It is hard to believe that it has already been three months since the conclusion of this year’s March Healthcare Classic. This year’s face-offs brought some of the most intense competition we have seen since the tournament’s inception in 2021. The powerhouse trends that landed a spot in the finals are: Lasting Effects of GLP1’s (8), Evolution of Medicare Advantage (1), Expansion of Self Care (8), and Focus on Women’s Health (5). Keep reading to discover how these trends are evolving and how the industry is responding to them.
2024 Champion: Lasting Effects of GLP1’s (8)
Lasting Effects of GLP1’s (8)—the 2024 Champion—has remained at the forefront of conversations, boasting a lot of attention in 2024. GLP1’s (Glucagon-like peptide-1) are a class of prescription drugs used to treat Type 2 Diabetes and obesity. These drugs include brands such as Ozempic and Wegovy. The drugs are making a substantial impact within the healthcare industry for their effectiveness in reducing the weight of the recipient and thus, decreasing the comorbidities that accompany Type 2 Diabetes and obesity.
Despite the effectiveness, different players within the industry remain divided on whether GLP1’s should be covered due to one primary reason: cost. For uninsured patients, the cost of treatment can reach $1,000 per month. According to a 2024 report published by The United States Senate Health, Education, Labor, and Pensions Committee, if all Americans living with obesity took GLP1’s, spending would total approximately $822.3 billion.
Currently, an estimated one-third of employers in the U.S. offer coverage of GLP1’s, up from 26% last year. A greater number of employers cover the drug solely to treat diabetes. However, more employers are considering the drug for weight loss purposes. Regarding the decision to cover GLP1’s, employers cite the high cost of other conditions often associated with Type 2 Diabetes and obesity.
However, some payors are not on board with the surge in popularity of these drugs. For instance, Blue Cross Blue Shield of Michigan (BCBSM) decided to withdraw its coverage of GLP1’s in 2025. Further, BCBSM updated prior authorization requirements for these drugs, effective August 2024. In a statement, the insurer said its decision was based on the “drugs’ efficacy, safety and access, and cost.”
In terms of safety, the long-term health impacts are still being studied and no definitive research has been published yet. Even with short-term use, GPL1’s have been shown to cause conditions such as gallstones, kidney disease, loss of appetite, and thyroid complications. Further, GLP1’s in other countries are only recommended for use for up to two years. However, a study of patients using GLP-1 medications for weight loss revealed that two-thirds regained the lost weight within a year of discontinuing the treatment. This poses long-term efficacy issues, especially pertaining to cosmetic and medical weight loss.
Amidst these debates, the landscape of healthcare delivery is evolving, with big-box retailers stepping into the GLP1 market. With the rise of retail health, other big-box retailers beyond our Big Four (Amazon, CVS Health, Walgreens, and Walmart) are creating innovative programs and healthcare delivery models. In April, Costco announced that its partnership with Sesame would expand to include a weight loss program. When Costco members sign up for the program through Sesame’s marketplace, they will receive three months of support from a clinician. A GLP1 drug will be prescribed on a case-by-case basis.
This poses some challenges for the model as pharmacies across the country cite shortages of GLP1’s. Demand for the drugs outruns Big Pharma’s ability to produce them. After months of limited stock, the Food and Drug Administration listed an update on the availability of Wegovy in April. While limited supplies are currently available, experts expect shortages to continue.
Ultimately, the industry will need to weigh the benefits of reducing chronic illnesses and the associated savings against the high cost of these drugs and their long-term efficacy. Keep an eye on our Champion as we suspect it will continue making a significant impact for the remainder of the year.
Top Two Trend: Evolution of Medicare Advantage (1)
Evolution of Medicare Advantage (1) was the runner-up in this year’s tournament and a Selection Committee favorite over the years.
Tensions between hospitals and Medicare Advantage (MA) insurers continue to rise. Hospitals state that revenue streams are being impacted by MA. Specifically, MA insurers are denying claims, paying less than what was billed, and not authorizing care in a timely way. Hospitals are still recovering from financial strains and workforce shortages due to the pandemic. Hospitals earn substantially less for MA patients compared to commercial patients, making MA less attractive from a business standpoint.
In May, Great Plains Health stated it would terminate all contracts with MA plans, effective January 2025. The Clinically Integrated Network (CIN) said MA does not align with its mission to put patients first as MA is denying care and imposing longer stays than necessary on patients.
However, it’s not just CINs and hospital systems that are making changes regarding MA. There are many adjustments taking place in the commercial payor market as well. CVS Health, one of our healthcare Big Four, is eliminating 10% of its MA plans. With first-quarter earnings $900 million below the predicted earnings, CVS Health’s Chief Financial Officer stated the company is prioritizing margins over membership. As the third-largest MA insurer in the country, upwards of 400,000 members may need to switch plans or forgo health coverage. Humana, one of the largest MA insurers, is also scaling back its MA plan benefits and geographic presence. Instead, Humana plans to prioritize private Medicare programs. Bids were due to CMS in June, and while there are federal guardrails limiting cutbacks, it remains to be seen just how much these decisions will impact the broader MA landscape.
These tensions occur as the Centers for Medicaid and Medicare Services (CMS) announces a 3.7% increase in MA plans for 2025, which equates to about $16 billion. Even though the government is expected to pay MA plans between $500 and $600 billion next year, MA insurers are flagging that this may not be enough to address the increasing cost of care. Insurers state that the increased costs and various policies will make it difficult to maintain benefits and manage premiums for the 33 million Americans on MA.
These strains occur as the spotlight also turns to MA star ratings. Currently, CMS allows MA plans that earn a rating of four out of five stars to eliminate two of the toughest parts of their rating. This allows plans to earn a higher star rating as well as more money. Over the last few years, CMS has been floating the idea of reserving this benefit to only those plans that earn five stars. This would save the government approximately $19.5 billion over the next ten years. However, this could result in less money for plans that have been doing well, leading to fewer benefits for the members of those plans.
Experts suspect this decision may be put into effect due to recent court rulings. Elevance, the parent company of Anthem Blue Cross and Blue Shield of Georgia, sued CMS in December 2024 and won. The legal battle was over CMS allegedly failing to follow standard procedures when modifying how the agency evaluates quality and distributes bonus payments. Now, CMS must recalculate Blue Cross and Blue Shield of Georgia’s star ratings. Separately, CMS agreed to revise the star ratings for four other MA contracts owned by Elevance. Chicago-based Zing Health is also suing CMS over star ratings.
The culmination of these changes may impact care for thousands of seniors across the nation.
Top Four Trend: Expansion of Self Care (8)
Expansion of Self Care (8) was a newcomer trend that garnered attention from the Selection Committee and made it to the semi-finals. It’s no surprise that with the advancements of technology and artificial intelligence, self-care becomes a more compelling option.
In April, SimpleHealth Kit partnered with Amazon to offer diagnostic kits for various chronic illnesses including common sexually transmitted diseases (STDs), diabetes, and respiratory infections. The diagnostic kits are available on Amazon.com and are the first product of their kind to be available on Amazon’s storefront. SimpleHealth Kit also offers end-to-end healthcare, meaning if a patient tests positive, they will have access to telehealth and prescriptions.
Also in the realm of self-tests, the FDA approved a self-test for human papillomavirus (HPV). The test, produced by Roche and BD, allows patients to take their own sample versus a doctor completing a pelvic exam. With more than 42 million cases per year, HPV is the most common sexually transmitted infection (STI). Self-tests have the potential to make diagnosing and treating various infections or conditions much more accessible.
While some may be skeptical of the efficacy of self-tests compared to those conducted by a healthcare provider, new research posits that the diagnostics are comparable. In a study encompassing six different STIs, it was found that self-collected specimens were comparable to physician-collected specimens and ultimately yielded the same results.
As predicted, Artificial Intelligence (AI) is also making an impact on the healthcare industry. With AI’s ability to store and gather massive amounts of data, it is poised to advance healthcare in terms of access to information, diagnoses, predictive models, and more. Recently, NYU Langone Health developed a self-taught AI tool with the ability to diagnose and predict the severity of common lung cancers. While these AI tools aren’t yet widely available to consumers, it’s not hard to imagine a time when these models may become the norm.
top four trend: Focus on Women’s Health (5)
Focus on Women’s Health (5) was a newcomer to the Classic this year and secured an impressive spot in the semi-finals. With a greater focus on care tailored specifically to women’s needs, there are several key advancements in just the few months following the Classic.
In June, a bipartisan Women’s Health Political Action Committee (PAC) was formed. With more government involvement and attention within the national political landscape, the goal is to achieve comprehensive women’s healthcare. The women’s healthcare space has been historically underfunded and stigmatized, which contributes to significant health disparities. The PAC not only unlocks major economic opportunities but also assures politicians remain focused on women’s health, including all races and ethnicities.
Advancements are also occurring in the private sector. Midi Health, an organization focused on midlife women’s care, raised $60 million in series B funding. Its total funding is now $100 million. The virtual care company focuses on women over 40 going through perimenopause and menopause. Earlier this year, the organization expanded its virtual care clinic to employers across all states.
Additionally, women’s health company Tia, founded in 2016, is announcing leadership changes as the organization plans to expand clinics and improve operations. The current CEO, co-founder Carolyn Witte, is transitioning to chairwoman of the board. Co-founder Felicity Yost will become the interim CEO. The co-founders stated this allows the organization to realign its priorities and focus on strategy. Serving 40,000 members, Tia operates nine clinics in four markets. The organization plans to open two more clinics by the end of 2024.
With increased funding, political support, and the expansion of private companies delivering women’s care, the momentum is set to continue.
Stay tuned for future posts and insights on the blog as well as LinkedIn.