Social Determinants of Health

News Briefs: CMS Will Now Cover and Pay for Over-the-Counter COVID-19 tests for Medicare Enrollees

Effective April 4 and through the end of the COVID-19 public health emergency, Medicare will cover and pay for over-the-counter COVID-19 tests at no cost to people with Medicare Part B, including those enrolled in Medicare Advantage plans. Through the new initiative, beneficiaries can obtain up to eight tests per month from participating pharmacies and health care providers, CMS said on April 4. The agency noted that this is the first time that Medicare has covered an over-the-counter self-administered test at no cost to beneficiaries.

UnitedHealth Group on March 29 said it will spend approximately $6 billion in cash to acquire LHC Group, Inc., a home health care company. If the deal goes as planned, LHC will be folded into UnitedHealth’s Optum division; the companies expect to complete the transaction in the second half of the year. The move will make UnitedHealth a major player in home care and hospice care, positioning it alongside rival Humana Inc., which purchased Kindred at Home last year.

Health Insurers Use Data Acumen to Tackle Health Disparities

Fueled by the COVID-19 pandemic’s deepening of disparities and the Biden administration’s own focus on the issue, health equity is undeniably top of mind for health insurers these days. But how can firms move beyond just appointing new C-suite officers or setting lofty mission statements — and instead weave equity initiatives into the fabric of their businesses?

To answer that question, payer executives during AHIP’s recent National Conference on Health Policy and Government Health Programs explained the business case for furthering health equity and how they’re marshaling processes like data analytics and vendor selections to achieve their goals.

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Health Care and Life Sciences Are Facing Headwinds, but Investors Remain Interested in Deals

Health care and life sciences (HCLS) organizations took a tremendous hit from COVID-19 and its secondary effects, including labor shortages, rising wages, supply chain problems and inflation. In addressing the challenge posed by the pandemic, these companies were able to produce impressive progress, not the least of which were the development and delivery of vaccines, therapeutics and tests for COVID. In addition, telehealth evolved quickly, producing new delivery models across multiple parts of the health care system.

But even when faced with multiple headwinds and more uncertainty, investors continue to compete for HCLS acquisitions. According to a recent KPMG LLP report, merger-and-acquisition (M&A) activity across both sectors “bounced back with a vengeance” in 2021: 1,839 deals, not counting joint ventures, minority investments and venture funding. That’s up from 1,618 deals in 2020 and 1,543 deals in 2019.

Payers, Governments Invest in Rural Areas During Pandemic

During the COVID-19 pandemic, payers and federal and local governments are taking steps to improve health outcomes in rural, non-metropolitan communities, where case and mortality rates are significantly higher than in metropolitan areas.

Some of those initiatives include offering grants to health care providers, expanding access to telehealth and hosting events and campaigns to increase vaccinations, according to three speakers who discussed the pandemic and rural health during a Feb. 28 webinar hosted by the National Institute for Health Care Management (NIHCM) Foundation.

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Specialty Pharmacies Can Tackle SDOH Issues, Boost Adherence

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:

Biomarkers’ Role in Oncology Is Growing, but They’ve Already Had Huge Impact

When the first targeted oncology therapy — Novartis Pharmaceuticals Corp.’s Gleevec (imatinib) — came to market in the U.S. more than 20 years ago, industry experts believed it was ushering in a slew of similar agents focused on a particular mutation, or biomarker. The field, however, did not quite live up to lofty expectations. And while more research has grown the industry exponentially in recent years, it still faces some challenges. But no one can deny that biomarkers have had a profound impact on cancer care.

Agents that target drivers of cancer “have fundamentally changed the way that we treat a wide range of cancers,” maintained Josina Reddy, M.D., Ph.D., global head and vice president of product development for lung, agnostic, skin and rare cancers at Genentech, Inc., a member of the Roche Group, during a recent webinar sponsored by her company. “And in this era of cancer care, identifying those biomarkers in a patient’s tumor tissue or using blood is an essential step in developing a personalized treatment plan, and for a growing share of patients, that treatment plan might include those targeted therapies.”

AHIP Will Prioritize Telemedicine, Health Equity Post-Pandemic

On Feb. 23, health insurer trade group AHIP hosted a virtual State of the Industry presentation, reviewing progress made in 2021 and important issues for the health insurance industry as it looks to a world beyond the COVID-19 pandemic.

Matt Eyles, president and CEO of AHIP, opened the conversation with a look at the organization’s 2021 initiatives and hopes for 2022. Eyles stressed the importance of the No Surprises Act, which aims to protect consumers from surprise medical bills. The legislation went into effect on Jan. 1, but it is currently the subject of a number of lawsuits filed by organizations including the American Hospital Association and American Medical Association. “AHIP continues to fight and protect the law,” Eyles said during the presentation.

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Pharma Industry Aims to Expand Its Role in Addressing Social Determinants of Health

From federal lawmakers to pharmaceutical companies, plans, providers and other health care stakeholders, efforts are coalescing to address social determinants of health (SDOH): the socioeconomic factors that create barriers to care and medications and risk worsening health outcomes. Initiatives are ramping up in response to COVID-19’s disparate impact on vulnerable populations and communities across the U.S. and include pharma collaborations with payers and health systems focusing on social determinants relevant to medication adherence and access.

As one pharma industry consultant puts it, the ongoing pandemic, now past the two-year mark, “has exposed and exacerbated the fractures in our health care and social delivery systems.”

CMS Rule Proposes to Take Dual Integration to the Next Level

In its new rule proposing an array of policy and technical changes for the 2023 Medicare Advantage and Part D contract year, CMS devoted a large section to advancing integration of Medicare and Medicaid benefits for dually eligible individuals. Though the rule is largely in line with the goals of the SNP Alliance, whose member plans serve approximately 2.5 million Special Needs Plan (SNP) enrollees, the organization says many of the proposals will require greater collaboration between states and plans, as well as more specificity and standardization around the proposed collection of social determinants of health (SDOH) data.

The proposed rule, Medicare Program; Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs (87 Fed. Reg. 1842, Jan. 12, 2022), included the following provisions:

On Higher FFS Costs, MA Risk Scores, CMS Proposes Pay Boost of 8% for 2023

In addition to floating a variety of potential changes aimed at advancing health equity in the Medicare Advantage and Part D programs, CMS in its Feb. 2 release of the 2023 preliminary rate notice estimated that MA plans will see an average pay boost of 8% in 2023. And that estimate could change: CMS for 2022 originally estimated that plans would receive an average reimbursement increase of 2.8%, then bumped that estimate up to 4.08% in the final rate announcement.

To Evercore ISI, the 2023 estimate isn’t far off from the “all-in” rate increase of 7.6% in 2022, when considering average risk coding trend, which varies by company.