The long-term care needs of the nation’s “silver tsunami” of 65-and-older population — a wave that began as the first of the baby boomer generation turned retirement age in 2011 — continue to elicit challenges in the broad health care buckets of spending, coverage, access to services and disparities in care. But during a recent webinar, experts discussed some promising solutions, including one health insurer’s initiative that takes a caregiver-centric approach to post-acute care.

Such pervasive problems in long-term care, an industry with a $415 billion tab in annual spending, were the primary theme of an Aug. 7 National Institute for Health Care Management (NIHCM) webinar, an event that framed the contributory elements of the country’s “long-term care crisis” — namely, underinvestment, a lagging workforce, fragmented care and an industry that often fails to take a person-centered approach.

White bagging continues to be a sore subject for providers, according to a June 21 Avalere Health report. As in past reports, providers surveyed by Avalere are concerned that white bagging can harm patients and lead to wasted medication — which can add up, since payers only use white bagging strategies for expensive specialty medications. The report also raised concerns that payer ownership of specialty pharmacies raises conflicts of interest and could accelerate provider consolidation.

White bagging is a payer practice that significantly changes the customary dispensing and billing arrangements around provider-administered drugs. Until recently, providers used the “buy-and-bill” framework with regard to such drugs. In buy-and-bill transactions, which still account for the vast majority of specialty pharmacy care, providers purchase a specialty drug, stock it in their facility and charge a payer for it after administering the drug to a patient.

CalPERS, the California state agency that administers state and local government employees’ benefits and retirement programs, on June 12 selected Blue Shield of California to administer the agency’s statewide PPO plan, which is projected to have about 400,000 members when the contract starts in the 2025 plan year. The size of the contract makes the deal notable, as does the fact that Blue Shield (which already administers a CalPERS HMO with approximately 175,000 members) will take CalPERS’ PPO business away from incumbent Elevance Health, Inc.

But the structure of the contract itself is what has the health insurance business abuzz. In the new deal, Blue Shield will take on both upside and downside risk based on the plan’s rate of medical cost growth. According to a CalPERS press release, Blue Shield in 2029 stands to gain $31 million in additional fees if it can cut spending growth by 5.5% annually — but Blue Shield would have to pay the agency $61.5 million if it hits “observed trend compared to benchmark” of 5.5%.

There are persistent challenges around the collection and transmission of that data between providers and payers. The same is true of the quality of the data itself. It's a key challenge for the health insurance industry as payers try to measure provider quality and transition to value-based contracting.

"I'll just say the accuracy of our directory is bad. It just is," said Mike Kane, senior vice president for provider data operations at UnitedHealthcare. Kane was speaking on a June 12 panel organized by the Council for Affordable Quality Healthcare (CAQH) at the 2024 AHIP Conference in Las Vegas. "About half of every single provider [data profile] that our members call, there's at least one data element in our directory that's wrong."

"It's a horrible, horrible experience," Kane said.

UnitedHealth Group’s Surest brand has become a hot product in recent months, with sales of the alternative benefit design accounting for one third of the health care giant’s new commercial business, according to some accounts. UnitedHealthcare, the firm’s managed care arm, pitches commercial clients on Surest by promising lower costs and higher quality — without sacrificing a broad network.

Alternatives to conventional PPO plans are more appealing than ever for commercial insurance plan sponsors, who have struggled with sharp medical cost and premium increases in recent years. But restrictive narrow network plans are often unpopular with plan members, and payer stakeholders have begun to shy away from models that shift costs to members.

Between 2019 and 2021, the use of remote physiologic monitoring (RPM) via wearable devices and mobile applications soared by more than 1,300% among Medicaid enrollees, which was driven by a small number of providers, according to a recent Health Affairs study.

Based on Transformed Medicaid Statistical Information System Analytic Files data from Jan. 1, 2019, to Dec. 31, 2021, the study found that the number of RPM recipients per 100,000 Medicaid enrollees increased from 2.1 recipients in 2019 to 29.6 recipients in 2021 and started to accelerate with the March 2020 onset of the COVID-19 public health emergency. Among over 5,600 distinct providers who billed RPM claims for Medicaid enrollees in 2021, more than half of the claims were from 5% of providers.

Medicaid managed care plans are going to invest significant money and time in making sure they comply with CMS’s recently released final rule pertaining to access, finance and quality, according to executives from consulting firm Sellers Dorsey who spoke during a May 20 webinar. Karen Brach, a Sellers Dorsey managing director and former health insurer executive, said “plans have quite a lift ahead of them,” although she added the rule presents a “tremendous opportunity for collaboration” among state Medicaid programs, plans and providers.

The final rule, which was published in the Federal Register on May 10, updates access and quality standards that were established in 2016 and 2020. It was released on the same day as another final rule addressing broader access issues, including requirements for home- and community-based services and fee-for-service Medicaid programs. Earlier this year, CMS announced a final rule on prior authorization and interoperability in Medicaid and a final rule on Medicaid eligibility and enrollment.

Between 2019 and 2021, the use of remote physiologic monitoring (RPM) via wearable devices and mobile applications soared by more than 1,300% among Medicaid enrollees, which was driven by a small number of providers, according to a recent Health Affair study.

Based on Transformed Medicaid Statistical Information System Analytic Files data from Jan. 1, 2019, to Dec. 31, 2021, the study found that the number of RPM recipients per 100,000 Medicaid enrollees increased from 2.1 recipients in 2019 to 29.6 recipients in 2021 and started to accelerate with the March 2020 onset of the COVID-19 public health emergency. Among over 5,600 distinct providers who billed RPM claims for Medicaid enrollees in 2021, more than half of the claims were from 5% of providers.

PBMs and health plans are increasingly relying on pharmacists to manage their members’ medication costs and improve adherence, particularly among marginalized groups who have often been overlooked, according to speakers at the third annual Pharmacoequity Conference, held May 3 at the University of Pittsburgh. The panelists also said pharmacists adopting a so-called “cost-plus” model can help bring more transparency to drug pricing, make medications more affordable, and help people become healthier and save payers money.

The term “pharmacoequity” was popularized in 2021 by Utibe Essien, M.D., an internal medicine physician and former professor at the University of Pittsburgh who is now at the University of California, Los Angeles. Essien has defined pharmacoequity as “equity in access to pharmacotherapies or ensuring that all patients, regardless of race and ethnicity, socioeconomic status, or availability of resources, have access to the highest quality of pharmacotherapy required to manage their health conditions.”

Since last summer, major health insurers’ reports of unusually high outpatient care utilization have proven to be a thorn in the industry’s side — inflating medical loss ratios and forcing Humana Inc. to significantly downgrade its 2024 earnings outlook. And according to some Wall Street analysts, the trend isn’t likely to go anywhere soon.

With the COVID-19 pandemic winding down, “grandma has been locked in her house for the last three years; she’s ready to go on a cruise and she wants that new hip, she needs that new knee,” Deutsche Bank Managing Director George Hill said during the annual Wall Street Goes to Washington Roundtable on April 8, hosted by the Brookings Institution. That increased demand, he said, “has resulted in a surge in outpatient orthopedic procedures that we’ve seen, particularly among seniors, particularly impacting the Medicare Advantage books of business.”