Editor's Corner—Fierce Health Payer's top 10 stories of 2023

2023-12-22

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Editor's Corner—Fierce Health Payer's top 10 stories of 2023

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来源: FierceHealthcare

Many of most-read health insurance stories from Fierce Healthcare in 2023 center on Medicare Advantage.

Among our most-read stories of the year, one topic clearly rose to the top: Medicare Advantage.

A number of significant changes came to the program in 2023. For one, the Biden administration finalized hotly-anticipated overhauls to MA risk adjustment in the early half of the year, and while payers did secure some wins in the process, overall the results were not entirely to their liking.

In addition, in the fall, the industry felt the first sting of updates to the methodology behind Medicare Advantage's star ratings. The impact led to declines in star ratings for payers large and small.

While MA-related headlines dominate our top 10, the most-read story overall instead centers on Medicaid. Frank Diamond dived into a study that highlights how the program could become a major player in housing.

Beyond regulatory topics, it's no surprise that the industry's largest player, UnitedHealth, makes multiple appearances on this list. That includes coverage of its $5.4 billion acquisition of home health provider LHC Group.

Here are the top 10 payer stories of 2023:

1. How Biden admin rules could pave way for Medicaid to be a major housing player

The Biden administration has taken steps to make it easier for Medicaid programs to support enrollees in addressing housing insecurity. It's backed pilot programs under Section 1115 that allow for funding to support housing needs and set clear ground rules for how states and managed care organizations can offer short-term assistance. However, experts say these programs are still somewhat "theoretical."

2. CMS to raise Medicare Advantage pay rates by 3.3% in 2024; phase in risk adjustment changes

While the proposed updates to risk adjustment audits were met with a negative reception in the industry, payers did score a win in the final rule, which established that the changes would be phased in over several years. In addition, insurers received a slight pay bump in Medicare Advantage compared to the proposal. Regulators said the goal is to ensure that payments to plans are accurate.

3. Majority of Medicare Advantage enrollees don't fully understand their plan

Enrollment in Medicare Advantage has only continued to grow over the past decade. However, an August survey found that under half of beneficiaries understand their plans, with 68% saying that certain elements have proven confusing. While insurers have work to do in addressing navigation and experience, most (71%) of those surveyed said they were satisfied with their coverage.

4. Medicare Advantage plans lose out in final RADV audit rule that ditches fee-for-service adjuster

MA insurers did secure a small boon in the proposed risk adjustment rule, which set that the new methodology would only apply to contracts dating back to 2018. However, the rule did ditch a key component payers sought to preserve, the fee-for-service adjuster, which became central to legal challenges later in the year. Predictions about the regulation, released in late January, dominated the conversation at the J.P. Morgan Healthcare Conference.

5. Medicare Advantage plan star ratings decline again in 2024

Amid changes to the methodology for calculating the star ratings, payers have seen several years of declines. For the 2024 plan year, about 42% of Medicare Advantage prescription drug plans will have a rating of at least four stars. That's down from 51% in 2023 and 68% in 2022. Plans that include drug coverage are rated on 40 measures, while MA-only coverage is scored based on 30 measures.

6. Optum exec: Medicare Advantage advance notice rule will hurt care for dual eligibles

Negative reaction from the industry to the risk adjustment changes in Medicare Advantage was swift. At the annual Health Datapalooza event, Patrick Conway, M.D., then the CEO of care solutions at UnitedHealth Group's Optum, argued that the updates could have potentially significant consequences for people dually eligible for Medicare and Medicaid due to several eliminated codes.

7. UnitedHealth sued by US Labor Department over 'thousands' of claims denials

The Department of Labor filed suit against UnitedHealth in early August, alleging that its UMR subsidiary, a third-party administrator, denied claims for emergency room services and urinary drugs screenings for thousands of patients. The lawsuit alleges that UMR failed to follow requirements in the Affordable Care Act and regulations from the Department on claims procedures.

8. Humana launches in-home primary care through CenterWell

In late August, Medicare Advantage insurer Humana announced that it would launch an in-home arm for its senior-focused primary care business, CenterWell. Called Primary Care Anywhere, the initiative will offer a number of services in patients' homes, including blood draws, vaccinations and prescription management. Building out CenterWell is a major strategic focus for Humana.

9. UnitedHealth, LHC Group close $5.4B merger deal

UnitedHealth Group is a massive sprawling giant that's only getting bigger. In February, it sealed the deal on a $5.4 billion acquisition of home health provider LHC Group, overcoming pushback from shareholders and concerns from regulators. LHC Group joined the fold at Optum. And UHG's dealmaking continued throughout the year, and we're watching for its acquisition of Amedisys to close in early 2024.

10. List prices for Ozempic, Wegovy far higher in the US than in peer nations: KFF

The conversation around GLP-1 drugs was a major throughline for the year. As demand rose, payers faced tough questions about affordability and access to these therapies. Part of the equation is the price, which is far higher in the United States than in other peer nations, according to an analysis from KFF. Industry experts expect this trend to continue into 2024.