Social Determinants of Health

Beneficiary switching from fee-for-service (FFS) Medicare to Medicare Advantage more than tripled between 2006 and 2022, contributing to the MA enrollment boom that’s taken shape over the past two decades, according to a study published this month in Health Affairs. MA enrollment has been “accelerating” since 2019, researchers said, and switchers from FFS to MA were the biggest driving force behind this trend.

The study authors broke down beneficiaries from CMS’s enrollment database into five categories: stayers, switchers to MA, switchers to FFS, beneficiaries who newly gained eligibility, and beneficiaries who lost eligibility (largely those who died during the year). While new enrollments among those who had recently turned 65 also contributed to MA enrollment growth, it was at a smaller scale than growth caused by switching activity among existing beneficiaries, researchers observed.

Economic instability, food insecurity, limited access to transportation and overall lack of support are seniors’ top barriers to staying healthy, according to new data from Alignment Health. Sponsored by the tech-enabled Medicare Advantage insurer, the second-annual Social Threats to Aging Well in America survey polled 2,601 seniors across Alignment’s six-state service area, asking them about their financial, physical and emotional needs — and how those needs are impacting their health. Their responses illuminate the types of supplemental benefits that could prove most valuable to seniors weighing their coverage options as the 2024 Annual Election Period approaches.

Not having enough money for medical expenses was the most common overall obstacle to health, reported by 41% of survey respondents who anticipate any upcoming challenges. And about 20% of respondents cited financial instability as their top obstacle to health and wellness. One in 5 seniors said they’ve skipped out on needed medical care, and lack of funds was the No. 1 reason for doing so. In addition, 14% of seniors said they have outstanding medical debt, and 11% do not think they will be able to pay all of their medical bills in the coming year. When asked about supplemental benefits, nearly half (46%) of respondents said they would take advantage of assistance with rent, mortgage payments, and/or utility bills. Seniors also responded positively to fuel and grocery allowances.

More than a quarter of HIV-positive Medicaid enrollees did not receive at least one of three necessary services for viral suppression in 2021, according to a new report from the HHS Office of Inspector General (OIG). According to one expert, that missed care is certain to rebound to Medicaid managed care organizations (MCOs) in the form of a heavy cost burden: If HIV isn’t continually treated with antiretroviral therapy (ART) drugs and patients are not monitored by practitioners, the virus will cause a patient to develop AIDS — and patients are more likely to transmit the virus to others.

Medicaid covers a notable portion — 40% — of people in the U.S. who contracted HIV in 2018, per OIG. In the report, OIG reviewed 2021 claims data for 265,493 enrollees with HIV across the country. The main findings of the report were:

The Section 1115 waiver that allows states to provide limited Medicaid coverage to incarcerated people has drawn applications from 18 states, according to KFF data from Aug. 11. Most of those states have chosen to limit the coverage to specific populations, such as incarcerated people with positive HIV/AIDS diagnoses, substance use disorder (SUD) or serious mental illness (SMI) — and experts say that the varied scope of state uptake could, over time, show which interventions are most effective in helping the vulnerable populations that the waiver is meant to serve.

Per KFF, of the 18 states that have submitted waivers, four — California, South Carolina, Utah and Washington — have had their waivers approved. Fifteen have pending waivers. (Utah and Oregon have both submitted multiple waivers; both of Oregon’s are pending approval from CMS, while Utah has had one approved and one is still under consideration.)

Supplemental benefits are popular among Medicare Advantage members, but they’re particularly valuable for Medicare-Medicaid dual eligibles, suggests a new report from Elevance Health, Inc.’s Public Policy Institute. Following legislation and regulatory changes in 2018 and 2019 that established new types of supplemental benefits and expanded the definition of what CMS considers “primarily health-related,” payers began to offer supplemental benefits that target members’ health-related social needs (HRSNs), such as food insecurity and lack of access to transportation. Elevance is one of the first payers to release any data on the uptake and utilization of these benefits, while research on duals’ unique social needs and supplemental benefit use continues to emerge. A July 2023 study from Humana Inc., for example, found that 80% of duals in a sample population of its MA enrollees reported experiencing at least one HRSN, vs. 48% of non-duals. Deft Research in its 2023 Dual Eligible Retention Study, meanwhile, found that duals “absolutely depend” on their supplemental benefits and are likely to switch plans if not satisfied with their supplemental benefits.

Just under half (49%) of Medicare-Medicaid dual eligibles were enrolled in Medicare Advantage or other private plans in 2020, according to a new analysis from KFF. But only 30% were enrolled in private plans or programs specifically designed for duals, such as Dual-Eligible Special Needs Plans (D-SNPs), Fully Integrated Dual-Eligible Special Needs Plans (FIDE-SNPs), Medicare-Medicaid Plans, or Programs of All-Inclusive Care for the Elderly (PACE). This could be concerning for lawmakers looking to leverage MA in their efforts to improve care coordination for this vulnerable population.

For the past couple of years, payers have been focusing more attention on health inequities related to race, income and other factors by hiring staff and investing money in programs to improve access to care and lower costs. More recently, they have adopted similar strategies to address inequities in the pharmacy side of their businesses, according to health plan executives who spoke at a conference last month at the University of Pittsburgh.

The push among payers is known as “pharmacoequity,” a term popularized by Utibe Essien, M.D., an internal medicine physician and assistant professor at UCLA. Essien, who moderated the panel with the payer executives, defines pharmacoequity as “equity in access to pharmacotherapies or ensuring that all patients, regardless of race and ethnicity, socioeconomic status, or availability of resources, have access to the highest quality of pharmacotherapy required to manage their health conditions.”

A large swath of Medicare Advantage members report experiencing health-related social needs (HRSNs), such as financial troubles and unreliable access to transportation, according to new research from Humana Inc. published in the July issue of Health Affairs. Researchers surveyed more than 60,000 Humana members (which also included about 12,000 Medicare-Medicaid dual eligibles) in 2019 and found that more than half (56%) reported experiencing at least one HRSN. Financial strain, food insecurity and poor housing quality were the most reported issues.

Some HRSNs — namely unreliable transportation — were more commonly associated with hospitalizations and heavier emergency department (ED) use, researchers found. The overall burden of HRSNs also made an impact, with beneficiaries reporting multiple HRSNs experiencing more hospitalizations.

In an effort to improve Medicare Advantage and Part D sponsors’ timeliness in processing Parts C and D coverage requests, CMS several years ago launched the Timeliness Monitoring Project (TMP) and began issuing fines to Part D plans with excessively high rates of “auto-forwarding” to the Independent Review Entity (IRE). And while CMS historically deducted one star from the appeals measure-level ratings based on IRE data integrity issues, the TMP also resulted in a scaled reduction intended to reflect the severity of the plan’s failures. Now, CMS is relieving MA organizations of that penalty by suspending the collection of Part C Organization Determinations, Appeals and Grievances (ODAG) universes for non-audited organizations that impacted the appeals measures.

Parts C and D sponsors are required to notify enrollees within specific time frames of their decisions on a coverage determination or redetermination. When plans miss that window, it’s considered an adverse decision, and sponsors are expected to automatically forward the case to the IRE within 24 hours. There are two Part C Star Ratings appeals measures that rely on data submitted to the IRE:

For the past couple of years, payers have been focusing more attention on health inequities related to race, income and other factors by hiring staff and investing money in programs to improve access to care and lower costs. More recently, they have adopted similar strategies to address inequities in the pharmacy side of their businesses, according to health plan executives who spoke at a conference last month at the University of Pittsburgh.

The push among payers is known as “pharmacoequity,” a term popularized by Utibe Essien, M.D., an internal medicine physician and assistant professor at UCLA. Essien, who moderated the panel with the payer executives, defines pharmacoequity as “equity in access to pharmacotherapies or ensuring that all patients, regardless of race and ethnicity, socioeconomic status, or availability of resources, have access to the highest quality of pharmacotherapy required to manage their health conditions.”