Mergers & Acquisitions

With the cost of hospital-based services rising ever higher — and sometimes varying dramatically between different institutions — the concept of regulating prices has become a perennial political issue. However, a new study suggests that certain markets are much better suited for price regulation than others: namely, those where there is little hospital competition.

In those concentrated markets, higher hospital prices do not appear to lead to lower patient mortality, meaning cost isn’t correlated with quality, according to a new working paper published by the National Bureau of Economic Research (NBER). But in hospitals in less concentrated markets, pricier hospitals are indeed associated with increased health care quality — and as a result, patients are 47% less likely to die than if they attended lower-priced facilities.

Medicare Advantage membership has grown by 8.5% since February 2021 to top 28.6 million lives, according to AIS Health’s analysis of data that included enrollment during the 2022 Annual Election Period (AEP). While nearly two-thirds of all new enrollees selected a plan from market leaders UnitedHealthcare, Humana Inc. or CVS Health Corp.’s Aetna, several regional insurers performed well above average, driven largely by service area expansions, provider pacts and benefit enhancements. (Per AIS’s research methodology, the following figures do not include lives enrolled in CMS’s Financial Alignment Initiative demonstration plans serving about 451,000 Medicare-Medicaid dual eligibles or participants in Programs of All-Inclusive Care for the Elderly.)

Approximately 2.2 million people enrolled in a Medicare Advantage plan from February 2021 to February 2022, bringing the total MA population to 28.6 million medical lives. That’s an 8.5% year-over-year increase, according to AIS Health’s analysis of data that included enrollment from the 2022 Medicare Annual Election Period (AEP), down from 9.9% growth during the prior-year period. Nearly two-thirds (64.3%) of all new enrollees selected a plan from UnitedHealthcare, Humana Inc. or CVS Health Corp.’s Aetna, while Centene Corp.’s major market expansion paid off, garnering more than 30% enrollment growth for the insurer. Meanwhile, Florida Blue parent GuideWell Mutual Holding Corp.’s completed acquisition of Triple-S Management Corp., one of the largest MA insurers in Puerto Rico, allowed it to crack the top 10 for the first time. Anthem, Inc. also completed a Puerto Rico MA deal with its July 2021 acquisition of MMM Holdings from InnovaCare Health. On the state level, four states saw MA growth of more than 20% (vs. 10 last year), including Delaware and Vermont, which have historically low penetration rates.

The U.S. Dept. of Justice (DOJ) on Feb. 24 sued to block UnitedHealth Group’s proposed $13 billion acquisition of Change Healthcare Inc., arguing that the deal would stymie competition not only in commercial health insurance markets but also the market for technology that allows insurers to process claims and reduce health care costs.

UnitedHealth has already indicated that it will challenge the legal action taken by the DOJ and attorneys general from Minnesota and New York — setting the stage for the first legal fight to save a major deal involving a health insurer since the failed Anthem/Cigna and Humana/Aetna tie-ups.

As transactions and outside investment in primary care become more common, many health care insiders see an opportunity to shift primary care reimbursement toward risk-based payment — but experts warn that value-based contracting can’t solve all of primary care’s problems on its own.

Primary care practices (PCPs) operating on a fee-for-service basis faced a crisis in 2020, when the pandemic discouraged patients from making routine visits to the doctor’s office. Many PCPs turned to outside financing to fund capital investments or make payroll. Others combined horizontally with other PCPs or sold to health systems.

The Dept. of Justice is preparing to file suit to block UnitedHealth Group’s proposed acquisition of Change Healthcare Inc., according to multiple media outlets citing Dealreporter. Reportedly, the DOJ will meet with UnitedHealth and Change Healthcare representatives in the next few days. The firms had looked into divesting assets to pass antitrust scrutiny, but the DOJ has not accepted any proposal so far, sources familiar with the transaction told Dealreporter.

AHIP asked CMS for more information regarding its National Coverage Determination (NCD) on Aduhelm, the controversial Alzheimer’s drug that garnered accelerated approval from the FDA in 2021 despite objections on scientific and ethical grounds. CMS said in January that Medicare will cover Aduhelm and other drugs in its class only for people who are enrolled in qualifying clinical trials. In a Feb. 10 letter signed by AHIP CEO Matthew Eyles, the trade group requested “that CMS provide clear guidance to MA plans on their coverage obligations under the NCD.” In particular, Eyles called for a list of clinical trials MA plans must cover.

For the fourth quarter and full-year 2021, CVS Health Corp. reported a strong financial performance across its vertically integrated health care business, but its health insurance division Aetna had mixed results. While Aetna delivered higher-than-expected enrollment in Medicare Advantage, it didn’t meet expectations for enrollment on the Affordable Care Act exchanges — a book of business the firm re-entered after several years away from the individual marketplaces.

Aetna took in $20.6 billion in revenue in the third quarter of 2021, according to a CVS press release, up from $19.1 billion in the same period of 2020. It recorded a medical loss ratio of 87%, up from 86.7% in the same period last year; for the full year, Aetna reported an MLR of 85%, up from 80.9% in 2020.

Despite Humana Inc.’s recently downgraded Medicare Advantage (MA) enrollment projections for 2022, Wall Street analysts praised the company’s high margins after the insurer reported fourth-quarter and full-year 2021 earnings on Feb. 2.

Humana posted earnings per share (EPS) of $1.24 for the quarter and $20.64 for the full year — both slightly above the company’s expectations — and reaffirmed its previously lowered projection of MA enrollment growth of 150,000 to 200,000 individuals in 2022.

Hospital consolidation has entered a new stage: Large regional hospital systems have finished acquiring most of their smaller local competitors and have begun to combine with large health systems of similar size. Experts say the new phase of market concentration, which also includes large hospital groups acquiring physician groups and outpatient centers, is bound to increase prices for health plans and consumers — and that there’s little regulators can do to stop or reverse it.

Hospital deals are not new: Over the past decade-plus, hundreds of hospital groups have combined, following a trend toward consolidation and vertical integration across the American economy. According to the American Hospital Association, nearly 1,600 hospital transactions took place between 1998 and 2017. Health system market power is now more concentrated than ever: in most regional markets, two or three players control most of the inpatient facilities. In fact, in a majority of U.S. metro areas, one hospital system controls more than half the market.

In 2021, investors poured a record amount of capital into health care, and industry insiders say that the flood of cash is likely to continue flowing in 2022. Experts predict that investments in health tech, which drew the highest level of investment of any health care sector last year, will continue to grow — and carriers may want to make a splash in new areas of business.

According to a white paper prepared by PricewaterhouseCoopers (PwC), deals in the U.S. health care sector increased by 56%, for a total volume of $203 billion, through Nov. 15, 2021, compared to the same period in 2020. Meanwhile, a report by Silicon Valley Bank (SVB) found that venture capital funding of health care startups in the U.S. and Europe hit $80 billion, “beating 2020’s record by more than 30%.”