High-Deductible Health Plans Fall From Grace In Employer-Based Coverage

https://www.thefiscaltimes.com/2018/10/03/High-Deductible-Health-Plans-Fall-Grace-Employer-Based-Coverage

With workers harder to find and Obamacare’s tax on generous coverage postponed, employers are hitting pause on a feature of job-based medical insurance much hated by employees: the high-deductible health plan.

Companies have slowed enrollment in such coverage and, in some cases, reinstated more traditional plans as a strong job market gives workers bargaining power over pay and benefits, according to research from three organizations.

This year, 39 percent of large, corporate employers surveyed by the National Business Group on Health (NBGH) offer high-deductible plans, also called “consumer-directed” coverage, as workers’ only choice. For next year, that figure is set to drop to 30 percent.

“That was a surprise, that we saw that big of a retraction,” said Brian Marcotte, the group’s CEO. “We had a lot of companies add choice back in.”

Few if any employers will return to the much more generous coverage of a decade or more ago, benefits experts said. But they’re reassessing how much pain workers can take and whether high-deductible plans control costs as advertised.

“It got to the point where employers were worried about the affordability of health care for their employees, especially their lower-paid people,” said Beth Umland, director of research for health and benefits at Mercer, a benefits consultancy that also conducted a survey.

The portion of workers in high-deductible, job-based plans peaked at 29 percent two years ago and was unchanged this year, according to new data from the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Deductibleswhat consumers pay for health care before insurance kicks in — have increased far faster than wages, even as paycheck deductions for premiums have also soared.

One in 4 covered employees now have a single-person deductible of $2,000 or more, KFF found.

Employers and consultants once claimed patients would become smarter medical consumers if they bore greater expense at the point of care. Those arguments aren’t heard much anymore.

Because lots of medical treatment is unplanned, hospitals and doctors proved to be much less “shoppable” than experts predicted. Workers found price-comparison tools hard to use.

High-deductible plans “didn’t really do what employers hoped they would do, which is create more sophisticated consumers of health care,” Marcotte said. “The health care system is just way too complex.”

At the same time, companies have less incentive to pare coverage as Congress has repeatedly postponed the Affordable Care Act’s “Cadillac tax” on higher-value plans.

Although deductibles are treading water, total spending on job-based health plans continues to rise much faster than the overall cost of living. That eats into workers’ pay in other ways by boosting what they contribute in premiums.

Employer-sponsored group health plans, which insure 150 million Americans — nearly half the country — tend to get less attention than politically charged coverage created by the ACA.

For these employer plans, the cost of family coverage went up 5 percent this year and is expected to rise by a similar amount next year, the research shows.

Insuring one family in a job-based plan now costs on average $19,616 in total premiums, the KFF data show. The American worker pays $5,547 of that in a country where the median household income is more than $61,000.

The KFF survey was published Tuesday; the NBGH data, in August. Mercer has released preliminary results showing similar trends.

The recent cost upticks, driven by specialty drug costs and expensive treatment for diseases such as cancer and kidney failure, are an improvement over the early 2000s, when family-coverage costs were rising by an average 7 percent a year. But they’re still nearly double recent rates of inflation and increases in worker pay.

Such growth “is unsustainable for the companies I have been working with,” said Brian Ford, a benefits consultant with Lockton Companies, echoing comments made over the decades by experts as health spending has vacuumed up more and more economic resources.

For now at least, many large employers can well afford rising health costs. Earnings for corporations in the S&P 500 have increased by double-digit percentages, driven by federal tax cuts and economic growth. Profit margins are near all-time highs.

But for workers and many smaller businesses, health costs are a heavier burden.

Premiums for family plans have gone up 55 percent in the past decade, twice as fast as worker pay, according to KFF.

Employers’ latest cost-control efforts include managing expenses for the most expensive diseases; getting workers to use nurse video-chat services and other types of “telemedicine”; and paying for primary care clinics at work or nearby.

At the “top of the list” for many companies are attempts to manage the most expensive medical claims — cases of hemophilia, terrible accidents, prematurely born infants and other diseases — that increasingly cost as much as $1 million each, Umland said.

Employers point such patients to the highest-quality doctors and hospitals and furnish guides to steer them through the system. Such steps promise to improve results, reduce complications and save money, she said.

On-site clinics cut absenteeism by eliminating the need for employees to drive across town and sit in a waiting room for two hours to get a rash or a sniffle checked or get a vaccine, consultants say.

Almost all large employers offer telemedicine, but hardly any workers use it. Thirty-nine percent of the larger companies covering telemedicine now make it comparatively less expensive for workers to consult doctors and nurses virtually, the KFF survey shows.

 

 

 

Hospital executives believe Amazon can deliver on its hype as a healthcare disrupter

https://www.fiercehealthcare.com/tech/provider-executives-survey-amazon-ceos-reaction-data-apple-google-telemedicine-mergers?mkt_tok=eyJpIjoiTjJRMlpERTBObU0yWldOaiIsInQiOiJPMDVjRGNQVzcxMjIzOGt1ZTZva0R2YU1PXC9mYkczVEtYVHNHWmZzSHc1TjU1RGRZZ1o4VVprZStEV3R3VWdXWFwvQlRoYVg4cGpzakZIOFFkMkthRnVPbVwvNEUwQ3ptOVozRGQ0U3IyVDFENENmZTErMjc3TDhRYlwvaUlrT1oxSWgifQ%3D%3D&mrkid=959610

Out of all the technology giants with ambitions in healthcare, hospital executives have overwhelmingly put their faith in Amazon, according to a new survey.

A full 59% of executives say Amazon will have the biggest impact, according to the survey by Reaction Data. Respondents cited resources available to the retail and technology behemoth, the company’s current influence and name recognition.

Comparatively, 14% said Apple, with its foray into EHRs, would be the most influential, followed by Google at 8% and Microsoft at 7%

Among healthcare CEOs—which accounted for 26 of the survey’s 97 respondents—75% said Amazon would make the biggest impact.

About 80% of survey respondents were from the C-suite, including chief nursing officers, chief financial officers and chief information officers. 

While Amazon alone may be generating significant excitement in boardrooms, a previous survey by HealthEdge shows consumers are largely skeptical about Amazon’s partnership with JPMorgan and Berkshire Hathaway.

Amazon’s push into healthcare “has been a shot across the bow for the entire industry,” Rita Numerof, Ph.D., president of Numerof & Associates told FierceHealthcare. The company’s consistent and deliberate investments indicate they are serious about making substantial changes within the industry.

“Amazon is known for its relentless focus on the consumer and its ability to use data systematically to identify and meet unmet needs in an accessible manner,” she said. “Unfortunately, access, consumer engagement, and segmentation haven’t been the hallmark of healthcare delivery.”

Executives were also bullish on telemedicine, with 29% saying the technology would have the biggest impact on healthcare, followed by artificial intelligence at 20%. That’s less surprising given that nearly 75% of respondents were already using telehealth in some way.However, 51% of respondents said telemedicine is revenue neutral, and key focus areas were split equally around rural patients, follow-up care and managing specific populations.

 

 

 

Why Apple’s Move On Medical Records Marks A Tectonic Shift

http://www.wbur.org/commonhealth/2018/01/26/apple-health-care-data

(Courtesy of Apple)

 

Apple has just announced a major upgrade that will allow customers with iPhones and iPads access to their own health records.

This announcement actually amounts to far less than meets the eye, but it could well also mark a tectonic shift in the health care landscape.

It is less than meets the eye because the data enabled is a mere trickle compared to the torrent of health care data that we all generate during our medical visits.

It’s also only a uni-directional data flow from the health care institutions — the hospitals, the medical practices — to your personal health record. Data will not flow in the other direction. You cannot update an incorrect observation in your health record, nor can you add missing facts or missing medications to your “official” health record. At least, not yet.

It’s also not a magic switch that will allow everyone access to their health care records. It requires that hospitals agree to work with Apple to provide this data at a reasonably timely interval or on demand. Currently, only a small number of hospitals have agreed to do so.

So why might this announcement be earth-shaking? Because it represents the first time a mass consumer platform that is in the hands of tens of millions of consumers daily and for hours on end — the iOS operating system — will get officially sanctioned health care observations from the formal institutional health care system.

This immediately enables a number of productive, cost-saving, pain-saving and even life-saving scenarios.

• First, when you show up at a health care system other than the one you normally visit and see an unfamiliar doctor or nurse, this data will let you speed up and make much more accurate the getting-to-know-you phase of the visit. It will help you avoid repeated, unnecessary, expensive and painful testing.

• Now that our data is on this accessible platform, we’ve opened the gates to a world of innovators — some commercial, some nonprofit — to provide decision support, advice and recommendations based on these accurately and authoritatively transmitted health care data.

For example, genetic tests are mostly reported these days without the genetics company knowing your health care details or sometimes even your age. Now, with the clinical information that you can make available, you can give permission to these third-party applications or apps on your iPhone to access these crucial health data.

These companies will now be able to deliver interpretation of your results that are not generic but truly customized to your particular circumstance, just as has been promised to us under the rubric of precision medicine.

• Third-party telemedicine services such as Teladoc or AmericanWell currently allow you to speak to a licensed doctor, including a video connection, within minutes using your smartphone to get a clinical opinion. Now, they will not have to rely only upon the patients’ recounting of their signs and symptoms, or their recollection of laboratory tests or scraps of their record that they have available.

These will be able to be presented in an integrated fashion as part of the telemedicine encounter, which will thereby enable essentially the practice of medicine across state barriers in a way that has previously been artisanal at best.

The fundamental shift that is enabling this transition is the selected health care systems that have voluntarily agreed to transfer data in a well-formatted, accurate messaging that can be represented faithfully on the digital consumer platform.

This represents a major crack in the previously implicit understanding between electronic health record providers and health care systems that data about their patients would only travel in ways that would not increase the ability of patients to get health care elsewhere.

Companies have attempted multiple workarounds to attain this goal, but this represents a major step forward: Now, it’s the electronic health record systems themselves and the providers that are enabling this to happen. Of course, this was functionality that was mandated multiple times by U.S. legislation, but there always were apparently small details that limited the actual implementation.

So has the new era arrived yet? This announcement is the clarion call, but it may not be the new age yet.

It remains fragile in that health care systems can choose to participate or not to participate. The health care record vendors can choose to be more helpful or less helpful to this effort. New regulatory obstacles may be placed to limit the use and reuse of this data.

But the mere fact of this small beginning shows that it is technically and organizationally possible.

In this era when we expect access to information that is important to us in all parts of our lives — from the news, to our financial information, to our personalized weather — the shift to similarly fluid access to our medical data and the creation of a far larger ecosystem of interpretation and health care decision making will gain increasing support.

It will undoubtedly generate business plans and enterprises seeking to birth their unicorns into this $3 trillion sector of the economy representing one-sixth of our gross domestic product.

Furthermore, because the data-messaging standards that are used in this system were developed not by Apple but by a community of informaticians and data scientists working with various research entities such as the National Institutes of Health, these standards are open, so other consumer health platforms such as Google’s Android should have no particular problem in immediately following suit.

Full disclosure: I have a dog in this fight. I worked with colleagues at Harvard and Boston Children’s Hospital to develop automated consumer access to health-record data with funding from the NIH and the Office of the National Coordinator for National Projects such as the huge study All Of Us.

But I am also a doctor and a patient, and I can tell you what I’m planning to do with this new Apple capability: Develop an app to tell any patient with enough data on their iPhone what questions they should ask their doctor about their diagnosis.

Paying more and getting less: As hospital chains grow, local services shrink

https://www.statnews.com/2018/01/24/hospital-chains-services-consolidation/

When most hospitals close, it’s plain to see. Equipment and fixtures are hauled out and carted away. Doctors and nurses leave and buildings are shuttered, maybe demolished.

But another fate befalling U.S. hospitals is almost invisible. Across the country, conglomerates that control an increasing share of the market are changing their business models, consolidating services in one regional “hub” hospital and cutting them from others.

In recent years, hospitals across the country have seen their entire inpatient departments closed — no patients staying the night, no nursery, no place for the sickest of the sick to recover. These facilities become, in essence, outpatient clinics.

Hospital executives see these cuts as sound business decisions, and say they are the inevitable consequence of changes in how people are using medical services. But to patients and local leaders who joined forces with these larger health networks just years ago, they feel more like broken promises: Not only are they losing convenient access to care, their local hospitals are also getting drained of revenue and jobs that sustain their communities.

“It’s not even just betrayal. It’s disgust, frankly,” said Mariah Lynne, a resident of Albert Lea, Minn., where Mayo Clinic is removing most inpatient care and the birthing unit from one of its hospitals. “Never would I have expected a brand of this caliber to be so callous.”

In 2015, the most recent year of data, these service reductions accounted for nearly half of the hospital closures recorded around the country, according to the Medicare Payment Advisory Commission. (By MedPac’s definition, the loss of inpatient wards is equivalent to closure.) These data do not capture more discreet closures of surgical and maternity units that are also happening at local hospitals.

And the trend doesn’t just affect nearby residents. It represents a slow-moving but seismic shift in the idea of the community hospital — the place down the street where you could go at any hour, and for any need. Does the need for that hospital still exist, or is it a nostalgic holdover? And if it is still needed, is it economically viable?

The eye of the storm

The effort to scale back inpatient care is occurring within some of the nation’s most prestigious nonprofit hospitals.

Mayo Clinic announced last summer that it would cease almost all inpatient care at its hospital in Albert Lea. The health network said it would keep the emergency department open, but send most other patients to Austin, 23 miles east.

In Massachusetts, sprawling Partners HealthCare said it will shut the only hospitalin Lynn, a city of 92,000 people near Boston, and instead direct patients to its hospital in neighboring Salem. Only urgent care and outpatient services will remain in Lynn.

And in Ohio, Cleveland Clinic has made similar moves. In 2016, it closed its hospital in Lakewood, a densely packed Cleveland suburb. It is replacing the hospital with a family health center and emergency department.

The cuts follow a period of rapid consolidation in the health care industry. Of the 1,412 hospital mergers in the U.S. between 1998 and 2015, nearly 40 percent occurred after 2009, according to data published recently in the journal Health Affairs.

As large providers have expanded their networks, they have also gained inpatient beds that are no longer in demand — thanks to improved surgical techniques and other improvements that are shortening hospital stays. Hence the closures.

But the hollowing-out of historic community hospitals has surfaced fundamental tensions between providers and the cities and towns they serve. Residents are voicing frustration with large health networks that build expensive downtown campuses, charge the highest prices, and then cut services in outlying communities they deem unprofitable.

Health scholars also note a growing dissonance between the nonprofit status of these hospitals and their increasing market power. While the nonprofits continue to claim tens of millions of dollars a year in tax breaks to serve the sick and vulnerable, some are functioning more like monopolies with the clout to shift prices and services however they wish.

“These providers say they are worth the high price and that in the American system, if you have a reputation for excellence, you deserve higher fees,” said Dr. Robert Berenson, a senior fellow at the Urban Institute. “My response to that would be, if we had a well-functioning market, that might make some sense. But we don’t.”

Changing demand among patients

The financial upheaval in community hospitals is driven by sweeping changes in the delivery of care. Procedures and conditions that once required lengthy hospitalizations now require only outpatient visits.

At Mayo Clinic, Dr. Annie Sadosty knows this evolution well because it roughly traces her career. She uses appendectomies as an example. Twenty-five years ago, when she was in medical school, the procedure was performed through a 5-inch incision and resulted in a weeklong hospitalization.

Today, the same procedure is done laparoscopically, through a much smaller incision, resulting in a recovery time of about 24 hours. “Some people don’t even stay in the hospital,” Sadosty said.

Something similar could be said for a wide range of medical procedures and services — from knee replacements to the removal of prostate glands in cancer patients. Hospital stays are either being eliminated or reduced to one or two days. And patients who were once routinely admitted for conditions like pneumonia are now sent home and managed remotely.

“Hospitals that used to be full of patients with common problems are no longer as full,” said Sadosty, an emergency medicine physician at Mayo and regional vice president of operations. “It’s been a breakneck pace of innovation and change that has led to a necessary evolution in the way that we care for people.”

That evolution has cratered demand for inpatient beds. In 2017, the Medicare Payment Advisory Commission noted that hospital occupancy is hovering around 62 percent, though the number of empty beds varies from region to region.

In Albert Lea, Mayo administrators said the changes at the hospital will only impact about seven inpatients a day. Currently, caring for those patients requires nursing staff, hospitalists, and other caregivers, not to mention overhead associated with operating a hospital around the clock. The financial result is predictable: Hospital executives reported that jointly Albert Lea and Austin hospitals have racked up $13 million in losses over the last two years.

With inpatient demand declining, hospital administrators decided to consolidate operations in Austin. The decision meant the removal of Albert Lea’s intensive care unit, inpatient surgeries, and the labor and delivery unit. Behavioral health services will be consolidated in Albert Lea.

Cleveland Clinic described similar pressures. Dr. J. Stephen Jones, president of the clinic’s regional hospital and family health centers, said use of inpatient beds has declined rapidly in Lakewood, dropping between 5 and 8 percent a year over the last decade. By 2015, 94 percent of visits were for outpatient services — a change that was undermining financial performance. The hospital lost about $46.5 million on operations that year, according to the clinic’s financial statements, and its aging infrastructure was in need of repair.

“Hospitals are very expensive places to run,” Jones said. “Lakewood was losing money on an operating basis for at least five years” before this decision was made.

Closures spark fierce protests

But the service cuts in Albert Lea, Lynn, and Lakewood — backed by nearly identical narratives from hospital executives — provoked the same reaction from the communities surrounding them.

Outrage.

Residents accused the hospital chains of putting their bottom lines above the needs of patients. Even if these individual hospitals were losing money, they said, nonprofits have an overriding mission to serve their communities.

“Why is profit such a priority, and more of a priority than the Hippocratic oath?” said Kevin Young, a spokesman for Save Lakewood Hospital, a group formed to oppose Cleveland Clinic’s removal of inpatient services. “Why are we allowing this to happen?”

The fight over Lakewood Hospital has persisted for more than three years, spawning lawsuits, an unsuccessful ballot referendum to keep the hospital open, and even a complaint filed by a former congressman to the Federal Trade Commission. None has caused Cleveland Clinic to reverse course.

Meanwhile, in Albert Lea, opponents to the service cuts have taken matters into their own hands: With Mayo refusing to back down, they are hunting to bring in a competitor.

A market analysis commissioned by Albert Lea’s Save Our Hospital group concluded that a full-service hospital could thrive in the community. The report included several caveats: A new provider would need to attract new physicians and capture market share from Mayo, a tall order in a region where Mayo is the dominant provider.

But members of the group said the findings directly contradict Mayo’s explanations to the community. They argue that, far from financially strained, the health system is simply trying to increase margins by shifting more money and services away from poorer rural communities.

“They don’t care what happens in Albert Lea,” said Jerry Collins, a member of the group. “Mayo cares what happens with its destination medical center.” He was referring to Mayo’s $6 billion project — funded with $585 million in taxpayer dollars — to expand its downtown Rochester campus and redevelop much of the property around it.

Sensitivity to Mayo’s service reductions is heightened by its control of the market in Southeastern Minnesota. It is by far the largest provider in the region and charges higher prices than facilities in other parts of the state. A colonoscopy at Mayo’s hospital in Albert Lea costs $1,595, compared to $409 at Hennepin County Medical Center in Minneapolis, according to Minnesota HealthScores, a nonprofit that tracks prices. The gap is even bigger for a back MRI: $3,000 in Albert Lea versus $589 at Allina Health Clinics in Minneapolis.

“All of Southeast Minnesota is feeling the domination of one large corporation,” said Al Arends, who chairs fundraising for Save Our Hospital. “They are ignoring the economic impact on the community and on the health care for patients.”

The community’s loud resistance has drawn the attention of the state’s attorney general and governor, as well as U.S. Rep. Tim Walz, who has begun a series of “facilitated dialogues” between Mayo and its opponents in Albert Lea.

So far, the dialogue has failed to forge a compromise. Mayo is proceeding with its plans. It has relocated the hospital’s intensive care unit to Austin, and inpatient surgeries and labor and delivery services are planned to follow.

Mayo executives reject the notion that they are abandoning Albert Lea or compromising services. The hospital plans to renovate the Albert Lea cancer wing and beef up outpatient care, improvements executives say have gotten lost amid the criticism.

As for inpatient care, they say, Mayo must consider quality and safety issues. With the hospital in Albert Lea only admitting a handful of patients a day, caregivers’ skills are likely to diminish, potentially undermining quality. They also cited recruiting challenges.

“It’s difficult to outfit both [Albert Lea and Austin] hospitals with all the incumbent equipment, expertise, multidisciplinary teams, and nursing staff,” vice president Sadosty said. “This is one way we can preserve and elevate care, and do it in an affordable way so our patients have access to high-quality care as close to their homes as possible.”

A strained system

Efforts to regionalize medical services also pose a new challenge: Can hospitals transport patients fast enough — and coordinate their care well enough — to ensure that no one falls through the cracks?

It is a question that will face stroke victims and expectant mothers who now must drive greater distances, sometimes in treacherous conditions, to make it to the hospital on time.

In Massachusetts, Partners HealthCare will face that test as it moves inpatient and emergency care from Union Hospital in Lynn to North Shore Medical Center in Salem. The hospitals are less than 6 miles apart. However, the short distance belies the difficulty of coordinating service across it.

Ambulances will have fewer options in emergencies. And if residents drive themselves to the wrong place in a panic, precious time gets wasted.

Dr. David Roberts, president of North Shore Medical Center, said the health system is working to educate patients to ensure that they go to the correct facility. He added that Partners already conducts risk assessments of patients with severe medical problems, and transfers them to hospitals with higher-level care when necessary.

In cases of suspected stroke, Roberts said, Partners employs a telemedicine program in which patients who arrive in its emergency rooms are examined by physicians at Massachusetts General Hospital in Boston. “They instantly, based on imaging, can decide which patient might benefit from having a clot pulled out of an artery in their head,” Roberts said. “They can say, ‘Yeah, this patient needs to be in our radiology suite in the next 30 minutes, and they make that happen.”

Still, opponents of the closure say it raises a broader concern about whether Partners’s actions are driven by a financial strategy to shift care away from low-income communities with higher concentrations of uninsured patients and those on Medicaid, which pays less for hospital services than commercial insurers. Union Hospital serves a largely low-income population.

“Why don’t we see these cuts across the Partners system? Why are we only seeing it in Lynn?” said Dianne Hills, a member of the Lynn Health Task Force. “Are we moving into a world where you have two systems of care — one for the poor and the old, and another for the affluent?”

Roberts said the consolidation at North Shore Medical Center in Salem has nothing to do with the income level of population in Lynn. He said the hospitals serve “identical” mixes of patients with government and commercial insurances.

“Our payer mix at both hospitals is adverse,” he said. “And despite that, Partners invested $208 million” to support the expansion of North Shore Medical Center.

Roberts acknowledged that the closure of the hospital in Lynn will have a negative impact on the city’s economy. But he said construction of a $24 million outpatient complex will mitigate some of that damage. The facility is expected to open in 2019. “It doesn’t take away the sting of losing a hospital,” Roberts said. “I’m hoping the [new] building goes a long way. We’re going to grow it as a vibrant medical village.”

Meanwhile, Mayo is proceeding with its changes in Albert Lea. Executives have assured Albert Lea residents that they will receive the same level of care for emergency services and upgraded facilities for outpatient care.

But some community members said they are already noticing problems with Mayo’s regionalization. One local pharmacist, Curt Clarambeau, said he can’t get timely responses to reports of adverse drug reactions. A call to the hospital in Albert Lea results in several phone transfers and no immediate response.

“It’s just impossible. It takes days,” Clarambeau said. “They’re trying to create efficiencies by not having everyone calling the doctors, but there are certain things we need to talk to them about.”

Don Sorensen, 79, said he’s also had trouble getting access to doctors at the hospital in Albert Lea. He said began to suffer from severe knee pain in November, but couldn’t get an appointment. His wife was put on hold for 40 minutes before learning the earliest appointment was still several days away.

At the suggestion of his RV repairman, Sorensen called a clinic in Minneapolis and got an appointment the same day. His wife, Eleanor, drove him, and he ended up with a brace, a prescription, and another follow up appointment.

But the couple is worried about continuing to make the drive if the logjam persists in Albert Lea. “We used to feel secure because we had Mayo here,” Eleanor Sorensen said. “We could get the care we needed. But now everybody our age feels very very vulnerable.”

 

 

Health insurer Oscar nears $1 billion in revenue

https://www.axios.com/oscar-2518896548.html

Image result for Health insurer Oscar nears $1 billion in revenue

Oscar, the healthcare insurance upstart co-founded by Joshua Kushner, tells Axios that it is expecting to generate nearly $1 billion in premium revenue for 2018. That’s up from “more than $300 million” in 2017 premium revenue. It also says that its insurance underwriting business is profitable for the first time, although the overall company remains in the red.

Why it matters: Oscar continues to grow, despite having originally launched to provide health insurance to individuals under an Affordable Care Act that the Trump Administration has been slowly dismantling.

  • More numbers: The company expects around 250,000 members in the individual markets, including in New York and California where open enrollment continues, representing around a 2.5x increase over last year, and doesn’t include Oscar’s recent expansion into employer plans.

Oscar CEO Mario Schlosser tells Axios that he isn’t too concerned about how the new tax bill repeals the ACA’s individual mandate, saying that much of the early instability has dissipated:

“It took a while to figure out how things work, but a lot of people now just have come around to thinking it’s smart to have health insurance. The loss of the mandate will have some impact on some states around country, but it won’t affect the overall stability of the individual markets.”

Oscar’s big marketing pitch is that it leverages technology to provide a more efficient healthcare experience, through such techniques as tele-medicine (25% of Oscar members have used it) and concierge teams that include both nurses and “care guides” (70% have used). It has taken steps to apply this tech-centric approach to the Medicare Advantage market, but tells Axios that it has slowed down those efforts a bit (i.e., no 2018 launch).

 

Docs: It’s Time to Certify Specialists in Telemedicine

http://www.healthleadersmedia.com/physician-leaders/docs-its-time-certify-specialists-telemedicine?spMailingID=12525418&spUserID=MTY3ODg4NTg1MzQ4S0&spJobID=1300773426&spReportId=MTMwMDc3MzQyNgS2

Image result for telemedicine

Virtual medicine practice is more than technological competence. A doctor who proposed the idea of telemedicine certification advocates why this is so.

As medicine sees advancements in technology and expansion of knowledge in care delivery, specialties and their commensurate board certifications continue to proliferate.

With telemedicine use and applications growing, a premier candidate for this process may be a specialty representing the “medical virtualist,” proposed two physicians at New York-Presbyterian (NYP) in a recent JAMA Viewpoint.

Paper coauthor Michael Nochomovitz, MD, chief clinical integration and network development officer at NYP, offers his insights on this topic.

The following transcript has been lightly edited.

HealthLeaders Media: What motivated you to share this idea?

Michael Nochomovitz, MD: Telemedicine started out with coughs, colds, rashes—easy things. But now with the technology improving and remote monitoring expanding, the need for a more sophisticated approach has become apparent.

A telemedicine visit isn’t the same as FaceTiming your cousin. It involves a true medical interaction that needs to be defined and categorized, and there are a number of people around the country who have set standards of their own, but they haven’t made any consensus because it’s too early.

Having said that, there are going to be people who do this for a living. There will be a career where you don’t touch a patient, and there will have to be a set of core competencies that will need to be codified.

HLM: Were you surprised by the level of reaction to your article?

Nochomovitz, MD: I don’t know. This is the first time the idea of a new specialty has actually gone public. We coined the phrase “medical virtualist,” and now people are chewing on the concept.

I think one of the reasons JAMA published it is that the idea is new and somewhat disruptive, and it’s unclear where it goes from here and how it will impact the rest of healthcare.

We’re excited by the response because the discussion is so needed.

There isn’t a major healthcare organization in the United States that doesn’t have telemedicine and telehealth as a priority. Now there almost needs to be a pause—a timeout—and ask what we are going to expect from the doctors who do this.

HLM: What is your response to those who say that a telemedicine certification and specialty are unnecessary?

Nochomovitz, MD: Those who say it’s not necessary just haven’t done enough of it, and they haven’t been exposed enough to the complexity of doing telemedicine with complicated patients.

HLM: What are some of the core competencies needed for medical virtualists?

Nochomovitz, MD: One important idea is that of “webside manner.” Doctors that see patients in an office each have a different personality. Some doctors are engaging; some are not. That will be exaggerated in a remote visit.

There are techniques that need to be taught on how people speak, where they look, how they engage, what they look for, how they reassure patients, how they address technical glitches, and how they recognize that a particular issue is not within the scope of the telehealth visit without making the patient nervous.

Keep in mind that with increased use of remote monitoring, doctors are going to have much more information at their disposal, and the physicians have to use some skill to put together the patient’s complaint, the patient’s appearance, and all of this additional information about the patient’s prior or current activity. It’s a different way of looking at the doctor-patient interaction.

HLM: If a certification were to become a reality, do you think it would deter physicians from pursuing telemedicine?

Nochomovitz, MD: Provided that the process is not overly onerous, I think that certainly the new generation will embrace it because technology is so engaging. And we’re so used to using it in our daily lives that we have a blurring of the edges between lifestyle technology commodities and applications in healthcare.

I don’t think there’s going to be a problem with adoption. Doctors will want to do it right.

New healthcare fraud trends managed care organizations need to watch

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Even traditional fraud schemes can be difficult to detect, and new methods will only make things more difficult for security teams watching healthcare dollars, says Shimon R. Richmond, special agent in charge at the Miami Regional Office in the Office of Investigations for the Office of the Attorney General.

Richmond gave a presentation on healthcare fraud trends on November 16 at the annual National Healthcare Anti-Fraud Association conference in Orlando, and says hypervigilance is key because obvious red flags are rare.

Where fraud is most prevalent

Richmond says these methods are often based in home health care, personal services, community-based services, and hospice care.

“We see a lot of unnecessary services and billing for services not provided. In the personal care services arena there are a lot of incestuous relationships in terms of who’s providing the care, who’s receiving the care, and who’s billing,” Richmond says. “One really kind of significant theme is pervasive and that’s the overwhelming influence of kickbacks in every area of fraud that we’re seeing.”

Kickbacks can be difficult to detect because this type of fraud often occurs outside of medical systems, he says. Data analytics systems can help, particularly if a system can recognize spikes in billing patterns or from certain providers.

“That’s a red flag. There are those anomalies that we can identify in a proactive manner. But the outside financial arrangements are really something that law enforcement is really only able to get into once we delve into an investigation,” Richmond says.

New fraud trends  

Emerging fraud trends are another challenge when counteracting fraud. It’s difficult to get in front of a new problem that hasn’t been seen before, and the game is always changing, Richmond says.

Recently, Richmond says he has seen an uptick in inappropriate prescriptions for  SUBSYS (fentanyl sublingual spray), which is meant to be prescribed to treat breakthrough pain in cancer patients.

“We’ve seen a huge issue lately where it is being marketed and prescribed to noncancer patients,” Richmond says. “Huge amounts of this drug are being prescribed, but the prescriber is not an oncologist.”

Pharmacies can also be involved in fraudulent activities by searching patient insurance plans to find high-cost prescriptions that can be filled and paid for. The pharmacies then target those consumers to push medications they don’t need, or bill for prescriptions that are never filled.

“A lot of times it’s a bait-and-switch type situation where they’ll do some kind of advertising for a knee brace or some other kind of thing just to get patients to call a number,” Richmond says. Once patients call, they are told the product they were interested in is not available but are offered a more expensive substitute. “There are a lot of marketing companies out there that are acting as lead generators where they are essentially selling to patients the idea of trying out these pains creams or scar creams.”

Hospitals and provider groups in financial distress are also becoming involved in fraud schemes, setting up in-house labs or working with outside labs to generate claims, often for fraudulent genetic testing or urine/drug screens. They may bill for unneeded tests with a kickback, or collect samples that never get tested but are still billed, he says.

Cyber threats and identity theft also continue to be a problem, Richmond says, with a huge spike in the area of telemedicine.

New fraudsters enter the arena

“We are seeing bulk cash transfers, weapons caches, and drug organizations migrating in as they develop their technological abilities and acumen in how to exploit electronic health records,” Richmond says. “This is kind of an evolving threat, and unfortunately, so much of the information is obtainable either online or through an employee that compromises the organization and practice.”

Security teams have to focus on trending information from data on encounters and billing practices, and analyze patterns just to try and keep up.

“I can’t emphasize enough the value of the investments in the analytics and proactive monitoring. That is crucial. Being in the law enforcement arena, a lot of our proactive efforts involve a combination of those analytics and looking for those outliers, or those parts that don’t make sense,” Richmond says. “At the end of the day, it’s all about hypervigilance.