Below is a roundup of payer-centric news headlines you may have missed during the month of January 2025.
Leading stories
Massachusetts to UnitedHealth Group: Pay $165M
UnitedHealth companies in Massachusetts were ordered by the state to pay more than $165 million after a court said it knowingly tricked vulnerable customers into buying supplemental health insurance.
It is the largest penalty imposed under the Massachusetts Consumer Protection Act in history, the state’s attorney general office said. The companies, based in Texas but operating in the state, are HealthMarkets, HealthMarkets Insurance Agency and The Chesapeake Life Insurance Company.
“For years, the defendants preyed on financially vulnerable individuals, deceiving them into buying products they didn’t need or couldn’t afford,” said Attorney General Andrea Campbell in a statement.
The defendants were found “intentionally engaging in bundling of major medical and supplemental insurance to deceive consumers into unknowingly buying supplemental policies, the state said.
Scripps Health, Anthem Blue Cross cut ties
San Diego-based Scripps Health is no longer in network with Anthem Blue Cross, impacting all commercial insurance and Covered California plans. Medicare supplemental plans are not impacted.
In a news release, Scripps said Anthem issued an “unacceptable” ultimatum, causing negotiations to end. Scripps said high healthcare costs are driven by a new healthcare minimum wage, rising drug costs and other government policies.
“Throughout the negotiation, Scripps’ focus was to change Anthem’s bureaucratic policies that cause unnecessary delays, burdens and barriers to patient care, while ensuring Scripps will receive fair and accurate payments for the high-quality care provided,” the heath system said. “It is disappointing Anthem was unwilling to reduce those barriers and offered rates below health care inflationary costs.”
Anthem told Fierce Healthcare a different telling of events.
"Despite our good faith efforts to reach a new agreement, Scripps chose to leave Anthem’s local care provider network effective Jan. 1," said an Anthem Blue Cross spokesperson. "Scripps demanded drastically increased prices for patients covered by Anthem—increases that would have led to higher out of pocket costs for our members and would have hit area employers particularly hard. More than 80% of Anthem Blue Cross members are insured by employers that pay their employees’ healthcare costs directly."
Industry
CMS allows Cigna members special election period
After reviewing a Medicare Advantage (MA) contract termination between Cigna and Bayhealth health system in Delaware, Cigna members are eligible for a special election period lasting two months.
The news was relayed by the Delaware Department of Insurance and Medicare Assistance Bureau. Though the state saw other contract changes between MA plans and hospital systems, the Centers for Medicare & Medicaid Services is only designating a special election period for these circumstances at this time.
Molina Healthcare teams up with Innovive Health in Iowa
Molina Healthcare of Iowa is partnering with home healthcare agency Innovive Health to reduce emergency room visits and inpatient readmissions.
Innovive Health helps patients with comorbidities and behavioral illness. Out of all 50 states, Iowa is ranked fourth for most hospital stays by people with depressive disorders, according to the Agency for Healthcare Research and Quality.
“It is important that we meet our members where they are and this partnership with Innovive Health helps Molina address the many factors that impact their health,” said Jennifer Vermeer, plan president of Molina Healthcare of Iowa. “This comprehensive approach provides our members the care they need to improve their quality of life.”
Clover’s Counterpart Health partners with Duke ACO
Counterpart Health, a physician enablement platform, will be used within Duke Connected Care (DCC), an accountable care organization part of the Duke University Health System.
DCC will integrate Counterpart within the ACO’s electronic health records to improve chronic disease management outcomes, Clover Health said in a news release.
“DCC’s reputation as a global leader in academic medicine and healthcare innovation makes this partnership especially meaningful,” said Counterpart Health CEO Conrad Wai. “Our technology is purpose-built to support clinicians by delivering personalized, data-driven insights, and we’re excited to see the transformative impact it is already having across Duke’s broad and diverse network of clinicians.”
CareSource acquires ACA co-op
Private insurer CareSource has acquired Common Ground Healthcare Cooperative, one of three remaining co-ops formed out of the Affordable Care Act, effective Jan. 1.
The transaction was approved by the Wisconsin Office of the Commissioner of Insurance. CGHC CEO Cathy Mahaffey will serve CareSource Market President in Wisconsin.
Just Mountain Health CO-OP and Community Health Options remain as the last standing co-ops.
Curai Health, Priority Health extend partnership
Nonprofit health plan Priority Health and virtual care provider Curai Health are extending their program to give free virtual health visits for uninsured residents in Michigan.
This option will be available to 400,000 eligible Michigan residents until June 30. The partnership was reported by Fierce Healthcare in August.
“With the success of this initiative and more residents learning about it each day, extending free virtual visits for an additional six months will give more people the opportunity to access the care they need,” said Praveen Thadani, president and CEO of Priority Health, in a statement. “This initiative seeks to address delayed care and poor health outcomes that can result from the lack of health coverage, promote access to care and remove some of the barriers that prevent people who are uninsured from getting the care they deserve.”
Studies
Drug prices
If you take 25 branded drugs with the highest Part D spending from 2022 not selected for the Biden administration’s drug price negotiation program, those drugs have increase by 98% since entering the market, reports the AARP.
These drugs include Ozempic and Trulicity for diabetes, Xtandi for cancer and Biktarvy for HIV.
“Brand-name drug prices have been increasing faster than the rate of general inflation for decades, putting life-saving medications out of reach for millions of patients who need them,” said Leigh Purvis, prescription drug policy principal at the AARP Public Policy Institute, in a news release. “Meanwhile, the median price of a new brand name prescription drug is now approximately $300,000 per year, so even a small price change could increase a drug’s price by thousands of dollars.”
Site-neutral payment reform
A new paper from conservative think tank Paragon Health Institute reiterates the organization’s support for site-neutral payment in Medicare.
The paper says it would “reduce wasteful spending, patient expenses and health care consolidation” by lowering the cost of services in hospitals. It also says any future legislation should not include price controls in the private market.
Savings from this policy could be used to reduce spending in Medicare Part B.
Per-capita Medicaid spending
If states had implemented per capita caps on Medicaid in 2018, almost every state would have lost federal funding over the next four years, a report from liberal think tank Center on Budget and Policy Priorities found.
A per capita cap means the federal government would pay states a fixed amount of funding per enrollee, shifting the rest of the costs to states. This cap compounds over time, meaning the cuts are more severe each year. These type of cuts would slash spending by at least $588 billion (PDF), according to the Congressional Budget Office. The report shows a block grant has a similar impact.
This could cause states to roll back Medicaid expansion under the Affordable Care Act, reducing benefits and lead to higher levels of medical debt for individuals.
In case you missed it …
- Medicare will cover Zepbound for sleep apnea, CMS told CNBC.
Other legal quick hits
- Lost in the shuffle over the holidays, Aetna sued (PDF) a network of private equity-owned radiology practices for defrauding the insurers for tens of millions of dollars through fraudulent medical claims. Aetna also said Radiology Partners wrongfully started thousands of arbitrations under the No Surprises Act.
- Additionally, Blue Cross and Blue Shield of Florida is suing (PDF) the federal government for giving the insurer unfair star ratings scores for the 2025 benefit year during extreme environmental circumstances. The Blues plan said flooding in the state, which led to FEMA disaster relief and a state of emergency, resulted in weakened care for members. But because Department of Health and Human Services Secretary Xavier Becerra didn’t declare a public health emergency, the Blues plan wasn’t eligible to receive a minimized impact on its ratings. The insurer felt this is unfair.
- The ERISA Industry Committee, National Labor Alliance of Health Care Coalitions and Cigna sued (PDF) the Minnesota Department of Commerce for its design of in-network pharmacies, the lawsuit reads. The plaintiffs say the state’s Pharmacy Benefit Manager Licensure and Regulation Act of 2019 requires them to hand over too much control determining which pharmacies must be in-network, as well as “micromanages” coverage terms for drug purchases.
- The Kaiser Foundation Health Plan was sued (PDF) by SpecialtyCare for failing to pay nearly $75,000 awarded to the company after winning an arbitration decision under the No Surprises Act. SpecialtyCare is a national provider of neuromonitoring services.
More miscellaneous items from December
- A new paper (PDF) in the American Bar Association Antitrust Law Section evaluates the impacts of vertical integration for payers and providers. It predicts vertical integration will represent the “next wave” of healthcare consolidation because of the Centers for Medicare & Medicaid Services' value-based care policy supporting risk-adjusted, capitated models. The paper suggests new guidelines on how antitrust agencies should view payer-provider transactions.
- CVS Health and Aetna Better Health of Illinois will issue $750,000 in grants toward maternal and behavioral health services.