The year kicked off with a bang at the J.P. Morgan Healthcare Conference, which its sponsor touts as “the largest and most informative healthcare investment symposium in the industry.” More than 8,000 attendees from health systems, insurers, pharmaceutical manufacturers and technology companies descended upon the San Francisco Bay Area for conversations centered on digital health, personalized care, healthcare policy changes and more.
Here’s a glance at four hot-button issues for health insurers in 2023.
1. Changes to the Medicare risk adjustment data validation (RADV) audit program are expected.
The Centers for Medicare & Medicaid Services (CMS) has until February 1, 2023, to finalize the rule, which was initially proposed in 2018 to change how RADV audits are conducted. The proposed rule could result in significant financial penalties for insurers, as it would extrapolate data generated from RADV audits dating to 2011 and would not use a fee-for-service adjuster to offset the error rate.This has, of course, been controversial among payers. A Fierce Healthcare article published in September 2022 quoted Better Medical Alliance, a Medicare Advantage (MA) advocacy group, as saying that the proposed rule “has potential to create disruption for plans and providers, which may, in turn, affect premiums and benefits for beneficiaries.”
At the JPM Conference, health insurers with a stake in MA were asked about the looming decision—and they had a single message: Don’t get rid of the fee-for-service adjuster, according to a conference recap by Fierce Healthcare.
2. Continuity of care is critical.
The continuous enrollment Medicaid provision enacted in response to the pandemic is set to end March 31, 2023. Medicaid enrollment surged during the public health emergency, and now anywhere from 5 million to 18 million people could lose coverage, at least temporarily, during the redetermination process.A Kaiser Family Foundation analysis published in January 2023 outlined key points about the unwinding of the requirement, among them the importance of streamlined renewal processes in promoting continuity of coverage. People who have moved since the start of the pandemic, those with limited English proficiency and those with disabilities are at increased risk of losing coverage.Insurers can help patients maintain continuity of care through the health insurance marketplace established by the Affordable Care Act. The extension of enhanced premium subsidies has increased the range of affordable options for more people, including the chronically uninsured or underinsured, one industry CEO told Fierce Healthcare.
Sabrina Corlette, Georgetown University’s Center on Health Insurance Reforms, and Jason Levitis, Urban Institute, emphasize the necessity of unbroken coverage for those who are most at risk, whether they remain with Medicaid or shift to the marketplace exchanges. In an “expert perspective” published by State Health & Value Strategies, a program of the Robert Wood Johnson Foundation, Corlette and Levitis say that partnerships among state-based marketplaces, Medicaid agencies, departments of insurance, consumer assistance programs and insurers will be increasingly vital to ensuring continuity.
Insurer participation in such initiatives may be voluntary, though some states could choose to flex their regulatory authority. Dozens of states, as well as the federal government, have enacted “in network” pricing protections for patients who are in the middle of treatment, in the last trimester of pregnancy or terminally ill when their provider is terminated from their network. Some states are also requiring such protection when the patient switches from Medicaid to a new health plan. Automatic protections against balance billing are another possibility that health plans should keep on their radar.
3. Focus on accountable care intensifies.
JPMorgan Chase, which launched its Morgan Health venture in May 2022, is investing $250 million in efforts to drive accountable care, creating “a coordinated healthcare experience anchored in improved outcomes.” Care navigation, increased transparency, higher care standards, more personalization, and high-value options to address acute and chronic care needs are among the pillars of this approach, which also stresses innovation and a strong focus on primary care. Providers are compensated more for delivering better patient outcomes, rather than by appointment.A key element of such an approach is elevating the level of consumer healthcare literacy, which is necessary to build trust and ease care (and health plan) transitions. Accountable care’s goal of care for everyone means reaching underserved communities more effectively. Here, too, community partnerships must play a central role.
4. Changes to proposed MA rates appear likely.
The higher-than-expected rates set by CMS over the past couple of years are likely to recede in 2024 or 2025, payer executives said. Such shifts between generous and conservative rates are cyclical, they said, and companies must be prepared to adjust when the pendulum swings in the opposite direction.If there’s a single thread running through these hot-button issues, it seems to be the constant of change. Insurers, like other players in the healthcare industry, must stay flexible as they continually adapt to change on multiple fronts, including technological, marketplace and regulatory.
Payer Next Steps
- Ensure care management teams make more high-value care decisions
- Implement Aerial™, an innovative solution that powers a coordinated healthcare experience
- Improve community partnerships to better address the SDOH needs of members
- Read more about the potential impact of changes to Medicare’s RADV audit program
- Be change-ready with guidance from the healthcare consultants at Aveus
About The Author: Medecision
Medecision® is a digital care management company whose solutions and services are used by leading health plans and care delivery organizations to support more than 42 million people nationwide. Aerial™, a HITRUST CSF®-certified, SaaS solution from Medecision, seamlessly connects the healthcare ecosystem to powerful data and insights that drive meaningful consumer engagement while creating efficiencies to reduce costs and support effective care, case and utilization management. Aveus, our professional services division, helps business leaders solve complex challenges and drive better performance, leaving organizations more capable.
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