Weekly Health Tech Reads

Humana & Health Affairs data indicates VBC is stalling, Anthem faces a class action lawsuit, & more

This week’s newsletter is sponsored by Elation

Elation, a collaborative EHR platform for high-value primary care, released results of a series of physician interviews by the American Academy of Family Physicians (AAFP) Innovation Lab, suggesting that primary care physicians who were using Elation experienced improved levels of satisfaction and reduced burnout.

One of the big questions digital health will likely grapple with over the coming year is whether new models are actually improving the physician experience in any meaningful way, and it’s good to see Elation sharing data here suggesting the answer to that question is yes for their platform.

Correction:

  • Last week we mistakenly said a UHC entity was the best performing entity in the 2021 Direct Contracting data. We were informed by a reader that the entity that the best performing DCE in 2021, United PA, is not in fact associated with UHC. It is United Physicians Association, Inc, a small provider group in California. Sorry for the confusion, and kudos to United Physicians Association on the performance!

News:

  • Humana's 2022 annual value based care report is out, again presenting interesting insights into the state of their VBC business and likely how the broader VBC market within Medicare Advantage is behaving. While the report for this year presents some nice data about current performance, what's particularly interesting here is how the data has trended year over year. While the reports from previous years are hard to access, the press releases are generally available still (see 2017, 2018, 2019, 2020, and 2021). For instance, it's interesting to see Humana referencing in this year's report that 1.2 million members have joined VBC relationships in the last five years, suggesting that is "evidence of the continued shift from the traditional quantity-based fee-for-service model to quality-based care delivery." Yet, when you look at the penetration of Humana's individual MA membership in VBC contracts, Humana was already at 66% of MA members in VBC contracts back in the 2017 report. That number that has only increased to 68% in this 2022 report. So from the data provided, it doesn't look like members are actually shifting from FFS to VBC as Humana suggests, but rather Humana is seeing growth in VBC because the total MA market is growing and Humana's book of business is growing as a result. Obviously for Humana's business, the growth of MA on the whole still provides for a strong tailwind, but it seems pretty clear the overall VBC penetration is stagnant. It's also interesting to note that while the number of members in VBC has almost doubled from 1.65 million in 2016 to just over 3 million in the most recent report, the growth of providers in VBC contracts has not been as significant, increasing from 51.5k to 74.1k. That implies those PCPs have gone from seeing 32 Humana MA VBC members on average, to 40 Humana MA VBC members today, which obviously would represent a very small portion of any provider's panel. It highlights that there is likely a long tail of providers who see very few Humana MA members but still have some sort of VBC contract with Humana. Meanwhile, it's also worth noting the shift in Humana's payments to primary care providers - in the 2021 report, they cited that VBC PCPs received 14.3 cents of every dollar, compared to 6.4 cents for non-VBC PCPs. In the 2021 report, this was 17.5 cents of the dollar for VBC, versus 6.7 cents for non VBC. In the 2020 report, it was 15.6 cents versus 6.6 cents. Humana's reporting on quality metrics also appears to highlight a business that has been consistently performing well, but not necessarily improving performance. For instance back in 2018 Humana was citing 10-11% higher colorectal and breast cancer preventative screening rates for VBC patients versus FFS, versus 6-10% in the 2022 report. In the 2018 report, HEDIS Stars score for VBC providers was 4.21, versus only 4.0 in the 2022 report. ER visits and hospital admits appear to be slightly improved (9% less and 6% less in 2022 versus 7% and 5% less in 2018). All in all, I look at this series of reports as highlighting an org that has reached the limits of VBC adoption - clearly it seems to be helping quality of care, but those improvements seem to have hit their limit for Humana. Of course, so long as MA is growing substantially, the business will continue to grow in importance as more people join Humana's book of business and funnel into VBC contracts. Link / Slack (h/t Duncan Reece)

  • Anthem, now Elevance, is facing a class action lawsuit as a self-insured employer is accusing Anthem of not sharing claims data with the employer in breach of its ERISA-related fiduciary requirements. (Note: we'll keep using Anthem here as the lawsuit references it as Anthem, not Elevance). The crux of the lawsuit is that an employer is using price transparency data to demonstrate that Anthem does not appear to be paying out claims properly, and Anthem refuses to share the claims data with the employer. The employer provides a few examples in the complaint of how Anthem is paying local hospitals the wrong rates based off data the hospitals have shared regarding negotiated rates (see, for instance, paragraphs 84 - 85 in the complaint linked below). In some cases, Anthem is actually paying out more than it should, while in other cases it is paying out less. For one claim, Anthem paid Hartford Healthcare more than double the negotiated rate, and also rather bizarrely, more than Hartford had originally billed Anthem. And note, this claim was for $42k, so it's not like it was a small dollar amount we're talking about here. We'll see what comes of this case, if anything - as Matthew Holt highlighted in Slack - Cigna is also facing a similar lawsuit, so you can imagine this behavior isn't unique to Anthem (or Cigna). Either way, Anthem doesn't come across looking great when it won't provide its employer clients the claims data they should legally have access to. Meanwhile, employers can now see Anthem doesn't appear to be paying claims correctly, which seems like a really good example of the power of price transparency to drive change over time (and dependent on where you sit, that may be a good or bad thing). Link / Slack (h/t Samir Unni)

  • At least one broker is reporting on twitter that they've been informed Oscar is ceasing new enrollments for its exchange offering in Florida on Monday. This is obviously an unusual move given we're right in the middle of open enrollment, apparently it was a "proactive decision with regulators to ensure the long-term sustainability of Oscar". It seems odd that a regulator would allow Oscar to make this move in the middle of open enrollment and allow them to continue offering plans in the state at all - i.e. it seems like you step in here as a regulator because you're worried about their financial situation and ability to pay out claims, but if that's the case, why allow them to continue offering insurance in the state at all? We saw a similar situation play out in Texas with the regulator asking Friday Health Plan to leave the state. Regardless, it seems like an ominous sign for Oscar. Link (tweet) / Slack

  • CMS proposed a new rule to improve the prior authorization process. There's a good conversation in Slack on the various implications of the proposed rule expansion. Link / Slack (h/t Brendan Keeler)

  • Pebble publicly announced its launch and $17 million in funding for a new health benefits platform for small employers (up to 500 employees). Link

  • Juno Health raised $12 million to scale its new hybrid brick + mortar and virtual primary care model for underserved communities. Individual plans are $20/mo, and it's pretty impressive to see their fourteen person clinical team in Harlem and Brooklyn that's featured on the website. You spend a few minutes perusing their website and pretty quickly want to see them succeed in this endeavor (or maybe that's just us). Link / Slack (h/t Rik Renard)

  • SaVia Health, a real-time clinical decision support tool that counts Intermountain as its first customer, raised $8.5 million. Link / Slack (h/t Rohan D'Souza)

  • Alio Health, a remote patient monitoring platform for patients on dialysis, raised $18 million. Link

HTN's First Annual Predictions SurveyAs we all know, December means it's time for everyone to put together their annual predictions lists. Rather than just give you our list of predictions, we spent a good deal of time putting together what we thought were an interesting list of questions to gather data from you all on what might happen in 2023.Please take a few minutes to fill out the survey below and share your wisdom on a variety of topics from deals, to consolidator activity, to startup impact, to regulatory change, and questions about patient impact. We'll compile and share out the results!Click here to take the survey

Opinions:

  • This Andreessen post on the rise of consumer health models is worth checking out. It provides a good breakdown of how consumer health opportunities may continue to materialize in 2023. As discussed in the Slack, I think one element of this story that will come much more to the forefront in this conversation about consumer health models in 2023 is the importance of the clinical workforce in terms of offering a meaningfully better consumer experience. So much of this comes back to whether organizations can hire, and retain, high quality clinical teams. And a big question for these startups will be whether they can do so at the scale required to be a meaningful venture business. Link / Slack

  • This is a good read on Morgan Health's general approach. JPMorgan essentially looks like an activist employer leveraging Morgan Health to drive change among its employee base (an approach that I'd imagine makes for interesting convos with JPMorgan's employee benefits team). It also seems like JPMorgan should be able to drive some meaningful change, particularly in markets where it has a large employee base like Columbus. What'll be really interesting to watch here is whether Morgan Health can successfully create a playbook that employers beyond JPMorgan are able to emulate.  Link / Slack

  • Business Insider had a nice retrospective of the unraveling of Bright Health's insurance business, highlighting how the desire to scale and grow the business too quickly overwhelmed its ability to execute. I still can't get over the fact that Bright couldn't process claims automatically, which the article highlights. It's a really good learning lesson in understanding that just because something is venture-backed doesn't mean it's actually a meaningful improvement on the existing model in any way.  Link (paywalled)

  • Pre-seed investor Owen Willis shared an interesting framework for how he thinks about getting conviction on investment opportunities. Worth checking out for founders looking to get early stage investors. Link

  • This is a good, tough, read on the implications of New York's recent move to reduce restrictions for police officers in deciding to hospitalize individuals involuntarily for psychiatric care. It sounds like a nightmare.Link / Slack (h/t Owen Muir)

Data:

  • This is an interesting analysis in Health Affairs looking at the stalled growth of ACOs over the last several years, with the chart below highlighting how total lives covered and the number of ACOs has been flat since the beginning of 2018. It's also interesting to note another chart in the analysis suggesting the percentage of ACO contracts that include downside risk has increased from ~20% in 2018 to ~40% in 2022. Link / Slack (h/t Kevin Wang)

  • In the latest Fair Health report on telehealth use, it includes this chart for top diagnoses in Sept 2022. While these numbers seem to be holding consistently with mental health utilization dominating telehealth, it's interesting to go back to pre-COVID and look at the top five diagnoses from Sept 2019 (see below).  Link (Fair Analysis, Sept 2022) / Link (Fair Analysis, Sept 2020)

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