Investors’ Deep-Pocket Push to Defend Surprise Medical Bills

September 11, 2019

As proposals to ban surprise medical bills move through Congress and state legislatures with rare bipartisan support, physician groups have emerged as the loudest opponents.

Often led by doctors with the veneer of noble concern for patients, physician-staffing firms — third-party companies that employ doctors and assign them out to health care facilities — have opposed efforts to limit the practice known as balance billing. They claim such bans would rob doctors of their leverage in negotiating, drive down their payments and push them out of insurance networks.

As proposals to ban surprise medical bills move through Congress and state legislatures with rare bipartisan support, physician groups have emerged as the loudest opponents.

Often led by doctors with the veneer of noble concern for patients, physician-staffing firms — third-party companies that employ doctors and assign them out to health care facilities — have opposed efforts to limit the practice known as balance billing. They claim such bans would rob doctors of their leverage in negotiating, drive down their payments and push them out of insurance networks.

Opponents have been waging well-financed campaigns. Slick TV ads and congressional lobbyists seek to stop legislation that had widespread support from voters. Nearly 40% of patients said they were “very worried” about surprise medical bills, which generally arise when an insured individual inadvertently receives care from an out-of-network provider….

Read the full Kaiser Health News article

Datapoint: CVS-Aetna Deal Receives Final Approval

September 11, 2019

A federal judge last week granted full clearance to the Justice Department’s decision to allow CVS Health to purchase Aetna, the third-largest health insurer in the nation, despite antitrust concerns. Aetna currently enrolls 21,402,587 members, with 16.9% enrolled in commercial risk-based products.

A federal judge last week granted full clearance to the Justice Department’s decision to allow CVS Health to purchase Aetna, the third-largest health insurer in the nation, despite antitrust concerns. Aetna currently enrolls 21,402,587 members, with 16.9% enrolled in commercial risk-based products.

Source: AIS’s Directory of Health Plans

Novartis’ Zolgensma Crisis May Not Impact Pickup

September 11, 2019

The FDA in August put out a statement addressing “data accuracy issues” with Zolgensma (onasemnogene abeparvovec-xioi), a new gene therapy to treat spinal muscular atrophy in people less than two years old who have bi-allelic mutations in the survival motor neuron 1 gene.

The FDA approved the drug from AveXis, Inc., which was acquired by Novartis AG last year, on May 24. On June 28, AveXis notified the FDA that there was “a data manipulation issue that impacts the accuracy of certain data from product testing performed in animals submitted in the biologics license application (BLA) and reviewed by the FDA.”

By Angela Maas

The FDA in August put out a statement addressing “data accuracy issues” with Zolgensma (onasemnogene abeparvovec-xioi), a new gene therapy to treat spinal muscular atrophy in people less than two years old who have bi-allelic mutations in the survival motor neuron 1 gene.

The FDA approved the drug from AveXis, Inc., which was acquired by Novartis AG last year, on May 24. On June 28, AveXis notified the FDA that there was “a data manipulation issue that impacts the accuracy of certain data from product testing performed in animals submitted in the biologics license application (BLA) and reviewed by the FDA.”

The FDA said Novartis learned about the issue March 14, but rather than informing the agency, which was assessing Zolgensma’s BLA at the time, the company conducted its own internal investigation, reporting its findings to the FDA after the investigation was completed. Still, the agency said that it “remains confident that Zolgensma should remain on the market.”

The one-time therapy is the most expensive drug in the world, with a price tag of $2.1 million.

In response, Novartis issued a press release Aug. 6 that read, in part, “we maintain that the totality of the evidence demonstrating the product’s effectiveness and its safety profile continue to provide compelling evidence supporting an overall favorable benefit-risk profile.”

Novartis recently said that Zolgensma has coverage plans from payers representing 40% of commercial lives, and high-profile news reports name Aetna Inc. and Anthem, Inc. among insurers expanding their policies to cover more patients. So will the current situation have any impact on pickup among payers and providers?

Based on the FDA’s statement, “I expect there will be no more than a minor and temporary blip in pickup of Zolgensma among providers and payers,” says Elan Rubinstein, Pharm.D., principal at EB Rubinstein Associates.

Datapoint: Cigna to Eliminate Cost-Sharing From Two Gene Therapies

September 10, 2019

Cigna Corp. last week said it will make two gene therapies, Spark Therapeutics and Novartis’ Luxturna, which treat blindness, and Novatis’ muscular atrophy drug Zolgensma available to members at no cost. Gene therapies are among the most expensive drugs in the world, with Zolgensma currently holding the top spot. Cigna, which merged with Express Scripts in 2018, currently serves 16,400,235 people, with 82.9% enrolled in self-funded plans. Cigna said it would consider adding more gene therapies to the program as more become available.

Cigna Corp. last week said it will make two gene therapies, Spark Therapeutics and Novartis’ Luxturna, which treat blindness, and Novatis’ muscular atrophy drug Zolgensma available to members at no cost. Gene therapies are among the most expensive drugs in the world, with Zolgensma currently holding the top spot. Cigna, which merged with Express Scripts in 2018, currently serves 16,400,235 people, with 82.9% enrolled in self-funded plans. Cigna said it would consider adding more gene therapies to the program as more become available.

Source: AIS’s Directory of Health Plans

Priority Health, Total Health Care Deal Continues Michigan Consolidation Trend

September 10, 2019

Grand Rapids-based Priority Health, the second-largest payer in Michigan, on Aug. 28 said it would acquire Total Health Care, a Detroit-based HMO. Industry insiders tell AIS Health that the deal could help the two smaller payers compete with dominant insurers like Blue Cross Blue Shield of Michigan.

Though the transaction is described as a merger by the two companies, Total Health Care will be a wholly owned subsidiary of Priority after the deal’s completion, spokesperson Jeremy Bakken says. The deal is expected to be completed in early 2020, pending approval by state regulators.

By Aine Cryts

Grand Rapids-based Priority Health, the second-largest payer in Michigan, on Aug. 28 said it would acquire Total Health Care, a Detroit-based HMO. Industry insiders tell AIS Health that the deal could help the two smaller payers compete with dominant insurers like Blue Cross Blue Shield of Michigan.

Though the transaction is described as a merger by the two companies, Total Health Care will be a wholly owned subsidiary of Priority after the deal’s completion, spokesperson Jeremy Bakken says. The deal is expected to be completed in early 2020, pending approval by state regulators.

Experts say the payer market is in “consolidation mode” both in Michigan and nationally. In addition, as payers gain more experience with insurance products sold to individuals and through employers, they’re more likely to offer products to Medicaid and Medicare Advantage beneficiaries.

For example, Health Alliance Plan (HAP), a Detroit-based not-for-profit health plan subsidiary of Henry Ford Health System, in June acquired TRUSTED Health Plan, a 9,000-member Medicaid MCO based in Detroit. And Grand Blanc-based McLaren Health Care, a 13-hospital health system, acquired Indianapolis-based HMO MDWise in 2018.

Providers also are joining forces in the state, says Greg Gulick, an adjunct professor at Michigan State University’s Eli Broad College of Business. He says those deals are focused on gaining market share, growing the health systems and discovering new delivery models.

For example, Spectrum Health, a large health system serving 13 counties in West Michigan (and the majority owner of Priority Health), moved to acquire St. Joseph-based Lakeland Health, a three-hospital system, in 2018. And in July, Southfield, Mich.-based Beaumont Health, a nonprofit eight-hospital system, signed a letter of intent to acquire Summa Health, a hospital system with more than 30 locations in the Akron/Canton area.