Health Plan Weekly

✦ The Trump administration and Republican state attorneys general filed a countermotion against a bid by Democratic state attorneys general and House Democrats to speed the Supreme Court’s review of the U.S. Court of Appeals for the 5th Circuit’s decision on Texas v. United States, which deemed the Affordable Care Act unconstitutional (HPW 1/6/20, p. 1). The House motion argued that delaying review would cause instability in health insurance markets, and adversely affect enrollees. America’s Health Insurance Plans (AHIP), a payer trade group, filed an amicus brief in support of the Democrats’ motion. “The district court’s original decision to invalidate the entire ACA was misguided and wrong,” said AHIP CEO Matt Eyles. View the court documents at https://bit.ly/2RmDVMR and https://bit.ly/2suLJUf.

✦ Kentucky Gov. Andrew Beshear (D) reissued a request for proposals (RFP) for Medicaid managed care contracts after the state legislature removed enrollee work requirements from the authorizing legislation (HPW 1/6/20, p. 7). Beshear’s administration set Feb. 7 as the deadline for proposals, and hopes to enter vendor agreements with up to five payers. Current contracts, which expire June 30, are in effect with CVS Health Corp.’s Aetna, Humana Inc., Anthem, Inc., WellCare Health Plans, Inc., and Kentucky non-profit payer Passport. UnitedHealth Group and Molina Healthcare, Inc. participated in the previous administration’s RFP. The state will additionally award a contract to one of the bidders that will provide care for youth living under state authority. View the RFP at https://bit.ly/373gVJl.

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.