Health Plan Weekly

The individual insurance market’s financial performance remained stable in the first nine months of 2019, despite the repeal of the individual mandate tax penalty, according to a recent analysis by the Kaiser Family Foundation. The individual market medical loss ratio (MLR) has improved in recent years and averaged 75% throughout the third quarter of 2019. Average gross margins per member per month, however, slightly declined to $131.17 from $146.13 in 2018. Average monthly premiums went up 1.7% from 2018 to 2019, while per person claims grew 6.7%.

UnitedHealth Group beat analysts’ earnings-per-share estimate for 2019’s fourth quarter, driven by strong performance in both its UnitedHealthcare and Optum segments.

For the full 2019 calendar year, earnings from operations grew $2.3 billion or 13.5% year over year to $19.7 billion, the company said. Full year adjusted net earnings per share of $15.11 grew 17% year over year, while fourth quarter adjusted net earnings per share of $3.90 grew 19% year over year, UnitedHealth reported.

The Supreme Court has agreed to hear a case that observers say ultimately could upend state-based efforts to regulate PBMs and potentially even lead to legislation on the federal level to rein them in. The lawsuit, which was brought by the Pharmaceutical Care Management Association (PCMA), challenges a 2015 Arkansas law.

The case boils down to whether PBMs are acting as agents under the Employee Retirement Income Security Act of 1974 (ERISA) and therefore are exempt from state-level regulation, or whether they are a “non-interested party and therefore subject to regulation,” says Jeff Myers, founder of health care consulting firm OptDis. He tells AIS Health that he believes it’s likely the high court justices will side with PCMA and the PBM industry, agreeing that ERISA bars state laws like the one at issue in Arkansas.

In the health care industry, it’s become almost dogma that a small number of “superutilizers” — typically patients with complex medical and social challenges — are driving a disproportionate share of costs in the system. But a newly published study suggests that efforts to improve care and lower costs associated with those individuals aren’t always as effective as they’re heralded to be. And some think that should serve as a gut check for how organizations like health insurers think about social determinants of health.

The subject of the study in question is the Camden Coalition of Healthcare Providers, which convened health systems, primary care officers, community organizations and other stakeholders in a bid to test whether short-term, intensive care management would help reduce the cost of caring for some of the hardest-to-treat patients after they’re discharged from the hospital.

✦ Startup health care company Bright Health said Jan. 8 that it signed an agreement to acquire the California-based, family-owned health plan Universal Care, which is doing business as Brand New Day. Brand New Day, which was founded in 1983, aims to improve health outcomes among vulnerable populations with complex health conditions by focusing on care management and patient-primary care relationships, according to a release from the companies. The transaction still requires regulatory approval and is expected to close this year; the companies did not disclose the dollar amount of the deal. Bright Health sells plans in the individual and Medicare Advantage markets in 12 states. Read more at https://prn.to/39TQEPk.

✦ Molina Healthcare, Inc. agreed to acquire NextLevel Health Partners, Inc., a Medicaid managed care insurer that serves about 50,000 members in Illinois’ Cook County. Molina will pay approximately $50 million for NextLevel Health, which estimated that its premium revenue for 2019 is about $270 million. Pending regulatory approval, the transaction is expected to close in early 2020. “Acquiring NextLevel Health increases our footprint in the state of Illinois, enables us to scale our existing business platform, and provides additional operating cost leverage,” said Pam Sanborn, president of Molina Healthcare of Illinois. “The existing base of acquired assets also provides Molina with expansion opportunities for our Medicare-Medicaid Plan (MMP) and Marketplace offerings.” Visit https://bwnews.pr/2FyDDNn.