Datapoint

Two large regional health systems, New Mexico-based Presbyterian Healthcare Services and UnityPoint Health, which serves the upper Midwest, have agreed to “explore the formation of a new healthcare organization,” according to a March 2 press release. The combination would create a parent company for the two nonprofit systems, which hold 48 hospitals between them. Both systems also operate health insurance units. Presbyterian Health Plan is one of the largest insurers in New Mexico, serving 581,174 members in commercial plans and the state’s managed Medicaid program. UnityPoint, meanwhile, is a co-owner of Quartz Health Solutions, Inc., alongside Gundersen Health System and UW Health. Quartz currently enrolls 361,832 members throughout Wisconsin, Illinois, Minnesota and Iowa.

The FDA on March 3 expanded Eli Lilly’s Verzenio’s use in hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-), node-positive, early breast cancer in patients that have a high risk of recurrence. Patients will no longer require a Ki-67 biomarker test to receive the drug, and will instead be identified based on nodal status, tumor size and grade. Verzenio was first approved as an adjuvant breast cancer therapy in 2021. The CDK4/6 inhibitor currently holds covered or better status for 97% of all insured lives under the pharmacy benefit. 15% of lives have preferred access to Verzenio, growing to 39% with utilization management restrictions applied.

CareFirst BlueCross BlueShield, the largest insurer in Maryland, is partnering with Aledade Inc., an independent primary care network, on a new value-based care initiative. Providers in CareFirst’s network will have access to Aledade’s technology platform to better manage electronic health records and onsite business support for their practices. The initiative will also focus on preventive care and helping patients avoid unnecessary hospitalizations using Aledade’s data analytics capabilities. CareFirst currently serves 2,991,793 lives across Maryland, northern Virginia and Washington, D.C. 45% of its members are enrolled in commercial risk-based plans.

A federal judge in Delaware tossed Johnson & Johnson’s initial motion in its patent suit against Amgen Inc.’s Stelara biosimilar, citing J&J’s “failure to comply” with the court’s rules on page limits. While J&J will have to refile the motion, the decision is likely just a minor setback. Stelara was J&J’s top-selling drug in 2022, bringing in $9.7 billion in worldwide sales. Evaluate Pharma projects revenue will begin to decline in 2024, with biosimilars from Biocon and Alvotech poised to launch as early as the second half of this year. The FDA has yet to approve any Stelara copies, but a decision on Amgen’s drug is expected in the next few months. Stelara was first approved in September 2009 for the treatment of moderate to severe plaque psoriasis, an indication for which it currently holds covered or better status for 77% of all insured lives under the medical benefit.

State legislators in North Carolina have struck a deal to expand Medicaid in the state, although the measure won’t be voted on until later this month at the earliest. Democrats and Republicans came together on the deal, which outlines that the state’s 10% share of covering the Medicaid expansion population would be paid through assessments on hospitals. North Carolina currently serves 2,321,805 Medicaid beneficiaries, with 77.1% enrolled in managed care plans. The state estimates the expansion deal will bring health coverage to about 600,000 people.

Blue Cross and Blue Shield of Minnesota and Homeward, a value-based care platform that focuses on reaching rural Americans, are collaborating to improve health access for rural Minnesotans. Homeward provides in-home visits, community-based visits and telehealth services, which will become available to Blue Cross’s Medicare Advantage members in 24 Minnesota counties. Homeward also provides care coordination services such as referrals and outpatient support. BCBS Minnesota is the largest Medicare Advantage insurer in its home state, serving 207,564 members.

Walmart and CareSource, one of the largest Medicaid insurers in the U.S., this week unveiled a new three-year partnership to address racial inequalities in health care. Select CareSource members enrolled in Medicaid, Medicare Advantage and exchange plans will have access to in-store community health workers at Walmart locations, monthly food stipends and a Walmart+ membership. The joint venture will kick off in Ohio, focusing on cardiovascular and metabolic conditions such as heart disease, stroke, diabetes and hypertension. CareSource is the largest Medicaid insurer in Ohio, serving 1,428,871 beneficiaries. The companies are also planning a maternal and child health program in Georgia, where CareSource serves 468,738 Medicaid members.

A recent survey from the Urban Institute found that more than 6 in 10 adults in Medicaid-enrolled families were not aware of the resumption of Medicaid eligibility redeterminations, a rate that has not changed much since June 2022. Medicaid rolls have skyrocketed since the outset of the COVID-19 pandemic, and states have been prohibited from conducting regular Medicaid eligibility checks throughout the public health emergency. As of February 2023, 94.6 million people receive full Medicaid or CHIP benefits in the U.S.

Humana Inc. on Feb. 23 said it will exit the commercial insurance business and focus exclusively on government books of business, cutting its membership rolls by about 8%. This includes all of the insurer’s fully insured, self-funded and Federal Employee Health Benefit plans (FEHBP). Humana currently covers 574,500 members in full-risk commercial products, 438,600 self-funded members and 20,008 FEHBP members. The move will not affect Humana’s TRICARE contract, which serves more than 5.9 million lives on a self-funded basis.

The West Virginia House of Representatives earlier this month introduced a bill that would create a Medicaid buy-in program aiming to help residents impacted by Medicaid redeterminations, according to a Feb. 17 report from West Virginia Public Broadcasting. Those losing Medicaid coverage and earning less than 200% of the federal poverty level would become eligible for the program. “There’s individuals that will…try to keep their income below to keep their insurance,” Cindy Beane, commissioner of West Virginia’s Bureau for Medical Services, told the outlet. “And that’s not what we want, we want people to have good jobs, be proud of their jobs and have a career and you don’t want health care being the barrier to that.” West Virginia currently serves 625,471 Medicaid beneficiaries, with 80.3% enrolled in managed care plans.