Health Plan Weekly

Experts Discuss Pros, Cons of Risk-Based Payment in Primary Care

As transactions and outside investment in primary care become more common, many health care insiders see an opportunity to shift primary care reimbursement toward risk-based payment — but experts warn that value-based contracting can’t solve all of primary care’s problems on its own.

Primary care practices (PCPs) operating on a fee-for-service basis faced a crisis in 2020, when the pandemic discouraged patients from making routine visits to the doctor’s office. Many PCPs turned to outside financing to fund capital investments or make payroll. Others combined horizontally with other PCPs or sold to health systems.

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Research Shows Various Ways Racial Disparities in Health Care Persist

While the Affordable Care Act improved health coverage across racial and ethnic groups, nonelderly American Indian and Alaskan Native (AIAN), Hispanic, Native Hawaiian and Other Pacific Islander (NHOPI), and Black populations remain much less likely than white individuals to have health insurance, according to a Kaiser Family Foundation study. In addition, the overall rate of cancer screening is lower among people of color compared to their white counterparts, though overall cancer incidence rates declined for all groups between 2013 and 2018. Meanwhile, as of late November 2021, Black and Hispanic people were more than 2.5 times as likely as white people to be hospitalized for COVID-19, accroding to data from the Centers for Disease Control and Prevention. Finally, a recent Commonwealth Fund report shows that closing the Medicaid coverage gap and extending enhanced marketplace premium subsidies under the Build Back Better Act would significantly improve racial equity in coverage rates, with people of color making up half of those slated to gain coverage.

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News Briefs: DOJ Reportedly Poised to Block UnitedHealth-Change Healthcare Deal

The Dept. of Justice is preparing to file suit to block UnitedHealth Group’s proposed acquisition of Change Healthcare Inc., according to multiple media outlets citing Dealreporter. Reportedly, the DOJ will meet with UnitedHealth and Change Healthcare representatives in the next few days. The firms had looked into divesting assets to pass antitrust scrutiny, but the DOJ has not accepted any proposal so far, sources familiar with the transaction told Dealreporter.

AHIP asked CMS for more information regarding its National Coverage Determination (NCD) on Aduhelm, the controversial Alzheimer’s drug that garnered accelerated approval from the FDA in 2021 despite objections on scientific and ethical grounds. CMS said in January that Medicare will cover Aduhelm and other drugs in its class only for people who are enrolled in qualifying clinical trials. In a Feb. 10 letter signed by AHIP CEO Matthew Eyles, the trade group requested “that CMS provide clear guidance to MA plans on their coverage obligations under the NCD.” In particular, Eyles called for a list of clinical trials MA plans must cover.

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Stop-Loss Market May Be Hot Opportunity for Health Insurers

While it’s become common knowledge in the health insurance sector that employer-sponsored coverage isn’t a major growth market, stop-loss insurance is bucking that trend. And with Blue Cross Blue Shield plans in particular not taking as much market share as they could, stop-loss could present attractive opportunities to health care-focused insurance carriers, experts say.

As it applies to health coverage, stop-loss insurance is typically paired with an administrative services only (ASO) contract, in which an employer pays its workers’ health care claims and hires an insurer to process those claims and perform other administrative functions. By adding stop-loss coverage, a self-funded employer is able to have that policy cover any “high-dollar” claim above a certain threshold, called an attachment point, thus minimizing the employer’s risk.

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Centene’s MA Gains Swell Stock, But Could Have Downside

Centene Corp.’s shares rose following its fourth-quarter and full-year 2021 earnings release on Feb. 8, with the market seemingly impressed with the insurer’s Medicaid and Medicare Advantage membership gains. Still, one equities analyst sounded a note of skepticism about what large MA enrollment gains will mean for Centene’s margins.

“Outsized share gains in MA are typically a cautionary sign for margin,” Jefferies analyst David Windley wrote in a Feb. 8 note to investors. Centene’s management “is signaling flat ’22 MA margin, but is flat still optimistic with multiple competitors calling out CNC’s aggressive pricing?”

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CVS Delivers Strong 4Q Results Amid Mixed Aetna Performance

For the fourth quarter and full-year 2021, CVS Health Corp. reported a strong financial performance across its vertically integrated health care business, but its health insurance division Aetna had mixed results. While Aetna delivered higher-than-expected enrollment in Medicare Advantage, it didn’t meet expectations for enrollment on the Affordable Care Act exchanges — a book of business the firm re-entered after several years away from the individual marketplaces.

Aetna took in $20.6 billion in revenue in the third quarter of 2021, according to a CVS press release, up from $19.1 billion in the same period of 2020. It recorded a medical loss ratio of 87%, up from 86.7% in the same period last year; for the full year, Aetna reported an MLR of 85%, up from 80.9% in 2020.

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MCO Stock Performance, January 2022

Here’s how major health insurers’ stock performed in January 2022. UnitedHealth Group had the highest closing stock price among major commercial insurers as of Jan. 31, 2022, at $472.57. Humana Inc. had the highest closing stock price among major Medicare insurers at $392.50.

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News Briefs: Rhode Island Subpoenas UnitedHealth Over Data Breach

Rhode Island Attorney General Peter Neronha, a Democrat, subpoenaed UnitedHealthcare over a recent data breach that saw the personal data of 22,000 plan beneficiaries get hacked by an unknown third party. The exposed beneficiaries were members of the health plan of the Rhode Island Public Transport Authority, which discovered the breach, Modern Healthcare reported.

The number of telehealth visits has declined as the pandemic has receded, according to analysis of Epic Systems Corp. data by the Kaiser Family Foundation. The research indicates telehealth visits accounted for 13% of outpatient visits between March and August 2020, but declined to 11% of outpatient visits between September 2020 and February 2021 and 8% of such visits from March to August.

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Insurers Are Wary, but States Say Standard Exchange Plans Work

In their public comments about a proposed rule that would bring back standardized plans to the Affordable Care Act exchanges, two health insurer trade groups make it clear that they believe such a move will “stifle innovation” in plan design. However, state-based marketplaces that already require plan standardization appear to have found a way to make that policy work for consumers and insurers alike, sources tell AIS Health.

“I’m not aware of anything to suggest that innovation — however one might define that — has been hampered to the detriment of consumers in the states where we see this policy in place,” says Justin Giovannelli, an associate research professor at Georgetown University’s Center on Health Insurance Reforms. Giovannelli co-authored a July 2021 piece for The Commonwealth Fund examining various states’ ACA plan standardization requirements.

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Aetna Could Face Class-Action Suit Over Proton Therapy Denials

Due to a Jan. 27 federal court order, CVS Health Corp.’s Aetna health insurance division could be the defendant in a class-action lawsuit regarding Aetna’s restrictive coverage decisions in breast and prostate cancer treatment. In a lawsuit filed in Florida district court, a federal judge found that Aetna improperly denied coverage of proton therapy to cancer patients who ultimately had to pay for the treatment out of pocket.

Proton beam radiation therapy (PBRT) is a type of cancer treatment “that uses high-powered energy to treat cancer and some noncancerous tumors,” according to the Mayo Clinic, which also notes that “studies have compared proton radiation and X-ray radiation, so it’s not clear whether proton therapy is more effective at prolonging lives.” The therapy isn’t widely available, although new proton therapy centers are being built in the U.S. and in other countries.

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© 2024 MMIT