How Will Interstate Telehealth Licensure Waivers’ Expiration Impact Medicare Beneficiaries?

During the pandemic, all 50 states and Washington, D.C., issued licensure waivers that allowed out-of-state clinicians to perform telehealth with patients across state lines. By analyzing telehealth usage by Medicare beneficiaries from 2017 to 2020, researchers found that out-of-state telehealth made up only a small percentage of all outpatient visits during the first year of the pandemic, though the percentage varied by state, according to a recent study published in Health Affairs.

The number of out-of-state telehealth services jumped from 17,286 in the first quarter to 171,754 in the second quarter of 2020, and then slightly declined. Before 2020, less than 1% of out-of-state new patient visits occurred via telehealth nationwide, while in 2020, the number jumped to 6%.


MCO Stock Performance, May 2022

Here’s how major health insurers’ stock performed in May 2022. Anthem, Inc. had the highest closing stock price among major commercial insurers as of May 31, 2022, at $509.61. Molina Healthcare, Inc. had the highest closing stock price among major Medicaid insurers at $290.22.


CMS Spends Billions on Drugs Granted FDA Accelerated Approval With Unproven Clinical Benefits

Through 2020, CMS spent $68 billion on 38 drugs that were granted accelerated approval from the FDA between 2012 and 2017, with spending after conversion to standard approval accounting for 75% of overall spending, according to a JAMA Health Forum study. However, only 34% of these drugs had a confirmatory trial evaluating a clinical outcome as a primary end point and more than $40 billion was spent for drugs evaluated using surrogate end points. Clinical trials for one drug that converted to standard approval (pembrolizumab) and three that remained unconverted (atezolizumab, durvalumab and olaratumab) for their original indications failed to confirm benefit for primary efficacy end points, while these drugs cost CMS $14 billion in total through 2020. The researchers concluded that “persistent evidentiary gaps should prompt payers to limit spending on promising drugs with unproven benefits.

Key Financial Data for Leading Health Plans — First Quarter 2022

Here’s how major U.S. health insurers performed financially in the first quarter of 2022. Health Plan Weekly subscribers can access more health plan financial data — including year-over-year comparisons of leading health plans’ net income, premium revenue, medical loss ratios and net margins. Just email to request spreadsheets for current and past quarters.


UnitedHealth Dominates While Startups Make Gains in 2022 Medicare Open Enrollment Period

Medicare Advantage enrollment grew by about 232,000 lives during the 2022 Open Enrollment Period (OEP), according to CMS’s May data release and AIS’s Directory of Health Plans. As in the Annual Election Period (AEP), UnitedHealthcare dominated, holding 45.1% of the overall OEP gains, followed by CVS Health Corp.’s Aetna at 16.9% and Centene Corp at 13.5%. Among other large, publicly traded insurers, Cigna Corp. and Humana Inc. both flopped in the OEP, losing 12,600 and 4,200 members, respectively. Meanwhile, insurance startups Bright Health and Clover Health both made the top 20 despite recent financial challenges and questioned viability. See the top 25 OEP performers, plus their AEP results and current enrollment, in the chart below.

The Vast Majority of Physicians Accept New Medicare and Private Insurance Patients

Most non-pediatric office-based physicians accepted new patients, with similar shares accepting new Medicare (89%) and privately insured patients (91%), according to a Kaiser Family Foundation analysis based on the 2019 National Electronic Health Records Survey. A smaller share of primary care physicians accepted new patients with Medicare or private insurance than physicians in other medical or surgical specialties. Across the nation, the share of physicians accepting new Medicare patients ranged from 95% in Iowa, Minnesota and Pennsylvania to 76% in the District of Columbia, similar to the range across states for privately insured patients. As of March 2022, only 1% of non-pediatric physicians formally opted out of the Medicare program, with psychiatrists accounting for 42% of these physicians opting out.


$35 Monthly Insulin Cap Could Save Part D Enrollees 29% Per Prescription

The House in March passed a bill that caps the out-of-pocket cost of insulin at $35 per month for Medicare Part D beneficiaries and for certain privately insured enrollees. A recent Kaiser Family Foundation analysis found that total out-of-pocket spending by Part D enrollees on insulin quadrupled between 2007 and 2019, reaching nearly $1 billion. If a $35 copay cap had been in place in 2019, Part D enrollees without low-income subsidies would have saved $14 per insulin prescription on average. Meanwhile, another study found that over one in four individual and small group enrollees paid more than an average of $35 per month out of pocket for insulin products in 2018. With a $35 cap, median monthly savings could reach $27 in the individual market and $19 in the small and large group markets.

Study: With High Prices, Rebate Revenue Is Growing for PBMs

New research published in JAMA Health Forum found that rebate revenue for PBMs grew between 2015 and 2019 — but that growing rebate revenue was not passed on to patients.

The research letter’s authors measured both prerebate and postrebate drug costs taken from medical loss ratio (MLR) filings made by plans to CMS. The research sample includes commercial insurance filings from small group, individual and large group health plans across “approximately 2,200 unique health plans” covering 70 million lives.

Medicaid Rolls Soar to Nearly 89 Million Beneficiaries as Redeterminations Loom

Nationwide Medicaid enrollment has grown more than 22% since the outset of the COVID-19 pandemic, topping 88.7 million lives, according to the latest update to AIS’s Directory of Health Plans. But the end of the Public Health Emergency (PHE) — which at press time was likely to be extended beyond mid-July — could leave between 5.3 million and 14.2 million people without coverage when redeterminations resume, asserted a May 10 analysis from the Kaiser Family Foundation. A separate study from the Georgetown University Heath Policy Institute found that 6.7 million children stand to lose CHIP coverage at the end of the PHE. See a state-by-state overview of three years of pandemic-fueled Medicaid enrollment changes in the chart below.

A Look at Third-Party Oncology Clinical Pathways

In order to improve patient outcomes and reduce variations in oncology care, more and more payers and providers are adopting oncology clinical pathways (OCPs) — treatment protocols that aim to provide the optimal cancer care to patients at the lowest cost, according to a recent MMIT webinar. The share of oncologists exposed to third-party oncology pathways increased from 20% in 2015 to 52% in 2021, with one third of oncologists choosing a provider-focused pathway as of the fourth quarter of 2021. Breast cancer, multiple myeloma and non-small cell lung cancer are among the top therapeutic areas managed by third-party pathways.