Sam’s Club launches $1 telehealth visits for members: 7 details

https://www.beckershospitalreview.com/telehealth/sam-s-club-launches-1-telehealth-visits-for-members-7-details.html?utm_medium=email

On-Demand Text-Based Primary Care App | 98point6

Sam’s Club partnered with primary care telehealth provider 98point6 to offer members virtual visits.

Seven details:

1. Sam’s Club now offers members access to telehealth visits through a text-based app run by 98point6.

2. Members can purchase a $20 quarterly subscription for the first three months; the regular sign-up fee is $30 per person. After the first three months, members pay $33.50 every three months.

3. The subscription gives members unlimited telehealth visits for $1 per visit. The service has board-certified physicians available 24 hours per day, seven days a week.

4. Members can also subscribe for pediatric care.

5. Physicians can diagnose and treat 400 conditions including cold and flu-like symptoms as well as allergies. They can also monitor chronic conditions including diabetes, depression and anxiety.

6. Members can use the app to obtain prescriptions and lab orders as well.

7. Sam’s Club has around 600 stores in the U.S. and Puerto Rico and millions of members.

Offering access to telemedicine was on our roadmap in the pre-COVID world, but the current environment expedited the need for this service to be easily accessible, readily available and most of all, affordable,” said John McDowell, vice president of pharmacy operations and divisional merchandise at Sam’s Club. “Through providing access to the 98point6 app in a pilot, we quickly realized that our members were eager to have mobile telehealth options and we wanted to provide this healthcare solution to all of our members as a standalone option.”

 

 

 

Administration’s Record on Health Care

President Trump’s Record on Health Care

President Trump's Record on Health Care | KFF

A review of Trump’s health care record so far. Avoiding the problematic issue of Trump’s alleged plan, analysts at the nonpartisan Kaiser Family Foundation released a report this week that examines President Trump’s record on health care over the last three and half years. Some highlights from the overview and the full analysis:

  • On the Affordable Care Act: “From the start of his presidential term, President Trump took aim at the Affordable Care Act, consistent with his campaign pledge leading up to the 2016 election. He supported many efforts in Congress to repeal the law and replace it with an alternative that would have weakened protections for people with pre-existing conditions, eliminated the Medicaid expansion, and reduced premium assistance for people seeking marketplace coverage. While the ACA remains in force, President Trump’s Administration is supporting the case pending before the U.S. Supreme Court to overturn the ACA in its entirety that is scheduled for oral arguments one week after the election.”

 

  • On Medicare and Medicaid: “The Administration has proposed spending reductions for both Medicaid and Medicare, along with proposals that would promote flexibility for states but limit eligibility for coverage under Medicaid (e.g., work requirements).”

 

  • On drug prices: “The President has made prescription drug prices a top health policy priority and has issued several executive orders and other proposals that aim to lower drug prices; most of these proposals, however, have not been implemented, other than one change that would lower the cost of insulin for some Medicare beneficiaries with diabetes, and another that allows pharmacists to tell consumers if they could save money on their prescriptions. The Trump Administration has also moved forward with an initiative to improve price transparency in an effort to lower costs, though it is held up in the courts.”

 

  • On the response to the coronavirus: “The Trump administration has not established a coordinated, national plan to scale-up and implement public health measures to control the spread of coronavirus, instead choosing to have states assume primary responsibility for the COVID-19 response, with the federal government acting as back-up and ‘supplier of last resort.’ The President has downplayed the threat of COVID-19, given conflicting messages and misinformation, and often been at odds with public health officials and scientific evidence.”

 

President Trump’s Record on Health Care – Issue Brief

 

Administration’s talking health care again, with 2020 in mind

https://www.politico.com/news/2020/07/26/trumps-health-care-again-with-2020-election-381473?utm_source=ActiveCampaign&utm_medium=email&utm_content=Republicans+Roll+Out+%241+Trillion+Coronavirus+Relief+Plan&utm_campaign=TFT+Newsletter+07272020

Tell us: How has Trump handled healthcare in his first 100 days ...

Polls show voters say Joe Biden would handle the issue better. And Trump is running short on options to make concrete changes before November.

President Donald Trump is suddenly talking about health care again.

He signed several executive orders on drug pricing on Friday. He vowed to unveil some new health plan by the end of next week, although he hasn’t provided specifics or an explanation of how he’ll do it. His aides are touting a speech in which Trump will lay out his health care vision. White House counselor to the president Kellyanne Conway has been calling Trump “the health care president.”

Yet it’s unlikely to amount to much in terms of policy ahead of the election. There’s almost no chance Congress will enact any legislation on the issue before November and policy specialists say the executive orders in question will make changes only at the margins — if they make any changes at all. Trump has also previously vowed to roll out a grand health care plan without following through.

That leaves Trump with mostly rhetorical options — even if he insists otherwise — cognizant that voters consistently rank health care as a top priority and say Joe Biden, Trump’s presumptive 2020 rival, would handle the issue better than the president. Meanwhile, Trump is running for reelection having not replaced Obamacare or presented an alternative — all while urging the Supreme Court to overturn the decade-old health law. And millions of Americans are currently losing their health insurance as the coronavirus-gripped economy sputters.

“I think politically, the main objective will be to have something he can call a plan, but it will be smaller than a plan. Just something that he can talk about,” said Drew Altman, president and CEO of the Kaiser Family Foundation, a nonpartisan health policy organization. “But it’s almost inconceivable that anything can be delivered legislatively before the election.”

Trump has long stumped on his pledges to kill Obamacare, the law his predecessor implemented that expanded Americans’ access to health insurance, set baseline standards for coverage, introduced penalties for not having insurance and guaranteed coverage for preexisting conditions. But conservatives say the law introduced too many mandates and drove up costs.

But after winning election in 2016, Trump failed to overturn the law in Congress — or even offer an agreed upon alternative to the law — despite holding the majority in both chambers on Capitol Hill. Democrats then retook the House in the 2018 midterms, essentially ending any chances the law, formally known as the Affordable Care Act, would be repealed.

Even some conservatives said the ongoing failure to present a concrete replacement plan is helping the Democrats politically.

Republicans, said Joe Antos, a health expert at the conservative American Enterprise Institute, “spent basically 2010 to today arguing that the ACA is no good. After 10 years, clearly there are some problems with starting all over again. I haven’t detected very strong interest, at least among elected officials, in revisiting that.”

But the coronavirus pandemic has added pressure to address health care costs, and Trump has lagged behind Biden on his handling of the issue in polls. Fifty seven percent of registered voters recently polled by Quinnipiac said Biden would do a better job on health care than Trump, while only 35 percent approved of Trump’s handling of health care as president. And on the issue of affordability, a CNBC poll found 55 percent of battleground voters favored Biden and the Democrats, compared with 45 percent who preferred Trump and the Republicans.

“At this point, there are two huge issues, jobs and the economy, and health care, i.e., the coronavirus. If anything that’s simply been magnified,” said David Winston, a Republican pollster and strategist. “Given the fact that it’s one of the top issues, it’s not like there’s a choice but to talk about it. If candidates aren’t making statements and proposing solutions around that, it’s a requirement. Both candidates have to address it.”

Biden has campaigned on expanding Obamacare while also promising to implement a “public option” similar to Medicare, which is government-run health insurance for seniors. On drug pricing, he and Trump embrace some of the same ideas, like allowing the safe importation of drugs from other countries where they are cheaper. Biden also supports direct Medicare negotiation of drug prices, a Democratic priority that Trump supported during the 2016 campaign before reversing course.

“Donald Trump has spent his entire presidency working to take health care away from tens of millions of Americans and gut coverage for preexisting conditions,” said Andrew Bates, a Biden campaign spokesman. “If the Trump campaign wants to continue their pattern of highlighting the worst possible contrasts for Donald Trump, we certainly won’t stop them.”

The Trump administration insists it can point to several health care victories during Trump’s term.

Trump frequently notes the removal of the penalty for Americans who do not purchase insurance as a major victory, falsely claiming it is equivalent to overturning Obamacare.

Trump also signed an executive order last year to fight kidney disease to encourage home dialysis and increase the amount of kidney transplants, and he expanded telehealth medicine during the pandemic.

More recently, the U.S. Court of Appeals for the District of Columbia upheld a Trump administration rule expanding the availability of short-term health plans, which Trump has touted as an alternative to Obamacare but Democrats deride as “junk.” The plans are typically cheaper than Obamacare coverage because they don’t provide the same level of benefits or consumer protections for preexisting conditions.

A federal judge in June similarly upheld another Trump administration rule requiring hospitals to disclose the prices they have negotiated with insurers. Price transparency in the health care system has long been a significant issue, with Americans rarely having clarity over how much their treatments will cost ahead of time. Trump called the win “bigger than health care itself,” in an apparent reference to Obamacare. It’s unclear whether transparency will force down health care prices, and hospitals opposing the rule have appealed the judge’s decision.

And on Friday at the White House, Trump held an event to sign four executive orders aimed at slashing drug pricing. The move aimed to tackle a largely unfulfilled signature campaign promise — that he would stop pharmaceutical companies from “getting away with murder.”

“We are ending the sellouts, betrayals and broken promises from Washington,” Trump said Friday.“You have a lot of broken promises from Washington.”

But the orders appeared largely symbolic for now, as they were not immediately enforceable, contained notable caveats and may not be completed before the election anyway. For instance, an order requiring drugmakers to pass along any discounts directly to seniors requires the health secretary to confirm the plan won’t result in higher premiums or drive up federal spending. But the White House had shelved that plan last summer over worries the move might hike seniors’ Medicare premiums ahead of the election and cost taxpayers $180 billion over the next decade.

Conway disputed that Trump had not made progress on issues like drug pricing.

“President Trump is directing the development of therapeutics and vaccines, has delivered lower prescription drug costs, increased transparency in pricing for consumers and is committed to covering preexisting conditions and offering higher quality health care with lower costs and more choices,” she said.

Yet a number of Trump’s other health care initiatives have faced hurdles — especially amid the coronavirus pandemic.

The opioid crisis, which the president had touted as a top priority and campaigned on in 2016, is getting worse. Drug overdose deaths hit a record high in 2019 and federal and state data shows they are skyrocketing in 2020.

“The overdose epidemic will not take a back seat simply because Covid-19 has hit us hard, and that needs to be reflected in policy,” said Andrew Kessler, founder and principal of Slingshot Solutions, a behavioral health consulting firm.

The president’s plan to end HIV by 2030 has similarly receded during the pandemic. And Trump’s proposal on improving kidney care — an issue that affects roughly 15 percent of American adults — is still in its early stages and will not be finalized until next year.

 

 

 

American patients can’t shop their way to a low cost healthcare system

American patients can’t shop their way to a low cost healthcare system

Hospital price transparency is a distraction from policies that could reduce costs without burdening patients, say Jamie Daw and Adam Sacarny.

 

The prices that hospitals charge privately insured patients in the US have long been shrouded in secrecy. These prices—which are negotiated between hospitals and private insurers—vary widely: the price for the same blood test could vary 39-fold within Tampa, Florida and the cost of a cesarean delivery varies by up to $24 000 in San Francisco, California.

A recent federal court decision stands to shine a light on opaque hospital pricing in the US. In a lawsuit brought forward by the American Hospital Association, a federal judge upheld a regulation issued by the Trump administration that will soon require hospitals to post a wealth of information on payment rates online.

This policy seems intuitive: in other sectors of the economy, consumers usually know the price of a service or product before they purchase it. By comparing prices, consumers can shop around and save money. In turn, sellers anticipate that behavior and are incentivized to keep prices low. Who wouldn’t want a virtuous circle like that in healthcare? 

The Trump administration argues that hospital price transparency will encourage value in healthcare by helping patients and employers find lower prices, while pressuring hospitals to cut them further. However, the potential effects—and who stands to benefit—are not so straightforward.

 

Firstly, giving consumers information on prices doesn’t necessarily mean that they will respond by seeking lower cost services. Studies have consistently found that patients tend not to use price transparency tools, and their effects on healthcare spending are small or nonexistent. Why? Shopping for healthcare services is often complicated or impossible. 

 

Many of the most expensive services are for emergencies where there is little scope for patients to shop.

Even when a patient has time to compare prices for non-urgent procedures or tests, the complexity of healthcare payment systems and insurance products makes it next to impossible for a patient to preemptively calculate what they would personally pay for an encounter. Establishing that amount requires patients to know the cost-sharing parameters of their insurance plan, the set of services they will use during the encounter, and how aggressively the hospital will bill for those services.

Insurance also obscures patients’ incentives to shop by insulating them from healthcare prices.

While patients can be given strong incentives to shop—and an increasing number of American workers are enrolled in high deductible health plans with this aim—these incentives are created by hoisting financial risk on patients. This financially burdens American families and can result in patients forgoing appropriate care.

 

Beyond the challenges posed by patient shopping, the empirical evidence supporting price transparency is weak.

It could even backfire. Economists have pointed out that in sectors with low competition, price transparency can facilitate collusion and lead to higher prices. This fear was borne out in Denmark when authorities began publishing the prices of ready-mixed cement. Prices proceeded to converge and rise, and the authorities eventually abandoned the idea. The most hopeful evidence in the US healthcare system comes from New Hampshire, where prices for medical imaging fell by 3% after the state established a price transparency website. But even effects of this magnitude, while beneficial, would only make a tiny dent in lowering US healthcare costs. 

 

Price transparency efforts reflect a broad trend for American policy makers to turn to consumer-driven strategies to reduce healthcare costs.

These strategies are built on the assumption that patients ought to be responsible for navigating their way to high quality, low cost healthcare. However, the challenges faced by patients in assessing the complex cost-quality tradeoffs in healthcare limit the potential for price transparency to have the impact that the administration advertises.

Perhaps more troubling is that these efforts could distract policy makers from addressing the main drivers of US healthcare prices, such as rapid and ongoing consolidation. Concentrated hospital markets are becoming the norm in the US and are strongly associated with higher prices. Antitrust actions, such as preventing hospital mergers, could reduce and reverse consolidation, likely leading to lower prices.

Another option for policy makers is to assume a greater regulatory role over healthcare prices, including introducing price caps and an all-payer rate setting. A Supreme Court decision made it much more difficult for state governments to collect the data that would undergird these efforts. As a result, the information released under the transparency rule may end up being more useful for states considering new price regulations than for patients shopping for healthcare services.

 

If we want to reduce prices without burdening patients with financial risk, then policy makers need to address the emerging causes of rising healthcare costs directly. Efforts to control costs are most likely to succeed when policy makers tackle the structural drivers behind the most expensive health system in the world.

 

 

 

 

Walmart confirms a new avatar — it’s also a health insurance agency

https://medcitynews.com/2020/07/walmart-confirms-a-new-avatar-its-also-a-health-insurance-broker/?utm_campaign=MCN%20Daily%20Top%20Stories&utm_medium=email&_hsmi=90973681&_hsenc=p2ANqtz-81Jwk3CVNhJLTDzB0d_5dxRASKqJQULhnQYEg1uxEGxr-l_EbrHhNlSq7UcPZ103ku0wBylrpCk8Y0i1vrK7rRE5rJuA&utm_content=90973681&utm_source=hs_email

Should I buy health insurance from Walmart? - Castaline Insurance ...

Walmart quietly launched a new health insurance business. The company, called Walmart Insurance, was filed with the Arkansas Secretary of State last month.

Walmart is making clear what an executive declared in a virtual conference: that it is firmly in the healthcare business, not just in retail healthcare.

News emerged today that the company is planning to throw its weight around in another healthcare segment in need of an overhaul: insurance. A spokeswoman from the Bentonville, Arkansas retail behemoth confirmed that the company has created “Walmart Insurance Services LLC” to sell insurance policies. The business entity’s name was first filed with the Arkansas Secretary of State in late June.

“We currently offer access to insurance information in our Walmart Health locations, and we have a long-standing education program called Healthcare Begins Here to help people find the right insurance plan for them,” spokeswoman Marilee McInnis wrote in an email. “We’re expanding our current insurance services to now include the sale of insurance policies to our customers.”

A handful of job postings at a call center in the Dallas metro also match up with Walmart Insurance Services, as first pointed out by Talk Business & Politics. Walmart has listings for licensed insurance agents and Medicare sales supervisors.

“Yes, you read that right, Walmart now has an insurance agency,” the listings read.

It looks like the new subsidiary will be focused on selling Medicare Advantage plans, though the company was mum when asked for additional details. The spokeswoman’s statement about the “sale of insurance policies to our customers” also leaves open the possibility of Walmart expanding its services beyond senior shoppers in the future.

Medicare Advantage plans have been experiencing rapid growth in the past decade, with more than a third of all beneficiaries enrolled in a plan managed by a private insurer. That figure is expected to increase in the future.

 

Deeper into the pharmacy space

Separately, on Tuesday, Walmart announced that it had struck a partnership with  PBM startup Capital Rx, which provides health plans real-time information on prescription drug prices.

Walmart has been a big player in the pharmacy space for several years, and the company appears to be deepening that through this partnership

“‘Everyday low price’ has been a guiding principle at Walmart. We take pride in providing affordable prices to more than 160 million customers who shop Walmart each week,” Walmart Health and Wellness Vice President Luke Kleyn said in a news release. “Working with Capital Rx will allow us to do the same for prescription drugs,”

Capital Rx was founded just over two years ago by AJ Loiacono, a former insurance auditor, with the idea of providing drug prices as part of pharmacy benefit plans.

Loiacono started his career in the pharmaceutical manufacturing industry, where “everything that comes out of that plant has a price.”

When he moved over to the auditing and procurement side, working with payers and self-insured companies, he was shocked to find out that none of their contracts included drug prices. To solve this, the company uses Medicaid’s National Average Drug Acquisition Cost, rather than the average wholesale price, to calculate costs.

As a standalone company, Capital Rx was able to provide price information for retail drugs, but they weren’t able to do the same for mail and specialty drugs. The partnership with Walmart will “complete the model,” with Walmart providing mail and specialty drug fulfillment.

With the partnership, Capital Rx was able to quickly sign on some payers, though it hasn’t yet disclosed which ones.

“Walmart is a diversified company. We liked the fact that they were independent. They’re not part of a PBM or a health system today,” Loiacono said. “The other part of it is, they have scale.”

Loiacono also pointed to similar goals in price transparency — something Walmart emphasized when it shared the cash pay prices for its new health clinics.

“This is what we’re seeing a little bit more of as the future in the roadmap,” Loiacono said. “They’re making a serious investment in healthcare.”

 

 

 

 

In blow to hospitals, judge rules for HHS in price transparency case

https://www.healthcaredive.com/news/in-blow-to-hospitals-judge-rules-for-hhs-in-price-transparency-case/580395/

UPDATE: June 24, 2020: The American Hospital Association said it will appeal Tuesday’s ruling  that upholds the Trump administration’s mandate to force hospitals to disclose negotiated rates with insurers. The hospital lobby said it was disappointed in the ruling and will seek expedited review. AHA said the mandate “imposes significant burdens on hospitals at a time when resources are stretched thin and need to be devoted to patient care.”

If AHA seeks to have the rule stayed pending an appellate ruling, the decision on such a request “is likely to be almost as significant as this ruling is, since absent a stay, the rule will likely go into effect before the appellate court rules,” James Burns, a law partner at Akerman, told Healthcare Dive.

Dive Brief:

  • A federal judge ruled against the American Hospital Association on Tuesday in its lawsuit attempting to block an HHS rule pushing for price transparency. The judge ruled in favor of the department, which requires hospitals to reveal private, negotiated rates with insurers beginning Jan. 1.
  • U.S. District Court Judge Carl Nichols, an appointee of President Donald Trump, was swayed neither by AHA’s argument that forcing hospitals to publicly disclose rates violates their First Amendment rights by forcing them to reveal proprietary information nor by the claim that it would chill negotiations between providers and payers. The judge characterized the First Amendment argument as “half-hearted.”
  • Nichols seem convinced that the requirement will empower patients, noting in Tuesday’s summary judgment in favor of the administration that “all of the information required to be published by the Final Rule can allow patients to make pricing comparisons between hospitals.”

Dive Insight:

The ruling is a blow for hospitals, which have been adamantly opposed to disclosing their privately negotiated rates since HHS first unveiled its proposal in July 2019. AHA did not immediately reply to a request for comment on whether it planned to appeal.

The legal debate hinges on the definition of “standard charges”, which is mentioned in the Affordable Care Act, though it was left largely undefined in the text. Trump issued an executive order last year that included negotiated rates as part of that definition.

Cynthia Fisher, founder of patienrightsadvocate.com, which filed an amicus brief in support of HHS, told Healthcare Dive on Tuesday the ruling could make shopping for health services more like buying groceries or retail.

“For the first time we will be able to know prices before we get care,” she said. “This court ruling rejects every claim to keep the secret hidden prices from consumers until after we get care.”

 

 

 

 

Hospitals tell court price transparency laws violate 1st Amendment

https://www.healthcaredive.com/news/AHA-HHS-price-transparency-oral-arguments/577613/

Dive Brief:

  • In the first round of oral arguments in their lawsuit against HHS over a rule requiring hospitals to reveal the secret rates they negotiate with insurers for services, hospital groups argued the requirement exceeds the government’s authority and violates the First Amendment by compelling hospitals to publicly post confidential and proprietary information​.
  • The American Hospital Association, along with other industry groups and health systems that brought the lawsuit, argued in the U.S. District Court for the District of Columbia on Thursday that medical bills aren’t considered commercial speech and don’t fall under the same regulations that traditional advertisements, flyers and other forms of commercial speech offering or promoting services do.
  • “There’s not another market that looks like the market for hospital services,” said U.S. Department of Justice Attorney Michael Baer, who was representing HHS. A majority of patients final bills’ include the negotiated rate, information that should be available to patients, acting as consumers, prior to receiving care, he said.

Dive Insight:

Thursday’s hearing was the first step in what’s likely to be a drawn out legal fight. Negotiated rates between hospitals and insurers have long been private, and hospitals want to keep it that way. 

When HHS passed the final price transparency rule last year, the hospital groups filed a lawsuit in December, warning that requiring disclosure of negotiated rates will confuse patients, overwhelm hospitals and thwart competition. The rule would go into effect Jan. 1, 2021.

According to the lawsuit, the rule creates undue burden on hospitals and health systems, which can have more than 100 contracts with insurers. There can even be multiple contracts with an individual carrier to account for the various product lines, including Medicare Advantage, HMO or PPO.

The rule would require various pricing information, including gross charges, payer-specific rates, minimum and maximum negotiated charges and the amount the hospital is willing to accept in cash from a patient.

Some payers and employer groups have also protested the new rule, calling it wrong-headed.

When the rule initially passed last year, HHS argued that patients already see this pricing data when they receive their explanation of benefits, pushing back against the idea that it’s proprietary business information. They said this information needs to come before a procedure, not after.​

HHS maintains that the rule is intended to give patients better access to payment information so they can make informed decisions as consumers. 

“Patients deserve to know how much it’s going to cost when they get hospital care,” Baer said. “They deserve to know before they open a medical bill or before they choose where they want to receive care.”

 

 

 

 

A Scalpel Instead Of A Sledgehammer: The Potential Of Value-Based Deductible Exemptions In High-Deductible Health Plans

https://www.healthaffairs.org/do/10.1377/hblog20200615.238552/full/?utm_campaign=HASU+6-21-20&utm_medium=email&utm_content=COVID-19%3A+Face+Mask+Mandates%2C+Immigration+Detention+Facilities%2C+Symptom+Monitoring%3B+Treatment+Of+Opioid+Use+Disorder%3B+Supreme+Court+LGBT+Decision%3A+Implications+For+The+ACA&utm_source=Newsletter

UM V-BID Center (@UM_VBID) | Twitter

High-deductible health plans (HDHPs) covered more than 30 percent of enrollees in employer-sponsored plans in the United States in 2019, up from 4 percent in 2006. In 2020, the Internal Revenue Service defines HDHP as any plan with a deductible of at least $1,400 for an individual or $2,800 for a family. An HDHP’s total yearly out-of-pocket expenses (including deductibles, copayments, and coinsurance) cannot be more than $6,900 for an individual or $13,800 for a family. However, this limit does not apply to out-of-network services.

The growth of HDHPs is driven by the pursuit of reduced health care spending and premiums for both employees and employers through channeling elements of consumerism and managed care. Often, HDHPs are offered along with a savings option (health savings account or health reimbursement arrangement) in a consumer-directed health plan.

Recently, however, there have been concerns about the out-of-pocket cost burdens imposed on patients by HDHPs and other plans. Reducing these costs has been the focus of major policy proposals, including prescription drug bills from both the House and the Senate; forthcoming plans for the Center for Medicare and Medicaid Innovation to test value-based insurance models following the president’s executive order 13890 on Protecting and Improving Medicare for Our Nation’s Seniors; and H.R. 2774, the Primary Care Patient Protection Act of 2019, which would create a primary care benefit for all HDHP holders, allowing for up to two deductible-free primary care office visits each year.

It is becoming increasingly clear that HDHPs’ indiscriminate reductions in care usage may not be the best way to contain health care costs. In this post, we suggest that combining the principles of HDHPs and value-based insurance design (VBID), by offering deductible exemptions for high-value services, could provide nuanced incentives with potential to preserve access to the most important services while reducing use of only more wasteful care.

Why Did HDHPs Fail To Deliver Their Intended Consequences?

The intended premise of HDHPs is that beneficiaries facing the full costs of health care services during the deductible phase will engage in price shopping and subsequently choose care commensurate with expected benefits of that care. The hope is that the combination of lower prices and a different mix of services could increase the value of health care used while also reducing costs. Unfortunately, evaluations of HDHPs suggest that consumers neither price shop nor can they discriminate between high- and low-value care when facing high deductibles; accordingly, they reduce use of both essential and inessential services. Not only is this behavior likely to lead to worse health for beneficiaries, but short-term savings for both the beneficiary and the insurer may be offset by increased long-term spending associated with preventable adverse health events. The lack of the hoped-for response to HDHPs (price shopping and reduction in unnecessary care only) may stem from a lack of price transparency, inability to pay for essential care during the deductible phase, or inadequate information about the value of alternate health care services and technologies.

The evidence on HDHPs should not be surprising. It matches older evidence from the RAND Health Insurance Experiment, where cost sharing caused people to reduce consumption of both appropriate and inappropriate care. The RAND experiment demonstrated that consumers may not have enough information available freely to them to address uncertainty and make rational choices about which services to purchase and which to forgo. For this reason, we suggest a variation on VBID, in which deductible exemptions for established high-value services would inform and incentivize beneficiaries to use the most valuable care, while disincentivizing low-value options. Such recommendations have been made in different forms in the literature but have not been widely adopted.

Tying-In Value Conversations Within HDHPs

VBIDs have developed over the past 15 years on the premise that when everyone is required to pay the same out-of-pocket amount for health care services whose benefits depend on patient characteristics, there is enormous potential for both underuse and overuse of care. It is also true that health services can be underused and overused when there are differential health-related returns across services, but patients are unaware of the differences. VBIDs have been used by insurers as a mechanism to address this information problem, by signaling the value of alternative health care technologies to consumers through variable cost sharing.

To date, most applications of VBID have focused on applying such designs to copays but not to deductibles. Moreover, most applications have applied reduced cost sharing for targeted high-value drugs, and only a few have also implemented concomitant increased cost sharing for low-value drugs. This means that the cost differences that the consumers faced between high- and low-value products continued to be small. Consequently, results of such applications show the promise of VBID, but to a limited scale, owing to the relative inelasticity of demand for care related to small copay variation. Tying value-based cost sharing within deductibles could generate a bigger “nudge” to align use with value.  

Only one study evaluated the application of VBID on cost sharing within an HDHP plan. This research analyzed Kaiser Permanente of Northern California, where patients were switched to HDHPs, but some of them were offered free chronic disease medications. Resulting improvements in adherence due to zero cost sharing for chronic disease medications were shown to offset the HDHP-associated adherence reduction, especially for patients with poor adherence at the start. Importantly, adherence improvements did not occur for more clinically complex patients, or patients living in poorer neighborhoods. The inclusion of active counseling in VBID plans has potential to address these limitations.

In another example of VBID, a not-for-profit health plan in the Pacific Northwest implemented a formulary that tied drug copays to cost-effectiveness. Researchers found larger shifts in demand within drug classes in which copays were simultaneously reduced for high-value treatments and increased for low-value treatments, compared to drug classes in which the copays only moved in one direction. The overall effect of the VBID implementation was welfare-increasing but small, perhaps because the price dispersion faced by the patient between high-value and low-value alternatives was still too low to alter demand.

Other applications of VBID, where cost sharing was removed for primary care visits, were found to reduce total spending, mainly due to reductions in use of emergency department (ED) and other outpatient services. A plan that bundled copays for back pain physical therapy found reductions in ED use, in addition to eventual reductions in primary care use, and better adherence to care guidelines.

Value-Based High-Deductible Plans

We suggest that value-based high-deductible plans (VHDP), which combine the principles of HDHPs and VBID, and have been suggested as “a natural evolution of health plans,” could provide a robust alternative in insurance markets and achieve the goals of both low costs and high value of health care delivery. Our enthusiasm for such designs stems from the dispersion of price-elasticities observed when a value-based system was implemented on copayments. We expect such dispersion can be expanded substantially when VBID is applied to develop VHDPs. Specifically, VHDPs would nudge consumers toward high-value technologies (for example, preventive medications) by exempting their costs from the deductibles, while also providing consumers with transparency on the full costs of low-value services (for example, MRI for back pain or headache), and disincentivizing their use. This would generate a more elastic demand for low-value services, which in turn could move the markets for insured health care services toward more efficient outcomes.

In health care, where we know that both quality and value are at least partially unobservable to the patient, efficient outcomes are typically not attainable, especially when cost sharing indiscriminately alters prices. A VHDP would provide nuanced cost sharing to influence behavior in a manner similar to prices in traditional markets, therefore resolving information asymmetries for low-value services, reducing distortions, and increasing social welfare. In addition, such a policy could improve equity by ensuring that all beneficiaries have access to the highest-value services, even in the deductible phase of a benefit package. Such plans are certainly in line with the spirit of the recent bipartisan legislation (signed by President Donald Trump under executive order 13877) that allows health savings account eligible high-deductible health plans the flexibility to cover essential medications and services used to treat chronic diseases prior to meeting the plan deductible.

Challenges To Adoption Of Value-Based HDHPs

While value-based pricing improves beneficiaries’ ability to observe value, and therefore reduces the information asymmetries inherent in health care markets, the definition of “value” is an open question. Current legislative options being considered by both political parties in Congress aim to regulate and reduce drug pricing. While these efforts are important, and reduced prices would likely factor into premiums and out-of-pocket costs for consumers, these policy proposals do not necessarily tie price reductions to the value of drugs. That is, they are not tied to any specifically desired outcome of care. As mentioned, earlier VBID applications have been designed to impact health outcomes by using cost-effectiveness in formulary design to signal value. However, many other attributes of care, in addition to cost-effectiveness, should be considered by payers (both public and private) in determination of deductible-exemption status in a VHDP. These attributes include if a service has positive externalities (such as vaccinations) and if a service is unlikely to have moral hazard consumption (such as trauma care or chemotherapy). These, and other elements of value, could be included in decisions about which services should be exempt from the deductible. The decision of which elements to consider in this decision will depend on the stakeholders and perspectives (for example, payer, health system, employer, societal).

A potential downside of VHDPs is plan complexity, but improved communication (perhaps through health plan stewards) could address this limitation; active counseling has already been effective for this purpose in VBID. It would be relatively straightforward to incorporate the cost-sharing design of VHDPs to a value-based tiering system, now widely used in cost sharing.

Qualitative studies of VBID have identified additional barriers to VBID implementation. For example, patients are skeptical of value-based tradeoffs, do not necessarily trust the information provided by their plan, and may resist changes in care delivery. Payers tend to be skeptical of the clinical significance of adherence improvements from VBID and have expressed concern over low return on investment and administrative and information technology hurdles. Finally, providers are concerned about changes to patient behavior that puts their practice at financial risk.

These concerns are important, but potentially addressable with education and carefully planned implementation, to allow VHDPs to strike a nuanced balance between reducing moral hazard consumption of care and adequate risk protection. Such a balance is critical to controlling health spending while maintaining access to the highest-value services and reducing financial uncertainty.

 

 

 

 

Navigating a Post-Covid Path to the New Normal with Gist Healthcare CEO, Chas Roades

https://www.lrvhealth.com/podcast/?single_podcast=2203

Covid-19, Regulatory Changes and Election Implications: An Inside ...Chas Roades (@ChasRoades) | Twitter

Healthcare is Hard: A Podcast for Insiders; June 11, 2020

Over the course of nearly 20 years as Chief Research Officer at The Advisory Board Company, Chas Roades became a trusted advisor for CEOs, leadership teams and boards of directors at health systems across the country. When The Advisory Board was acquired by Optum in 2017, Chas left the company with Chief Medical Officer, Lisa Bielamowicz. Together they founded Gist Healthcare, where they play a similar role, but take an even deeper and more focused look at the issues health systems are facing.

As Chas explains, Gist Healthcare has members from Allentown, Pennsylvania to Beverly Hills, California and everywhere in between. Most of the organizations Gist works with are regional health systems in the $2 to $5 billion range, where Chas and his colleagues become adjunct members of the executive team and board. In this role, Chas is typically hopscotching the country for in-person meetings and strategy sessions, but Covid-19 has brought many changes.

“Almost overnight, Chas went from in-depth sessions about long-term five-year strategy, to discussions about how health systems will make it through the next six weeks and after that, adapt to the new normal. He spoke to Keith Figlioli about many of the issues impacting these discussions including:

  • Corporate Governance. The decisions health systems will be forced to make over the next two to five years are staggeringly big, according to Chas. As a result, Gist is spending a lot of time thinking about governance right now and how to help health systems supercharge governance processes to lay a foundation for the making these difficult choices.
  • Health Systems Acting Like Systems. As health systems struggle to maintain revenue and margins, they’ll be forced to streamline operations in a way that finally takes advantage of system value. As providers consolidated in recent years, they successfully met the goal of gaining size and negotiating leverage, but paid much less attention to the harder part – controlling cost and creating value. That’s about to change. It will be a lasting impact of Covid-19, and an opportunity for innovators.
  • The Telehealth Land Grab. Providers have quickly ramped-up telehealth services as a necessity to survive during lockdowns. But as telehealth plays a larger role in the new standard of care, payers will not sit idly by and are preparing to double-down on their own virtual care capabilities. They’re looking to take over the virtual space and own the digital front door in an effort to gain coveted customer loyalty. Chas talks about how it would be foolish for providers to expect that payers will continue reimburse at high rates or at parity for physical visits.
  • The Battleground Over Physicians. This is the other area to watch as payers and providers clash over the hearts and minds of consumers. The years-long trend of physician practices being acquired and rolled-up into larger organizations will significantly accelerate due to Covid-19. The financial pain the pandemic has caused will force some practices out of business and many others looking for an exit. And as health systems deal with their own financial hardships, payers with deep pockets are the more likely suitor.”

 

 

 

 

Now Is the Time to Address Surprise Billing

https://www.medpagetoday.com/blogs/marty-makary/86455?xid=fb_o&trw=no&fbclid=IwAR1boFFgBZuSqJ9-1728UdSFeIK790TTXNeoJJ9mky9jCKbGyQ_G4jqwrfk

Tips to avoid surprise medical bills

The doctor-patient relationship is being undermined.

Private equity companies have spent millions in dark money to stall and effectively kill all versions of surprise billing reform. But this week, the issue will come before Congress again. Legislation was introduced Tuesday in the House that, among other things, would further assist hospitals with more relief funds. With this potential third disbursement of federal dollars comes an opportunity to finally address the embarrassing problem of surprise billing that has eroded the public trust in our great medical profession.

Physicians across the country are now signing a letter urging leaders of Congress to address surprise billing once and for all. I have already signed this letter and encourage you to consider doing so as well.

One reason the medical profession is the greatest profession in the world is that patients put their faith and trust in us. But 64% of Americans now say they have avoided or delayed medical care for fear of the bill. As more and more patients lose faith in the system, the doctor-patient relationship is being undermined by surprise billing and the modern-day business practices of price gouging and predatory billing. In fact, these egregious practices have become part of the business model of some private equity groups, which seek to replace physician autonomy with corporate medicine.

Our system today is unnecessarily complicated and works against patients’ interests by putting them in the middle of a finger-pointing blame game, which leaves them holding the bag. It doesn’t make sense for us to accept people with open arms, treat their ailment, and then ruin their lives financially. Medical science is a bastion of scientific and intellectual genius. We can fix this problem. Already, some efforts are advancing price transparency by creating a transparent marketplace for patients.

I’ve spent many years looking at the systematic cost issues that face our health system and patients. Simply put, the lack of fairness and transparency in pricing and billing practices has created financial toxicity and increased the general mistrust of the medical system for millions of Americans. No one designed it to be this bad. In fact, we have good people working in a bad system. When I explain details of pricing, billing, and collections with doctors and hospital leaders, they are invariably shocked and furious to learn how out of control their billing offices have gotten in overcharging patients and shaking people down for more than a reasonable amount for a service.

The current COVID-19 crisis is a stark reminder of the gaps in our health system that exacerbate the pressures facing providers and patients. Many Americans are getting crushed right now. Despite many years of debate in Washington and bipartisan agreement that something must be done, there is still no federal protection in place to safeguard consumers from an egregious surprise medical bill if they need emergency care or have limited options. The reality is that special interests — including the very private equity firms that stand to benefit financially from these exploitative business practices — continue to spend millions to maintain the status quo.

It’s time for a bipartisan compromise to end the non-transparent game of surprise medical billing. It’s time that Congress takes meaningful action to protect patients during this COVID-19 crisis and finally address this issue. Congress has solutions on the table that would bring much greater fairness and transparency to the healthcare system, protect patients from these predatory charges, and ensure that physicians are paid fairly for our services, as we deserve. It’s time we put an end to the cycle of financial toxicity and rebuild the great public trust in the medical profession.