Health Plan Weekly

Premera Blue Cross, Other Blues Apply Artificial Intelligence to Guide Better Care

March 7, 2019

Premera Blue Cross has broadened its partnership with predictive health care analytics startup Cardinal Analytx Solutions with a view toward identifying why certain individuals have extreme escalations in medical treatment.

Cardinal Analytx’s machine learning models “can predict members with near-term care needs, accurately and consistently over time,” says Colt Courtright, director of corporate data and analytics at Premera.

By Jane Anderson

Premera Blue Cross has broadened its partnership with predictive health care analytics startup Cardinal Analytx Solutions with a view toward identifying why certain individuals have extreme escalations in medical treatment.

Cardinal Analytx’s machine learning models “can predict members with near-term care needs, accurately and consistently over time,” says Colt Courtright, director of corporate data and analytics at Premera. He adds that the Blues plan has found these members are willing to engage in care management support. This indicates the program both will help members and eventually show a population-level return on investment, he says.

Premera and Cardinal are exploring whether to provide primary care physicians with the information, says Nigam Shah, M.D., who founded Cardinal Analytx with lead investor Cardinal Partners. Ultimately, “we want to use AI to improve a patient’s health trajectory, empower the PCP with more information, and remove clinical and financial burdens on the patient,” Courtright says.

At BlueCross BlueShield of Western New York and BlueShield of Northeastern New York, data teams now are able to identify members who are pre-diabetic through predictive analytics, and then engage them to ensure a proper care plan is in place, says Adam Dunning, director of health care economics for the New York Blues plans.

Meanwhile, Health Care Service Corp. has focused on analytics for providers “to make it easier for providers to gain insight into their quality of care and close care gaps,” according to Gary Stanford, vice president and actuary, HCSC provider network analytics.

Insurers Work with Communities to Address Food Insecurity

March 5, 2019

As part of their efforts to address the social factors affecting members’ lives, some health insurers are deploying a variety of initiatives to improve access to healthy food. A common thread among insurers that AIS Health spoke to was the importance of working alongside community organizations — rather than trying to duplicate their efforts.

UCare, for example, is working with a group called Second Harvest Heartland on programs aimed at addressing food insecurity among its members, most of whom are Medicaid beneficiaries.

By Leslie Small

As part of their efforts to address the social factors affecting members’ lives, some health insurers are deploying a variety of initiatives to improve access to healthy food. A common thread among insurers that AIS Health spoke to was the importance of working alongside community organizations — rather than trying to duplicate their efforts.

UCare, for example, is working with a group called Second Harvest Heartland on programs aimed at addressing food insecurity among its members, most of whom are Medicaid beneficiaries.

One way the two organizations are collaborating is an effort to connect qualifying members to the federal Supplemental Nutrition Assistance Program and other community resources, says Nicole Lier, health promotion manager at UCare.

The insurer and Second Harvest also started a program called FoodRx, which focuses on members who have been diagnosed with high blood pressure. A nutritionist puts together boxes packed with food, educational materials and recipes, Lier says, and members involved in the program get one free box delivered to their home each month.

While UCare’s projects focus on adults, Cigna Corp. is working on tackling food insecurity in children.

The insurer in January kicked off a $25 million, five-year global initiative, called Healthier Kids for Our Future, with a one-day event in which its employees collaborated with the nonprofit Blessings in a Backpack to fill 16,500 backpacks with food for elementary school children who might otherwise go hungry on weekends. As part of the broader initiative, Cigna plans to work with school districts around the country to help fight childhood hunger.

What Utah’s Move to Restrict Medicaid Expansion May Mean for MCOs

February 28, 2019

In November’s midterm elections, Utah voters approved a ballot initiative to expand Medicaid. Now, though, Utah has passed a law that requires state officials to apply for a waiver that would implement a more limited form of Medicaid expansion, which could make things tricky for the state’s Medicaid managed care organizations.

Utah’s new law directs the state to submit a Section 1115 waiver application that seeks to cover a capped number of nonelderly adults with incomes of up to 100% of the federal poverty level (FPL), rather than at 138% of the FPL under full Medicaid expansion.

By Leslie Small

In November’s midterm elections, Utah voters approved a ballot initiative to expand Medicaid. Now, though, Utah has passed a law that requires state officials to apply for a waiver that would implement a more limited form of Medicaid expansion, which could make things tricky for the state’s Medicaid managed care organizations.

Utah’s new law directs the state to submit a Section 1115 waiver application that seeks to cover a capped number of nonelderly adults with incomes of up to 100% of the federal poverty level (FPL), rather than at 138% of the FPL under full Medicaid expansion.

If CMS doesn’t approve that waiver request, full Medicaid expansion would go into effect, but with some caveats. If that, too, fails to gain federal approval, an unrestricted form of Medicaid expansion would go into effect by July 1, 2020.

“Uncertainty is definitely the first word that comes to mind,” Patricia Boozang, a senior managing director at Manatt Health, tells AIS Health when asked how Utah’s legislation will affect the state’s Medicaid MCOs.

One potential source of that uncertainty is whether Utah’s waiver request will get approved — making it unclear when the state’s Medicaid expansion will occur, she says. And if Utah’s waiver is approved, it could see legal challenges similar to those challenging Kentucky and Arkansas’ work requirements waivers, creating another source of uncertainty, Boozang notes.

“In Kentucky, for instance, they’re really relying on their health plans to implement features of their waiver, and there has been at least two starts and stops” due to litigation, she says.

CVS Launches ‘HealthHUB’ Stores, Reports 4Q Earnings

February 27, 2019

Despite some skepticism from Wall Street over headwinds primarily arising from its long-term-care pharmacy, along with soft 2019 profit guidance and overhanging debt from its $70 billion acquisition of Aetna Inc., CVS Health Corp. touted its strong long-term viability during its fourth quarter and full-year 2018 earnings call.

The company recently launched three “concept stores” in Houston, which are set to pilot many of the health care services that the company anticipates offering together with Aetna. Each store has an expanded health clinic, lab and wellness rooms for yoga and seminars, and offers in-person counseling with clinicians and more.

By Judy Packer-Tursman

Despite some skepticism from Wall Street over headwinds primarily arising from its long-term-care pharmacy, along with soft 2019 profit guidance and overhanging debt from its $70 billion acquisition of Aetna Inc., CVS Health Corp. touted its strong long-term viability during its fourth quarter and full-year 2018 earnings call.

The company recently launched three “concept stores” in Houston, which are set to pilot many of the health care services that the company anticipates offering together with Aetna. Each store has an expanded health clinic, lab and wellness rooms for yoga and seminars, and offers in-person counseling with clinicians and more.

CVS President and CEO Larry Merlo cautioned “it’s still early as we’re in the learning phase and working to define a hub-and-spoke approach, but it’s an example of the work underway.”

Industry consultant Ashraf Shehata, a principal in KPMG’s health care and life sciences advisory practice and a partner at the firm’s Global Healthcare Center of Excellence, says CVS offers a prime example of how organizations throughout the health care field are working to position themselves.

The open-ended question is where consumers will gravitate. “If retail will be the ‘new front door’ to the health care system, that could be quite disruptive,” he says. Consumer behavior is being redefined, and the process is being driven by millennials and baby boomers — and everyone in between. Thus, he says, “This will have to be a very accommodating ‘front door.’”

For the quarter ended Dec. 31, CVS reported a net loss of $421 million on revenues that increased 12.5% to $54.4 billion year over year.

CMS Interoperability Proposal Could Bring Challenges for Insurers

February 26, 2019

Recently, the Trump administration issued new proposed regulations that aim to promote interoperability in the health care industry. But industry experts tell AIS Health that task might be easier said than done, and it could come with high costs for smaller health plans that lack hefty IT budgets.

One provision in the new proposal would require Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and qualified health plan issuers in the federally facilitated exchanges to implement, test and monitor application programming interfaces (APIs) “to make patient claims and other health information available to patients through third-party applications and developers.”

By Leslie Small

Recently, the Trump administration issued new proposed regulations that aim to promote interoperability in the health care industry. But industry experts tell AIS Health that task might be easier said than done, and it could come with high costs for smaller health plans that lack hefty IT budgets.

One provision in the new proposal would require Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and qualified health plan issuers in the federally facilitated exchanges to implement, test and monitor application programming interfaces (APIs) “to make patient claims and other health information available to patients through third-party applications and developers.”

Levin, M.D., chief medical officer of Sansoro Health, says the first challenge for insurers to comply with the new requirements is that organizations will need to understand where to go get the data, “and my guess is that varies quite a bit, and there’s probably the usual data governance and data quality issues around that.”

Second, some entity has to find a software solution that will create an API, populate it and share that data. Larger insurers might have the ability to do those tasks on their own, but it would be a challenge for smaller plans, Levin says.

Managed care expert Peter Kongstvedt says his “biggest worry” is that complying with CMS’s proposal will strain smaller insurers’ IT budgets. “If it’s something that we want to do, we should find a way to protect the smaller plans if we want to have a competitive marketplace,” he says.