Abstract

Health Plans Take Proactive Approaches to Confront U.S. Measles Outbreak

May 14, 2019

Confronting the worst measles outbreak in the U.S. in a quarter century, some health care organizations are taking innovative steps.

As part of its containment effort, CDC is urging people who know they received an earlier formulation of measles vaccine that was given to fewer than 1 million people between 1963 and 1968 and is no longer used to talk to their doctor about getting revaccinated with the current, live measles-mumps-rubella (MMR) vaccine.

By Judy Packer-Tursman

Confronting the worst measles outbreak in the U.S. in a quarter century, some health care organizations are taking innovative steps.

As part of its containment effort, CDC is urging people who know they received an earlier formulation of measles vaccine that was given to fewer than 1 million people between 1963 and 1968 and is no longer used to talk to their doctor about getting revaccinated with the current, live measles-mumps-rubella (MMR) vaccine.

Most insurers seem to be engaging in generalized outreach to members, though Priority Health tells AIS Health that concern about some people getting the ineffective measles vaccine in the 1960s prompted its recent communication efforts.

Priority Health has sent “proactive communications and recommendations throughout our network, including providing information to our provider network and partners, and our sales teams to inform our commercial clients,” Priority Health spokesperson Aaron Miller says. The thrust of Priority Health’s communications is ensuring that members know the MMR vaccine is covered at no cost for most of them when they get the shot from an in-network provider, he says.

Horizon Blue Cross Blue Shield of New Jersey recently posted a “measles alert” on its home page, “and we are about to amplify the messaging and content through our social media channels,” spokesperson Thomas Vincz said May 8.

On April 29, CareFirst BlueCross BlueShield in Maryland put out a reminder that members in its Maryland, northern Virginia and Washington, D.C., service area may obtain a measles vaccine at no cost from their in-network primary care provider.

CBO Says Proposed Drug Rebates Rule Will Increase Government Spending by $177B

May 13, 2019

When HHS unveiled a proposed rule in late January aimed at eliminating drug rebates in Medicare Part D and Medicaid managed care, the proposal was met with mixed responses. A recently released score from the Congressional Budget Office (CBO) calls into question whether the administration chooses to move forward with the proposal in its current form.

The proposal would do away with the safe harbor protection in the anti-kickback statute for rebates negotiated between manufacturers and PBMs starting Jan. 1, 2020.

By Angela Maas

When HHS unveiled a proposed rule in late January aimed at eliminating drug rebates in Medicare Part D and Medicaid managed care, the proposal was met with mixed responses. A recently released score from the Congressional Budget Office (CBO) calls into question whether the administration chooses to move forward with the proposal in its current form.

The proposal would do away with the safe harbor protection in the anti-kickback statute for rebates negotiated between manufacturers and PBMs starting Jan. 1, 2020.

In the CBO’s report, the agency projects that if the rule is implemented as proposed, it will increase federal spending by approximately $177 billion from 2020 to 2029. Of that total, spending on Medicare Part D premiums would increase by about $170 billion. Without rebates to keep premiums low, beneficiaries would face higher premiums. The agency anticipates that “rather than lowering list prices, manufacturers would offer the negotiated discounts in the form of chargebacks,” which are shared with beneficiaries via a manufacturer payment to a pharmacy.

The report, however, also concludes that “no current system could both meet the proposed rule’s standards and facilitate chargebacks.”

If “rebates could no longer be paid to PBMs in Medicare Part D,” but “systems are not available to support retail pharmacy chargebacks,…this would be an untenable situation,” says Elan Rubinstein, Pharm.D., principal at EB Rubinstein Associates, making it “reasonable to delay” the proposed implementation date.

“The increase in premiums was expected by many, but the growth in federal spending was somewhat surprising given that lower upfront prices would generally benefit the end payer, which in this case is the federal government,” says Jeremy Schafer, Pharm.D., senior vie president, director, access experience team at Precision for Value. “It seems changing the safe harbor may not accomplish patient savings or reduced government spending as hoped for by the administration.”

Molina, Cigna and CVS Health Report Solid First-Quarter Earnings

May 9, 2019

Several major publicly traded managed care companies, including some newly merged combinations, reported solid first-quarter 2019 earnings. Medicare for All, a health system overhaul being urged by many congressional Democrats, didn’t overshadow their earnings calls as it arguably did for harbinger UnitedHealth Group, which reported strong quarterly results in mid-April.

President and CEO Joe Zubretsky noted during Molina Healthcare, Inc.’s April 29 earnings call that there obviously are various proposals at the state and federal level “for public option, single-payer Medicare for All-type arrangements.” But Molina considers “most of these positions to be political rhetoric” still in the discussion phase.

By Judy Packer-Tursman

Several major publicly traded managed care companies, including some newly merged combinations, reported solid first-quarter 2019 earnings. Medicare for All, a health system overhaul being urged by many congressional Democrats, didn’t overshadow their earnings calls as it arguably did for harbinger UnitedHealth Group, which reported strong quarterly results in mid-April.

President and CEO Joe Zubretsky noted during Molina Healthcare, Inc.’s April 29 earnings call that there obviously are various proposals at the state and federal level “for public option, single-payer Medicare for All-type arrangements.” But Molina considers “most of these positions to be political rhetoric” still in the discussion phase.

Zubretsky focused on the impact of Molina’s corporate restructuring efforts, saying first-quarter results seem to validate that durable financial and operational improvements will allow the company to sustain attractive margins built in 2018, “all while we begin to grow the top line again.” For the three months ended March 31, Molina reported premium revenue of $4 billion, down 9% year over year, in line with the company’s expectations.

Molina raised its full-year 2019 earnings guidance, and Wall Street analysts by and large view the company as poised for growth.

This was Cigna Corp.’s first quarter reporting as a combined company following its acquisition of Express Scripts. Cigna President and CEO David Cordani said the company remains on track to deliver “attractive growth” in 2019 and beyond.

CVS Health Corp. beat first quarter expectations and raised its full-year outlook. Chief executive Larry Merlo described CVS Health’s first full quarter as a combined company as “a success on many fronts” following its acquisition of Aetna Inc.

CMS Extends Options to States to Test Innovative Dual-Eligible Care Models

May 8, 2019

Although independent evaluations of ongoing demonstrations to integrate care for dual-eligible Medicare-Medicaid beneficiaries are still underway, an April 24 letter from CMS Administrator Seema Verma signaled the agency’s commitment to proving the value of the models as well as testing alternatives.

By Lauren Flynn Kelly

Although independent evaluations of ongoing demonstrations to integrate care for dual-eligible Medicare-Medicaid beneficiaries are still underway, an April 24 letter from CMS Administrator Seema Verma signaled the agency’s commitment to proving the value of the models as well as testing alternatives.

In the letter to state Medicaid directors, CMS extended three new opportunities to “test state-driven approaches” for integrating duals’ care:

(1) For interested states with capitated Financial Alignment Initiative (FAI) model demos, CMS said it is “open to partnering on revisions.”

(2) For interested states without capitated demos, CMS said it welcomes interest in testing the model through new demos in additional states.

(3) CMS said it is open to partnering with states on testing new state-developed models to better serve dual eligibles and invited states to respond with ideas, concept papers and/or proposals.

Kevin Malone, a senior counsel in the Health Care and Life Sciences practice in the Washington, D.C., office of Epstein Becker & Green, P.C. and a former duals officer at CMS, predicts that, for states with existing demos, they will not only revisit their memoranda of understanding that outline the terms of their agreements with CMS, but will use it as a chance to amend their three-way contracts with CMS and plans. This presents a unique opportunity for the plans to suggest changes around certain programmatic requirements or provider training that may reduce some of their burden and streamline some of the technical details of their arrangements.

Why Some Employee Wellness Programs Work, Others Don’t

May 7, 2019

A major wholesaler’s program recently grabbed the national spotlight after researchers studied it, published their findings in JAMA, and told The New York Times there is “a really weak evidence base” on whether such programs are worthwhile. But experts tell AIS Health the study focused on one problematic program, and its tepid results shouldn’t be extrapolated to other workplace wellness initiatives.

The study examined the BJ’s Wholesale Club wellness program after 18 months, and found some positives, including more regular exercise and active weight management among participants than in the control group.

By Judy Packer-Tursman

A major wholesaler’s program recently grabbed the national spotlight after researchers studied it, published their findings in JAMA, and told The New York Times there is “a really weak evidence base” on whether such programs are worthwhile. But experts tell AIS Health the study focused on one problematic program, and its tepid results shouldn’t be extrapolated to other workplace wellness initiatives.

The study examined the BJ’s Wholesale Club wellness program after 18 months, and found some positives, including more regular exercise and active weight management among participants than in the control group.

But the wellness program failed to align with many evidence-based best practices, asserts Jeff Dobro, M.D., strategy and clinical services leader in Mercer’s health care consulting practice. If a wellness program isn’t structured in the right way, by offering a “compelling design” of sufficient duration, along with effective employee communication and engagement, then incentives won’t drive change, he says. Moreover, it typically takes “two years or more to see a real health or financial benefit” from improved behaviors.

Dobro explains there are two main components to health improvement programs. First is the quality of the program itself. Second is the use of incentives for employees to participate. He asserts incentives have been shown to drive people to engage.

Dobro says his advice to employers is to avoid “narrow, rigid” wellness programs. “There is no one design that’s going to work with everybody,” he says, “because an employee population encompasses many types of people.”

Leavitt Partners Presents Multiyear MA Framework

May 6, 2019

In the age of value-based contracts and social determinants of health, why shouldn’t plans have an opportunity to serve Medicare Advantage (MA) beneficiaries for longer periods of time and maximize the potential to improve health outcomes and reduce costs?

That’s the question at the center of “Multi-Year Medicare Advantage Plans: A Framework for Action,” a new white paper by consulting firm Leavitt Partners.

By Lauren Flynn Kelly

In the age of value-based contracts and social determinants of health, why shouldn’t plans have an opportunity to serve Medicare Advantage (MA) beneficiaries for longer periods of time and maximize the potential to improve health outcomes and reduce costs?

That’s the question at the center of “Multi-Year Medicare Advantage Plans: A Framework for Action,” a new white paper by consulting firm Leavitt Partners.

Under the MyMAP demonstration project proposed in the paper, MA insurers would be able to offer a multiyear product to beneficiaries with certain high-cost chronic disease needs or high-cost acute medical episodes and test the hypothesis that making “upfront investments” would be recovered over a multiyear period because they produced better care management and better outcomes for beneficiaries.

The authors recommended a contract period of at least three years between health plan and member. To incentivize members to enroll in a multiyear plan, the MyMAP framework suggested that plans could focus on attractive benefits and cost-sharing. Moreover, it might be possible for insurers to guarantee beneficiaries $0 premiums across multiple years of the model, they added.

Moving forward, “the idea will be acted on with specifics,” says former Utah Governor and HHS Secretary Mike Leavitt. He adds that the firm is working with two organizations that are not yet prepared to go public and that focus on certain conditions that would fit well within the framework.

“Multiyear contracting deserves further thought — perhaps as a demonstration,” says Michael Adelberg, a principal with Faegre Baker Daniels Consulting and a former top CMS MA official. “If beneficiaries are locked in, that begs the question of whether plan benefits, networks, service areas also will be locked in.”