This Week in Managed Care: November 29, 2019

A group of hospitals sue over Medicare reimbursement, researchers may have found how to slow progression of MS, and Humana says it is saving billions through value-based care.

Welcome to This Week in Managed Care, I’m Laura Joszt.

Hospitals Sue HHS Over Payment Dispute

Fifteen hospitals in New York and New Jersey have sued HHS, saying the agency is ignoring a US Supreme Court ruling in their favor on a payment dispute. Led by Capital Health System of New Jersey, the hospitals say that Medicare has not changed its payment practices in the 7 months since the court upheld a lower court ruling in Allina Health Services versus Price.

In 2014, HHS changed the way it counted days spent serving low-income patients, which hit hard on hospitals with large numbers of patients who can’t pay. The hospitals argued successfully that HHS had unlawfully changed reimbursement rates in renewing a policy that dates back to 2004, without a formal rule-making.

The new complaint states: “Although the D.C. Circuit has twice ruled against the Secretary’s 2004 policy, and the Supreme Court has upheld the Allina II decision, the Secretary nonetheless has not acquiesced in those decisions.”

The lower court ruling that the Supreme Court upheld was written by current Justice Brett Kavanaugh, when he was with the DC Circuit.

Slowing MS Progression

There is no cure for multiple sclerosis, but researchers in Montreal may have identified a way to slow its progression.

Results published in Science Translational Medicine show that blocking a key molecule that controls the entry of B cells into the brain can delay deterioration of tissue. So far, blocking the activated leukocyte cell adhesion molecule, known as ALCAM, has worked in both in vitro human and in vivo mouse studies

Alexandre Prat, MD-MSc, BSc, “The molecule ALCAM is expressed at higher levels on the B cells of people with multiple sclerosis. By specifically targeting this molecule, we will now be able to explore other therapeutic avenues for the treatment of this disease.”

Read more.

Humana Saves With Value-Based Care

A report from Humana says the insurer saved $3.5 billion in 2018 through value-based care, reducing both emergency department (ED) use and hospital stays among its Medicare Advantage clients. The report pegged the savings against what would have been spent under traditional fee-for-service models.

Humana officials say recent innovations in Medicare Advantage allow them to connect members with healthy food sources, offer transportation, and direct dollars to tackle social isolation.

Said Humana’s Bruce Broussard: “What excites us most about these results is what they say about how we’re helping seniors improve their health, while also helping them better afford the care they receive. Our members count on us every day to improve their overall healthcare experience, and we are doing that. At the same time, as these results demonstrate, we’re getting better at supporting doctors, nurses, and other care providers in their work to help people live healthier lives. In 2020 and beyond, we will keep at this.”

Humana has been signing more value-based agreements with varying levels of risk for the providers, and now has two-thirds of 3.5 million Medicare Advantage members under some type of value-based model.

Read more.

Rural Healthcare Delivery

November is Rural Health Month, which gives both health plans and policy leaders a chance to focus on the challenges of rural healthcare delivery and the inequities between rural and urban care.

AJMC^® Contributor Kelly Munson, executive vice president for WellCare’s Medicaid plans, addresses this issue in a new article that finds many of the problems boil down to access. Rural areas are less likely to have resources, such as substance abuse treatment centers or specialists for high risk pregnancies, despite greater impact from social determinants of health.

Munson writes: “This lack of access puts an undue strain on the rural emergency department to serve as a point of care, driving up unnecessary utilization.… Rural ED visit rates increased by more than 50% [over the decade through 2016], while urban rates barely increased. With an average ED visit costing $1389, this can add up.”

The solution, Munson says, could be greater use of community paramedicine, which is an advanced level of training for paramedics to offer preventive services and healthcare monitoring to rural residents.

WellCare has 2 models for this practice, which could offer work for transitioning military personnel who seek a second career.

Read the full article.

Oncology Payment Models

Finally, The American Journal of Managed Care^® (AJMC^®) this week featured coverage of our most recent installment of the Institute for Value-Based Medicine^®, which took place just before CMS’ announcement of the Oncology Care First model.

At the meeting in Nashville, Stephen Schleicher, MD, MBA, of Tennessee Oncology urged practices to focus on 3 areas:

• Understanding new payment models in depth, because value-based care is here to stay;
• Working to educate payers on ways to improve their models, so that cost control does not come at the expense of patients;
• Optimizing care coordination to reduce ED visits and hospitalizations, facilitate end-of-life care planning, and avoid unnecessary tests and treatments.

Read full coverage.

For all of us at AJMC^®, I’m Laura Joszt. Thanks for joining us.