Health Plan Weekly

Ohio Attorney General Dave Yost filed a lawsuit accusing The Cigna Group’s Express Scripts, Blue Cross Blue Shield-owned Prime Therapeutics, Humana Pharmacy Solutions and Ascent Health Services of colluding to “illegally drive up drug prices” and push those higher costs onto patients. In a March 27 press release, Yost called PBMs “modern gangsters” who have been “scheming in the shadows to control drug prices on all sides of the market” rather than using their negotiating power to drive down prescription costs, as advertised. The suit accuses the PBMs of multiple violations of the Valentine Act, Ohio’s antitrust law, and was filed in the Delaware County Common Pleas Court. “In the case of Express Scripts, the company added insult to injury when it responded to mounting public criticism of PBMs by forming the ‘group purchasing organization’ Ascent Health Services in 2019 — purportedly to take over the company’s pricing and rebate negotiations with drug manufacturers,” Yost’s press release stated. 

Struggling health insurer Bright Health Group Inc. raised eyebrows with its recent announcement that CEO George Mikan III and other top executives earned more than $3.7 million in performance bonuses — despite posting a net loss of more than $600 million last year. The troubled startup insurer is under supervision by at least two state regulators, and one persistent critic of the firm’s executives tells AIS Health, a division of MMIT, that the bonuses are “outrageous.” 

Bright’s 2022 Form 10-K, an annual filing all publicly traded companies are required to submit to the Securities and Exchange Commission (SEC), revealed that Mikan received $1.69 million, with other notable officers of the company receiving between $190,115 and $765,000 in bonuses. Each of the executives who were awarded a bonus received the full amount they could have received based on performance incentives. Bright added in the filing that Mikan’s total compensation was $9,993,169, while the median compensation for a Bright employee was $71,500, meaning Mikan earned 140 times the average Bright employee. 

Point32Health, the nonprofit health care company that was formed two years ago through the merger of Harvard Pilgrim Health Care and Tufts Health Plan, earlier this year launched a partnership with Included Health to better serve LBGTQ+ health plan members and their families.  

Starting on Jan. 1, Tufts Health Plan’s fully insured commercial beneficiaries began gaining free access to Included Health’s LBGTQ+ Health product through which they can connect with care coordinators who can answer questions and refer them to services such as in-network gender-affirming care providers. Harvard Pilgrim’s fully insured commercial members will gain access to the product later this year.  

In the space of less than a month, a health care technology company called Aledade has announced new alliances with two health insurers and expanded an existing partnership with another. Those insurers — CareFirst BlueCross BlueShield, Humana Inc. and Cigna Healthcare — say their goal in working with the company is two-fold: (1) to help physician practices remain independent rather than opting for corporate ownership, and (2) to hasten the move from fee-for-service to value-based payment models.

Aledade says it has a “proven, scalable model” aimed at bolstering independent primary care practices. That model includes data analytics, guided workflows, health care policy expertise and “integrated care solutions.” The company says it currently participates in risk-based arrangements with more than 1,500 practices in 45 states and the District of Columbia. Aledade’s CEO, Farzad Mostashari, M.D., is the former national coordinator for health information technology at HHS during the Obama administration.

Outpatient visits to a physician’s office, urgent care center or emergency department were coded at higher levels from 2004 to 2021, leading to substantial increases in health care spending, according to Peterson-Kaiser Family Foundation Health System Tracker.

Providers and facilities bill outpatient evaluation and management claims based on visit complexity at five levels. Level 1 visits have the lowest complexity cases, with less time required or straightforward medical decision-making, while level 5 visits are the highest complexity cases, with more time required or very complex medical decision-making. Payers generally pay larger reimbursements, and patients with deductibles may pay more out-of-pocket, for visits with higher complexity.