Health Plan Weekly

The University of Pittsburgh Medical Center is the largest employer in the Pittsburgh area, with hundreds of job openings on any given day. At the same time, the integrated network’s UPMC Health Plan covers nearly one in five Medicaid beneficiaries in the state of Pennsylvania.

So when the health plan launched its Pathways to Work program this July, it made sense for Medicaid members to be a focal point of the program’s workforce development efforts.

by Jinghong Chen

The year 2020 has been filled with unpredictability amid all the changes ushered in by the COVID-19 pandemic. Because of the pandemic-driven economic crisis and ballooning unemployment, member enrollment has seen significant shifts from commercial health coverage toward managed Medicaid plans, according to AIS’s Directory of Health Plans. Though insurers are required to cover coronavirus testing and many chose to waive out-of-pocket costs for coronavirus treatment, their gross margins soared compared to 2019 as a result of significant drops in elective and routine care utilization.

After years of failed attempts, Congress has finally come to an agreement on a measure to end the practice of surprise medical billing — leaving experts debating whether the new policy can slow the growing cost of health care and the inflation of premiums. The legislation is part of the Dec. 21 Consolidated Appropriations Act, a coronavirus economic relief bill that was passed by Congress but at press time faced an uncertain future after President Donald Trump on Dec. 23 condemned the bill’s $600 direct payments to Americans as too low.

Surprise billing, also known as balance billing, is the practice of charging patients for out-of-network procedures that insurers refuse to pay for in whole or in part. Often, patients incur these balance bills without their knowledge: Some patients are incapacitated when treated by an out-of-network specialist like an anesthesiologist and cannot consent to the procedure they receive. The new legislation would ban providers from sending such a bill to patients, and would instead require providers to negotiate reimbursement with the patient’s insurer or submit the dispute to a binding arbitration process. The measure would not apply retroactively.

✦ The Center for Medicare & Medicaid Innovation on Dec. 17 rolled out a new demonstration model aimed at incentivizing Medicaid managed care organizations to coordinate and improve care for the population that is dually eligible for Medicare and Medicaid. By allowing MCOs to participate as direct contracting entities, CMS hopes to encourage them to take steps such as targeting care coordination resources toward dual-eligible beneficiaries at risk of high Medicare spending, training in-home aides on meal preparation for individuals with nutrition-sensitive conditions like diabetes, and entering into value-based purchasing arrangements with nursing facilities that factor in facilities’ hospitalization rates, among other actions. Read more at https://go.cms.gov/3al7Pfv.

✦ The U.S. Dept. of Justice (DOJ) will require Tufts Health Plan to sell its commercial health insurance business in New Hampshire — called Tufts Health Freedom Plan Inc. — in order to proceed with its merger with Harvard Pilgrim Health Care. UnitedHealth Group, the nation’s largest insurer, will buy Tufts’ New Hampshire holdings, the DOJ said in a Dec. 14 press release. Tufts and Harvard Pilgrim, both of which are based in Massachusetts, announced their deal last year (HPW 8/19/19, p. 1), saying that a combined entity will be better positioned to “bring value to the communities we serve.” Read more about the settlement at https://bit.ly/2LHVnfv.

A new study from Avalere Health comparing quality outcomes for Medicare Advantage enrollees vs. traditional fee-for-service (FFS) Medicare beneficiaries found that high-need, high-cost populations enrolled in MA had better care experiences for most clinical quality measures and had significantly higher rates of preventive screenings for several measures. While MA didn’t outperform FFS across all measures, the findings suggest that care management in MA results in higher quality of care for this vulnerable population, observed the report.

Commissioned by Better Medicare Alliance (BMA), the independent analysis compared performance for similar beneficiaries in three categories: preventive screening and therapy services; inpatient and outpatient services; and management of prescription drugs. Avalere used propensity score matching to control for differences between the MA and traditional FFS population and drew from a nationally representative sample of beneficiaries, resulting in a “matched” study population of 1,262,180 in each group.