This Week in Managed Care: August 16, 2019

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This week, the top managed care stories included the Trump administration looking to bar legal immigrants from using public benefits; a study in The American Journal of Managed Care® finding that a law to limit surprise medical bills is working; data on Affordable Care Act enrollment showing the effect of subsidies.


The Trump administration looks to bar legal immigrants from using public benefits, an AJMC® study finds a law to limit surprise medical bills is working, and having a subsidy makes a difference for Affordable Care Act (ACA) enrollment.

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

Trump Administration Publishes Final Rule Aimed at Legal Immigrants Using Public Benefits

Legal immigrants who seek public benefits, which includes assistance for food or housing or Medicaid, would harm their chances of becoming citizens under a Department of Homeland Security rule that became final this week. The National Immigration Law Center said it will sue to overturn the rule, which takes effect October 15.

While the administration says it wants to promote self-sufficiency, most of the 266,000 comments it received opposed the rule. Many noted that immigrants perform many low wage jobs, including those of home health aides that will be needed as the population ages. Robert Greenstein of the Center on Budget and Policy Priorities said the rule would lead many immigrants who are here legally to forgo health coverage and other assistance that they are eligible for under federal law to keep their families together.

Said Greenstein: “This fear will be even more severe if the Trump administration adopts another rule it has under consideration, one that reportedly would use receipt of benefits under the expanded public charge definition as a basis to deport some groups of immigrants.”

Influence of Out-of-Network Payment Standards on Insurer—Provider Bargaining

A study published this week in The American Journal of Managed Care® found that a California law limiting surprise medical bills is helping consumers, but is also leading to more negotiating between insurers and providers. Authors from the RAND Corporation found that the bill has shifted the bargaining leverage in favor of insurers, and small practices are now consolidating. Under the law that took effect in July 2017, patients who use an in-network hospital are only required to pay in-network cost sharing if they have non-emergency care from an out-of-network doctor.

Said author Erin Duffy, PhD, MPH, adjunct researcher, Rand Corporation: “The approach taken by California legislation that limits the fees that can be charged by out-of-network physicians appears to be reducing the number of surprise medical bills that patients receive for care at in-network hospitals. It also appears to be reducing physicians’ leverage to negotiate higher in-network payments, and in turn is speeding the consolidation of physician groups as they seek to regain lost leverage.”

Notably, the law only applies to plans regulated by California’s insurance laws, not to self-funded plans.

For the full study, visit

ACA Enrollment Numbers Are Mixed

Data from CMS show enrollment on exchanges created by the ACA remains stable for those with low incomes who have subsidies to help pay for their coverage. But for those whose incomes are too high to qualify for such help, rising premiums caused a 24% decline in enrollment.

Among those who qualify for assistance, average premiums fell 1% from 2018 to 2019, and another 300,000 people signed up for coverage. Insurers have stopped losing money on ACA coverage, and experts say that the Trump administration’s cuts to the premium subsidies and elimination of the tax penalty for not having insurance are creating market distortions.

Said Larry Levitt, executive vice president for Health Policy at the Kaiser Family Foundation: “As premiums have risen recently, middle-class people have taken it on the chin.”

Researchers Develop an Approach to Further Suppress HIV Infection

Researchers have announced a new approach that further suppresses HIV infection. While antiretroviral therapy can lower infection to undetectable levels, dormant HIV remains, and scientists have pressed for a cure. Now, researchers at the University of Texas Medical Branch have found a protein that plays a key role in producing new HIV gene copies after the virus works its way into a person’s genetic code.

What’s more, they developed a small molecule that programmed this protein, called BRD4, to keep suppressing HIV after the patient stopped taking antiretroviral therapy.

Said author Haito Hu, PhD, assistant professor of microbiology & immunology, The University of Texas Medical Branch: “Our findings are exciting because they not only improve our understanding of the biology of HIV epigenetic regulation, they also present a promising approach for the development of probes and/or therapeutic agents for silencing HIV, hopefully leading to a cure of the virus eventually.”

For more, visit

Diagnosing and Treating Hereditary Cancers

Finally, the current issue of Evidence-Based Oncology™ examines issues in the diagnosis and treatment of hereditary cancers, including coverage for genetic testing.

In this issue:

  • Authors from My Gene Counsel outline deficiencies in Medicare’s genetic testing coverage
  • Leaders from the advocacy group FORCE discuss the importance of genetic testing after cancer diagnosis
  • The founder of Oneinforty writes about the need to identify populations at high risk of genetic cancer
  • Andrew Norden, MD, MPH, MBA, of COTA Healthcare discusses a collaboration with FDA to explore the possibilities of real-world evidence

For the full issue, visit