Health Plan Weekly

MA Insurers Tap Papa Pals to Provide Companionship for Seniors

December 3, 2019

In a bid to improve seniors’ quality of life, Aetna, a division of CVS Health Corp., is partnering with a company called Papa to offer “grandkid-on-demand” services to the health insurer’s Medicare Advantage (MA) members.

Robert Mirsky, M.D., chief medical officer for Medicare at Aetna, says the insurer wants to do more than support seniors living in their homes. “It goes beyond [aging in place], to thriving in place,” he says.

By Aine Cryts

In a bid to improve seniors’ quality of life, Aetna, a division of CVS Health Corp., is partnering with a company called Papa to offer “grandkid-on-demand” services to the health insurer’s Medicare Advantage (MA) members.

Robert Mirsky, M.D., chief medical officer for Medicare at Aetna, says the insurer wants to do more than support seniors living in their homes. “It goes beyond [aging in place], to thriving in place,” he says.

Aetna and other insurers are tackling isolation among seniors, driven by issues from lack of mobility to vision or hearing loss. Mirsky also points out that multiple generations no longer live together in the same home — or even nearby — and that contributes to seniors’ loneliness, which compounds their physical and mental challenges.

The benefit will be available to what Mirsky describes as the payer’s “most vulnerable members,” those who are eligible for Medicare and Medicaid, in six counties in Florida: Broward, Miami-Dade, Orange, Osceola, Palm Beach and Seminole.

MA members will have access to a Papa Pal — typically, a college student — who will come to the senior’s home for up to 10 hours a month to help with tasks such as driving the member to doctor appointments and grocery shopping, or simply to provide companionship.

“We find that members like having different Pals. It helps them keep up with social engagement,” Papa CEO Andrew Parker says.

Papa Pals are the “eyes and ears” of the payer, he adds. Once a Pal enters the senior’s home, they can communicate about concerns such as a ripped carpet, which could cause an unnecessary fall. Pals also warn of potential fraud or abuse experienced by the senior.

The company, which recently completed a $10 million Series A round of funding, has also signed contracts with Humana Inc., Alignment Health Plan, Priority Health and Capital BlueCross, in addition to Aetna.

Trump Administration’s Transparency Rules Are Part of Larger Effort

November 26, 2019

On Nov. 15, the Trump administration released two rules — one final, one proposed — outlining new price transparency requirements for hospitals and health insurers, which the industry has long warned will impede competitive rate negotiations without actually benefiting patients.

By Leslie Small

On Nov. 15, the Trump administration released two rules — one final, one proposed — outlining new price transparency requirements for hospitals and health insurers, which the industry has long warned will impede competitive rate negotiations without actually benefiting patients.

In the proposed rule, slated for publication in the Nov. 27 Federal Register, the administration would require all non-grandfathered group and individual health plans to:
✦ Provide consumers with personalized out-of-pocket cost information for all covered health care items and services through an “internet-based self-service tool” and in paper form upon request, and
✦ Make their negotiated rates with in-network providers and historical allowed amounts to out-of-network providers available to the public in “standardized, regularly updated machine-readable files.”

In a simultaneously issued final rule, the administration outlines transparency requirements for hospitals. It says they must make public, in a machine-readable format, all “standard charges” for items and services — which the rule defines as gross charges, payer-specific negotiated charges, de-identified minimum and maximum negotiated charges, and discounted cash prices. Plus, hospitals will have to publicly post standard charges for at least 300 “shoppable services” in a consumer-friendly format.

Previously, “standard charges” simply meant hospital chargemaster prices, explains David Kaufman, a partner at Laurus Law Group LLC and former general counsel of Blue Cross Blue Shield of Illinois. Whether CMS is allowed to expand that to include negotiated rates is “going to be the key issue” in a court challenge that hospital groups have promised to file, he tells AIS Health.

But while legal challenges could delay or even prevent one or both rules from being implemented, that doesn’t mean health care organizations have nothing to worry about, says attorney Katie Keith, a principal at Keith Policy Solutions, LLC.

“I guess if I was in the industry, I wouldn’t have my head in the sand about this,” she says. “Insurance companies, to the extent that they have not developed these tools and are not working on this and are not focused on transparency, it does seem like they’re going to want to increase focus on it, because I don’t know that every lawsuit will be successful.”

Industry Leaders Mourn Kaiser Permanente CEO Bernard Tyson

November 21, 2019

From California’s governor to America’s Health Insurance Plans (AHIP), tributes poured in following the sudden death of Kaiser Permanente Chairman and CEO Bernard J. Tyson on Nov. 10. In an unusually emotional statement, AHIP’s board said it was “devastated” to learn the news and described Tyson, 60, as “a revered leader.”

The Alliance of Community Health Plans (ACHP), of which Kaiser Permanente is a member, described Tyson as “a visionary leader with a passion for health equity, quality care and serving those in need” whose work had a broad, positive impact on millions of Americans.

By Judy Packer-Tursman

From California’s governor to America’s Health Insurance Plans (AHIP), tributes poured in following the sudden death of Kaiser Permanente Chairman and CEO Bernard J. Tyson on Nov. 10. In an unusually emotional statement, AHIP’s board said it was “devastated” to learn the news and described Tyson, 60, as “a revered leader.”

The Alliance of Community Health Plans (ACHP), of which Kaiser Permanente is a member, described Tyson as “a visionary leader with a passion for health equity, quality care and serving those in need” whose work had a broad, positive impact on millions of Americans.

The board of directors of Kaiser Permanente named Gregory Adams, executive vice president and group president, as interim chairman and CEO.

Tyson, a California native, was the first African American to lead Kaiser Permanente. His tenure in the managed care organization spanned more than three decades; he became CEO in 2013.

“I think that by having the long career at Kaiser Permanente and coming up through the ranks, Bernard always had a deep appreciation for the [integrated] model of care,” says Ceci Connolly, ACHP’s president and CEO. Moreover, Tyson “was always an innovator on data and technology,” focused on getting evidence-based care protocols into the hands of clinical teams, she says.

With his “deep understanding,” Tyson advanced the Kaiser Permanente model’s concepts early on, “and as CEO, he took the power of the model out into the community,” Connolly says.

In June, Kaiser Permanente launched its Thrive Local program that aims to provide coordinated social supports within three years to its members nationally as well as the 68 million people in the communities that Kaiser Permanente serve.

In its latest financials released Nov. 8, Kaiser Permanente reported spending $2.8 billion on community health in 2018.

HCSC and Fidelis Care Launch Efforts to Boost Enrollment

November 19, 2019

While the Affordable Care Act (ACA) exchange market appears to be stabilizing, enrollment in 2019 ACA plans decreased slightly compared with 2018. And, starting in 2017, the Trump administration drastically cut ACA advertising and outreach funding.

Taken together, those events appear to have spurred some insurers to launch efforts aimed at ginning up enrollment.

By Leslie Small

While the Affordable Care Act (ACA) exchange market appears to be stabilizing, enrollment in 2019 ACA plans decreased slightly compared with 2018. And, starting in 2017, the Trump administration drastically cut ACA advertising and outreach funding.

Taken together, those events appear to have spurred some insurers to launch efforts aimed at ginning up enrollment.

For example, Health Care Service Corp. (HCSC) recently unveiled a campaign — called “Be Covered” — that will provide civic associations, schools, places of worship and community leaders with educational materials and other resources to help uninsured and underinsured people navigate the enrollment process. The insurer is also holding events aimed at educating the public about health insurance and preventive care, and offering wellness screenings, family activities and healthy food giveaways.

HCSC-owned Blue Cross and Blue Shield of Texas is taking a lead role in the campaign, as it serves a state that has the highest uninsured rate in the country.

“What we know very clearly is a lot of people — who are actually eligible for that coverage, and who could even be eligible for coverage that’s significantly subsidized — don’t sign up. At the very least, we need to make sure people understand that if they’re eligible, they need to sign up for it,” says Paul Hain, M.D., chief medical officer and divisional senior vice president of market delivery for the Texas Blues plan.

In New York City, Centene Corp.-owned Fidelis Care is bringing its enrollment efforts to people’s doorsteps. The health plan on Nov. 4 unveiled an expanded and rebranded fleet of “mobile outreach centers” as part of its StreetSide RV program.

In more than 39 locations across the New York metropolitan area and Long Island, individuals can apply for or renew coverage individual market and Medicare Advantage coverage, plus have their insurance questions answered, according to a press release from the health plan.

‘Breakthrough’ Cystic Fibrosis Drug Could See High Demand

November 14, 2019

The FDA recently approved a drug therapy for cystic fibrosis (CF) that is being viewed as a “game-changer” for the roughly nine in 10 patients with the rare, progressive disease who might benefit from it. Where does this leave payers facing rising specialty drug costs across the board? Industry experts predict that most payers likely will cover this latest cystic fibrosis treatment option despite an annual price tag topping $300,000.

By Judy Packer-Tursman

The FDA recently approved a drug therapy for cystic fibrosis (CF) that is being viewed as a “game-changer” for the roughly nine in 10 patients with the rare, progressive disease who might benefit from it. Where does this leave payers facing rising specialty drug costs across the board? Industry experts predict that most payers likely will cover this latest cystic fibrosis treatment option despite an annual price tag topping $300,000.

Vertex Pharmaceuticals, Inc.’s Trikafta (elexacaftor/tezacaftor/ivacaftor and ivacaftor), taken as a twice-daily pill regimen, is the first triple combination therapy available to treat patients with the most common cystic fibrosis mutation. The drug directly addresses the underlying cause of the illness — mutations in the CFTR protein.

The FDA approved Trikafta for patients 12 years and older with at least one F508del mutation in the CFTR gene, which is estimated to represent 90% of the cystic fibrosis population — many of whom have had no approved therapeutic options previously.

“From a utilization management standpoint, there is nothing in the marketplace that will be more effective or significantly less costly” than Trikafta, says Yusuf Rashid, R.Ph., vice president of pharmacy and vendor relationship management at Community Health Plan of Washington.

Manu Jain, M.D., professor of medicine and pediatrics at Northwestern University’s Feinberg School of Medicine and director of Northwestern’s adult CF program, expects the payer community generally will approve Trikafta. But coverage “definitely will be uneven,” he says.

According to Jain, certain people on Kalydeco won’t be candidates for the new drug; but most on Symdeko or Orkambi likely will switch to Trikafta.

During Vertex’s third-quarter 2019 earnings call, Vertex’s Chief Commercial Officer Stuart Arbuckle said the first patients have already been prescribed Trikafta by their physicians, “underscoring the strong interest in the medicine.” But he added that such demand for the new product might prompt launch delays.