Nonprofit health plans focus on reducing premiums, expanding benefits

https://www.healthcarefinancenews.com/news/nonprofit-health-plans-focus-reducing-premiums-expanding-benefits

Nonprofit payers have used a variety of strategies to address plan affordability throughout the next year, including reducing premiums by as much as 10% in some instances, finds a new report from the Alliance of Community Health Plans.

ACHP’s inaugural Report on Affordability found that when health plans manage premiums, provide enhanced benefits, smooth the way for access and reduce costs for governments and employers, the system – and outcomes – improve.

This is exemplified by some of the strategies employed by ACHP member plans, which largely reduced insurance premiums or held them flat, with some member companies reducing premiums by as much as 10%.

On top of that, every plan added new health benefits, or expanded existing ones, without increasing costs to consumers, the report found. Some of the additional benefits include free vaccines, transportation, hearing aids, reduced insulin costs, nutrition classes and meal services, smoking cessation programs and $0 co-pays for mental health visits.

Roughly three-quarters of ACPH plans moved acute and recovery services out of the hospital setting, which was deemed too expensive in most cases. By establishing hospital-at-home programs and remote patient monitoring, plans have generated significant savings for both consumers and the health system, plus improved consumer satisfaction, results showed.

Meanwhile, about two-thirds of the plans offered price transparency tools meant to allow consumers to make more-informed choices. They included information on inpatient and outpatient services, behavioral health, prescription drugs, lab and imaging services and other fees, and many provided options for several locations and virtual care, a move intended to reduce travel costs.

Priority Health’s cost estimator has tallied $13.8 million in shared savings and paid out roughly $4.1 million in rewards to members.

In a bid to improve access, all plans expanded telehealth offerings, smoothing access to mental healthcare as well as to specialties such as Medication Assisted Treatment, physical and occupational therapy, medication management, speech therapy and dialysis. Most eliminated co-pays and cost sharing.

WHAT’S THE IMPACT?

In the last year, ACHP members expanded the hospital-at-home care model, attempting to offer more efficient ways to provide acute and recovery care as well as care management in a home setting. The expansion of virtual care, complete with remote monitoring and social support, reduces the risk of infection, keeps patients comfortable at home and alleviates inpatient hospital bed shortages, according to the report.

For example, SelectHealth and its owner system, Utah-based Intermountain Healthcare, launched Connect Care Pro, a virtual hospital meant to enable access for patients in remote locations. The online, digital program connects more than 500 caregivers across the Intermountain system, enabling patients to receive both basic medical and specialty care without making a long journey, including by helicopter.

Presbyterian Health of New Mexico’s Complete Care, on the other hand, is a wrap-around program that combines primary, urgent and home care for patients with complex medical needs, including those with functional decline and at risk of needing long-term institutional care. Patients receive and manage their care from home, 24/7, including acute and palliative care, house-call and same-day visits, as well as medication management. In addition, care coordinators and social workers manage social needs, including transportation and food insecurity.

And the Home Care Recovery program from Wisconsin’s Security Health Plan and Marshfield Clinic Health System brings the elements of acute inpatient recovery to a patient’s home, eliminating fixed-cost allocations associated with traditional hospital-level care and reducing post-acute utilization and readmissions for 150 traditional inpatient conditions such as congestive heart failure, pneumonia and asthma.

THE LARGER TREND

A 2016 report from the Centers for Medicare and Medicaid Services found that nonprofit organizations and health plans tend to receive higher star ratings than their for-profit counterparts.

For Medicare Part Ds, about 70% of the nonprofit contracts received four or more stars compared to 39% of the for-profit MA-Part-Ds. Similarly, roughly 63% of nonprofit prescription drug plans received four or more stars, compared to 24% of the for-profit PDPs.

Kaiser blasts 30% price hike sought by Oregon system

https://www.beckershospitalreview.com/finance/kaiser-blasts-30-price-hike-sought-by-oregon-system.html?utm_medium=email

Kaiser Permanente Blasts 30% Price Hikes Sought By Salem Health | The Lund  Report

Oakland, Calif.-based Kaiser Permanente says the 30 percent price hike Salem (Ore.) Health is seeking for Kaiser insurance members in the Salem market is too steep. Salem Health argues the increase is justified, according to The Lund Report

Kaiser and Salem Health last negotiated their agreement seven years ago. Salem Health says it’s seeking a steep increase because prices under the current agreement lag the market by 30 percent. 

“Over the past year, Salem Health has consistently communicated with Kaiser the need for a new, market-based contract,” Salem Health said in a statement to The Lund Report

The old contract expired two weeks ago, and talks between Kaiser and Salem Health are at a stalemate. Kaiser says the price hike is unreasonable and excessive. 

“These overinflated prices are unnecessary, and they are not the direction we want to be going regionally and nationally,” Caroline King, MD, a physician leader at Kaiser in Salem, told The Lund Report. “And so if we feel there is a player in the market that is doing this, it is for us to speak up.” 

Any agreement entered into between the organizations will affect the healthcare costs of about 40,000 Kaiser insurance members in the Salem market, according to the report. 

Los Angeles hospital can force Anthem to cover ER visits, court rules

https://www.beckershospitalreview.com/legal-regulatory-issues/los-angeles-hospital-can-force-anthem-to-cover-er-visits-court-rules.html?utm_medium=email

Innovating in Emergency Medicine: CMS Launches ET3 — A New Treatment Model  for EMS | by StartUp Health | StartUp Health

A federal appellate court recently ruled that Anthem is required to pay Martin Luther King Jr. Community Hospital in Los Angeles for about 75 emergency room visits from covered patients, according to Bloomberg Law

The appeal centered on whether Anthem was required to cover services MLK Jr. Community Hospital rendered to employees of Budco Group, an Ohio company, when the hospital was assigned the patients’ benefit payments. Anthem is the administrator of Budco’s Employee Retirement Income Security Act plan, and the employees who received services at the hospital were beneficiaries of the plan. 

Between 2015 and 2017, Budco employees visited MLK Jr. Community Hospital’s emergency room at least 75 times and assigned their benefits under the company’s ERISA plan to the hospital as a condition of receiving care. Instead of paying MLK Jr. Community Hospital, which was out of Anthem’s network, the insurance company paid the beneficiaries, forcing the hospital to attempt to recover payment from the beneficiaries. The Budco employees deposited payment into their personal accounts and did not send any of the benefit payments to the hospital. 

The hospital sued Anthem and Budco in 2016, seeking benefit payments and declaratory relief. The district court granted summary judgment in favor of the hospitals, and Anthem and Budco appealed. 

On appeal, Anthem argued the case was blocked by a provision in its health plan that prevented patients from assigning their rights to third parties such as MLK Jr. Community Hospital, according to Bloomberg Law. The hospital argued that the “anti-assignment” provision did not bar assignments in this case. 

In an unpublished split decision filed Oct. 2, the U.S. Court of Appeals for the Ninth Circuit ruled in favor of the hospital, holding that the language cited by Anthem allowed assignments to healthcare providers, including those that were out of network. 

“The provision lists three entities other than the beneficiary that Anthem may pay directly. Providers are included among those entities,” the court stated. “In the same paragraph, and only two sentences later, the anti-assignment provision forbids beneficiaries from assigning benefits to ‘anyone else.’ This sentence restricting assignment must be read consistently with the entire paragraph, which concerns benefit payments to entities other than the beneficiary. Thus, we interpret the anti-assignment provision’s reference to ‘anyone else’ to permit assignments to those entities, including ‘providers.'”

Alternatively, the appellate court held that the anti-assignment provision is not part of the health plan documents. 

“The anti-assignment provision is plainly not a benefit, and therefore the district court correctly determined it should not be incorporated as a description of the plan’s benefits,” the appellate court held. 

In his dissenting opinion, Judge Daniel Collins said the anti-assignment provision is an express term of the documents that govern the Budco plan. He also disagreed with the majority’s alternative conclusion that the language of the anti-assignment provision did not bar the assignments that plan beneficiaries made to MLK Jr. Hospital. 

Walmart Health COO outlines health insurance business: 5 things to know

https://www.beckershospitalreview.com/payer-issues/walmart-health-coo-outlines-health-insurance-business-5-things-to-know.html?utm_medium=email

NCDHHS on Twitter: "A few years ago, Durham's David Tedrow couldn't drive a  car. He'd forgotten how to answer a telephone. Now, he's started Senior  Health Insurance Brokers, LLC, and was honored

Lori Flees, senior vice president and COO of Walmart Health, officially launched Walmart Insurance Services Oct. 6. The insurance agency will “assist people with enrolling in insurance plans and simplify what’s historically been a cumbersome, confusing process,” Ms. Flees said.

Five things to know:

1. Ms. Flees outlined the operations of Walmart Insurance Services in a Oct. 6 blog post. Walmart will begin selling Medicare insurance plans during this year’s open enrollment period, from Oct. 15 through Dec. 7. 

2. Walmart Insurance Services will provide Medicare products, including Part D, Medicare Advantage and Medicare Supplement plans. The products will be offered by Humana, UnitedHealthcare, Anthem Blue Cross Blue Shield, Amerigroup, Simply Health, WellCare, Clover Health and Arkansas Blue Cross and Blue Shield. More insurers will be added, Ms. Flees said.

3. In July, the Arkansas Democrat Gazette broke news that Walmart had started seeking Medicare sales managers and insurance agents for a new entity called Walmart Insurance Services.

4. In early October, Walmart announced its partnership with Medicare Advantage insurer Clover Health on its first health insurance plans, which will be open to half a million people in eight counties in Georgia.

5. Walmart’s insurance business is licensed in all 50 states and Washington, D.C. Ms. Flees said the company has hired insurance agents to help people find insurance plans.

HAP and Henry Ford collaboration creates new health plan for Michigan businesses

https://www.healthcarefinancenews.com/news/hap-and-henry-ford-collaboration-creates-new-health-plan-michigan-businesses

HAP introduces innovative health plan for Michigan businesses in  collaboration with Henry Ford Health System

Health Alliance Plan (HAP) and Henry Ford Health System have furthered their partnership through the release of Pivotal, a new health plan for Michigan-based businesses.

The plan was created for businesses with more than 100 employees and offers customized benefit options for each company.

WHAT’S THE IMPACT

Pivotal’s network includes seven hospitals, more than 6,000 physicians and 3,500 ancillary providers including urgent care, labs, radiology, imaging, rehab services, long-term care and nursing facilities, and physical, occupational and speech therapy.

Its members will have access to providers within the Henry Ford Health System, Henry Ford Physician and Jackson Health networks, Henry Ford Allegiance Health, as well as HAP’s ancillary provider and pharmacy network, and its contracted pediatric providers.

The plan recognizes the current need for telehealth services by offering virtual care for zero cost-share for in-network visits.

Members can use Pivotal’s telehealth offerings in three different ways: through at-home video visits, clinic-to-clinic video visits where providers can connect with specialists at other facilities, and with e-visits where non-emergency visits are conducted through email.

Pivotal plans also come with concierge services that include personalized onboarding for every employer group, phone support, as well as guaranteed same-day appointments with a primary care physician for sick visits and specialist appointments within 10 business days.

THE LARGER TREND

HAP has been working with Henry Ford since it became a subsidiary of the health system in 1986.

Henry Ford leveraged another partnership with CarePort during the COVID-19 public health emergency to communicate directly with post-acute care providers to share the COVID-19 testing status of patients. This allows providers to take the necessary safety precautions, including deciding if the facility can admit the patient at all, triaging care and managing the use of personal protective equipment.

ON THE RECORD

“HAP and Henry Ford have a long history of working together and sharing the same focus,” Genord said Dr. Michael Genord, president and CEO of HAP. “Working together, we’ve made sure that as many Michigan businesses as possible have access to high-quality affordable care, whether they’re in Detroit or Jackson or anywhere in between.”

 

 

 

 

UPMC’s revenue tops $11B in first half of year

https://www.beckershospitalreview.com/finance/upmc-s-revenue-tops-11b-in-first-half-of-year.html?utm_medium=email

UPMC tops $11B in revenue in 1st half of 2020 | TribLIVE.com

UPMC reported higher revenue in the first half of this year than in the same period of 2019, but the Pittsburgh-based health system’s operating income declined year over year, according to unaudited financial documents.

UPMC reported revenue of $11.1 billion in the first six months of this year, up nearly $1 billion from the same period of 2019. A year-over-year decline in net patient service revenue attributed to volume declines linked to the COVID-19 pandemic was offset by gains in insurance enrollment revenue. Enrollment in UPMC’s health plans grew to 3.9 million members as of June 30.

Expenses also increased year over year. UPMC reported operating expenses of $11.1 billion in the first half of this year, up from $10.1 billion a year earlier. Operating income for the first two quarters of 2020 totaled $59 million, down $20 million from the same period last year.

The health system ended the first half of this year with a net loss of $165 million, compared to net income of $372 million a year earlier. The net loss was attributed to a $423 million loss on investments from January through July. 

Though UPMC continues to experience some disruption to operations as a result of the COVID-19 pandemic, the system’s interim CFO Edward Karlovich said it’s on solid financial footing.

“We’re positioned with an organization of great financial strength to deal with what comes at us,” Mr. Karlovich said during a news conference Aug. 26, according to TRIBLive

 

 

 

 

In-Person, Mask-Free Classes: Some Schools About To Resume Despite Coronavirus Resurgence

https://www.forbes.com/sites/danielcassady/2020/07/28/in-person-mask-free-classes-some-schools-about-to-resume-despite-coronavirus-resurgence/#52f69637511d

In-Person, Mask-Free Classes: Some Schools About To Resume Despite ...

TOPLINE

As coronavirus infection rates continue to spike across the nation, some school districts—including Jefferson City Schools in Jefferson, Georgia—have decided to trudge forward with reopening plans and offer face-to-face classes without requiring face masks.

 

KEY FACTS

Jefferson City Schools plans to begin face-to-face classes on Friday, one of the earliest starting dates in the country, according to a report from the New York Times.

School officials in Jefferson said they would strongly encourage students or teachers to wear face masks, but wouldn’t require them to do so.

The debate over face masks has proven divisive among the town’s residents, 80% of whom voted for Trump in 2016, with high school students creating petitions both for and against mandatory face masks.

Jackson county, of which Jefferson is the county seat, has seen 162 new Covid-19 cases in the past 7 days while Georgia as a whole, a recent hotspot for the virus, has seen over 170,000 cases and more that 3,500 deaths.

At least 14 other school districts have chosen to open for full, in-person classes between July 27 and August 7, according to Ed Week, each with different rules regarding face masks.

At least 14 other school districts have chosen to open for full, in-person classes between July 27 and August 7, according to Ed Week, each with different rules regarding face masks.

KEY BACKGROUND

There has been a debate about when and how schools should reopen almost since the coronavirus pandemic began. Last week President Trump, who has been adamant that schools reopen in the fall, reversed course saying that schools in coronavirus hotspots should delay reopening, but that doing so would prevent them from receiving billions in federal aid. The CDC has also backed reopening schools as of last week, saying in a statement “Reopening schools creates opportunity to invest in the education, well-being, and future of one of America’s greatest assets — our children — while taking every precaution to protect students, teachers, staff and all their families.” Some school districts are operating more judiciously, halting reopenings until the coronavirus outbreaks subside, or relying on virtual lessons and hybrid classes.