Speaker 0: This is where health insurance leadership comes together. Becker's fourth annual spring payer issues roundtable brings together over 400 payer and health plan executives and more than 100 speakers to Chicago April. This year's event includes keynote conversations with the industry's top leaders and former president George w Bush. For the full agenda and event details, visit beckershospitalreview.com and click on the events tab in the upper right. We're looking forward to hosting you here in Chicago.

Speaker 1: This is Scott Becker with the Beckers Health Care Podcast. Thrilled to say to be visiting with brilliant journalist Jacob Emerson. Jacob follows the payer area and what's going on in the payer world. Jacob, tell us what's going on currently. What are the big stories you're watching in the payer universe currently?

Speaker 0: Yeah. Hey, Scott. Good to talk with you. So last night, we had the state of the union with president Donald Trump, the first one of his second administration. And health care was a topic during the speech.

Longest speech in in history in terms of state of the unions, hundred and seven minutes, and health care got about four minutes of that. So, you know, I think that kind of speaks for itself in terms of where the policy focuses for for the administration in terms of health care right now. And I can I can dig into that a bit in terms of, some of the lack of details we have around specific things like ACA subsidies moving forward? We we would love you too.

Speaker 1: We we would love you too. Tell tell us what's going on there. I know that, like, I was on the on the podcast yesterday with leader of Banner Health, leader of of HonestHealth, and basically saying in terms of value based care, they're gonna have several 100,000 people in the city of Arizona coming off of health insurance. So we've gotta make sure they get to cure those people as well as possible. Yeah.

And and as efficiently as possible because there'll be there'll be not only no margin, probably no reimbursement for a lot of those people as they gotta and and it it plays right into this discussion, but it's a brilliant discussion about value based care and how important it is. We're particularly in the areas we gotta take care of people who don't pay, and you have to make sure they're still taken care of really well but efficiently. But yeah. So tell us what what you heard coming out of the State of the Union. Yeah.

Speaker 0: And and it's interesting you talk about what Banner told you, Scott, because we heard, I believe it was last week from Tenet Healthcare executives projecting a 20% drop in exchange enrollment nationally. And last year, there's about 24,000,000 people, a little more than that, enrolled in in the exchange plans. So a 20% drop. That's, you know, that's a huge, patient population coverage shift for or a payer mix shift. For for health systems all over the country, a volume shift, more people going to the ED for for basic care.

So huge on that front alone. But in terms of the president's speech, he he definitely used the address to criticize the ACA. Nothing new for the president, but calling it the unaffordable care act and basically reiterating some of the, I don't know if I wanna say their policy proposals, but some of the ideas that he and and some Republicans have been, pushing forward last year, a little bit early this year as some of the talks over the enhanced subsidies continued, which is basically, you know, going against the insurers completely, really just talking trash about the insurance companies and proposing having funds, instead of subsidies, having funds go straight to Americans. A lot of Republicans supporting the idea of that being through HSAs, which as we know, you know, it's not really a replacement for a health insurance plan, funding an HSA just because, HSA funds can't be used to, pay insurance premiums. And, you know, funding HSA of, let's say, like, $2,000, that doesn't really get you anywhere in terms of premiums that can cost you 20 plus thousand dollars annually every year.

So that's kind of where things are at with that. But I think overall, it's we're operating in a space now where the the marketplace now that these these talks around the subsidies have completely fallen apart, there is no where to go really with them at this point, it seems like. The marketplace is operating without any clear federal policy direction for the first time in a long time. So no no real plan right now from either side. Ideas, like I just mentioned, but no votes, no details, no implementation path.

So, you know, for for the for the hospital systems, let's say that it's it's a scary time because you've got, like, according to tenant, 20% less exchange enrollees and, you know, a lot of change to your payer mix. And then on the insurer side, a lot less members, and overall, just a a directionless marketplace as things currently stand.

Speaker 1: Right. And you and you do see some of the big insurers peering down their Medicare Advantage marketing and populations in in in areas that they're serving. Is that is that is that right?

Speaker 0: It is it is correct. And a lot of it was very deliberate. Basically, they got too big, and we're really talking about the national carriers. And and I put an asterisk there because there were some exceptions that we saw in some of the most recent enrollment data during the annual enrollment period that just wrapped up last fall. But, yes, United, Aetna, CVS, Elevants, and then some of the big Blue Cross conglomerates besides Elevants, all seen really big reductions in in disenroll NA disenrollments.

And, again, a lot of that was very deliberate. But I thought what was really interesting is, Humana actually enrolled over a million people just this past fall. So Humana kind of bucking the trend of of the national publicly traded insurers. And then what we really saw, in the enrollment data was the the start up, the smaller insurers, the nonprofits, some of the Blue Cross plans, plans that, you know, have a very special focus. They they focus in one region or they focus on a specific population for Medicare.

They they boomed. We saw plans double their enrollment, in in in already having in the hundreds of thousands of members. So, so we're actually speaking with insurance about that this week, but it it was a definitely noticeable trend that the small guys, some of the hospital and insurers did fantastic. And then deliberately, a lot of the big publicly traded guys, lost a a lot of members for United up to, a million just, because of the the rising utilization costs and trying to shed some of those unprofitable, plans.

Speaker 1: Right. I mean, they truly tried to move out of those markets because they're they're not making money in those markets, and and they'd rather not do it. It. Where does that leave us in terms of Medicare Advantage? Is it still last year, I think it ended up up 54% of Medicare.

Where where is that currently at? Do we have a sense of that or not not exactly?

Speaker 0: As as it stands now, it's at, over 55%. It it slowed. The, the enrollment rate itself actually slowed during this past annual enrollment. We're we're in open enrollment. So people, you know, there's still people enrolling, but for new enrollees, that was happening this past fall, and the rate did slow.

I I think, though, Scott, one one story I did wanna mention that contextually is a part of all of this, and it's just it it it's massive. It's, it's the largest Medicare Advantage fraud settlement to date, with Kaiser Permanente. And that happened in January between them and the DOJ. $556,000,000, settlement to resolve allegations from the government that basically the health system, gained the the MA payment system by doing the upcoding that we've heard about in the headlines for over a decade now, but basically inflating patient diagnosis codes to get higher, higher payments from the government. And this is all alleged, but it's a it's a big scheme, a lot of details that the DOJ alleged in in their release about this.

And, again, it's a record fraud settlement, which I just think is interesting even just from the fact that Kaiser often has some of the highest quality rated Medicare Advantage Plans in the country. In some of their markets, they get five out of five stars in some of their markets with CMS. So CMS's highest quality Medicare Advantage Plans arguably now having the largest Medicare Advantage fraud settlement. So, you know, I I I would let the the listeners, you know, come to their own conclusions about that, but I just think it's a very interesting contrast, in terms of recent developments.

Speaker 1: No. It's it's, you're fascinated. You've got some actually moving in the right direction, some moving in the wrong direction. Even though the growth is slow to Medicare Advantage, it's still up to 55% as opposed to retrenching. That's fascinating too, isn't it?

Speaker 0: Yeah. Definitely. And where we saw most of the growth, majority of the growth, was not in traditional Medicare Advantage with healthy seniors. It was in, dual special needs plan special special Medicare Advantage Plans that take care of very sick chronic chronically sick, populations or people who are dually eligible for Medicaid and Medicare. So really, really low income seniors.

That is where that is the fastest growing portion of Medicare Advantage now across the country for the entire program, and that's what drove most of the growth this last fall as well. So not normal MA anymore.

Speaker 1: And who are the payers that specialize in that market? Are there peers that really specialize there?

Speaker 0: Honestly, they they all they all, they all, have have, business lines in this market because it's growing so fast. They and it's really Scott, it's grown. I'd say in the last two, three, four years is where we've really started to see, resources invested in this this space and and then the the corresponding enrollment. A lot a lot of the reasons because you get higher reimbursements for taking care of, sicker populations, especially when they're dually eligible for Medicaid.

Speaker 1: Right. And that was that was the next one I was gonna ask you. Is is there higher reimbursement because they're more more sick, and those payers are still making money off it so that part of the market grows. I mean, it's fascinating how it works, how things really do follow the money. And I don't mean in a bad way or good way, just an observational way.

Speaker 0: Yeah. Definitely. But I think some would argue that now these individuals, pretty vulnerable populations, are now getting health benefits that are a lot more comprehensive than just traditional Medicaid, traditional Medicare, which, you know, doesn't really cover much, on the Medicare side, much of anything beyond just, you know, the hospital stays and and stuff like that. You know? Now they're getting at least dental benefits, hearing benefits, things like that.

So some could argue, you know, the growth here is a good thing because it's it's getting better benefits for some of these more vulnerable populations.

Speaker 1: A 100%. I mean, those are the people that need it the most. And if you could manage it efficiently, get them some extra benefits, god bless. What what a fascinating thing to watch. I mean, well, you sort of have a little bit of a government policy that's all over the board, not very clear.

You do have Medicare advantage. Man, it's growing in certain segments even though the big traditional MA is slowing down some and some of the big payers have moved out of it. It's a lot to digest there, isn't it?

Speaker 0: It is. And and, like, connected to, you know, some of the tensions we've seen with the health systems and and MA, they use that as kind of a marketing piece to tell people, well, if you come into our MA plan that we own, you're not gonna go out of network like you would with some of the big guys who are always in danger of that. So it kind of all works together what we saw, but but like I said, the smaller guys, the hospital owned insurers with MA, they they did really well this past year, and that's what they told us they were they were hoping to do.

Speaker 1: Absolutely fascinating. Jacob, anything else you want to share today?

Speaker 0: No. I don't I don't think so. I mean, the president's speech also touched a little bit on Trump RX. We've covered that pretty, extensively on the websites, with Becker's. And then, you know, I think just overall, insurers don't have a lot of friends in Washington

Speaker 1: right now. Yeah. Tell us. And that's unusual because for thirty, forty years, they've had an insane amount of friends in Washington partly because of so much lobbying in Washington and a general bent to turn over a lot of government health care to have it managed for the payers. And that seems like it's not going as well as people expected.

Certainly, it's become very expensive. Lots of concerns about denials and pre auths, all the things that you needed the payers to do to try and manage cost, but aren't that the population actually just hates. And so what a fascinating what a fascinating situation where that's gone sort of, you you know, for so long, AHIP was so strong, you know, in in in a in a great job advocating for their members, the big payers. They were so strong in Washington, both sides of the island. Now you see a little bit of there's just a populist pushback against it.

It's fascinating to watch.

Speaker 0: Yeah. And I I think it's also it's just a perfect storm right now, Scott, in terms of the the economics of all this with the Medicaid cuts coming down the line, the fact that employers are facing just huge costs right now, with self insured plans because of just rising costs overall with with health care, but also the GLP one factor that's rising, care costs with everybody. ACA falling apart, Medicare Advantage costs going up, all the tensions with providers and going out of the network. So I think everybody is affected by all these insurance issues now, whereas maybe in the past, it was just certain segments, certain populations. And then during these hearings with the insurance CEOs last month, you had congressmen complaining to the CEOs talking about, I couldn't get this prescription of mine covered by by my health plan through you.

I couldn't get this prior authorization approved. The congressmen are are are complaining about health insurance at this point in term and and care delays. It's affecting everyone. It's it's impossible to ignore anymore, and I think that's why we're seeing there there's very little friends.

Speaker 1: But I think that's fascinating because at the end of the day, there's two different things here that that I that you mentioned right there. One is we always thought congress was somewhat immune to this because the rest of us see this as consumers, the challenge getting the access we need. But even those with better access that know everybody, there's just a shortage of physicians and caregivers. So as much as you know you know the CEO of this, you know the CEO of this, it's still hard to get the right on college when you're the right on college, just the right whoever, when you need the right whoever. It's just just it's just getting more challenging.

I mean, the flip side is you could point the fingers at the insurers, but this is completely a problem that DC created by turning over so much of the federal government spend and Medicaid spend through the payers. And it's it it it it's arguably cost a lot of hyperinflation in health care, and no one at least none of them are focused on the real issue. The congressman yelling at at AHIP members. Well, AHIP members have funded the congressman, and they've had this mutual sort of love for each other is literally the height of political theater in some ways. And instead of complaining about the insurance companies, it's trying to solve problems.

Like, how do we end up with more specialists, more doctors, more primary care? How do we end up actually fill solving the problem versus just political theater, which is yelling at the payers? You you you say it right. The payers know a lot of friends in Washington, but but even the Washingtonians don't seem to be really focused on solving the problem. They're just they're just they're just grandstanding from what I could tell, and and it is what it is.

Speaker 0: Yeah. I think I mean, I think you talk to any of our our audience, the people we interview. It's a mess, and nobody really seems to know how to solve the problem. Nobody knows what to tackle first. Yeah.

Because it's just this giant messy web. So yeah. Yeah.

Speaker 1: It is what it is, but we but we we, we need more doctors and nurses particularly and more specialists and everything. I mean, you look at the benches for oncology. The benches for some of these specialties, these are really important. Once you get past the the the front lines, there's just a real shortage and lots of specialties, and it's gonna get a lot worse for the next ten years. Yeah.

So no. I I agree with you. People don't know where to start, but we could tell them where we think they should start. But, it is what it is. Jacob, as always, fantastic to visit with you.

I always learn something. It's my favorite podcast of the week, Greg, to visit with you and learn something. Thank you for joining us on the Becker's Healthcare Podcast.

Speaker 0: I appreciate that. It's good to talk with you, Scott.