Payer Roundup–Cigna invests in 9amHealth; Democrats tell insurers to cover contraception; state AGs urge PBM action;

Below is a roundup of payer-centric news for the week of Feb.19, 2024.

UPDATED: Friday, February 23 at 3:52 ET

Democrats tell insurers to cover contraception

The Democratic Women's Caucus, along with more than 150 House and Senate Democrats expressed concern that the Affordabe Care Act's (ACA) contraception coverage is not being followed by insurance plans.

In a letter to America's Health Insurance Plans (AHIP) — endorsed by the Planned Parenthood Federations of America, Reproductive Freedom for All and Physicians for Reproductive Health — they advocated for a "therapeutic equivalence standard" that would ensure coverage without cost-sharing of birth control products without generic equivalents. Democrats said House-led investigations show the ACA is violated by plans that routinely are "imposing administrative hurdles like prior authorizations and step therapy."

In January, the Biden Administration released new guidance that reinforced payers' and hospitals' federal obligations.

State AGs urge PBM action

The National Association of Attorneys General (NAAG) sent a bipartisan letter to Congressional leaders speaking of the importance of reforming pharmacy benefit managers (PBMs). It was signed by 39 attorney generals.

Three bills, the DRUG Act, Protecting Patients Against PBM Abuses Act and the Lower Costs, More Transparency Act, were singled out as the most critical bills the AGs said should be passed. They said the bills would curb increasing drug prices and require publicized pricing data to plans and regulators.

"Because a PBM ultimately decides which drugs it covers, it can bargain for rebates from drug manufacturers who want to get their products on its “formularies,” or lists of covered drugs," a NAAG news release said. "As a result of this leverage, PBMs essentially force drug manufacturers to raise list prices in order to provide ever-growing rebates."

Voters worry about insurance premium costs

Nearly half of insured adults in a new KFF poll said they worry about being able to afford their monthly premiums.

The survey asked about eligible voters' opinions on healthcare costs, the Affordable Care Act (ACA), inflation and more.

Respondents also expressed appreciation for the ACA's protections for people with preexisting conditions that don't allow insurance companies to deny coverage based on medical history, yet less than 4 in 10 people knew that protection is a provision in the ACA. Just 35% knew the uninsurance rate has decreased since the bill passed in 2010.

"A majority of voters, including seven in 10 Republican voters, say they do not think President Trump has a health care plan to replace the ACA or they are not sure if he has a plan," the study's authors said.

Cigna leads 9amHealth funding round

The Cigna Group led a VC funding round for virtual cardiometabolic health provider 9amHealth for $9.5 million.

9amHealth CEO Frank Westermann said employers are looking to manage the costs of in-demand GLP-1 drugs, putting the company in a unique position to curb spending and provide cardiometabolic care. The company has seen up to $284 monthly gross savings per member, according to a news release.

The company will use the funds to scale the company's solutions and expand its internal team of specialists, doctors and advisers.

"The Cigna Group Ventures' mission is to partner with companies and entrepreneurs that are engaging patients in new ways to ultimately improve their health outcomes," said Craig Cimini, head of The Cigna Group Ventures. "9amHealth has made great strides in improving access to care for patients diagnosed with obesity and diabetes, and we are excited to help accelerate their next phase of growth."

Other investors included 7Wire Ventures, Define Ventures, Leaps by Bayer and Founders Fund.

MA enrollees received less intensive post-acute care: study

When a group of retired Ohio-based employees switched to traditional Medicare when a Medicare Advantage (MA) plan was discontinued, members received more intensive post-acute care in fee-for-service Medicare, a study out of JAMA Health Forum revealed.

"MA plans receive capitated per enrollee payments that create financial incentives to provide care more efficiently than traditional Medicare; however, incentives could be associated with MA plans reducing use of beneficial services," the study explained. "Post-acute care can improve functional status, but it is costly, and thus may be provided differently to Medicare beneficiaries by MA plans compared with traditional Medicare."

Data analyses were performed from September 2019 to November 2023 on three high-volume conditions. The study looked at care received in various facilities and at home, hospital readmission and mortality, among other measures.

The study did not find significant change in short-term post-discharge outcomes.

Medicare-Medicaid Integration Alliance launches

A new advocacy organization is born.

Designed to help dually eligible Medicare and Medicaid members, the Medicare-Medicaid Integration Alliance (MMIA) has three principles: Ensure access to integrated coverage, support easier enrollment in coverage and guarantee coverage is held accountable, according to a news release.

"Recent proposed updates to federal rules and the ongoing work of a working group in the Senate prove there is support among policymakers for bold action that advances integration, and it's shared by leaders in both political parties," said Mark Miller, executive vice president of health care at Arnold Ventures, a member of MMIA. "People who are dually eligible for Medicare and Medicaid live in every community across the country. This coalition wants to elevate and amplify their concerns so that policymakers act."

The coalition includes Arnold Ventures, the Association for Community Affiliated Plans, Community Catalyst and the Medicare Rights Center.

OIG audits MediGold

A Trinity Health Medicare Advantage plan was audited by the Department of Health and Human Services Office of Inspector General (OIG), the office announced Friday.

The audit estimated that the Centers for Medicare & Medicaid Services overpaid MediGold at least $3.7 million for 2017 and 2018, but the agency requested just $2.2 million due to federal regulations that limit risk adjustment data validation audits to payment years 2018 and on. OIG believed most of the diagnosis codes submitted by MediGold did not comply with federal requirements, according to a news release.

MediGold disputed some of the OIG's findings, causing the office to revise its first recommendation.

Point32Health acquires Baystate Health subsidiary

Point32Health, the parent company of Harvard Pilgrim Health Care and Tufts Health Plan, has agreed to acquire Health New England, a subsidiary of Baystate Health.

Health New England is a nonprofit plan offering commercial, Medicare and Medicaid plans serving 180,000 members in western Massachusetts, according to a news release. Point32Health offers employer-sponsored, Medicare and Medicaid plans to nearly two million members.

“It is vitally important to the communities that we serve that Health New England and its programs continue to grow and evolve,” said Mark Keroack, M.D., CEO of Baystate Health, in a statement. “Point32Health is a vibrant organization and is widely recognized for the quality of its products, strength of its network and commitment to underserved populations.

The acquisition is still subject to regulatory approvals.

In-person counseling not accessible to some Medicare members: study

Some areas do not have State Health Insurance Assistance Programs (SHIPs) locations nearby, a study from the American Journal of Managed Care said.

SHIPs, overseen by the Administration for Community Living within the Department of Health and Human Services, give counseling and education on coverage options for Medicare beneficiaries.

"There is a disproportionate number of individuals eligible for Medicare in localities without a SHIP site," the authors said. "Moreover, the population living in areas without in-person SHIP sites is more likely to have low income and fewer years of education than the population living in areas with a SHIP site."

The authors suggest that SHIP location expansion could benefit Medicare beneficiaries who most need the support.

Medical Mutual partners with Strive Health

Ohio-based Medical Mutual is enlisting value-based kidney care company Strive Health as its new partner to help members with chronic kidney disease and end-stage kidney disease.

The new partnership will apply to members in individual, commercial group and Medicare Advantage plans. It's expected Strive will help more than 10,000 people with a kidney condition. The Denver-based company will give Medical Mutual members in-person and telehealth guidance to create an individualized care plan.

“We’ve seen great results with patients in slowing the progression of their kidney disease through our care model,” said Farhad Modarai, chief clinical officer of population health at Strive Health, in a news release. “In one instance, a patient came to us with CKD 4 and uncontrolled type 2 diabetes. Since our first interaction, we have connected the patient with our team of nurses and dietitians to ensure the patient follows a specific diet and to educate the patient on the importance of diabetes management and the negative effects it can have on CKD. The patient is now more active and engaged in their overall care, which is a direct result of our hands-on approach to patient interactions.”