Most state Medicaid programs require managed care plans to cover some common treatments and medications for substance use disorder (SUD), according to a study published this month in Health Affairs. However, Lauren A. Peterson, one of the study’s authors, tells AIS Health, a division of MMIT, it is “concerning” that only half of the states that contract with managed care plans require coverage of all treatments and services recommended by the American Society of Addiction Medicine (ASAM).

While Peterson, a Ph.D. candidate at the University of Chicago, acknowledges that “states are really making a commitment to cover [SUD treatments],” she says she and her co-authors agree with ASAM that all SUD treatments should be available.

Cancer has become the top condition driving costs for employers, and a recent report found that most of them expect their annual spend on the condition will increase by up to 9% each year over the next three years. Last fall, the Midwest Business Group on Health and the Florida Alliance for Healthcare Value, in collaboration with MBGH employer members, shared information around the management of oncology benefits with an eye on making sure that the right care is given to the right person at the right place, right time and right price, for both the employer and the member.

Among the topics of discussion for the Oncology Learning Collaborative were prevention, including screening and early identification; navigation, including psychosocial support and return to work; and diagnosis, including a second opinion, biomarkers and treatment.

While use cases for artificial intelligence are still largely being tested in health care, AI may be helpful right now for health plans seeking to manage their provider directories — a troublesome task that even the largest payers struggle to handle.

“There’s a lot of hype here, and really, so far, not much has really materialized,” said Neel Butala, M.D., cofounder of HiLabs, during a June 25 AHIP webinar.

“However, there’s a big appetite [for AI]…everything ranging from automating administrative tasks, apps, data analytics, to risk prediction, and even you know, personalized medicine. AI has applications in each of these buckets with varying ranges of maturity. And we feel, right now at least, that the easiest thing for people to engage AI in right now is automating administrative tasks. And this is because it improves efficiency; has direct, easily measurable ROI; and it’s pretty low risk for health plans in particular, as it's not really directly involved in member care. And finally, an easy win here can help any AI across an organization that can then be used…for other types of applications that are more advanced, that have a big impact.”

Outside of serving seniors through a Special Needs Plan geared toward institutional/institutional equivalent enrollees, Medicare Advantage plans are not fundamentally designed to support seniors’ long-term care needs. But with their inherent focus on care coordination and recent innovations in nonmedical benefits that can support aging in place, MA plans are uniquely positioned to address gaps in the continuum between Medicare and Medicaid, which is the primary payer of long-term services and supports (LTSS).

Speaking during a prerecorded session of the upcoming Virtual Fifth National Medicare Advantage Summit, panelists agreed that while nonmedical benefits were initially perceived as marketing tools to differentiate plans from their competitors, there is great potential for them to serve enrollees in the long term. Participants in the panel discussion, “The Opportunity for Medicare Advantage Plans to Address Long-Term Care Needs,” which will be livestreamed and archived on July 10, discussed a variety of benefit innovations and the mounting evidence around their impact to costs, outcomes and quality of life.

After interest among long-term care providers and Medicare Advantage insurers to partner on Institutional Special Needs Plans plateaued during the COVID-19 pandemic, a somewhat ambiguous provision in a recent CMS final rule has the potential to significantly increase the I-SNP market. By expanding the definition of qualifying facilities that serve institutionalized members, SNP experts say it could reduce current barriers to enrollment and garner interest from assisted living facilities (ALFs), which have largely been shut out of the I-SNP opportunity.

I-SNPs, which were permanently authorized in the Bipartisan Budget Act of 2018, currently restrict enrollment to MA-eligible individuals who meet the definitions of “institutionalized” (i.e., they continuously reside for 90 days or longer in one of several types of long-term care facilities or are expected to need the level of services provided in such a facility) or “institutionalized-equivalent,” meaning they reside in an ALF and get the same level of care they’d receive in a qualifying long-term care facility. Such facilities that currently qualify (as defined by Medicaid or Medicare statute) are skilled nursing facilities, nursing facilities, intermediate care facilities for individuals with intellectual and developmental disabilities, psychiatric hospitals, rehabilitation hospitals or units, long-term care facilities and “swing-bed” (e.g., critical access) hospitals.

More and more plan sponsors are interested in introducing risk-based reimbursement in their contracts with health insurers. That interest has grown into a range of plan designs: On the extreme end, plan sponsors like CalPERS are introducing upside and downside risk to entire third-party administrator contracts. A more incremental approach sees health insurers offering upside risk to plan sponsors based on the health insurer’s ability to control costs for a specific condition.

UnitedHealthcare on June 26 launched such an offering, called the Level2 Assured Value Program. It’s a new payment model for an existing Type 2 diabetes management benefit design called Level2.

The U.S. health care system could save billions if it increases access to treatment for hepatitis C, now that a series of curative therapies approved in the 2010s have decreased in price, according to the Congressional Budget Office (CBO). However, one expert says that federal and state governments will have to force health plans — particularly Medicaid managed care organizations — to increase access to those therapies.

Doubling hepatitis C treatment access in Medicaid could save the federal government $7 billion over 10 years, the CBO found in a report published June 14. In addition, a 2023 white paper from researchers affiliated with the National Bureau of Economic Research found that a Biden administration budget request for a federal program to eliminate hepatitis C would diagnose and cure about 90% of all U.S. hepatitis C patients, saving the health care system $18.1 billion, of which $13.3 billion would accrue to the federal government.

Ever since racial justice activism swept the country in 2020 following the death of George Floyd, racial disparities in health care have become a focus in the health care industry. Perhaps even more than in recent years, health equity was one of the most-discussed topics at the AHIP 2024 conference in Las Vegas.

But presenters at the conference made clear — as have their counterparts at other industry meetups — that health equity is a work in progress. Awareness of racial health disparities may be at an all-time high, but tangible progress is as elusive as ever.

There are persistent challenges around the collection and transmission of that data between providers and payers. The same is true of the quality of the data itself. It's a key challenge for the health insurance industry as payers try to measure provider quality and transition to value-based contracting.

"I'll just say the accuracy of our directory is bad. It just is," said Mike Kane, senior vice president for provider data operations at UnitedHealthcare. Kane was speaking on a June 12 panel organized by the Council for Affordable Quality Healthcare (CAQH) at the 2024 AHIP Conference in Las Vegas. "About half of every single provider [data profile] that our members call, there's at least one data element in our directory that's wrong."

"It's a horrible, horrible experience," Kane said.

Data from two clinical studies found that people with inflammatory bowel disease — ulcerative colitis and Crohn’s disease — who were enrolled in one company’s IBD-focused digital care coordination program experienced decreases in both emergency department (ED) visits and hospitalizations compared with control groups. The data, says the company’s CEO, show the benefits of partnerships among stakeholders to manage chronic gastrointestinal (GI) care.

Established in 2018, SonarMD, Inc. enters into risk-bearing value-based care arrangements with health plans and gastroenterology practices. It currently has five such arrangements with large plans and partners with hundreds of U.S. gastroenterologists.