Health Plan Weekly

✦ Anthem, Inc. will acquire myNEXUS, Inc., “a comprehensive home-based nursing management company,” the insurer said on March 24. The provider-facing myNEXUS platform facilitates authorization by a payer for home nursing services. “Bringing the right level of whole person care into the home has been demonstrated to improve outcomes, reduce readmissions and improve members’ and their family’s experience of wellbeing,” said Prakash Patel, M.D., Anthem executive vice president, and president of its Diversified Business Group. myNEXUS currently serves 1.7 million Medicare Advantage members across 20 states, according to the release, and “combines an advanced analytic rules engine, with a clinical staff of over 250 clinicians to effectively plan for and to optimize home care” and “has established a nationwide network of high performing home health providers and nurse agencies.” Read more at https://bit.ly/3cmWjAK.

✦ The Biden administration has extended the pandemic-driven special enrollment period (SEP) on HealthCare.gov through Aug. 15. The SEP started on Feb. 15, and previously was slated to end on May 15. The extension will allow enrollees to take advantage of expanded tax credits now offered as part of recently passed COVID-19 relief legislation — including people currently enrolled in exchange plans, who will have the opportunity to choose a new plan with an updated price. Research by the Kaiser Family Foundation found that “the number of people eligible for a subsidy to purchase Marketplace coverage has increased 20% from 18.1 million to 21.8 million” after passage of the pandemic relief bill. Learn more at https://go.cms.gov/31l6xvq and https://bit.ly/2NTkA8d.

Orange, Calif.-based Alignment Healthcare, Inc. just became the third startup insurer in recent months to go public. Banking on the strong value proposition of Medicare Advantage, Alignment said it already has a “national expansion strategy” that it will put into action next year, but some experts question whether the measured growth the insurer has achieved primarily in California can be duplicated in other markets. The insurer on March 25 announced the initial public offering of 27.2 million shares of its common stock at $18 per share and on March 26 was expected to begin trading on the Nasdaq Global Select Market under the symbol “ALHC.”

David Mandelbaum, a health care portfolio manager with Bleakley Financial Group, says the trend of insurer startups going public is most likely driven by pressure from the investors and bankers behind the companies. “The academic rationale is to raise capital to expand,” but the real reason is “the aligned interests who are all invested in the company are looking for liquidity,” Mandelbaum tells AIS Health.

A bundled payment program run by San Francisco-based digital health company Carrum Health resulted in an average per-episode savings of more than $16,000 per orthopedic or surgical procedure performed by a provider in the bundled program, a RAND Corp. analysis found.

Overall, counting both procedures reimbursed under the bundled payment program and procedures reimbursed outside the program, per-episode costs for the three procedures studied — spinal fusion, major joint replacement and bariatric surgery — were 10.7% lower overall, on average, than costs for comparable procedures prior to implementation of the program. That added up to a total savings of $4,229 per episode, the study found.

Health insurers on the Affordable Care Act (ACA) exchanges are consistently overestimating the amount they spend on enrollee benefits as part of their medical loss ratio (MLR) reporting, resulting in “hundreds of millions of dollars in underpaid policyholder rebates,” according to new research. Health policy experts tell AIS Health that the findings could fuel greater regulatory scrutiny on individual market carriers, which are increasingly making a profit on the exchanges and had to shell out less than usual in claims last year due to routine-care deferral during the COVID-19 pandemic.

“With the pandemic, I think it is definitely changing the dynamics of the different stakeholders in the health care markets — so obviously the hospitals and physicians lost a lot of money last year, whereas the plans did pretty well because of that; their claims costs went down,” says Krutika Amin, an associate director for the Kaiser Family Foundation (KFF) Program on the ACA, who was not involved with the study. “So I think that is creating a conversation around whether there’s a need to update MLR requirements.”