Care Coordination

The $2.5 billion deal between Elevance Health, Inc. and Blue Cross and Blue Shield of Louisiana is facing some hiccups, per the New Orleans Times-Picayune. The Louisiana Blues affiliate must reissue ballots to 92,000 policyholders that will allow them to approve or reject the sale and invalidate proxy ballots that it’s already received. The insurer will also reschedule a meeting and official vote until after the state’s Dept. of Insurance has held a two-day hearing on the proposed sale. Louisiana Insurance Commissioner Jim Donelon and Attorney General and gubernatorial frontrunner Jeff Landry — both Republicans — have been critical of the deal, the Times-Picayune reported. The newspaper also said that attorneys in the state Dept. of Insurance “fully expect litigation” over the proposed transaction, which Elevance announced in January.

Vermont’s all-payer accountable care organization (ACO), OneCare Vermont (OCV), has reduced Medicare costs but has had minimal impact on the state's Medicaid and commercial segments, a new report commissioned by CMS says. However, the state’s largest carrier — nonprofit commercial insurer Blue Cross and Blue Shield of Vermont (BCBSVT) — withdrew from the program at the end of the 2022 plan year and does not currently plan to return.

The report, prepared by NORC at the University of Chicago on behalf of the CMS Center for Medicare and Medicaid Innovation (CMMI), focused most of its cost and quality improvement analysis on Medicare. The report did not make any quantitative assessments of OneCare Vermont’s impact on the commercial market. NORC found that the ACO reduced gross spending for Medicare enrollees by $686.40 per member per year, or 6.2% per year, during the first four years of implementation, resulting in a $124.9 million net reduction of Medicare spending during those years, a drop of 5.7%. However, quality improvement and utilization assessments were more difficult to make due to the COVID-19 pandemic, which distorted utilization patterns during 2020 and 2021.

The Dept. of Justice (DOJ) and Federal Trade Commission (FTC) on July 19 released new draft guidance outlining its approach to antitrust enforcement after rescinding decades-old regulations the week before. The moves could further entrench and formalize the Biden administration’s aggressive anti-consolidation agenda. Health care insiders tell AIS Health, a division of MMIT, that the proposed guidance’s impact on health care insurers and providers is far from certain, but they say that the proposal could complicate any or all of data sharing, quality ratings, and value-based contracting — and stymie an active dealmaking environment.

The draft guidance, which is subject to a public comment period and may change, could have profound impacts on the broader economy, not just health care. The Biden administration’s antitrust regulators have evinced much more aggressive legal and economic theories of antitrust enforcement than any administration in decades. The new guidance is further evidence of the administration’s willingness to try and block deals such as acquisitions by health insurers of providers; provider mergers; and insurer deals for other non-insurance assets, such as business services and technology firms.

Since implementing diabetes-related programs in 2021, Capital Blue Cross said it has saved its members and their employers nearly $6 million in health care costs. Meanwhile, Humana Inc. has launched a diabetes self-management education and support (DSMES) program through its CenterWell Home Health subsidiary that has seen an uptick in usage among health plans. The initiatives are part of a growing trend among payers that recognize the health burden and huge costs associated with diabetes.

Kelly Brennan, Capital Blue Cross’s senior director of Health Promotion and Wellness, tells AIS Health that the insurer’s beneficiaries with diabetes often have other chronic conditions, “which can be expensive to manage, both for our members and for business leaders who rely upon us to provide strategic solutions that curb health care spending and ensure their employees can be their healthiest.”

New data from Deft Research suggests that Medicare Advantage plans continue to struggle with retaining their dual eligible members, mainly because of problems associated with the supplemental benefits offered to address social needs. Published on June 29, Deft’s 2023 Dual Eligible Retention Study found that duals switch plans at about twice the rate of other MA beneficiaries. And while Deft says duals “absolutely depend” on supplemental benefits such as dental care, grocery allowances and utility assistance, duals’ reported issues with their current health coverage often stem from these enhanced offerings, whether they be a source of confusion or just prove difficult to use.

An estimated 30% of dual eligibles make a coverage change over the course of a year, and 8% of duals have already made a switch this year as of mid-May, according to Deft. (Dual eligibles can enroll in or switch dual plans once per quarterly Special Enrollment Period or during the Medicare Annual Election Period). By contrast, Deft in its 2023 Medicare Shopping and Switching Study, which is based on the responses of about 5,000 Medicare beneficiaries, observed that switching by “full pay” (i.e., those receiving no extra help) MA beneficiaries shot up to 15% this past AEP, compared with 12% in the prior two periods.

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.

Health insurers have competed against each other to buy up home-care providers over the past several years. The most recent transaction involves UnitedHealth Group, which revealed a $3.26 billion bid to buy home care provider Amedisys at the end of May. UnitedHealth acquired LHC, another home care provider, in a 2022 deal worth $6 billion. CVS Health Corp. and Humana Inc. have also closed their own blockbuster home care transactions in recent years.

Monique Reese, Highmark Health's senior vice president for home and community care, has a unique perspective on the flurry of transactions that promise to transform home care. Before coming to Highmark in 2018, she led Sutter Health's home care division between 2015 and 2018, and she oversaw UnityPoint Health's home care division between 2010 and 2015.

To succeed with value-based behavioral health care contracts, Medicaid managed care plans need to tailor those pacts to the unique needs of a given provider, MCO executives say. And plans may not be able to use risk-based contracts with individual practitioners and other small providers — especially if network adequacy is at stake.

“We really try to think about it in three broad categories: Are we bringing clinical value, operational value or financial value” as a result of a value-based contract? posed Kevin Wheeler, M.D., medical director for practice transformation and value-based contracting strategy at AmeriHealth Caritas, during a June 14 session of the AHIP 2023 conference in Portland, Oregon. “And we’re thinking about this in terms of our relationships with our providers and with our members.”

On June 5, Amedisys, Inc. revealed that UnitedHealth Group's Optum subsidiary made a $3.26 billion unsolicited offer to purchase the home health provider, which had recently entered a merger agreement with home infusion provider Option Care Health, Inc. Experts say that the deal shows Optum's growing interest in adding home health care to its value-based care offerings, adding that it could generate notable operating efficiencies given Optum's existing home care assets.

In contrast with the debt- and stock-based Option Care deal, which valued Amedisys at $97.38 per share, the UnitedHealth offer valued Amedisys at $100 per share and would compensate shareholders with cash. Amedisys’ ‘board said in a press release that negotiations with UnitedHealth are ongoing, but that “the unsolicited proposal received from Optum could reasonably be expected to result in an ‘Amedisys Superior Proposal’ as defined in Amedisys’ merger agreement with Option Care Health.”

With an eye on improving medication adherence for people with rare diseases or chronic conditions, AllianceRx Walgreens Pharmacy recently launched RightGuide. The program helps digitally connect pharma manufacturers to patients and their caregivers in order to provide education on a variety of topics, from training people how to self-administer injectable agents to helping with financial issues and addressing the side effects of medications.

The specialty pharmacy is working with manufacturers to create customized, brand-specific resources “to help facilitate patient conversion, adherence and retention — while minimizing treatment barriers for patients and caregivers,” explains Tracey James, R.Ph., chief operating officer at AllianceRx Walgreens Pharmacy.