Health Plan Weekly

Most of the health plans ranked by the National Committee for Quality Assurance received an overall rating of 3.5 stars or higher, according to the NCQA’s 2023 health plan ratings.

Of the rated plans, only two out of the 1,095 plans listed received five stars this year: Kaiser Foundation Health Plan of the Mid-Atlantic States and Independent Health Association, Inc. In the 2022 ratings, six out of 1,048 health plans earned five stars. Commercial health plans had a higher overall rating compared to Medicaid and Medicare health plans.

The House is reportedly poised to vote soon on legislation that consolidates a host of previously introduced health care measures — including a step toward site-neutral payment reform. Aimed at stopping “price gouging” by hospital outpatient departments (HOPDs), those provisions are enthusiastically supported by payers but opposed by the hospital industry, which argues that they would result in payment reductions. 

The legislation also would codify existing regulations that lay out new price transparency requirements for health plans and hospitals, and it would implement modest PBM reforms.  

Blue Cross Blue Shield of Michigan announced on Sept. 7 that it plans to reduce the use of prior authorization (PA) by 20%, becoming the latest payer to cut its PA requirements. While the moves make care delivery less burdensome for providers and patients, health insurers should also benefit from not relying as much on PA, according to health policy experts who spoke with AIS Health, a division of MMIT. 

Michael Lutz, a senior consultant at Avalere Health, says that insurers can lower their administrative burden and focus on services where PAs are essential such as costly or high-volume procedures. He adds that plans announce their PA reductions as a marketing tool, too.  

The CEOs of CVS Health Corp. and The Cigna Group on Sept. 12 downplayed the potential for PBM market disruption that could result from Blue Shield of California’s recent deal to unbundle its pharmacy benefit contracts. But both executives hedged by emphasizing their PBMs’ flexibility, and Cigna’s boss suggested that its Express Scripts subsidiary has an a la carte PBM menu. 

CVS and Cigna leaders also said, during presentations at the Morgan Stanley Health Care Conference, that they are confident that their Medicare Advantage Star Ratings will improve, and they promised further MA growth. Both firms assured investors that their recent, multibillion-dollar provider transactions will lead to future growth. And both firms, which own two of the “Big Three” PBMs, said that biosimilars will be a boon to payers — with CVS promising as much as 80% savings on its forthcoming Humira (adalimumab) biosimilar line.