Benefit Design

Leqembi Treatment Infrastructure: If Medicare Pays For It, They Will Come

Eisai Co., Ltd. and its partner Biogen, Inc. crossed over the biggest barrier in their quest to commercialize Leqembi (lecanemab) now that Medicare will cover the cost of the Alzheimer’s disease drug. The next hurdles for doctors and patients will be obtaining blood tests and PET scans for confirming amyloid pathology in the brain, genetic testing to assess APOE4 status, MRIs to monitor for amyloid-related imaging abnormalities (ARIA) and infusion centers to administer the medicine — facilities that exist, but not in the numbers and locations needed to serve all of the US patients eligible for treatment.

CMS said that it will cover the cost of Leqembi on July 6, the day that the FDA converted the amyloid protofibril-targeting antibody’s accelerated approval for the treatment of mild cognitive impairment or mild dementia associated with Alzheimer’s disease (AD) into full approval. Eisai and others believe that while uptake of Leqembi will be slow as the health care system catches up with the diagnostic, monitoring and infusion requirements associated with the therapy, Medicare coverage gives providers the confidence they need to offer those services.

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© 2024 MMIT

With Rinvoq’s Recent Approval for Crohn’s Disease, Agent Enters Highly Competitive Class

The FDA recently expanded the indication of AbbVie Inc.’s Rinvoq (upadacitinib), making it the first oral treatment and the first Janus kinase (JAK) inhibitor for Crohn’s disease. Still, the agent is entering a highly competitive class in which manufacturer rebates play a big role. And while respondents to a Zitter Insights survey said the drug will somewhat lessen the unmet need in the treatment of the condition, they said that a moderate level of need still exists with the agent’s approval.

On May 18, the FDA expanded the label of Rinvoq to include the treatment of adults with moderately to severely active Crohn’s disease who have had an inadequate response or intolerance to at least one tumor necrosis factor (TNF) inhibitor. The agency initially approved the JAK inhibitor on Aug. 16, 2019. This is the seventh indication the drug has gotten across rheumatology, dermatology and gastroenterology.

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© 2024 MMIT

Insurers Say New Medicaid Regs Will Overburden MCOs, States

In comments submitted to CMS about two new proposals aimed at improving the Medicaid program, health insurers and their lobbying groups told the agency in no uncertain terms that implementing the regulations could require more resources than health plans currently have — especially since they’re also trying to navigate the recently resumed Medicaid redetermination process.

The regulations in question are both notices of proposed rulemaking (NPRM) that CMS introduced in May — the “Medicaid and Children's Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality” NPRM, and the “Ensuring Access to Medicaid Services” NPRM. Together, the two proposals represent the first significant regulatory update to Medicaid managed care since 2020.

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Accumulators, Maximizers, Alternative Funding Models Contribute to ‘Doom Loop of Specialty Drug Benefits’

As plan sponsors continue to grapple with the high costs of specialty drugs, they have undertaken various strategies to deal with them. The use of copayment accumulators, copay maximizers and alternative funding companies has been a fairly recent trend, noted longtime industry expert Adam J. Fein, Ph.D., CEO of Drug Channels Institute, during a recent webinar. But as that use continues to increase, multiple questions exist around the practices and what the future holds for them.

Fein explained that he chose the focus of the June 23 webinar, titled PBMs and the Battle Over Patient Support Funds: Accumulators, Maximizers, and Alternative Funding, because the entities are a hot industry topic currently. “And I think this is a topic of great relevance to manufacturers, to PBMs, to plan sponsors, to patients, to pharmacies, to everyone in the channel. And it’s one that I found is not well understood,” he stated.

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New MVP Health Care Offering Seeks to Smooth Access for Dual Eligibles

After a long history of serving Medicare and Medicaid beneficiaries in New York State, Schenectady, N.Y.-based MVP Health Care in 2022 launched a Dual Eligible Special Needs Plan (D-SNP) through a joint venture with Belong Health, which specializes in in helping regional payers launch MA and SNP products. This month, the insurer expanded its duals portfolio with a new integrated product and extended its managed Medicaid service area to eight New York counties.

Effective July 1, MVP’s Medicaid and Medicaid-adjacent plans for adults and children who don’t qualify for Medicaid became available in Clinton, Essex, Franklin, Fulton, Hamilton, Herkimer, Montgomery and St. Lawrence counties. Enrollees in these areas will also be able to access virtual primary and specialty care through digital health company Galileo.

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With Addition of HEI to Stars, Clock Is Ticking for MAOs to Advance Health Equity

So as not to penalize Medicare Advantage plans serving a large proportion of enrollees with social risk factors (SRFs) that impact care quality, CMS has previously taken steps to adjust for within-contract disparities in Star Ratings performance among MA and Part D contracts. But beginning in 2027, insurers will be rewarded for their efforts to assess SRFs and address disparities in certain quality measures with the new health equity index (HEI). MA and Part D organizations must act now to assess disparities within their contracts' current performance and begin to pinpoint where their efforts can make the biggest impact in the two years of data leading up to the reward, according to industry experts who spoke at AHIP’s 2023 conference.

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COVID Test Provider Curative Pivots to Employer-Plan Market

Curative Inc., the Texas startup that launched as a COVID-19 testing provider and pivoted to selling commercial health insurance last year, bought bankrupt Illinois-based life insurance firm American Country Insurance Company (ACIC) earlier this month for an undisclosed sum. The transaction will allow Curative to sell health plans in Illinois, but health care insiders doubt that the firm’s signature offering — large-group commercial health plans with no deductibles — can viably be delivered by a small startup.

Curative said on June 15 that it acquired ACIC, which entered bankruptcy in 2020 and has been in receivership in the states where it operates ever since. Terms of the deal were not disclosed. Per a Curative press release, the ACIC deal will allow the firm to operate “licenses to sell large-group health insurance in select additional states.” Michael Abrams, principal of Numerof & Associates, tells AIS Health, a division of MMIT, that one of those states will be Illinois, as ACIC held both life insurance and health insurance licenses in that state.

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By Making More Telehealth Free, UnitedHealth Hopes to Curb Unneeded ER Visits

UnitedHealthcare will remove out-of-pocket costs and deductibles for remote urgent-care visits, effectively making them free for 5 million members in fully insured employer plans.

The goal is to remove financial barriers that prevent members from getting necessary acute care while deterring them from costlier settings like the emergency room, Donna O’Shea, M.D., chief medical officer of population health for UnitedHealthcare, tells AIS Health, a division of MMIT.

UnitedHealthcare’s effort to steer patients away from the ER is not new — but its $0 copay telehealth visits represent more of a consumer-friendly strategy than it has previously employed. In 2021, the insurer walked back a proposed policy that generated considerable outrage: It would have led to denials of some ER claims that were deemed non-emergencies after the fact.

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As Friday Shuts Down and Bright Teeters, Experts Offer Look at What Went Wrong

Friday Health Plans Management Services Company, Inc. is in the death throes of its life as an Affordable Care Act exchange insurer — regulators are stepping in to take over its operations, and it’s laying off all employees in its home state of Colorado. Meanwhile, Bright Health Group, Inc., which has already exited every ACA exchange in which it operated, reached a deal to sell its California Medicare Advantage plans to Molina Healthcare, Inc. in order to satisfy Bright’s creditors.

Experts tell AIS Health, a division of MMIT, that both insurers largely followed the same playbook: raising massive amounts of funding from venture capital (VC) investors and promising to delight customers with tech-driven, differentiated products. But those big plans fell apart when faced with the realities of an industry that is especially challenging to disrupt, and then capital infusions dried up when interest rates rose.

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Copay Amounts Have Significant Impact on Cardiovascular Medication Adherence

People with higher copays are significantly less likely to adhere to their commonly prescribed cardiovascular medications than those with low copays, according to a study published this month in JAMA Network Open. Utibe R. Essien, M.D., the study’s lead author, tells AIS Health the variations in adherence based on copays are “striking” and could have broader implications if some of the drugs are approved for obesity as expected and become even more widely used.

Utibe adds that people who do not take these drugs could have serious medical complications, leading to more of a health burden for them and financial burden for payers due to the high costs associated with hospitalizations, emergency room visits and other expenses.

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© 2024 MMIT