#6things That Happened in Health Policy This Week

6 Things That Happened in Health Policy This Week is produced by a mix of research assistants from the Healthcare Quality & Outcomes (HQO) Initiative at the Harvard T.H. Chan School of Public Health. In each edition we feature a variety of news articles, reports, and studies focused on U.S. health policy and health services research. This week’s edition includes contributions from Zoe Lyon (@zoemarklyon), Yevgeniy Feyman (@YFeyman), and Kim Reimold (@KimReimold).

Health Affairs/KHN: People who gained coverage under the ACA filled more prescriptions but had lower out-of-pocket costs

  • A new study in Health Affairs examines what happened when people were insured through the ACA—either on the exchanges or through Medicaid expansion—and how that affected the number of prescriptions they filled
  • Using data from 6.7 million people, the study analyzed those who filled prescriptions in January 2012 and followed their patterns of medication use and out-of-pocket spending through 2014
  • 30% of the people tracked were uninsured before ACA coverage took effect in January 2014
  • Findings:
    • There was a 30% reduction in the proportion of this population that was uninsured in 2014 compared to 2013
    • Those who were previously uninsured and gained private coverage filled, on average, 28% more prescriptions and had 29% less out-of-pocket spending per prescription in 2014 compared to 2013
    • Those who gained coverage under Medicaid expansion had larger increases in fill rates (79%) and reductions in out-of-pocket spending per prescription of 58%
  • The results of this study speak to the effectiveness of the law in improving access to health care resources; however, it is not enough evidence to say that this increased access results in better health
  • Still, the findings highlight an important step: Andrew Mulcahy, lead author on the study said: “If the goal of the coverage expansion was to reduce the financial burden of being insured, this is direct evidence of that…if the goal was to improve health, we’re one step short of that…but the signs align.”

Modern Healthcare: New reimbursement paths present a crossroads, few docs ready for risk under MACRA

  • Provider groups are now in the process of deciding which of the two possible reimbursement paths they will take under MACRA, which replaced the sustainable growth-rate formula previously used to determine physician pay
  • Under MACRA, providers will use either the Merit-based Incentive Payment System (MIPS) or an alternative payment model (APM)
    • Under MIPS, physician payment will be based on a compilation of quality measures and meaningful use of EHRs
    • About 90% of physicians are expected to take this path
  • Most providers will choose MIPS because they are not ready to take on the other option, which requires a substantial amount of risk and represents uncharted territory
  • A survey released in July by Delotte found that about 50% of non-pediatric physicians and never even heard of MACRA
  • No matter which path physicians choose, there will be major decisions ahead that could create ripples throughout organizations
    • Organizations will be forced to examine their ability to practice successful care management, determine population health and improve quality overall
  • CMS is pushing back against rumblings of delaying the start date from MACRA
  • MACRA presents unique challenges to small and rural providers, who lack the capital and infrastructure to adapt quickly to MACRA
  • However, MACRA is coming and pushing the start date would only be forestalling the inevitable

CMS.gov: CMS examines inappropriate steering of people eligible for Medicare or Medicaid into Marketplace plans

  • The Centers for Medicare and Medicaid Services (CMS) is soliciting public comments for cases where healthcare providers and provider-affiliated organizations may encourage Medicare or Medicaid eligibles into ACA marketplans in order to receive higher reimbursement rates.
    • The private plans typically have higher copays and coinsurance requirements from patients, higher premiums, and pay higher rates to providers than do Medicaid programs.
  •  In addition to inappropriate financial gain, CMS is concerned that continuity and coordination of care may be decreased following changes to networks of providers.
  • CMS is also thinking about instituting some other operational and regulatory guidelines that:
    • Limit premium payments
    • Waive cost-sharing for qualified health plans by health care providers
    • Revise Medicare and Medicaid provider enrollment rules
    • Introduce civil monetary penalties when correct information about enrollees is not provided and for providers when they their enrollees face late enrollment fees

NPR: Aetna CEO To Justice Department: Block Our Deal And We’ll Drop Out Of Obamacare

  • Recently, Aetna announced that it would be leaving 70 percent of its ACA exchange markets.
  • Aetna has defended their pullback as a business decision, despite suggesting in a recent investor call that the exchanges represented a “good investment.”
  • This decision comes on the heels of the Department of Justice’s (DOJ’s) decision to litigate Aetna’s proposed merger with Humana.
  • A letter from Aetna CEO Mark Bertolini to the Department of Justice, discovered by Huffington Post reporters, appears to have warned the DOJ in July that should their proposed merger with Humana be litigated, the insurer would leave many exchange markets.
    • Two weeks after the letter, the DOJ decided to fight the Aetna merger, and shortly thereafter, Aetna announced its decision to leave the exchanges.
  • Should Aetna’s merger be blocked, the insurer would owe Humana a $1 billion fee, about 2.7% of the merger’s value.

USA Today: New cholesterol drugs could add $120 billion to annual U.S. health costs

  • An economic analysis published in JAMA this week found that new cholesterol drugs Praluent and Repatha—the first cholesterol-lowering medications to hit the market since statins in 1987—could add $120 billion to US health care costs if taken by all eligible patients.
  • This would be equivalent to a 4% increase for annual health spending in the US, which Dr. Dhruv Kazi called “astronomical” for a single medication.
  • In response to the costs, insurers have pointedly blocked access to the drugs after doctors have prescribed them.
  • The annual price of the drug per person would have to be reduced by nearly $10,000 in order to be considered cost-effective (cost less than $100,000 for every year of healthy life saved).
    • However, the cost-effectiveness could change as studies on the drugs’ ability to prevent heart attacks and strokes have yet to be published.

The Commonwealth Fund: Latinos and Blacks have made major gains under the Affordable Care Act, but inequalities remain

  • Blacks and Latinos have been disproportionately uninsured for many, many years.
  • Although uninsured rates have decreased for everyone since the introduction of the ACA, compared to whites and blacks, Latinos are a growing share of the uninsured (29% of Latinos compared to 13% of blacks in 2016).
  • A large portion of Latinos that are uninsured are unauthorized immigrants (56%), but a large share of uninsured Latinos is not accounted for in this number.
  • Spreading awareness about health insurance options available through the ACA may the key to increasing coverage, as only 45% of Latinos reported being aware of the marketplace.

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