Health Plan Weekly

Although UnitedHealth Group is facing a host of headwinds — including responding to a massive cyberattack and managing elevated care utilization — Wall Street analysts largely deemed its first-quarter earnings report on April 16 “better than feared,” albeit with a few asterisks.

The cyberattack in question started in February and targeted UnitedHealth’s Change Healthcare division. It significantly disrupted providers’ ability to file claims and receive reimbursement, spurring UnitedHealth to issue short-term loans to some affected providers and temporarily suspend prior authorization for certain services, among other remediation measures.

Elevance Health, Inc. posted solid results in the first quarter of 2024 and announced an agreement to build a new primary care-focused provider unit with financing from private equity firm Clayton, Dubilier and Rice LLC (CD&R). Wall Street analysts were positive about the results, praising the firm’s relatively low care utilization — an area where other health insurers have struggled in recent quarters.

Elevance has been busy with dealmaking in recent months. The CD&R deal, announced April 15, will see the private equity firm and Elevance combine what a CD&R press release termed “certain care delivery and enablement assets of Elevance Health’s Carelon Health and CD&R portfolio companies, apree health and Millennium Physician Group” into a “payer-agnostic” primary care provider focused on value-based contracting, including for patients covered by commercial insurance. It will serve 1 million patients from its inception.

A bipartisan group of politicians wrote a letter on April 15 to UnitedHealth Group CEO Andrew Witty seeking information about the cyberattack on Change Healthcare, a UnitedHealth subsidiary since 2022. They wrote that they were interested in UnitedHealth’s “efforts to secure Change Healthcare’s systems since it was acquired by your company and the efforts you are taking to restore systemic functionality and support patients and providers affected by the attack.” The letter noted that Change’s systems process about 15 billion transactions each year and are linked to about 900,000 physicians, 118,000 dentists, 33,000 pharmacies and 5,500 hospitals. House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-Wash.) and Ranking Member Frank Pallone, Jr. (D-N.J.), Subcommittee on Health Chair Brett Guthrie (R-Ky.) and Ranking Member Anna G. Eshoo (D-Calif.) and Subcommittee on Oversight and Investigations Chair Morgan Griffith (R-Va.) and Ranking Member Kathy Castor (D-Fla.) signed the letter.

More than 20 million people lost their Medicaid or Children’s Health Insurance Program (CHIP) coverage as of April 11, 2024, according to data released by states and CMS on the Medicaid eligibility redetermination process. Medicaid enrollment peaked at 94.5 million in April 2023, when states were permitted to resume disenrolling people from Medicaid who no longer qualify after a multiyear pause during the COVID-19 public health emergency.

States have reported Medicaid renewal outcomes for two-thirds of Medicaid/CHIP enrollees, as of April 2024, according to KFF’s Medicaid Enrollment and Unwinding Tracker. Overall, about one-third of enrollees with a completed renewal lost their Medicaid coverage, and 69% of those coverage losses were due to procedural reasons — meaning individuals didn’t return their renewal form within a specific time frame or the state was unable to reach them. Disenrollment rates varied significantly across states, ranging from 57% in Utah to 12% in Maine.

Payers and providers are increasingly adopting value-based care, although they need to continue to invest in the models and collaborate to make them work, according to a report released on April 10 by AHIP, the American Medical Association (AMA) and the National Association of Accountable Care Organizations (NAACOS). The 74-page report identified best practices for developing payment arrangements for value-based care, including establishing clearly defined contract terms and considering ways to incentivize payers and providers to participate and move away from fee-for-service arrangements.

“Our goal here — AMA, AHIP and NAACOS — is to identify these real world best practices, get those in the hands of health plans, of physicians and clinicians and the teams in general, the VBC entities, so that they can really absorb this information [and] take action based on it related to their own participation in these models, so that we can really scale this nationwide,” Danielle Lloyd, AHIP’s senior vice president of private market innovations and quality initiatives, said during an April 12 panel discussion at the NAACOS Spring 2024 conference in Baltimore.

Since CVS Health Corp. dropped the blockbuster drug Humira (adalimumab) from its national commercial template formularies on April 1, the number of prescriptions written for Humira biosimilars has jumped from just 5% to 36%, according to a recent equity analyst report.

Speakers at the Academy of Managed Care Pharmacy (AMCP) conference in New Orleans said the development is encouraging and could change the game for future biosimilars — including those in the pipeline for another immunosuppressive drug, Stelara (ustekinumab). But clinicians speaking at the conference also said that the transition to biosimilars has not always gone smoothly for patients.

For example, rheumatologist Mark Box, M.D., said the potential cost savings associated with switching patients to biosimilars compared to the administrative burden on providers “often does not balance.”

Medicaid managed care organizations’ compliance with mental health parity laws and regulations varies widely by state, according to an HHS Office of Inspector General (OIG) report and industry experts. The wide range and, in some cases, widespread noncompliance with parity laws will be the subject of possible new regulations in Medicaid managed care.

The OIG report is an early sign that the Biden administration intends to train its sights on state Medicaid agencies and their MCOs’ mental health parity compliance, which would follow several years of heightened scrutiny on commercial plans’ compliance with mental health and substance use disorder (SUD) parity rules. MCOs and states may squirm when they start their time in the hot seat: OIG found that in eight studied states, “states and their MCOs did not conduct required parity analyses…and all eight states may not have ensured that all services were delivered to MCO enrollees in compliance with [mental health]/SUD parity requirements.” OIG also pointed a finger at CMS, blaming the agency for not scrutinizing states’ enforcement of parity rules.

Clover Health Investments Corp. said on April 4 that a federal district court preliminarily approved its settlement agreement to resolve multiple shareholder-filed lawsuits against the Medicare Advantage startup. Clover had faced several class-action lawsuits that accused it of concealing material information from investors — including an active Dept. of Justice investigation — when it went public in 2021. That litigation stemmed from a highly critical report from an activist short-selling firm. In April 2023, Clover agreed to pay $22 million to pay one of the consolidated shareholder lawsuits against it. The more recent settlement agreement — which was first disclosed last June and received preliminary court approval on March 5 — would resolve the remaining shareholder-led civil cases filed against Clover in Delaware, New York, and Tennessee courts. While this settlement does not involve any monetary payment, it will require Clover to “implement a suite of corporate governance enhancements.”

High gross premiums in the Affordable Care Act marketplaces are related to limited choices of health plans and high levels of hospital concentration, a recent Urban Institute report shows.

The study analyzed insurer and premium participation data from more than 503 rating areas on HealthCare.gov and state-based marketplaces from 2019 to 2024. In 2024, the average national benchmark premium — the second-lowest-cost silver premium — is $473. State average benchmark premiums range from $335 in New Hampshire to $886 in Alaska. Average annual premium growth between 2019 and 2024 was modest, averaging 0.2% per year.

Here’s how major health insurers’ stock performed in March 2024. Elevance Health, Inc. had the highest closing stock price among major commercial insurers as of March 28, 2024, at $518.24. Humana Inc. had the highest closing stock price among major Medicare insurers at $346.72.