A Healthcare Excellence Agenda, Small Group Market Deteriorates, & Prior Auth in Medicare Advantage

Hey all,

Month 1 of 2025 is almost in the books. I was especially happy Sebastian’s post on the 8VC blog targeted Medicare Advantage plans collecting payments for veterans who use VA services, essentially getting paid for doing. Enjoy the rundown!

Jacob Brody (Co-Founder & CEO, ZorroRX)

(8VC) A Healthcare Excellence Agenda for the New Administration

 8VC partner Sebastian Caliri outlines a transformative plan for U.S. healthcare, emphasizing deregulation, technological innovation, and structural reforms to improve efficiency and patient outcomes. Key proposals include removing the AMA’s influence over physician payment structures, creating a national provider credentialing clearinghouse, and taking antitrust action against EPIC to enhance data interoperability. Additionally, the agenda highlights anti-fraud measures, such as stronger oversight of CMS payments and stricter sanctions for Medicare Advantage brokers who exploit seniors. Full Article

(Health Affairs) The Decline of the Small-Group Health Insurance Market

 A new commentary by health policy researchers Mark Meiselbach and Jean Abraham highlights the steady decline of small-group health insurance, with only 30% of small employers offering coverage in 2023, down from 47% in 2002. The researchers argue that policymakers must decide whether to intervene or let small-group plans be replaced by alternatives like Affordable Care Act exchanges, Medicaid, or individual coverage health reimbursement arrangements (ICHRAs). While some experts, including Oscar Health CEO Mark Bertolini, suggest employers should exit the health benefits market entirely, others warn against disrupting a system that still provides coverage to half of Americans. The commentary also notes that previous regulatory efforts to strengthen the small-group market, such as limiting self-insurance options, may have unintentionally accelerated its decline. Full Article

(KFF) Prior Authorization in Medicare Advantage

 A new KFF analysis highlights the rising volume of prior authorization requests in Medicare Advantage, which reached nearly 50 million in 2023, up from 37 million in 2021. Despite a slight decline in denial rates (6.4% in 2023 vs. 7.4% in 2022), only 11.7% of denials were appealed—yet 81.7% of those appeals resulted in overturned decisions, raising concerns about unnecessary barriers to care. The report also reveals significant variation in denial rates and authorization requests across insurers, emphasizing the need for greater transparency and potential reforms to ensure timely access to medical services. Full Article