Datapoint

A new report from the Montana Healthcare Foundation found that the state’s Medicaid expansion reduced emergency room visits by 10 to 30%, as more people were able to use outpatient services. The state expanded Medicaid in 2016, and currently serves 353,760 lives, about one-third of the overall population.

The Medicare Advantage penetration rate reached 46.2% as of April 2022, according to a data release from CMS. Enrollment in original Medicare (fee-for-service) was 30,582,826 in April, compared to 29,188,064 in Medicare Advantage.

Kansas’ Office of the Medicaid Inspector General earlier this month reported that the state paid more than $190 million in eligible claims to its contracted MCOs for home and community-based services. The audit, which tracked services rendered from January 2018 to April 2021, found nearly 3,000 beneficiaries did not have claims filed for a year or more, and should have been removed from the waiver program. Kansas’ three Medicaid MCOs (Aetna, Centene Corp. and UnitedHealthcare) currently serve 469,012 lives.

Bristol Myers Squibb could pay up to $11 million to settle a lawsuit brought by HIV activists, which claimed the company used anticompetitive practices to block generic competition to its HIV drugs, including Evotaz. Evotaz is a cocktail therapy, made in partnership between BMS and Gilead Sciences. Gilead and Johnson & Johnson are set to move forward with a trial, beginning sometime in 2023. Under the pharmacy benefit, 92% of all insured lives have covered or better access to Evotaz as an HIV antiviral. 47.3% of lives have preferred access to Evotaz, without utilization management restrictions.

Startup insurer Bright Health will exit the individual and group risk markets in Illinois, New Mexico, Oklahoma, South Carolina, Utah and Virginia for the 2023 plan year. Those markets made up less than 5% of Bright Health’s revenue, according to a press release. Bright Health currently serves 588,350 individual members, with Florida, North Carolina and Colorado as its three largest markets.

Over the next five years, California Medicaid insurer CalOptima will invest $50 million into 26 community health centers in its service area, the company’s largest-ever investment in value-based care. The initiative will support medical homes for vulnerable populations, including unhoused patients, improve care coordination and reduce avoidable hospitalizations. CalOptima is the sixth-largest Medicaid MCO in California, with 854,264 members.

Blue Cross Blue Shield of Michigan subsidiary AF Group last week said it has entered an agreement to purchase AmeriTrust Group, an insurance company that offers specialty products including workers’ compensation, commercial package and automotive business coverages. The deal will bolster BCBSMI’s diversification efforts and mitigate the financial impact of the COVID-19 pandemic, the press release detailed. The Blues affiliate is currently the largest insurer in Michigan, with 4,520,146 members — 43.1% of the state’s medical lives.

GlaxoSmithKline last week unveiled plans to purchase Sierra Oncology for $1.9 billion. The highlight of the deal is momelotinib, Sierra’s promising JAK inhibitor. In a recent phase 3 clinical trial, momelotinib outperformed Incyte and Novartis’ Jakafi in controlling myelofibrosis, a rare blood cancer, and prevented anemia in patients. Sierra intends to file for FDA approval during the second quarter of 2022. For the treatment of myelofibrosis, virtually all insured lives have covered or better access to Jakafi. 17.5% of lives have preferred access to Jakafi without utilization management restrictions.

Philadelphia-based insurtech startup Sidecar Health last week launched its first fully insured health plans, targeting employer groups of 51+ people in Ohio. Sidecar, founded in 2018, has traditionally offered its members non-ACA compliant direct pay plans, leveraging new pricing transparency laws. The top three group risk-based insurers in Ohio are Anthem, Inc (533,807 lives), Medical Mutual of Ohio (252,810 lives) and UnitedHealthcare (205,596 lives).

CMS on April 7 finalized its narrow coverage of Biogen’s controversial Alzheimer’s drug Aduhelm, limiting coverage to Medicare beneficiaries enrolled in clinical trials. The monoclonal antibody is the only drug approved to treat Alzheimer’s, and holds covered or better status for just 24% of all insured lives in the U.S.