Health Plan Weekly

✦ The U.S. Supreme Court on Dec. 10 ruled unanimously against the Pharmaceutical Care Management Association (PCMA) in a case challenging an Arkansas law regulating PBMs. In Rutledge v. PCMA, the justices rejected the trade group’s argument that the Arkansas law is preempted by the Employee Retirement Income Security Act of 1974. By permitting the Arkansas law to stand, the ruling paves the way for legislation regulating PBMs in other states. Read the opinion at https://bit.ly/375ArY5.

✦ Humana Inc. on Dec. 10 said it plans to launch a new value-based payment model called Primary Care First (PCF). The model was first established by the CMS Center for Medicare and Medicaid Innovation and applied to fee-for-service Medicare, and Humana will be the only private insurer to offer its own version of PCF in all 48 contiguous states and the District of Columbia. Humana’s PCF model, which will launch on July 1, 2021, will apply to “members of certain Humana Medicare Advantage plans.” For participating practices, the model will offer “a prospective capitated payment, which takes into account achievement of quality and outcomes-based measures,” according to Humana. Read more at https://bwnews.pr/341nH2I.

Most insurers waived member cost sharing for COVID-19 treatment through the end of 2020, and some payers, mainly nonprofits, have begun to extend those waivers into 2021. An industry insider expects more for-profit carriers will soon feel obliged to do the same.

According to America’s Health Insurance Plans, these non-profit and Blue Cross Blue Shield plans have waived member cost sharing for in-network COVID-19 treatment for some or all members:

The COVID-19 pandemic has led to a digital revolution in behavioral health care, with an explosion in virtual care that has increased access in the short-term. And care delivery is likely to fundamentally change even after the pandemic ends, two stakeholders say.

“Both our patients, as well as providers, have gotten comfortable with digital and virtual behavioral health care, and we’ve really seen these demonstrated advantages,” Douglas Nemecek, M.D., chief medical officer for behavioral health at Cigna Corp., told attendees during a Dec. 8 virtual panel during America’s Health Insurance Plans’ Consumer Experience & Digital Health Forum 2020.

by Jinghong Chen

So far in 2020, spending on health care services is down 2.4% compared to 2019, marking the first time that patient care expenditures have dropped since records became available in the 1960s, according to a recent analysis by the Kaiser Family Foundation. In April when the first surge of coronavirus infections was at its peak, personal expenditures on health care services saw an unprecedented 31.9% decrease on an annualized basis. Among health care facilities, outpatient care centers and physicians’ offices experienced the largest drops in revenue year-to-date. The use of telemedicine services has increased dramatically during the pandemic, yet it was not large enough to offset drops in in-person care. The analysis suggested that though health care spending and utilization have rebounded, they could fall again if the current spike in COVID-19 cases causes hospitals and patients to put off elective care.

With Pfizer Inc. and BioNTech’s coronavirus vaccine on the cusp of FDA authorization, Moderna Inc.’s offering not far behind and AstraZeneca plc also touting promising results from its vaccine, in the coming months there will undoubtedly be a variety of vaccines being administered to Americans. While in normal circumstances private insurers might steer members toward one manufacturer’s vaccine over another, or even refuse to cover certain inoculations, policy experts say that the usual rules do not apply when it comes to the COVID-19 pandemic.

“Few things in health policy are simple, but in the case of the COVID-19 vaccine, there is a very simple take-home message, which is that no one going to get the vaccine will be charged for the vaccine or its administration, no matter what type of insurance they have, or whether they have insurance at all,” Karyn Schwartz, a senior fellow at the Kaiser Family Foundation (KFF), said during a Dec. 3 web briefing about vaccination logistics.