Distrusting Trump, States Plan to Vet COVID Vaccines Themselves. Bad Idea, Say Experts.

October 7, 2020

As trust in the Food and Drug Administration wavers, several states have vowed to conduct independent reviews of any COVID-19 vaccine the federal agency authorizes.

But top health experts say such vetting may be misguided, even if it reflects a well-founded lack of confidence in the Trump administration — especially now that the FDA has held firm with rules that make a risky preelection vaccine release highly unlikely.

As trust in the Food and Drug Administration wavers, several states have vowed to conduct independent reviews of any COVID-19 vaccine the federal agency authorizes.

But top health experts say such vetting may be misguided, even if it reflects a well-founded lack of confidence in the Trump administration — especially now that the FDA has held firm with rules that make a risky preelection vaccine release highly unlikely.

At least six states and the District of Columbia have indicated they intend to review the scientific data for any vaccine approved to fight COVID-19, with some citing concern over political interference by President Donald Trump and his appointees. Officials in New York and California said they are convening expert panels expressly for that purpose….

Read the full Kaiser Health News article

Datapoint: MVP to Offer New Group Risk Products in Vermont

October 7, 2020

MVP Health Care last week said it is partnering with Health Plans, Inc. to bring new level-funded employer group plans to the state of Vermont. MVP is currently the third-largest insurer in Vermont, with 40,193 members. It enrolls 35.2% of the state’s group risk commercial market.

MVP Health Care last week said it is partnering with Health Plans, Inc. to bring new level-funded employer group plans to the state of Vermont. MVP is currently the third-largest insurer in Vermont, with 40,193 members. It enrolls 35.2% of the state’s group risk commercial market.

Source: AIS’s Directory of Health Plans

COVID-19 Pandemic May Lower Health Care Costs, But Deferral Impact Exists

October 7, 2020

Health insurers will probably have lower health care expenditures in 2020 and 2021 than before the COVID-19 pandemic, according to a new analysis from Willis Towers Watson. However, the white paper emphasizes that substantial risk is still possible and says plan sponsors need to take proactive steps to blunt the future impact of deferred care.

The policy environment could change suddenly and dramatically depending on the outcome of California v. Texas, a suit that could lead the Supreme Court to overturn the Affordable Care Act, and the presidential election.

By Peter Johnson

Health insurers will probably have lower health care expenditures in 2020 and 2021 than before the COVID-19 pandemic, according to a new analysis from Willis Towers Watson. However, the white paper emphasizes that substantial risk is still possible and says plan sponsors need to take proactive steps to blunt the future impact of deferred care.

The policy environment could change suddenly and dramatically depending on the outcome of California v. Texas, a suit that could lead the Supreme Court to overturn the Affordable Care Act, and the presidential election.

“Pursuant to the upcoming case on the ACA, and obviously the current Supreme Court nomination and whether or not it gets through — so many major factors really put a lot of these pieces into an unknown place,” says Trevis Parson, Willis Towers Watson’s managing director and chief actuary for health and benefits, who coauthored the analysis.

According to the paper, “the likelihood of deferred care returning to the system will vary based on the type of care. In fact, we expect that a significant portion of deferred care will be completely forgone and never return. Further, the return time will depend on status of the pandemic, system capacity, public policy, patient willingness to visit care settings and the urgency of the need for care.”

Worryingly, the paper found that “the largest decreases in utilization have been in preventive care and other office-based services.” Parson says plan sponsors were not doing a very good job emphasizing preventive care and holistic health before the pandemic, and the care deferrals could make that problem worse.

The paper also attempts to project the short- and middle-term impact of the pandemic on utilization. Parson and coauthor Jeff Levin-Scherz, M.D., the North America co-leader of the health management practice at Willis Towers Watson, modeled four scenarios, and found that any of the four scenarios would result in a 2.7% to 3.8% net decrease in medical costs per member over the course of the combined two years.

These findings are welcome news to health insurance stakeholders, as previous projections of the pandemic’s costs were much more catastrophic. However, Parson urges plan sponsors to resist complacency — a point he regards as the “key message” of the paper.

Datapoint: Gateway Health Plots D-SNP Expansion

October 6, 2020

Pittsburgh-based Gateway Health Plan, Inc. last week revealed plans to expand its Dual Eligible Special Needs Plan (D-SNP) to nine new counties in Pennsylvania in 2021. The insurer said its D-SNPs will also offer enhanced benefits, such as no-cost hearing aids, home safety items, transportation to medical appointments and nutrition counseling. Gateway Health is the largest duals insurer in Pennsylvania, with 46,369 members, or 27.6% of the statewide market.

Pittsburgh-based Gateway Health Plan, Inc. last week revealed plans to expand its Dual Eligible Special Needs Plan (D-SNP) to nine new counties in Pennsylvania in 2021. The insurer said its D-SNPs will also offer enhanced benefits, such as no-cost hearing aids, home safety items, transportation to medical appointments and nutrition counseling. Gateway Health is the largest duals insurer in Pennsylvania, with 46,369 members, or 27.6% of the statewide market.

Source: AIS’s Directory of Health Plans

Major Blues Plans May Gain Opportunities From Tentative Antitrust Settlement

October 6, 2020

The Blue Cross and Blue Shield Association (BCBSA) has reportedly reached a tentative settlement in a lengthy legal battle over whether its member plans engage in anticompetitive business practices.

The lawsuit in question was filed in 2012 on behalf of employers and policyholders who took issue with Blues plans’ agreement to divide the country among the association’s 36 members and to restrict members’ ability to offer non-Blues products. A related lawsuit filed by health care providers alleged that the Blues’ anticompetitive practices improperly depressed their reimbursement.

The Blue Cross and Blue Shield Association (BCBSA) has reportedly reached a tentative settlement in a lengthy legal battle over whether its member plans engage in anticompetitive business practices.

The lawsuit in question was filed in 2012 on behalf of employers and policyholders who took issue with Blues plans’ agreement to divide the country among the association’s 36 members and to restrict members’ ability to offer non-Blues products. A related lawsuit filed by health care providers alleged that the Blues’ anticompetitive practices improperly depressed their reimbursement.

On Sept. 24, the Wall Street Journal reported that BCBSA negotiated a tentative agreement in which it would pay $2.7 billion to the employer/policyholder plaintiffs. BCBSA also reportedly agreed to:

Relax rules that currently require a national employer to work through the Blues insurer where its headquarters are located when seeking coverage from a Blues plan;

Allow certain national employers to request a bid from a second Blues insurer of their choice when seeking coverage; and

Abandon the rule that requires member plans to derive at least two-thirds of their national health insurance revenue from Blues brands.

Jay Godla, a partner at Strategy&, PwC’s strategy consulting practice, tells AIS Health that the “bigger Blues are obviously very thrilled about the idea of lifting restrictions on the two-thirds rule, because that allows them to grow.”

But there are bigger question marks surrounding how the settlement would affect the national accounts market, according to Godla, who says he could see three primary ways that would play out. Under one scenario, a smaller Blues plan would team up with a larger one in order to enter the national accounts market. Or there could be “account-level collaboration,” in which a smaller Blues plan partners with a larger organization to pursue the business of select national employers. And “the third thing is free for all, where Anthem is competing with Blue Cross Blue Shield of Michigan for autos in Michigan,” Godla says, referring to Detroit-based large employers such as General Motors or Chrysler Group. That last scenario, he says, is probably the least likely.

But Credit Suisse’s A.J. Rice, in a research note to investors, wrote that Anthem “and other well-capitalized Blue plans may be able to compete more aggressively in the markets of other Blue plans if they choose to.”

Datapoint: Nucala Scores FDA Nod for Hypereosinophilic Syndrome

October 5, 2020

The FDA last week approved GlaxoSmithKline’s immunology powerhouse, Nucala, for the treatment of hypereosinophilic syndrome (HES), a rare white blood cell disease. This latest nod gives Nucala an edge over one of its strongest competitors, AstraZeneca’s Fasenra, which is also pursuing HES approval. Nucala is best known for its treatment of eosinophilic asthma, where it holds preferred status under the pharmacy benefit for 2% of covered lives, growing to 31% with utilization management restrictions.

The FDA last week approved GlaxoSmithKline’s immunology powerhouse, Nucala, for the treatment of hypereosinophilic syndrome (HES), a rare white blood cell disease. This latest nod gives Nucala an edge over one of its strongest competitors, AstraZeneca’s Fasenra, which is also pursuing HES approval. Nucala is best known for its treatment of eosinophilic asthma, where it holds preferred status under the pharmacy benefit for 2% of covered lives, growing to 31% with utilization management restrictions.

SOURCE: MMIT Analytics, as of 9/30/20

Surprise Billing Reform Could Reduce Billions in Premiums, Study Shows

October 5, 2020

A study published Sept. 11 in the American Journal of Managed Care found that a federal law to rein in surprise medical billing could reduce overall health insurance premiums by 1% to 5%.

The study, which was prepared by researchers at the USC-Brookings Schaeffer Initiative for Health Policy, is based on 2017 data compiled by the Health Care Cost Institute, which is drawn from claims submitted to UnitedHealthcare, Humana Inc. and CVS Health Corp.’s Aetna.

By Peter Johnson

A study published Sept. 11 in the American Journal of Managed Care found that a federal law to rein in surprise medical billing could reduce overall health insurance premiums by 1% to 5%.

The study, which was prepared by researchers at the USC-Brookings Schaeffer Initiative for Health Policy, is based on 2017 data compiled by the Health Care Cost Institute, which is drawn from claims submitted to UnitedHealthcare, Humana Inc. and CVS Health Corp.’s Aetna.

The cost reduction finding is based on a model that assumes new legislation would reduce procedures that are currently surprise billed either by 15% altogether, or reduce their costs to 150% of traditional Medicare rates. In the former scenario, legislation would save commercially insured members about $12 billion, and in the latter, those members would save roughly $38 billion.

Loren Adler, a fellow at the USC-Brookings Schaeffer Initiative for Health Policy and an author of the study, says surprise bills have an underappreciated impact on overall health plan spending.

“Fundamentally, surprise billing is obviously awful for the people who receive the surprise bills themselves. But this study shows that we’re talking about a pretty substantial effect on premiums,” he adds.

“To me, what really matters is, how much money would you save per member per year if you could get the average payment [of surprise bills] down to what the average payment is for in-network physicians? [The study’s] number is $212 per member per year,” says Joseph Antos, a resident scholar at the American Enterprise Institute.

Antos points out that providers who surprise bill are acting rationally in an unfair set of economic conditions that is enabled by a failure of government.

That gap in the rules has not gone unnoticed by public officials, but Washington, D.C. insiders say that surprise billing legislation isn’t likely to advance any time soon. Many were hopeful that surprise billing legislation would pass Congress by now, but progress has stalled.

“It feels very unlikely that anything constructive is going to be done in health care legislatively at this point, just given everything else that is going on and given that we’re so close to the election. I think that we’re looking into a window of lame duck or into the next session,” says Avalere founder Dan Mendelson.

People on the Move

October 2, 2020

A Closer Look at COVID-19 Diagnostic, Antibody Testing Charges

October 2, 2020

The rates that providers and laboratories charge for COVID-19 diagnostic and antibody testing — prices that “have important implications for out-of-network plans, uninsured patients, and other payers with little negotiating power” because of provisions in the CARES Act — far exceeded their Medicare reimbursement rates, according to a recent study published in the Society of General Internal Medicine. By analyzing administrative claims data from the COVID-19 Research Database, the study found that independent labs — which performed almost half of all COVID-19 diagnostic tests — charged $140.41 on average, while the Medicare rate was $51.31. Independent labs performed more than 95% of all antibody tests, with an average charge of $62.30, compared to the Medicare rate of $42.13. Across the country, average diagnostic testing fees ranged by state, from a low of $64.98 in Utah to a high of $505.65 in Washington, D.C. For antibody testing, New Mexico providers and labs charged an average of $195.41, more than four times of the average charge in New York ($45.85).

by Jinghong Chen

The rates that providers and laboratories charge for COVID-19 diagnostic and antibody testing — prices that “have important implications for out-of-network plans, uninsured patients, and other payers with little negotiating power” because of provisions in the CARES Act — far exceeded their Medicare reimbursement rates, according to a recent study published in the Society of General Internal Medicine. By analyzing administrative claims data from the COVID-19 Research Database, the study found that independent labs — which performed almost half of all COVID-19 diagnostic tests — charged $140.41 on average, while the Medicare rate was $51.31. Independent labs performed more than 95% of all antibody tests, with an average charge of $62.30, compared to the Medicare rate of $42.13. Across the country, average diagnostic testing fees ranged by state, from a low of $64.98 in Utah to a high of $505.65 in Washington, D.C. For antibody testing, New Mexico providers and labs charged an average of $195.41, more than four times of the average charge in New York ($45.85).

NOTES: States that had 10 or fewer claims were classified as “no data.” This study was funded by Arnold Ventures.

SOURCE: “Charges of COVID-19 Diagnostic Testing and Antibody Testing Across Facility Types and States,” Society of General Internal Medicine 2020, DOI: 10.1007/s11606-020-06198-y. Visit https://bit.ly/32WJtEH.

Datapoint: Molina to Acquire Affinity Health Plan

October 1, 2020

Molina Healthcare last week said it has entered an agreement to acquire all assets of Affinity Health Plan, a Medicaid managed care plan in New York that currently serves 285,035 members. This is the latest in a string of acquisitions for Molina, which has also made deals with Kentucky’s Passport Health Plan, Illinois’ NextLevel Health and the multistate Magellan Complete Care. With the Affinity deal, Molina is also quickly ramping up its New York Medicaid market presence — the insurer completed its acquisition of YourCare Health Plan in July 2020. Molina is currently the fifth-largest managed Medicaid insurer in the U.S., with 3,046,020 members.

Molina Healthcare this week said it has entered an agreement to acquire all assets of Affinity Health Plan, a Medicaid managed care plan in New York that currently serves 285,035 members. This is the latest in a string of acquisitions for Molina, which has also made deals with Kentucky’s Passport Health Plan, Illinois’ NextLevel Health and the multistate Magellan Complete Care. With the Affinity deal, Molina is also quickly ramping up its New York Medicaid market presence — the insurer completed its acquisition of YourCare Health Plan in July 2020. Molina is currently the fifth-largest managed Medicaid insurer in the U.S., with 3,046,020 members.

Source: AIS’s Directory of Health Plans