‘There’s a Lot of Screaming Into the Void’: Toddler’s Parents Battle for Coverage of $2.1 Million Gene Therapy

July 10, 2019

When a $2.1 million gene therapy offering the chance of a cure for her daughter’s rare disease won government approval in May, Lauren Sullivan was struck by a sense of “dangerous hope.’’

But after UnitedHealthcare said it would not cover the treatment, Sullivan’s hope has given way to an anxious race against the calendar.

When a $2.1 million gene therapy offering the chance of a cure for her daughter’s rare disease won government approval in May, Lauren Sullivan was struck by a sense of “dangerous hope.’’

But after UnitedHealthcare said it would not cover the treatment, Sullivan’s hope has given way to an anxious race against the calendar.

The Food and Drug Administration said the new drug, which works by replacing the defective gene that causes Daryn’s spinal muscular atrophy with a good one, must be administered by age 2. Daryn’s second birthday arrives in early October.

With time running out, the family is caught in a battle over who gets treated with a cutting-edge drug that is also extraordinarily expensive.

Read the full The Washington Post article

Datapoint: UnitedHealthcare Enrolls More Than a Quarter of Medicare Advantage Lives

July 10, 2019

Of the 55.8 million people currently covered by Medicare, 40.4% are currently enrolled in Medicare Advantage (MA) plans. UnitedHealthcare is the current MA leader, with 25.9% national market share.

Of the 55.8 million people currently covered by Medicare, 40.4% are currently enrolled in Medicare Advantage (MA) plans. UnitedHealthcare is the current MA leader, with 25.9% national market share.

Source: AIS’s Directory of Health Plans

States’ 2020 Agendas Target PBMs, Reinsurance and Opioid Crisis

July 10, 2019

Going into 2020, state lawmakers likely will continue to target prescription drug prices with proposals largely aimed at PBMs, but they may also tackle bills on a wide range of topics, including reinsurance, the opioid epidemic and maternal mortality.

More than 260 bills to rein in the cost of prescription drugs — many of which specifically banned common PBM business practices — cropped up in the U.S. this past spring, and Gerard (Jerry) Vitti, founder and CEO of Healthcare Financial, Inc., says he anticipates more of the same going forward.

By Jane Anderson

Going into 2020, state lawmakers likely will continue to target prescription drug prices with proposals largely aimed at PBMs, but they may also tackle bills on a wide range of topics, including reinsurance, the opioid epidemic and maternal mortality.

More than 260 bills to rein in the cost of prescription drugs — many of which specifically banned common PBM business practices — cropped up in the U.S. this past spring, and Gerard (Jerry) Vitti, founder and CEO of Healthcare Financial, Inc., says he anticipates more of the same going forward.

“The debate will be around drug pricing — around half of the [2019] bills are PBM-related,” Vitti tells AIS Health.

While pharmacy and drug pricing measures are likely to heat up again in states through the fall and into 2020, other issues of interest to insurers also are likely to get some attention.

For example, lawmakers in additional states are likely to approve proposals asking CMS to grant them Affordable Care Act Section 1332 waivers to implement reinsurance programs designed to lower premiums in their individual marketplaces, says Alex Shekhdar, founder of Sycamore Creek Healthcare Advisors.

State lawmakers also are likely to continue tackling the opioid crisis, using federal funding to finance various prevention and treatment programs, he says.

Going forward, “we continue to see more red states attempt to expand Medicaid under flexible arrangements,” Vitti notes. These arrangements might include work requirements, even though courts struck down Medicaid work requirements in Arkansas and Kentucky.

Vitti notes that some conservative-leaning states also may consider Medicaid beneficiary cost-sharing, adding, “there really is an appetite in state legislatures for these types of conservative policies.”

Datapoint: Nearly 40% of Covered Lives Are Enrolled in ASO Products

July 9, 2019

Of all medically covered lives in the U.S., 38.1%, or 124.6 million people, are enrolled in administrative services only (ASO) insurance arrangements, or self-funded plans.

Of all medically covered lives in the U.S., 38.1%, or 124.6 million people, are enrolled in administrative services only (ASO) insurance arrangements, or self-funded plans.

Source: AIS’s Directory of Health Plans

Centene, Molina Will Pay Less Than Estimated Into Risk Adjustment Program

July 9, 2019

Some health insurance companies received welcome news when CMS released its summary report on risk adjustment transfers for the 2018 benefit year.

The Affordable Care Act’s permanent risk adjustment program, which applies to the individual and small-group markets, redistributes funds between health plans with lower-risk enrollees and those with higher-risk enrollees.

By Leslie Small

Some health insurance companies received welcome news when CMS released its summary report on risk adjustment transfers for the 2018 benefit year.

The Affordable Care Act’s permanent risk adjustment program, which applies to the individual and small-group markets, redistributes funds between health plans with lower-risk enrollees and those with higher-risk enrollees.

Centene Corp. estimated that it would have to pay $928 million into the risk adjustment program for 2018, but would actually end up owing $669 million, according to analyses from Credit Suisse and Citi. Another winner appeared to be Molina Healthcare, Inc., as its risk adjustment payable is $93 million less than what was accrued on its balance sheet at the end of 2017, Evercore ISI analysts noted.

Some Blues plans, meanwhile, are set to receive sizeable payouts, with Blue Shield of California ($975 million), Health Care Service Corp. ($655 million) and Blue Cross Blue Shield of Florida ($536 million) leading the pack, according to Credit Suisse’s A.J. Rice.

Some have blamed the risk adjustment program for contributing to the massive financial losses that led many of the ACA-created Consumer Operated and Oriented Plans (CO-OPs) to shutter. The CO-OP New Mexico Health Connections even filed a lawsuit challenging the federal government’s decision to make the program budget neutral and use statewide average premiums in the risk adjustment formula.

While that litigation is ongoing, “there’s no danger” that the risk adjustment program will disappear, according to Katie Keith, a research professor at Georgetown University’s Center on Health Insurance Reforms. “The biggest risk is that CMS has to make changes to its risk adjustment methodology,” she tells AIS Health via email, adding, “but I think even that is unlikely.”