4Sight Health’s David Johnson

Payors

Spotlight on Medicare Advantage, Q2 Results

Medicare Advantage stole the spotlight last week with a steady barrage of new reports, investigations, and Q2 payor results.  

KFF kicked things off with its MA Enrollment and Key Trends Update, which showed that 54% of eligible Medicare beneficiaries – 32.8M people – are now enrolled in private MA plans.

• That’s quite the jump from just 19% in 2007, and the CBO projects that percentage to continue climbing to 64% by 2034.

• The report also underscored the high concentration of MA enrollment among a small number of firms, with UnitedHealthcare (29%) and Humana (18%) accounting for an eye-popping 47% of nationwide enrollees. 

Things only heated up from there, with the Wall Street Journal publishing a home visit hit piece on the “one hour nurse visits that let payors collect $15 billion from Medicare.”

• The investigation found that major Medicare Advantage players frequently push nurses to make diagnoses during home health assessments, which often involves inaccurate diagnostic tests or deliberate misinterpretation of questionnaires.

• Right on cue, STAT scorched UnitedHealth with its own report on several of the same issues, particularly problems related to the QuantaFlo device used to identify peripheral artery disease during home visits.

CVS and Humana added to the action with their Q2 investor calls, which both highlighted headwinds for their Medicare Advantage operations.

• CVS lowered its full-year forecast after its MA business saw elevated utilization across inpatient, benefits, and pharmacy, with CEO Karen Lynch stepping back into her old role at the helm of Aetna to oversee $2B in cost-cutting.

• Humana also revealed that it will likely lose a “few hundred thousand” MA members next year after shrinking its benefits and exiting markets in an effort to improve margins, marking the first time the payor has predicted membership losses from culling its plans.

The Takeaway

There’s nothing like a few hit pieces and payors trimming their forecasts to lure out the Medicare Advantage doomsayers, but the MA program isn’t going anywhere, even if it isn’t quite the margin machine that it once was.

The State of Payor Enrollment and Credentialing

We’re on the brink of a new era in healthcare. From AI-enabled chatbots to GenAI, Medallion’s latest report sheds light on how healthcare organizations are prioritizing automation, actively shaping their future with it, and hoping it can live up to its promise. Get the full report here.

BrainX Live Event: Implementing Ambient AI

Curious about the tangible benefits Ambient AI brings to health systems? Join the next BrainX Community live event on August 21 to hear Nabla CMO Dr. Ed Lee and Cleveland Clinic’s Dr. Paul Bryson share their experiences with the hottest tech in healthcare.

Curate, Create, & Share at the Point of Care

It’s hard to find a more unique vantage point on AI than Playback Health co-founder Dr. Langer, whose role as the Chair of Neurosurgery at Lenox Hill allows him to actually use the platform he helped create. Head over to Dr. Langer’s latest blog to see how Playback is helping him spend more time caring for patients and enabling providers to “Curate, Create, & Share” at the point of care.

The Wire

• Walgreens Explores VillageMD Exit: Walgreens appears to be calling it quits on VillageMD, or at least exploring its options. A recent securities filing revealed that the beleaguered pharmacy chain is weighing “strategic alternatives” in light of VillageMD’s substantial capital requirements, including divesting its entire remaining stake in the primary care provider. Things are escalating quickly from the plans Walgreens shared during its brutal Q3 investor call in June, when it only expected to trim its ownership in VillageMD and close underperforming stores to contend with a $13B year-to-date operating loss.

• New Breakthrough Device Coverage: Patients could see faster access to novel medical devices after CMS finalized its long-awaited Transitional Coverage for Emerging Technologies pathway. TCET covers devices that are “highly relevant” to the Medicare population on a case-by-case basis after they receive breakthrough designation, but while additional safety research is still being conducted. One potentially significant downside is that TCET requires vendors to go through cumbersome determination processes rather than automatically providing coverage, which may limit the pathway’s popularity.

• Detecting AI Hallucinations: UMass Amherst and clinical AI startup Mendel are teaming up to develop a system for detecting “hallucinations” in AI-generated medical notes. A small pilot study compared 100 medical summaries generated by leading open-source (Llama-3) and closed-source (GPT-4o) large language models to categorize their hallucination errors into distinct buckets. GPT-4o generated longer summaries and had more hallucinations tied to incorrect reasoning, while Llama-3 notes contained fewer hallucinations but were generally lower-quality.

• Geisinger Gears Up for VBC: Kaiser’s Risant Health is rolling out its new value-based care platform at Geisinger before the end of the year, with the goal of addressing more care needs upstream before they become serious issues. The three core components include (1) delivering evidence-based treatment by integrating clinical guidelines directly into care team workflows, (2) optimizing access by directing patients to appropriate resources through digital solutions, (3) simplifying the provider experience using tools designed to reduce administrative burden.

• RPM + CCM = Improved Outcomes: New research on 42k patients using HealthSnap’s remote patient monitoring portals demonstrated the positive cardiometabolic impact of integrated RPM and chronic care management. Hypertensive patients enrolled in the program for over 90 days saw an average SBP reduction of 23.8 mmHg and DBP reduction of 14.5 mmHg, while type 2 diabetics with severe hyperglycemia (≥180 mg/dL) achieved an impressive 56.8 mg/dL improvement (vs. ~40-60 mg/dL for common non-insulin medications like Metformin and GLP-1s).

• Medicaid Redeterminations Rage On: The percentage of Americans without health coverage jumped to 8.2% in Q1, reversing much of the progress made in recent years as states continue culling their Medicaid rolls. The uninsured rate hit a historic low of 7.2% last spring as pandemic policies made it easier for people to access coverage, although new CDC data showed that an additional 1.6M beneficiaries lost coverage during the first quarter. The total number of Americans without health coverage now stands at 27.1M.

• FDA Clears Big Health’s SleepioRx: Big Health clinched FDA clearance of its SleepioRx digital therapeutic for insomnia. SleepioRx can now be prescribed as a supplement to usual care for chronic insomnia and other sleep disorders, delivering self-directed cognitive behavioral therapy as a 90 day treatment. Big Health presumably has the protocol pretty polished considering the existing Sleepio solution that the digital therapeutic is based on originally launched over a decade ago.

• Community Center Struggles: Right on the heels of HHS reporting record volume at community health centers, the Commonwealth Fund released survey data showing that 70% of these centers are battling shortages of PCPs, nurses, or mental health professionals (up from 54% in 2018). The responses underscore a growing need for new technologies to help “do more with less” and for federal grants to bridge the remaining gap. Other pain points included difficulty supplying specialty care appointments (73%) and a lack of patient access to broadband or necessary devices (94%).

• Amazon Health Predicts $1B Loss: Amazon is projecting that its healthcare businesses, which include One Medical and Amazon Pharmacy, will lose just over $1B throughout 2024. Business Insider got the scoop on the forecast after an Amazon employee leaked an internal planning document. While a 10-figure loss definitely isn’t what you’re going for, it’s actually a slight improvement over the $1.28B lost last year.

• AI Appears Safe: The number of FDA AI approvals is growing, but how safe are the AI solutions hitting the market? An analysis from medical attorney Brad Thompson examined medical device reports (MDRs) submitted to the FDA (typically filed when something goes wrong) and suggested that current AI applications are generally pretty safe. Thompson compared MDRs filed for AI/ML-enabled devices with those for all other medical devices, finding that “AI devices are currently producing fewer MDRs than the medical device universe in general.”

High-Quality Care at Patient Fingertips

K Health is making high-quality medical care a reality for patients everywhere by turning their smartphones into the first stop along their care journey. Discover how K Health’s clinical-grade AI is reducing time-to-treatment and improving the patient experience while allowing more providers to practice at the top of their license.

Clear Arch Health Reduces Readmissions at Altru

When Altru Health System set out to reduce hospital readmissions, it turned to Clear Arch Health to find the solution. Learn how Clear Arch Health’s complete RPM platform and clinical monitoring system helped Altru lower readmissions while improving post-acute care quality.

RPM Designed to Streamline Your Workflow

Discover Withings’ suite of connected devices and user friendly platform where you can benefit from dedicated tech support, ensuring continuous monitoring and minimizing any disruptions in patient care.

The Industry Wire

1. Private equity investors see turnaround for healthcare services.
2. Included Health taps Optum exec Mark Flakne as new CFO.
3. McLaren Health Care confirms cyberattack after IT disruptions.
4. Prospect Medical offloads Crozer Health to real estate firm.
5. FL-based BayCare Health System locks in expansion capital.
6. FDA seeks health equity feedback for medical devices.
7. Fierce layoff tracker: Texas Children’s and Novant Health.
8. OSF HealthCare mandates GenAI training to ready workforce.
9. Gauging the state of women’s healthcare access in the U.S.
10. Providers offer 4 reimbursement reforms to support practices.