Health Plan Weekly

More than a quarter of HIV-positive Medicaid enrollees did not receive at least one of three necessary services for viral suppression in 2021, according to a new report from the HHS Office of Inspector General (OIG). According to one expert, that missed care is certain to rebound to Medicaid managed care organizations (MCOs) in the form of a heavy cost burden: If HIV isn’t continually treated with antiretroviral therapy (ART) drugs and patients are not monitored by practitioners, the virus will cause a patient to develop AIDS — and patients are more likely to transmit the virus to others. 

Medicaid covers a notable portion — 40% — of people in the U.S. who contracted HIV in 2018, per OIG. In the report, OIG reviewed 2021 claims data for 265,493 enrollees with HIV across the country. The main findings of the report were: 

Now that the COVID-19 public health emergency has ended, the health care system — including insurers — are grappling with how to proceed in the “new normal” amid shifted habits and utilization patterns. To that end, two new studies offer insights into the implications of patients’ growing use of telehealth for mental health care services.  

“The COVID-19 pandemic has caused massive amounts of changes in health care delivery, but then also in terms of how individuals are dealing with the pandemic. There’s been extensive research about how anxiety has increased or [how] other mental health disorders have increased,” observes Jonathan Cantor, Ph.D., a policy researcher at RAND Corp. With that in mind, Cantor and his fellow researchers sought to build on a previous study and measure how both telehealth and in-person mental health utilization and spending has changed from 2019 to 2022. 

Annual health care costs for a hypothetical American family of four covered by an employer-sponsored preferred provider plan (PPO) are estimated to reach $31,065 in 2023, an increase of 5.6% year over year, according to the 2023 Milliman Medical Index (MMI).

On average, annual health care costs per person covered by a PPO plan will grow from $6,472 in 2021 to $7,221 in 2023, the actuarial and consulting firm predicted. Approximately 36% of those total expenses are attributed to inpatient and outpatient hospital services, while professional services alone will account for 30% of total spending in 2023.

The Biden administration on Aug. 29 released its long-awaited list of the first 10 drugs that will be subject to price negotiation in the Medicare program, representing the first major step toward implementing the most ambitious drug-pricing reform in the Inflation Reduction Act (IRA).  

While the new price-negotiation program will apply only to Medicare — not employer-based or individual market plans — industry experts say it will almost certainly affect the commercial insurance market indirectly. But they tell AIS Health, a division of MMIT, that exactly what the impact will look like hasn’t fully come into focus.