Health Plan Weekly

While payers have long used telephonic-based care management teams to improve outcomes for members with asthma, more recently, they’re also deploying algorithms to fine-tune their outreach to members who are in most need of support. Those algorithms incorporate data such as asthma-related emergency room visits and hospitalizations, first-time prescriptions for asthma medications, additional comorbidities and frequent refills for albuterol inhalers, which suggests that members’ asthma isn’t well managed using long-term control medications.

According to the Centers for Disease Control and Prevention, 7.7% of adults and 7.5% of children in the United States have asthma. Forty-five percent of working adults had an asthma attack between 2011 and 2016, whereas 10% visited the ER due to an asthma-related emergency, per the federal agency. Asthma is the cause of 1.6 million ER visits each year. The average cost of an ER visit to treat asthma is $1,502, according to a 2014 study.

As two federal proposed rules aimed at improving health care data sharing — interoperability — between payers, providers and patients await finalization, America’s Health Insurance Plans (AHIP), Medicaid Health Plans of America (MHPA) and other groups are advocating for phased-in or delayed implementation so that patient privacy, data standards, administrative and operational concerns can be addressed. Both rules are targeted for 2020 implementation. The 21st Century Cures Act provides for expanding interoperability to increase health care efficiency and transparency.

One proposed rule, from CMS, concerns interoperability and patient access and impacts Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and insurers offering qualified health plans in federally facilitated exchanges. Those payers will be required to give patients access to their own health data via third-party apps, including claims information. The impacted organizations must also participate in a health information network of their choice.

✦ Medicare Advantage (MA) enrollment grew by 9.4% year over year in February 2020, covering approximately 24.4 million lives, according to an analysis by Axios. The growth rate increased from 2019’s 6.8% enrollment rise. UnitedHealth Group Inc. maintained its position as the top MA payer, with approximately 6.3 million lives, a 10% increase from last year. Read the Axios story at https://bit.ly/2I0ky88.

✦ The rate of Alzheimer’s and dementia diagnoses in commercially insured Americans increased by 200% from 2013 to 2017, according to a report compiled by the Blue Cross Blue Shield Association. According to the report, approximately 131,000 people aged 30 to 64 were diagnosed with either condition in 2017. Of commercially insured Alzheimer’s and dementia patients, 58% were women as of 2017. The average age of people living with a form of dementia was 49. Read the report at https://bit.ly/38545Ke.

With an estimated pay boost just under 1% and the continued increase of encounter data used in determining Medicare Advantage plans’ risk scores, MA reimbursement in 2021 isn’t looking as robust as it has in recent years now that both parts of the 2021 Advance Notice have come out.

Meanwhile, MA plans face new uncertainties as patients diagnosed with end-stage renal disease (ESRD) can begin enrolling in such plans on Jan. 1, 2021. And while some changes in Part II of the Advance Notice stand to lower rates for serving ESRD enrollees, CMS in a separate memo proposed a new methodology for setting maximum out-of-pocket (MOOP) cost limits that will partly account for ESRD costs starting in 2021.