Data & Analytics

Three Insurers Tap Aledade to Boost Independent Practices, Value-Based Payment

In the space of less than a month, a health care technology company called Aledade has announced new alliances with two health insurers and expanded an existing partnership with another. Those insurers — CareFirst BlueCross BlueShield, Humana Inc. and Cigna Healthcare — say their goal in working with the company is two-fold: (1) to help physician practices remain independent rather than opting for corporate ownership, and (2) to hasten the move from fee-for-service to value-based payment models.

Aledade says it has a “proven, scalable model” aimed at bolstering independent primary care practices. That model includes data analytics, guided workflows, health care policy expertise and “integrated care solutions.” The company says it currently participates in risk-based arrangements with more than 1,500 practices in 45 states and the District of Columbia. Aledade’s CEO, Farzad Mostashari, M.D., is the former national coordinator for health information technology at HHS during the Obama administration.

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© 2024 MMIT

MMIT Reality Check on Crohn’s Disease (1Q2023)

A review of market access for Crohn’s disease treatments shows that under the pharmacy benefit, about 51% of the lives under commercial formularies are covered with utilization management restrictions. Around 46% of the lives under Medicare formularies are not covered for at least one of the drugs.

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© 2024 MMIT

MMIT Reality Check on Non-Small Cell Lung Cancer EGFR-Mutated (1Q2023)

A review of market access for non-small cell lung cancer epidermal growth factor receptor (EGFR)-mutated treatments shows that under the pharmacy benefit, about 59% 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.

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© 2024 MMIT

Highmark Pilots Disease-Tracking Tech Program to Help Members Avoid Illness

Although spring is just around the corner, many families are still reeling from an autumn and winter season that served up a severe onslaught of respiratory syncytial virus (RSV) and influenza cases. But also starting last fall, select members of Highmark Inc. health plans have been given access to a tool that helps them mitigate their risk: a “local illness alert” program that offers regular, data-driven reports about what’s going around in their area.

The insurer and the company Kinsa, which developed the tool, tell AIS Health, a division of MMIT, that there is already evidence that the pilot program is driving behavioral changes among members, such as avoiding crowded indoor spaces when illness levels are high. And if final results from the pilot also look promising, Highmark will expand the program to more members — possibly spurring other insurers to do the same.

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Study Suggests Part D Payers’ Prior Authorization Policies for New Drugs May Be Too Strict

Most new drugs covered under Medicare Part D are subject to prior authorization (PA) requirements, largely due to their high launch prices. A recent study published in JAMA Health Forum observed that these policies are frequently inconsistent across payers and may prove too burdensome for patients and providers.

Researchers identified drugs approved between 2013 and 2017 and reviewed the 2020 formularies of the eight largest Part D payers, which cover about 90% of all Part D beneficiaries. They compared PA policies to each drug’s FDA-approved indications and noted if payers mirrored the approved labeling or were more restrictive than the drug’s label. Researchers observed substantial variation in the frequency and type of PA across payers, and they found that about 40% of the new drugs had PA criteria that went beyond the drug’s labeling.

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© 2024 MMIT

MCO Stock Performance, February 2023

Here’s how major health insurers’ stock performed in February 2023. UnitedHealth Group had the highest closing stock price among major commercial insurers as of February 28, 2023, at $475.94. Humana Inc. had the highest closing stock price among major Medicare insurers at $495.02.

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© 2024 MMIT

MMIT Reality Check on HIV (1Q2023)

A review of market access for HIV treatments shows that under the pharmacy benefit, about 11% of the lives under commercial formularies are covered with utilization management restrictions. Around 12% of the lives under Medicare formularies are not covered for at least one of the drugs.

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© 2024 MMIT

Analyses Highlight Profitability of Private Medicare, Medicaid Plans

By the end of 2021, gross margins per enrollee in the Medicare Advantage market had returned to pre-pandemic levels, and were significantly higher than gross margins in other health insurance markets, according to a recent Kaiser Family Foundation analysis. In 2021, gross margins for MA plans averaged $1,730 per enrollee, more than double the margins in the individual market ($745), the fully insured group ($689) and the Medicaid managed care market ($768). Gross margins for the individual market and group markets were 36% and 17% lower, respectively, in 2021 than they were in 2019, whereas the gross margins per enrollee for Medicaid managed care plans were higher in 2021 than pre-pandemic.

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© 2024 MMIT

Medicaid Drug Spending Growth Hit Double Digits in 2021, Magellan Rx Reports

In 2021, the net cost per prescription drug claim in 25 Medicaid fee-for-service (FFS) programs went up 11.0%, or $5.81, according to Magellan Rx Management’s latest annual Medicaid Pharmacy Trend Report. It is the first time that drug spending growth reached double digits since the inception of Magellan’s report in 2016. Net spending on specialty drugs continued to see double-digit growth at 13.0%, compared with 10.9% in 2020, while net trend on traditional drugs rose 5.8%, up 4.1 percentage points from 2020. For the second year in a row, specialty drugs accounted for more than half of total drug spending in Medicaid FFS, while only representing 1.3% of total pharmacy utilization.

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Medicare Advantage Rolls Reflect 7% Year-Over-Year Growth, Slower 2023 Annual Election Period

Medicare Advantage enrollment is approaching 31 million lives as of February 2023, a 7.4% increase from this time last year, according to AIS Health’s analysis of data that included enrollment from the 2023 Medicare Annual Election Period (AEP). And while CMS says MA enrollment now represents about half of the total Medicare population, the rate of that growth seems to be slowing down — AIS’s analysis of the 2022 AEP recorded an 8.5% annual increase, and a 9.9% increase in 2021.

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© 2024 MMIT