Data & Analytics

A review of market access for psoriatic arthritis treatments shows that under the pharmacy benefit, about 73% of the lives under commercial formularies are covered with utilization management restrictions. Around 40% of the lives under Medicare formularies are not covered for at least one of the drugs.

A lawsuit filed July 24 in a California district court accuses Cigna Healthcare of violating a state law requiring insurers to give each claim a “thorough, fair and objective investigation.” The proposed class-action suit filed on behalf of two Cigna enrollees claims that the insurer uses the system PxDx to deny claims in bulk rather than examine them individually. It cites a ProPublica article published in March that found Cigna doctors denied over 300,000 requests for payment using PxDx over a two-month period in 2022, spending an average of just 1.2 seconds reviewing each request. Cigna, however, hit back in a press release issued July 27 “in response to recent media representations.” The insurer says that PxDx is “a simple process that has successfully helped accelerate payments to physicians for common, relatively low-cost tests and treatments over the last several years,” adding that patients “are not denied care through this review in any way — it occurs after the patient has received treatment and once their physician bills for the treatment.” What’s more, the “vast majority” of claims reviewed through the PxDx process are automatically paid, the firm said, adding that CMS and other health insurers use a similar process.

A review of market access for acute lymphoblastic leukemia treatments shows that under the pharmacy benefit, about 39% of the lives under commercial formularies are covered with utilization management restrictions. Around 33% of the lives under Medicare formularies are not covered for at least one of the drugs.

Participants in the Affordable Care Act risk adjustment program will pay a record $9.24 billion for the 2022 benefit year, according to CMS. Among the 608 issuers that participated in the program, startup insurers owe the highest amounts of payouts, while a handful Blue Cross Blue Shield companies are slated to receive significant payments.

The ACA’s risk adjustment program, launched in 2014, transfers funds from insurers that cover lower-risk enrollees to insurers that cover higher-cost and higher-risk populations in the individual and small group health insurance markets.

A review of market access for hemophilia A or B with inhibitors treatments shows that under the pharmacy benefit, about 40% of the lives under commercial formularies are covered with utilization management restrictions. Around 20% of the lives under health exchange formularies are not covered for at least one of the drugs.

Enrollment in both commercial health coverage and public health insurance slightly increased over the past six months, according to AIS’s Directory of Health Plans. Managed Medicaid membership continued to grow, from 74.0 million in 2022 to 76.5 million in 2023, while a record high 16.7 million people enrolled in Affordable Care Act marketplace coverage. Commercial (employer-based) health coverage grew by nearly 1 million lives, with several major national health plans reporting double-digit growth.

A review of market access for type 2 diabetes (SGLT2 and combo) treatments shows that under the pharmacy benefit, about 43% of the lives under commercial formularies are covered with utilization management restrictions. Around 22% of the lives under Medicare formularies are not covered for at least one of the drugs.

Here’s how major health insurers’ stock performed in June 2023. UnitedHealth Group had the highest closing stock price among major commercial insurers as of June 30, 2023, at $480.64. Humana Inc. had the highest closing stock price among major Medicare insurers at $447.13.

A review of market access for urothelial/bladder cancer shows that under the pharmacy benefit, about 39% of the lives under commercial formularies are covered with utilization management restrictions. Around 60% of the lives under Medicare formularies are not covered for at least one of the drugs.

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.