health care utilization

Editor's Note: This article has been updated to include a statement from Glenview Capital.

In a development that drew mixed reactions from analysts, CVS Health Corp. is reportedly considering breaking up its diversified health care enterprise due to the poor performance of its Aetna health benefits division.

The news of CVS’s deliberations on the company’s future — reported by multiple outlets citing anonymous sources — came shortly after a hedge fund investor, Glenview Capital, reportedly met with CVS executives to offer ideas about turning the company around. However, Glenview Capital then denied that it as pushing for a breakup of CVS.

Employers expect their health care costs will increase next year at a higher rate than in previous years, as they continue to deal with inflation and other headwinds, according to recent surveys and database analyses from major benefits brokers. Actuaries from two of those firms tell AIS Health, a division of MMIT, that the increases are being driven by a few factors, including higher reimbursement for hospitals and providers, a rise in care utilization now that the coronavirus pandemic is over, and a higher percentage of people using expensive specialty medications and GLP-1 drugs.

Aon predicts the average cost for employer-sponsored health plans will increase by 9% in 2025, up from a 5.8% increase this year. Meanwhile, WTW projects a 7.7% increase in health care costs next year compared with a 6.9% increase this year and a 6.5% increase last year. Mercer anticipates a 7% increase in costs for employer plans in 2025.

Amid reports of increasing prior authorization (PA) requests and coverage denials, dozens of hospitals and health systems are exiting or threatening to exit insurers’ Medicare Advantage networks. Although some departures have already taken effect, many will impact the 2025 plan year, which MA insurers have begun promoting in advance of the Annual Election Period (AEP). While on the surface the disputes reflect providers’ growing frustrations with insurers’ PA policies, two industry experts say hospitals’ latest round of muscle-flexing may reflect a trend of health systems looking more strategically at their markets and seeking the best deals.

As of Oct. 1, Becker’s Hospital Review had counted at least 27 health care providers nationwide that have unveiled MA network departures this year. And that is not an exhaustive list, as additional reports of providers joining the exodus continue to pour in from local news outlets across the U.S.

With nearly all states having completed the Medicaid “unwinding process” that shed millions of people from the rolls, a new analysis notes that total Medicaid and Children’s Health Insurance Program (CHIP) enrollment is actually higher than it was before the COVID-19 pandemic. One expert tells AIS Health that private insurers helped conduct crucial outreach to ensure people losing coverage could get insured elsewhere — although Medicaid managed care organizations (MCOs) still are grappling with the financial consequences of the unwinding.

The unwinding process began in April 2023 after the end of the continuous enrollment provision in the Families First Coronavirus Response Act. This provision was enacted due to the COVID-19 public health emergency to ensure that no one covered by Medicaid lost their insurance — even if a change in income rendered individuals ineligible. Enrollment had reached an all-time high of 94 million when unwinding began, up from 71 million in February 2020.

Aging in place, lack of transportation and economic insecurity are the top social threats to seniors’ health, according to new data from Alignment Health. Sponsored by the tech-enabled Medicare Advantage insurer, the third-annual Social Threats to Aging Well in America survey polled more than 2,000 seniors across the U.S., asking them about their financial, physical and emotional needs — and how those needs are impacting their health. Their responses also highlight the types of supplemental benefits that could prove most valuable to seniors as they consider their coverage options while the 2025 Annual Election Period looms.

Since Oregon placed a payment cap on hospitals for its state employee health plans, beneficiaries have seen a reduction in out-of-pocket spending and an increase in utilization, according to a recent JAMA Health Forum study. Roslyn Murray, Ph.D., the lead author, tells AIS Health that “there’s an appetite” from other states to implement similar price regulations, although they have faced pushback from providers.

The Oregon State Legislature passed a law in 2017 limiting in-network facility prices at 24 urban hospitals to 200% of Medicare prices and out-of-network hospital facility prices to 185% of Medicare prices. The legislation applied to members of the state employee plans, which provide benefits for two groups: educators in school districts and community colleges (known as the Oregon Educators Benefit Board) and employees of state agencies and universities (known as Public Employees Benefit Board).

Health Care Service Corp. (HCSC), which owns Blue Cross Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma and Texas, recently rolled out an “alternative health plan” that combines what essentially is a tiered provider network, price transparency and streamlined medical billing.

Industry experts who spoke to AIS Health, a division of MMIT, say HCSC’s new benefit design has a variety of intriguing elements that could prove attractive to employers. Indeed, UnitedHealthcare has in recent earnings calls been touting the rising popularity of a similar offering.

In the first quarter of 2024, annual growth in health care spending exceeded the levels seen before the COVID-19 pandemic. Yet hospital inpatient admissions, on a per capita basis, remained lower than pre-pandemic levels, reflecting a shift to outpatient centers, according to a recent Peterson-KFF Health System Tracker analysis.

As many elective hospitalizations were canceled or delayed at the beginning of the pandemic, health care spending dipped in late 2019 and early 2020. Shortly after that, year-over-year growth in health services spending rebounded to pre-pandemic levels and remained high, with double-digit growth since early 2023. Nursing and residential care facilities spending saw year-over-year growth ranging from 10.0% to 13.4% since the beginning of 2023.

David Cordani, CEO of The Cigna Group, made it clear during a Sept. 5 presentation at the Morgan Stanley Healthcare Conference that the firm doesn’t view the elevated medical costs facing health insurers this year as a threat to its diversified portfolio.

Cigna Healthcare, the firm’s health insurance business, in the “recent timeframe” has been able to deliver “good, predictable” medical loss ratios (MLRs), Cordani said, referring to a closely watched metric that shows the percentage of premiums spent on medical claims.

During the Wells Fargo Healthcare Conference on Sept. 4, executives from Centene Corp. and Humana Inc. shared new details about how the headwinds facing their Medicaid and Medicare businesses are expected to play out. And within those updates, there was both good and bad news.

Centene Chief Financial Officer Drew Asher said during his presentation that the firm is “continuing to get Medicaid pressure,” largely due to the resumption of routine eligibility checks that restarted last spring after a multiyear pause during the COVID-19 pandemic. Centene discussed the issue at length during its second-quarter earnings call in July, “and so you might ask, all right, what’s changed in the last month and a half?” Asher said.