COVID

If the COVID-19 public health emergency (PHE) expires in April 2023, about 18 million Medicaid enrollees could lose their coverage over the following 14 months, an Urban Institute analysis projected. Among them, about 9.5 million people could transition to employer-sponsored insurance, 3.2 million could move to Children’s Health Insurance Program (CHIP) coverage, and 3.8 million could become uninsured. If the PHE were extended for an additional quarter, the number of people losing coverage could rise to nearly 19 million. The PHE is set to last at least through January, as the Biden administration is concerned about the potential of a winter wave of COVID infections.

As the pharma industry dealt with the ongoing COVID-19 pandemic amid heightened economic pressures, it largely weathered the storm that was 2022. But with provisions of the Inflation Reduction Act (IRA) set to start rolling out next year, many questions remain that may impact pharma manufacturers. The industry, however, saw continued innovation in novel therapeutics, and in the second half of the year, the number of gene therapies on the U.S. market more than doubled with the approval of three new agents. And while the merger and acquisition (M&A) activity may have been a bit muted compared with past years, 2022 is closing out with the unveiling of the biggest biotech deal of the year: Amgen Inc.’s agreement to purchase Horizon Therapeutics plc for $27.8 billion. AIS Health, a division of MMIT, spoke to industry experts about other 2022 pharma trends.

The pandemic-induced telehealth revolution expanded access to an exciting new modality of care delivery, but a new report from federal watchdogs found that federal payers face new, telehealth-derived challenges in stopping waste, fraud and abuse. Those findings mean the commercial carriers that administer certain federally underwritten health insurance plans have a new auditing and accountability challenge as telehealth settles in as a permanent part of the care delivery landscape.

The report, prepared by six Offices of Inspectors General (OIGs) from HHS, the Dept. of Justice, Dept. of Defense, Dept. of Veterans Affairs (VA), Dept. of Labor and Office of Personnel Management (OPM), found that “while the expansion of telehealth has been essential to maintaining individuals’ access to care, there have been concerns about the potential for fraud, waste, and abuse associated with expanded telehealth services.”

Nov. 9: The FDA issued an emergency use authorization to Amgen Inc.’s Kineret (anakinra) for the treatment of COVID-19 in hospitalized adults with pneumonia requiring supplemental oxygen (low- or high-flow oxygen) who are at risk of progressing to severe respiratory failure and likely to have an elevated plasma soluble urokinase plasminogen activator receptor (suPAR). The agency initially approved the interleukin-1 receptor antagonist (IL-1Ra) on Nov. 14, 2001. The recommended dosing for this latest use is 100 mg administered daily by subcutaneous injection for 10 days. Drugs.com lists the price of one 100 mg prefilled syringe as more than $1,265.

A COVID-19 hospitalization cost more than $40,000 on average for people with large-employer health coverage in 2020, according to the Peterson-Kaiser Family Foundation Health System Tracker. Half of those hospital admissions cost over $25,000, and a quarter cost almost $39,000. About 38% of COVID-related hospitalizations in 2020 included an intensive care unit stay, and the average cost of such admissions was $65,569 — more than double the average amount paid for COVID admissions without an ICU stay.

A new behavioral health venture that sprung from an innovative Horizon Blue Cross Blue Shield of New Jersey initiative is focused on embedding its integrated approach within other health plans and provider groups. NovaWell, a Horizon affiliate that launched Nov. 14, is offering a suite of technology-forward solutions aimed at tackling the country’s ongoing mental health crisis. Jolted into the public consciousness by the COVID-19 pandemic, the crisis is characterized by rising rates of anxiety and depression amid a shortage of trained professionals.

Backed by more than five years of testing and program design aimed at addressing the behavioral health needs of Horizon’s members, the NovaWell suite brings an integrated care management approach supported by network-enhancing solutions to a wider audience. Two of the company’s four core offerings, a fully integrated clinical model called NovaClinical and a network solution known as NovaNetwork, are positioned to bolster health plans, Suzanne Kunis, president and CEO of NovaWell, tells AIS Health, a division of MMIT.

A recent survey from UnitedHealthcare found that 71% of respondents said they would likely use virtual care in the future, up from 53% in last year’s survey. Donna O’Shea, M.D., UnitedHealth’s chief medical officer of population health, tells AIS Health that the results indicate the use of virtual care is more than just a COVID-19-specific trend and is likely to become a permanent part of health care.

Still, that’s not to say that people prefer virtual care over visiting doctors in their offices. In fact, the 2022 UnitedHealthcare Consumer Sentiment Survey found that 60% of respondents preferred in-person appointments for non-emergency issues such as allergies, flu or rashes, while 26% preferred virtual appointments and 14% had no preference. The question assumed that the quality and costs of care were comparable between in-person and virtual settings.

Open enrollment for 2023 Affordable Care Act exchange plans starts on November 1, with the Biden administration hoping to continue the enrollment growth seen over the past few years. As of early 2022, about 16.9 million people were enrolled in the individual market, a 20% increase from early 2020, according to a recent Kaiser Family Foundation analysis.

The growth is largely driven by enhanced subsidies enacted by American Rescue Plan Act (ARPA) and extended through 2025 by the Inflation Reduction Act. Overall, about 75% of individual market enrollees are now subsidized. The study estimated that about 3 million people will buy unsubsidized coverage off- marketplace during 2023 open enrollment, a decrease compared to prior years.

At some point in the next year, it’s likely that Medicaid eligibility redeterminations will resume — a process that will be kicked off when the Biden administration declares an end to the COVID-19 public health emergency (PHE). Medicaid has hit record-high enrollment this year, meaning states and managed care organizations will have to contact more people than they ever have before in a short period of time; meanwhile, MCOs will also have to deal with looming cuts to reimbursement and rising provider rates.

Margins for MCOs seem likely to shrink. Provider rate increases are coming soon, though it’s likely that they will vary in timing and scope depending on market and contract cycles. However, the pricing effects of workforce shortages and inflation will impact every plan and provider, sources previously told AIS Health.

Since the COVID-19 pandemic began, the federal government has spent tens of billions of dollars purchasing vaccines, treatments and tests and providing them for free to the public. Congress has also passed legislation ensuring private and public payers cover those countermeasures for as long as the public health emergency (PHE) is in place.

However, that may soon be ending as Congress has yet to authorize additional COVID-specific funding and the PHE is likely to expire sometime next year. That could lead to questions about access, pricing and insurance coverage, according to panelists who spoke during a Kaiser Family Foundation (KFF) webinar on Oct. 19.