Datapoint: Fallon Health to Exit Commercial Insurance Market

April 7, 2021

Worcester, Massachuetts-based insurer Fallon Health last week said it will “shift away” from most commercial product lines as of April 1, citing a renewed focus on Medicare and Medicaid. Fallon currently has 52,208 members in commercial risk-based plans, with 61% enrolled in a group risk product. The insurer also covers 72,500 lives through self-funded contracting arrangements.

Worcester, Massachuetts-based insurer Fallon Health last week said it will “shift away” from most commercial product lines as of April 1, citing a renewed focus on Medicare and Medicaid. Fallon currently has 52,208 members in commercial risk-based plans, with 61% enrolled in a group risk product. The insurer also covers 72,500 lives through self-funded contracting arrangements.

Source: AIS’s Directory of Health Plans

T-MSIS Fails to Maintain Full Medicaid Managed Care Payment Data, OIG Reports

April 7, 2021

A new review of the CMS Transformed Medicaid Statistical Information System (T-MSIS) found that most states did not provide complete or accurate data on managed care payments to providers for January 2020, according to an HHS Office of Inspector General report released March 30.

Managed care organizations, which cover about 70% of the Medicaid population, are required to submit an encounter claim for each enrollee encounter or visit to a provider. States must then validate those claims for accuracy before submitting them to T-MSIS.

NOTE: The abstract below is a shortened version of the RADAR on Medicare Advantage article “OIG: T-MSIS Lacks Full Medicaid Managed Care Payment Data.”

By Lauren Flynn Kelly

A new review of the CMS Transformed Medicaid Statistical Information System (T-MSIS) found that most states did not provide complete or accurate data on managed care payments to providers for January 2020, according to an HHS Office of Inspector General report released March 30.

Managed care organizations, which cover about 70% of the Medicaid population, are required to submit an encounter claim for each enrollee encounter or visit to a provider. States must then validate those claims for accuracy before submitting them to T-MSIS.

Having accurate payment data is essential to monitoring and administering the Medicaid program, OIG explained. For example, states use payment data to set capitation rates for MCOs and to monitor the services they provide. CMS and other stakeholders can use the data to manage and oversee plans, and to examine payments to detect fraud, waste and abuse. And with more individuals enrolling in and using Medicaid over the last year, “[p]rotecting the fiscal integrity of Medicaid during the pandemic has taken on a new urgency,” OIG argued.

Yet 31 out of 39 states with managed care last year did not provide complete or accurate data to T-MSIS on provider payments for January 2020 made by their largest plan. A record was considered incomplete or inaccurate if it had inappropriate zeros, missing data or negative amounts, clarified OIG. Moreover, many states had incomplete or inaccurate information for two or more types of payment data.

Although CMS has identified improving data quality in the system as a priority, OIG maintained that CMS must “strengthen its efforts to improve the accuracy and completeness of managed care payment data in T-MSIS.” Specifically, it recommended that CMS:

✦ Review states’ managed care payment data in T-MSIS and certify that states have corrective action plans to improve data completeness and quality, as appropriate;

✦ Publicize the findings of such reviews, including the extent to which the payment data are complete and accurate for each individual managed care plan; and

✦ Clarify and expand its initiative on payment data.

CMS did not agree with any of the recommendations. In a letter dated Jan. 19, then-CMS Administrator Seema Verma responded that the agency has over the last several years taken steps to improve T-MSIS.

Datapoint: Sarclisa to Compete with Darzalex in Multiple Myeloma

April 6, 2021

The FDA last week approved Sanofi’s Sarclisa (in tandem with Amgen’s Kyprolis and dexamethasone) for the treatment of relapsed or refractory multiple myeloma in patients who have had at least one prior treatment. This will put Sarclisa in direct competition with Amgen’s Darzalex, which scored the same indication in August 2020. For the treatment of multiple myeloma, Darzalex currently holds preferred formulary placement for 7% of covered lives, growing to 17% with utilization management restrictions applied.

The FDA last week approved Sanofi’s Sarclisa (in tandem with Amgen’s Kyprolis and dexamethasone) for the treatment of relapsed or refractory multiple myeloma in patients who have had at least one prior treatment. This will put Sarclisa in direct competition with Johnson & Johnson’s Darzalex, which scored the same indication in August 2020. For the treatment of multiple myeloma, Darzalex currently holds preferred formulary placement for 7% of covered lives, growing to 17% with utilization management restrictions applied.

SOURCE: MMIT Analytics, as of 4/5/21

Health Insurers Rethink Workplaces in Post-COVID Future

April 6, 2021

With COVID-19 vaccination becoming increasingly widespread, businesses of all types are starting to plan for what their workplaces — both remote and office-based — will look like in the “new normal” created in the pandemic’s aftermath. Health insurers are no exception.

CareFirst BlueCross BlueShield, for example, recently unveiled “the next phase of a reimagined employee and workplace experience strategy.” The nonprofit insurer explained in a March 24 news release that it is “working collaboratively with technology partners to design a new multi-faceted platform for employees that will be interactive and help foster a fully integrated work experience” wherever workers are located.

NOTE: The abstract below is a shortened version of the Health Plan Weekly article “With Pandemic’s End in View, Insurers Rethink Workplaces.”

By Leslie Small

With COVID-19 vaccination becoming increasingly widespread, businesses of all types are starting to plan for what their workplaces — both remote and office-based — will look like in the “new normal” created in the pandemic’s aftermath. Health insurers are no exception.

CareFirst BlueCross BlueShield, for example, recently unveiled “the next phase of a reimagined employee and workplace experience strategy.” The nonprofit insurer explained in a March 24 news release that it is “working collaboratively with technology partners to design a new multi-faceted platform for employees that will be interactive and help foster a fully integrated work experience” wherever workers are located.

CareFirst just passed the one-year anniversary of having 95% of its associates working fully remote, the insurer noted, but it doesn’t plan to have that be the case forever. “In the future we plan to implement a hybrid strategy,” the insurer tells AIS Health. “Approximately 55% [of workers] will be enabled to work in a full-time remote capacity spending one day or less a week in an office setting; 30% will divide their time in an office 2-3 days a week and [be] remote the remainder of the time; and close to 15% will be full-time in a CareFirst office location 4-5 days a week.”

Similar to CareFirst, Highmark Inc. has kept most of its associates out of the office since the start of the pandemic. “And we have told employees it is unlikely that any employees will return to an office environment before July of this year,” the company said.

Those two insurers’ strategies are not out of step with what Willis Towers Watson has been observing through its polling and conversations with employers, says Rachael McCann, senior director of health and benefits at the benefits consulting firm.

“For the most part…we are seeing more companies across all industries, [in] the U.S. and global in nature, pushing pause because they’re looking at their real estate,” she says.

In Willis Towers Watson’s “2021 Emerging From the Pandemic Survey,” released in February, companies in the health care industry reported that an average of 44% of their employees worked remotely as of the first quarter of 2021, and they expect the share to be 30% by the end of the year.

Datapoint: Medicaid Enrollment Grows More Than 10% Year-Over-Year

April 5, 2021

From March 2020 to March 2021, the total U.S. Medicaid population (including managed care plans and traditional fee-for-service coverage) grew 11.1% to 81.9 million lives, according to the latest update to AIS’s Directory of Health Plans. This growth is largely a result of the COVID-19 pandemic, though one state, Idaho, implemented Medicaid expansion in January 2020.

From March 2020 to March 2021, the total U.S. Medicaid population (including managed care plans and traditional fee-for-service coverage) grew 11.1% to 81.9 million lives, according to the latest update to AIS’s Directory of Health Plans. This growth is largely a result of the COVID-19 pandemic, though one state, Idaho, implemented Medicaid expansion in January 2020.

Source: AIS’s Directory of Health Plans

Diabetes Reversal Platform Shows Positive Outcomes, Calif. Blues Plan Reports

April 5, 2021

Diabetes prevention and diabetes management are both key tenets of Medicare Advantage insurers’ approach to addressing this costly condition that impacts one in three Medicare enrollees. But one tech-savvy startup aims to popularize a third category — diabetes reversal — and early adopter Blue Shield of California says the program has achieved very desirable results in less than two years.

Utilizing a nutrition protocol combined with high frequency interaction with health coaches to achieve significant reductions in blood glucose levels — all done virtually — Virta Health has a mission of reversing type 2 diabetes in 100 million people by 2025.

NOTE: The abstract below is a shortened version of the RADAR on Medicare Advantage article “Calif. Blues Plan Sees Promise in Diabetes Reversal Platform.”

By Lauren Flynn Kelly

Diabetes prevention and diabetes management are both key tenets of Medicare Advantage insurers’ approach to addressing this costly condition that impacts one in three Medicare enrollees. But one tech-savvy startup aims to popularize a third category — diabetes reversal — and early adopter Blue Shield of California says the program has achieved very desirable results in less than two years.

Utilizing a nutrition protocol combined with high frequency interaction with health coaches to achieve significant reductions in blood glucose levels — all done virtually — Virta Health has a mission of reversing type 2 diabetes in 100 million people by 2025.

“It is a highly individualized virtual care team that’s working with the member,” says Steve Hastings, health plan sales leader with Virta. As part of the nutrition protocol, coaches work with patients to figure out what they can eat in their own “food environment,” and interact with members based on their preference.

Blue Shield of California includes Virta as an optional benefit enhancement in its Wellvolution platform, which offers online and in-person programs for general wellbeing and disease reversal.

Blue Shield Senior Director of Lifestyle Medicine Angie Kalousek says Virta is one of Wellvolution’s highest-performing providers, and in the short time members have been engaging with the program, they have demonstrated improved outcomes and reported multiple positive side effects.

In aiming to get members “off the medications they’re sort of shackled to as diabetics, they’re not only tackling the cost of health care but they’re really improving the life of the member,” says Kalousek of Virta. For the members who have engaged with Virta, nearly 65% have achieved statistically significant clinical outcomes.

In a small study looking at prescription drug claims for 60 members using the Virta treatment platform, Blue Shield of California observed that 85% of members lost weight. In addition, more than half of members narrowed their diabetes medications down to one agent, and 30% discontinued their medications altogether.

Meanwhile, the insurer is starting to look at ways to measure the cost effectiveness of using such a program. Considering the estimated lifetime expense of treating a diabetic patient is $100,000, and Blue Shield can pay up to $3,900 per member to Virta — although most members achieve maintenance levels at a lower cost — “there’s an argument that there’s a lot of cost savings on the table,” says Kalousek.

People on the Move

April 2, 2021

Copay Accumulator Usage Is on the Rise

April 2, 2021

At least two-thirds of health insurance plans offered in the Affordable Care Act marketplaces in 32 states include a copay accumulator adjustment policy (CAAP), which prevents drug manufacturer coupons from counting toward patients’ annual deductibles or out-of-pocket cost limits, according to a recent study by The AIDS Institute. Meanwhile, the 2021 Large Employers’ Health Care Strategy and Plan Design Survey from Business Group on Health showed that large companies are increasingly adopting copay accumulator programs to reduce prescription drug costs, as 49% of employers said they either had such a program in place in 2020 or were adding one in 2021, and another 14% planned one for 2022-2023.

by Jinghong Chen

At least two-thirds of health insurance plans offered in the Affordable Care Act marketplaces in 32 states include a copay accumulator adjustment policy (CAAP), which prevents drug manufacturer coupons from counting toward patients’ annual deductibles or out-of-pocket cost limits, according to a recent study by The AIDS Institute. Meanwhile, the 2021 Large Employers’ Health Care Strategy and Plan Design Survey from Business Group on Health showed that large companies are increasingly adopting copay accumulator programs to reduce prescription drug costs, as 49% of employers said they either had such a program in place in 2020 or were adding one in 2021, and another 14% planned one for 2022-2023.

SOURCES: “Double-Dipping: Insurance Companies Profit at Patients’ Expense,” The AIDS Institute, March 2021. Visit https://bit.ly/3rgN3Td. “2021 Large Employers’ Health Care Strategy and Plan Design Survey,” Business Group on Health, August 2020. Visit https://bit.ly/3f8L692.

Datapoint: Blues Plans Enroll Half of Group Risk Market

April 1, 2021

Nearly half (47.3%) of the national group commercial risk insurance market is enrolled in a Blue Cross and Blue Shield affiliate plan. Of the 26.2 million group risk lives enrolled in a Blues plan, 20.5% are Anthem, Inc. members.

Nearly half (47.3%) of the national group commercial risk insurance market is enrolled in a Blue Cross and Blue Shield affiliate plan. Of the 26.2 million group risk lives enrolled in a Blues plan, 20.5% are Anthem, Inc. members.

Source: AIS’s Directory of Health Plans

Inside the CDC’s Battle to Defeat the Virus

April 1, 2021

It’s been a long year for basically everyone — and especially for Dr. Henry Walke. For months on end, Walke has been pulling 13-hour work days as the COVID-19 incident response manager at the Centers for Disease Control and Prevention, a job he took on last July.

He never expected the job to last this long. “The scale of this pandemic is mind-boggling, and it’s affected all of us — every facet of our work and home,” he says.

It’s been a long year for basically everyone — and especially for Dr. Henry Walke. For months on end, Walke has been pulling 13-hour work days as the COVID-19 incident response manager at the Centers for Disease Control and Prevention, a job he took on last July.

He never expected the job to last this long. “The scale of this pandemic is mind-boggling, and it’s affected all of us — every facet of our work and home,” he says.

Walke is heading up the largest and most challenging outbreak response in the agency’s history — an all-agency effort involving more than 8,000 employees, working to guide the U.S. out of a public health emergency that has claimed more than 550,000 lives….

Read the full NPR article