These Big Health Insurers Covered Fewer People in the Commercial Market in 2023 Than They Did in 2013. Yet Profits Were Up. Here’s How.

By Joey Rettino - UnitedHealth, Humana and CVS/Aetna insured fewer people in the commercial market in 2023 than they did a decade before. And yet, their profits were way up compared to then. How can commercial enrollment be down but profits up? Read Full Article…

HVBA Article Summary

1. Dominance in the Drug Supply Chain: UnitedHealth and CVS/Aetna have seized significant control over the drug supply chain through their pharmacy benefit businesses. Together, these companies now command over half of the market share in this sector. In 2023, their pharmacy benefit operations contributed more than 30% to their total revenues, illustrating their substantial reliance on this revenue stream.

2. Utilization of Taxpayer-Funded Programs: These health insurers, including UnitedHealth, CVS/Aetna, and Humana, extensively utilize taxpayer-funded government programs. By contracting with federal entities, they administer programs such as Medicaid, Tricare, and Medicare Advantage. These arrangements allow them to channel taxpayer dollars through their operations, contributing to their profitability.

3. Transformation into Diversified Entities: The traditional role of health insurers has evolved dramatically. Today, companies like UnitedHealth, CVS/Aetna, and Humana not only provide insurance coverage but also function as pharmacies, intermediaries in the drug supply chain, and major government contractors akin to defense giants like Lockheed Martin and Raytheon. This transformation underscores their multifaceted business models, which blend insurance services with substantial roles in healthcare delivery and government program administration.

PSNC 2024: Applying a Fiduciary Standard to Health Care

By Remy Samuels - A federal law enacted three years ago is adding new fiduciary responsibilities for plan sponsors as that law and other federal regulations are driving risks and opportunities around health plans. Under the Consolidation Appropriations Act of 2021, plan sponsors are required to attest that their fees for health care plans are fair and reasonable for the services provided. Read Full Article…

HVBA Article Summary

1. Importance of Fiduciary Process: Plan sponsors must apply a fiduciary process, mandated by ERISA, to health care plans. This involves establishing formal committees to ensure compliance and prudent management, as emphasized by Barbara Delaney and Jamie Greenleaf.

2. Legislative Impact: Plan sponsors need to navigate significant legislative changes affecting health care plans, such as hospital price transparency and the Transparency in Coverage rule. These regulations aim to empower employees with information to make informed health care decisions and penalize non-compliance.

3. Contractual Transparency: Removing gag clauses and ensuring full disclosure of compensation from service providers (like PBMs and insurers) is crucial. This transparency enables sponsors to run effective fiduciary processes and benchmark fees, similar to practices in retirement plans under ERISA section 408(b)(2).

Three Healthcare Challenges Overcome by Virtual Specialty Care — And Why Employers Should Take Note

By Ted Hong - In the dynamic landscape of healthcare, virtual specialty care has emerged as an entirely new care model poised to revolutionize the way Americans access healthcare. This modernized form of engagement is quickly gaining steam as more people recognize its benefits for patients, employers, and payers alike. Read Full Article…

HVBA Article Summary

1. Care Model and Scope:

   • Telemedicine: Primarily involves remote consultations between patients and physicians using digital communication tools like video calls, often replacing in-person visits for routine care.

   • Virtual Specialty Care: Goes beyond telemedicine by integrating a multidisciplinary team approach. It utilizes digital platforms to connect patients not only with physicians but also with specialists across various disciplines, offering comprehensive, longitudinal care plans tailored to individual needs.

2. Clinical Integration and Approach:

   • Telemedicine: Focuses on immediate, direct patient care through virtual consultations, suitable for minor ailments and follow-up appointments, typically maintaining continuity in primary care.

   • Virtual Specialty Care: Emphasizes team-based care involving specialists, leveraging multiple data sources (e.g., remote monitoring, patient-reported outcomes) to develop and manage complex treatment strategies. This approach aims for sustained health improvements and management of chronic conditions.

3. Impact on Healthcare Challenges:

   • Telemedicine: Addresses basic accessibility barriers and improves convenience, making healthcare more readily available, especially in underserved areas.

   • Virtual Specialty Care: Tackles broader healthcare challenges such as cost containment, quality enhancement, and equitable access to specialized care. By reducing unnecessary procedures and enhancing care coordination, it aims to optimize outcomes while controlling healthcare expenditures.

Sanders hopes pressure will force down Ozempic price

By Peter Sullivan - Sen. Bernie Sanders is trying to use the bully pulpit to lower the price of wildly popular anti-obesity drugs the same way he helped pushed drugmakers to limit inhaler and insulin costs. But this bid could be much more of an uphill climb. Read Full Article…

HVBA Article Summary

1. Rising Drug Costs vs. Patient Impact: The soaring demand for drugs like Ozempic and Wegovy highlights a looming financial burden on Medicare and patients, exacerbated by steadfast drug list prices that remain resistant to reduction.

2. Political Pressure and Legislative Action: Senator Sanders' upcoming scrutiny of Novo Nordisk's CEO underscores growing political pressure to lower drug prices. While recent legislative wins capped out-of-pocket expenses for insulin and inhalers, they fell short of reducing initial list prices, prompting calls for broader reforms.

3. Industry Response and Future Prospects: Novo Nordisk defends its pricing strategies, citing substantial investments in research and production. Despite claims of affordability through rebates, disparities with international prices persist, fueling concerns over long-term cost sustainability under current healthcare frameworks.

Putting Payers in the Driver’s Seat: How the New CMS Interoperability and Prior Authorization is Changing Healthcare

By Donald Rucker - One increasingly subtle but important theme in US healthcare is the shift to care allocated by payers rather than providers. Historically, decisions on what care to provide patients were made by physicians and hospitals – payer interventions were rare. Today that landscape is much different. The entire design of Medicare Advantage (now covering over 50% of Medicare patients) and managed Medicaid is to have payers manage care actively rather than simply paying for claims submitted by providers. Read Full Article…

HVBA Article Summary

1. Evolution of Care Decision-Making: Historically, health maintenance organizations like Kaiser emphasized joint decision-making between providers and patients. Today, Medicare Advantage plans predominantly dictate care decisions using mechanisms such as prior authorization and at-risk contracts, reflecting economic incentives to reduce costs.

2. Challenges of Capitated Care and Policy Responses: Capitated care introduces moral hazards where reducing care can save costs. Despite this, policies like Medicare Advantage's STARS payment program incentivize quality through differential payments, affecting major participants in the market.

3. Integration of Clinical and Financial Data: The future of healthcare efficiency hinges on integrating clinical data from EMRs with payer claims data. Advances in data standards like HL7 FHIR and CMS Interoperability Rule's APIs enable this integration, promising a shift towards consumer-driven healthcare choices and improved operational efficiency for payers.

Uninsured rate to hit 8.9% by 2034, CBO projects

By Bridget Early - The uninsured rate is poised to climb over the coming decade, the Congressional Budget Office predicts in an article published in the journal Health Affairs Tuesday. Read Full Article…

HVBA Article Summary

1. Current Uninsured Rates and Projections:

   • The uninsured rate in 2024 stands at 7.7%, marking an increase from the record low of 7.2% in 2023, according to the CBO.

   • Projections by the nonpartisan agency suggest a further rise to 8.9% by 2034, influenced by factors such as the expiration of enhanced subsidies for health insurance exchange plans and increasing immigration.

2. Impact of Medicaid Redeterminations and Immigrant Population:

   • Approximately 23 million people lost benefits during the Medicaid redetermination process initiated in April 2023, contributing to the recent increase in the uninsured rate.

   • The CBO anticipates that the uninsured rate will continue to climb as more immigrants, historically uninsured at higher rates, arrive in the country. Federal health programs generally do not cover unlawfully residing individuals but provide restricted coverage to legally present immigrants.

3. Health Coverage Sources and Historical Trends:

   • Medicare enrollment is projected to grow as the population ages, while employer-sponsored plans remain the predominant source of coverage, according to CBO forecasts.

   • Despite the projected increase, the 8.9% uninsured rate in 2034 would be higher than pre-COVID-19 pandemic levels but lower than before the Affordable Care Act of 2010, reflecting significant shifts in health coverage over the past decade.

Experts See Generative AI’s Potential to Transform Public Health

By Mark Hagland - Even as concerns continue over the sub-optimal use of artificial intelligence (AI), particularly that of generative AI, in healthcare, some healthcare leaders and researchers see tremendous opportunities for transforming the United States’ public health infrastructure using generative AI tools. Read Full Article…

HVBA Article Summary

1. Public Health 3.0 Framework Evolution: The commentary highlights the evolution of public health practices towards the Public Health 3.0 framework, emphasizing the need for real-time, granular data and cross-sector collaboration. The COVID-19 pandemic underscored the necessity to enhance data systems and technological capabilities, prompting further evolution in public health strategies.

2. Generative AI in Public Health Practice: The authors explore the potential of generative AI to revolutionize public health. They discuss its applications in enhancing public communication by personalizing health information across languages and literacy levels. Additionally, generative AI offers tools to streamline administrative tasks, thereby optimizing organizational performance and freeing up staff time for strategic initiatives.

3. Advancing Insights and Interventions: Generative AI enables advanced analytics that integrate diverse data modalities, such as medical reports and social media activity, to inform novel interventions for complex health issues. This capability promises to revolutionize health practices by providing deeper insights and innovative solutions at a population level.

Novant Health gives up $320M hospital deal after FTC secures appeals court injunction

By Dave Muoio - Novant Health is throwing in the towel on its $320 million plan to purchase two Community Health Systems hospitals after the Federal Trade Commission (FTC) scored an injunction on the deal from an appellate court. Read Full Article…

HVBA Article Summary

1. Legal Battle Overview: The U.S. Court of Appeals for the Fourth Circuit has granted an injunction pending appeal, halting Novant Health's acquisition of Lake Norman Regional Medical Center and Davis Regional Medical Center. This decision overturns an earlier ruling by U.S. District Judge Kenneth Bell, who had allowed the transaction to proceed. The appeal process could extend over two years, introducing significant delay and uncertainty.

2. Novant Health's Perspective: Novant Health, which announced the acquisition in early 2023, expressed frustration with the FTC's opposition throughout the regulatory process. Despite asserting that joining Novant Health would benefit the hospitals and their communities, the nonprofit health system now faces the prospect of abandoning the transaction due to the prolonged legal challenges.

3. Stakeholder Concerns and Legal Arguments: The dispute revolves around whether the acquisition would enhance competition or harm it by consolidating healthcare services under Novant Health in the region, second only to Atrium Health. While Judge Bell initially leaned towards allowing the deal, the appellate court's decision reflects broader concerns about competitive impact and the potential closure of Davis Regional Medical Center in the absence of a sale, highlighting contentious legal and economic arguments.

Large CT Study Shows Benefits of AI in Predicting CV Risks in Patients Without Obstructive CAD

By Jeff Hall - Artificial intelligence (AI) analysis revealing a very high perivascular fat attenuation index (FAI) score, based on coronary computed tomography angiography (CCTA), is associated with a greater than fourfold higher risk of major adverse cardiac events (MACEs) and a greater than sixfold higher risk of cardiac mortality in comparison to those with low or medium FAI scoring, according to new multicenter research published in the Lancet. Read Full Article…

HVBA Article Summary

1. AI-Risk and FAI Score Predictions: The AI-Risk algorithm, incorporating the FAI score, effectively predicts major adverse cardiac events (MACEs) and cardiac mortality. Patients classified as very high risk by AI-Risk had significantly elevated risks, with a 6.75-fold increase in cardiac mortality and a 4.68-fold increase in MACEs compared to low or medium-risk patients.

2. Impact on Patients Without Obstructive CAD: Even in patients without obstructive coronary artery disease (CAD), the AI-Risk algorithm identified individuals at high risk for cardiac events. This underscores the importance of detecting coronary inflammation early, which may precede plaque formation and contribute to adverse outcomes.

3. Clinical Management Changes: The use of AI-Risk classification led to substantial changes in clinical management, affecting 45% of patients. This included initiating statin therapy in 24% of cases, suggesting that integrating AI-based risk assessment could optimize treatment strategies beyond traditional guidelines, potentially improving patient outcomes.