health care utilization

While publicly traded insurers’ fourth-quarter and full-year 2023 earnings reported thus far have highlighted concerning trends in Medicare Advantage, a new report from Moody’s Investors Services suggests that the MA market even prior to the current climate is showing “signs of weakening.” Nevertheless, with per-member earnings far greater than in other sectors, MA can still be profitable when properly managed and will stay competitive, suggests an analyst with the credit ratings firm.

Among the 10 insurers rated by Moody’s — which account for approximately two-thirds of all MA members — aggregate earnings stemming from MA decreased by 2% from $10.8 billion in 2019 to $10.6 billion in 2022, the most recent year available. During that same period, the aggregate MA earnings margin fell from 4.9% to 3.4% and earnings per member dropped by 28% ($732 to $526). While those earnings remain higher compared to other segments, earnings per member in the Medicaid and commercial segments increased, leading to an overall decline of 2.7% to $216 per member, according to the Jan. 23 Moody’s report.

Although a recent Humana Inc. regulatory filing had already prepared the market for a lackluster fourth-quarter earnings report, Wall Street analysts appeared to be shellshocked on Jan. 25, when the Medicare Advantage-focused insurer detailed just how much of a financial hit it expects to take from an unanticipated care utilization surge.

“Worst case scenario plays out,” Justin Lake of Wolfe Research wrote in a note to investors published shortly after Humana released its financial results — which included a newly revised 2024 adjusted earnings per share (EPS) outlook of “approximately $16.”

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.

Elevance Health, Inc. reported stronger results for its 2023 fourth quarter earnings than its other publicly traded managed care peers so far, driven by relatively low utilization across its diverse mix of business lines. The results received positive reviews from Wall Street analysts, who contrasted the strong results with other carriers’ struggles.

Elevance, the for-profit Blue Cross and Blue Shield affiliate formerly known as Anthem, experienced lower care utilization than other managed care heavyweights like UnitedHealth Group and Humana Inc. — something that analysts were quick to note in their coverage of Elevance’s results. Elevance has substantive business in commercial insurance, Medicare and Medicaid.

If the market reactions to a Humana Inc. regulatory filing and to UnitedHealth Group’s latest earnings report are any indication, concerns about elevated care utilization that cropped up in the second half of 2023 have followed health insurers into the new year.

While Humana had already expected that heightened medical care use among its senior enrollees would continue through the rest of 2023, “actual fourth quarter results reflect an additional increase in Medicare Advantage medical cost trends,” the company said in a Jan. 18 filing with the Securities and Exchange Commission.

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.

Tremendous strides have been made in personalized medicine over the past several years — not only in drugs but in the various biomarkers used to identify the right drug for the right patient at the right time. While many people may think of this approach as one mainly solely for cancer, the potential for personalized medicine to have a broader impact on health outcomes when it is used proactively has not fully been realized.

In September, InformedDNA — which provides genomic solutions to an array of health care stakeholders to improve outcomes — acquired gWell Health, a digital health, genomics and wellness company. As part of the deal, gWell founder and CEO Surya Singh, M.D., transitioned to CEO of InformedDNA. Singh has worked in various health care organizations in more than 20 years, including serving as corporate vice president and chief medical officer at CVS Health Specialty.

In the midst of uncertainty around the U.S. economy, dealmaking in the life sciences industry held steady in the third quarter, with 194 deals unveiled or closed. That’s one of the findings from KPMG’s third-quarter 2023 report on life sciences merger and acquisition (M&A) activity. Dealmaking varied based on the actual sector, but the industry may be poised to ramp up activity as the year comes to a close, according to one industry expert.

Third-quarter 2023 was the fifth in a row that the industry’s major sectors — medical devices, pharmaceutical services, and diagnostic and lab services — remained steady, notes Kristin Pothier, leader of KPMG’s Global and US Healthcare & Life Sciences Deal Advisory & Strategy.

With the filing of a proposed class action lawsuit this month, Humana Inc. became the third major insurer in recent history to be accused of using artificial intelligence to wrongfully deny patients’ care and the second insurer to face allegations specific to Medicare Advantage members. While industry experts agree that AI holds promise for improving the patient experience, it also comes with risks, and lawsuits and other regulatory actions offer a warning to insurers of all types to come up with a proper risk mitigation strategy as they increasingly deploy AI to streamline certain operations.

In the Dec. 12 complaint, which was filed in the U.S. District Court for the Western District of Kentucky, Humana MA members accuse the insurer of relying on the nH Predict AI model to make “rigid and unrealistic” projections for how long a patient will require post-acute care after an inpatient hospital stay. The AI model was developed by naviHealth, a subsidiary of UnitedHealth Group, and was the subject of a highly critical investigation published by STAT in November and subsequent lawsuit filed against UnitedHealth by the estates of two deceased MA members.