(Medcity News | Mar 10, 2023)To look ahead, you sometimes need to look backward. As a new uncertain year ahead rolls on, we can clearly see the major trends that shaped the healthcare industry over the last 12 months. More importantly, many of the trends that prevailed in 2022 offer clues to where the industry might be headed in 2023 and beyond. Let’s take one last look at the year that was by examining the following six trends:

Trend #1: The popularity of Medicare Advantage (despite criticisms)

There was plenty of good news for Medicare Advantage (h MA) in 2022. The program has been a popular choice for Americans, and it remains robust. In fact, 28.5 million seniors and people with disabilities were enrolled in MA plans in 2022, up 8.8% from 2021.

To meet the demand, MA plan options have expanded impressively in recent years. The number of available MA plans has doubled since 2017, and we’re seeing the largest number in more than a decade. With more options available, plans are experiencing more competition for enrollees. Some larger plans have cut their growth projections. At the same time, several startups reported significant enrollment increases while also incurring financial losses.

Despite the program’s popularity, fiscal conservatives made calls to restructure MA or eliminate subsidies and establish a basis for controlling or even cutting MA payments. Nonetheless, Senate support for the program is unmistakable, as evidenced by a letter signed by 63 senators to the Centers for Medicare & Medicaid Services (or CMS). Such widespread, bipartisan support indicates that it is unlikely any curtailing of MA would pass through Congress.

Trend #2: The rise of the ‘payvider’

Throughout 2022, we saw a trend of payer and provider operations merging into a new hybrid dubbed the “payvider.” The payvider model has gained favor as a cost-effective option because these types of organizations have more control over member care. As a result, primary care centers have been expanding across the country.

Wall Street also appears to be bullish on payviders. Goldman Sachs forecasted strong earnings for payers that are capitating and issued buy ratings for companies that are emphasizing coordinated care, such as UnitedHealth Group and Alignment Healthcare. Expect to see a continued merging of payer and provider organizations in 2023.

Trend #3: Oversight, oversight, and more oversight

If there was one primary theme throughout 2022, it would be oversight. Throughout the year, a number of government agencies unveiled plans to tighten controls and oversight. CMS announced more stringent reporting for MA plans. The Office of Inspector General (known as OIG) ramped up audits of individual plans and added pandemic-specific inquiries to its set of audits, including analyses of improper billing in telehealth.

As we moved into the second half of the year, these oversight plans were put into action. Between the second quarter and third quarter of 2022, over nine MA plans were targeted for audits and the Department of Justice joined a fraud case against one insurer.

Furthermore, OIG has grown more efficient and expeditious in identifying inaccurate information. In its Fiscal Year 2022 Justification of Estimates for Congress, OIG touted investments in artificial intelligence to accelerate its ability to investigate high-risk Medicare and Medicaid providers and support fraud detection. Similarly, CMS doubled its auditing budget this year and outlined three new sets of required quality measures that will apply to care in 2023. Thus, there is every reason to believe we’ll see more audits and tighter oversight in the coming years.

Trend #4: A big boost to the Affordable Care Act

Inflation and the threat of a recession dominated headlines throughout the latter part of 2022. In an attempt to address these economic concerns, Congress passed the Inflation Reduction Act o 2022, which included $98 billion for healthcare programs.

This act did very little for MA and telehealth plans, but Affordable Care Act (or ACA) plans benefited greatly. ACA premium subsidies had been set to expire, and the initial attempts to extend them failed in Congress. However, the legislation extended the subsidies to 2025. As a result, we should see more plans entering the ACA exchanges in the next couple of years.

Trend #5: The long-term goal of interoperability

It seems like we’ve been talking about interoperability in healthcare for years, and it remains a priority. Although challenges persist, we saw significant momentum toward interoperability last year:

All of this confirms what we already knew — interoperability is coming, and everyone in the industry needs to be prepared.

Trend #6: The end of the public health crisis?

Of course, the dominant event over the past three years has been the public health emergency (or PHE) sparked by the coronavirus pandemic. Even though Cofie-19 hasn’t gone away, we might be seeing some light at the end of the tunnel. The PHE is set to expire on January 11, 2023, and there is some speculation that it might not be extended for an additional three months.

Although we would all welcome the end of the PHE, it will have specific repercussions for the healthcare industry. CMS has already ended the six-month extension for MA final supplemental submissions that was put into effect during the pandemic. The final deadline for 2022 dates of service will now be January 2024. As we move into 2023 and beyond, we should expect to see more pandemic-related dispensations fall away.

The calendar might now say 2023, but the big trends from 2022 continue to impact the healthcare industry and will do so for the rest of the year. If you understand what these trends are telling us, you’ll have a head start on what to expect in this brand-new year. Use this knowledge to make 2023 your most productive and successful year yet.