Study Says Big Health Plans Will Continue Growth
A new analysis from Morningstar has a fairly optimistic view of big health plan growth over the next decade but notes some headwinds. It says big plans will continue to grow market share.
The study says Aetna, Centene, Cigna, Elevance Health, Humana and UnitedHealthcare will insure 56% of Americans by 2034. They had 41% in 2014 and 52% in 2024, so growth will be far more measured. United and Elevance will continue to lead the way.
The study notes these plans have some critical competitive advantages and that there is continued outsourcing of government program lives. Headwinds noted, though, are elevated utilization impacting profits, increased uninsured rates due to the budget reconciliation healthcare cuts, and new regulatory scrutiny. The last headwind includes prior authorization reforms, claims scrutiny, and risk adjustment reform. A possible headwind may be a move to have vertically integrated firms with health plans shed pharmacy benefits managers (PBMs). While reform of PBMs is likely, such disposition is less likely.
I am perhaps a little more pessimistic about big plan prospects. I think regulatory pressure could be far worse than expected and big plans may battle big time with provider entities and regional plans in the future. But yes, the big guys have a lot of advantages.
#healthplans #margins
Will Democrats Join A CR To Keep Government Open?
Democrats in the House and Senate seem ready to vote against a continuing resolution (CR) and risk a government shutdown, especially if their demands are not taken into consideration. That includes on healthcare. The GOP could go it alone in the House if leaders keep a fractious caucus together. But in the Senate, Democratic votes would be needed for a CR. The GOP is considering a four-month funding to the end of January so as to work on a wider package.
Democrats notably want to extend expiring Exchange premium subsidy enhancements. They also want rollbacks of cuts in the recent budget bill. Rollbacks won’t happen. Some vulnerable moderate Republicans want a premium extension, but most conservatives loathe the idea. The House Speaker and Senate Majority Leader do not seem keen.
#budget #ffy2026 #congress #healthcare
https://www.medpagetoday.com/washington-watch/washington-watch/117453
PA Reform Passes CA Legislature
Two prior authorization reform bills passed the California legislature and are headed to Gov. Gavin Newsom’s desk.
One bill would require payers to answer electronic prior authorization requests within three business days for standard requests and within 24 hours for urgent care. As well, it would require payers to answer non-electronic requests within five business days for standard reviews and within 48 hours for urgent requests.
The second bill would allow the California Department of Managed Health Care to waive prior authorizations for services or prescriptions that payers approve at least 90% of the time. It also would require payers to report prior authorization data.
#ca #priorauthorization #healthplans
Blumenthal Wants Rescission Of Downcoding
Sen. Richard Blumenthal wants Cigna to rescind its new policy that could downcode many claim submissions. He said it will create “onerous administrative burdens for physicians, needlessly raises costs for healthcare providers and jeopardizes patient care.”
Cigna’s new Evaluation and Management Coding Accuracy policy will review CPT evaluation and management codes 99204-99205, 99214-99215, and 99244-99245 for billing and coding accuracy. Some services may be adjusted by one level when guidelines are not met.
#claimsdenials #healthplans
— Marc S. Ryan
