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Radar on Market Access: Kansas Works Out Medicaid Expansion Deal

Posted by Lauren Flynn Kelly on Jan 21, 2020

Kansas Gov. Laura Kelly (D) and Republican Senate Majority Leader Jim Denning on Jan. 9 said they’d reached a compromise proposal to extend Medicaid coverage to an estimated 130,000 more low-income Kansans, AIS Health reported.

If approved, Kansas will pursue a full expansion of Medicaid to 138% of the Federal Poverty Level (FPL) with a 90/10 funding match. The state will also seek Section 1332 waiver approval to establish a reinsurance program and Section 1115 waiver approval to transition individuals whose incomes fall between 100% and 138% of the FPL from Medicaid to the exchange no later than Jan. 1, 2022, although expansion is not dependent on those waivers. If CMS denies either waiver, full Medicaid expansion will be implemented on Jan. 1, 2021, according to a summary of the pending legislation.

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Topics: Industry Trends, Provider, Payer

Radar on Market Access: State Lawmakers Tee Up Bills on PBMs, Drug Pricing This Year

Posted by Jane Anderson on Jan 16, 2020

State lawmakers will continue to focus on the cost of prescription drugs as the 2020 legislative season gets underway, potentially advancing measures to require the disclosure of manufacturer drug pricing information and bills to limit or eliminate the role PBMs play in state Medicaid programs, AIS Health reported.

However, the abbreviated length of the election-year legislative sessions, plus some unexpected hiccups in states that already have passed bills on those issues, could limit how much actually gets done at the state level in 2020, legislative observers say.

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Topics: Data & Analytics, Provider, Payer

Radar On Market Access: 2020 Could Be 'Wild Year' for Consolidated PBMs

Posted by Leslie Small on Jan 14, 2020

Though the two major transactions that upended the PBM landscape — Cigna Corp. buying Express Scripts Holding Co. and CVS Health Corp. acquiring Aetna Inc. — have already taken place, that doesn't mean the sector won't see more changes this year, industry experts tell AIS Health.

"The market is evolving," says Brian Anderson, a principal with Milliman, Inc. The year 2020 will be marked by a presidential election and significant price pressure on manufacturers, along with pharmacies trying to retain their margin, he adds, "so it's going to be a really wild year."

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Topics: Specialty, Market Access, Data & Analytics, Provider, Payer

Perspectives on UnitedHealth/Diplomat Deal

Posted by Leslie Small on Jan 9, 2020

Diplomat Pharmacy, Inc., which has been in a tailspin amid mounting financial losses, agreed to a deal with UnitedHealth Group on Dec. 9 that will see the larger firm's OptumRx division purchase the midsized specialty pharmacy provider/PBM, AIS Health reported.

Diplomat's difficulties began to come into focus earlier this year, when the firm disclosed customer losses in its PBM business and "increased competitive pressure in the specialty market." In August, Diplomat said it was "reviewing strategic alternatives" to maximize shareholder value. Then on Dec. 9, UnitedHealth disclosed that it agreed to pay $4 per share for Diplomat's outstanding stock and assume its debt. Equities analysts noted that Diplomat's stock was trading at $5.81 as of market close on the Friday before the transaction was unveiled.
 
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Topics: Industry Trends, Provider, Payer

Radar On Market Access: Health Care Deals May Slow in 2020, but Government Markets Remain Hot

Posted by Jane Anderson on Jan 9, 2020

The pace of health care mergers and acquisitions likely will cool slightly in 2020, some industry experts tell AIS Health. Still, insurers are likely to seek out companies with assets such as care management or information technology solutions, while provider consolidation will continue in certain markets, AIS Health reported.

"We expect that payer M&A will continue into 2020, with a bias toward vertical rather than horizontal deals," says Michael Abrams, managing partner of Numerof & Associates, Inc. "Payers will use such deals to expand into adjacent market spaces to differentiate their offerings as integrated platforms that can deliver superior value, customer experience and innovation."

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Topics: Industry Trends, Provider, Payer

Radar On Market Access: Navajo Nation, Molina Partner on Medicaid Managed Care in New Mexico

Posted by Jane Anderson on Jan 7, 2020

The business arm of the Navajo Nation plans to contract with Molina Healthcare, Inc., to offer Medicaid managed care as part of a partnership between New Mexico, tribal officials and the insurer, AIS Health reported.

The program would be the first-ever Medicaid managed care program dedicated solely to the health care, cultural needs and geographic needs of native populations living in the Navajo Nation, according to Molina.

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Topics: Data & Analytics, Provider, Payer

Radar On Market Access: New Sickle Cell Medications Offer Both Opportunities and Challenges

Posted by Judy Packer Tursman on Jan 2, 2020

The first targeted therapy to treat pain crises in people with sickle cell disease presents a "welcome" new option that payers likely will embrace, a PBM head tells AIS Health. While the drug's manufacturer cites "positive" early discussions with payers on it, some experts note the lifetime treatment — via a monthly intravenous infusion — is costly: around $100,000 annually.

On Nov. 15, the FDA approved Novartis' Adakveo (crizanlizumab-tmca), a treatment to fight the underlying cause and reduce the frequency of vaso-occlusive crisis, described as a common and painful complication of sickle cell disease. It is approved for patients ages 16 and older with the genetic blood disorder.

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Topics: Specialty, Market Access, Data & Analytics, Provider, Payer

Perspectives on Dual Eligible SNPs

Posted by Lauren Flynn Kelly on Dec 26, 2019

Through strategic acquisitions, product launches and geographic expansions, Medicare Advantage insurers across the U.S. are offering new Special Needs Plans (SNPs) aimed at improving the lives of members who are dually eligible for Medicare and Medicaid, AIS Health reported.

According to an analysis of the 2020 "landscape" files posted by CMS in September, Chicago health care consultancy Clear View Solutions, LLC, estimates that there are 171 net new SNP IDs, up from 60 net new plans in 2019. And 97 of those net new plans are dual eligible SNPs, compared with 47 D-SNPs that were introduced for 2019.
 
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Topics: Industry Trends, Provider, Payer

Radar On Market Access: Health Insurers Receive Multiple Gifts In Year-End Spending Package

Posted by Leslie Small on Dec 26, 2019

For health insurers, there's a lot to like in a spending package passed by Congress to avoid a government shutdown.

One of the two measures that make up the $1.4 trillion spending package will completely repeal the long-reviled health insurer fee (HIF) starting in 2021, which will especially help insurers in the Medicare Advantage business. The legislation also includes two provisions to that could stabilize the Affordable Care Act exchanges by thwarting any attempts to ban silver loading or auto-reenrollment, AIS Health reported.

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Topics: Data & Analytics, Provider, Payer

Radar On Market Access: Uptake of New MA Supplemental Benefits Remains Modest in 2020, Report Says

Posted by Lauren Flynn Kelly on Dec 24, 2019

Despite Medicare Advantage insurers' enthusiasm for increased flexibility in allowable supplemental benefits and a slew of recent plan press releases touting goodies such as pest control and "Papa Pals" for the 2020 plan year, uptake of more "resource intensive" benefits geared toward seriously ill seniors remains relatively modest, according to a new report from the Duke Margolis Center for Health Policy.

The December report, "Improving Serious Illness Care in Medicare Advantage: New Regulatory Flexibility for Supplemental Benefits," showed that a total of 507 standard MA plans in 2019 offered one of five types of benefits addressing serious illness, accounting for roughly 11% of the approximately 4,500 standard MA plans in 2019, AIS Health reported. By contrast, 377 in 2020 offered at least one of the five benefits highlighted in the report, while no plans in 2019 offered more than one of these benefits. But that drop was mainly driven by one major carrier abandoning its caregiver support benefit for 2020. Meanwhile, about 175 plans offered at least two of these types of these benefits, according to Robert Saunders, research director and one of the report's authors.

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Topics: Data & Analytics, Provider, Payer