In recent years, publicly traded managed care organizations have jumped on a growing corporate trend of publishing annual environmental, social and governance (ESG) reports designed to spotlight the larger impact their company is having on society. Alignment Healthcare Inc., for one, in 2022 released its inaugural ESG report highlighting efforts from the previous year that focused on delivering high-quality care at a lower cost compared to fee-for-service Medicare and addressing social determinants of health (SDOH). In 2023, The Cigna Group’s 98-page ESG report categorized similar efforts into four “pillars” — healthy society, healthy workforce, healthy company and healthy environment — and included efforts to reduce greenhouse gas emissions in the latter category.

In a 2022 podcast hosted by law firm K&L Gates LLP, speakers suggested that the health care industry by nature is “mission-driven…focused on the improvement of the human condition” and “is particularly well suited to address ESG issues.” And insurers’ efforts in recent years to address health inequities mirror the increased focus from the Biden administration and CMS on tying health equity to reimbursement, such as the CMS Innovation Center incorporating health equity into models that drive value-based care.

For the first time ever, Medicare Part D beneficiaries in 2025 will have the opportunity to spread their prescription drug expenses over the course of the plan year. While Part D sponsors must offer the option to enrollees effective Jan. 1, 2025, plans face multiple considerations and tasks prior to then. One of their most immediate concerns, industry experts say, is factoring in potential administrative costs and/or financial losses associated with the new Medicare Prescription Payment Plan (M3P, as many are calling it) into bids due next month.

Created under the Inflation Reduction Act, the M3P requires stand-alone Prescription Drug Plans and Medicare Advantage Prescription Drug plans to give enrollees the option to pay out-of-pocket prescription drug costs in the form of capped monthly payments versus paying the full amount at the pharmacy. Program participants will pay $0 at the pharmacy but receive a monthly bill from their Part D carrier, which must reimburse the pharmacies in full.

The pharmaceutical industry continues to bring innovative therapies to market, but payers are continuing to grapple with how they can manage their financial impact. And while the Inflation Reduction Act (IRA) may bring some relief to Medicare beneficiaries in the form of lower drug prices and out-of-pocket costs, uncertainties remain about how that legislation could impact commercial payers, according to speakers at AHIP’s 2024 Medicare, Medicaid, Duals & Commercial Markets Forum, held March 12 through 14 in Baltimore.

During a March 13 session, titled “Trends in Prescription Drug Affordability, Innovation and Access,” a large part of the panel discussion focused on the IRA, which put “a lot of pressure on all parts of our health care system, but pharma got the brunt of it,” observed Rena Conti, Ph.D., associate professor at Boston University’s Questrom School of Business. While much of the focus from pharma and politicians has been on the drug price negotiation process, the Medicare Part D redesign “is actually a really big thing, because that’s what’s going to lower prices for seniors,” she asserted. “And it also will put a fair amount of pressure back on plans to manage this benefit.”

As Medicare Advantage and Part D sponsors prepare their bids for 2025 amid revenue challenges, benefit cuts and other changes that plans are contemplating to maintain margins will undoubtedly trickle down to Accountable Care Organizations (ACOs) and other entities that take risk in MA. As a result, risk-bearing providers should be asking tough questions of their plan partners and conducting internal analyses to understand where their revenue stands to be impacted, according to value-based care experts.

From the transition to v28 — the new version of the Part C CMS-Hierarchical Condition Categories (HCC) model that will make it harder for plans and providers to apply more codes for risk adjustment — to increased inpatient utilization, a -0.16% drop in MA plans’ base pay and other changes, risk-bearing providers are bracing for a “perfect storm” of events in MA that will require preparation, said Zach Davis, a Wakely actuary who helps ACOs manage insurance risk, during a LinkedIn Live session recorded on April 24.

Janssen Pharmaceutical Cos. and Bristol Myers Squibb Co. failed to convince a district court judge that the Inflation Reduction Act’s drug price negotiation program violates the drug industry’s First Amendment rights, the Takings Clause of the Fifth Amendment or the Unconstitutional Conditions Doctrine, per a summary judgement issued in favor of the government 29 April.

The opinion from Judge Zahid Quaraishi of the United States District Court in the District of New Jersey, adds to the list of industry’s legal arguments that have failed to successfully challenge the law. BMS already has appealed the judgement.

Drugs in the Medicare price negotiation process will be at a disadvantage in Part D plans because their lack of manufacturer rebates and discounts will mean lower profits for plans and more pressure on premiums relative to competitors.

The realization is more dreary news for products that end up in the crosshairs of the Inflation Reduction Act (IRA) pricing process, even though the law requires Part D plans to cover negotiated drugs. There is no requirement that plans put those products on a preferred formulary tier, nor are there limits on utilization management tools like prior authorization or step therapy that plans can impose.

After pushing for new limits on broker compensation and other changes to ensure seniors are guided to Medicare Advantage and Part D plans that best meet their needs, the Alliance of Community Health Plans (ACHP) on April 4 celebrated a victory with the release of CMS’s final rule making policy and technical changes for the 2025 plan year. ACHP, which represents provider-aligned, not-for-profit health plans, had spelled out its hopes for these policies in its broader “MA for Tomorrow” framework and provided Senate testimony on the impact of excessive “add-on” broker fees paid by larger plans. After CMS issued its final rule containing new marketing-related policies, AIS Health, a division of MMIT, spoke with ACHP’s executive vice president of public policy, Dan Jones, to learn more about the group’s position.

Building on a sweeping set of marketing-related provisions that went into effect this year, CMS’s recently finalized 2025 Medicare Advantage and Part D rule put new restraints on agent and broker compensation, among other things. The provisions advance the Biden administration’s ongoing efforts to shield consumers from misleading marketing, but with more of a focus on activities performed by independent agents and brokers rather than the broader third-party marketing organization (TPMO) industry that was targeted in previous rulemaking. Industry experts tell AIS Health, a division of MMIT, that the finalized provisions are still open to interpretation when it comes to the role of one type of TPMO — field marketing organizations (FMO) — which often conduct lead generating and advertising on behalf of plans.

As Medicare Advantage insurers face revenue headwinds driven by changes to risk adjustment, Star Ratings and benchmark rates, one overarching question at recent conferences and webinars has been, how will MA plans do more with less? Medicare beneficiaries in recent years have flocked to MA largely because of rich benefit offerings they can’t get in fee-for-service Medicare, and they have grown accustomed to items like comprehensive dental, flex cards and fitness benefits. But as the June 3 bid deadline approaches, insurers are considering what benefits they may have to tweak and how they’ll market those benefits to consumers for 2025.

During an April 3 webinar cohosted by Deft Research and Rebellis Group, Deft Vice President of Client Services Rob Lourenço said the market is already showing signs of revenue changes trickling down to the consumer. In its latest Medicare Shopping and Switching Study, Deft observed a slight “pullback in certain benefits” and at a high level saw more removals of benefits than additions this year. Comparing plans that were offered in both 2023 and 2024, Deft saw that routine eye exam coverage remained stable, while 4% of plans removed eyewear coverage and 1% added the benefit, resulting in a net decline of -3% for eyewear access.

Although a newly finalized health insurance regulation clocks in at 748 pages, it is missing something patient advocates have been eagerly hoping to see: language stating CMS will enforce a court ruling regarding the use of copay accumulator programs. Due to that omission, a patient advocacy group says it is once again exploring its legal options to curtail the practice in which payers prevent drug manufacturer coupons from applying toward patients’ out-of-pocket cost obligations.

Patients and advocacy groups for years have filed official comments on the annual Notice of Benefit and Payment Parameters (NBPP), urging federal officials to curtail the use of copay accumulator programs, according to Carl Schmid, executive director of the HIV+Hepatitis Policy Institute. “And every year, they’ve completely ignored those comments,” he tells AIS Health, a division of MMIT.