Below is a roundup of payer-centric news headlines you may have missed during the month of February 2025.
Leading stories
Aetna faces suspension in New Hampshire
The New Hampshire Insurance Department is warning Aetna it could face a minimum fine or have its license suspended in the state.
A notice (PDF) said Aetna has failed to respond with information requested from the insurance department after a customer filed a complaint with the attorney general's office over denials.
Aetna could be forced to pay at least $7,500 or have its license revoked until the company adequately responds to the complaint. A hearing is set for April 8.
Humana partners with Thyme Care
Humana Medicare Advantage members will benefit from a new value-based care agreement with oncology platform Thyme Care, the companies announced.
The partnership includes around-the-clock virtual care navigation and is designed to reduce costs, a news release said.
Members in Illinois, Indiana, Michigan, New Jersey, New York, Pennsylvania and Tennessee are eligible.
Industry
BCBSMA adds virtual women’s care, diabetes option
Blue Cross Blue Shield of Massachusetts members now have access to Visana Health, a virtual women’s health clinic.
Visana says one in three women have gaps in care, and its specialist team helps women treat conditions including menopause, fibroids, endometriosis and polycystic ovary syndrome.
"It's important that women have access to the services they need to take charge of their own health and well-being," said Monica Ruehli, M.D., Blue Cross' clinical director of reproductive health and gender affirming services, in a statement. "Adding more options like Visana Health ensures we can show up for our members and better support women throughout their health journeys.”
Members will also have access to Verily Onduo, a virtual care option for members with Type 1 or Type 2 diabetes. Most members also have access to Virta Health, Teladoc and Omada.
Additionally, the company is launching a pilot program with Curant Health for its Medicare Advantage members to improve outcomes for those with diabetes, hypertension and high cholesterol.
BCBSMA reported a net loss of $224 million for the full year 2024. GLP-1 drug spending totals 20% of all pharmacy spend for the company.
Aetna adds to OCD treatment care with InStride partnership
Aetna members in Massachusetts and Connecticut can now capitalize on InStride Health benefits, a company that gives pediatric anxiety and Obsessive-Compulsive Disorder (OCD) treatment.
More than 90% of commercial members in these states now have access to InStride, a news release states.
“This partnership reinforces our commitment to ensuring more kids, teens and young adults receive the appropriate treatment from providers with specific clinical expertise, and we look forward to expanding to additional markets,” said John Voith, co-founder and CEO of InStride.
Express Scripts, Kroger finally reach deal
More than two years after facing criticism from pharmacies, Express Scripts has agreed to a pharmacy provider arrangement with Kroger Health.
Kroger can now service Cigna’s Express Scripts Part D and Tricare members, while Express Scripts commercial and Medicaid clients can include Kroger in its networks, Kroger announced in a news release.
Cigna owns Express Scripts, its pharmacy benefit manager.
Legislation
Arkansas signs Medicaid eligibility law
Arkansas Governor Sarah Huckabee Sanders signed the Healthy Moms, Healthy Babies Act, which adds “presumptive” Medicaid eligibility for pregnant women and gives reimbursements for doulas and community health workers, reported the Arkansas Advocate.
The law does not expand coverage to postpartum mothers to 12 months after birth, keeping Arkansas the only state in the country without this requirement.
Studies/Opinions
An argument against value-based payments
President Trump should move away from value-based payments because the system creates more middlemen, limits reform and promotes consolidation, a JAMA Network viewpoint outlines.
Instead, the new administration should focus on making traditional Medicare more affordable and improving the pricing policy, among other changes, two Brown University School of Public Health experts said.
“This agenda would couple better [fee-for-service] payment with labor and capital policy to promote clinician-led care insulated from corporate consolidation,” they explained. “Policies would include more deliberate efforts to train and allocate the types of clinicians that society needs, particularly in primary care.”
UnitedHealth Group study: Optum PCPs outperform for MA patients
Optum Health primary care clinics do better on cost and quality than hospital or physician-owned groups for Medicare Advantage patients, a report from UnitedHealth Group (UNH) claims.
From 2012 to 2022, the share of physicians employed by hospitals increased by 41%. But practices owned by these groups have a conflict of incentives, the company said.
The research says Optum-owned clinics perform approximately 4-6% better on cost and 2-4% better on quality.
“Medicare beneficiaries deserve a health system where care providers and payers are fully aligned to deliver more coordinated, seamless care,” said Wyatt Decker, M.D., executive vice president and chief physician for value-based care and innovation for UNH. “As this research shows, we’re leading a transformation toward an outcomes-based system that puts patients first and delivers higher-quality care while reducing costs.”
Florida, Pennsylvania receive failing grades on copay accumulators
More than 40% of individual market health plans include copay accumulator adjustment programs, an analysis from The AIDS Institute found.
These programs negatively impact an individual’s ability to treat chronic illness. New York and Arizona received “A” grades, while Florida and Pennsylvania received failing scores.
"Despite significant legislative progress in some states, far too many Americans are still at risk of losing access to life-saving treatments,” said Rachel Klein, deputy executive director of The AIDS Institute.
Quick hits
- The Department of Justice charged two people for submitting fraudulent enrollments to Affordable Care Act plans to earn millions in commission payments, causing the government to pay $162 million.
- Healthcare programs for illegal immigrants were far more costly to Illinois’ budget than initially anticipated, a state audit found as reported by Capitol News Illinois.
- The White House has named Don Dempsey, former vice president of policy and research at the Better Medicare Alliance, as associate director for health in the Office of Management and Budget. He served in the President George W. Bush administration and as VP of policy and regulatory affairs for CVS Health.
- In April, CMS will reevaluate Idaho’s proposal to deny extended postpartum Medicaid coverage (PDF) to people who’ve had abortions.
- Acacia Bamberg Salatti, a former vice president of external affairs for UnitedHealth Group, is now senior advisor to Jim Clyburn, R-South Carolina.
- A government employee inside the General Services Administration resigned in protest after a Department of Government Efficiency team member requested access to “all components” of the Notify.gov system, which contains personally identifiable information, reported 404 Media. This system shows whether a person is enrolled in Medicare or Medicaid.
- Left-leaning think tank The Century Foundation has hired former CMS Administrator Chiquita Brooks-LaSure as a senior fellow.
- L.A. Care Health Plan approves $10 million donation to providers, counties and community-based organizations in wildfire relief support.
- Health tech benefits administrator company Capital Rx announced Judi Health, a pharmacy and medical claims processing platform for employer sponsors, health systems and plans.
- Counterpart Health, an AI-powered platform from Clover Health, has partnered with Southern Illinois Healthcare system.
- PlushCare, the direct-to-consumer virtual care platform by health benefits company Accolade is now accepting Medicare Part B in all 50 states.