Benefit Design

Infographic: Out-of-Pocket Prescription Drug Costs Remain a Burden for Medicare Beneficiaries

Most older adults in the U.S. have been diagnosed with one or more chronic illnesses, and managing these conditions presents a significant cost burden, according to a January study in JAMA Internal Medicine. The authors studied eight of the most common chronic conditions, both as single disease states and in clusters, and determined hypothetical annual out-of-pocket (OOP) costs for individual seniors enrolled in Medicare Advantage-Prescription Drug plans and Standalone Part D plans in 2009 and 2019. While annual costs for many of the conditions dropped, likely due to the availability of new generic drugs, OOP costs for atrial fibrillation, type 2 diabetes and heart failure skyrocketed. This was attributed to the introduction of brand-name therapies without generic alternatives that received clinical guideline recommendations. To remedy this, study authors urged Congress to act on drug pricing reforms, including allowing Medicare to negotiate list prices and cap annual OOP costs for seniors.

New York Medicaid Insurer Hopes Virtual Care Will Boost Access

MVP Health Care has launched a new virtual care offering for its New York Medicaid members that allows them to connect with primary care and specialty care physicians through an app made by the digital health company Galileo. Kimberly Kilby, M.D., the insurer’s vice president and medical director of health and well-being, and Christopher Del Vecchio, president and CEO of MVP Health Care, tell AIS Health that they want the new partnership to improve health equity for the insurer’s Medicaid beneficiaries.

The new partnership with Galileo is part of a multiyear effort at MVP to address an unmet need for virtual care. “Over the last 18 months, nearly 40% of MVP’s Medicaid members have not seen a primary care physician (PCP), often due to competing demands on time and resources such as transportation and language barriers,” Del Vecchio tells AIS Health, a division of MMIT, via email.

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FDA Approves Novartis Drug That Will Go Up Against PCSK9s

More than a year after pandemic travel restrictions pushed back the FDA’s approval decision on Novartis Pharmaceuticals Corp.’s inclisiran, the agency finally approved it. The new first-in-class therapy targets so-called bad cholesterol and is set to compete with two other biologics that target the same protein.

On Dec. 22, the FDA approved Leqvio as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with clinical atherosclerotic cardiovascular disease (ASCVD) or heterozygous familial hypercholesterolemia (HeFH) who require additional lowering of low-density lipoprotein cholesterol (LDL-c).

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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High Prices, Pandemic Strain Employer-Backed Insurance

Pandemic-driven macroeconomic uncertainty and rising prices remain the biggest challenges for employer-sponsored insurance plans, according to experts. The cost of health insurance premiums has made employer-backed health insurance unaffordable to the point of being useless for many families, while the pandemic has created a volatile environment for many employers, particularly small businesses.

During a Jan. 26 panel hosted by the Bipartisan Policy Center, a Washington, D.C. think tank, employer health insurance experts sounded off on the myriad difficulties facing plan sponsors and employee beneficiaries. Worries over cost and the pandemic took up most of the discussion.

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FDA Approves Cholesterol-Lowering Drug That Will Go Up Against PCSK9s

More than a year after pandemic travel restrictions pushed back the FDA’s approval decision on Novartis Pharmaceuticals Corp.’s inclisiran, the agency finally approved it. The new first-in-class therapy targets so-called bad cholesterol and is set to compete with two other biologics that target the same protein.

On Dec. 22, the FDA approved Leqvio as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with clinical atherosclerotic cardiovascular disease or heterozygous familial hypercholesterolemia who require additional lowering of low-density lipoprotein cholesterol.

2022 Outlook: MA Insurer Execs Plan Investments Supporting Equity, SDOH

For our annual series of forward-looking articles, AIS Health recently featured the perspectives of multiple industry experts on what Medicare Advantage stakeholders will be focusing on in 2022. For a follow-up installment, we asked several health plan leaders to share how their respective organizations will be innovating this year to meet aging members’ needs, advance health equity and address social determinants of health (SDOH) amid the backdrop of the ongoing COVID-19 pandemic.

“The pandemic emphasized how our most daunting challenge — reaching our members in a new remote, digital-first landscape — remains our most compelling opportunity. Delivering home-based care to our nearly 10 million Medicare members and equipping them with the resources they need to age in place are central to our 2022 agenda,” says Jamie Sharp, M.D., vice president and chief medical officer of Aetna Medicare, a CVS Health company.

2022 Outlook: This Year, ‘Smooth Sailing’ Appears Likely for ACA Exchanges

For health insurers that operate in the Affordable Care Act exchanges, 2022 is shaping up to be a relatively stable, profitable year with few regulatory surprises, health policy experts tell AIS Health. Still, there will be some regulatory uncertainty that plans must grapple with as well as a newly proposed rule effective in 2023 that imposes tighter controls on benefits and network design than even the Obama administration attempted.

That regulation is the Notice of Benefit and Payment Parameters (NBPP) 2023 Proposed Rule, released by the Biden administration on Dec. 28. Perhaps the biggest change included in the annual omnibus exchange rule — the move to require standardized ACA marketplace plans — was already known to the industry but still promises to make a significant impact.

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UnitedHealthcare Says It Won’t Restrict ER Services Coverage

UnitedHealthcare — which last summer drew the ire of provider groups when it announced plans to roll out more restrictive coverage policies for emergency care — is now making it clear that it has no plans to implement such a change.

In a letter sent Dec. 30 to the American Hospital Association (AHA), the insurer sought to reassure the trade group that “consistent with our prior communication in June 2021, UnitedHealthcare is not implementing any new policy regarding coverage criteria for emergency level care on January 1, 2022.”

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Rewards and Incentives Rule Has Compliance, Stars Implications

Although it may have gone largely unnoticed by Medicare Advantage plans this year, a clarification regarding rewards and incentives (R&I) programs embedded in an 894-page final rule issued in January 2021 could have significant implications for plans’ star ratings strategy in addition to posing compliance risks and added costs in 2022. Industry experts say now is the time for plans to get compliant with the provision, which goes into effect on Jan. 1, 2022, and to begin rethinking their R&I programs to incentivize healthy behavior across the broader MA population and not just those members who are falling behind in their star measures.