Health Plan Weekly

In a blow to the managed care industry, the Supreme Court chose to delay intervening in Texas v. United States, the Republican state attorneys general-led lawsuit that would overturn the Affordable Care Act (ACA).

“By declining to take up this case in an expedited manner, the Supreme Court leaves in place the cloud of uncertainty that hangs over the Affordable Care Act,” said Association for Community Affiliated Plans (ACAP) CEO Margaret A. Murray in a press release. “We are disappointed in the Court’s decision. Consumers will continue to pay the price for this confusion as the case stagnates, but we remain confident the ACA will withstand this challenge.”

As payers brace themselves for accelerated approvals of cell and gene therapies, they are searching for ways to manage those costs. In an effort to keep pace with competitors, CVS Health Corp. entered the fray, sketching out its strategy for delivering and covering gene therapy in the white paper “Gene Therapy, Keeping Costs From Negating Its Unprecedented Potential.”

There are 800 investigational new drug applications for cell and gene therapies, according to Sarah Butler Donovan, head of client solutions, marketing and operations at Avalere, and the FDA has had to hire 50 new reviewers that are going to be focusing on these new areas. “We’re anticipating, starting this year, roughly 10 approvals for cell and gene therapies a year,” Donovan said during a recent webinar.

With Medicaid demonstration programs that include work requirements struck down in three states, it’s become increasingly clear that such waivers may not survive legal scrutiny. So Nebraska, which last month submitted its own Section 1115 waiver application, is trying a different tactic.

In its application to CMS, the state proposes to modify voter-approved Medicaid expansion by creating two tiers of coverage: Basic, which includes “comprehensive medical, behavioral health and prescription drug coverage” as required by federal law, and Prime, which is the Basic package plus vision, dental and over-the-counter medication coverage. To access the Prime benefits, non-exempted adults must complete “certain wellness, personal responsibility and community engagement activities” such as choosing a primary care provider, regularly attending scheduled doctor appointments, and engaging in a job or volunteer work.

Access to primary care is one of the crucial challenges facing the health care system. As payers and providers try to rein in specialist and acute care overuse, preventive medicine and patient education — central aspects of primary care — have become more important than ever, especially as the baby boomer generation ages into Medicare plans.

Yet a shortage of primary care physicians (PCPs) has frustrated efforts to manage care systemwide. Physician assistants and nurse practitioners have started to fill some demand, but the number of people with a PCP declined between 2002 and 2015, according to a December 2019 JAMA Internal Medicine study.

✦ 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.