Health Plan Weekly

As transactions and outside investment in primary care become more common, many health care insiders see an opportunity to shift primary care reimbursement toward risk-based payment — but experts warn that value-based contracting can’t solve all of primary care’s problems on its own.

Primary care practices (PCPs) operating on a fee-for-service basis faced a crisis in 2020, when the pandemic discouraged patients from making routine visits to the doctor’s office. Many PCPs turned to outside financing to fund capital investments or make payroll. Others combined horizontally with other PCPs or sold to health systems.

The Dept. of Justice is preparing to file suit to block UnitedHealth Group’s proposed acquisition of Change Healthcare Inc., according to multiple media outlets citing Dealreporter. Reportedly, the DOJ will meet with UnitedHealth and Change Healthcare representatives in the next few days. The firms had looked into divesting assets to pass antitrust scrutiny, but the DOJ has not accepted any proposal so far, sources familiar with the transaction told Dealreporter.

AHIP asked CMS for more information regarding its National Coverage Determination (NCD) on Aduhelm, the controversial Alzheimer’s drug that garnered accelerated approval from the FDA in 2021 despite objections on scientific and ethical grounds. CMS said in January that Medicare will cover Aduhelm and other drugs in its class only for people who are enrolled in qualifying clinical trials. In a Feb. 10 letter signed by AHIP CEO Matthew Eyles, the trade group requested “that CMS provide clear guidance to MA plans on their coverage obligations under the NCD.” In particular, Eyles called for a list of clinical trials MA plans must cover.

While it’s become common knowledge in the health insurance sector that employer-sponsored coverage isn’t a major growth market, stop-loss insurance is bucking that trend. And with Blue Cross Blue Shield plans in particular not taking as much market share as they could, stop-loss could present attractive opportunities to health care-focused insurance carriers, experts say.

As it applies to health coverage, stop-loss insurance is typically paired with an administrative services only (ASO) contract, in which an employer pays its workers’ health care claims and hires an insurer to process those claims and perform other administrative functions. By adding stop-loss coverage, a self-funded employer is able to have that policy cover any “high-dollar” claim above a certain threshold, called an attachment point, thus minimizing the employer’s risk.

MVP Health Care has launched a new virtual care offering for its New York Medicaid members that allows them to connect with primary care and specialty care physicians through an app made by the digital health company Galileo. Kimberly Kilby, M.D., the insurer’s vice president and medical director of health and well-being, and Christopher Del Vecchio, president and CEO of MVP Health Care, tell AIS Health that they want the new partnership to improve health equity for the insurer’s Medicaid beneficiaries.

The new partnership with Galileo is part of a multiyear effort at MVP to address an unmet need for virtual care. “Over the last 18 months, nearly 40% of MVP’s Medicaid members have not seen a primary care physician (PCP), often due to competing demands on time and resources such as transportation and language barriers,” Del Vecchio tells AIS Health, a division of MMIT, via email.