We Read Democrats’ 9 Plans for Expanding Health Care: Here’s How They Work

March 20, 2019

Democrats are lining up behind Medicare-for-all. But what exactly do they mean?

Democrats are lining up behind Medicare-for-all. But what exactly do they mean?

Last year, dozens of Democratic candidates ran — and won — on a promise to fight to give all Americans access to government-run health care. A new Medicare-for-all bill in the House already has more than 100 co-sponsors. Many of the 2020 Democratic presidential candidates have endorsed the idea.

“Medicare-for-all” has become a rallying cry on the left, but the term doesn’t capture the full scope of options Democrats are considering to insure all (or at least a lot more) Americans. Case in point: There are currently more than half a dozen proposals in Congress, which all envision very different health care systems…..

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New Nasal Spray Offers Hope for Depression Treatment, But Coverage May Be Tricky

March 20, 2019

Many clinicians have publicly expressed cautious optimism about the FDA’s recent approval of a nasal spray for major depressive disorder in adults who have been resistant to multiple other treatments. But payer issues abound for Spravato (esketamine), partly because the FDA is imposing strict parameters on its use due to safety concerns.

By Judy Packer-Tursman

Many clinicians have publicly expressed cautious optimism about the FDA’s recent approval of a nasal spray for major depressive disorder in adults who have been resistant to multiple other treatments. But payer issues abound for Spravato (esketamine), partly because the FDA is imposing strict parameters on its use due to safety concerns.

Esketamine is derived from ketamine, a general anesthetic first approved by the FDA in 1970. Similar to ketamine, Spravato is designated as a Schedule III controlled substance that may carry the risk of illicit use or diversion. In approving Spravato on March 5, The FDA said that the nasal spray cannot be taken at home. Instead, the patient must self-administer it under the supervision of a health care provider in a doctor’s office or clinic certified by the drug’s manufacturer — a distribution model that will further add to the cost of an already expensive treatment.

Typically, the cost of generics for antidepressants is “really inexpensive, less than $50 a month,” notes Dea Belazi, Pharm.D., president and CEO of AscellaHealth, a Berwyn, Pa.-based PBM. By comparison, the cost would mushroom into thousands of dollars monthly for Spravato.

Janssen’s nasal spray can work faster than other treatment options, with some antidepressants requiring four to six weeks of use to become effective, Belazi notes. “Some psychotherapists I’ve talked to see esketamine as a bridge while antidepressants kick in,” he says. However, “because of the price point, I’d guess 99% of payers will limit this to a treatment-resistant population.”

The bottom line is, “there’s a significant cost implication here for the payers,” Belazi says, “and most payers will want to calculate what the patient population could look like to estimate costs. The data aren’t very clear on that….At the end of the day, it’s a debilitating disease. But if it’s high cost, you’d likely be looking at other options.”

Datapoint: Humana Will Partner With Accolade to Reduce Costs for ASO Members

March 19, 2019

Humana Inc. last week said it will partner with Accolade, a health data solutions company, to reduce costs for its members and employer groups enrolled in self-funded plans. Humana will use Accolade’s data platform to engage with members directly, helping them choose lower-cost providers and services. Humana currently enrolls 6,377,300 self-funded members, though the program will initially focus on the Cincinnati and Milwaukee areas.

Humana Inc. last week said it will partner with Accolade, a health data solutions company, to reduce costs for its members and employer groups enrolled in self-funded plans. Humana will use Accolade’s data platform to engage with members directly, helping them choose lower-cost providers and services. Humana currently enrolls 6,377,300 self-funded members, though the program will initially focus on the Cincinnati and Milwaukee areas.

Source: AIS’s Directory of Health Plans

Cambia, BCBS North Carolina’s New Deal Could Set a Trend

March 19, 2019

In an era of U.S. health care consolidation, what two major Blues insurers describe as their “strategic affiliation,” announced March 12, would bring together dominant regional not-for-profits with combined net revenue of $16 billion and more than 6 million covered lives. Industry experts tell AIS Health this deal between Cambia Health Solutions and Blue Cross and Blue Shield of North Carolina to create a stronger presence could start the ball rolling, possibly serving as a model for more strategic partnerships among Blues organizations.

By Judy Packer-Tursman and Jane Anderson

In an era of U.S. health care consolidation, what two major Blues insurers describe as their “strategic affiliation,” announced March 12, would bring together dominant regional not-for-profits with combined net revenue of $16 billion and more than 6 million covered lives. Industry experts tell AIS Health this deal between Cambia Health Solutions and Blue Cross and Blue Shield of North Carolina to create a stronger presence could start the ball rolling, possibly serving as a model for more strategic partnerships among Blues organizations.

“I wouldn’t be surprised to see more combinations, more consolidation among Blues because I think many insurers, not just Blues, are looking to grow and gain economies of scale and efficiencies,” says attorney David Kaufman, a partner at Laurus Law Group LLC and former general counsel of Blue Cross Blue Shield of Illinois, a unit of Health Care Service Corp.

The two Blues organizations are quick to point out the parameters of their deal, which insurance regulators still must approve. It would involve merged operations and administrative functions, but their respective health plans and provider networks would continue to operate independently.

“Now that we’re getting into this next wave, consolidations as we know them are different,” says Ashraf Shehata, a principal in KPMG’s health care life sciences advisory practice and the firm’s Global Healthcare Center of Excellence. Instead of jumping into a merger directly, plans are testing the water first with strategic affiliations, he says.

Shehata says strategic affiliations work differently from mergers. Mergers operate by identifying where the two merging organizations have duplicate functions, and combining those functions, he says, but a strategic integration starts by identifying areas of synergy, while “you defer the merger talk until later.”

Datapoint: Blue Cross and Blue Shield of North Carolina to Partner With Cambia Health Solutions

March 18, 2019

Blue Cross and Blue Shield of North Carolina and Cambia Health Solutions last week announced a “strategic affiliation” between the two health insurers in an effort to lower costs and improve quality of care for their members. The two insurers will share administrative and operational services, as well as a CEO, though neither company is calling the deal a merger. The North Carolina Blues plan currently serves 2,311,411 people, while Cambia enrolls 1,731,067 medical lives under its Regence brands and other entities throughout the Northwest.

Blue Cross and Blue Shield of North Carolina and Cambia Health Solutions last week announced a “strategic affiliation” between the two health insurers in an effort to lower costs and improve quality of care for their members. The two insurers will share administrative and operational services, as well as a CEO, though neither company is calling the deal a merger. The North Carolina Blues plan currently serves 2,311,411 people, while Cambia enrolls 1,731,067 medical lives under its Regence brands and other entities throughout the Northwest.

Source: AIS’s Directory of Health Plans