If shareholders approve, Anthem, Inc. will change its name to Elevance Health Inc. The rebranding is meant to show that Anthem is moving beyond mainly offering health insurance products. “Elevance Health represents who we are today. Powered by industry-leading capabilities and a digital platform for health, Elevance Health’s companies will serve people across the entire care journey, connecting them to the care, support, and resources they need to lead healthy lives,” President and CEO Gail Boudreaux said in a March 10 press release. While Anthem’s affiliate health plans won’t change their names, the company “does expect to streamline the number of other brands in the market.”

Optum, Inc. recently unveiled Optum Specialty Fusion, a specialty drug management solution that’s focused on streamlining care for people on those products and lowering medication costs. According to the company, which is part of UnitedHealth Group, the approach has the potential to deliver 17% total cost savings in health plans’ medical and pharmacy spend.

Providers are able to request prior authorization for specialty agents via a portal, which then compares treatment options, including their costs, across both the medical and the pharmacy benefit. According to the company, “informed by Optum data and insights, Specialty Fusion provides savings options such as preferred products, dosage management policies, best sites of care and additional cost-control levers such as available discounts and pharmacy networks.” The solution narrows down treatment options to the ones or one that “makes the most clinical and financial sense” and provides approval for that treatment in real time, regardless of the benefit the agent falls under. Optum maintains that this approach lessens “administrative hassle and results in an expected 50% faster access to therapy for patients, while lowering costs.” Specialty Fusion is available for large health plans.

Social determinants of health (SDOH), which researchers have suggested account for up to 80% of health outcomes, can also complicate medication adherence, which can be particularly challenging for people taking specialty drugs. Specialty pharmacies are uniquely suited to address these issues and provide the support and resources that their patients need to overcome barriers to effective treatment, industry experts tell AIS Health, a division of MMIT.

According to the Healthy People 2030 initiative from HHS’s Office of Disease Prevention and Health Promotion, SDOH “are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” These factors can be grouped into five areas:

With the cost of hospital-based services rising ever higher — and sometimes varying dramatically between different institutions — the concept of regulating prices has become a perennial political issue. However, a new study suggests that certain markets are much better suited for price regulation than others: namely, those where there is little hospital competition.

In those concentrated markets, higher hospital prices do not appear to lead to lower patient mortality, meaning cost isn’t correlated with quality, according to a new working paper published by the National Bureau of Economic Research (NBER). But in hospitals in less concentrated markets, pricier hospitals are indeed associated with increased health care quality — and as a result, patients are 47% less likely to die than if they attended lower-priced facilities.

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.

The cost of emergency ground ambulance trips has risen considerably in recent years, according to recent research, and experts tell AIS Health that payers have limited power to push back. Nevertheless, the issue has caught the eye of policymakers amid a larger push to increase health care cost transparency and eliminate surprise medical billing, signaling that change may be on the horizon.

From 2017 to 2020, average charges and allowed amounts for both basic life support (BLS) and advanced life support (ALS) emergency ground ambulance transport increased, according to a new white paper from the nonprofit claims-data research organization FAIR Health.

UnitedHealth Group’s Optum division recently unveiled an analytics-fueled medication management system aimed at tackling rising costs in the specialty drug market. The company says the new product, known as Specialty Fusion, has the capability to generate significant savings while reducing administrative burden for prescribers.

Positioned as a solution for commercial health plans, Specialty Fusion is designed to integrate medical and pharmacy benefit data into a single point-of-service management system. According to Optum, the Specialty Fusion system differs from other solutions on the market because it provides “a full integration” of medical and pharmacy benefits. The system incorporates various cost determinants at the point of care, such as available rebates, lower cost sites of care and manufacturer assistance programs, in addition to a carousel of more affordable drug therapies.

Primary care practices are consolidating at a rapid pace: Independent physician practices are combining on their own, and growth-oriented, outside investors — such as private equity funds, health insurers and health systems — are taking stakes in practices or buying them outright. Experts tell AIS Health, a division of MMIT, that the impact of such deals will vary, but warn that consolidation and investment by private equity firms has raised prices across the board in other areas of health care.

According to a July 2021 report by investment bank Provident Healthcare Partners, 41 primary care transactions worth over $2 billion closed in 2020, a higher deal volume than any year since 2010. Meanwhile, 2019 set a record for capital invested, with $5.1 billion spread across 26 primary care deals. At the time, investors were on pace to shatter both records in 2021: 31 primary care deals worth $4.8 billion had been announced when the report was published. A February 2022 Provident report made note of several major transactions in the last quarter of 2021:

While it’s become common knowledge in the health insurance sector that employer-sponsored coverage isn’t a major growth market, stop-loss insurance is bucking that trend. And with Blue Cross Blue Shield plans in particular not taking as much market share as they could, stop-loss could present attractive opportunities to health care-focused insurance carriers, experts say.

As it applies to health coverage, stop-loss insurance is typically paired with an administrative services only (ASO) contract, in which an employer pays its workers’ health care claims and hires an insurer to process those claims and perform other administrative functions. By adding stop-loss coverage, a self-funded employer is able to have that policy cover any “high-dollar” claim above a certain threshold, called an attachment point, thus minimizing the employer’s risk.

The specialty pharmacy industry will continue its growth in 2022, experts tell AIS Health, a division of MMIT. Multiple agents for rare diseases are poised for FDA approval, and the market may see additional cell and gene therapies. In addition, payers will carry on their efforts to keep prices for specialty medications affordable, among other trends.

AIS Health: What are some specialty pharmacy issues to keep an eye on in 2022, and why?