Health Plan Weekly

Hospitals Charged Private Health Plans 2.5 Times Medicare Rates in 2022

Employers and private insurers, on average, paid 254% of what Medicare did for the same inpatient and outpatient services at the same facilities in 2022, according to a new RAND Corp. study.

The report examined data from more than 4,000 hospitals across all U.S. states except Maryland and found that average relative prices paid by private insurers increased from 241% of Medicare rates in 2020 to 254% in 2022, which was largely driven by growth in inpatient relative prices.

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© 2024 MMIT

Brokers Blame Tech Vulnerabilities for ACA Plan Switching, Signup Scams

CMS recently said it received tens of thousands of complaints from people who were enrolled in Affordable Care Act marketplace plans without their consent by unscrupulous brokers during the first three months of this year. That led the National Association of Benefits and Insurance Professionals (NABIP), a broker trade group, to criticize CMS for its handling of the situation and claim that all brokers had been unfairly blamed by the agency.

But one industry expert says that there is “plenty of blame to go around” for the unauthorized enrollments, which can result in financial harm to plan members and insurers alike.

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© 2024 MMIT

Telehealth Policies May Get Extended, but Conference Speakers Call for More Research

Although telehealth policies that were put in place in March 2020 following the onset of the COVID-19 pandemic are set to expire at the end of the year, congressional leaders are taking steps to extend the policies for an additional two years. Even if the legislation passes, more research needs to be done to assess the benefits and downsides of treating people virtually from a payer, provider and patient perspective, according to speakers at a May 1 panel organized by the National Institute for Health Care Management (NIHCM) Foundation.

The House Ways and Means Committee on May 8 unanimously advanced legislation that would preserve Medicare beneficiaries’ access to telehealth through 2026. Reps. David Schweikert (R-Ariz.) and Mike Thompson (D-Calif.) are sponsors of bill H.R. 8261, which is known as the Preserving Telehealth, Hospital, and Ambulance Access Act.

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© 2024 MMIT

MCO Stock Performance, April 2024

Here’s how major health insurers’ stock performed in April 2024. Elevance Health, Inc. had the highest closing stock price among major commercial insurers as of April 30, 2024, at $528.58. Humana Inc. had the highest closing stock price among major Medicare insurers at $302.09.

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© 2024 MMIT

News Briefs: Judge Allows RICO Suit Against Centene to Proceed

A federal judge on May 2 ruled that the majority of claims against Centene Corp. can move forward in a lawsuit that accuses the insurer of defrauding customers via its marketing of Affordable Care Act exchange plans. The suit, filed in August 2022, accuses Centene and two of its subsidiaries of misleading consumers by publishing provider directories that are not up to date and that misrepresent the benefits that members will receive when they purchase an Ambetter insurance plan. Those primarily low-income consumers then have trouble finding providers who will take their insurance, according to a press release from the law firm representing the plaintiffs. The suit claims that this alleged scheme violates the Racketeer Influenced and Corrupt Organizations Act (RICO) and numerous state laws, and attorneys for the plaintiffs are seeking to certify the lawsuit as a class action.

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© 2024 MMIT

California’s 3% Health Care Spending Target Prompts Angst, Anxiety

California recently became the latest state to implement a limit on health care spending growth, with a new state agency targeting an increase of no greater than 3% by 2029. Commercial payers have largely backed the spending targets, but providers have argued that the targets aren’t reachable and Medicaid stakeholders — including the state’s largest managed care organization — are concerned that the target may curtail access for beneficiaries and harm the solvency of safety net providers.

The spending target was set by the board of the Office of Health Care Affordability (OHCA), which was established in 2022. The board’s membership was appointed by Gov. Gavin Newsom, a Democrat. The board set target spending growth rates of 3.5% in 2025 and 2026, 3.2% in 2027 and 2028, and 3.0% in 2029. OHCA will require payers regulated by the state and providers alike to meet the designated spending targets. Organizations that don't meet the spending targets will be subject to a state-overseen corrective action plan and possibly fines.

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© 2024 MMIT

HSA-Eligible Plans Have Mixed Impact on Health Care Use, No Impact on Spending

People with health savings account-eligible high-deductible health plans (HDHPs) use less outpatient services and fill fewer prescription medications than people with PPOs, but HSA plan enrollment appears to have no impact on total health care spending, according to a recent study published by the Employee Benefit Research Institute (EBRI).

As of 2022, 57.9% of employees were enrolled in an HSA-eligible health plan, while 32.3% of them were in an HDHP that was not associated with an HSA.

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© 2024 MMIT

DOJ Probe of UnitedHealth Could Spawn Optum Spinoffs, SEC Review of Stock Sales

A group of lawmakers is urging federal regulators to investigate UnitedHealth executives’ sale of company stock right after learning that the health care firm was the target of a Dept. of Justice (DOJ) investigation concerning its provider-acquisition spree. As for the investigation itself, one antitrust lawyer says it could take years before the DOJ files a case — but if it does, regulators could try to force the health care giant to spin off all or part of its Optum division.

Meanwhile, the DOJ’s antitrust division on May 9 announced a new Task Force on Health Care Monopolies and Collusion, which it said will “guide the division’s enforcement strategy and policy approach in health care, including by facilitating policy advocacy, investigations and, where warranted, civil and criminal enforcement in health care markets.” Some of the competition concerns the task force will examine include “issues regarding payer-provider consolidation” and “serial acquisitions.”

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Insurers, Retailers Rethink Clinics After ‘Exuberant’ Spending Spree

Some insurers and retailers are backing away from their investments in provider verticals, especially retail health brands. Cigna's stake in VillageMD, a joint venture with Walgreens Boots Alliance Inc., has lost money, and VillageMD will soon close many locations instead of pursuing aggressive growth. Walmart Inc. also said it will close its health care venture.

In recent years, diversified insurers have seen clinics in which they own a stake as a place where they can control cost of care and, ideally, improve member satisfaction by reducing the friction required to access basic care services — in addition to growing revenue in a segment that isn’t capped by medical loss ratio (MLR) rules. But that premise hasn’t always amounted to much more than a compelling story in practice.

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© 2024 MMIT

Racial Health Care Disparities Persist in All States, With Significant Divides in Premature Deaths

Substantial racial and ethnic disparities in health and health care are pervasive across all states in the U.S., according to The Commonwealth Fund 2024 State Health Disparities Report.

The report evaluated 25 health indicators of health system performance for Black, white, Hispanic, American Indian and Alaska Native (AIAN), and Asian American, Native Hawaiian, and Pacific Islander (AANHPI) populations. It found that racial health disparities are a bigger problem in some states than in others. Massachusetts, Rhode Island and Connecticut saw relatively high performance for all racial and ethnic groups, while Oklahoma, West Virginia and Mississippi performed poorly for all groups.

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© 2024 MMIT