Health Plan Weekly

More and more health care is making a permanent move to the internet following the pandemic-driven virtual care boom — which is a big reason why Medicaid MCOs are doing more to bring telehealth and even broadband internet access to their members. That’s according to a Sept. 23 panel of federal officials and an insurance executive at the AHIP National Conference on Medicare, Medicaid and Dual Eligibles.

“Over the last 18 months, we saw a huge uptake of telehealth in the [U.S.] — it’s like nothing we’ve seen before,” said Joanne Jee, policy director and congressional liaison at the Medicaid and CHIP Payment and Access Commission (MACPAC). “All the states turned on a dime to expand their Medicaid coverage in very meaningful ways. Prior to the pandemic, nearly all states covered some form of telehealth. But what we saw in the pandemic is that all states are covering telehealth in a more expansive way.”

In recent weeks, rankings and survey results have emerged that seek to answer a timeless question for health insurers: How can plans better serve and engage their members?

While the methodology of these reports varies considerably, as do the results, all of their findings offer insights into best practices for an ever-changing industry.

JPMorgan Chase Co. has revamped its troubled effort to become a major player in health care by taking an insider approach and staffing its new venture, Morgan Health, with career health care executives — a move that comes after the firm initially positioned itself as a disruptor with its flashy Haven joint venture alongside Amazon and Berkshire Hathaway. Morgan Health will instead focus on a familiar goal — “improving employer-sponsored healthcare,” per its website — through an emphasis on primary care and capitated reimbursement, while building on JPMorgan’s existing relationships with Cigna Corp. and CVS Health Corp.’s Aetna.

Beyond the goal of reducing JPMorgan’s health care costs, Morgan Health will eventually sell analytics, benefit design and care coordination insights and a capitated reimbursement model to other employer plan sponsors. In contrast with Haven, Morgan Health is directed solely by JPMorgan. Morgan Health also controls a $250 million venture fund, of which $50 million was spent in August to invest in primary care provider Vera Whole Health, where Morgan Health now holds a board seat. Vera’s primary care practice is funded solely by risk-based, capitated reimbursement.

✦ Three centrist Democrats on the House Energy and Commerce committee on Sept. 15 voted down language in a bill that would have enabled Medicare to negotiate drug prices. Reps. Scott Peters (Calif.), Kathleen Rice (N.Y.) and Kurt Schrader (Ore.) joined the committee’s Republicans to keep the measure from advancing. Committee Chair Rep. Frank Pallone (D-N.J.) made several public appeals in favor of drug price negotiation to the trio, who according to Politico all voted in favor of Medicare price negotiation in 2019. Despite the setback, price negotiation is far from dead, according to James Gelfand, executive vice president of public affairs at the ERISA Industry Committee. “My understanding is that the bill can be completely rewritten in the Rules Committee if need be,” Gelfand tells AIS Health via email. He adds that Democratic leaders “have to offer something to Rice…I don’t know exactly what yet. But they cannot afford to blow a $5-600 billion hole in the bill before it gets to the Senate.”

✦ After a plan member filed suit against CVS Health Corp.’s Aetna, accusing the payer of discriminating against LGBTQ+ members in fertility care reimbursement, the health plan announced plans to change its coverage. According to the National Women’s Law Center (NWLF), whose lawyers filed the complaint, “the suit alleges that Aetna’s policy for coverage of IVF and IUI fertility treatments unfairly discriminates against LGBTQ couples by requiring them to pay out of pocket for 12 cycles of IUI before Aetna will provide them with coverage.” NWLF told Modern Healthcare that “we are pleased to learn that there is interest in resolving the matter.”

A newly published report from UnitedHealthcare makes a strong financial case for moving routine, non-complex medical procedures — such as a gallbladder removal — from hospital outpatient departments to ambulatory surgery centers (ASCs). However, one industry observer cites a potential downside to shifting low-risk surgeries away from hospitals, and research suggests that access to ASCs is not equal across all populations.

For its report, UnitedHealthcare examined claims data from the insurer’s employer-sponsored plan members during the 12 months ending February 2020. Of the 6 million routine outpatient procedures that were performed in hospital outpatient departments for this population, 56% involved non-complex patients who had an ASC within a short distance from their homes. If such patients were to choose an ASC as their site of care, it would reduce the cost of routine procedures by an average of 59% — saving consumers $684 on average per procedure, according to UnitedHealthcare.