Health Plan Weekly

✦ 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.

With unpredictable risk caused by the intensifying COVID-19 pandemic, estimating claims and enrollment will be more difficult than ever for health insurance companies in 2021, and the task has particularly high stakes for smaller payers.

Member enrollment has shifted a great deal during the pandemic-driven economic crisis, with many Americans losing their jobs and employer-backed health insurance. A substantial portion of those people have enrolled in Medicaid or Affordable Care Act (ACA) exchanges, but analysts and actuaries are still working to determine how many people landed in what part of the health insurance industry and how many people lost coverage altogether.

Building on previously finalized regulations aimed at advancing data interoperability in health care, CMS on Dec. 10 proposed a new rule that would require certain health plans to make their prior authorization processes more efficient and share even more data with providers and patients.

Although the proposal is arriving in the waning days of the Trump administration, it will likely survive the transfer of executive power, one health policy expert tells AIS Health. As for the affected health plans, complying with the new directives probably won’t take a herculean effort considering they’re already doing so much to modernize their data systems to align with the new interoperability mandates, another expert says. However, preparing to comply with all the new requirements is going to be challenging.