Social Determinants of Health

Innovative, mostly non-medical supplemental benefits have seen tremendous growth in the few years the Medicare Advantage program has allowed them. But that growth is still from a base of zero, and industry experts suggest that numerous barriers are keeping adoption of these new supplemental benefits at a relatively slow pace.

Starting with plan year 2019, MA organizations began offering a wider range of benefits such as Adult Day Care and In-Home Support Services thanks to CMS’s reinterpretation of the definition of “primarily health-related supplemental benefits.” And with the passage of the CHRONIC Care Act of 2018, MA plans in 2020 began offering Special Supplemental Benefits for the Chronically Ill (SSBCI), a category of “non-primarily health related” items and services that can be made available to certain beneficiaries.

Innovative, mostly non-medical supplemental benefits have seen tremendous growth in the few years the Medicare Advantage program has allowed them. But that growth is still from a base of zero, and industry experts suggest that numerous barriers are keeping adoption of these new supplemental benefits at a relatively slow pace.

Starting with plan year 2019, MA organizations began offering a wider range of benefits such as Adult Day Care and In-Home Support Services thanks to CMS’s reinterpretation of the definition of “primarily health-related supplemental benefits.” And with the passage of the CHRONIC Care Act of 2018, MA plans in 2020 began offering Special Supplemental Benefits for the Chronically Ill (SSBCI), a category of “non-primarily health related” items and services that can be made available to certain beneficiaries.

Sen. Elizabeth Warren (D-Mass.) and other progressive lawmakers wrote CMS Administrator Chiquita Brooks-LaSure asking the agency to reconsider recently finalized policies that would lead to an average revenue increase of 8.5% for Medicare Advantage plans next year. Citing the Medicare Payment Advisory Commission’s March 2022 Report to the Congress, lawmakers wrote that MA plans last year were paid 4% more per enrollee than fee-for-service Medicare, even though the program was designed to generate savings by paying insurers rates set at 95% of those used by FFS Medicare. “To preserve Medicare and its Hospital Insurance (HI) Trust Fund, we urge CMS to mitigate the announced payment increases for Medicare Advantage plans so they are on par with payments to fee-for-service Traditional Medicare and take additional steps to address overpayments and increase transparency in the Medicare Advantage program,” they wrote on April 20.

CareFirst BlueCross BlueShield, a not-for-profit payer serving a population of 5.3 million in Maryland, Virginia and Washington D.C., has launched a new Public Health Infrastructure team and chosen a leader for its team: Djinge Lindsay, M.D.

CareFirst says its new public health initiative is all about improving health outcomes and health equity for its members. Lindsay tells AIS Health, a division of MMIT, that she and her team plan to leverage data and tackle the biggest barriers standing in the way of health equity.

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.

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.

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.

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:

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.”

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.