Radar on Medicare Advantage

✦ Aiding in its efforts to deliver timely care and meet members in their “preferred environments,” Anthem, Inc. on March 24 said it will buy home-based nursing management company myNEXUS, Inc. According to a March 24 press release from the firms, myNEXUS provides integrated clinical support services for approximately 1.7 million Medicare Advantage members across 20 states. It utilizes a digital platform that combines an advanced analytic rules engine and a staff of more than 250 clinicians to “effectively plan for and to optimize home care.” It also has a nationwide network of high-performing home health providers and nurse agencies, including nine of the top 10 highest quality national and local providers. The transaction will allow myNEXUS to “broaden our capabilities as we strive to transform how quality healthcare is delivered to the people we serve,” said myNEXUS CEO Juan Vallarino. Upon close, myNEXUS will operate as a wholly owned subsidiary of Anthem and will join its Diversified Business Group. MyNEXUS currently manages approximately 830,000 Anthem MA members and group retirees in all states except Florida, Tennessee and New Jersey. The deal is expected to close in the second quarter of 2021 and is subject to customary closing conditions. Contact Leslie Porras at leslie.porras@anthem.com.

✦ Minneapolis-based not-for-profit insurer UCare has joined the industry-wide Community Connectors Program led by America’s Health Insurance Plans, which aims to vaccinate 2 million vulnerable Americans against COVID-19 over 100 days. UCare will utilize its community partners to help as many eligible members as possible receive their vaccines. Building on its current efforts to support vaccination, UCare will do the following: Host two large-scale COVID-19 vaccine events at the State Fairgrounds in spring and summer, offer UCare Healthmobile COVID-19 vaccine events in greater Minnesota and targeted neighborhoods in the Twin Cities metro starting this spring, conduct a multicultural educational campaign in UCare member languages and communities, make outreach calls to eligible members to help schedule COVID-19 appointments and/or register them with the Minnesota Dept. of Health COVID-19 Vaccine Connector, operate a vaccine hotline, and conduct community outreach and education to “ensure fair and just access to the vaccine for all populations UCare serves.” The insurer provides health benefits to 550,000 members, including those enrolled in Medicare and/or Medicaid, throughout Minnesota and parts of western Wisconsin. Contact Wendy Wicks at wwicks@ucare.org.

A new review of the CMS Transformed Medicaid Statistical Information System (T-MSIS) found that most states did not provide complete or accurate data on managed care payments to providers for January 2020, according to an HHS Office of Inspector General report released March 30. Moreover, two states failed to provide any T-MSIS data for that month. The national data system is critical to ensuring proper oversight of Medicaid, and maintaining accurate Medicaid data is more important than ever as the COVID-19 pandemic continues to drive enrollment and changes in utilization, observed OIG.

Managed care organizations, which cover about 70% of the Medicaid population, are required to submit an encounter claim for each enrollee encounter or visit to a provider. States must then validate those claims for accuracy before submitting them to T-MSIS. The claims include information such as the total amounts billed, allowed and paid for the encounter or visit, but they do not include the capitated payments that the state pays to the managed care organization, according to the report.

Diabetes prevention and diabetes management are both key tenets of Medicare Advantage insurers’ approach to addressing this costly condition that impacts one in three Medicare enrollees. But one tech-savvy startup aims to popularize a third category — diabetes reversal — and early adopter Blue Shield of California says the program has achieved very desirable results in less than two years.

MA plans, on average, face an annual increase in diabetes drug costs of about 3% to 6%, according to Virta Health. That’s because their go-to strategies are promoting medication adherence and/or shifting treatment to different drug classes to try to manage the condition, maintains Steve Hastings, health plan sales leader with the San Francisco-based company. For example, a plan might transition a member from a sulfonylurea to a drug in an emerging class like glucagon-like peptide (GLP-1) receptor agonists or pursue a combination of drugs. “Virta comes to the table and says, ‘Hey, how about we just get them off the drugs altogether?’”

Centene Corp.’s handling of pharmacy benefits in its managed Medicaid contracts has now become the subject of separate investigations in two states. Following the news of Ohio’s attorney general suing Centene over an alleged breach of contract, it was reported that Mississippi’s AG is looking into the Medicaid insurer’s drug benefit practices. Meanwhile, Ohio has delayed announcing the winners of its competitive managed care procurement — which Centene has bid on — and Mississippi is preparing a rebid of its own.

As part of an overhaul of its Medicaid program, Ohio in January selected Gainwell Technologies to serve as the program’s sole pharmacy benefit manager that will be rewarded for patient wellness and health outcomes. The agency said it hopes to achieve greater transparency and accountability in its $3 billion Medicaid pharmacy program and “eliminate costly duplicative processes” with the use of a single PBM.

Long before the COVID-19 pandemic broke out, Medicaid managed care organizations were working with limited revenue streams and navigating across various waivers to address social determinants of health (SDOH). But the pandemic created a new hurdle for low-income enrollees struggling to access basic needs like food and transportation, underscoring the fragmented system in which communities and states currently function, according to panelists at the 12th Annual Medicaid Innovations Forum, hosted virtually from Feb. 1 to 4 by Strategic Solutions Network.

While the previous administration issued a “roadmap” for state health officials highlighting the various demonstration opportunities they have to address different SDOH categories, “there’s a lot more this new administration could do to accelerate progress on [SDOH] and to advance health equity,” starting with infrastructure, suggested Eric Beane, vice president of regulatory and government affairs with Unite Us, speaking during a Feb. 2 panel. “Right now, federal government programs are incredibly siloed. You have individual programs that look at one need of an individual — they don’t look at a whole person’s need, much less the needs of that family or that community — and it’s challenging to communicate…and collaborate across systems.”