Radar on Medicare Advantage

Aiming to ensure that Medicare Advantage payments are more equally distributed across geographies and that the federal government can share in the “efficiency” of MA plans, the Medicare Payment Advisory Commission (MedPAC) in its June report to Congress envisioned a “rebalancing” of the current MA benchmark policy used to calculate payment rates. Although the proposal would not translate to a complete overhaul of the current rate structure, it would mean a pay cut for many MA plans if authorized by Congress.

In the first of 10 chapters in its June 2021 Report to the Congress: Medicare and the Health Care Delivery System, MedPAC estimated that Medicare payments to MA plans this year will average about 104% of fee-for-service (FFS) spending. Meanwhile, plan bids were at 87% of FFS Medicare spending and approximately 91% of MA plans submitted bids “below the amount FFS Medicare would spend for similar beneficiaries,” stated the report.

Since the COVID-19 pandemic forced more seniors to stay at home and maintain a physical distance from loved ones, the impact to their mental health has been a key concern of Medicare Advantage organizations over the last year. In response, many MAOs ramped up efforts to address social isolation and loneliness and expanded their telehealth benefits to include visits with behavioral health providers. And while health plans also eased Part D restrictions to smooth members’ access to medications, a recent Health Affairs study shows that new starts of antidepressants and anti-anxiety drugs among seniors were well below expected and historical levels, suggesting there may be an opportunity for insurers to better integrate pharmacy management into their whole-person care of MA members.

Antidepressant New Starts Fell in 2020

The June study, “Decline In New Starts Of Psychotropic Medications During The COVID-19 Pandemic,” sheds some light on prescription drug statistics from the first five months of the pandemic. Researchers analyzed IQVIA Longitudinal Prescription Data collected from Jan. 1, 2018, to Aug. 8, 2020, to assess changes in the number of new starts for three categories of psychotropic medications — antidepressants, anxiolytics and antipsychotics — compared with pre-COVID norms and forecasted levels. During the initial stay-at-home period of mid-March to mid-May, new starts of all three medication types fell dramatically from expected levels, and over the first five months of the pandemic, there were approximately 7.5% fewer new starts of antidepressants, 5.6% fewer new starts of anxiolytics and 2.6% fewer new starts of antipsychotics, according to the study.

This time last year, protests were erupting across the U.S. calling for racial justice and the COVID-19 pandemic was disproportionately impacting communities of color — events that prompted many health insurance providers to release statements affirming their commitment to addressing racial disparities and place diversity and inclusion officers in the C-suite. Now, industry experts agree that concrete action must follow intentions and discussed some of the puzzle pieces to addressing health inequity during the AHIP 2021 Institute & Expo Online, which was held June 22-24.

“Longstanding institutional and social prejudices have kept people of color from adequate health care, frankly, for generations. Unfortunately, this is a complex issue, which is why it hasn’t been solved yet. No individual or even any single company can solve it alone; it’s going to take public sector and private sector partnerships working together to address social determinants of health,” said Gateway Health President and CEO Cain Hayes during the keynote session, Health Equity in America: An Urgent Call to Action. “Health plans, providers, employers, government agencies and others really have a unique opportunity to help address the impact of race, ethnicity and gender on people’s health outcomes.”

✦ Centene Corp. on June 14 said it reached no-fault agreements with the attorneys general of Ohio and Mississippi to resolve claims made by the states related to services provided by Envolve Pharmacy Solutions, Inc. The Ohio Dept. of Medicaid and the state in March accused Centene of violating its Medicaid contract by using a “web of subcontractors” to hide pharmacy information from ODM. Those subcontractors included Envolve, one of its pharmacy benefit manager subsidiaries, which will no longer serve as a PBM on behalf of Centene’s local health plans, according to the company. As a result of the settlement, Centene will pay $88 million to Ohio and $55 million to Mississippi; it did admit any liability for the pharmacy practices alleged by both states.

✦ Three Medicare Advantage insurers that challenged a temporary star ratings policy implemented by CMS last April lost their legal battle. In AvMed, Inc. et al v. Azar et al (No. 20-3385), filed Nov. 20, 2020, in the U.S. District Court for the District of Columbia, Florida-based AvMed and Nevada-based Prominence HealthFirst argued that CMS unlawfully changed the ratings in a way that unfairly penalized organizations when it issued an interim final rule suspending the collection of certain data. In an opinion issued June 1, U.S. District Court Judge John D. Bates sided with CMS, arguing that the agency’s “analytical path was clear” and that there’s no way to confirm that the plaintiffs’ ratings would have improved if not for the suspended data collection.