Employer Group Health Plans

The Kraft Heinz group has sued Aetna, alleging the insurer “leveraged its role as the third-party administrator or ‘TPA’ to enrich itself to Kraft Heinz’s detriment” and breached its fiduciary duties to the employer. The lawsuit contends that Aetna “(a) paid millions of dollars in provider claims that never should have been paid, (b) wrongfully retained millions of dollars in undisclosed fees, and (c) engaged in claims-processing related misconduct to the detriment of Kraft Heinz,” which contracted with the insurer to provide medical and dental benefits for the company’s employees, retirees and their family members. The firm is asking the court to force Aetna to reimburse it for losses linked to the insurer’s alleged fiduciary breach, along with any related profits.

Blue Cross Blue Shield insurers are again set to collect major payouts from the Affordable Care Act’s risk adjustment program, STAT reported based on an analysis of new federal data. The risk adjustment program transfers funds from ACA marketplace insurers that have lower-risk enrollees to those with higher-risk enrollees. STAT found that more than two dozen Blues insurers are projected to collect over $4.7 billion in risk-adjustment transfers for 2022, with Florida Blue, Health Care Service Corp. and Blue Shield of California due the largest amounts.

Although several PBM reform measures are already circulating in Congress, lawmakers recently added even more legislative proposals to the fray. The Senate Finance Committee released a discussion draft that would introduce a host of financial reporting requirements for PBMs contracted by Medicare Part D plans, and then announced it would mark up a package including that measure and other PBM reforms later this month. And, following a markup, the House Education and Workforce Committee advanced a spate of bills focused on promoting transparency for PBMs, health care providers and insurers.

A Capitol Hill insider tells AIS Health, a division of MMIT, that how exactly these measures will fit into a final package of PBM reform legislation remains to be seen, although a few possible scenarios are beginning to come into view.

Alex Oshmyansky, M.D., the CEO of Mark Cuban Cost Plus Drug Co. (MCCPDC), the online cash pharmacy funded by the eponymous billionaire investor, said the company has become a licensed drug wholesaler nationwide and has plans to roll out quasi-PBM business lines including a retail pharmacy network. Oshmyansky discussed these new ventures — and addressed criticism by health care experts that his firm can’t lower specialty pharma costs — during a June 13 keynote at the 2023 AHIP Conference in Portland, Oregon.

“I think it was always our ambition” to work with retail pharmacies, Oshmyansky said. “I think there’s a variety of products where it just doesn’t necessarily make sense for them to be mail-order products,” citing “cold supply chain” and “acute care medications” as examples.

Curative Inc., the Texas startup that launched as a COVID-19 testing provider and pivoted to selling commercial health insurance last year, bought bankrupt Illinois-based life insurance firm American Country Insurance Company (ACIC) earlier this month for an undisclosed sum. The transaction will allow Curative to sell health plans in Illinois, but health care insiders doubt that the firm’s signature offering — large-group commercial health plans with no deductibles — can viably be delivered by a small startup.

Curative said on June 15 that it acquired ACIC, which entered bankruptcy in 2020 and has been in receivership in the states where it operates ever since. Terms of the deal were not disclosed. Per a Curative press release, the ACIC deal will allow the firm to operate “licenses to sell large-group health insurance in select additional states.” Michael Abrams, principal of Numerof & Associates, tells AIS Health, a division of MMIT, that one of those states will be Illinois, as ACIC held both life insurance and health insurance licenses in that state.

UnitedHealthcare will remove out-of-pocket costs and deductibles for remote urgent-care visits, effectively making them free for 5 million members in fully insured employer plans.

The goal is to remove financial barriers that prevent members from getting necessary acute care while deterring them from costlier settings like the emergency room, Donna O’Shea, M.D., chief medical officer of population health for UnitedHealthcare, tells AIS Health, a division of MMIT.

UnitedHealthcare’s effort to steer patients away from the ER is not new — but its $0 copay telehealth visits represent more of a consumer-friendly strategy than it has previously employed. In 2021, the insurer walked back a proposed policy that generated considerable outrage: It would have led to denials of some ER claims that were deemed non-emergencies after the fact.

Alex Oshmyansky, M.D., the CEO of Mark Cuban Cost Plus Drug Co. (MCCPDC), the online cash pharmacy funded by the eponymous billionaire investor, said the company has become a licensed drug wholesaler nationwide and has plans to roll out quasi-PBM business lines including a retail pharmacy network. Oshmyansky discussed these new ventures — and addressed criticism by health care experts that his firm can’t lower specialty pharma costs — during a June 13 keynote at the 2023 AHIP Conference in Portland, Oregon.

“I think it was always our ambition” to work with retail pharmacies, Oshmyanksy said. “I think there’s a variety of products where it just doesn’t necessarily make sense for them to be mail-order products,” citing “cold supply chain” and “acute care medications” as examples.

The share of group health insurance plan enrollees with high health care spending increased from 2013 to 2021, and over 80% of them in 2021 had one or more chronic diseases, according to two studies from the Employee Benefit Research Institute.

By analyzing health care claims of millions of enrollees in a group health plan from the Merative MarketScan Commercial Database, the study found that the share of enrollees incurring spending $100,000 or more per year on health care went up 50%, from 0.6% in 2013 to 0.9% in 2021. The group with the highest spending ($2,000,000 or more) was 2.5 times larger in 2021 compared to 2013.

For the second time in recent history, New York City Comptroller Brad Lander is refusing to register the city’s contract with a Medicare Advantage insurer. But this time it’s not just legal challenges that has the comptroller questioning the city’s move away from fee-for-service (FFS) Medicare, but the broader trends in the MA industry. And CVS Health Corp.’s Aetna is ready to defend its positioning as an experienced provider of retiree health benefits.

After multiple delays, the city was planning to transition some 250,000 retirees and their eligible dependents on Sept. 1 to a PPO plan administered by Aetna. The contract is valued at $15 billion over the first five-plus years of the agreement.

Customer satisfaction with commercial health plans declined year over year, according to J.D. Power’s 2023 Commercial Member Health Plan study. The data analytics firm noted that overall satisfaction decreased by 13 points (on a 1,000-point scale), while there were declines in satisfaction with customer service by 33 points, coverage and benefits by 20 points, provider choice by 16 points, and information and communication by 16 points.

During the previous five years, overall satisfaction increased by 17 points, although there was no change from 2021 to 2022.

Christopher Lis, Ph.D., who is J.D. Power’s managing director of global health care intelligence, tells AIS Health, a division of MMIT, that plans can improve their members’ satisfaction in a few ways. He notes that plans can become “an active health partner” and provide timely and transparent information to beneficiaries and provide individualized support and service.

Although health plans’ formularies have largely been making it easier for people to access buprenorphine in recent years, new research indicates that coverage barriers and access gaps remain — particularly for a newer, costlier extended-release formulation of the opioid use disorder (OUD) drug.

However, a recent FDA approval could usher in more competition that decreases the price and increases coverage of extended-release buprenorphine, which has major advantages over the immediate-release versions, according to one of the study authors.