Health Plan Weekly

Mobile health clinics can help health care organizations achieve their business objectives and reduce disparities in care, according to a report released on July 6. The researchers involved in the project tell AIS Health, a division of MMIT, that insurers and other payers can benefit by helping care for people who otherwise would not receive treatments and reduce overall spending by improving people’s health over the short and long term.

The report was sponsored by the Mobile Healthcare Association, a nonprofit trade group, and Mobile Health Map, an initiative led by Harvard Medical School and MHA to provide an online resource to track, research and analyze mobile health clinics. The researchers conducted interviews via telephone or video conferencing with 25 health care leaders, including executives at Harvard Medical School, Cedars-Sinai Medical Center, Kaiser Permanente and Blue Cross Blue Shield of Massachusetts.

CMS on July 6 released new reporting requirements for states regarding Medicaid and CHIP. The new reporting requirements include updated network adequacy and access standards, a standard format for medical loss ratio reporting, and updates to a web portal for reporting submissions and, eventually, rolled-up data and dashboards compiled from regulatory filings. “The tools we’re releasing today reflect the latest — and certainly not the last — step CMS is taking to increase transparency and ensure that people served through Medicaid and CHIP managed care programs are receiving high-quality, high-value care,” said CMS Administrator Chiquita Brooks-LaSure in a press release.

The FDA will allow pharmacists to prescribe Pfizer Inc.’s Paxlovid. Patients may be prescribed Paxlovid from a state-licensed pharmacist if they test positive for COVID-19 and provide “electronic or printed health records less than 12 months old, including the most recent reports of laboratory blood work for the state-licensed pharmacist to review for kidney or liver problems,” and “a list of all medications they are taking, including over-the-counter medications so the state-licensed pharmacist can screen for drugs with potentially serious interactions with Paxlovid,” per an FDA press release. The federal government purchased a large amount of Paxlovid doses and has distributed them to pharmacies and clinics across the country — though the drug is not being used as widely as experts predicted.

Optum says it hopes to create the industry standard for genetic testing benefit management programs — across all business lines and payers nationwide — with a solution that the UnitedHealth Group subsidiary is launching with Avalon Healthcare Solutions using genetic testing codes and other assets licensed from Palmetto GBA.

The solution is part of a comprehensive laboratory benefit management program that the companies unveiled June 22. Although 99% of all lab tests conducted today are routine tests, 10 new genetic tests are coming to the market each day, says John Hoffman, vice president of payer market at Optum. He and colleagues from Optum and Avalon outlined the solution at AHIP 2022 in Las Vegas.

Here’s how major health insurers’ stock performed in June 2022. UnitedHealth Group had the highest closing stock price among major commercial insurers as of June 30, 2022, at $513.63. Molina Healthcare, Inc. had the highest closing stock price among major Medicaid insurers at $279.61.

When pharma companies launch a successful product, the process leading up to that point contains many key decisions from various teams across a manufacturer, including commercial. And with science leading to more and more innovations and many drugs coming to market via an accelerated process, it’s critical now more than ever to understand when to bring in the commercial team and how it can help with the development of a drug and its ultimate success in the market.

During a recent webinar, which was part of the Fierce Leaders in Sciences Forum sponsored by Fierce Pharma, moderator Lisa Johnson Pratt, a board member for Assembly Biosciences, kicked off the discussion by asking what the biggest challenges are for companies that are trying to bring a strong commercial point of view and input into the product development process.

Meeting Medicaid network adequacy requirements for behavioral health providers continues to be a challenge for health insurers, as shown by a recent $4.6 million settlement between Molina Healthcare, Inc., its former behavioral health subsidiary, Pathways of Massachusetts, and the Department of Justice.

In the case, Molina and Pathways of Massachusetts agreed to pay $4.625 million to resolve False Claims Act allegations that they submitted claims to MassHealth — the state’s Medicaid program — while violating regulations governing how staff are licensed and supervised, the U.S. Attorney’s Office for the District of Massachusetts said on June 21. The settlement in the case, which was first brought by four whistleblowers who were Pathways employees, calls for the former employees to receive $810,000.

After abortion suddenly became illegal in large swaths of the country following the Supreme Court ruling in Dobbs v. Jackson Women’s Health Organization, the health benefits industry is scrambling to figure out whether and how to deliver abortion care to plan members. Chaos and uncertainty are the order of the day, and the upheaval is likely to continue as states consider new restrictions and penalties for administering, funding and being treated with abortions.

Overnight, health plans are being forced to contend with critical legal and operational issues relating to abortion. Plans with operations across states where abortion is legal and where it has been banned face unprecedented civil — and potentially criminal — liability for delivering benefits. At the same time, plan sponsors and carriers must figure out how to implement travel benefits for employees who reside in states where abortion is banned but are seeking abortion care in states where the procedure is legal (see infographic). And plans may be compelled to share health records relating to abortion benefits and reimbursement with law enforcement agencies prosecuting patients and providers involved in abortions.

The proportion of open abortion facilities that accept any type of health insurance declined from 89% in 2017 to 80% in 2019 and 2020, while median patient self-pay charges for abortion are going up, according to a study published in Health Affairs in April. The South has the lowest percentage of health insurance acceptance, yet the Midwest saw the largest decrease over the four years, from 88% in 2017 to 75% in 2020.

In its Thursday ruling striking down Environmental Protection Agency (EPA) emissions standards, the Supreme Court restricted the power of federal agencies across the government to issue regulations, legal experts say. The Supreme Court found that the EPA violated the “major-questions” doctrine, which according to SCOTUSblog is the legal doctrine “that if Congress wants to give an administrative agency the power to make ‘decisions of vast economic and political significance,’ it must say so clearly.” Attorney Katie Keith, a researcher at Georgetown University’s Center on Health Insurance Reforms, wrote on Twitter that the ruling is “a blockbuster.…beyond inhibiting federal efforts to mitigate climate change, it will be used to tie the hands of federal agencies (esp. on health issues) for years to come.”

Centene Corp. revealed during its June 17 investor day that it plans to reduce by 65% the amount of office space it leases across the United States as a way to cut costs and appease employees who prefer working from home. Like many large employers, other health insurers have followed suit — or are considering doing so — as they adjust to an office environment that looks much different than was standard before COVID-19.

Several major insurance companies declined to discuss their office leasing plans when contacted this week by AIS Health, a division of MMIT. But most, if not all, are actively evaluating their real estate footprints, according to Dan Mendelson, the CEO of Morgan Health, JPMorgan Chase Co.’s health care arm.