Dual Eligibles

SCAN, CCA Team Up to Support PACE Enrollees Through myPlace

As the pandemic underscores the importance of enhanced support for community-dwelling seniors with complex care needs, two not-for-profit Medicare Advantage organizations have teamed up to sponsor an “integrated care delivery organization” designed to serve enrollees who qualify for Programs of All-Inclusive Care for the Elderly (PACE). Long Beach, Calif.-based SCAN Health Plan and Boston-based Commonwealth Care Alliance (CCA) last month unveiled the launch of myPlace Health as part of their shared mission of keeping seniors healthy and independent.

Robbie Pottharst, CEO of the newly launched company, confirms that myPlace is seeking to become a PACE organization and align with local health plans that may already serve dual eligibles who qualify for PACE and that, in his words, “can lend capability, expertise and a lot of accelerators to build this business.” Pottharst previously held leadership roles with Cityblock Health, Kaiser Permanente and CareMore Health, where Sachin Jain, M.D., served as president and CEO before taking over the reins at SCAN.

News Briefs: CMS Is Seeking Applicants for the 2023 MA VBID and Part D Senior Savings Models

CMS on March 1 issued a request for applications (RFA) for the 2023 Medicare Advantage Value-Based Insurance Design Model, which will include new elements such as a Health Equity Incubation Program that will encourage testing of interventions in “the most promising focus areas” (e.g., food insecurity) and designing best practices for such interventions. Thirty-four MA organizations are currently offering benefit packages that feature tailored VBID model benefits and rewards and incentives to more than 3.7 million enrollees, according to the model’s website. CMS on Feb. 28 also released an RFA from Medicare Part D sponsors and pharmaceutical manufacturers interested in participating in the 2023 Part D Senior Savings Model. Now in its third year, the insulin-focused model is intended to lower out-of-pocket costs for seniors by featuring “predictable” copayments of no more than $35 for a broad set of insulins. The voluntary model has 106 participants, including five manufacturers. CMS is accepting applications for the VBID model through April 15 and for the SSM through April 8.

InnovAge Stock Falls as Regulators Scrutinize PACE Operations

Despite better-than-expected financial results posted for its fiscal-year 2022 second quarter, shares of InnovAge — the largest provider of Programs of All-Inclusive Care for the Elderly (PACE) — tumbled last week amid concerns about its ability to grow in the face of intensifying regulatory scrutiny. Between federal audits and issues with its state partners, InnovAge’s many struggles relate to program compliance and may demonstrate the difficulties of scaling up a specialized care model in a highly regulated industry.

Providing services primarily through a dedicated center, PACE organizations support frail, elderly Americans who require a nursing-home level of care by offering comprehensive medical care and social supports to help them remain at home. The PACE market serves about 51,000 participants, most of whom are dually eligible for Medicare and Medicaid, and it is largely composed of regional organizations. As the dominant PACE organization, InnovAge serves 12% of that market.

CMS Rule Proposes to Take Dual Integration to the Next Level

In its new rule proposing an array of policy and technical changes for the 2023 Medicare Advantage and Part D contract year, CMS devoted a large section to advancing integration of Medicare and Medicaid benefits for dually eligible individuals. Though the rule is largely in line with the goals of the SNP Alliance, whose member plans serve approximately 2.5 million Special Needs Plan (SNP) enrollees, the organization says many of the proposals will require greater collaboration between states and plans, as well as more specificity and standardization around the proposed collection of social determinants of health (SDOH) data.

The proposed rule, Medicare Program; Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs (87 Fed. Reg. 1842, Jan. 12, 2022), included the following provisions:

InnovAge Replaces CEO After CMS Imposes Second Enrollment Freeze on the PACE Organization

Shortly after Denver-based InnovAge learned that CMS suspended enrollment in the company’s Colorado programs due to noncompliance, the leading Programs of All-Inclusive Care for the Elderly (PACE) provider unveiled the resignation of its longtime CEO, Maureen Hewitt. InnovAge serves more than 6,300 PACE participants, or 12% of PACE enrollees overall, and is in the midst of a major expansion. The company on Jan. 3 said Hewitt was leaving to “pursue other opportunities” and it promoted Patrick Blair, the current president, to president and CEO.

InnovAge in March 2021 began trading on the Nasdaq Global Select under the ticker symbol “INNV,” and at the time said it planned to expand its footprint of 16 centers in five states. The company in November said it expected to open three centers in fiscal year 2023 and was looking at additional locations and eyeing acquisitions in new markets.

Aduhelm Price Cut May Not Sway Private Payers’ View of Drug

Since the FDA greenlit the Alzheimer’s drug Aduhelm (aducanumab) in July under the accelerated approval program, concerns over the drug’s hefty price tag and overall effectiveness have been mounting. Now, the drug’s manufacturer, Biogen Inc., has cut the price approximately in half. One expert tells AIS Health that the move may cause private insurers to view the drug slightly more favorably, but they’re still likely to impose coverage restrictions on it. And a health plan trade group signaled that it isn’t impressed by the price cut.

After all, the furor surrounding Aduhelm is not all about price. “The clinical evidence that the FDA relied upon when approving the drug had various limitations, and the findings of the two clinical studies were conflicting,” James Chambers, Ph.D., MPharm., an associate professor at the Tufts Medical Center Institute for Clinical Research and Health Policy Studies, tells AIS Health via email.

PACE Is Poised for Expansion as COVID Highlights Home Needs

As Congressional lawmakers consider additional funding for home and community-based services (HCBS) in Medicaid and the pandemic underscores the importance of enhanced support for community-dwelling seniors, a small but growing segment of the Medicare market is experiencing a resurgence. Programs of All-Inclusive Care for the Elderly (PACE) are designed to support frail, elderly Americans who require a nursing home level of care by providing comprehensive medical care and social supports to help them remain at home, and sources tell AIS Health that PACE competition is heating up as more venture capital firms look to invest in PACE organizations and as multiple states expand their programs.

PACE Market Sees Steady Growth, Diverse Pool of Providers

Enrollment in Programs of All-Inclusive Care for the Elderly (PACE) topped 51,000 people in 2021, according to AIS’s Directory of Health Plans, representing a small but impactful segment of the Medicare market that’s seen consistent annual growth. Notably, no large national entities have a significant PACE presence, leaving regional actors to control the market. The largest PACE organization, InnovAge, enrolls just 12% of all lives, and the average PACE organization enrolls about 430 participants, per AIS data. There will be 14 new PACE plan IDs on the market in 2022, according to research from Clear View Solutions, LLC, up from 12 in 2021. And just two IDs have exited the market for 2022, Clear View found. See an overview of the current PACE market below.

Medicare Advantage Insurers Step Up SNP Offerings for 2022, Particularly for Duals

As Medicare Advantage enrollment soars and the number of individual MA plans available across the U.S. reaches a new high for 2022, the MA Special Needs Plan market is also seeing continued growth. According to estimates from Clear View Solutions, LLC, there will be 926 plans available next year that were offered in 2021, compared with 766 plans that carried over from 2020 to 2021 (see infographic). Dual Eligible SNPs (D-SNPs), in particular, will rise from 477 plans offered in 2020 and 2021 to 569 plans available this year and next, according to the consulting firm’s analysis of the 2022 SNP Landscape files from CMS.

MVP Health Care Taps Into ‘Underserved’ Market With D-SNP

Schenectady, N.Y.-based MVP Health Care has long served Medicare beneficiaries in New York and Vermont with Medicare Advantage and Medicare Savings Account plans. It is also a contractor for the New York State Medicaid program, caters to employers, and offers individual and family plans on and off the Affordable Care Act exchanges. For 2022, the not-for-profit insurer is launching a Dual Eligible Special Needs Plan (D-SNP) through a joint venture with Belong Health, a new company that was co-founded by former Cigna Corp. executive J. Patrick Foley and specializes in helping regional payers launch MA and SNP products.