July 2021 Industry Updates
CMS: American Rescue Plan Tax Credit Reduces ACA Marketplace Coverage Costs
More than one million consumers are paying $10 or less per month for health insurance Marketplace coverage due to the American Rescue Plan’s (ARP) expansion of advance premium tax credit (APTC) payments, according to a recent Centers for Medicare & Medicaid Services (CMS) press release.
The CMS press release indicates that 34% of all consumers selected a plan of $10 or less per month after the April 1 implementation of ARP expanded APTC, which includes 43% of new consumers and 30% of returning consumers. Of 1,034,624 beneficiaries, 687,275 consumers were returning and 347,349 were new.
Nearly 2.3 million returning Marketplace beneficiaries reduced their monthly premiums by over 40% (on average, $103 to $61) after APTC. Additionally, the average monthly premium for new enrollees was reduced by 26% and the median deductible by 83%.
A record 31 million Americans had coverage under the ACA as of February 2021. Since then, more than 1.2 million additional Americans have enrolled in Marketplace programs during the special enrollment period implemented by the current administration.
Newly included demographic data in the special enrollment period report indicate that 15% of new enrollees were Black and 18% were Hispanic, compared to 11% and 16%, respectively, in previous years.
“Having access to quality, affordable health coverage gives Americans peace of mind when they need to seek care,” said Xavier Becerra, secretary of the US Department of Health and Human Services, “…each week we continue to see more Americans experience the relief and security that comes with affordable, quality health coverage.” —Maria Asimopoulos
Digital Therapeutic for Opioid Use Disorder Cuts Medical Costs
A prescription digital therapeutic authorized by the US Food and Drug Administration for the delivery of neurobehavioral therapy to patients with opioid use disorder treated with buprenorphine reduced hospital-based medical costs by $2385 per engaged patient, according to study findings published online in Hospital Practice.
“Engagement and continued treatment with reSET-O in patients with opioid use disorder treated with buprenorphine is associated with substantial real-world reductions in medical costs in the 6-month period following the initiation of the reSET-O prescription,” researchers wrote.
The study looked at claims for health care resource utilization 6 months before and 6 months after prescription of reSET-O, which operates on mobile devices.
Among 351 total patients prescribed the digital therapeutic, the analysis focused on 321 patients who continued on therapy after week 1 and were thus considered “engaged patients.”
Over all 321 patients, reSET-O treatment was associated with a cost reduction of $765,450, or $2385 per patient, in the 6 months after it was prescribed, according to the study.
Prescription costs for reSET-O were $584,415 across all engaged patients, or $1665 per patient. However, refunds to payers offset costs $49,950 overall, or $142.31 per patient.
“The medical cost reduction in engaged patients offset the cost of the therapeutic,” researchers reported, “resulting in an overall cost reduction of $230,985 in this cohort (net savings of $720 per patient).”To avoid an inpatient visit, the number needed to treat was 4.8, the study showed. —Jolynn Tumolo
Payer, Provider Disagreements on PCSK9 Inhibitors for Cholesterol Management
Payers and providers agree that prior authorization forms and awareness of cost-effectiveness are barriers regarding the use of PCSK9 inhibitors and support more standardized eligibility criteria and documentation.
PCSK9 inhibitors are used for treatment in patients with atherosclerotic cardiovascular disease (ASCVD) or familial hypercholesterolemia. Researchers of a study published in Journal of Managed Care & Specialty Pharmacy. sought to understand discordance and facilitate face-to-face discussion between payers and providers.
Six focus group meetings were conducted in 2019 with local groups of three payers and three providers serving large US cities (population exceeding 500,000). Forums featured cardiologists or lipidologists and payer leaders from major health care management organizations.
Meetings were aimed at identifying barriers to appropriate use of PCSK9 inhibitors and aligning understanding of clinical, cost, safety, and efficacy data. Participants responded to surveys before and after the meetings to indicate how payer and provider responses changed.
Premeeting survey results indicated that most providers and payers (67% to 78%) agreed that high copayments and inadequate prior authorization documentation were significant barriers to optimal use. However, 72% of providers but only 44% of payers believed that prior authorization presents excessive administrative burden. Additionally, 56% of payers, but only 6% of providers, believed that current evidence does not support PCSK9 inhibitors cost-effectiveness.
Post-meeting surveys indicated that an increased number of providers (6% to 22%) believed that current authorization criteria accurately distinguish patients who benefit most from treatment, while payers decreased in this belief (72% to 50%).
More providers (22% to 50%) believed that properly documented prior authorization forms expedite access. Payers increasingly believed in standardized prior authorization requirements (50%-83%) and less stringent prior authorization requirements for patients with familial hypercholesterolemia (33% to 72%), considerations with which 89% of providers agreed.
Both providers and payers reported increased belief that PCSK9 inhibitors are cost-effective (44% to 61% and 28% to 50%, respectively) and were more willing to consider it as a treatment at the low-density lipoprotein threshold of >70 mg/dL for patients with ASCVD (78% to 83% and 44% to 67%) or familial hypercholesterolemia (22% to 39% and 22% to 33%).
Additionally, 83% of all participants supported educational programs for patient treatment adherence, and support for physician/staff prior authorization processes education increased from 83% to 94%.
“Provider and payer representatives… provided recommendations to improve quality of care in patients eligible for PCSK9 inhibitors,” researchers noted. “Participants also provided tactical recommendations for streamlining prior authorization documentation processes and improving awareness of PCSK9 inhibitors cost-effectiveness and clinical efficacy.” —Maria Asimopoulos
Mental Health Needs to Be Prioritized Among People With HIV/AIDS, Study Says
People with HIV/AIDS are 100 times more likely to die by suicide compared with the global general population, according to study findings published online in General Psychiatry.
“There is an urgent need to prioritize mental health screening and care into all HIV testing and treatment settings,” said Paddy Ssentongo, MD, PhD, researcher and epidemiology doctoral student at Penn State College of Medicine. “Suicide risk should be assessed in all HIV patients, especially in those who are newly diagnosed and those with advanced disease.”
Dr Ssentongo and colleagues came to the finding by conducting a systematic review and meta-analysis, which included 40 studies spanning 185,199 people with HIV/AIDS from around the world.
They found that 1 of 2 people with HIV/AIDS who have suicidal thoughts will attempt suicide, and 1 of 13 of those suicide attempts will end in death. For comparison, 1 of 3 people in the general population who have suicidal thoughts will attempt suicide, and 1 of 286 of those suicide attempts will result in death.
The study also found that people with HIV/AIDS in North America are 50 times more likely to commit suicide than people with HIV/AIDS in Europe.
The highest rates of suicide attempts among people with HIV/AIDS are in North America, South America, and Australia.
“This risk is directly associated with HIV progression; however, antiretroviral treatment and higher CD4 counts seem to be protective against suicide attempts,” researchers wrote.
“We suggest that suicide risk assessment be provided to people living with HIV/AIDS in conjunction with antiviral treatment,” they added, “to improve clinical outcomes, patient longevity, and quality of life.” —Jolynn Tumolo
AMA Votes Against Insurers Paying Patients to Switch Treatments
The American Medical Association (AMA) will support state and federal legislation to oppose insurance companies offering financial incentives for patients to switch from a prescribed treatment to a payer-preferred treatment following the passage of a resolution at its House of Delegates June 2021 Special Meeting.
The American College of Rheumatology (ACR) drafted the resolution, which received unanimous support in its hearing prior to full House of Delegates approval, after learning Cigna was offering patients $500 pre-paid debit cards to switch from Cosentyx (secukinumab) to an alternative medication. Secukinumab is a biologic drug used to treat patients with psoriatic arthritis, moderate to severe plaque psoriasis, and ankylosing spondylitis.
“We are sensitive to the need for affordable health care, and we share payers’ desires to see cost-effective treatment options for our patients…,” said Chris Phillips, MD, chair of ACR’s insurance subcommittee. “However, a one-time payment to switch from a therapy that is working well to one the patient may not respond to unnecessarily puts the patient at risk and crosses a moral and ethical line by potentially creating a conflict between what is in the patient’s financial and health interests.”
According to the ACR, the organization reached out to Cigna this spring, explaining its ethical and professional concerns over the program. Specifically, ACR outlined the medical complexity of treating patients with rheumatic disease and the potential harmful effects of a switch orchestrated by a party other than the patient and their medical treatment team.
“Due to the complex nature of autoimmune diseases, two patients can have very different immune responses to the same medication in the same drug class,” said Dr Phillips. “This can make finding the treatment that works a challenge, so the decision to choose one biologic over another requires careful clinical evaluation and consideration by a physician and patient. Factors such as an individual patient’s age, gender, diagnosis, medications, specific organ manifestations, antibody status, disease severity, comorbid conditions, and ability to tolerate the route of administration strongly influence the choice of each specific biologic.”
The insurer responded that it disagreed that the financial incentive program was coercive and that it would not be altering it, according to the ACR.
“We are grateful that, through the passage of this ACR-led AMA resolution, the larger house of medicine has agreed with us that financially incentivizing patients to switch medicines is wrong,” said Dr Phillips.
“We are hopeful the AMA’s new stance will increase scrutiny of these practices,” said Gary Bryant, MD, chair of the ACR’s delegation to the AMA House of Delegates, “and encourage policymakers to pass legislation prohibiting financial payments for nonmedical switching.” —Jolynn Tumolo
Value-Based Oncology Payment Models Lack Needed Clinical Granularity, Study Suggests
Bundling cancer treatment in ways that better reflect resource utilization for an appropriate standard of care would improve value-based payment models in oncology, such as Medicare’s Oncology Care Model, according to an abstract presented at the 2021 American Socity of Clinical Oncology Annual Meeting.
“Aggregating different subtypes of cancers into bundles is an important methodology in oncology payment reform as an alternative to fee for service,” wrote authors from Tuple Health in Washington, DC, and Florida Cancer Specialists North/Sarah Cannon Research Institute, Gainesville, FL. “However, expected resource utilization can vary significantly across cancer subtypes.”
The study focused on chronic leukemia subtypes of chronic myelogenous leukemia (CML) and chronic lymphocytic leukemia (CLL).
When the chronic leukemia subtypes were modeled using the aggregate Oncology Care Model bundle, CML and CLL had significantly different cost distributions and different patterns of expected resource utilization, researchers found.
On average, CLL episodes were 13.7% over target, while CML episodes were 6.1% under target, according to the study. Average CLL episodes cost $52.2 thousand compared with an average target of $47.6 thousand, and 54% of CLL episodes cost more than the target. Meanwhile, average CML episodes costs $45.2 thousand compared with an average target of $50.3 thousand, and 43% of CML episodes exceeded the target.
“Insufficient clinical granularity in bundle construction can lead to provider performance being influenced by the distribution of patient subtypes at the practice,” researchers advised. “This can lead to inappropriate shifts of risk from payers to providers in value-based
models.” —Jolynn Tumolo
Member Retention Rates May Inform Payment Plans for Beneficiaries With Rare Diseases
Beneficiaries with rare diseases have higher retention rates than those without in commercial insurance programs, so payers may need to account for data regarding rare diseases when establishing multiyear payment arrangements for genetic therapies, a new analysis suggests.
Study authors conducted an analysis of four population cohorts to determine estimates for member retention among adults with certain rare diseases:
- self-insured/all subscribers;
- self-insured/rare medical condition;
- fully insured/all subscribers; and
- fully insured/rare medical condition.
The seven prospectively selected rare diseases included cerebral palsy, cystic fibrosis, Gaucher disease, hemophilia, sickle cell disease, spina bifida, and thalassemia.
Researchers used the IBM MarketScan Commercial Claims and Encounters database to gather information on adult subscribers or their partners for a 10-year period ending in 2016. Retention rates were estimated using the Kaplan-Meier method. Study was limited to include subscribers and subscribers spouses aged 18 years and older, excluding dependents.
According to the results, the member retention rate among those with rare conditions was significantly higher than the all-subscribers cohort in both self- and fully-insured cohorts by at least 12 points at each 1-year period.
After 5 years, approximately 20% more of the rare disease cohort was retained than all subscribers. Members with each condition also had a statistically significant higher probability of retention regardless of payer type.
The authors noted that member retention is a key component of multiyear payments for treatments, alongside efficacy, durability of effect, and mortality.
“Health insurers and plan administrators may have inaccurate expectations if standard assumptions based on all member populations are used,” concluded the researchers. “This study found that adults diagnosed with 1 of 7 rare medical conditions are retained longer, on average, than all adult subscribers.” —Maria Asimopoulos
Prescriptions Drive Higher Costs for Moderate-to-Severe Pediatric Psoriasis
Health care resource use and costs increased with psoriasis severity in a real-world claims analysis of pediatric patients with psoriasis in the United States, according to study results published online in Advances in Therapy.
The retrospective analysis tapped IBM MarketScan databases for the years 2016 through 2018 for data on patients younger than 18 years who were newly diagnosed with psoriasis.
The average age at psoriasis diagnosis was 12.6 years, according to the study. Just over 13% of the patients were diagnosed with moderate to severe psoriasis. The most prevalent comorbidities observed in the study population were anxiety (6.6%), depression (4.1%), and obesity (3.9%).
For first-line treatment, 79.1% of patients with mild psoriasis and 52% of patients with moderate to severe psoriasis were prescribed topical treatments. Other first-line therapies prescribed to patients with moderate to severe psoriasis were nonbiologic systemics (21%), phototherapy (15%), and biologics (9.2%), analysis showed.
Average annual total all-cause costs per patient were $27,541 for patients with moderate to severe psoriasis and $5034 for those with mild psoriasis.
“Higher unadjusted health care costs by severity were driven by outpatient prescription costs,” researchers reported. —Jolynn Tumolo
Real-World CLL Patient Data Shows Substantial Economic Burden for Medicare
Adverse events (AEs) experienced by patients with chronic lymphocytic leukemia (CLL) account for substantial economic burden, according to a study published in Cancer Medicine.
For the study, researchers examined real-world patient outcomes and costs associated with CLL from existing clinical trial data. In a population-based retrospective cohort study, researchers assessed overall survival (OS), incidence of AEs, and real-world economic burden for Medicare enrollees.
Patients from the Medicare claims database receiving one or more systemic therapies from 2013 to 2015 were included in the study through December 2016 or patient death.
Among 7965 patients, the most frequently recorded AEs were neutropenia, hypertension, anemia, and infection. Mean monthly all-cause cost during patient follow-up was $8974, with costs increasing per number of AEs from $5144 in patients with one to two AEs to $10,077 for those with six or more.
Most common treatments included ibrutinib monotherapy, chlorambucil monotherapy, and bendamustine/rituximab. Using the Kaplan-Meier method, 24-month OS estimates after first observed therapy were:
- 69% among 2708 ibrutinib monotherapy patients,
- 68% among 1620 chlorambucil monotherapy patients, and
- 79% among 1485 bendamustine/rituximab patients.
“Our findings highlight considerable susceptibility to AEs and unmet medical need in Medicare patients with CLL treated in routine practice,” researchers concluded. “Medicare incurred substantial economic burden following initiation of systemic therapy, and patients with greater numbers of AEs accounted disproportionately for the high overall cost of CLL management.” —Maria Asimopoulos
Examining a Predictive Payer Model for Unplanned Health Care Utilization
Compared with claims data alone, merging claims data with Patient-reported Outcomes Measurement Information System (PROMIS) data only slightly improved the performance of a payer model for predicting unplanned health care utilization and cost, according to study findings published online in Medical Care.
Corresponding author Suzanne Kinsky, MPH, PhD, of the UPMC Center for High-Value Health Care in Pittsburgh, and coauthors conducted a retrospective analysis of patients insured by a private health plan and who were seen at 18 neurology clinics affiliated with the plan. As part of routine care, the neurology clinics collected data for the following PROMIS domains: anxiety, cognitive function abilities, depression, fatigue, pain interference, physical function, sleep disturbance, and ability to participate in social roles and activities.
For the study, researchers looked at associations of covariates to health care utilization and cost using claims data alone, as well as claims data combined with the first PROMIS data collected between June 2018 and April 2019.
Compared with claims data alone, area under the receiver operating characteristic curve values for unplanned health care utilization were slightly higher and Akaike information criterion for unplanned health care costs criteria values were similar for combined claims and PROMIS data, researchers reported. The combined claims and PROMIS model had slightly higher sensitivity and equivalent specificity with claims data alone in predicting the top 15% of unplanned care costs.
Although combined claims and PROMIS data offered some predictive improvement, researchers concluded it was “likely not to an extent that indicates improved practical utility for payers.” —Jolynn Tumolo
Medicare Advantage Sees Increasing Number of Black and Hispanic Enrollees
The number of Black, Hispanic, and dually enrolled Medicare Advantage (MA) beneficiaries increased at a faster rate than White and nondual beneficiaries between 2009 and 2018, according to a new study published in Health Affairs.
The study gathered data on 82,626,490 people from the Medicare Master Beneficiary Summary File and reports by the Centers for Medicare & Medicaid Services. The number of beneficiaries who are Black, Hispanic, and dually enrolled increased from 23% to 38%, 33% to 48%, and 18% to 37%, respectively.
MA thus saw a 66% increase among Black beneficiaries, a 43% increase among Hispanic beneficiaries, and a 101% increase among those dually enrolled. By comparison, White beneficiaries increased by 46% and nondual enrollees by 43%.
Enrollment in special needs plans fluctuated throughout the study period. In 2018, however, 43% of Hispanic and 55% of dually enrolled beneficiaries enrolled in special needs plans in comparison to 10% of White beneficiaries.
White beneficiaries were overall “more broadly distributed” across different plans. Beneficiaries from racial and ethnic minority groups were more likely to select lower-quality plans, and Hispanic beneficiaries were more likely to select plans with lower premiums.
People were more likely to enroll in MA if they lived in neighborhoods with higher quintiles of disadvantage, with those in the highest quintile of disadvantage contributing to the largest growth in MA enrollment over time.
MA comprised 35% of all Medicare beneficiaries in 2018, compared to 23% in 2009. The study notes that MA enrollment could include most of Medicare’s Black, Hispanic, and dually enrolled beneficiaries within 5 years if current trends continue.
“MA plans may need to become a key partner in finding effective ways to address those disparities,” researchers concluded. “Specifically, the fact that Black and Hispanic beneficiaries tended to be enrolled in lower-quality plans may need greater
attention from policy makers.” —Maria Asimopoulos
Publicly Insured Individuals Report Higher Satisfaction, Lower Costs Than Privately Insured
People enrolled in private and employer-sponsored insurance programs were more likely to report poor access to and lower satisfaction with care, as well as higher costs, than people enrolled in public insurance options, a new JAMA Network Open study showed.
“In this survey study, individuals covered by private insurance appeared to experience less access to care, higher costs of care, and decreased satisfaction with care compared with individuals with Medicare or VHA or military coverage,” said researchers.
Researchers conducted a survey of 149,290 people across 17 states and the District of Columbia using data from the 2016 to 2018 Behavioral Risk Factor Surveillance System, accounting for underlying health conditions. The final cohort was representative of 61 million US adults.
Of the survey participants, 63.9% were covered by private insurance (of which 79% had employer-sponsored coverage), 23.8% by Medicare, 8.9% by Medicaid, and 3.4% by Veterans Health Administration or military coverage.
Survey question topics included access to care, costs of care, and patient-reported satisfaction of care. In comparison to those covered by Medicare, individuals with employer-sponsored insurance were:
- less likely to report having a personal physician (odds ratio [OR], 0.52; 95% CI, 0.48-0.57);
- more likely to report instability in insurance coverage (OR, 1.54; 95% CI, 1.30-1.83), difficulty seeing a physician because of costs (OR, 2.00; 95% CI, 1.77-2.27), not taking medication because of costs (OR, 1.44; 95% CI, 1.27-1.62), and having medical debt (OR, 2.92; 95% CI, 2.69-3.17); and
- less satisfied with their care (OR, 0.60; 95% CI, 0.56-0.64).
In comparison with Medicaid, individuals with employer-sponsored insurance were:
- more likely to report having medical debt (OR, 2.06; 95% CI, 1.83-2.32) and
- less likely to report difficulty seeing a physician because of costs (OR, 0.83; 95% CI, 0.73-0.95) and not taking medications because of costs (OR, 0.78; 95% CI, 0.66-0.92).
The survey found no difference in satisfaction between those with Medicaid and those with employer-sponsored insurance.
The ACA has resulted in the expansion of public insurance options to more than 20 million adults in the United States. Data from this survey population represented “the experiences of more than 61 million US adults,” researchers noted.
“As US policymakers continue to debate health insurance reform, efforts directed at increasing the number of individuals covered by Medicare or improving protections for individuals covered by private insurance against increasing out-of-pocket costs, high deductibles, and surprise billing may be associated with improved experience of and satisfaction with health care,” researchers wrote. —Maria Asimopoulos
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