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Are we approaching an MA profitability cliff?

For the better part of a decade now, the general industry view on Medicare Advantage has been one of overwhelming positivity. It’s been a steadily growing profit center for legacy plans and providers, and a relatively safe bet for newer market entrants and healthcare investors. The "why" behind this sentiment is relatively straightforward: enrollment growth in MA has only continued to accelerate—as of just this year, more seniors are enrolled in MA than in traditional Medicare—and its profitability (to plans, at least) is more than double that of any other business line.

But more recently, I’ve begun to hear rumblings of a different story on MA crop up with greater frequency. As MA has grown, it has also attracted more scrutiny and more competition, and some of the savviest healthcare strategists I know have begun to question whether we might be approaching an MA profitability cliff—whether driven by a policy-enabled crackdown on MA reimbursement and spending, or by the over-saturation of the market with new competitors, or a combination of both.

So when I saw last week’s news that Bright Health had sold off its last Medicare Advantage insurance asset, it certainly caught my eye. At first blush, the announcement seems to support the fears about the end of MA’s salad days. On the other hand, it feels like it runs directly counter to the other major MA insurance story of 2023: Humana’s announcement that it would be pulling out of the employer market in order to deepen its focus on its government-sponsored business (of which the vast majority is MA). So I decided this was as good a time as any to start digging a bit deeper: what is the outlook for MA, really, as of July 2023? Which of the above narratives, if either, is the correct one?

Three conclusions on the current—and future—state of Medicare Advantage

Conclusion #1: Investment in MA is likely to continue, but enablement is increasingly winning over displacement (in more ways than one).

A few months back, I wrote a piece arguing that value-based care/payment is increasingly enabling existing business models, rather than replacing them. I think we’re seeing a variation on that same theme in the Medicare Advantage space—it has proved exceptionally difficult to displace legacy players in the MA insurance market, particularly as MA has become a strategic cornerstone for health plan giants such as United and Humana. In fact, despite an uptick in the number of headline-grabbing start-up MA plans (aside from Bright Health, players like Devoted Health, Clover Health, Oscar Health, and Alignment come to mind), the large national insurers (particularly United) have only increased their foothold in the MA space across the past 10 years. 84% of the MA market is owned by just seven players—a significant increase from the 76% of the market those same seven players held a decade ago ( it's worth noting that one of the seven is the combination of all Blues, which of course is not truly a singular entity).

That the MA insurance market has proven difficult to disrupt is perhaps unsurprising in retrospect. The health insurance market in general is tricky to disrupt, as many health systems learned firsthand amid the wave of provider-sponsored health plans that were launched in the wake of the Affordable Care Act. And MA can be a particularly difficult insurance market to break into due to its unique dynamics: Star ratings, for example, tend to be an important driver of enrollment trends, and it takes new plans time to work toward the most desirable four- or five-star ratings. MA has higher administrative complexity than other business lines: preparing for the annual bidding process, ensuring benefit packages meet federal compliance standards, and navigating frequent audits by CMS. And enrollment must be won one hard-fought enrollee at a time, requiring significant investment in direct-to-consumer sales and marketing.

On the other hand, MA-focused businesses that work in concert with the existing structure of the insurance market—such as senior-focused primary care—have continued to flourish. And those centered around the enablement of value-based care models within MA have been particularly successful. In fact, this will be Bright Health’s focus moving forward—the company operates over 75 value-based primary care clinics through its NeueHealth arm.

Conclusion #2: Policymakers have already begun to gradually chip away at MA reimbursement and are likely to continue making incremental adjustments moving forward.

In particular, scrutiny on the MA risk adjustment process has been growing. In January of this year, CMS released a final rule reforming the MA Risk Adjustment Data Validation (RADV) program that CMS uses to recover improper risk adjustment payments made to MA plans. The final rule was less of a blow to MA plans than a prior version would have been, but still estimates significant future recoveries by CMS. This rule was followed by the 2024 MA rate announcement, which finalized a proposal to significantly revise the risk adjustment model. Those who are curious can dig into the technical details here, but the important thing to note is that CMS estimates the revisions will deliver $7.6 billion in net savings to the Medicare Trust Fund in 2024. It is important to call out that CMS appeared to respond to a substantial lobbying effort against the revisions by MA plans by phasing in the changes over the course of three years (the proposed rule would have had all changes take effect in year one). As a signal of what could be next for reforms to the risk adjustment model, President Biden’s 2024 budget includes a proposal to confirm diagnoses for risk adjustment with the medical record before CMS makes a risk adjusted payment to improve MA payment accuracy.

MA benchmarks are another way CMS could look to reign in MA plan payments. Currently, MA plans offer bids based on the historical fee-for-service Medicare spending in a service area. But research shows that enrollees who switch from traditional Medicare to MA have lower expenditures than those with similar risk profiles who opt to remain in the traditional Medicare program—leading some to argue that an MA payment structure based primarily around expected FFS expenditures may drive overpayments to MA plans. Note that most studies on this “favorable selection” focus on expenditures after enrollees switch to MA, which makes it difficult to control for insurers’ efforts to reduce unnecessary spending and steer enrollees to more cost-effective sites of care/treatments. Still, emerging evidence suggests that “switchers” have lower expenditures even prior to enrolling in MA, implying that there is at least an element of selection bias coming into play. As a result, there is increasing discussion about the need to reform the MA benchmarking system—and this conversation is only likely to gain momentum as traditional Medicare comes to represent a shrinking minority of seniors. In fact, around the same time the RADV rule was released, CMMI Director Liz Fowler emphasized that CMS needs to change the way it thinks about benchmarks as MA becomes a bigger part of the Medicare program.

Conclusion #3: The aging of the >65 population will present new challenges—and MA may have to confront those challenges sooner than the traditional Medicare program.

As important as the policy outlook is, I believe there’s an even bigger threat to MA profitability looming: impending demographic changes within the MA population. Now that the majority of Baby Boomers have aged into Medicare, the average age of the Medicare population, which has skewed younger in recent years due the Boomer influx, will start to steadily increase. Over time, this will result in an increase in the average number of comorbidities among Medicare enrollees. For providers, care will shift from more profitable procedural services that are common among younger Medicare enrollees to less profitable medical care common among older ones. Plans can expect increased complexity in patient management, meaning it may become more difficult to maintain current profit margins (more on that in a minute), especially if policymakers are simultaneously tightening the screws on reimbursement.

This trend will impact both the traditional Medicare program as well as Medicare Advantage. But MA may feel the impact of the shift more quickly. Although the average age of enrollees in MA and traditional Medicare are similar (71.5 for MA and 71.3 for traditional Medicare, as of 2019), traditional Medicare has a relatively higher share of enrollees who are under the age of 70, while MA has a relatively higher share of enrollees between the ages of 70 and 90.

If you’re wondering why this is the case, especially as MA has overtaken traditional Medicare as the preeminent form of coverage among seniors, it's because new Medicare beneficiaries tend to choose traditional Medicare in their first year of eligibility. MA penetration among the newly-eligible lags overall MA penetration by two-to-three percentage points. However, once people switch to MA, they tend not to switch back to traditional Medicare, at least in recent years: in 2020, nearly 7% of beneficiaries switched from traditional Medicare to MA, while only 2% switched from MA to traditional Medicare. Those switching from MA to traditional Medicare tend to have higher-intensity health care needs, perhaps explaining why traditional Medicare has a higher share of enrollees in the oldest age bracket of 90+.

In sum: We’re probably not approaching a sudden MA profitability cliff, but MA is likely to become incrementally less profitable over time, due in part to crackdowns on reimbursement (which will certainly impact plans and may trickle down to providers), but also due to impending demographic shifts (which will almost certainly impact provider margins, and may also impact plan margins).

What does this mean for industry stakeholders? The levers of profitability must change.

While we can debate the extent to which coding and documentation has been the primary profit lever for MA plans and providers, there’s no denying that it has been a core strategy for many players in the MA space. Moving forward, reliance on coding and documentation as a profit lever will necessarily diminish due to ongoing reforms to the RADV model.

On the other hand, patient segmentation, high-risk patient management, proactive intervention with the “rising risk”, and steerage to lower-cost interventions/sites of care among patients of all risk profiles will become more important as the population grows in complexity and as policymakers continue not only to reform the risk adjustment model, but also to make changes to the overall MA reimbursement structure (e.g. the benchmarking methodology). In other words, the core tenets of value-based care are likely to become must-have competencies—those who already have them (or who are actively working to develop them today) will be best positioned to maintain profitability in the face of the shifting demographic/reimbursement landscape.

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