Reimbursement

In its annual release of the Medicare Part D bid information for the coming plan year, CMS on July 31 projected that the average total monthly Part D premium will decrease from $56.49 in 2023 to $55.50 in 2024, thanks in large part to the basic part of the premium being held down by a stabilization provision in the Inflation Reduction Act (IRA). But unlike previous years, where the national average monthly bid amount (i.e., the weighted average of the estimated cost to Part D plan sponsors of providing their benefit package) steadily dropped, CMS reported that the bid amount will rise from $34.71 for 2023 to $64.28 in 2024. That’s largely because of IRA-mandated changes and CMS’s recent rulemaking on pharmacy price concessions.

Starting in 2024, the IRA limits the annual increase in the base beneficiary premium to no more than 6%. The base beneficiary premium, which is the starting point for calculating a plan-specific basic Part D premium, is projected to rise by 5.9% to $34.70 in 2024.

Two health care sector heavyweights— AHIP, the insurance trade group, and the American Medical Association (AMA), a physician group — are teaming up on an effort to boost value-based care by increasing data sharing. A health care industry insider says that the tentative partnership between two longtime adversaries is just the latest indication that, due to plan sponsor pressure on carriers and providers, value-based care could become the industry standard in independent physician practices and primary care.

AHIP, AMA and an additional partner, the National Association of Accountable Care Organizations (NAACOS), on July 25 rolled out a “playbook” for providers and insurers seeking to adopt value-based reimbursement or become partners in an accountable care organization (ACO). The document, which the three groups say is just the first of several such releases, focuses on how providers and plans can effectively share both individual medical and population data.

A lawsuit filed July 24 in a California district court accuses Cigna Healthcare of violating a state law requiring insurers to give each claim a “thorough, fair and objective investigation.” The proposed class-action suit filed on behalf of two Cigna enrollees claims that the insurer uses the system PxDx to deny claims in bulk rather than examine them individually. It cites a ProPublica article published in March that found Cigna doctors denied over 300,000 requests for payment using PxDx over a two-month period in 2022, spending an average of just 1.2 seconds reviewing each request. Cigna, however, hit back in a press release issued July 27 “in response to recent media representations.” The insurer says that PxDx is “a simple process that has successfully helped accelerate payments to physicians for common, relatively low-cost tests and treatments over the last several years,” adding that patients “are not denied care through this review in any way — it occurs after the patient has received treatment and once their physician bills for the treatment.” What’s more, the “vast majority” of claims reviewed through the PxDx process are automatically paid, the firm said, adding that CMS and other health insurers use a similar process.

North Carolina and Colorado recently became the latest in a string of states that have taken over the reins of Friday Health Plans Management Services Company, Inc.’s subsidiaries in a bid to ensure consumers and providers aren’t harmed by the insurer’s implosion. The company’s downfall has implications for health insurers, too, as they may not receive the risk-adjustment funds they’re expecting if Friday can’t pay its share, an industry expert previously told AIS Health.

Insurance Commissioner Mike Causey said June 20 that Friday Health Plans of North Carolina Inc. “consented to being placed into receivership to protect North Carolina policyholders due to its reported insolvency and inability to raise additional funds from outside investors.” Technically, the action is not yet completed, as the state said it filed its receivership petition with the Wake County Superior Court and will post the order on the North Carolina Dept. of Insurance's website once it is signed.

Optum Rx, the PBM owned by UnitedHealth Group, recently launched new programs that will reimburse community pharmacies for helping vulnerable and underserved patients access critical health care services. The move comes as major PBMs like Optum Rx are facing ever-increasing scrutiny for their business practices — including from rural and independent pharmacies that contend big PBMs are driving them out of business.

A trade group for community pharmacists and a health policy expert both say that the programs have promise, although they also say it’s unclear how big of an impact Optum Rx’s initiatives will ultimately make.

Walgreen Co. filed a lawsuit last month asking a judge to overturn a $642 million arbitration judgment awarded to Humana Inc. pertaining to a dispute over drug pricing. The pharmacy giant alleged that it was seeking the reversal in part because a law firm that used to represent Walgreens allegedly switched sides and encouraged Humana to seek the arbitration. “This arbitration began in betrayal and ended in a miscarriage of justice,” Walgreens’ filing claimed.

The case highlights a common disagreement between payers and pharmacies over reimbursement, although it is unusual to see a company blame a law firm for sparking such a clash, according to a lawyer and pharmacist who spoke with AIS Health, a division of MMIT.

After the Trump administration loosened the regulations governing association health plans — and ignited a court battle that ultimately blocked the new rules — AHPs and their close cousin, multiple employer welfare arrangements (MEWAs), have largely faded from the headlines. However, a recent announcement from the Dept. of Labor (DOL) regarding a MEWA that failed to pay $54 million in health claims shows that the fraud and insolvency issues that have long plagued such plans haven’t gone away.

“My sense is that there are what we call self-funded MEWAs out there that may be kind of operating under the regulatory radar,” says Sabrina Corlette, co-director of Georgetown University’s Center on Health Insurance Reforms (CHIR).

On May 3, Option Care Health, Inc., the largest independent provider of home and alternate site infusion services in the U.S., revealed that it was acquiring Amedisys, Inc., which provides home health, hospice and high-acuity care, for $3.6 billion. While opinions on the deal differed, one industry expert contends that the transaction offers multiple long-term benefits within the ever-evolving health care space, especially the home setting.

The deal comes less than a week after Option Care unveiled its wholly owned subsidiary Naven Health, Inc., a nationwide home infusion nursing network and platform employing more than 1,500 nurses and serving all 50 states.

Pear Therapeutics, Inc. this month filed for Chapter 11 bankruptcy, saying that it had laid off about 92% of its staff but would still pursue a sale of the company or its assets. Health care insiders tell AIS Health, a division of MMIT, that the announcement by one of the pioneers in the prescription digital therapeutics (PDT) industry highlights the challenges such companies face getting their products reimbursed. The difficulties are exacerbated by investors being wary of backing companies that promise future growth but have yet to turn a profit.

In 2017, Pear’s reSET digital app to treat patients with substance use disorder became the first FDA-approved PDT, which are software-based therapies to treat medical and behavioral conditions. Since then, the FDA has approved more than 40 DPTs, according to Brandon Aylward, Ph.D., director of digital health for RTI International, a nonprofit research institute.

Many of the largest U.S. hospital systems reported negative net income from 2022, a list that includes Kaiser Permanente, Mass General Brigham, and the Cleveland Clinic, each of which lost at least $1 billion. Although some prominent hospital systems’ red ink is due to negative investment income, the latest available data suggest that inpatient volumes are down from their pre-pandemic baseline and are likely to stay that way. As a result, experts tell AIS Health, a division of MMIT, hospitals are likely to be even more aggressive with payers than they have been in recent rate negotiation rounds to replace some of that lost revenue and expired federal pandemic relief funds.

Consulting firm Kaufman Hall & Associates, which compiles monthly indices of hospital finances, found in a March 28 report that the median hospital operating margin was -1.1% in February, a slight decrease from January’s -0.8%. The report added that “due to external economic factors, relatively flat margins are likely to continue in the near term.”