Health Plan Weekly

Payers should look at the looming interoperability mandate as a chance to gain a lasting advantage over their competitors, according to two health care information technology (IT) experts.

In a March 26 webinar hosted by America’s Health Insurance Plans (AHIP), IBM Vice President Michael Curry of Watson Health and Jeff Rivkin, research director for payer IT strategies at IDC Insights, said payers should do more than meet the minimum interoperability standards.

When the Affordable Care Act banned individual market insurers from denying coverage to people with pre-existing conditions or charging them higher rates, it created a new option for patients with end-stage renal disease (ESRD), who previously could not access affordable plans in that market. But the ACA’s reforms also opened the door to a practice that has stirred up controversy in the health care sector: dialysis facilities steering patients to higher-reimbursing private plans by indirectly subsidizing their premiums. While attempts to ban such behavior have failed so far, a new study offers reasons why policymakers may want to take another shot at addressing the issue.

The study, published in JAMA Internal Medicine, examined 2016 data from ACA-compliant on- and off-exchange health plans, finding that patients with ESRD comprised just 0.10% of individual market member months but 3.3% of spending. For such patients, average monthly spending on dialysis and other services was 33 times that of patients without ESRD, “underscoring the incentive for [dialysis] facilities to encourage individual market enrollment,” the study stated.

With COVID-19 vaccination becoming increasingly widespread, businesses of all types are starting to plan for what their workplaces — both remote and office-based — will look like in the “new normal” created in the pandemic’s aftermath. Health insurers are no exception: In fact, CareFirst BlueCross BlueShield recently unveiled “the next phase of a reimagined employee and workplace experience strategy” even though most of the mid-Atlantic insurer’s workers are still remote.

Another insurer that shared its plans with AIS Health, Pittsburgh-based Highmark Inc., says it won’t transition its employees back to the office until it can ensure their safety. But one expert says that even though the pandemic clearly isn’t over, companies still need to be carefully planning for the post-COVID future.

UnitedHealth Group’s deal to acquire Change Healthcare Inc. will receive extra scrutiny from the Dept. of Justice, according to a recent filing. Regulators’ decision regarding the deal could have significant implications in the broad digital transformation of the health insurance industry mandated by interoperability and price transparency rules, experts tell AIS Health.

UnitedHealth announced an agreement with Change in January to fold the health data company into the diversified health insurer’s in-house data analytics shop, Optum. DOJ antitrust regulators gave notice to both firms on March 24 that they would have to provide additional information and documentary materials in order to have the deal approved, according to a Securities and Exchange Commission filing. The expanded investigation follows a formal complaint letter from the American Hospital Association (AHA), which requested the DOJ take a deeper look at the deal.