health care utilization

Spike in Remote Patient Monitoring During Pandemic Is Driven by a Fraction of Providers

Billing for remote patient monitoring (RPM) jumped by more than four times during the first year of the pandemic, according to a recent Health Affairs study. The increase was mostly driven by a handful of primary care providers. Using medical claims data from the OptumLabs Data Warehouse collected between Jan. 1, 2019 to March 31, 2021, the researchers found that there were 19,762 general RPM claims in March 2021, compared with 4,355 claims in February 2020. Continuous glucose monitoring, however, only saw a slight increase over the same period of time.

In addition, RPM claims were highly concentrated. The top 0.1% of primary care providers — identified by the researchers as “high-volume provider group” — accounted for 69% of all general RPM claims.

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Medicare Advantage Plans Pay Higher Prices Than CMS for Dialysis Care

A new study published in Health Affairs urged government leaders to limit market consolidation among the largest dialysis providers as more and more seniors choose Medicare Advantage over fee-for-service (FFS) Medicare. Analyzing 2016 and 2017 outpatient Medicare claims data, the study authors found that MA organizations paid inflated costs for dialysis services compared to what FFS Medicare would have paid, especially to large national dialysis organizations — where the majority of patients receive treatment. Notably, MA plans’ median cost for in-network hemodialysis (the most common form of the therapy) was $301, which was markedly higher than the $232 median cost for out-of-network treatments. Findings were similar for peritoneal dialysis, the less common form of dialysis.

Overall, MA plans paid 131% of the FFS price for in-network hemodialysis at large chains, compared to 120% of the FFS price at regional chains, and they paid 112% of the price at independently owned facilities. These markups were also found for in-network peritoneal dialysis but were not observed for out-of-network services.

Medicare Advantage Plans Pay Higher Prices Than CMS for Dialysis Care

A new study published in Health Affairs urged government leaders to limit market consolidation among the largest dialysis providers as more and more seniors choose Medicare Advantage over fee-for-service (FFS) Medicare. Analyzing 2016 and 2017 outpatient Medicare claims data, the study authors found that MA organizations paid inflated costs for dialysis services compared to what FFS Medicare would have paid, especially to large national dialysis organizations — where the majority of patients receive treatment. Notably, MA plans’ median cost for in-network hemodialysis (the most common form of the therapy) was $301, which was markedly higher than the $232 median cost for out-of-network treatments. Findings were similar for peritoneal dialysis, the less common form of dialysis.

Incomes, Consumer Prices, Medicaid Expansion Explain Health Spending Variation Across States

Health care spending per person varied significantly across the nation in 2019, and differences between states grew across time, according to a recent Health Affairs study. State-level health care spending per person ranged from $7,250 in Utah to $14,500 in Alaska in 2019, while annualized growth rates per person ranged from 1.0% in Washington, D.C., to 4.2% in South Dakota from 2013 to 2019.

In 2019, Medicare and Medicaid spending combined accounted for more than one third of total health expenditures in most states, ranging from 27% in Alaska to 48% in Arkansas. The study shows that out-of-pocket spending varied more than overall spending. For example, while South Dakota’s overall health care spending is 50% higher than Arizona, the average South Dakotan spent nearly three times as much out-of-pocket per year ($4,600) compared to the average Arizonan ($1,700).

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Health Spending Per Capita Is Expected to Grow Moderately Over Time

The COVID-19 pandemic significantly impacted health spending in 2020 and its long-term health effects are adding more uncertainties looking ahead, according to the Peterson-Kaiser Family Foundation.

Health spending per capita jumped at a rate of 9.3% in 2020 from the prior year, mainly caused by the COVID-related public health activities. Meanwhile, out-of-pocket health spending declined 4.0% per capita in 2020, as a result of delayed or forgone routine care during the early months of the pandemic. Looking forward, CMS expects health spending and prescription drug spending to grow moderately through 2030, but the new COVID variants and treatments add a great deal of uncertainties to the coming years. Out-of-pocket health spending growth was expected to rebound starting in 2021 and average at a rate of 3.5% for the following seven years.

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In 2Q, Some PBMs Report Dampened Margins, Customer Pipelines

Unlike in recent periods, PBMs were not necessarily stars of the show as the country’s largest publicly traded managed care organizations reported their second-quarter 2022 earnings. However, executives across the board still touted PBMs as a key component of their growth and diversification strategies.

At UnitedHealth Group, the first major MCO to report its quarterly results, one equities analyst queried the health care giant’s leaders about why OptumRx’s “strong” revenue and membership growth haven’t translated into larger margins.

Researchers Examine CF, UC/Crohn’s Adherence, Say Specialty Pharmacies ‘Could Help Reduce Medical Burden’

Two recent studies of specialty-drug treated conditions examined the impact of adherence on hospitalizations and medical costs. Findings of the studies — one on cystic fibrosis (CF) and the other on ulcerative colitis (UC)/Crohn’s disease — from AllianceRx Walgreens Prime (which changed its name to AllianceRx Walgreens Pharmacy in late June) demonstrate the importance of specialty pharmacy interventions in helping keep patients adherent to therapy.

The study posters were presented at the recent International Society for Pharmacoeconomics and Outcomes Research 2022 Conference held in Washington, D.C.

Seniors’ Unmet Social Needs Drive Greater Acute Care Utilization

Health-related social needs (HRSNs) can increase acute care utilization among Medicare Advantage members — including avoidable hospital stays and emergency department (ED) visits — asserts a July 8 investigation published in the Journal of the American Medical Association’s Health Forum. Researchers studied a group of about 56,000 older adults enrolled in MA plans offered by Humana Inc., and found that HRSNs, such as housing, utility and food insecurity, limited access to transportation, and financial difficulties, were associated with significantly higher acute care usage. Notably, 13.6% of the selected population were Medicare-Medicaid dual eligibles, a particularly vulnerable cohort.

Boosted by Low Utilization, Humana Posts Robust Earnings for Second Quarter of 2022

Humana Inc. delivered robust financial results in the second quarter of 2020, with earnings far outstripping the Wall Street consensus. The Medicare Advantage-focused insurer credited lower-than-expected utilization for the strong result, provided investors with more detail about its plans to reorganize following several notable provider transactions, and touted plans to expand its Medicaid business.

Humana took in more than $23.7 billion in adjusted earnings in the second quarter, generating $959 million in adjusted cash flow and adjusted earnings per share of $8.67, beating the Street’s estimate by about $1.00 per share. The firm’s medical loss ratio (MLR) for the quarter was 85.8%. Executives raised the company’s end-of-year earnings projection by $0.25, a move that Oppenheimer & Co. analyst Michael Wiederhorn said “reflect[s] some conservatism” in a July 27 note to investors.

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CMS-Sponsored Report Shows Medicare Advantage Members Encounter Significant Racial Disparities

Medicare Advantage members can experience markedly different outcomes in measures related to prescription drugs based on race and/or ethnicity that ultimately impact their overall quality of care, according to the CMS Office of Minority Health’s latest report on health disparities in MA. The report, “Disparities in Health Care in Medicare Advantage by Race, Ethnicity, and Sex,” was funded by CMS and conducted by RAND Health Care’s Quality Measurement and Improvement Program. The report authors studied both the 2021 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and the 2021 Healthcare Effectiveness Data and Information Set (HEDIS), highlighting disparities in several clinical areas. In addition to the prescription drug measures illustrated in the graphics below, the report also covered other clinical care measures such as cancer screening rates and patient experience measures including the ease of getting medical appointments and customer service experiences.