More Health Systems Likely to Drop Out of Medicare Advantage, Analyst Predicts

More Health Systems Likely to Drop Out of Medicare Advantage, Analyst Predicts

More health systems are going to be opting out of Medicare Advantage (MA) plans, George Hill, a managing director at Deutsche Bank in Boston, predicted Monday at a “Wall Street Comes to Washington” webinar hosted by the Brookings Institution.

“I think you’re going to see more large provider organizations threaten to opt out of networks, particularly as it relates to MA,” Hill said, adding that there are a number of reasons for this. “Prior authorizations are the problem, claims denials are a huge problem, delayed payments and rates are the problem — barriers in access to care in all varieties are the problem.”

Health systems’ actions in this area won’t necessarily be “all or none,” he continued. “There are a lot of intermediate steps. Maybe there’s a flagship hospital that can’t be used by an MA patient. Maybe there’s some type of clinic or some type of service that can’t be used by them, or some other type of steerage that goes on … Given the [financial] pressure that the Medicare Advantage plans felt like they were under in 2023, are going to be under in 2024, and expect to be under in 2025, this is a problem that gets worse before it gets better.”

Jailendra Singh, managing director at Truist Securities in New York City, said the disputes between MA plans and health systems “are always about rates … Hospitals claim that MA plans don’t reimburse at the same level [as traditional] Medicare, and that they can delay or deny care through prior authorization, or impose other limitations.”

Telehealth is a good example, he said. “Payers still believe it should be way cheaper than when you provide care in the four walls of the clinic, whereas providers keep saying, ‘we are spending the same amount of time and resources; we should be paid really close to the same level.'”

For its part, the Centers for Medicare & Medicaid Services (CMS) has begun scrutinizing the number of diagnostic codes that MA plans are assigning to patients, Hill said; the plans get higher payments for enrollees with more diagnoses. “You’ll see a lot of other diagnostic coding that goes into these beneficiaries, which then doesn’t show up as treatment,” he said. “I think CMS recognizes that and is working on that now.”

He added that people with knowledge of Capitol Hill have been telling him, “‘Don’t be surprised if the populist Republicans actually want to go after MA,’ with the thesis being they don’t like what supplemental benefits cover, and they don’t like the idea that Medicare is covering all this stuff that it was never intended to cover.”

Panelists also discussed the recent “unwinding” — eligibility re-determinations — that state Medicaid programs had to do once the COVID-19 public health emergency ended. “More Medicaid beneficiaries lost coverage than expected,” with about 80% of disenrollments reportedly due to administrative reasons, said Ann Hynes, managing director at Mizuho Americas in Boston.

Despite the disenrollments, “people are still getting health insurance” through the Affordable Care Act exchanges or through their employer, now that they no longer have the Medicaid option, Hynes said. “Exchange growth is very strong this year, and I also would be surprised as [commercial insurers] report earnings, if you see an uptick in just regular commercial growth … We haven’t seen a huge uptick in the uninsured, so I think it is settling out.”

One of the reasons so many people were disenrolled may be that Medicaid plans are having difficulty reaching them, Hill said, noting that when he was at a health insurance industry conference recently, “you heard state administrators talk about [how] ‘mail is dead,’ and people aren’t answering phone calls from people they don’t know. So if the state Medicaid agency is calling you, what does that mean? What we’ve seen is younger, healthier, people get ‘re-determined out’ while the older, sicker people are going to pay much closer attention to their healthcare” and make more of an effort to stay in the program.

The high cost of prescription drugs, such as GLP-1 inhibitors that are now being used for weight loss, also came under discussion. Whether employers choose to cover such drugs will vary from one to the next, Hynes said. “Employers who tend to have an employee who stays with them longer term” — such as automakers or other large employers — “I think they’re more willing to do a carve-out and a test” to see whether it’s cheaper to provide employees with access to weight-loss drugs and possibly avoid some obesity-related illnesses, or to not cover the drugs and let providers manage obesity in other ways, she said.

Hill had another idea. “I feel like it’s rare that anyone ever gets to say this, but could this be a case of PBMs [pharmacy benefit managers] to the rescue?” he said. “The only people [who could blunt] the impact of the high cost of GLP-1 drugs are probably the PBMs.” He noted that hepatitis C drugs were a case in point. “Those drugs are basically free now” thanks to the PBMs, “as opposed to drugs that came on the market at a $90,000 list price.”