Enacting value-based care payment models has been a priority of payer and provider organizations in recent years, but the implementation has been uneven, with care centers serving underprivileged or vulnerable populations being left in the lurch. Helping close the gap is pivotal to reaching the US Centers for Medicare and Medicaid Services (CMS) goal of transitioning to value-based payment models for the majority of Medicaid and Medicare reimbursements.
With over 70% of Medicaid beneficiaries being enrolled in plans from managed care organizations (MCOs), managed care has become a major player in the American health insurance industry. A new article by the Kaiser Family Foundation (KFF) takes a look at five of the largest MCOs and how they are influencing the managed care landscape.
The Biden administration and the US Department of Health and Human Services (HHS) have put forward a proposed rule that would set the limit for short-term health insurance to 4 months, reversing a Trump-era rule that gave them durations up to one year with the chance of renewal. Democrats derided these forms of insurance as “junk insurance,” noting that although they are cheap, they have poor coverage and are only meant to serve as a stop-gap measure.
Eisai and Biogen’s Alzheimer’s treatment Leqembi (lecanemab) has received full approval by the US Food and Drug Administration (FDA). This marks the first full approval for an Alzheimer’s disease treatment in decades and clears the path to Medicare reimbursement, which previously required providers contribute data to a patient registry.
A report by PwC projects that healthcare costs will rise by 7% next year. The report was based on interviews with major payer organizations covering over 110 million patients in the US. Estimated increases in costs are attributed to labor shortages, rising drug prices, provider contracts, and more.
Extensive research has explored how Medicaid expansion has impacted health outcomes in 40 US states, generally finding that it improves health outcomes for patients and provides financial benefits for state governments. A new report by the Kaiser Family Foundation reviews the recent literature exploring the impact of Medicaid expansion on reproductive and sexual health, beginning with coverage.
The shift towards value-based care has the potential to benefit patients, providers, and payers alike, but it brings about unique challenges for managed care plans. In a new Managed Healthcare Executive article, learn more about value-based care payment models and strategies to apply them successfully in managed care organizations.
A recently published study in JAMA finds that sicker patients of advanced age tend to stick with managed care plans. This is a change of pace from recent years, when the industry was decried for preferentially selecting healthier patients. The study was conducted using Medicare enrollment data taken from 45,000 patients.
The UK’s National Institute for Health and Care Excellence (NICE) has sent a request to Eli Lilly asking for more data regarding Mounjaro (tirzepatide) before it will cover it for NHS patients. The decision comes based on data comparing the drug’s efficacy to Novo Nordisk’s rival drug Ozempic and standard insulin therapy. While the data showed Mounjaro was more effective at weight loss and glucose control, NICE needs more information before making a coverage decision.
The US Centers for Medicaid and Medicare Services (CMS) has been busy over the past few months. In a new Becker’s Payer Issues article, learn about the 13 latest moves by the agency that you should know. The first is a new projection by the agency, which expects to see a 7.7% increase in payer spending this year, as well as a 2.1 drop in Medicare spending.
A wave of stock sell-offs in the managed care industry represent a buying opportunity, according to analysts at Wells Fargo. The sell-offs were sparked by comments from UnitedHealth and Humana that noted an uptick in procedures covered by Medicare Advantage plans that were likely postponed during the pandemic.
The US Congress’s Medicare Payment Advisory Commission (MedPAC) has asked the Centers for Medicare and Medicaid Services (CMS) to ramp up telehealth utilization while, at the same time, cutting the payment rates associated with it. The request comes as the post-pandemic status of telehealth looks uncertain with policy changes following the recent end of the COVID-19 public health emergency.
With labor costs rising, decreased demand, and supply chain issues cropping up across the board, health systems faced financial difficulties in the past year. This is expected to get more pronounced over the coming years, despite consumer inflation outpacing inflation in healthcare prices. Changes in patient usage are further contributing to cost increases.
The European Federation of Pharmaceutical Industries and Associations (EFPIA) has released a report highlighting the need for harmonized regulatory requirements for digital health devices and apps. As it stands, only a few countries in the EU have standards for value assessment, reimbursement, and funding pathways. The EFPIA argues that this lack of harmonization constitutes a barrier to access for patients.
Although Medicare Advantage (MA) has been greatly beneficial for participating payer organizations, the picture is less rosy for providers, according to an analysis from the Kaiser Family Foundation (KFF). Providers must deal with a more complex policy framework when working with MA plans, resulting in an increased administrative burden and higher costs.
Specialty Rx carve-outs allow for dedicated management of high-cost specialty medications by bypassing traditional pharmacy benefit managers (PBMs). Doing so, according to a new article in Corporate Wellness Magazine, can help improve employee health by applying specialized expertise to coverage decisions, better coordinating care management, and reducing costs.
Shortly following the end of the COVID-19 public health emergency, pandemic-era restrictions on Medicaid redetermination ended. In that time, over 500,000 people have been disenrolled, interrupting their coverage and impacting their access to healthcare. Some states have kicked off more beneficiaries than others, with Florida taking the lead.
As nursing homes increasingly look for ways to incorporate value-based care into their practices, some are moving towards payvider models, wherein they partner with a Medicare Advantage insurer and play the roles of payer and provider together. A panel of experts spoke about this strategy in a recently broadcast webinar by NetSmart Technologies.
The US drug pricing reform in the Inflation Reduction Act was concocted by John Barkett of the Berkely Research Group. In a new interview, Politico’s Ben Leonard spoke to Barkett to talk about the process and the next steps for the Centers for Medicare and Medicaid Services (CMS). Barkett first spoke about pharma’s criticism of the move and the agency.
COVID-era policies expanded access to Medicaid and Marketplace plans for millions of people in the US, resulting in the lowest rates of uninsured status ever. However, these policies are set to expire soon, resulting in many people under 65 losing their coverage. In a new Health Affairs article, learn more about the state of insurance coverage of people under 65 years of age and how it’s set to change in the coming decade.
A newly published study in JAMA Health Forum found that new Medicare Part D price caps on out-of-pocket prescription drug costs will help new beneficiaries switching from commercial plans. The study found that the $2000 price cap in the provision, included in the Inflation Reduction Act, would save people switching from commercial plans to Part D.
The US 340B program requires drugmakers to provide certain medications at a significant discount to safety-net care centers that provide care for patients in economically disadvantaged areas through Medicaid and Medicare Part B. In a new BenefitsPRO interview with Sarah Hearn of RxBenefits, learn how the 340B program has impacted manufacturers and commercial payers.
A US Federal appeals court has issued a stay on a lower court’s ruling that would gut the preventative care requirements in the Affordable Care Act. If not paused, the lower court’s ruling would end the requirements for payers to cover preventative care services like physicals, Pap tests, cancer screenings, and pre-exposure prophylaxis (PrEP) for HIV.
Several states have adopted policies that make Medicaid managed care plans put money back into local communities to promote health equity and community health by targeting social determinants of health (SDoH) associated with poor health outcomes. In a new Health Affairs Forefront article, learn about the challenges blocking the full realization of these policies’ potential and best practices in developing them.
A newly released proposed rule by the US Centers for Medicare and Medicaid Services (CMS) targets transparency, quality, care access, and payment rates for Medicaid and Children’s Health Insurance Program (CHIP) managed care. States would need to provide an annual payment analysis of all managed cares payment rates for a variety of services. In addition, states will need to develop a quality rating system for Medicaid and CHIP plans.