Cigna’s 2021 strategies highlight MA trends and the resulting effects on providers

• Cigna’s 2021 Medicare Advantage strategies include a rapid expansion and new benefits.
• Of Cigna’s MA network physicians, 85% are in value-based payment arrangements, and half of those are in two-sided risk.
• New benefits for 2021 include virtual physical therapy in response to enrollee fears of contracting COVID-19.

The plans and priorities of a fast-growing Medicare Advantage (MA) health plan demonstrate some of the significant trends shaping the industry, as well the impact on provider behavior.

While Cigna’s national MA market share remains in the low single digits, its strategy of focusing on certain markets has made it a top-three plan in many locations.

HFMA met virtually with Brian Evanko, president of government business for Cigna, to talk about the company’s MA expectations for 2021, during which it projects to expand from 154 counties to 221 and grow its member base by between 10% and 15%.

HFMA: What are your plans in the virtual care space?

Evanko: We’ve expanded virtual care services to all of our markets in 2021. As part of that we have $0 access to behavioral health providers through virtual care services because the pandemic has really brought to bear the importance of virtual care for not only seniors but everyone in the healthcare ecosystem. We think that’s a trend that’s here to stay.

We are not of the view that a virtual-only solution is the right move for Cigna. We think it’s important that our customers have choice relative to how they access care, whether that’s face-to-face with a doctor, whether that’s virtually, whether that’s in-home.

HFMA: Are your MA plans looking to encourage more outpatient procedures, given CMS moves regarding site-neutral payment?

Evanko: As we think about affordability, broadly speaking, in the MA space, we believe optimizing site of service is an important part of that. So, whether that’s using virtual care in place of a series of visits [with] an in-person, face-to-face physician experience, or whether that’s an outpatient surgery instead of an inpatient surgery, or whether that’s urging someone to utilize an urgent care center instead of a more costly emergency room, that’s an important part of our affordability journey at Cigna.

Part of that is how we influence the way customers behave, part of that is how we partner with physicians.

We have a long tradition of physician collaboration in MA, where we have over 85% of our customers aligned with value-based physicians who are taking shared risk with us. And so those physicians naturally are aligned with us to make sure our customers are not only getting high-quality care but also using the most cost-effective site of service.

That’s an important part of our short-term and long-term strategy to create affordability benefits for our customers.

HFMA: Amid your expansion of post-hospitalization meal delivery, are there any other benefit additions related to social determinants of health?

Evanko: For 2021, we’ve got a couple new ones that I’d mention: One we put in place in the Mid-Atlantic area — parts of Pennsylvania, Maryland and Delaware — called the Healthy Benefits Plus program. It gives an allowance to customers of up to $30 per month to give them access to fresh fruits and vegetables. It’s essentially a produce card, because many of our customers are very low-income and have not placed a premium on nutrition. And so, we found that’s one area we’re interested in testing in 2021.

Additionally, we have virtual physical therapy in place in a number of our plans in 2021. We’ve found some individuals are just not comfortable going to a bricks-and-mortar setting and exposing themselves to the risks of COVID.

HFMA: How is Cigna using network and benefit design to encourage members to use high-quality, low-cost providers?

Evanko: Overall, we’re constantly evaluating our network relative to the size of it, the performance of it and the cost efficiency of it. So, we use data and analytics on a constant basis to decide how we want to refine, strengthen and improve the network.

For 2021, we’ve added physicians on a net basis year over year, but there are also some that over time we decided to remove from the network for those reasons.

That’s the primary driver we use. We don’t have specific benefit drivers — with the exception of out-of-network, for example in a PPO — but there’s no further tiering that would encourage utilization.

HFMA: What share of your MA plans payments fall within shared savings, shared risk and population-based payment? Any future targets there?

Evanko: Among the 85% of physicians aligned with a value-based pay arrangement, about half of our physician relationships are where the physicians are taking two-sided risk with us. And the balance of those are the more population-based incentives or upside for specific behaviors. As an example, this year we think it’s particularly important that people get a comprehensive wellness exam. We also think it’s particularly important that people get flu shots this year as we head into the fall and winter. And we also think it’s particularly important that our female customers have mammograms and such.

We set up objectives for our physician partners and therefore align incentives that way to drive the right behaviors among our customers. I call it the triple win — the win between the customers, physicians and Cigna that ends up creating a virtuous circle and therefore better outcomes and lower costs over time.

HFMA: Are hospitals part of your MA health plan shared-risk arrangements?

Evanko: The majority of our business today as it relates to value-based physician partnerships is with independent physicians. However, we have some health systems and hospital systems where we have relationships such as that. That runs down the line, including their own physicians who are part of their systems. But the lion’s share of our business today is with independent physicians.

HFMA: Why is that?

Evanko: We’ve found over time that because independent physicians are at the very top of the waterfall, that by aligning there we can control the downstream costs most effectively. That’s been the primary reason we have focused there.

HFMA: How does Cigna view the coming CMS requirement that hospitals report their median contracted payer-specific negotiated rates for MA plans?

Evanko: We have been active in this conversation through our trade association, AHIP, as well as Cigna. There’s a lot beneath this one, in terms of the devil in the details. While transparency in general and choice in general are good things, we think there could be some unintended consequences of the transparency rules that are being finalized.

And while they don’t directly impact us because it is the hospitals that must comply with them, there’s plenty of economic research out there that shows this type of situation can lead to different types of outcomes. So, we’ve expressed some of the concerns that we have about how the market could unfold. But we think we’re well-positioned to win in MA in any scenario, regardless of how the transparency rules are finalized and implemented.

HFMA: Do you give your contracted providers access to risk-score data you collect on beneficiaries?

Evanko: Risk-score data, in and of itself, has not been something we shared with providers directly. But as part of our strong physician collaborations, in terms of our value-based care partnerships, naturally we’ll share data insights in terms of who’s getting the care that is needed, who needs to be seen, that sort of thing. But it is in the vein of delivering high-quality outcomes for our customers, versus a risk-score orientation.

HFMA: Any concerns about the financial challenges of CMS requiring 2021 coverage of ESRD patients?

Evanko: It’s obviously a significant change for 2021 with ESRD beneficiaries now being able to choose MA plans without restrictions. We’ve been very active, both in terms of advocacy with CMS to make sure we understand the rules of the road there, the network adequacy requirements, etc.

And in aggregate, the way we designed our products for 2021, we do not have ESRD-specific plans. We expect we are going to get many ESRD beneficiaries to choose our plans but in a similar proportion as any other MA carrier would expect to see. We already serve a number of ESRD beneficiaries and aim to provide them the best-quality outcomes at the lowest cost.

We expect we are going to have more, but in aggregate we believe it is both manageable in the context of our operations and something we’re well-prepared for come Jan. 1.

Editor’s note: The interview was edited for clarity and length.