Health Plan Weekly

Alternative payment models (APMs), including value-based and accountable care, are growing across all lines of business, according to a survey from the Health Care Payment Learning & Action Network (HCP-LAN). Adoption of APMs increased from 41.3% in 2022 to 45.2% in 2023. Experts tell AIS Health, a division of MMIT, that while the results are encouraging, more work is needed to encourage adoption of value-based care arrangements, particularly in the commercial sector. 

The annual survey, conducted by HCP-LAN in partnership with AHIP and the Blue Cross Blue Shield Association, gathered data from 73 health plans, four fee-for-service Medicaid states, and traditional Medicare. In 2023, 21.6% of commercial payments flowed through APMs with downside risk, in which providers are financially responsible for failing to meet quality and cost goals, compared to 16.5% in 2022. Medicare Advantage led the way with 43% of payments passing through downside-risk APMs in 2023 vs. 38.9% the previous year. Traditional Medicare had 33.7% of payments run through APMs in 2023 vs. 30.2% in 2022. And 21.1% of Medicaid payments flowed through APMs in 2023 vs. 18.7% in 2022. 

Nearly one-quarter of adults in the U.S. are enrolled in health plans that are unaffordable and leave them in a potentially precarious financial position, according to a survey released on Nov. 21 from the Commonwealth Fund. Joseph Betancourt, M.D., the nonprofit foundation’s president, noted the results reveal “a critical weakness in the U.S. health insurance system.” And the report’s authors suggested policymakers could address the issue by expanding Medicaid eligibility in all states and permanently extending enhanced premium tax credits for Affordable Care Act exchange coverage. 

The survey was conducted between March and June of this year via telephone and online interviews in English and Spanish with a nationally representative sample of 8,201 adults who were at least 19 years old. All told, 56% of the respondents had been insured all year and were not deemed to be underinsured, 12% were insured at the time of the study but had been uninsured at some point in the previous 12 months and 9% were uninsured.  

The Dept. of Justice (DOJ) on Nov. 12 joined attorneys general from four states in suing to block UnitedHealth Group’s proposed purchase of Amedisys Inc. Their complaint, filed in the U.S. District Court for the District of Maryland, alleges that the $3.3 billion deal would eliminate competition between two of the country’s largest providers of home health and hospice services.

The move comes just under two months before Donald Trump will be sworn in for his second term as president — an administration largely believed to be much more receptive to industry consolidation than the Biden administration has been. But one former federal antitrust official says there are reasons to believe the DOJ’s lawsuit against the UnitedHealth/Amedisys transaction might survive even when control of the federal law enforcement agency changes hands.

During the UBS Global Healthcare Conference on Nov. 12, Elevance Health, Inc. Chief Financial Officer Mark Kaye attempted to reassure investors that the company is on the right track despite recent struggles in its managed Medicaid business. However, he said the turnaround would take some time as the insurer works with states to increase reimbursement for treating a sicker pool of Medicaid beneficiaries.

“If I step back, 2025 is going to be a tale of two halves, with continued headwinds in the first half giving way to recovery in business performance and margins in the second half,” Kaye told UBS analyst A.J. Rice.