Medical Costs

Nearly 4.6 million have enrolled in Affordable Care Act exchange plans for 2024 since open enrollment began on Nov. 1, including 919,900 people who did not have exchange plans this year. The data captures sign-ups through Nov. 18 for people in the 32 states that use HealthCare.gov for enrollment and through Nov. 11 for people in the 17 states and Washington, D.C., that have state-based marketplaces. CMS Administrator Chiquita Brooks-LaSure said in a press release that “we have seen an increase in plan selections and a significant increase in the number of new enrollees year over year.” The open enrollment period runs through Jan. 15, 2024, for states using the HealthCare.gov website, while deadlines for state-based marketplaces vary.

The Biden administration on Nov. 16 released reports outlining steps it is taking to address social determinants of health and emphasizing the need to improve individuals’ social circumstances. The documents include the U.S. Playbook to Address Social Determinants of Health, the Call to Action to Address Health-Related Social Needs and a Medicaid and CHIP Health-Related Social Needs Framework. HHS Secretary Xavier Becerra said in a press release that “it is clear that the health of our people does not exist in a vacuum, but it is affected by our access to stable housing, healthy food and clean air to breathe.”

Three quarters into 2023, Moody’s Investors Service says the predictions it made at the start of the year for the health insurance sector — namely, earnings growth in the mid-to-high single digits — have largely proven accurate. However, while financial results were consistent with the credit rating firm’s expectations, analysts said in a new report that the reasons for those results were not exactly what they predicted.

“Our outlook was premised on reduced membership as a result of Medicaid redeterminations and the impact of a possible recession on commercial membership,” the analysts wrote in a report released on Nov. 20. “However, with no recession this year, commercial membership has been better than expected, but its growth has been offset by higher-than-expected MA [Medicare Advantage] utilization.” Additionally, “although Medicaid redeterminations are underway, their impact so far has been relatively small.”

A new report from the Employee Benefit Research Institute (EBRI) confirms that primary care for commercially insured patients is in the midst of a significant transformation. In a study of claims data from 2013 to 2021, EBRI found that fewer patients have a primary care practitioner (PCP), more non-physician practitioners deliver primary care than ever, and sites of care are changing. And the author of the report says he believes the COVID-19 pandemic accelerated the shift.

EBRI’s findings are a mixed bag for payers. On the one hand, the report confirms that the size of the workforce able to deliver primary care is likely growing, and more patients may have better access to a variety of primary care options: 95-97% of all primary care visits were in an office setting prior to 2020, but that share declined to 86% in 2020. Seven to eight percent of primary care visits went to telemedicine that year and 3-4% went to urgent care clinics. However, the report also found that primary care costs have not gone down despite broader access.

Across the U.S. in 2022, 24.5% of health care payments involved two-sided financial risk reimbursement arrangements, according to an analysis published on Oct. 30 from the Health Care Payment Learning & Action Network (HCPLAN). That is up from 19.6% in 2021 and 17.9% in 2020.

While the upward trend is encouraging for those interested in shifting away from a fee-for-service model, health policy experts tell AIS Health, a division of MMIT, that more needs to be done to encourage providers to embrace value-based care. They add that adoption varies based on the payer, with Medicare leading the way and private commercial plans lagging.

Zepbound (tirzepatide), Eli Lilly and Co.’s latest glucagon-like peptide 1 (GLP-1) agonist product and Lilly's first entrant in that category to be marketed only as a weight loss drug, garnered FDA approval on Nov. 8. The approval intensified already fierce public interest in using GLP-1s for weight loss — which could be bad news for payers, especially commercial plan sponsors, who were already concerned before Zepbound’s approval that the high cost and broad appeal of the drugs will cause premiums to spike.

A recent WTW survey found that 38% of employer-backed health plans cover weight loss drugs, while 22% are considering adding coverage. Mercer found that 42% of large employers cover GLP-1 drugs for weight loss. Brokers and employer plan sponsor trade groups have identified burgeoning GLP-1 utilization as a possible reason for future premium hikes.

Rising utilization in Medicare Advantage caught the attention of investors earlier this year after UnitedHealth Group disclosed an increase in outpatient care utilization in June, followed by Humana Inc.’s revelation that it was also seeing elevated medical costs due to an increased use of services. When reporting second-quarter 2023 earnings this summer, several insurers indicated that they were able to factor such trends into their bids for the 2024 plan year. Now, it appears that insurers’ rich supplemental benefit offerings continue to drive costs, as both CVS Health Corp. and Humana attributed elevated medical loss ratios (MLRs) in the third quarter to higher-than-normal uptake of benefits such as dental and flexible spending cards.

An analysis of Humana Inc. commercial insurance data from markets across the U.S. shows a wide variation of prices across regions for seven common procedures, according to a research letter published on Oct. 27 in JAMA Health Forum. Benjamin L. Chartock, Ph.D., the study’s lead author, tells AIS Health, a division of MMIT, this is the first peer-reviewed paper that examined data shared by insurers via the final Transparency in Coverage (TIC) rule that HHS and the Depts. of Labor and Treasury released in October 2020.

The TIC regulation went into effect starting in July 2022, with more requirements phasing in this year and next year. Chartock admits that, while insurers as of January 2023 are required to provide on their website a list of prices for 500 shoppable items, services and prescription drugs as well as a price comparison tool to allow people to compare cost-sharing and provider information, “it’s extremely complicated in terms of processing [for consumers], and on its own, it is not very useful data.”

The Cigna Group posted results for the third quarter of 2023 that impressed Wall Street, driven by a lower-than-expected medical loss ratio (MLR). However, Cigna executives faced questioning from analysts on potential PBM regulations.

Cigna enjoyed relatively low care utilization, with MLR at 80.5%, beating the Wall Street consensus projection by 12 basis points. The managed care division’s adjusted revenues were $12.7 billion, up 14% year over year.

“Our medical care ratio was better than expectations, driven by our U.S. commercial business. More specifically, our favorable [MLR] performance was a reflection of ongoing disciplined pricing and continued affordability initiatives,” said Cigna Chief Financial Officer Brian Evanko during a Nov. 2 earnings call.

Humana Inc.’s stock dipped after its third-quarter 2023 earnings report, with analysts largely blaming the firm’s revised estimate of its full-year medical loss ratio (MLR). The Medicare Advantage-focused insurer said that while it had been expecting health care utilization to stabilize, instead it continued at the elevated level that Humana first started noticing earlier in the year.

“This morning, we reported that our insurance segment benefit ratio exceeded expectations by 40 basis points due to higher medical costs in our Medicare Advantage business,” Chief Financial Officer Susan Diamond said during the company’s Nov. 1 earnings call. “We continue to experience an increase in COVID admissions in the third quarter, whereas our forecast previously assumed that this would occur in the fourth quarter.”

Two recent surveys from KFF and WTW indicate employer-sponsored health plans are concerned with rising health care costs, driven by factors such as inflation, increased utilization and rising prescription drug expenditures. However, the results suggest that employers are becoming more hesitant to raise health insurance costs for workers at a higher rate than their salary increases.

While the average annual family premiums for employer-sponsored coverage increased 7% this year to $23,968 after not increasing a year ago, according to the KFF Employer Health Benefits Survey, workers’ average wages increased 5.2% and inflation was up by 5.8%. During the past five years, premiums increased 22%, while wages rose by 27% and inflation increased 21%.