Health Plan Weekly

  • Decline in Primary Care Use Presents Challenge for Payers

    A new report from the Employee Benefit Research Institute (EBRI) confirms that primary care for commercially insured patients is in the midst of a significant transformation. In a study of claims data from 2013 to 2021, EBRI found that fewer patients have a primary care practitioner (PCP), more non-physician practitioners deliver primary care than ever, and sites of care are changing. And the author of the report says he believes the COVID-19 pandemic accelerated the shift. 

    EBRI’s findings are a mixed bag for payers. On the one hand, the report confirms that the size of the workforce able to deliver primary care is likely growing, and more patients may have better access to a variety of primary care options: 95-97% of all primary care visits were in an office setting prior to 2020, but that share declined to 86% in 2020. Seven to eight percent of primary care visits went to telemedicine that year and 3-4% went to urgent care clinics. However, the report also found that primary care costs have not gone down despite broader access. 

  • While Insurers Tout Value-Based Wins, Wide Adoption Remains Elusive

    Across the U.S. in 2022, 24.5% of health care payments involved two-sided financial risk reimbursement arrangements, according to an analysis published on Oct. 30 from the Health Care Payment Learning & Action Network (HCPLAN). That is up from 19.6% in 2021 and 17.9% in 2020.

    While the upward trend is encouraging for those interested in shifting away from a fee-for-service model, health policy experts tell AIS Health, a division of MMIT, that more needs to be done to encourage providers to embrace value-based care. They add that adoption varies based on the payer, with Medicare leading the way and private commercial plans lagging.

  • Elevated Outpatient Care, No Recession: 2023 Has Surprised Analysts

    Three quarters into 2023, Moody’s Investors Service says the predictions it made at the start of the year for the health insurance sector — namely, earnings growth in the mid-to-high single digits — have largely proven accurate. However, while financial results were consistent with the credit rating firm’s expectations, analysts said in a new report that the reasons for those results were not exactly what they predicted. 

    “Our outlook was premised on reduced membership as a result of Medicaid redeterminations and the impact of a possible recession on commercial membership,” the analysts wrote in a report released on Nov. 20. “However, with no recession this year, commercial membership has been better than expected, but its growth has been offset by higher-than-expected MA [Medicare Advantage] utilization.” Additionally, “although Medicaid redeterminations are underway, their impact so far has been relatively small.” 

  • Medicare Part D Coverage for Humira Biosimilars Has Inspector General’s Attention

    The HHS Office of Inspector General will evaluate the extent and quality of Medicare Part D plan coverage for biosimilars to AbbVie Inc.’s Humira (adalimumab) and expects to issue a report on the study in 2025, according to a recent update to the OIG’s work plan.

    The study could provide fodder for reforms to pharmacy benefit manager rebating practices and for changes in Part D coverage policy that could help boost the uptake of biosimilars. Stakeholders and policy makers have viewed adalimumab biosimilars as a test case for the viability of the biosimilar model.

  • Nurse Practitioners, Urgent Care Take Center Stage as Patient Trends Shift

    Fewer people with employment-based health plans visited primary care practices, while more have turned to telemedicine and urgent care clinics since the COVID-19 pandemic, according to a report published by the Employee Benefit Research Institute.

    Using claims data from 2013 to 2021, researchers found that primary care office visits at a family/general practice, internal medicine practice or with a medical doctor dropped during that time. The share of visits with a nurse practitioner, however, increased significantly, from 4% in 2013 to 16% in 2021.

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