Sanders (I-Vt.) would not allow a vote on an amendment that would prohibit PBMs from charging administrative fees based on a percentage of a drug’s list price, as that amendment did not yet have a Congressional Budget Office score. The measure passed on an 18-3 vote with Sen. Rand Paul (R-Ky.), Sen. Mitt Romney (R-Utah) and Sen. Tommy Tuberville (R-Ala.) voting no.


MA Insurers Tap Into ‘Tech-Savvy’ Seniors for Marketing, Wellness and More

As marketing experts from regional Medicare Advantage plans and their strategic partners shared success stories from the recent Medicare Annual Election Period and their year-round member engagement campaigns at the 14th Annual Medicare Market Innovations Forum, there was one commonly recurring theme: Today’s MA beneficiaries are increasingly embracing technology for everything from conducting AEP research to maintaining a healthy lifestyle.

In his experience working with digital marketing agency Amsive, Dan Paladino noted that Medicare consumers are relying on digital tools to research their coverage options “early and often” and that clients have experienced a surge in digital use “across many channels” this past AEP.


2023 AEP May Dictate Post-COVID Marketing, Benefit Design Strategies

Since the conclusion of the 2023 Medicare Annual Election Period (AEP), several common threads have emerged from industry reports, Medicare Advantage insurers and marketing experts. These include a slow start to the AEP, a higher rate of switching among MA enrollees, increased use of digital channels, and member confusion or frustration with certain benefits. These observations and other data may help MA insurers and their marketing partners predict future member movement and influence strategy when it comes to both marketing and benefit design.

While the midterm elections certainly created a distraction, inflation and economic concerns may have created a drag in signups, suggested Dan Paladino, vice president of healthcare client experience with Amsive, while speaking at the 14th Annual Medicare Market Innovations Forum, held March 27-29 in Orlando. At the same time, the digital marketing agency observed more people using digital tools to conduct their research about coverage, such as online educational videos and Google search. “When that happens, they’re not picking up the phone and calling as early as we would probably like and I think some of our clients would like,” said Paladino, during a panel discussion moderated by AIS Health.


Though Remote Patient Monitoring Use Spikes, Barriers to Uptake Still Exist

The use of remote patient monitoring skyrocketed during the COVID-19 public health emergency, with RPM claims volume jumping by 1,294% from January 2019 to November 2022, according to a report released by Definitive Healthcare.

Since 2018, CMS added five new reimbursement codes for RPM services, and introduced five codes related to remote therapeutic monitoring in 2022. By November 2022, RPM claims volumes were already 27% higher than they were during 2021.

Internal medicine physicians were more likely to use RPM, with 28.7% of their procedure claims related to RPM. Cardiological and family practice providers ranked second and third at 21.3% and 19.4%. An analysis of diagnosis categories suggested similar trends. Essential hypertension saw the highest share of RPM-related claims at 51.0%, followed by diabetes mellitus with complications (10.4%) and diabetes mellitus without complications (6.4%).


Remote Monitoring Faces Coding Challenges After Public Health Emergency Ends

Federal remote monitoring regulations tied to the COVID public health emergency (PHE) are expiring soon, and insurers and providers must make sure that remote monitoring is being used effectively and in compliance with permanent regulations. Health care experts say that payers and providers have an opportunity to improve clinical outcomes and increase value by applying pandemic-era lessons learned and best practices to ongoing remote monitoring-assisted care. 

Remote patient monitoring became a vital tool for practitioners during the COVID-19 pandemic’s darkest days. Hospitals were overwhelmed and, in many places, barred from providing elective services, creating an urgent need for “hospital-at-home” care. The Biden and Trump administrations facilitated expanded use of remote monitoring technologies through emergency regulations tied to the duration of the PHE, but it is set to end on May 11. In particular, hundreds of emergency use authorizations (EUAs) from the FDA will expire unless they have undergone a review process. Going forward, some reimbursement codes set up by CMS during the pandemic will be phased out, and others will carry on until the agency can set up permanent protocols.