Health Plan Weekly

BMA, Avalere Report Shows MA Outperformance on Multiple Care Measures

December 23, 2020

A new study from Avalere Health comparing quality outcomes for Medicare Advantage enrollees vs. traditional fee-for-service (FFS) Medicare beneficiaries found that high-need, high-cost populations enrolled in MA had better care experiences for most clinical quality measures and had significantly higher rates of preventive screenings for several measures. While MA didn’t outperform FFS across all measures, the findings suggest that care management in MA results in higher quality of care for this vulnerable population, observed the report.

By Lauren Flynn Kelly

A new study from Avalere Health comparing quality outcomes for Medicare Advantage enrollees vs. traditional fee-for-service (FFS) Medicare beneficiaries found that high-need, high-cost populations enrolled in MA had better care experiences for most clinical quality measures and had significantly higher rates of preventive screenings for several measures. While MA didn’t outperform FFS across all measures, the findings suggest that care management in MA results in higher quality of care for this vulnerable population, observed the report.

Commissioned by Better Medicare Alliance (BMA), the independent analysis compared performance for similar beneficiaries in three categories: preventive screening and therapy services; inpatient and outpatient services; and management of prescription drugs. Avalere used propensity score matching to control for differences between the MA and traditional FFS population and drew from a nationally representative sample of beneficiaries, resulting in a “matched” study population of 1,262,180 in each group.

Avalere then divided beneficiaries into five clinical segments and focused its findings on three groups in particular: individuals who are under 65 and enrolled in Medicare due to a disability, the frail elderly, and those with chronic, complex conditions.

The study found that “high-cost, high-need” beneficiaries had significantly higher rates of preventive screening compared with similar populations in FFS Medicare. For example, 74% of beneficiaries with major complex chronic conditions and 71% of frail elderly in MA received a pneumonia vaccine, while 49% and 48% of similar beneficiaries, respectively, in FFS received the vaccine. But not all differences were that notable: 77% of the overall FFS population received a cholesterol screening, compared with 75% of MA enrollees, and those results varied across the three high-need groups. On the therapy services side, while the overall MA population had higher rates of initiating treatment for substance misuse or dependence, they were less likely to remain engaged with such treatment.

In addition, the study found that high-need, high-cost MA beneficiaries had substantially lower rates of avoidable hospitalizations and readmissions compared to their FFS counterparts. For example, the average rates of avoidable hospitalizations for acute and chronic conditions among those with major complex chronic conditions were 57% and 45%, respectively, below traditional FFS Medicare. Avalere also found that emergency room visits and costs were significantly greater for frail elderly beneficiaries in MA compared to FFS Medicare.

Biden Probably Won’t Roll Back New Prior Authorization Proposal

December 22, 2020

Building on previously finalized regulations aimed at advancing data interoperability in health care, CMS on Dec. 10 proposed a new rule that would require certain health plans to make their prior authorization processes more efficient and share even more data with providers and patients.

If finalized, the rule would apply only to managed care Medicaid and CHIP plans, fee-for-service Medicaid and CHIP plans, and Qualified Health Plans (QHPs) on the federally facilitated exchanges.

By Leslie Small

Building on previously finalized regulations aimed at advancing data interoperability in health care, CMS on Dec. 10 proposed a new rule that would require certain health plans to make their prior authorization processes more efficient and share even more data with providers and patients.

If finalized, the rule would apply only to managed care Medicaid and CHIP plans, fee-for-service Medicaid and CHIP plans, and Qualified Health Plans (QHPs) on the federally facilitated exchanges.

“The proposed rule is a welcome step toward helping clinicians spend their limited time on patient care,” the American Hospital Association said in a statement, adding that “we are deeply disappointed, however, that CMS chose not to include Medicare Advantage plans.”

The new proposal builds on an interoperability rule that CMS finalized in May. That rule requires Medicaid, CHIP, QHP and MA plans to share claims and other health information with patients through a Patient Access API, which will allow them to obtain their data through any third-party application they choose.

Under the new rule, starting Jan. 1, 2023, affected payers would have to include information in their already established Patient Access APIs about patients’ pending and active prior authorization decisions.

The rule would also make several changes to streamline the prior authorization process itself. As a press release from CMS explained, Medicaid, CHIP and QHP payers would be required to build and implement APIs that “allow providers to know in advance what documentation would be needed for each different health insurance payer, streamline the documentation process, and enable providers to send prior authorization requests and receive responses electronically.”

Although the incoming Biden administration could opt to reverse some of the more controversial regulations issued by the Trump administration in recent weeks, Andrew Van Ostrand, a principal in Avalere Health’s policy practice, says he doesn’t expect this latest rule will be among them.

The official comment period for the rule closes on Jan. 4, so CMS is likely to be able to finalize it before President-elect Joe Biden’s inauguration on Jan. 20, he says. “I also think that this larger issue of data interoperability…that’s been a bright spot from a bipartisan perspective.”

Therefore, “I do expect a Biden administration to carry these initiatives forward and build on them,” Van Ostrand says. However, he says there could be “tweaks to deadlines and tweaks to specific requirements.”

Biden’s HHS Nominee Xavier Becerra Is Known for Backing ACA

December 16, 2020

Health care insiders praised President-elect Joe Biden’s decision to nominate California Attorney General Xavier Becerra, a Democrat, to be the next HHS secretary. Though he is not a specialist in health care, experts say Becerra brings relevant expertise to HHS.

Since his appointment in 2016 as California’s attorney general, Becerra defended the Affordable Care Act (ACA) from a legal challenge in the case now known as California v. Texas. In 2018, Becerra sued California nonprofit hospital giant Sutter Health over allegations of anticompetitive business practices and high prices for care.

By Peter Johnson

Health care insiders praised President-elect Joe Biden’s decision to nominate California Attorney General Xavier Becerra, a Democrat, to be the next HHS secretary. Though he is not a specialist in health care, experts say Becerra brings relevant expertise to HHS.

Since his appointment in 2016 as California’s attorney general, Becerra defended the Affordable Care Act (ACA) from a legal challenge in the case now known as California v. Texas. In 2018, Becerra sued California nonprofit hospital giant Sutter Health over allegations of anticompetitive business practices and high prices for care.

Becerra’s nomination was generally well-received by health care insiders, including payer groups.

Citi analyst Ralph Giacobbe wrote that the nomination lends credence to the consensus that the Biden administration’s main health care policy goal will be bolstering the ACA.

“We view Becerra’s role in leading the Democratic states in defending the ACA in the ongoing lawsuit as an incremental signal of the Biden administration’s continued support of the ACA and continue to expect the new administration to be focused on increasing coverage through building on the ACA and leveraging existing platforms to expand upon the Medicaid program and modernize the Exchanges,” Giacobbe opined in a Dec. 7 investor note.

Dan Mendelson, founder of consultancy Avalere Health, says that Becerra’s relationships on Capitol Hill will be helpful to the new administration.

“If they’re going to make progress on the uninsured and passing significant COVID relief, they’re going to need to have strong relationships with legislators, and they’re going to need to figure out what is the art of the possible,” Mendelson says. “I think he’ll be very good at that. Having political experience really helps.”

Becerra’s role in the Sutter Health suit could indicate that the administration will take an aggressive approach to combatting hospital consolidation, according to Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy.

However, “the HHS secretary does not have complete control over health policy in the United States,” Mendelson notes. “With that said, there’s been a real laxity in federal enforcement around antitrust in the provider space. It’s of concern to a lot of plans, and a lot of [regional] markets are becoming monopolies or duopolies. That’s something that I do think [Becerra] will touch.”

First Round of Vaccines Are Expected to Be Free to the Public

December 15, 2020

With FDA issuing emergency use authorization to the coronavirus vaccine from Pfizer Inc. and BioNTech last week and Moderna Inc.’s offering not far behind, in the coming months there will undoubtedly be a variety of vaccines being administered to Americans. But who will be paying for them?

“In the case of the COVID-19 vaccine, there is a very simple take-home message, which is that no one going to get the vaccine will be charged for the vaccine or its administration, no matter what type of insurance they have, or whether they have insurance at all,” Karyn Schwartz, a senior fellow at the Kaiser Family Foundation (KFF), said during a Dec. 3 web briefing.

With FDA issuing emergency use authorization to the coronavirus vaccine from Pfizer Inc. and BioNTech last week and Moderna Inc.’s offering not far behind, in the coming months there will undoubtedly be a variety of vaccines being administered to Americans. But who will be paying for them?

“In the case of the COVID-19 vaccine, there is a very simple take-home message, which is that no one going to get the vaccine will be charged for the vaccine or its administration, no matter what type of insurance they have, or whether they have insurance at all,” Karyn Schwartz, a senior fellow at the Kaiser Family Foundation (KFF), said during a Dec. 3 web briefing.

The U.S. government has already paid for initial doses of coronavirus vaccines, and those doses will be provided for free to providers who will not be allowed to charge consumers for them — though they can bill insurers or the government for administering the vaccine, Schwartz said.

In addition, “some of the usual rules that govern vaccine coverage for people with insurance have been strengthened for the COVID-19 vaccine,” she added.

The Affordable Care Act requires most group and individual market health plans to cover any vaccines recommended by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) without cost sharing, according to a recent KFF issue brief. The federal Coronavirus Aid, Relief, and Economic Security Act builds on that by requiring non-excepted group and individual plans to cover a coronavirus vaccine without cost sharing 15 days after it is recommended by ACIP. CMS also released an Interim Final Rule with Comment Period on Oct. 28 clarifying that even vaccines administered out-of-network must be available without cost-sharing.

ACIP voted to officially recommend the Pfizer/BioNTech vaccine on Dec. 12. The panel is expected to do the same for Moderna if its vaccine is granted an EUA, which means payers won’t be allowed to decide not to cover one over another, Jennifer Kates, KFF’s senior vice president and director of global health and HIV policy, tells AIS Health.

People with Medicare, Medicaid and the uninsured, meanwhile, will also be able to access the government-purchased vaccines free of charge, according to Schwartz.

Employers Show Interest in Moving to ICHRAs

December 10, 2020

Health care industry insiders say that employers of all sizes are beginning to take a serious look at moving some of their health benefits to Individual Coverage Health Reimbursement Arrangements (ICHRAs) starting in 2022.

In July 2019, the Trump administration finalized new regulations for ICHRAs, giving employers greater flexibility to reimburse qualifying employees buying health insurance policies on the individual market.

By Peter Johnson

Health care industry insiders say that employers of all sizes are beginning to take a serious look at moving some of their health benefits to Individual Coverage Health Reimbursement Arrangements (ICHRAs) starting in 2022.

In July 2019, the Trump administration finalized new regulations for ICHRAs, giving employers greater flexibility to reimburse qualifying employees buying health insurance policies on the individual market.

While the new ICHRA regulations took effect starting in the 2020 plan year, adoption has been slow so far. That could be changing: a Nov. 16 survey by Willis Towers Watson of large, national employers found that 15% of respondents are “planning to offer or considering offering ICHRAs to at least some portion of… employees in 2022 or later.”

Jason Karcher, an actuary at Milliman Inc., explains that, while ICHRAs do offer employers a real advantage by reducing the administrative burden of managing health benefits, it’s not clear they save employers money.

“The individual market is frequently more expensive on a benefit-for-benefit basis than what you find on the employer market,” Karcher explains. “So if you’re looking to offer something with value, it’s not like it’s an excellent savings.”

Ashraf Shehata, the national sector leader for health care and life sciences at KPMG, says that the administrative question alone is driving interest in ICHRA. While Shehata agrees that commercial employer plans tend to get better deals on reimbursement, “the feeling is that the offsets to that would be a reduction in administrative costs.”

“I think people are looking for more ways to give consumers choice in their health benefits,” Shehata adds. “The only way to do that today, in a more structured benefits model, will actually drive up your administrative costs as an employer. So if you can forgo some of the tax advantages, but you pick up a reduction of your administrative burden and you empower the employees to select their own plans, that could be a very interesting model.”

Katherine Hempstead, senior policy adviser at the Robert Wood Johnson Foundation, suggests that the incoming Biden administration’s stated intention to peg the benchmark for premium tax credits to the second-lowest cost gold plan instead of the current silver benchmark would make ICHRAs much more appealing to employers, as it would allow enrollees to more easily afford lower-deductible plans.