Health Plan Weekly

Humana Inc. and Blue Shield of California recently became the latest payers to ink deals with prior authorization (PA) and billing tech vendors, following a national trend. Experts tell AIS Health that such deals by insurers are key to managing utilization and spending; improving patients’ and providers’ experiences; and complying with federal mandates for interoperability, price transparency and cost estimation — and could be a strategic differentiator for proactive carriers.

✦ The Biden administration released a diminished version of its proposed spending package, and several health care policies coveted by progressive Democrats — including drug price reform — are among the items that got cut. Critically, Medicare drug price negotiation is not included in the so-called “Build Back Better framework.” However, House Speaker Nancy Pelosi (D-
Calif.) reportedly was working on a last-ditch effort to include some drug-pricing provisions. The package would extend the expanded tax credits for Affordable Care Act exchange premiums, made available during the pandemic, to 2025, and Medicare would be expanded to include hearing benefits, but would not include vision or dental.

In a series of recent moves, large retailers with pharmacy operations have struck deals with or acquired smaller companies with the aim of adding on-demand, retail clinics at national scale — and marketing them to health plans or employers. While storefront clinics aren’t new, especially in big box stores, health care insiders say the emphasis on selling to plans over consumers is novel, and that health plans may come to see such agreements as an essential benefit.

UnitedHealthcare and Centene Corp. have added “virtual first” plan designs to their employer-sponsored offerings, becoming the latest commercial insurance giants to offer benefit designs built around virtual pri...

✦ UnitedHealth Group will reprocess all of its commercial claims for COVID-19 vaccine administration after a federal investigation found the integrated health care giant paid providers less than 40% of the Medicare reimbursement rate for administering inoculations. Sen. Bob Casey, Jr. (D-Pa.), chair of the special committee on aging, wrote in a letter to UnitedHealth that it must inform the committee of the number of claims it expects to reprocess by Nov. 5. UnitedHealth will owe about $15 million for every 1 million claims it reprocesses, according to press reports.

A growing amount of treatment for substance use disorders (SUDs) has moved to telehealth providers due to the COVID-19 pandemic. This trend likely increased patients’ access to treatment, among other benefits, but researchers and plan sponsors say that the efficacy and value of virtual care modalities in SUD settings is still an open question.

UnitedHealth Group’s third-quarter 2021 financial results impressed Wall Street, with equities analysts describing the company’s performance as “solid across the board” and “generally positive” even though the company did see health care costs related to COVID-19 rise during the quarter.

Air ambulances have been villainized in recent years for charging patients with surprise bills at eye-popping amounts. Comprehensive new research by FAIR Health confirms that air ambulance costs went up very fast — and experts say that even though surprise billing has been banned, high prices are here to stay.

About 73% of health insurance markets in the metropolitan statistical areas were highly concentrated in 2020, while in 46% of those markets, a single insurer’s market share reached at least 50%, according to the 2021 edition of an annual report from the American Medical Association. The consolidation trend is also pronounced with providers, a trend that is likely to be accelerated due to revenue shortfalls caused by the pandemic. A Health Affairs study found that the share of primary care physicians affiliated with vertically integrated health systems increased from 38% in 2016 to 49% in 2018, while more than half of physicians and 72% of hospitals were affiliated with one of 637 health systems in 2018. Yet several studies suggested that there is no clear evidence that provider consolidation leads to higher quality of care.

✦ CMS for the first time on Oct. 12 approved a state’s request to provide gender-affirming care as an essential health benefit (EHB) in the individual and small-group health insurance markets. Colorado’s new EHB-benchmark plan will offer transgender individuals access to a wider range of services than what is currently covered by their health plans, such as eye and lid modifications, face tightening, facial bone remodeling for facial feminization, breast/chest construction and reductions, and laser hair removal. Effective Jan. 1, 2023, Colorado is also adding EHBs in its benchmark plan to include mental wellness exams and expanded coverage for 14 prescription drug classes.