Trends in Common Ownership among Insurers in Medicare Part D.

BACKGROUND: Recent studies document the rising prevalence of common ownership by institutional investors in specific industries. Those investors offer products, such as mutual and index funds, to trade securities on behalf of others and often own shares of multiple firms in the same industry to diversify portfolios. However, at present, few studies focus on common ownership trends in health care. OBJECTIVES: This paper examines institutional investors' common ownership in the major insurers offering plans in the Medicare Part D stand-alone prescription drug plan (PDP) market between 2013 and 2020. RESEARCH DESIGN: Using data from the Securities and Exchange Commission (SEC) database and the Center for Research in Securities Prices, we compute the percentages of outstanding shares of each insurer owned by institutional investors. Data visualization and network analysis are employed to assess the trends in common ownership among major insurers. RESULTS: We document a high prevalence of and substantial increase in shared institutional investors in the PDP market. From 2013 to 2020, the degree of common ownership increased by 7% on average, and the common ownership network became more connected. Common ownership also varies across the 34 PDP regions depending on their reliance on listed insurers, that are traded in the stock exchange, offering stand-alone PDPs. CONCLUSIONS: High and rising common ownership in the Medicare Part D PDP market raises policy questions about potential effects on plan offerings, premiums, and quality for consumers.

From the Past to the Present: Insurer Coverage Frameworks for Next-Generation Tumor Sequencing.

Next-generation sequencing promises major advancements in precision medicine but faces considerable challenges with insurance coverage. These challenges are especially important to address in oncology in which next-generation tumor sequencing (NGTS) holds a particular promise, guiding the use of life-saving or life-prolonging therapies. Payers' coverage decision making on NGTS is challenging because this revolutionary technology pushes the very boundaries of the underlying framework used in coverage decisions. Some experts have called for the adaptation of the coverage framework to make it better equipped for assessing NGTS. Medicare's recent decision to cover NGTS makes this topic particularly urgent to examine. In this article, we discussed the previously proposed approaches for adaptation of the NGTS coverage framework, highlighted their innovations, and outlined remaining gaps in their ability to assess the features of NGTS. We then compared the three approaches with Medicare's national coverage determination for NGTS and discussed its implications for US private payers as well as for other technologies and clinical areas. We focused on US payers because analyses of coverage approaches and policies in the large and complex US health care system may inform similar efforts in other countries. We concluded that further adaptation of the coverage framework will facilitate a better suited assessment of NGTS and future genomics innovations.

Competition and Premium Costs in Single-Insurer Marketplaces: A Study of Five Rural States.

Issue: In 2017, five states--Alabama, Alaska, Oklahoma, South Carolina, and Wyoming--had only one issuer participating in their health care marketplaces, limiting consumer choice and competition among insurers. Goal: Examine the history of participation in the individual market from 2010 (before the Affordable Care Act was enacted) to 2017, and analyze premium changes among marketplace plans. Methods: Robert Wood Johnson Foundation's HIX Compare, which provides national data on the marketplaces from 2014 to 2017. Findings and Conclusions: In 2010, the individual insurance market was already concentrated in the five study states, with Blue Cross and Blue Shield (BCBS) plans covering the majority of enrollees. By 2015, with the marketplaces in full swing, more issuers were competing in the five states. But by 2016, co-ops were facing bankruptcy and left the marketplaces in these states; and in 2017, citing large financial losses, national issuers UnitedHealthcare, Aetna, and Humana also exited, leaving only a single BCBS plan in each state. Three of the five states experienced substantially higher annual premium increases than the national average. Policy options with bipartisan support, such as resuming cost-sharing reduction payments and reestablishing reinsurance and risk corridors, could help attract new or returning issuers to marketplaces in these states.

Turmoil in the Health Insurance Marketplaces.

The first three years of the Affordable Care Act's Health Insurance Marketplaces have been tumultuous ones, with rapid entry and exit of insurers and recent spikes in premiums. As concerns mount about the stability and viability of the Marketplaces, this brief provides some insight into the forces behind the headlines and presents six options for policymakers to consider.

Growth and variability in health plan premiums in the individual insurance market before the Affordable Care Act.

Before we can evaluate the impact of the Affordable Care Act on health insurance premiums in the individual market, it is critical to understand the pricing trends of these premiums before the implementation of the law. Using rates of increase in the individual insurance market collected from state regulators, this issue brief documents trends in premium growth in the pre-ACA period. From 2008 to 2010, premiums grew by 10 percent or more per year. This growth was also highly variable across states, and even more variable across insurance plans within states. The study suggests that evaluating trends in premiums requires looking across a broad array of states and plans, and that policymakers must examine how present and future changes in premium rates compare with the more than 10 percent per year premium increases in the years preceding health reform.

Longitudinal Trends in Insurer Participation in Multisector Population Health Activities.

Healthcare organizations increasingly engage in activities to identify and address social determinants of health (SDOH) among their patients to improve health outcomes and reduce costs. While several studies to date have focused on the evolving role of hospitals and physicians in these types of population health activities, much less is known about the role health insurers may play. We used data from the National Longitudinal Survey of Public Health Systems for the period 2006 to 2018 to examine trends in health insurer participation in population health activities and in the multi-sector collaborative networks that support these activities. We also used a difference-in-differences approach to examine the impact of Medicaid expansion on insurer participation in population health networks. Insurer participation increased in our study period both in the delivery of population health activities and in the integration into collaborative networks that support these activities. Insurers were most likely to participate in activities focusing on community health assessment and policy development. Results from our adjusted difference-in-differences models showed variation in association between insurer participation in population health networks and Medicaid expansion (Table 2). Population health networks in expansion states experienced significant increases insurer participation in assessment (4.48 percentage points, P < .05) and policy and planning (7.66 percentage points, P < .05) activities. Encouraging insurance coverage gains through policy mechanisms like Medicaid expansion may not only improve access to healthcare services but can also act as a driver of insurer integration into population health networks.

[Market oriented occupational medicine]. / Piaci viszonyok a foglalkozás-egészségügyben.

The history and the recent state of occupational medicine in Hungary, and its relation with governmental labor organizations are analyzed. In the past 20 years, large "socialist" factories were replaced by smaller companies employing fewer workers. They have been forced to establish contract with occupational health providers. Many of them offer primary care services, whereas family physicians having a board examination in occupational medicine are allowed to work in this field as well. The market of occupational medicine is less regulated, and ethical rules are not always considered. Undercutting prices is a common practice. The recent system could be improved by some regulations which should be respected. There is no reason to make rough changes establishing a new market for profit oriented insurance companies, and to allow employees and employers to work without specification neglecting international agreements. Occupational medicine should be supervised again by the health authorities instead of economists who have quite different, short-term priorities.

Physical and Mental Health-Related Quality of Life Changes Among Insurer Subgroups Following Bariatric Surgery.

OBJECTIVE: This study sought to determine improvements in mental and physical health-related quality of life (HRQOL) following bariatric surgery in Medicaid and commercially insured patients. METHODS: Using data from the Longitudinal Assessment of Bariatric Surgery, an observational cohort study of adults undergoing bariatric surgery (2006-2009), changes in Short Form 36 mental component summary (MCS) and physical component summary (PCS) scores were examined in 1,529 patients who underwent Roux-en-Y gastric bypass, laparoscopic adjustable band, or sleeve gastrectomy and were followed for 5 years. Piecewise linear mixed-effects models estimated MCS and PCS scores as a function of insurance group (Medicaid, N = 177; commercial, N = 1,352) from 0 to 1 year and from 1 to 5 years after surgery, with interactions between insurance group and surgery type. RESULTS: Patients with Medicaid had lower PCS and MCS scores at baseline. At 1 year after surgery, patients with Medicaid and commercial insurance experienced similar improvement in PCS scores (commercial-Medicaid difference in PCS change [95% CI]: Roux-en-Y gastric bypass, 1.5 [-0.2, 3.3]; laparoscopic adjustable band, 1.9 [-2.2, 6.0]; sleeve gastrectomy, 6.4 [0.0, 12.8]). One-year MCS score improvement was minimal and similar between insurance groups. In years 1 to 5, PCS and MCS scores were stable in all groups. CONCLUSIONS: Both insurance groups experienced improvements in physical HRQOL and minimal changes in mental HRQOL.

Terminating Cost-Sharing Reduction Subsidy Payments: The Impact Of Marketplace Zero-Dollar Premium Plans On Enrollment.

The termination of cost-sharing reduction subsidy payments to insurers in 2017 by the administration of President Donald Trump resulted in a proliferation of Marketplace plans having zero-dollar premiums in 2018 and 2019. While it is known that lower premiums increase Marketplace enrollment, it is not clear whether a zero-price effect exists in which enrollment spikes when health insurance is free. We examined whether such an effect exists and found that increased availability of zero-dollar premium plans would have caused a 14.1 percent enrollment increase among lower-income Marketplace enrollees in 2019. If zero-dollar premium plans had not been available in 2019, our simulation results suggest that enrollment in the federally facilitated Marketplace would have decreased by roughly 200,000 enrollees. When we accounted for this zero-price effect, we found that variation in premiums above zero dollars was not associated with enrollment changes. These results suggest that efforts to insure lower-income populations should focus on making health insurance free to potential enrollees, instead of simply reducing premiums. However, increased enrollment in zero-dollar premium plans could result in increased cost sharing among Marketplace enrollees and increased federal outlays for Advance Premium Tax Credits.

Diminishing Insurance Choices In The Affordable Care Act Marketplaces: A County-Based Analysis.

While the Affordable Care Act has expanded health insurance to millions of Americans through the expansion of eligibility for Medicaid and the health insurance Marketplaces, concerns about Marketplace stability persist-given increasing premiums and multiple insurers exiting selected markets. Yet there has been little investigation of what factors underlie this pattern. We assessed the county-level prevalence of limited insurer participation (defined as having two or fewer distinct participating insurers) in Marketplaces in the period 2014-18. Overall, in 2015 and 2016 rates of insurer participation were largely stable, and approximately 80 percent of counties (containing 93 percent of US residents) had at least three Marketplace insurers. However, these proportions declined sharply starting in 2017, falling to 36 percent of counties and 60 percent of the population in 2018. We also examined county-level factors associated with limited insurer competition and found that it occurred disproportionately in rural counties, those with higher mortality rates, and those where insurers had lower medical loss ratios (that is, potentially higher profit margins), as well as in states where Republicans controlled the executive and legislative branches of government. Decreased competition was less common in states with higher proportions of residents who were Hispanic or ages 45-64 and states that chose to expand Medicaid.