Health Plan Weekly

Hospitals, buoyed by stabilized finances, have resumed a robust level of transactions. Those deals have drawn more frequent antitrust action by the Biden administration and many state governments, which view hospital mergers and acquisitions as an omen of high health care prices — and augur tough rate negotiations for health insurers.  

An increasing number of those transactions involve so-called “cross market” partnerships, in which hospitals from different markets — and often different states — tie up to avoid antitrust scrutiny from state regulators. State antitrust officials often have more leeway to block hospital transactions, since federal regulators are not allowed to investigate either most intrastate deals or interstate deals with combined revenues of under $111 million.  

The Centers for Medicare and Medicaid Services wants clarification from the federal court that recently ruled against the agency’s interpretation of the law when it comes to commercial insurance plans’ use of copay accumulators before it revises its current policy on such programs.

The Health and Human Services Department filed a motion with the U.S. District Court for the District of Columbia on Nov. 27 seeking an explanation for the court’s late September decision that the policy, which allows plans to use copay accumulators broadly, must be set aside and remanded back to CMS because of the agency’s contradictory reading of the same statutory and regulatory language. 

Nearly 4.6 million people have enrolled in Affordable Care Act marketplace coverage since the start of the 2024 open enrollment period on Nov. 1, a 36% increase compared to the same point during the 2023 OEP, according to CMS. This year’s open enrollment season will last from Nov. 1, 2023, to Jan. 15, 2024, in most states and longer in some state-based marketplaces (SBMs).

More than 4 million people have enrolled through HealthCare.gov in the 32 states that use that platform, and another 501,962 have enrolled across 18 states and the District of Columbia, which use their own marketplaces. Most states are seeing significant membership growth in 2024 compared with the same period last year. Mississippi reported a signup surge of almost 114%.

Former President and current Republican presidential candidate Donald Trump posted on TruthSocial on Nov. 25 that he is “seriously looking at alternatives” to the Affordable Care Act. He added that the failure to overturn the ACA during his presidency “was a low point for the Republican Party, but we should never give up!” Following Trump’s comments, Citi analyst Jason Cassorla wrote in a note to clients that “we got the sense that the Trump headline didn’t have as much of a dampening impact in comparison to the headlines from back in 2017 when the repeal/replace rhetoric was in full swing and Republicans offered alternative such as block grants and other considerations.” Cassorla added that “as the 2024 election rhetoric heats up, we remain watchful of any momentum change on this front.” 

CVS Health Corp.-owned Aetna has reversed course on a previously announced telehealth coverage change, Politico reported. The insurer had planned on ending virtual coverage for intensive outpatient and partial hospitalization program care on Dec. 1, but an Aetna spokesperson told Politico that Aetna would no longer go through with that decision. Groups such as the American Society of Addiction Medicine and the Consortium Representing Eating Disorders Care raised concerns about the proposed change.  

A new report from the Employee Benefit Research Institute (EBRI) confirms that primary care for commercially insured patients is in the midst of a significant transformation. In a study of claims data from 2013 to 2021, EBRI found that fewer patients have a primary care practitioner (PCP), more non-physician practitioners deliver primary care than ever, and sites of care are changing. And the author of the report says he believes the COVID-19 pandemic accelerated the shift. 

EBRI’s findings are a mixed bag for payers. On the one hand, the report confirms that the size of the workforce able to deliver primary care is likely growing, and more patients may have better access to a variety of primary care options: 95-97% of all primary care visits were in an office setting prior to 2020, but that share declined to 86% in 2020. Seven to eight percent of primary care visits went to telemedicine that year and 3-4% went to urgent care clinics. However, the report also found that primary care costs have not gone down despite broader access.