COVID

Plans Are Likely to Treat Paxlovid Like Other Drugs if U.S. Isn’t Paying

With COVID-19 infections surging once again, the Biden administration has stepped up efforts to increase the supply of Paxlovid, the Pfizer Inc. antiviral that garnered emergency use authorization as a therapeutic treatment for the coronavirus. However, increased availability for Paxlovid might end in coming months — Congress has stalled on providing the increased COVID-19 response funding that the administration requested, and experts say health plans are likely to treat the drug like any other if the federal government isn’t picking up the tab for treatments.

The Biden administration has pushed in recent weeks to increase the availability of Paxlovid, free of charge, to COVID-19 patients. On May 26, the White House released a statement touting the rollout of more than 2,500 “test-to-treat” sites where free testing and Paxlovid courses are available, along with 40,000 locations where antivirals are available for patients. The administration also noted that it had “increased the number of people benefiting from oral antivirals in the last seven weeks, from about 27,000 prescriptions filled each week to more than 182,000 last week.”

How Will Interstate Telehealth Licensure Waivers’ Expiration Impact Medicare Beneficiaries?

During the pandemic, all 50 states and Washington, D.C., issued licensure waivers that allowed out-of-state clinicians to perform telehealth with patients across state lines. By analyzing telehealth usage by Medicare beneficiaries from 2017 to 2020, researchers found that out-of-state telehealth made up only a small percentage of all outpatient visits during the first year of the pandemic, though the percentage varied by state, according to a recent study published in Health Affairs.

The number of out-of-state telehealth services jumped from 17,286 in the first quarter to 171,754 in the second quarter of 2020, and then slightly declined. Before 2020, less than 1% of out-of-state new patient visits occurred via telehealth nationwide, while in 2020, the number jumped to 6%.

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OCM Nears Its June 30 Conclusion Without Successor in Place

The Oncology Care Model (OCM) that CMS’s Center for Medicare & Medicaid Innovation (CMMI) launched almost six years ago is nearing its June 30 end. And while CMMI introduced its Oncology Care First model in November 2019 with an eye on the OCM successor launching before its predecessor’s end, it is unclear what the program’s status is at this point. OCM participants tell AIS Health, a division of MMIT, that their overall experience has been good as they await next steps from CMMI.

The OCM voluntary pilot started in July 2016 with 17 payers and 196 practices; five payers and 126 practices currently are participating. While it began as a five-year program, CMMI extended it for one additional year in 2020 due to the COVID-19 pandemic. The program reimburses providers for episodes of care in the form of a per-beneficiary per-month payment, as well as a possible performance-based payment, if Medicare expenditures are below a target price for an episode. The amount of the payment is tied to a provider’s achievement on various quality measures. All participants began with one-sided risk but could shift to two-sided risk in 2017. Following the 2018 introduction of an alternative two-sided risk arrangement, starting in January 2020, practices that did not earn at least one performance-based payment had to enter one of the two-sided risk options or leave the OCM. Practices that earned at least one performance-based payment could remain in one-sided risk.

Marketplace, MCOs Will Face a Rocky Transition When PHE Ends

When the Biden administration ends the COVID-19 public health emergency (PHE), states will disenroll millions of Medicaid beneficiaries — and insurers will have to take Medicaid MCO members off their books. Experts tell AIS Health, a division of MMIT, that carriers can take steps to retain some of those members by helping them enroll in Affordable Care Act (ACA) marketplace coverage — but say the number of people who make the switch will be far lower than the number of people who joined the Medicaid rolls during the pandemic (see infographic).

Medicaid and individual exchange enrollment have both boomed with the higher federal funding that was included in the American Rescue Plan Act (ARPA) — and both segments’ total enrollment and enrollee profiles will change significantly when that extra funding ends.

State Medicaid Agencies Grapple With Moving PHE End Date

With the COVID-19 public health emergency presumably continuing into October, state Medicaid agencies and their partners theoretically have more time to communicate with enrollees and prepare for the inevitable resumption of eligibility redeterminations once the PHE ends. But ongoing uncertainty over the PHE’s end date presents a host of challenges for states as they handle unprecedented numbers of Medicaid enrollees and attempt to conduct other program work unrelated to redeterminations, according to officials from California, Iowa and North Carolina who spoke during a May 24 webinar hosted by the National Association of Medicaid Directors (NAMD).

Throughout the PHE, which was declared in January 2020 and first renewed that April, states have received a temporary 6.2 percentage-point increase in their Federal Medical Assistance Percentage (FMAP) in exchange for maintaining continuous enrollment of nearly all Medicaid recipients. Once the PHE ends, states have 12 months to initiate eligibility reverifications for everyone enrolled in Medicaid and CHIP and 14 months overall to complete redetermination efforts.

News Briefs: Biden Admin. Likely to Extend PHE

Biden administration officials confirmed that they would extend the COVID-19 public health emergency (PHE) past July 15, when it is currently set to expire, according to press reports, though HHS Sec. Xavier Becerra has not yet issued an official proclamation to that effect. The administration has promised states that it will give them at least 60 days’ notice before the end of the emergency, in part to assist state officials as they restart Medicaid eligibility redeterminations. The PHE also allows for certain flexibilities in areas including telehealth practice. According to news reports, the PHE is likely to be extended until at least Oct. 13.

Nationally, commercial health plans pay 224% more than Medicare rates for services at hospitals, according to new research from the RAND Corp. The study is the latest in a series on hospital prices; the last installment came in 2018. Relative prices vary widely from state to state, with some states’ plans reimbursing below 175% of Medicare rates and some seeing rates of 310% or higher. The study also found that “a large portion of price variation is explained by hospital market power.”

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PHE Unwinding Delay Gives States, MCOs Time to Ease Transitions

With radio silence from HHS on May 16 — when states at the very latest had expected to hear whether the COVID-19 public health emergency would end in July — HHS at press time appeared to be gearing up for another extension of the PHE. This will give states, insurers and other stakeholders more time to prepare for the inevitable resumption of Medicaid eligibility redeterminations, which could cause millions of adults and children to lose health insurance coverage.

The PHE has been extended multiple times since the start of the pandemic and remains a moving target. As a condition of receiving enhanced federal funds during the PHE, states have been required to ensure continuous Medicaid and CHIP coverage for most enrollees by pausing eligibility redeterminations. And the Biden administration has promised to provide states 60 days’ notice before any possible termination or expiration. But without such notification, sources estimate the next end date could be Oct. 13. Bloomberg on May 16 reported that the PHE would be extended past mid-July, “according to a person familiar with the matter.”

Medicaid Rolls Soar to Nearly 89 Million Beneficiaries as Redeterminations Loom

Nationwide Medicaid enrollment has grown more than 22% since the outset of the COVID-19 pandemic, topping 88.7 million lives, according to the latest update to AIS’s Directory of Health Plans. But the end of the Public Health Emergency (PHE) — which at press time was likely to be extended beyond mid-July — could leave between 5.3 million and 14.2 million people without coverage when redeterminations resume, asserted a May 10 analysis from the Kaiser Family Foundation. A separate study from the Georgetown University Heath Policy Institute found that 6.7 million children stand to lose CHIP coverage at the end of the PHE. See a state-by-state overview of three years of pandemic-fueled Medicaid enrollment changes in the chart below.

Telehealth Usage Expands by Over 7,000% During the Pandemic

Driven by the COVID-19 pandemic, telehealth utilization increased 7,060% from 2019 to 2020, while utilization dropped 38% in ambulatory surgery centers, 30% in emergency rooms, 16% in urgent care centers and 4% in retail clinics, according to a new FAIR Health white paper. The FH Medical Price Index tracks the weighted average growth in median procedure charges and median allowed amounts. Among the six procedure categories it studied, hospital evaluation and management saw the largest percent increase in both the charge amount index and allowed amount index.

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With Medicaid Cliff Looming, Payers Scramble to Limit Outflow

The end of the COVID-19 public health emergency (PHE) is likely to significantly downsize Medicaid enrollment around the nation, and managed care organizations (MCOs) must figure out how to keep enrollment steady and maintain continuity of coverage among members.

Since February 2020, fueled by a COVID-induced economic downturn and resulting federal policy changes, the Medicaid ranks have ballooned by 14.6 million members, a roughly 21% increase, nearing 86 million enrollees, according to the Kaiser Family Foundation (KFF).

As a condition of receiving enhanced federal funds during the PHE, states have been required to ensure continuous Medicaid and CHIP coverage for most enrollees by pausing eligibility redeterminations. A quartet of large for-profit plans that hold 40% Medicaid market penetration nationally — Anthem, Inc., Centene Corp., Molina Healthcare, Inc., and UnitedHealth Group — are all expecting “modest enrollment declines” once the PHE ends, according to a recent KFF issue brief.

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