Payer Roundup—UNOS under pressure from lawmakers; Medicare Advantage could make up 60% of market

Below is a roundup of payer-centric news for the week of March 18, 2024.

UPDATED: March 22 at 2:56 p.mET

Indiana sues PBMs, drug companies

A lawsuit filed by Indiana Attorney General Todd Rokita could cause headaches for major pharmacy benefit managers and drug companies.

He claims that although a vial of insulin costs just a couple of dollars, these companies conspire to raise prices of medication to profit off regular people, as reports the Indiana Capital Chronicle. Caremark, CVS Health, Express Scripts, OptumRx were a few of the PBMs mentioned in the lawsuit, but drug company Eli Lilly was not included because the state believes they've been more cooperative.

"We believe, we have alleged, and we will prove that they have taken advantage of people with serious medical conditions like diabetes," said Rokita.

Estimates show Medicare Advantage growing into the 2030s

By 2030, it's expected about 60% of Medicare enrollees will be covered by a Medicare Advantage (MA) plan, a new report from Moody's Ratings finds.

This trend could cause providers to rely on the largest commercial insurers more than ever before. Hospitals may be concerned about the increasing delays in prior authorization and denials, as more MA contracts with hospitals are terminated or expire. The report also notes that because the MA landscape is not as profitable as it once was, plans may further restrict provider networks and become more demanding in negotiations to regain profits they once saw.

"UnitedHealth, Humana, Aetna and Elevance (formerly Anthem) now cover about 65% of MA patients, in addition to dominating the commercial market," the report said. "Hospitals will thus become increasingly reliant on these big payers."

United Network for Organ Sharing under fire

Bipartisan members of the Energy and Commerce Committee are looking toward the Health Resources and Services Administration (HRSA) on ideas to reform the Organ Procurement and Transplantation Network (OPTN).

The United Network for Organ Sharing (UNOS) is facing more heat from lawmakers. The group was the catalyst sparking bipartisan legislation that opened up the bidding process that previously allowed UNOS to be the sole contractor for OPTN. In February, HRSA issued RFPs for various contracts.

Lawmakers are worried UNOS technology needs to be modernized and protected from cybersecurity threats, citing reports calling the organization's core systems "fragile" and "insufficient."

"An August 2022 report from the Department of Health and Human Services (HHS) OIG found multiple, basic cybersecurity failures by UNOS," a letter (PDF) to UNOS reads. "The OIG report noted that UNOS’s policies and procedures for access controls, risk assessment, and system monitoring 'were either in draft or did not exist.'"

The committee is asking UNOS to describe its IT system security, to list all known tech outages impacting donors and to open up its organization's practices for increased transparency.

It is also requesting all communications related to people mentioned in Richmond Times-Dispatch reporting that detail retaliation toward whistleblowers and advocates, and it wants communications regarding UNOS' competitors to see how they may be interfering with its competitors' business practices.

Republicans question SAMHSA funding

The House Committee on Energy and Commerce has sent a letter to the Government Accountability Office (GAO) asking how the Substance Abuse and Mental Health Services Administration (SAMHSA) is managing its funding.

At the root of the disconnect, lawmakers don't understand why SAMHSA has an annual budget of $5.8 billion but has received more than $7.8 billion in additional money through COVID-19 supplemental funding.

"Last year, we requested that SAMHSA provide a full accounting for the influx of funding it received," the letter (PDF) reads. "SAMHSA’s response showed that it had obligated most of this funding—$8.2 billion in COVID-19 supplemental funding and over 850 million for the 988 Program as of November 2023—primarily through grants to states and other grantees. However, SAMHSA’s response also shows that the states and other grantees had used less than half of these obligated amounts by that date."

It is asking the GAO to investigate how the states are allocating funds and how SAMHSA is monitoring the funding.

Meridian Health Plan helping hospitals win certification

Centene subsidiary Meridian Health Plan of Illinois is reimbursing part of the Health Care Equity Certification program fee offered by The Joint Commission for state hospitals.

The health plan will subsidize 25% of the fee for safety net and critical access hospitals. All other hospitals will be reimbursed 15%. It is the first Medicaid plan in the country to undergo this effort to improve health equity.

"Together, we will work to ensure our providers have the right resources and supports to deliver high quality and equitable care with dignity and respect for all people we collectively serve," said Cristal Gary, Meridian Health Plan president and CEO.

Prime Therapeutics allies with Capital Rx

Health tech provider Capital Rx is partnering with Prime Therapeutics.

Prime will obtain access to JUDI, Capital Rx's enterprise health platform, and, in return, Capital Rx will augment Prime's clinical expertise, a press release said. Prime will become a minority investor in Capital Rx.

"It is imperative for our industry to modernize our technology for the benefit of clients and patient," said Mostafa Kamal, president and CEO of Prime, in a statement. "We evaluated several other platforms and quickly recognized that JUDI represents a new industry standard. This move will enable us to accelerate our pace of innovation while enhancing our core capabilities and ensuring state-of-the-art security."

JUDI combines pharmacy benefit manager operations on a single platform. Prime said the change gives it an advantage over other PBMs that utilize decades-old technology

Among privately insured, perinatal mood and anxiety disorder soars

From 2008 to 2020, perinatal mood and anxiety disorder (PMAD) diagnoses increased 93.3%, according to a new study in Health Affairs.

The study discovered diagnoses grew faster in the later years of the analysis, suggesting the problem could be getting worse. It also found that associated suicidality and psychotherapy increased over the 12 years studied, though suicidality rates declined between 2015 and 2020 relative to 2008 to 2014.

It's believed the Affordable Care Act (ACA), which requires insurance plans to cover maternity and preventive services, was a likely cause for PMAD screening and detection to increase.

"The ACA also likely captured a vulnerable population with its coverage, increasing the likelihood of PMAD diagnosis among people at elevated risk," the authors said. "Simultaneously, the Bringing Postpartum Depression Out of the Shadows Act of 2017 and subsequent Biden administration initiatives to address maternal behavioral health provided needed financial resources to mental health services for perinatal people."

They also speculated that more awareness, changing diagnostic coding and less stigma as possible reasons for the rate to jump. The authors suggest focusing on improving outcomes by targeting subpopulations like the younger and Black demographics.

"Overall, access to psychotherapy may have stemmed suicidality despite increasing PMAD diagnoses," they said. "But although more PMAD diagnoses may have led to increased psychotherapy, therapy access depends on provider availability, which varies by geographic region and insurance coverage network.