Health Care Matters | September 20, 2024
PACE Program Expansion Planned in California
Habitat Health has raised $50 million dollars in capital in preparation for launch of its first Program of All-Inclusive Care for the Elderly (PACE) in Sacramento California. Habitat Health was formed by Kaiser Permanente and Town Hall Ventures last spring to provide integrated home care and health care services to low income individuals. According to Matthew Bennett, the new CEO, this round of funding will expand PACE programs throughout California.
Why It Matters
The PACE program has been around for decades and has a proven track record delivering improved care and outcomes to dual eligible beneficiaries through its interdisciplinary care team framework and financing model. While much research has been done that heralds the merits of the PACE program, currently, less than 65,000 beneficiaries participate nationwide. Over the last few years, five states have increased their enrollment by more than 25% (AK, CA, KA, MI, WA). While a positive sign, this sharp increase is a drop in the bucket compared to the overall dual eligible population in the US of 12.5 million. Some have cited large upfront infrastructure costs as one of the impediments to starting a PACE program. Private ventures such as Habitat Health provide potential new avenues for PACE expansion. Their ability to demonstrate cost savings and improved outcomes could lead to additional investment in this space.
Elevance Asking for Money Back From Providers, Alleging Ozempic Overprescribing
Bloomberg news reports that Elevance Health Inc.’s, Anthem Blue Cross Blue Shield, is alleging that providers are falsifying patients’ medical records to secure coverage of weight loss drugs like Ozempic. Anthem is requesting money back from the providers which in some cases totaled more than $1 million. Doctors are disputing the claims, with specialists in some cases stating that they prescribed Ozempic off-label to treat obesity. Ozempic is approved to treat diabetes but contains the same ingredients as Wegovy which is approved to treat obesity. Insurers have some flexibility in their decisions for coverage of off-label prescriptions.
Why It Matters
Since 2017, GLP-1s like Ozempic, Wegovy and Mounjaro have soared in popularity, becoming some of the most popular prescription drugs in the country. Insurance companies and employers are caught weighing short-term costs with potential long-term health benefits. While Elevance's approach may be an outlier, many employers and insurers are trying to determine if and when to cover these medications and when to require prior authorizations for continued use. In Medicare, where treatment for obesity is not covered, Wegovy was recently approved for use in reducing the risk of heart attacks and stroke in people with cardiovascular disease who are obese, possibly opening the door for coverage in Medicare Part D plans.
What We Are reading
Improving Primary Care Payments for Better Medicare Outcomes
In a Health Affairs Forefront article, Primary Care Collaborative (PCC) President and CEO Ann Greiner, American Academy of Family Physician’s Executive Vice President and CEO R. Shawn Martin and Humana Chief Medical Officer Kate Goodrich review recent policymaker proposals on how primary care is funded and supported.
The Latest Edition of Regs & Eggs
Jeff Davis and the McDermott Plus summarize comments received on the 2025 physician fee schedule proposed rule.
What We Are Excited About
Patient-First Care
United States of Care (USofCare) released a dedicated website on Patient-First Care (PFC) with resources, webinars, events, messaging guidance to effectively communicate about PFC, and opportunities to share visions for a better health care system. Check out the Pop Health Podcast where we interview Dr. Venice Haynes, the architect behind their report on the Patient First Care Model.
