A Prescription for Texas Medicaid
State budgets are clearly feeling the strain of rapidly rising health care costs, with prescription drugs leading the way as the fastest growing cost category of all Medicaid services. A number of states including Texas are addressing this challenge head-on by attempting to introduce competition and flexibility into their Medicaid prescription drug programs. A key tool in their arsenal is fully integrating the Preferred Drug List (PDL) into Medicaid managed care, allowing managed care organizations (MCOs) to identify drugs that are therapeutically appropriate and less costly. In our view, it’s time for Texas to adopt the fully integrated PDL approach as a way to improve care and save taxpayer dollars.
Medicaid MCOs have been fully responsible for pharmaceutical costs since 2012 when prescription drug benefits were “carved-in” to Medicaid managed care contracts in Texas. In the process, MCOs were assigned the full risk for cost, quality, and care associated with Medicaid MCO consumers, but were not given the tools that are typically used in the private health insurance market and Medicare to control costs and improve health outcomes.
As a result of this incomplete carve-in, the Health and Human Service Commission (HHSC) is holding MCOs financially accountable for improving health care outcomes, but is unable to give them the latitude to manage costs using an integrated PDL. Instead, the MCOs are saddled with a single statewide formulary maintained by HHSC. Unfortunately, this approach has proven slow to respond to market changes and updates to clinical data and safety guidelines. The current system’s lack of flexibility is limiting MCO efforts to improve the quality of health care outcomes.
According to a study completed in 2012 by Milliman and HHSC’s own estimates, the state could realize a cost savings between $64 million and $73.7 million per biennium by moving to MCO developed formularies. A full carve-in would save the state significant dollars by leveraging MCO insights to improve generic dispensing rates and increase the use of generic and lower-cost drugs.
TAHP believes that the 84th Legislative Session offers the perfect opportunity to fully coordinate Medicaid managed care benefits by moving to a fully carved-in pharmacy benefit and reducing the duplication caused by HHSC administering a process that is already effectively administered in the private market. To maximize the efficiency of these programs in Texas, MCOs should be tasked with both the clinical and administrative oversight for Medicaid and CHIP prescription drug management and continue to be held at risk for these services.
HHS Enrollment Snapshot–Week 7
The Department of Health and Human Services (HHS) has released its weekly snapshot of enrollment in the federally-facilitated Marketplace for the week of December 27 through January 2. HHS indicates that plan selections totaled 102,896 in this time frame—bringing total enrollment since November 15 to 6,593,388.
Other cumulative data since November 15 include:
- Applications Submitted: 8,436,130
- Call Center Volume: 7,412,617
- Window Shoppers on Healthcare.gov: 5,749,154
The data in the HHS weekly snapshot are preliminary and are subject to revision.
HEALTH PLAN HIGHLIGHTS
Cigna Expands Sponsorship with runDisney
Cigna (NYSE:CI) has expanded its sponsorship with runDisney through a multi-year agreement to serve as the presenting sponsor of the Walt Disney World Marathon Weekend and Disneyland Half Marathon Weekend.
“Cigna and runDisney share a commitment to inspire healthy living and active lifestyles across all ages and fitness levels,” said Lisa Bacus, Executive Vice President and Global Chief Marketing Officer at Cigna. “runDisney’s stature as one of the most respected race series in the nation gives Cigna and our customers and employees the opportunity to showcase our passion for community service. At the same time, we’ve been able to share inspiring personal stories of the customers, military veterans and so many others who have been part of our runDisney teams.”
For Cigna employees, runDisney events have become an opportunity to come together to serve as guides for athletes with disabilities and raise money for non-profit organizations they support. For many employees, it has also represented a milestone in their own healthy lifestyle journey. “After suffering a stroke at age 32, I vowed to myself, my wife and my newborn daughter that I would make changes to maintain a healthy lifestyle,” said Peter Chuchro, a Cigna employee who was one of three employees who earned entry into the 2014 Walt Disney World Marathon Weekend. “Finishing my first-ever marathon symbolized how far I’d come as well as a promise kept to myself and my family.”
“Cigna and runDisney share a commitment to inspire healthy living and active lifestyles across all ages and fitness levels.”
Lisa Bacus—Cigna Executive Vice President and
Global Chief Marketing Officer
Among the initiatives Cigna launched at the Walt Disney World Marathon Weekend, Cigna sponsored athletes from Achilles International , an organization that provides athletic opportunities for people with disabilities, including military veterans and children with autism.
“After being diagnosed with a degenerative eye disease at the age of 14, I never imagined I would be able to run, let alone finish a race,” said Jodi Stout, Cigna long-term disability customer and Achilles International athlete. “Thanks to the Cigna customer referral program and Achilles, I completed the Disney Family Fun Run 5K with the help of a Cigna employee who guided me throughout the race. Crossing the finish line gave me a sense of accomplishment and inspired me to pursue more races in the future.”
Walt Disney World Marathon Weekend, which attracts more than 100,000 participants and spectators from all over the world, is one of the largest events held in Central Florida and is among the largest marathon race weekends in the United States. Runners of all ages and skill levels take part in a variety of family-friendly events and races, including Goofy’s Race and a Half Challenge (running the half marathon and the full marathon on consecutive days), Walt Disney World Marathon, Walt Disney World Half Marathon, Walt Disney World 10K, Dopey Challenge (running the 5K, 10K, half marathon and full marathon on consecutive days), Family Fun Run 5K and runDisney Kid’s Races.
Cigna Corporation (NYSE: CI) is a global health service company dedicated to helping people improve their health, well-being and sense of security. All products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Life Insurance Company of North America and Cigna Life Insurance Company of New York. Such products and services include an integrated suite of health services, such as medical, dental, behavioral health, pharmacy, vision, supplemental benefits, and other related products including group life, accident and disability insurance. Cigna maintains sales capability in 30 countries and jurisdictions, and has approximately 85 million customer relationships throughout the world. To learn more about Cigna®, including links to follow us on Facebook or Twitter, visit www.cigna.com.
runDisney, one of the largest race organizers in the nation, hosts a series of nine event weekends providing runners unique opportunities to run various distances through Disney theme parks. Race participants earn Disney-themed medals, experience legendary Disney entertainment and guest service and ultimately celebrate their accomplishments with a Disney vacation. The original event in the series, the Walt Disney World Marathon Weekend presented by Cigna, takes place in January followed by the Disney Princess Half Marathon Weekend presented by Children’s Miracle Network Hospitals in February, Expedition Everest Challenge in May, the Twilight Zone™ Tower of Terror 10-Miler in October and the Disney Wine & Dine Half Marathon Weekend in November. Disneyland hosts the Star Wars Half Marathon Weekend presented by Sierra Nevada Corporation in January, the Tinker Bell Half Marathon Weekend presented by PANDORA Jewelry in May, the Disneyland Half Marathon Weekend presented by Cigna during Labor Day Weekend and the Avengers Super Heroes Half Marathon Weekend in November. More than 163,900 running enthusiasts participate in runDisney events each year. For more information, visit www.runDisney.com and follow us on Facebook (runDisney), Twitter @runDisney and Instagram.
AFFILIATE MEMBER HIGHLIGHTS
CareCore National and MedSolutions Merge
CareCore National, LLC (“CareCore”) and MedSolutions, Inc. (“MedSolutions”), two leading providers of Specialty Benefits Management (SBM) services to managed care organizations and risk-bearing provider organizations, today announced the completion of a merger that will help advance the companies’ collective commitment to containing healthcare costs and achieving quality medical outcomes.
“We are now even better positioned to enhance health plans’, hospitals’ and ACOs’ ability to control cost growth and improve health outcomes by ensuring patients receive appropriate, evidence-based care.”
John J. Arlotta—CareCore CEO
The merger allows the two complementary businesses to jointly develop a broader range of innovative and efficient solutions, in addition to those that each company already manages. These include radiology, cardiology, radiation therapy, medical oncology, musculoskeletal and pain management, post-acute care, sleep therapy, lab management and participation in the CMS Bundled Payment for Care Improvement Initiative. The combined company will also be able to invest even more heavily in the information and analytics technologies that both companies have been developing.
“We are now even better positioned to enhance health plans’, hospitals’ and ACOs’ ability to control cost growth and improve health outcomes by ensuring that patients receive appropriate, evidence-based care,” said John J. Arlotta, chairman and CEO of CareCore. “Together we can develop new offerings that will further the core goals of U.S. healthcare reform: containing medical cost growth while improving the quality of care for millions of Americans.”
“Through this exciting merger, the complementary strengths and best practices of two leading organizations are brought together, further improving the service delivered to clients and patients,” said Curt Thorne, president and CEO of MedSolutions. “This merger is an incredible growth opportunity for both businesses, allowing us to expand our portfolio even more rapidly than we could separately.”
Mr. Arlotta now serves as CEO of the combined company, while Mr. Thorne is retiring after a successful 16-year career at MedSolutions. Mr. Arlotta brings 40 years of healthcare industry expertise and extensive senior management experience spanning over 30 years. The combined company’s management is comprised of a talented and deeply experienced team culled from both companies.
The new company is continuing to operate under both the CareCore and MedSolutions brands for the time being and is headquartered in Bluffton, South Carolina, where CareCore is currently headquartered. MedSolutions’ Franklin, Tennessee office remains open and critical to ongoing operations. Additionally, all other current locations for both companies, including call centers, will remain open.
Mr. Arlotta continued, “Both CareCore and MedSolutions have a proven track record of effective medical cost management and ensuring medically appropriate treatment for patients. We have developed a great integration plan that will maximize the strengths of both organizations, and I am excited about how we can enhance our programs and the customer experience through our combined company.”
“Through this exciting merger, the complementary strengths and best practices of two leading organizations are brought together, further improving the service delivered to clients and patients.”
Curt Thorne—MedSolutions president and CEO
RBC Capital Markets LLC and Evercore Partners Inc. served as financial advisors and Constantine Cannon LLP, Paul, Weiss, Rifkind, Wharton & Garrison LLP, and Epstein Becker & Green, P.C. provided legal counsel to CareCore. Goodwin Procter LLP, McDermott Will & Emery LLP, and Bressler, Amery & Ross, P.C. provided legal counsel to MedSolutions.
CareCore–MedSolutions offers proven, diversified medical cost management solutions that help clients reduce costs while increasing quality of care for their members. The company provides these solutions to managed care organizations and risk-bearing provider organizations serving commercial, Medicare and Medicaid populations. Powered by a team of specialized medical professional resources, extensive evidence-based guidelines and advanced technologies, the company supports clients by ensuring the right evidence-based care is delivered at the right time to the right patient at the right site of care. Flexible medical benefit management solutions are offered in: Diagnostic Testing and Imaging; Cardiology; Comprehensive Musculoskeletal and Pain Management; Medical and Radiation Oncology; Sleep Services; Lab Management; and Post-Acute Care (including participating in the CMS Bundled Payments for Care Improvement Initiative). CareCore–MedSolutions is proud to help over 77 million Americans receive higher quality, lower cost healthcare. For more information, please visit www.CareCoreNational.com and www.MedSolutions.com.
Representative Terry Canales 1/1
Representative Senfronia Thompson 1/1
Armando A. (Mando) Martinez 1/6
Representative Joseph Moody 1/09
Representative Travis Clardy 1/13
Senator Eddie Lucio, Jr. 1/20
Representative Jim Keffer 1/20
Representative Larry D. Gonzales 1/29