Datapoint: Aetna to Expand Illinois Duals Plan

June 17, 2021

Aetna will expand its Illinois Medicare-Medicaid Alignment Initiative demonstration health plan from Chicago and central Illinois to the entire state, according to a June 11 news release. Automatic enrollment into the expanded plan will begin in September. 61,577 dual eligibles are currently enrolled in Illinois’ MMAI demonstration plans, with Aetna holding 15.4% of the market.

Aetna will expand its Illinois Medicare-Medicaid Alignment Initiative demonstration health plan from Chicago and central Illinois to the entire state, according to a June 11 news release. Automatic enrollment into the expanded plan will begin in September. 61,577 dual eligibles are currently enrolled in Illinois’ MMAI demonstration plans, with Aetna holding 15.4% of the market.

Source: AIS’s Directory of Health Plans

Datapoint: Nevada Gov. OKs Public Option Insurance

June 16, 2021

Following Washington’s lead, Nevada will become the second state to create a public option insurance market. Governor Steve Sisolak (D) on June 9 signed a bill that will make a public option available by 2026. The new law requires the public option plans to offer 5% lower premiums than plans on the state’s exchange market, with the ultimate goal of reducing premium costs by about 15%. Approximately 3.2 million people have health insurance in Nevada, with 55,696 currently enrolled in an exchange plan. About 22.6% of the insured population receives Medicaid benefits.

Following Washington’s lead, Nevada will become the second state to create a public option insurance market. Governor Steve Sisolak (D) on June 9 signed a bill that will make a public option available by 2026. The new law requires the public option plans to offer 5% lower premiums than plans on the state’s exchange market, with the ultimate goal of reducing premium costs by about 15%. Approximately 3.2 million people have health insurance in Nevada, with 55,696 currently enrolled in an exchange plan. About 22.6% of the insured population receives Medicaid benefits.

Source: AIS’s Directory of Health Plans

Datapoint: Alignment Healthcare Expands to Arizona

June 15, 2021

Medicare Advantage startup Alignment Healthcare last week said it will expand its plan offerings to Arizona in 2022. The plans will be available in two of the state’s most populous counties, Pima and Maricopa. Alignment currently serves 81,477 members in California, Nevada and North Carolina.

Medicare Advantage startup Alignment Healthcare last week said it will expand its plan offerings to Arizona in 2022. The plans will be available in two of the state’s most populous counties, Pima and Maricopa. Alignment currently serves 81,477 members in California, Nevada and North Carolina.

Source: AIS’s Directory of Health Plans

Datapoint: Gilead Snags Priority Review in ALL for Tecartus

June 14, 2021

Following positive Phase 2 trial data, the FDA granted Gilead Sciences’ Tecartus priority review for the treatment of adult acute lymphoblastic leukemia (ALL). The initial target date for the decision is Oct. 1. If approved, Tecartus will have to go up against Novartis’ CAR-T therapy, Kymriah, which was first approved for ALL in 2017. Under the medical benefit, Kymriah is covered for 88% of all insured lives.

Following positive Phase 2 trial data, the FDA granted Gilead Sciences’ Tecartus priority review for the treatment of adult acute lymphoblastic leukemia (ALL). The initial target date for the decision is Oct. 1. If approved, Tecartus will have to go up against Novartis’ CAR-T therapy, Kymriah, which was first approved for ALL in 2017. Under the medical benefit, Kymriah is covered for 88% of all insured lives.

SOURCE: MMIT Analytics, as of 6/9/21

UnitedHealth Puts ER Coverage Policy on Ice After Backlash

June 11, 2021

UnitedHealthcare — which recently followed in the footsteps of Anthem, Inc. by rolling out a policy that would retroactively deny certain emergency room visit claims — is now planning to hold off on implementing the change after facing fierce blowback from provider groups. Health care policy experts, meanwhile, have mixed opinions about whether the policy was wise to implement in the first place during an ongoing pandemic.

“How anyone at United thought this was a good idea is a mystery for the ages,” says Joe Paduda, principal of Health Strategy Associates LLC. “The correct reaction would be for the company to ask why it handled this so poorly.”

UnitedHealthcare — which recently followed in the footsteps of Anthem, Inc. by rolling out a policy that would retroactively deny certain emergency room visit claims — is now planning to hold off on implementing the change after facing fierce blowback from provider groups. Health care policy experts, meanwhile, have mixed opinions about whether the policy was wise to implement in the first place during an ongoing pandemic.

“How anyone at United thought this was a good idea is a mystery for the ages,” says Joe Paduda, principal of Health Strategy Associates LLC. “The correct reaction would be for the company to ask why it handled this so poorly.”

But Ari Gottlieb, a principal with the health care consulting firm A2 Strategy Group, suggests that UnitedHealth could have made the new policy work. “I’m struck by the pre-emptive outrage at a policy that depending on how implemented, may have been quite limited in scope and impact and generally appeared to be aligned with lowering healthcare costs,” he tells AIS Health, a division of MMIT.

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OneMedical-Iora Deal Follows Pandemic Primary Care Trends

June 11, 2021

National primary care provider OneMedical Group Inc., a startup with an annual subscription service and virtual care offerings, on June 7 announced it will purchase senior-focused provider Iora Health, Inc. for $2.1 billion in an all-stock deal. Experts say the deal is a good bet for a firm that is already an appealing employer for talented, young primary care physicians who don’t want to enter private practice — or work for a large hospital group.

The primary care field has changed since the beginning of 2020, as long-term challenges related to fee-for-service reimbursement, regional provider consolidation and virtual care accelerated because of the pandemic. The OneMedical rollup is an indication that some of the changes to primary care wrought by the pandemic are becoming permanent. Executives expect the deal to close in the third or fourth quarter of this year.

National primary care provider OneMedical Group Inc., a startup with an annual subscription service and virtual care offerings, on June 7 announced it will purchase senior-focused provider Iora Health, Inc. for $2.1 billion in an all-stock deal. Experts say the deal is a good bet for a firm that is already an appealing employer for talented, young primary care physicians who don’t want to enter private practice — or work for a large hospital group.

The primary care field has changed since the beginning of 2020, as long-term challenges related to fee-for-service reimbursement, regional provider consolidation and virtual care accelerated because of the pandemic. The OneMedical rollup is an indication that some of the changes to primary care wrought by the pandemic are becoming permanent. Executives expect the deal to close in the third or fourth quarter of this year.

Particularly in the second quarter of 2020, primary care providers (PCPs) faced declining fee-for-service (FFS) revenue as many local and state governments mandated patients stay away from health care providers for non-emergent care. Many practices pivoted to virtual visits — a change that was possible due to loosened telehealth regulations and revised carrier reimbursement practices for virtual care — but both the number of visits and per-visit reimbursement rate of telehealth visits were often lower than PCPs were used to experiencing.

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As COVID-19 Recedes, What Are Next Steps for Telehealth?

June 11, 2021

Telemedicine utilization boomed during the COVID-19 pandemic, filling some of the unprecedented gaps in care. But its greatly expanded use uncovered some areas where more investment is needed to encourage adoption, while at the same time creating fears that because of its convenience, the pendulum could swing to overutilization, stakeholders say.

In a webinar held June 8, CareFirst BlueCross BlueShield convened a panel of experts to discuss the future of telemedicine services and their potential role in reaching patients with chronic illnesses. They discussed potential barriers to telemedicine use and how they expected the service to evolve post-pandemic.

Telemedicine utilization boomed during the COVID-19 pandemic, filling some of the unprecedented gaps in care. But its greatly expanded use uncovered some areas where more investment is needed to encourage adoption, while at the same time creating fears that because of its convenience, the pendulum could swing to overutilization, stakeholders say.

In a webinar held June 8, CareFirst BlueCross BlueShield convened a panel of experts to discuss the future of telemedicine services and their potential role in reaching patients with chronic illnesses. They discussed potential barriers to telemedicine use and how they expected the service to evolve post-pandemic.

A study in Health Affairs published in February and co-authored by panel participant Ateev Mehrotra, M.D., associate professor of health care policy and medicine at Harvard Medical School, found that during the pandemic, 30.1% of all visits were provided via telemedicine. In addition, the weekly number of telemedicine visits increased 23-fold compared with the pre-pandemic period. Telemedicine use was lower in communities with higher rates of poverty.

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Key Financial Data for Leading Health Plans — First Quarter 2021

June 11, 2021

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News Briefs

June 11, 2021

HHS Secretary Xavier Becerra on June 9 sent a letter to health insurers and providers warning them that COVID-19 vaccines and tests must be provided free of charge to patients. “In light of recent reports of consumer cost concerns,” he wrote — citing a recent New York Times article that indicated concern over unexpected medical bills was a reason cited by people who indicated they are hesitant to get the coronavirus vaccine — “I am reminding health care providers of their signed agreements to cover the administration of COVID-19 vaccines free-of-charge to patients, and group health plans and health insurers of their legal requirement to provide coverage of COVID-19 vaccinations and diagnostic testing without patients shouldering any cost.” Health plans that fail to comply with those legal requirements may be reported to appropriate state insurance departments or CMS “for possible enforcement action,” Becerra said.

HHS Secretary Xavier Becerra on June 9 sent a letter to health insurers and providers warning them that COVID-19 vaccines and tests must be provided free of charge to patients. “In light of recent reports of consumer cost concerns,” he wrote — citing a recent New York Times article that indicated concern over unexpected medical bills was a reason cited by people who indicated they are hesitant to get the coronavirus vaccine — “I am reminding health care providers of their signed agreements to cover the administration of COVID-19 vaccines free-of-charge to patients, and group health plans and health insurers of their legal requirement to provide coverage of COVID-19 vaccinations and diagnostic testing without patients shouldering any cost.” Health plans that fail to comply with those legal requirements may be reported to appropriate state insurance departments or CMS “for possible enforcement action,” Becerra said.

Clover Health Investments, Corp. on June 9 unveiled plans to expand its in-home primary care program, Clover Home Care, through CMS’s Direct Contracting model. The Medicare Advantage-focused startup insurer has bet big on that new model, which aims to lower costs and improve care quality for fee-for-service Medicare beneficiaries, but it also revealed during its first-quarter 2021 earnings report that it will likely have far fewer people covered by that program than it originally anticipated. In its most recent announcement, Clover said that “the goal of Direct Contracting is to make the Medicare program more financially sustainable for taxpayers while improving health outcomes for beneficiaries, which aligns with the work of Clover Home Care.” The company said its first two partners in the new effort, Spiras Health and Upward Health, “were chosen because of their record of exceptional care delivery in the home via a multidisciplinary model, which is core to Clover’s strategy for complex care management.”

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FDA Approval of Alzheimer’s Drug Stirs Up Heated Debate

With Chart: Current Market Access to Alzheimer’s Disease Medications

June 10, 2021

The FDA on June 7 delivered its much-anticipated approval of Biogen Inc.’s Aduhelm (aducanumab-avwa), immediately stirring up a furor over its high cost, reigniting doubts about its effectiveness, and spurring speculation about how public and private payers will approach coverage for the first novel treatment approved for Alzheimer’s disease since 2003.

Alzheimer’s, which affects more than 6 million Americans and tens of millions of people worldwide, is marked by progressive cognitive and functional decline that eventually results in death. It kills more people than breast and prostate cancers combined and, along with other forms of dementia, is expected to cost the U.S. $355 billion this year alone, according to the Alzheimer’s Association.

The FDA on June 7 delivered its much-anticipated approval of Biogen Inc.’s Aduhelm (aducanumab-avwa), immediately stirring up a furor over its high cost, reigniting doubts about its effectiveness, and spurring speculation about how public and private payers will approach coverage for the first novel treatment approved for Alzheimer’s disease since 2003.

Alzheimer’s, which affects more than 6 million Americans and tens of millions of people worldwide, is marked by progressive cognitive and functional decline that eventually results in death. It kills more people than breast and prostate cancers combined and, along with other forms of dementia, is expected to cost the U.S. $355 billion this year alone, according to the Alzheimer’s Association.

Aduhelm stands out from the other drugs currently used to treat Alzheimer’s (see infographic, p. 6) because it aims to slow the progression of the disease rather than just address its symptoms, Douglas Scharre, M.D., tells AIS Health, a division of MMIT. Scharre is a neurologist and director of the division of Cognitive Neurology at Ohio State Wexner Medical Center, and he worked on clinical trials for the drug.

“Aducanumab is the first of a kind in that it is designed to get rid of this protein called amyloid from the brain,” Scharre says.

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