December 1, 2023


Expect exquisite business

Medicare Advantage, consolidation drove healthcare insurer trends in 2021

Photograph: FG Trade/Getty Visuals

It was challenging to forecast craze traces for the payer and well being insurance coverage industry in 2021, mostly simply because of persistent uncertainties because of to the COVID-19 pandemic. Consumer actions has develop into extra unpredictable, care models and offerings are altering and payers are adapting to a globe that is evolving rapidly and in unforeseen strategies.

1 element that has been rendered exceptionally unpredictable by the virus is the economic well being of the nation’s main insurers, which soared for the duration of the first waves of the pandemic in 2020 but then settled again down to earth towards the conclusion of that 12 months. In 2021, insurers nonetheless posted mainly substantial earnings, but they were being significantly from the heights observed the past 12 months.

Around the system of the 12 months a several standard themes begun to arise. Insurers are plowing ahead with digital transformation initiatives, including the enlargement of telehealth and digital well being. Artificial intelligence and equipment discovering have labored their way into the blend and 50 % of payers now have innovation labs in the perception that digital innovation will be the key to the upcoming.

Insurers also ongoing to consolidate in 2021, ensuing in very concentrated marketplaces that have drawn the consideration of the federal governing administration, which seeks to suppress consolidation in a bid to empower individuals.

And then there is certainly Medicare Benefit, which carries on to increase it’s estimated MA strategies will go over extra people in 2022 than first Medicare. Numerous main insurers have taken notice, increasing their MA offerings in an hard work to seize extra of the sector.

It is been a wildly various 12 months in the payer space, but the way it has performed out indicates lots of of these craze traces may perhaps go on into 2022 … and over and above.


COVID-19 carries on to have an effect on every facet of American everyday living and the health care industry, and it’s driving tendencies in the payer globe as very well. At the HIMSS Condition of Health care celebration in June, Shreesh Tiwari, principal at ZS, reported the coronavirus has led to an enhance in payer adoption of engineering and innovation.

Sixty-4 p.c of well being insurance coverage executives report an accelerated adoption of digital well being initiatives such as digital well being. A different 53% report an acceleration in adoption of artificial intelligence and equipment discovering practices, whilst 42% reported COVID-19 has helped facilitate the adoption of benefit-centered care arrangements, according to Condition of Health care study by HIMSS, the mother or father firm of Health care Finance Information.

COVID-19 has helped to drive improvements not just in engineering, but in mindset, Tiwari reported. The mental and cultural limitations in phrases of adoption are no lengthier remaining observed as issues.

Around 50 % of payers have an innovation lab and feel AI and equipment discovering will drive innovation ahead. But 53% feel health care startups will lead the way in driving significant engineering innovation, Tiwari reported.

The governing administration also performs a key purpose. Forty-6 p.c of payers believe present-day guidelines and rules will facilitate innovation.

“Payers have tasted the fruits of innovation in the earlier several months,” Tiwari reported at the time. “Interoperability is remaining observed as a key driver in phrases of running issues coming out of the engineering infrastructure, info infrastructure issues we have, closely followed by info privateness and info safety.”

Not all of insurers’ digital initiatives are likely flawlessly, nevertheless. Wellness strategies are revamping their digital offerings in a bid to please individuals, but these initiatives are complicated, a Deloitte study uncovered in June. Several strategies are struggling to appropriately prioritize jobs, suggesting a deficiency of obvious vision.

In truth, about 50 % of the 35 engineering leaders surveyed identified this deficiency of vision as an impediment to these ongoing digital transformation initiatives. 

Buyers are the ones mostly affected, as shopper-experiencing platforms have designed the least development. A minor in excess of 50 % of respondents, fifty seven%, reported they are nonetheless in the course of action of advancing these courses, whilst the remainder haven’t however begun but say they’ll do so in just the upcoming two a long time.

There are other parts that are lagging as very well. The study concentrated on modernization initiatives of five engineering platforms – administrative, analytics, medical, core, purchaser provider and engagement – and only two respondents reported they had modernized one of those people platforms.

Those people surveyed identified cyber and details safety as the amount two financial investment precedence after enterprise intelligence. But they warned it could be pricey to correct cyber-relevant problems, notably ones having to do with cloud configuration. Baking in cybersecurity in DevOps from the outset could make for a extra productive and resilient course of action.

The findings speak to the broader dilemma of individual engagement, which has been an ongoing difficulty for well being strategies and insurers. A J.D. Energy 2020 U.S. Industrial Member Wellness Prepare study uncovered that 60% of privately insured U.S. well being system users reported they had not been contacted by their well being system with guidance or details relevant to COVID-19, and almost 50 % (forty eight%) reported their well being system has not shown problem for their well being due to the fact the pandemic began.

Wellness strategies have not obtained purchaser centricity, as just 36% of business well being system users reported their well being system functions in their finest curiosity “always” or “most of the time,” and just 25% reported they watch their well being system as a dependable associate in their well being and wellness.

This deficiency of purchaser-centric positioning resulted in an total gratification score final 12 months for business well being strategies of 719 on a one,000-point scale, among the least expensive of all industries evaluated, according to J.D. Energy.


Medicare Benefit enrollment ongoing to enhance and quite a few main insurers expanded their MA footprints. It is develop into a very hot sector for insurers heading into the new 12 months.

The Facilities for Medicare and Medicaid Companies reported that in 2022, MA is projected to reach 29.5 million people when compared to 26.9 million enrolled in a Medicare Benefit system in 2021. 

For lots of seniors, MA is the preferred well being insurance coverage simply because of its lower upfront every month charges and additional gains. Medicare Benefit strategies will go on to offer you a extensive variety of supplemental gains in 2022, including eyewear, hearing aids, both preventive and thorough dental gains, access to foods (for a minimal length), in excess of-the-counter products, health gains and around the globe emergency/urgent coverage. 

In addition, the share of strategies providing specific supplemental gains for chronically unwell folks will enhance from 19% to 25%.

An increasing amount of Medicare Benefit dual qualified specific wants strategies go over both Medicare and Medicaid services for people who are dually qualified. In 2022, 295 strategies (when compared to 256 in 2021), will go over all Medicare services, moreover Medicaid-covered behavioral well being cure or very long-term services.

CMS will go on to take a look at the Portion D Senior Savings Model for insulin for seniors in extra than 2,one hundred strategies in 2022. This 12 months, in excess of five hundred new Medicare Benefit and Portion D prescription drug strategies, as very well as two new pharmaceutical manufacturers of insulin, are joining the product that lowers out-of-pocket shelling out.

Furthermore, extra than one,000 Medicare Benefit strategies will take part in the CMS Innovation Center’s Medicare Benefit Price-Based Insurance coverage Design Model in 2022, which exams the impact of providing a projected million people personalized gains intended to much better handle their diseases and handle social wants from meals insecurity to social isolation. 

The VBID Model’s Hospice Profit Element, now in its second 12 months, will also be made available by a hundred and fifteen Medicare Benefit strategies in portions of 22 states and U.S. territories. It supplies enrollees improved access to palliative and integrated hospice care. 

To enable with their Medicare charges, lower-cash flow seniors and grownups with disabilities may perhaps qualify to get economic help from the Medicare Savings Programs. Only about 50 % of qualified people are enrolled, CMS reported.

Cigna is receiving on on the act by increasing its MA strategies, increasing into 108 new counties and 3 new states – Connecticut, Oregon and Washington – which will enhance its geographic existence by almost thirty%, the insurance provider reported in October.

As aspect of the enlargement, Cigna reported most present-day prospects will shell out the identical or lessen premiums, and promised that every sector will have at least one $ top quality system. Other gains will involve a social link program to combat loneliness, personalized strategies for people with diabetic issues and incentives for yearly wellness tests and other preventive care.

Cigna has improved its geographic existence in MA by eighty% due to the fact 2019, the insurance provider reported. The firm now presents strategies in 477 counties throughout 26 states and the District of Columbia.

Centene, meanwhile, reported this 12 months it will be broadening its reach in the Medicare Benefit space in 2022, increasing into 327 new counties and 3 new states: Massachusetts, Nebraska and Oklahoma.

In all, this represents a 26% enlargement of Centene’s MA footprint, with the providing out there to a potential forty eight million beneficiaries throughout 36 states. Now, Centene serves extra than million MA users throughout 33 states.

In September, Centene also declared it would consolidate its present-day Medicare brands, including Allwell, Wellness Web, Fidelis Care, Trillium Benefit, ‘Ohana Wellness Prepare and TexanPlus, under one unified manufacturer dubbed Wellcare.

In the meantime, UnitedHealthcare, which currently has major sector manage with its Medicare Benefit strategies, will bolster its foothold in the space by increasing its MA strategies in 2022, introducing a potential million users and achieving ninety four% of Medicare-qualified individuals in the U.S.

Now, extra than seven.three million people are currently enrolled in UnitedHealthcare’s Medicare Benefit strategies. The insurance provider reported the enlargement will target on decreasing prescription drug charges, and improving upon gains and the member experience.

But whilst UnitedHealthcare has a significant foothold in the Medicare Benefit space, it underwent scrutiny from the federal governing administration earlier this month, when the Facilities for Medicare and Medicaid Companies blocked 4 Medicare Benefit strategies from enrolling new users in 2022 simply because they didn’t invest the least threshold on health care gains. 3 UnitedHealthcare strategies and one Anthem system unsuccessful to strike the needed 85% mark 3 a long time in a row.

Medicare Benefit strategies are needed to invest a least of 85% of top quality dollars on health care costs failure to do so for 3 consecutive a long time triggers the sanctions.

For UHC, the penalties utilize to its MA strategies in Arkansas, New Mexico and the Midwest, which encompasses Missouri, Kansas, Nebraska and Iowa. UHC strategies go over about 83,000 users, and the Anthem system handles about one,200 users. They can’t offer you select strategies to users right until 2023, assuming they strike the 85% threshold upcoming 12 months – what is actually referred to as the health care loss ratio (MLR). If they fall short to strike the threshold for five a long time in a row, the governing administration will terminate the contracts.

UHC associates advised Bloomberg that it skipped the 85% benchmark in sure marketplaces in aspect simply because of sufferers deferring health care care because of to the COVID-19 pandemic.

Humana also declared it would debut a new Medicare Benefit PPO system in 37 rural counties in North Carolina in response to sector demand from customers in the japanese aspect of the point out. 


Wellness insurance provider consolidation has been a different ongoing craze – and one the present-day administration would like to see with tighter reigns.

An executive purchase issued by President Joe Biden in July cracked down on clinic and well being insurance coverage consolidations and other steps it reported decreases level of competition and drives up costs. The 4 parts of health care focused are: prescription medicine, clinic consolidation, well being insurance coverage consolidations and hearing aids.

Consolidation in the well being insurance coverage industry has meant that lots of individuals have minor choice when it arrives to picking out insurers, the purchase reported. 

Biden directed the Division of Wellness and Human Companies to standardize system possibilities in the well being insurance coverage marketplace so people can comparison store extra quickly. Programs made available on the exchanges are complicated by the numerous services made available and differences in deductibles, the purchase reported.

Rick Pollack, president and CEO of the American Medical center Association, urged federal organizations at the time to target on guidelines that handle level of competition among business well being insurers.

“In truth, with business well being insurance coverage strategies, almost 3 out of 4 marketplaces were being very concentrated in 2019 and the top five most significant insurers by yourself manage almost fifty% of the sector. Scientific tests have uncovered that when an insurance coverage sector is very concentrated, insurers decrease company payments and do not move financial savings alongside to the shopper.”

The outcomes of consolidation in 2021 also extended to prescription medicine. Consolidation among standalone Medicare Portion D prescription drug strategies was the root trigger of a 23% drop in offerings for 2022, according to findings printed final month by the Kaiser Spouse and children Basis.

The common Medicare beneficiary will have a choice of 23 stand-by yourself prescription drug strategies (PDPs) in 2022, seven less PDP possibilities than in 2021, the info confirmed. Although the amount of PDP possibilities in 2022 is significantly lessen than the peak in 2007 – when there were being fifty six such possibilities, on common – there are nonetheless a lot of standalone drug system possibilities, according to KFF.

The comparatively substantial minimize in the amount of PDPs for 2022 is mostly the outcome of consolidations of system offerings sponsored by Cigna and Centene, ensuing in the sector exit of 3 countrywide PDPs from each and every agency in each and every location: all 3 of Cigna’s Categorical Scripts PDPs and 3 of Centene’s 6 Wellcare PDPs. Portion D sponsors are minimal to providing no extra than 3 PDPs in each and every location. 

This accounts for just in excess of 200 PDPs made available in 2021 that will no lengthier be made available in 2022. Enrollees in these consolidated strategies will be automatically switched to other strategies made available by the identical system sponsor, whilst they can decide on to switch into a various system for the duration of the yearly open up enrollment interval.

The amount of corporations sponsoring stand-by yourself drug strategies has declined steadily in excess of time, from extra than 40 corporations in 2010 and earlier a long time, dropping under 25 corporations beginning in 2015, and at sixteen corporations in 2022. That’s lessen than in any other 12 months due to the fact Portion D begun. 

PDP enrollment is envisioned to be concentrated in a little amount of corporations in 2022, as it has been every 12 months. Based on August 2021 enrollment, eight out of ten enrollees in 2022 are projected to be in PDPs operated by just 4 corporations: CVS Wellness, Centene, UnitedHealth and Humana. All 4 corporations offer you PDPs in all 34 regions upcoming 12 months.

Despite these 12 months-to-12 months improvements in system coverage and charges, as very well as improvements in beneficiaries’ well being wants, a past KFF assessment uncovered that most Medicare beneficiaries did not review strategies for the duration of a latest open up enrollment interval, and most Portion D enrollees did not review the coverage made available by their drug system to other drug strategies.

The quantities are very similar throughout both Medicare Benefit and common Medicare, with sixty eight% of MA beneficiaries indicating they really don’t review health care strategies, and 73% of those people in common Medicare professing the identical.

Twitter: @JELagasse
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