Category Archives: Population Health

The health of a community depends on fair health insurance practices

Posted on by • Posted in Charity Care, Community Benefit, Health Insurance Industry, Health System, Hospital, Hospital Industry, Market Power, Market Trends, Outcomes, Patient Experience, Population Health • Leave a comment

https://www.healthcaredive.com/news/the-health-of-a-community-depends-on-fair-health-insurance-practices-antonio-rios/644475/

The health of a community is measured by the health of its individual members, and the health of its members depends on their access to local, high-quality medical care. Health coverage is a key indicator of the health and wellness of an individual. When people have health insurance, they have greater access to care, reduced mortality, and better health outcomes, according to a report from the American Hospital Association.

However, the current approach taken by some of the nation’s largest health insurers, or payers, is putting this at jeopardy as payers focus on profits and quarterly earnings, strip rates and put the long-term viability of health systems at risk. With hospitals in the middle of the worst economic performance in decades, it is time for payers to own up to how their actions negatively impact the communities and those they claim to serve.

As a physician and the chief of population health at a large metro-area health system, Northeast Georgia Health System, my patients’ ability to readily access medical care at our facilities — and have that care be covered by insurance — matters greatly. Any disruption in a patient’s experience, such as restricting access to care by their health plan or going out of network with an insurance company, can wreak havoc on population health. It’s no secret that many health systems across the country have felt the weight of increased administrative and contractual burdens from health insurers as denial rates continue to creep upwards.

Health insurance companies, like the nation’s largest, UnitedHealthcare, have seen profits soar in recent years. UnitedHeatlhcare’s profits were up 28 percent during the third quarter of 2022 – achieving a profit of $5.3 billion in just those three months – before closing the year at $28.4 billion in net earnings in 2023. Elevance (formerly Anthem), Cigna, and Aetna have also posted record profits recently.

We have seen the impact of the pressure payers are putting on hospitals across the country. Nearly 200 hospitals have closed since 2005, according to the Sheps Center for Health Services Research at the University of North Carolina. Many of these hospitals have closed because they failed to receive fair contracted rates from large payers and thus were insolvent.

Community benefits like charity care, health education and economic impact are provided by hundreds of hospitals nationally, but that impact is at risk if they are not fairly compensated for the services they provide.

A resurgent interest in outsourcing

Posted on by • Posted in Core Services, Health System, Hospital, Hospital Industry, Information Security, Information Technology, Non-Core Services, Outsoucing, Population Health, Vendor Relationship Management • Leave a comment

https://mailchi.mp/12e6f7d010e1/the-weekly-gist-february-24-2023?e=d1e747d2d8

Unsurprisingly, given the mounting economic pressures many health systems are facing, we’re beginning to hear more discussions among executives about outsourcing non-core services as a way of containing costs. Whether it’s contracting with an outside company for things like laundry and dietary services, or more extensive outsourcing to vendors for revenue cycle and IT services (such as the much-ballyhooed partnerships with Optum that have grabbed headlines recently), we’ve seen a resurgence of interest in finding ways to offload key areas of non-clinical operations.

In some ways it makes sense: we’ll stick to our knitting, and let someone else handle areas that they’re probably better at. But a recent comment from one system CEO captured our concern about the outsourcing trend. “For us, outsourcing is like Lucy and the football…we’ve been here before.

What we’ve learned is the complexity of managing the vendor relationship often outweighs any potential cost savings. And in the end, we never seem to garner enough savings to make it worth the effort.” 

As to the broader “partnerships” around revenue cycle, IT, and population health, she added, “We’d never give up control of those aspects of the business—they’re too important. Plus, I’m not sure how you’d ever unwind it once you’d let your own staff become employed by a vendor.” We’ll be keeping a close eye on these outsourcing deals as the year goes on, and we’d love to hear your experience with the strategy as well.

An overhaul for Medicare’s pay transformation program

Posted on by • Posted in ACA, Accountable Care Organization (ACO), Alternative Payment Model, American Medical Association (AMA), Health Policy, Medicare Shared Savings Program (MSSP), Population Health, Value Based Care Model, Value-Based Healthcare • Leave a comment
https://www.axios.com/2022/11/02/overhaul-medicares-pay-transformation-program?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

The Biden administration is trying to jump start a Medicare program that pays health providers based on patient outcomes rather than by how many services they perform.

Why it matters: The alternative payment effort was created through the Affordable Care Act, but participation has plateaued since 2018 amid waning interest from providers.

Driving the news: The Biden administration finalized an overhaul of the initiative, known as the Medicare Shared Savings Program, on Tuesday. Changes include offering groups of providers in rural and other underserved areas upfront payments to help them start out in the program.

  • The rule includes other provisions to make it less financial risky for provider groups to join, and makes it easier for participants to earn money back from the government year after year — a central perk of joining the program.

Zoom out: Medicare traditionally pays on a “fee-for-service” basis pegged to the number of patients seen and volume of procedures performed.

  • But one of the main funding sources for Medicare is set to run dry in 2028 if the federal government doesn’t make changes. Advocates say the solution at least partially lies in value-based care programs, like the Shared Savings Program.
  • Under the program, doctors, hospitals and other providers join form groups known as accountable care organizations. ACOs take responsibility for the care of a set of traditional Medicare patients.
  • If ACOs reduce total care costs for their members, they can get back a portion of that savings from the government. ACOs at more advanced stages of the program must pay the government back if total patient spending crosses a threshold.

By the numbers: ACOs have saved the federal government more than $17 billion since 2012, according to the National Association of Accountable Care Organizations.

  • In 2022, 483 ACOs participated in the program and took care of more than 11 million Medicare enrollees. But that’s down from 517 ACOs participating in 2020.
  • CMS set a goal last year to bring all 63 million-plus Medicare beneficiaries into a value-based care model by 2030. ACOs are a key player in achieving the goal.

Go deeper: Providers and value-based care advocates are also pushing Congress to extend a 5% pay bump for providers that participate in advanced alternative payment models, including some tracks of the Medicare Shared Savings Program. The bonus expires Dec. 31.

  • “If the bonus is not continued, it will soften or dampen the momentum toward alternative payment models, because it would create this mentality, or the view, that we’re not serious about that transformation,” said Mara McDermott, vice president at McDermott+Consulting and executive director of the Value Based Care Coalition.
  • Losing the bonus would also make it harder to recruit new providers into alternative payment models, she added.
  • The American Medical Association and five other health care groups launched a separate coalition Tuesday to rally around an extension of the 5% bonus.
  • “Patients and the healthcare system in the United States quite literally cannot afford to return to the days before Medicare incentivized healthcare providers for generating good results,” Clif Gaus, CEO of the National Association of ACOs, said in a news release about the coalition.

Also notable: The rule finalized Tuesday outlines physician payment rates for 2023. Interventional radiologists and vascular surgeons will see the largest Medicare cuts among physician specialties next year, though the final cuts are slightly lower than what CMS proposed in July.

  • Congress could stave off the cuts when they come back to Washington later this month.
  • “The Medicare payment schedule released today puts Congress on notice that a nearly 4.5 percent across-the-board reduction in payment rates is an ominous reality unless lawmakers act before Jan. 1,” American Medical Association President Jack Resneck said in a statement.
  • CMS finalized a slew of other policy proposals Tuesday, including provisions to reduce barriers to behavioral health care.

Still a long way away from real “value” 

Posted on by • Posted in ACA, Accountable Care Organization (ACO), Health Insurance Industry, Health Policy, Health System, Hospital, Hospital Industry, Medicare Shared Savings Program (MSSP), Population Health, Risk, Risk Tolerance, Risk-Based Compensation, Risk-Based Contracting, Strategy, Value Based Care Model, Value-Based Healthcare • Leave a comment

https://mailchi.mp/cd392de550e2/the-weekly-gist-october-21-2022?e=d1e747d2d8

The belief that healthcare should, and would, transition from “volume to value” was a key pillar of the Affordable Care Act (ACA). However, with more than a decade of experience and data to consider, there is little indication that either Medicare or the healthcare industry at large has meaningfully shifted away from fee-for-service payment. Using data from the National Association of Accountable Care Organizations, the graphic below shows that the Medicare Shared Savings Program (MSSP)—the largest of the ACA’s payment innovations, with over 500 accountable care organizations (ACOs) reaching 11M assigned beneficiaries—has led to minimal savings for Medicare. In its first eight years, MSSP saved Medicare only $3.4B, or a paltry 0.06 percent, of the $5.6T that it spent over that time.  
 
Policymakers had hoped that a Medicare-led move to value would prompt commercial payers to follow suit, but that also hasn’t happened. The proportion of payment to health systems in capitated or other risk-based arrangements barely budged from 2013 to 2020—remaining negligible for most organizations, and rarely amounting to enough to influence strategy. The proportion of risk-based payment for doctors is slightly higher, but still far below what is needed to enable wholesale change in care across a practice.

While Medicare has other options if it wants to increase value-based payment, like making ACOs mandatory, it’s harder to see how the trend in commercial payment will improve, as large payers, who are buying up scores of care delivery assets themselves, seem to have little motivation to deal providers in on risk. 

While financial upside of moving to risk hasn’t been significant enough to move the market to date, we aren’t suggesting health systems throw out their population management playbook—to meet mounting cost labor pressures, systems must deliver lower cost care, in lower cost settings, with lower cost staff, just to maintain economic viability moving forward.

Health Panel recommends Regular Anxiety Screenings for Adults

Posted on by • Posted in Adult Anxiety Screenings, Behavioral Health, Dept of Health and Human Services (HHS), Innovative Care Models, Mental Health, Population Health, US Preventative Services Task Force • Leave a comment

https://mailchi.mp/e60a8f8b8fee/the-weekly-gist-september-23-2022?e=d1e747d2d8

The US Preventative Services Task Force, which is appointed by an arm of the Department of Health and Human Services, issued draft guidance this week recommending that all adults under age 65 be screened for symptoms of anxiety disorders.

The panel made a similar recommendation for children and teenagers earlier this year. COVID accelerated an already widespread mental health crisis, with the prevalence of anxiety and depression increasing by 25 percent globally during the first year of the pandemic. The panel’s recommendations are not mandatory, but carry strong influence over primary care physician practices. Draft guidance will be finalized in the coming months after a review of public comments.

The Gist: Policymakers and providers are right to respond to the population-wide increase in anxiety and depression brought on by COVID, and regular screenings will surely help quantify the scope of a problem we’re now facing.

However, given our nation’s undersupply of behavioral health practitioners, widespread screenings are likely to unleash a flood of demand that traditional providers will struggle to meet. Given virtual care’s staying power in the behavioral health space, we hope that the inevitable wave of mental health diagnoses will be matched with innovative care models designed to treat this growing issue at scale.

JP Morgan Chase’s Morgan Health invests $30M in Centivo

Posted on by • Posted in Health Insurance Self Funded, Health Plan Administrator, Innovation, Narrow Network, Narrow Network Customized, Population Health, Pricing Leverage • Leave a comment

https://mailchi.mp/efa24453feeb/the-weekly-gist-july-22-2022?e=d1e747d2d8

Centivo, a Buffalo, New York-based health plan administrator for self-funded employers, has clients in 13 states. Founded in 2019, the company works with national and mid-market employers and health system partners to deliver a consumer-forward, access-driven model, creating customized provider networks that include free primary care and an unlimited virtual care option.

The company aims to reduce consumer out-of-pocket exposure and overall employee healthcare costs by identifying and partnering with high-performing providers in each market it serves. Using this model, Centivo is able to lower costs for self-insured employers by at least 15 percent compared to traditional insurers, through narrow networks with low-cost, high-quality providers.

Morgan Health, which has styled itself as a private sector version of Medicare’s innovation center, has invested $85M in companies that look to transform employer-sponsored healthcare—taking stakes in Seattle-based primary-care company Vera Whole Health and Nashville-based Embold Health, in addition to Centivo.  

The Gist: We’ve had the opportunity to work directly with the Centivo team since its early days, as outside advisors. We’ve been continually impressed by the company’s success in navigating the complicated landscape of self-funded employers, broker relationships, and incumbent health systems. 

The “ground war” of piecing together these bespoke offerings for employers stands in stark contrast to the approach of traditional payers, who simply aggregate scale and rely on brute-force pricing leverage to manage employer cost trend. 

It’s also an interesting juxtaposition to Amazon and other “disruptors”, who bring a relatively naïve, Silicon Valley view to healthcare, and often find themselves frustrated by just how hard it is to drive change amid overwhelming complexity.   

The missing Americans: early death in the United States 1933-2021

Posted on by • Posted in Centers for Disease Control & Prevention (CDC), Gun Related Deaths, Gun Violence, Health Insurance Coverage Adequacy, Health Policy, Life Expectancy, Mortality, Population Health, Public Health, Social Determinants of Health • Leave a comment
The missing Americans: early death in the United States 1933-2021

Figure. Excess deaths in the U.S. relative to other wealthy nations, 1933-2021. Source: Human Mortality Database. Note: Figure shows the difference between the number of deaths that occurred in the U.S. each year and the number of deaths that would have occurred if the U.S. had age-specific mortality rates equal to the average of other wealthy nations. The comparison set includes Austria, Belgium, Canada, Denmark, Finland, France, Germany, Iceland, Italy, Japan, Luxembourg, Netherlands, Norway, Portugal, Spain, Sweden, Switzerland, and the United Kingdom. The average of other wealthy nations excludes Portugal prior to 1940, Austria and Japan prior to 1947, Germany prior to 1956, and Luxembourg prior to 1960. From 1960, all countries are represented (solid dots).

COVID-19 led to a large increase in U.S. deaths. However, even before the pandemic, the U.S. had higher death rates than other wealthy nations. How many deaths could be avoided if the U.S. had the same mortality rates as its peers?

In a new study, we quantify the annual number of U.S. deaths that would have been averted over nearly a century if the U.S. had age-specific mortality rates equal to the average of 18 similarly wealthy nations. We refer to these excess U.S. deaths as “missing Americans.”

The annual number of “missing Americans” increased steadily beginning in the late 1970s, reaching 626,353 in 2019 (Figure). Excess U.S. deaths jumped sharply to 991,868 in 2020 and 1,092,293 in 2021 during the COVID-19 pandemic.

In 2021, nearly 1 out of every 3 U.S. deaths would have been averted if U.S. mortality rates had equaled those of its peer nations. Half of these excess deaths were among U.S. residents under 65 years. We estimate that the 1.1M excess deaths in 2021 were associated with 25M years of life lost, accounting for the number of years the deceased would otherwise be expected to live.

We also compared mortality rates of U.S. racial and ethnic groups with the international benchmark. Black and Native Americans accounted for a disproportionate share of the “missing Americans.” However, the majority of “missing Americans” were White non-Hispanic persons.

Our findings are consistent with recent reports that the life expectancy gap between the U.S. and peer nations widened during the pandemic, with U.S. life expectancy falling from 78.9 to 76.6 years. Life expectancy is widely reported, but it is a complex measure and may be misinterpreted as reflecting small differences in mortality at advanced ages.

In fact, the greatest relative differences in mortality between the U.S. and peer countries occur before age 65. In 2021, half of all deaths to U.S. residents under 65 years – and 90% of the increase in under-65 mortality since 2019 – would have been avoided if the U.S. had the mortality rates of other wealthy nations. In addition to the loss of life, these early deaths often leave behind child (and elder) dependents without key social and economic support.

Our calculations were based on recently released mortality data, obtained from the U.S. Centers for Disease Control and Prevention WONDER Database and the Human Mortality Database. The international comparison group included all available countries with relatively complete mortality data starting in 1960 or earlier, after excluding former communist countries. Our paper builds on prior analyses of excess deaths by our study team and by others.

We find a very large increase in excess U.S. deaths during the COVID-19 pandemic. However, this spike occurred on top of a growing trend that reached 600,000 excess deaths in 2019. Future COVID-19 deaths could be reduced with broader vaccine uptake, worker protections, and masking during surges. Even if COVID-19 mortality were eliminated, however, the U.S. would likely suffer hundreds of thousands of excess deaths each year, with many linked to firearms, opioids, and obesity.

Addressing excess deaths in the U.S. will require public health and social policies that target the root causes of U.S. health malaise, including fading economic opportunities and rising financial insecurity, structural racism, and failures of institutions at all levels of government to invest adequately in population health.

Podcast: All Healthcare Is Politics?

Posted on by • Posted in Access, Access & Quality of Healthcare, American Dream, Attitude, Government, Health Insurance Coverage Adequacy, Health Policy, Mortality, Opinion, Population Health, Public Health, Public Opinion, Public Perception, Public Trust, Social Determinants of Health, Trust, Underinsured, Uninsured, Vulnerable Populations • Leave a comment
Podcast: All Healthcare Is Politics? 6/17/22

Does Your Vote Affect Your Healthcare?

What role should the federal government play in addressing major healthcare issues? And does the way you vote affect your prospects for a long and healthy life? We talked about it on today’s episode of the 4sight Friday Roundup podcast.

  • David Johnson is CEO of 4sight Health.
  • Julie Vaughan Murchinson is Partner of Transformation Capital and former CEO of Health Evolution.
  • David Burda is News Editor and Columnist of 4sight Health.

Subscribe on Apple Podcasts, Spotify, and other services.

Becoming a healthcare platform

Posted on by • Posted in Anywhere Anytime Care, Capability Building, Care Ecosystem, Care Supplier, Customer Loyalty, Health System, Hospital Industry, Integrated Delivery System, Population Health, Population Management Platform, Population Manager, Premium Owner, Strategy, Strategy Sustainable Long Term • Leave a comment

https://mailchi.mp/d73a73774303/the-weekly-gist-may-27-2022?e=d1e747d2d8

As we’ve been discussing over the past few years, several environmental forces—shifting consumer behavior, evolving demographics, new technology, and a flood of new market entrants—are pushing health systems to adopt a more consumer-centric business model. Systems must develop the capabilities needed to create an omnichannel consumer loyalty and population management platform. This platform will be the foundation for connecting consumers, curating providers, and coordinating care.
 
To achieve this vision, health systems must deliver value across two dimensions: increasing their proximity to the consumer (our y-axis) and their proximity to the premium dollar (our x-axis), as shown in the graphic above. Traditionally, health systems have operated primarily in the lower-left quadrant, as “care suppliers.” Some have spent considerable time and resources across the last decade, pushing closer to the premium dollar, to become “population managers.” But, importantly, managing population health is neither patient-facing, nor something consumers demand and seek.

To build deeper consumer loyalty, health systems must also move up the y-axis, creating a “care ecosystem” that provides “anywhere, anytime” care through multiple channels, including virtual and home-based solutions. And for certain populations, like Medicare Advantage, it will make sense for many systems to also explore becoming the “premium owner”, owning the full care budget and ensuring the incentives to design a consumer-centric offering. 

The ideal health system platform should combine all four of these identities, tailored to the local market situation.

Payers discuss Medicare Advantage (MA) misses at JP Morgan healthcare conference

Posted on by • Posted in Aging Population, Business Model, Competition, Cost Management, Expectations, Medicare, Medicare Advantage, Population Health, Scale • Leave a comment

https://mailchi.mp/92a96980a92f/the-weekly-gist-january-14-2022?e=d1e747d2d8

2021 JP Morgan Healthcare Conference | Zoetis

Large insurers Humana and Cigna, along with “insurtech” startups Bright Health and Alignment Healthcare, all lowered expectations for their MA membership growth after missing 2022 enrollment targets. The companies blamed fierce competition for the nation’s estimated 29.5M MA lives, and highlighted a focus on diversifying revenue through other business arms like healthcare delivery and service sales.    

The Gist: Insurers’ missed expectations are leading some to question whether the MA market is beginning to weaken, but these concerns are overblown, with last fall’s enrollment affected by the pandemic, which hindered brokers’ ability to reach seniors. 

Some MA-focused startups are finding challenges in their attempts to scale, and their stock prices will continue to retreat from the lofty valuations that drove their public offerings.

Insurers still have plenty of running room to grow their MA books of business, but will face increasing scrutiny of their ability to manage patients and control costs for the aging population.