Entries in Riddle, Clive (285)


Recent Uber and Lyft Healthcare Transportation Collaborations

By Clive Riddle, December 1, 2017 

Yesterday (November 30th) Cigna-HealthSpring reported on its collaboration with Lyft for medical transportation of Medicare Advantage members. They stated that "more than 14,500 transports have occurred through this collaboration. Since its introduction in May, 92 percent of Cigna-HealthSpring customers using Lyft have made it their preferred transportation option, according to customer surveys. On average, participants are waiting less than eight minutes for Lyft to take them to or from their appointments." They explain that "the service is for ambulatory customers in non-emergencies only and is only available to Cigna-HealthSpring customers whose benefit plan includes supplemental non-emergent medical transportation coverage through Access2Care at no additional cost. Participants need to contact Access2Care to establish Lyft as their designated transportation provider." 

I decided to check out what other developments have occurred during the past month regarding Uber, Lyft and medical transportation collaborations. 

The AHA during November published a nice 27-page report in their Social Determinants of Health Series on Transportation and the Role of Hospitals. In their chart summarizing transportation strategies, they state that “When transportation is unavailable, health care systems may need to provide transportation directly to patients and staff,” and their recommendations include that hospitals “partner with ride-sharing companies like Uber or Lyft.” 

A November1st Catholic Health World article Ministry systems tackle transportation barriers for vulnerable patients, that included these four examples of Uber and Lyft healthcare transportation collaborations: 

  • “St. Vincent Charity Medical Center in Cleveland launched a program in the spring to provide free transportation via the ride-sharing company Uber to patients undergoing addiction treatment in the hospital's Rosary Hall Intensive Outpatient Program.....Between June and September, 30 new clients logged 507 Uber rides, and 29 clients achieved 100 percent participation in the group and individual counseling sessions. In the 30 days before launch, Rosary Hall had 76 percent client participation in group sessions and 62 percent client participation in individual counseling sessions. “
  • “Trinity Health of New England has pinpointed pickup and drop-off locations exclusively for Uber riders to and from its five hospital campuses in Connecticut and Massachusetts that can be selected on the Uber smartphone app so the driver knows exactly where to deliver or meet a patient. Uber rides also can be scheduled through each hospital's website....Trinity also uses Uber to transport select patients from its Mandell Center for Multiple Sclerosis in Hartford, Conn., for services at nearby Saint Francis Hospital and Medical Center.”
  • “St. Louis-based Ascension was the first health care system to form a partnership with Lyft. Since February, Ascension has put agreements in place in 21 of its markets, and Lyft has provided more than 8,000 rides.....Ascension staff members use Lyft's concierge platform to schedule the rides.”
  • “Broomfield, Colo.-based SCL Health announced last month that it is collaborating with Lyft to make nonemergency on-demand or scheduled transport available to its vulnerable patients living in the front range of the Rockies near Denver.”  

The Advisory Board Care Transformation Center Blog featured this post on November 28th5 ways MedStar's nurse-inspired partnership with Uber has paid off, starting off by telling us “Since 2016, Uber has announced partnerships with MedStar Health, Hackensack University Medical Center, and Boston Children's Hospital. Lyft has announced partnerships with transportation service organizations National Medtrans Network and Logisticare, as well as BCBSA. Why have these organization, among others, turned away from more traditional van or cab service? We learned a bit more about MedStar's arrangement with Uber to try and figure it out.” They cite these key benefits of the Medstar/Uber partnership: Patient Transportation Service is now faster; Service is more reliable; Service is less expensive; Clinic staff workflow is more manageable; and Analytics on MedStar transportation support offer new opportunities. 

But there are concerns patients are beginning to use Uber and Lyft in emergent situations. The CBS affiliate in Cincinnati reported on November 9th on The "Uberlance" trend: People turn to Uber to offset high hospital transportation costs.  They tell us that “the new trend is forcing Uber drivers to act as first responders. The drivers asked to not have their identities revealed, but they still wanted to tell their stories of what is now being referred to as ‘Uberlance.’ ‘I said to him ‘why didn't you call an ambulance?’ His hand was bleeding. He goes ‘because you're quicker and you're cheaper,’ said ‘Johnny’, an Uber driver. ‘I've had people get in my car, they're dizzy, they don't feel well, their chest hurts,’ said ‘Brian’, an Uber driver. Drivers say passengers opt for Uber over an ambulance for speed and cost.” 

Despite these concerns of patients taking matters in their own hands and using Uber or Lyft to avoid dispatching an ambulance, some EMS, healthcare and health plan organizations are proactively pursuing such arrangements for urgent care visits to avoid use of ambulances in non-emergencies.  The San Diego Union Tribune on November 5th ran the story San Diego exploring new emergency response model amid ambulance crisis, stating that EMS officials there were seeking “an alternative model where non-emergency patients could take a taxi or Uber to a clinic or urgent care facility and get reimbursed by private insurers, Medicare or Medi-Cal.” The article cites that “Anthem Health Insurance recently announced it will start covering such alternative modes of transportation in 2018.”


The State of Medicaid in the States

The State of Medicaid in the States

by Clive Riddle, November 8, 2017


Mark Farrah Associates has just released their Mid-Year 2017 Medicaid Market and Enrollment Trends report which cites national Medicaid coverage was “74.3 million as of June 2017. This represents approximately 17.5 million more covered lives, a 31% increase, when compared to the population of Medicaid recipients prior to Affordable Care Act (ACA) implementation.”


They fix Medicaid managed care enrollment nationally at 48.6 million, and tell us “total year-over-year managed Medicaid grew by only 187,000 members, a substantial difference from the 3.6 million increase between 2Q15 and 2Q16. Most of the top five managed care companies– Centene, Anthem, UnitedHealth, Molina and Wellcare – did however, experience enrollment increases. Among the leaders, Centene commanded 12% of the Medicaid market share as of second quarter 2016, enrolling approximately 6 million members. Anthem and UnitedHealth increased year-over-year membership with both attaining 11% market share. Molina and WellCare rounded out the top five Medicaid managed care leaders accounting for 7 and 5 percent market share, respectively. These top five Medicaid companies control 45% of the overall Medicaid Managed Care market.”


Meanwhile, CMS Administrator Seema Verma this week gave a major speech discussing “her vision for the future of Medicaid and unveiled new CMS policies that encourage states to propose innovative Medicaid reforms, reduce federal regulatory burdens, increase efficiency, and promote transparency and accountability.”


CMS reports that Verma emphasized “her commitment to ‘turn the page in the Medicaid program’ by giving states more freedom to design innovative programs that achieve positive results for the people they serve and pledged to remove impediments that get in the way of states achieving this goal. She announced several new policies and initiatives that break down the barriers that prevent state innovation and improvement of Medicaid beneficiary health outcomes.”


CMS touts that they have published new public website content that reflects “CMS’s willingness to work with state officials requesting flexibility to continue to provide high quality services to their Medicaid beneficiaries, support upward mobility and independence, and advance innovative delivery system and payment models.” Veema emphasized their “commitment to considering proposals that would give states more flexibility to engage with their working-age, able-bodied citizens on Medicaid through demonstrations that will help them rise out of poverty.”  In shorthand, this means that states have a path to impose work requirements on applicable Medicaid beneficiaries and deny continued coverage for those that do not comply. 


Other changes CMS shares include:

·         Allowing states to request approval for certain 1115 demonstrations for up to 10 years;

·         Providing for states to more easily pursue “fast track” federal review

·         Reducing certain state 1115 reporting requirements;

·         Expediting SPA and 1915 waiver efforts through a streamlined process and by participating in a new “within 15-day” initial review call with CMS officials.

·         Developing “Scorecards that will provide greater transparency and accountability of the Medicaid program by tracking and publishing state and federal Medicaid outcomes.”


Meanwhile, the question of the day is what to make of the Maine election results this week approving Medicaid expansion, with their Governor subsequently stating he will block implementation.


Three Recent Studies and Three Different Perceptions of Value Based Payments

Three Recent Studies and Three Different Perceptions of Value Based Payments

by Clive Riddle, November 3, 2017


Three different recently released studies addressing value based payments fuel three different perceptions: (1) value based payments have solid momentum; (2) that hospitals view value based care is growing more slowly than anticipated; and (3) physicians prefer FFS systems to value based care.


The Health Care Payment Learning & Action Network has just released a report with survey results indicating “29% of total U.S. health care payments were tied to alternative payment models (APMs) in 2016 compared to 23% in 2015, an increase of six percentage points.” The Network states that “the survey collected data from over 80 participants, accounting for nearly 245.4 million people, or 84%, of the covered U.S. population.”  


While 29% of payments were value based and totaling “approximately $354.5 billion dollars nationally” in 2016, the Network determined that 43% of payments were “traditional FFS or other legacy payments not linked to quality” and 28% was “pay-for-performance or care coordination fees.”


Deloitte recently released results from their 2017 Survey of US Health System CEOs which includes are chapter on Population health and value-based care that provides these insights:

·         “Survey participants say the transition to value-based care is happening, but at a slower rate than initially anticipated. Still, many of the CEOs report that they are developing and expanding innovative delivery and payment models, and are focusing on MACRA and physician activation.

·         “Many CEOs also are looking into strategies to generate physician buy-in and encourage behavioral change, which will help them be better prepared for the transition to population health and value-based care.”

·         “Many of the surveyed CEOs express concern about operating under two different payment systems—FFS and value-based care—and having misaligned incentives. Moreover, moving towards population health and bearing financial risk likely will require a large patient population.”

·         “Many CEOs who previously had acquired and invested in physician practices report being more engaged and prepared for MACRA implementation than other survey respondents. “

·         “In our survey, some respondents indicate they are using tools including clinical integration, employment contracts with incentives, ACOs and risk-sharing agreements, among others to better activate physicians in care delivery transformation.”


Meanwhile, Bain & Company recently released their Front Line of Healthcare Report 2017, in which they surveyed 980 physicians and concluded that “more than 60% of the physicians we surveyed believe it will become more difficult to deliver high-quality care in the next two years as they struggle to cope with a complex regulatory environment, increasing administrative burdens and a more difficult reimbursement landscape. After years of experimentation, physicians now want evidence that new models for care management, reimbursement, policy and patient engagement will actually improve clinical outcomes. Without it, they see little reason to alter the status quo and move toward widespread adoption.”


Specific to physician receptivity toward value based care, Bain found that physicians very much prefer FFS if they had their druthers: “More than 70% of physicians prefer to use a fee-for-service model, citing concerns about the complexity and quality of care associated with value-based payment models. Fifty-three percent of physicians say that capitation reduces the quality of care, and most see little advantage from pay-for-performance models either. Further, many believe their organizations are not sufficiently prepared for the shift to value-based care.”


CVS, Aetna, Retail Integrated Delivery Systems and the Strange World of Frenemies

by Clive Riddle, October 27, 2017

As widely reported, including in the Wall Street Journal, CVS is making a very serious bid to acquire Aetna for more than $200 a share, equating to $66 billion. The most often cited drivers behind this deal include:

  • CVS’s strategic response to Amazon’s potential entry into the pharmacy business
  • CVS strategic response seeking growth outside core business, after antitrust regulators rejected Walgreens/Rite Aid merger
  • Aetna strategic response seeking growth outside core business after antitrust regulators rejected Aetna/Human and Anthem/Cigna mergers
  • Aetna would serve as significant source of members for CVS PBM division, customers for CVS pharmacies and patients for Minute Clinics
  • CVS and Aetna’s strategic response to competitors aligning health plans and PBMs such as UnitedHealth acquisition of Catamaran

Much attention has been given to initiatives for integrated delivery systems between hospitals and medical groups that take on purchaser functions. Does this signal a different focus – on retail integrated instead of clinically integrated systems - bringing together pharmacies, retail clinics, health care coverage, wellness services, patient engagement and care coordination?

But Wall Street experts remind us that doesn’t mean this deal is a sure thing.  Things could fall apart simply due to details in the financial terms, or because of new changes in direction by competitors or in the overall market. The Street quotes Jeremy Bryan, a portfolio manager at Gradient Investments, a minor CVS shareholder: "There's just no case study for this. There could be regulatory hurdles. But we have cautious optimism." The Wall Street Journal states “The deal almost surely would attract close scrutiny from U.S. antitrust enforcers who have expressed concern about health-care consolidation.”

Assuming however there is a clear path forward for CVS and Aetna, the question remains for them what lies in wait for them down the road? A few potential concerns include:

  • Would the deal jeopardize the recently announced Anthem/CVS relationship whereby CVS will service Anthem’s new PBM?
  • Would the deal drive other competing health plans away from the CVS PBM and pharmacies?
  • What if CVS is counting on Aetna becoming a more significant force in Medicare Advantage to drive CVS PDP business, and Aetna fails to deliver?
  • What if the Trump Administration and Republican Congress succeed in further scaling back Medicaid, causing Aetna’s significant investment in Medicaid business to erode and become a drag on CVS overall performance?
  • What if Aetna focuses its pharmacy and retail clinic network offerings on CVS locations, and loses market share to competitor plans with broader offerings?

On the other hand, maybe the deal wouldn’t cause competitors to blow up relationships with CVS or Aetna. The Washington Post quotes Adam Fein, president of Pembroke Consulting: “This is part of the strange world of the health insurance and PBM industry. Many companies are frenemies.”


A Dozen Things To Know About The Trump Healthcare Executive Order and Elimination of CSR Payments

A dozen Things To Know About The Trump Healthcare Executive Order and Elimination of CSR Payments

by Clive Riddle, October 13, 2017


1.       Attorney General Jeff Sessions issued a legal opinion to HHS and the Treasury Department that that money appropriated to HHS “cannot be used to fund” Cost Sharing Reduction (CSR) payments.

2.       The Trump administration has filed notice to the U.S. Court of Appeals for the D.C. Circuit, “that the Department of Health & Human Services (HHS) has directed that cost-sharing reduction payments be stopped because it has determined that those payments are not funded by the permanent appropriation for ‘refunding internal revenue collections.” they were not formally appropriated by Congress.

3.       Health Plans still have to provide marketplace subsidized discounts to low-income customers. Without CSR reimbursement, one must assume participating plans will raise premiums as soon as feasible.

4.       A CBO report indicates the decision to end CSR payment payments is likely to cost the federal government more than making the payments due to ACA required subsidies to cover anticipated premium increases.

5.       The health plans most impacted by the CSR elimination include mostly Blue Cross and Blue Shield companies and insurers focused on Medicaid, such as CenteneCorp. and Molina Healthcare Inc.

6.       CSR lawsuits are likely. Impacted health plans may sue. The Hill reports attorneys general from California and New York say they are prepared to sue the Trump administration to protect health-care subsidies that the White House said would be cut off.

7.       As Sam Baker, Axios healthcare editor posts, “Congress can solve this. University of Michigan law professor Nicholas Bagley, an expert on this issue, told me that if Congress appropriates the money for these subsidies, they would begin flowing again immediately.”

8.       The Trump Executive Order does not equate to immediate changes. As healthcare policy expert Timothy Jost posts in Health Affairs, the Executive Order “is a direction to draft rules. Under the Administrative Procedures Act these agencies will first have to publish proposed rules and then receive and respond to public comments before publishing the rules in final form. The fact sheet accompanying the order acknowledges that regulations will proceed through notice and comment rulemaking. This will likely take months. Indeed, rulemaking will likely be proceeded by studies by the affected departments, and any proposed and final rules will likely have to be reviewed by the Office of Management and Budget. Therefore, changes are unlikely to affect plans beginning on January 1 of 2018, although some changes may take effect mid-year.”

9.       The executive order instructs the Department of Labor to expand the availability of association health plans under the Employee Retirement Income Security Act of 1974 (ERISA).

10.   The executive order instructs the Departments of Labor and HHS to pursue expanded Availability of Short-Term, LimitedDuration Insurance.

11.   The executive order instructs the Departments of Labor, Treasury and HHS to increase the usability of HRAs, to expand employers' ability to offer HRAs to their employees, and to allow HRAs to be used in conjunction with nongroup coverage.

12.   As Timothy Jost notes in another Health Affairs post, small employers already received expanded ability regarding HRAs in 2016, when “Congress adopted in Title XVIII of the [21st Century] Cures Act a new type of arrangement, the Qualified Small Employer HRA (QSEHRA), that is effectively an exception to the HRA prohibition, but only for small employers — employers that have fewer than 50 full-time equivalent employees and therefore are not subject to the large employer mandates. These employers may pay or reimburse employees through a QSEHRA for premiums for health insurance that qualify as minimum essential coverage.” Thus the Executive Order would have more impact on larger employers.