Featured Health Business Daily Story, Jan. 27, 2011

Happy ‘Flu’ Year: As Season Ramps Up, Insurers Must Reach Vulnerable Members (with Map: Weekly Influenza Surveillance Report, Week Ending Dec. 31, 2011)

Reprinted from HEALTH PLAN WEEK, the industry's leading source of objective business, financial and regulatory news of the health insurance industry.

By ,
January 17, 2011Volume 21Issue 2

First, the good news: This year’s influenza vaccine is said to be very effective at combating the three main circulating flu viruses: H3N2, H1N1 and type B. Now the bad news: Immunization rates are low — between 30% and 50% — even among those most at risk for flu-related complications. To help keep members out of the hospital, health plans must reach out to their members as well as to their network physicians to explain the importance of immunizations.

While the flu season is in its early stages, widespread infections have been seen in several southern states (see map, below) and in New York City, according to the most recent data from the Centers for Disease Control and Prevention (CDC).

Flu activity typically peaks in January or February, but seasonal flu activity can continue into May, according to CDC. Deciding on which components to include in the vaccine typically takes place in the spring before the next flu season begins. Some years, the virus that becomes most prevalent isn’t included in the vaccine, which makes it less effective.

But this year’s vaccine “couldn’t be better,” says Doris Bucher, Ph.D., associate professor of microbiology and immunology at New York Medical College, Valhalla, N.Y. Two of the components of this year’s vaccine, including H1N1, were made at NYMC.

Both CDC and Google Flu Trends indicate that the incidence of influenza-like illnesses (ILI) has been increasing since the beginning of the year. Google data, as of Jan. 8, 2011, reveal an estimated national ILI percentage of 3%, well above the 2.3% average from the prior five years, Stifel, Nicolaus & Co. analyst Tom Carroll wrote in a Jan. 10 note to investors.

CDC, however, noted a slight improvement during the last week of 2010 from the prior week. A flu season that is more severe than anticipated could put downward pressure on first-quarter 2011 earnings, Carroll wrote. While managed care organizations had predicted a “normal” flu season, he notes that it’s still too early to tell if that prediction will be accurate.

For plan years that begin on or after Sept. 23, 2010, new policies must provide coverage — without cost sharing — for preventive services and preventive screenings for adults, infants and children. This includes flu vaccines. While most policies previously covered vaccinations for the flu, members typically were responsible for a copayment or coinsurance.

2010’s higher-than-expected earnings for publicly traded health plans were due — at least in part — to a milder-than-expected flu season. Concern about an H1N1 pandemic last year prompted high vaccination rates, which might have helped keep some members out of the hospital.

So far, ILI levels appear to be highest in the Southeast and Mid-Atlantic regions, where Medicaid managed care firms — including AMERIGROUP Corp., Centene Corp. and WellCare Health Plans, Inc. — “have significant exposure,” according to Carroll.

Among the states where Molina Health Care, Inc. operates Medicaid managed care plans, four of them (Florida, Missouri, Ohio and Texas) are experiencing higher ILI’s than most other states, notes Michael Siegel, M.D., Molina’s corporate vice president of utilization management and quality improvement.

“So far, [the flu season] has been mild. But in the outpatient setting, we are seeing a little bit of an increase over baseline infection rates,” he tells HPW. The flu season, Siegel notes, typically gets into full swing between January and late March or early April.

On the Medicare side, Humana Inc., UnitedHealth Group, HealthSpring, Inc., Aetna Inc., WellPoint, Inc., Universal American Corp. and Coventry Health Care, Inc. also have significant exposure to states with material ILI, according to Carroll. “However, it is important to note that five of the most severely impacted states are already past peak levels and that it is premature to suggest extraordinary financial impact,” he noted.

Plans Must Reach High-Risk Members

To reach its most vulnerable members, Siegel says Molina identifies members who are most at risk for flu-related complications and makes sure that they receive informational postcards and/or automated telephone calls to “reinforce the need for them to get immunized,” he says. The company also “incentivizes” physicians to treat Molina’s high-risk members. In addition, the company has arrangements with some pharmacies to offer flu shots at no charge to members.

The CDC recently added “morbid obesity” to the conditions that place individuals at a higher risk for flu-related complications. A year ago, the H1N1 virus hit obese people (i.e., those with a body mass index of 40 or higher) particularly hard, says Bucher. Here’s a look at other types of members who could be at high risk for flu-related complications:

  • Pregnant women: CDC identified pregnant women as a high-risk group in 2004. The medical community, however, hasn’t placed as much emphasis on this group, says Siegel. Bucher agrees and says pregnant women tend to have low immunization rates. Part of the reason is that their Ob-Gyns haven’t been effective in communicating the benefits of immunization, she explains. Pregnant women “had a very high rate of winding up in intensive care last year,” she says. While they have a higher incidence of flu-related complications than do non-pregnant women, the flu also poses a risk to the unborn child.

The results of a three-year study conducted by Yale School of Medicine researchers determined that vaccinating pregnant women against influenza is more than 90% effective in preventing their infants from being hospitalized with influenza in the first six months of life. The findings were published in the Dec. 15 issue of the journal Clinical Infectious Diseases.

  • Children: Those who are older than six months, but younger that five years — particularly children younger than two years old — are most at risk. Last year, there was a high number of pediatric deaths due to flu, Bucher notes. Along with flu viruses, other respiratory viruses such as respiratory syncytial virus (RSV) can hit children particularly hard, which can significantly boost utilization for Medicaid managed care firms. “Because so many of our members are children — more than a regular commercial plan would have — not only could we see a big impact from influenza, we also have RSV. And even if we don’t have a big flu season, we could have a big RSV season,” Siegel says.

  • Chronically ill: The CDC notes that there is an elevated risk for people who suffer from chronic conditions including asthma, neurological and neurodevelopmental conditions (e.g., cerebral palsy, epilepsy, stroke), chronic lung disease, heart disease, blood disorders (e.g., sickle cell disease), kidney or liver disorders, AIDS and cancer.

  • Adults age 65 and older: Older members typically have weaker immune systems. A new vaccine — Fluzone High-Dose — has been designed specifically for people aged 65 and older, according to CDC. Fluzone High-Dose contains four times the amount of antigen (the part of the vaccine that prompts the body to make antibody) contained in regular flu shots. The additional antigen is intended to create a stronger immune response, CDC says.

Weekly Influenza Surveillance Report, Week Ending Dec. 31, 2011

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SOURCE: The Centers for Disease Control and Prevention, January 2011

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