Health Plan Weekly

In the world of government-sponsored health plans, there’s an often-underserved “hidden population” that is long overdue for increased attention from both payers and policymakers, panelists said during a recent session at AHIP’s virtual Medicare, Medicaid and Dual-Eligibles conference. That population consists of so-called partial dual eligibles, or individuals whose incomes are low enough to qualify for financial assistance from state Medicaid programs to help them pay Medicare cost sharing and premiums but not quite low enough to count them as full dual eligibles — a population that receives Medicaid benefits such as behavioral health services and long-term services and supports (LTSS). “Eligibility for partial duals actually varies a fair bit from state to state, because remember, this turns on the Medicaid program, and Medicaid eligibility varies a fair bit from state to state. So a partial dual eligible in one state may very well be a full dual eligible in another...

Health plans, always reliant on data, have deepened their focus on quantitative analysis and predictive algorithms in recent years — and experts warn that trend might also embed structural racism in health care even further. In response, Colorado passed a law earlier this year that bans health insurance companies from discriminating against members through “algorithms and predictive models,” which health care insiders say could kick off a nationwide trend of similar legislation.

Actuarial work has always been a fundamental part of the health insurance business. Even so, its importance has increased as firms have attempted to leverage emerging “big data” technologies to trim costs, calculate risk scores, and set premium rates; meanwhile, more provider contracts have moved to outcomes-based, capitated reimbursement based on intricate calculations. In addition, an industrywide attempt to address racial disparities in care and social determinants of health relies heavily on population health data and nonmedical demographic data. Ironically, that emphasis on taking race into account may have backfired.

In recently filed lawsuits, major health insurers accuse pharmaceutical companies of engaging in behavior that illegally boosted sales of their products. However, the alleged schemes are very different both in terms of how they work and whether policymakers are likely to step in and definitively end the practices, experts tell AIS Health.

Two of the lawsuits concern “pay-for-delay” deals, in which drug manufacturers sidestep competition for their branded products by offering patent settlements that effectively pay generic manufacturers not to bring their products to market. Humana Inc. and Centene Corp., in separate lawsuits filed in New Jersey’s District Court on Sept. 22, accuse Merck & Co., Inc. of using such a tactic when conspiring with generic manufacturers to delay the market entry of generic substitutes for two blockbuster cholesterol drugs, Vytorin and Zetia.

✦ Cigna Corp. on Sept. 23 unveiled several shifts in its top executives’ roles. Eric Palmer will become the president and CEO of the company’s Evernorth health services division, and Paul Sanford will occupy the newly created role of executive vice president of operations, the company said. In addition, Noelle Eder, the company’s executive vice president and global chief information officer, will expand her role to oversee “global data, analytics and automation,” while Everett Neville will take on an expanded leadership role as executive vice president of strategy, corporate development and solutions. Meanwhile, current Evernorth CEO Tim Wentworth, Cigna President of Government and Solutions Matt Manders, and Cigna Chief Clinical Officer Steve Miller, M.D., will retire.

✦ HHS and the Treasury Dept. on Sept. 17 issued a final rule cementing the administration’s plans to lengthen the Affordable Care Act open enrollment period and add a new special enrollment period (SEP), among other provisions. The annual enrollment period will now have an extra 30 days — spanning from Nov. 1, 2021, to Jan. 15, 2022 — and the SEP will be available monthly for certain low-income individuals, HHS said. Both changes were opposed by health insurers, which submitted comments to the administration expressing concerns about potential adverse selection. The final rule also reversed select Trump-era policies, including those that allowed states to transition away from HealthCare.gov and required insurers to send consumers a separate bill for abortion services.

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