Health Plan Weekly

In a Sept. 9 webinar hosted by the Brookings Institution and Robert Wood Johnson Foundation, leading health care economists debated the value of government intervention in prices — and got into an extended argument about what makes U.S. health care prices so high in the first place.

The event was held in honor of the late Princeton economist Uwe Reinhardt, who wrote the seminal 2003 health care economics paper “It’s the Prices, Stupid” and advocated for the U.S. to shift to an all-payer system along the lines of his native Germany, in which prices for health care services and products are subject to uniform schedules.

If there’s any upside to the COVID-19 pandemic, it’s that it has laid bare what both the country and health care organizations need to prioritize moving forward, suggested two keynote speakers during the America’s Health Insurance Plans (AHIP) National Conference on Medicare, Medicaid & Dual Eligibles, which was held online from Sept. 14-17.

“I really do hope that we don’t just look at this as a fire to be put out, but we look at it as a real opportunity to address some underlying kindling that was there,” VADM Jerome Adams, M.D., the U.S. Surgeon General, said during a Sept. 14 panel hosted by AHIP President and CEO Matt Eyles. A major part of that “kindling,” he said, are the stark disparities in social and economic conditions experienced by different racial and ethnic groups across the country.

Experts say that many health insurers are not on track to meet the impending July 2021 and January 2022 deadlines for implementing HHS’s interoperability final rule under the 21st Century Cures Act, a problem that has been exacerbated by the COVID-19 pandemic. However, they also say organizations that have been proactive about building up their technological capacity are in a position to make substantial gains in their analytics capabilities and relationships with members.

The HHS final rule, which was published in May, requires insurers that sell Medicare Advantage, Medicaid and CHIP managed care, and Affordable Care Act exchange plans to launch an application programming interface (API) that will allow patients to access their complete medical and claims history on demand along with a continually updated provider directory by July 2021. Payers must also make all of their patient and claims data available to other insurers on a payer-to-payer data exchange, which must be in place by January 2022. Those deadlines were both extended this summer, as health care stakeholders have been overwhelmed by the COVID-19 pandemic.

Given that enrollment in the Affordable Care Act (ACA) exchanges has basically flatlined at around 11.4 million — a lower level than originally projected and just a small fraction of the overall health insurance market — one might not expect insurers to view the exchanges as a growth opportunity. But recent moves by some of the country’s largest payers suggest otherwise.

Centene Corp., for example, said on Sept. 11 that it will widen its ACA marketplace footprint by selling plans in “nearly 400 new counties” next year. The St. Louis-based company will increase its presence in 13 of the states where it already sells plans, plus enter two new states: Michigan and New Mexico. In total, it will sell its Ambetter-branded plans in 22 states in 2021. Centene, which is also a Medicaid managed care powerhouse, has consistently expanded into new ACA markets since the exchanges’ inception — even when many of its publicly traded peers pulled back (see infographic, p. 8).

✦ Cigna Corp. will offer Affordable Care Act exchange plans in 80 new counties in 2021, reaching 27% more customers in that market, the company said on Sept. 9. The insurer’s ACA marketplace footprint will comprise 10 states: Arizona, Colorado, Florida, Illinois, Kansas, Missouri, North Carolina, Tennessee, Utah and Virginia. Cigna said its 2021 marketplace plans will feature $0 virtual care “that now includes behavioral health providers,” a new plan that offers no-cost diabetes equipment and supplies, and “coverage for holistic services including acupuncture in select counties.” Read more at https://bit.ly/35nrkBx.

✦ Humana Inc. on Sept. 10 rolled out two value-based programs that will be available for select Medicare Advantage plans. The Coronary Artery Bypass Grafting Episode-Based Model is a bundled payment initiative designed to improve quality, outcomes and cost across an entire episode of care for patients undergoing heart bypass surgery. And the Total Shoulder Specialist Rewards Program offers clinicians additional payment for achieving better health outcomes and for lowering costs by incentivizing independent surgeons to perform shoulder replacement procedures at ambulatory surgical centers when it’s clinically appropriate. Humana already has two other orthopedic value-based programs: one for total hip and knee replacement surgeries and one for spinal fusion procedures. See https://bwnews.pr/3m8Rkqd.