Latest / Becker’s Healthcare Podcast / Jakob Emerson on Medicare Advantage Changes, GLP-1 Access and Shifts in the Payer Landscape

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Jakob Emerson on Medicare Advantage Changes, GLP-1 Access and Shifts in the Payer Landscape · Becker’s Healthcare Podcast

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  This is Scott Becker with the Beckers HealthCare
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  podcast.
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  We're thrilled today to be joined by brilliant
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  writer,
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  journalist, editor,
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  Jacob Emerson.
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  Jacob helps us weekly untangle and and let
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  us know
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  what's going on in the payer space in
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  in the country.
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  Jacob, give us a sense what are the
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  big issues that you're following currently.
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  Yeah. Hey, Scott. It's good to talk with
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  you.
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  So I thought the story we should talk
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  about today or one of is,
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  CMS publishing its 2027
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  Medicare Advantage and Part d proposed rule last
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  week. It's the December
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  now.
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  Basically, you know, putting into place all the
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  federal regulations that will oversee,
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  Medicare Advantage Plans in in 2027.
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  And then that'll also determine how much money
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  they get from the federal government, in terms
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  of quality bonus payments, which can really it
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  can be really high in the in the,
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  in the millions of dollars,
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  in toward the end of the decade. So
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  so basically, the federal government has put out
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  some new rules,
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  or a proposed rule around Medicare Advantage. And
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  there's some really interesting tidbits,
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  I thought we could talk about in term
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  it's a 400 page over 400 page document.
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  And there's there were some things in there
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  that,
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  really hearken back to a lot of the
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  reporting we've done over the last few years
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  here at Becker's.
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  And and it seems like CMS is now
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  responding to some of these issues that we've
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  been picking up on.
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  Fantastic. Tell us about a couple of the
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  highlights that you see in there and and
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  what impact those have.
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  Yeah. And and I do wanna say, you
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  know, I'm not correlating these two things at
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  all. I'm not saying that CMS is putting
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  out this policy
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  based off of our reporting. But it's interesting
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  that,
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  you know, we've been reporting now for a
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  few years about all the different health systems
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  across the country that have told us explicitly
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  in in one on one interviews that they
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  they get fed up with certain Medicare Advantage
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  Plans, certain carriers.
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  It's the prior authorization denial rates. It's the
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  administrative issues,
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  the the slow reimbursements from these plans that
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  they say they're experiencing.
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  And then we've seen this trend where these
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  health systems across the country, some of the
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  largest ones,
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  will either drop single carriers or on the
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  smaller end, we've seen some systems even drop
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  the entirety of the program, just not accepting
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  Medicare Advantage at all
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  anymore.
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  Though it's it's usually the former of just
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  dropping sing singular,
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  plans that aren't working well with them. So
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  that's been going on for a few years.
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  And,
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  as as it stands right now, basically,
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  if if that happens, then the MA plan
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  can go to CMS and say, hey, we've
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  had a provider network disruption. CMS can evaluate
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  that. And then if they determine that there
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  has been a network disruption for that Medicare
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  Advantage member that is now out of network
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  with the hospital system, CMS then can then
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  create a special enrollment period to,
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  let that that let that senior pick another
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  Medicare Advantage plan that is in network with
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  them. So it's a whole convoluted process and
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  administrative process basically to get back in in
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  network with your local system if you're if
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  you're in main plan goes out of network.
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  That's that's how things currently stand. And now
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  in this new 2027 rule, CMS is proposing,
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  that for those who have providers that leave
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  their plans network midyear,
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  that then there can just be a a
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  modified special enrollment period,
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  so that, those members can can find covered
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  care within their area. So, basically, CMS wants
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  to remove all these roadblocks,
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  that currently exist when when this situation happens,
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  and make it much easier for these seniors
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  that are now, you know, surprised out of
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  network with their local hospital system. They can
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  just now go and select a new plan,
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  if if this rule, is is approved in
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  in the new year.
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  Fantastic. So we're watching that, the ability to
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  select a different plan,
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  which is fascinating because Yeah. Yeah. You've got
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  both health systems
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  increasingly
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  disliking the Medicare Advantage plans in in the
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  prior auths and the rules and the challenges
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  versus seeing Medicare patients directly.
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  And then you've got Medicare patients all over
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  the board in terms of their satisfaction with
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  Medicare Advantage.
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  Some very positive, some negative, a a real
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  mix, but fascinating to see these kinds of
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  changes.
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  Yeah. What else are you watching closely there?
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  Yeah. And and like you said, it's just
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  interesting. The the the federal government is responding
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  directly to this to this issue that we've
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  been seeing play out for a few years
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  now.
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  But another interesting thing that I saw in
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  this proposed rule where they're they're,
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  requesting feedback
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  from people across the industry,
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  on, you know, issues that are affecting the
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  entire industry. And they basically CMS wants feedback
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  on,
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  on their current risk adjustment system, their the
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  coding practices some payers employ around Medicare Advantage
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  that have made a lot of headlines, in
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  the most recent decade,
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  around, you know, fraud and upcoding and things
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  like that. But CMS is basically now writing
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  that they recognize that the current risk adjustment
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  system might disadvantage smaller, newer,
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  less well resourced Medicare Advantage Plans, and that
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  their their current rules may encourage
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  MA plans to prioritize investment in coding activities
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  that could lead them, coding more intensely than
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  original Medicare. So, basically, CMS
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  is saying that we understand that regional smaller
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  nonprofit Medicare Advantage Plans are struggling compared to
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  the big guys right now. United, Humana, CVS,
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  Aetna,
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  and we also recognize that they're because of
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  the how the current rules and system and
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  coding exists that there is an incentive to
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  code higher in Medicare Advantage, than there is
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  in original Medicare. So CMS basically wants feedback
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  about that. And I just think that that's
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  interesting that the government is is recognizing
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  that the biggest players in the industry need
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  more oversight, but that some of the smaller
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  players within Medicare Advantage need more help, to
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  stay competitive against these these giants.
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  No. Fascinating. And and the smart plans really
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  are in
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  really struggling on it. It seems like on
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  a variety of different ways, specifically as reimbursement
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  doesn't jump and health systems begin to hate
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  the plans, the whole the whole combination becomes
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  more and more challenging, I take it. Yeah.
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  Yeah. Definitely. So, you know, we'll see what
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  happens with that. CMS is always asking for
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  for,
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  you know, public feedback when it puts out
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  these proposed rules, and it doesn't necessarily always
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  put into place new policy based off of,
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  you know, the the the feedback that it
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  was wanting on a certain topic. So it
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  it, you know, it's up in the air
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  at this point, but it's just interesting that
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  the government is acknowledging that that is a
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  very real issue.
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  And then the last thing I wanted to
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  just note for you, Scott, in terms of
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  some new data that we got in from
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  a group that looks into how GLP one
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  medications are being covered across the country. You
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  know, it's a big another massive issue within
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  the industry. It's driving up health care costs
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  for everybody, because plans are having to cover
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  the premiums for these very, very expensive medications.
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  And specifically when it comes to the marketplace
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  plans, so the Affordable Care Act, Obamacare, whatever
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  you call it, that access to GLP ones
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  for weight loss specifically, so not for diabetes
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  treatment,
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  that access is shrinking all over the country.
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  And that it really is becoming almost a
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  lottery of
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  if you're lucky enough to live in a
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  place, in a state that,
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  has health plans that are offering GLP one
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  coverage for obesity,
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  then then you're one of the few in
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  the country that can. It's a small percentage
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  at this point.
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  But it really that it's a lottery that
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  it's it comes down to it seems almost
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  like luck, that you live in a state
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  that might offer this kind of thing. And
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  and there's only two states, California and North
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  Dakota, where all health plans on the on
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  their marketplaces are offering coverage for GLP ones
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  for obesity.
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  And the list is only a little bit
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  bigger,
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  for for plans that are available on those
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  state marketplaces.
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  So the the bigger point here is basically
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  that GLP one access, if you're on an
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  Obamacare or ACA plan,
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  going into next year, it's declining. And and
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  this does seem to be a general theme
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  we see around the country. And and, you
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  know, you could argue that access is getting
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  easier with some of the direct to consumer
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  things we're seeing with with the manufacturers, the
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  drug manufacturers. But, overall, if you want your
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  health plan to cover GLP ones for obesity
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  next year and you're shopping on an ACA
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  marketplace, it's it's probably,
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  low chances that you'll be able to have
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  that happen.
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  Literally, fascinating. And and what's happened in this
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  GLP market and this is so crazy to
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  me
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  that you you could now buy them through
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  the
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  compounded pharmacies and so forth at prices that
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  are not that different
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  than European prices and other place prices, literally,
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  you know, and and but if you get
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  it through your insurance company,
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  I mean, it's insane to me. It's still
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  a thousand dollars a month or so. I
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  mean, it seems to me just insane
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  that bifurcated market and
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  and and and and I don't know.
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  Obviously, there's there's movement here because there's more
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  price competition.
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  Well, the GOP ones are still trying to
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  get paid well by the medical establishment, but
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  really seems insane to me.
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  It it it's like going to college. Nobody
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  pays the same price anymore. It's GLP one
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  seem to be the same thing. It seems
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  to be just insane how that's evolved. You
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  know? I think what what you're basically pointing
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  to, Scott, it's it's really you know, this
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  is not a new issue, but I think
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  what it's really the GLP one thing over
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  the last few years has really
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  exposed the issue of the fact that sometimes
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  when you use your health insurance to cover
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  a prescription medication, that it actually makes it
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  more expensive than if you went for, than
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  if you just paid out of pocket or
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  if you went to the manufacturer directly, which
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  you now can with some of these GLP
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  ones,
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  or or like you said, you do the
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  compounding. You know, and it's a bit outside
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  of my wheelhouse of understanding of how all
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  the, you know, the contracts and the PBMs
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  and all that works together. It's a very
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  complicated issue,
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  but, you know, it it does still stand
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  that people, I think, are are seeing that
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  a lot of the times when you use
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  for some of these, especially specialty medications, it's
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  often yeah. It's more expensive when you get
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  your health plan involved.
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  And now there's a lot more issues in
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  terms of just the consumerism
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  of it all to access these medications.
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  And I think that's really, you know, playing
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  a part in how insurers and and their
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  PBM subsidiaries kind of navigate business strategies moving
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  forward as well. At least that's something that
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  we're definitely seeing. No. A 100%. It it
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  is literally fascinating to watch how this is
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  evolving.
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  Just so interesting. I I can't even tell
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  you. So CMS regulations,
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  Medicare Advantage Plans, all over the board in
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  terms of what's going on in those.
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  GOP one pricing, whether a health plan or
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  buying it directly through a compounder,
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  a crazily
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  evolving market, just insane literally.
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  Anything else that's top of mind that you
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  wanted to share with us today?
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  No. I think that that covers it, Scott.
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  I mean, we're really just, trying to stay
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  on top of these last few minute issues,
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  especially when ACA subsidies going into next year.
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  Will they, won't they? It's looking like won't
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  they,
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  as of now in terms of where the
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  president and and Republicans stand. So that's really
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  the main issue we're gonna be tracking pretty
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  much day by day at this point through
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  the end of the year of what happens
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  to these subsidies,
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  because the hospital and the insurance executives that
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  we're talking to daily are, are worried in
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  terms of what it means for their businesses
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  if these subs don't continue. So that's gonna
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  be top of mind for us.
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  A 100%.
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  Jacob Emerson, the best in the business. Thank
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  you so much for joining us today on
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  the Bector's Health Care podcast. Thank you very,
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  very much. Thank you, Scott.