Health Plan Weekly

Health insurers, like most companies, are experimenting with how to incorporate artificial intelligence into their work processes to help them make more timely decisions, cut costs, improve profitability and help members. While it is still early to assess how AI will be most effective, plans should make sure they apply AI in an ethical manner and involve multiple stakeholders in any efforts, according to three executives who spoke during a July 26 webinar sponsored by consulting firm ZS. 

Onyinyechi Daniel, Ph.D., who until recently was Highmark Health’s vice president of data and analytics strategy, noted that using AI was “nothing new” for employees in companies’ data and analytics departments. But she added that “the onset of generative AI brought a lot more visibility and really amplified efforts,” especially among executives who are leading the charge in pushing for the adoption of AI throughout their organizations.  

Participants in the Affordable Care Act risk adjustment program will pay a record $10.3 billion for the 2023 benefit year, according to CMS. CVS Health Corp.’s Aetna is estimated to owe the highest amount, while several not-for-profit Blue Cross Blue Shield plans are slated to receive significant payments.

The ACA’s risk adjustment program, launched in 2014, transfers funds from insurers that cover lower-risk enrollees to insurers that cover higher-cost and higher-risk populations in the individual and small group health insurance markets.

CVS Health Corp. announced on Aug. 1 an initiative to provide timely excessive heat alerts and outreach to at-risk members of Aetna health plans. CVS is focusing on people “most vulnerable to extreme weather events that can worsen existing chronic conditions,” according to a press release. This fall, it will expand to people who are susceptible to reduced lung function, asthma and cardiac problems. CVS plans to make the service available eventually to its MinuteClinic and CVS Pharmacy locations. CVS said care managers have worked with “hundreds of at-risk patients” in 20 states since launching the initiative two weeks ago. 

Eleven Democratic Senators on July 23 introduced a bill, the Stop Corporate Capture Act, that would overturn the Supreme Court’s rulings last month that effectively repealed Chevron deference, a legal precedent that gave agencies broad leeway to interpret laws. Sen. Elizabeth Warren (D-Mass.), one of the bill’s sponsors, said in a statement that the act “will bring transparency and efficiency to the federal rulemaking process, and most importantly, will make sure corporate interest groups can’t substitute their preferences for the judgement of Congress and the expert agencies.” A July 23 Reuters article noted the bill “has slim chances of passing in an election year in the Senate, which the Democrats only narrowly control.” Reuters also reported that a similar bill is pending in the House of Representatives.  

With Vice President Kamala Harris now poised to get the Democratic nomination for president, Wall Street analysts have been busy prognosticating what that means for the array of for-profit health care firms they cover — including health insurers. 

So far, select analysts are predicting that Harris’ ascendence will give Democrats a greater chance of winning the election, which would be bad news for Medicare Advantage-focused insurers but good for those more focused on Medicaid and the Affordable Care Act exchanges. 

Molina Healthcare, Inc. has agreed to pay $350 million to acquire ConnectiCare, a subsidiary of EmblemHealth that covers about 140,000 medical livesa in Connecticut. The July 23 announcement occurred one day before Molina reported second-quarter earnings results that beat Wall Street analysts’ projections. The ConnectiCare deal is expected to close in the first half of next year and is subject to regulatory approvals. 

Fellow insurer Centene Corp., meanwhile, reported second-quarter financial results on July 26 that underscored the elevated cost trends it’s seeing in its dominant Medicaid segment. Like other insurers, Centene is feeling the effects of a higher-acuity risk pool created by the exodus of millions of people from the Medicaid rolls since states restarted routine eligibility checks last spring. Still, other positive developments for Centene led one Wall Street analyst to declare its quarterly performance “mixed.”