Thursday
Aug312017

Are you ready to meet the challenge of managing member identities? 

By Claire Thayer, August 31, 2017

 

Healthcare consumers believe that their providers and health plans are taking measures to protect their digital healthcare data, yet a recent Accenture survey on Healthcare Cybersecurity and Digital Trust finds that one of four health care consumers (26%) has experienced a breach of their digital healthcare data, which may include their Social Security number, contact information, electronic medical record or health  insurance ID. And, of these, half were victims of medical identity theft.  Following a breach one-quarter (25%) of those experiencing a breach changed their healthcare providers, 21 percent changed their health insurance company, and 34% lost trust in the organization.

This weeks’ edition of the MCOL Infographic, co-sponsored by LexisNexis, highlights some of the issues and challenges involved in actively managing member identities and impact of security breaches: 


MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more here.

Friday
Aug252017

Fighting Over Who The Healthcare Punching Bag Should Be: Health Plans vs. Pharma

By Clive Riddle, August 25, 2017

Earlier this month the Doctor-Patient Rights Project released Not What the Doctor Ordered: Barriers to Healthcare Access for Patients an eighteen page report presenting consumer survey results regarding health insurance coverage denials. The Project issued statements in conjunction with the report including from Stacey Worthy, Executive Director of Aimed Alliance and one of the Project’s founding members, who said “our research reveals a hidden healthcare crisis. The current debate about healthcare reform has focused on getting more Americans covered. Yet, the real crisis is among patients with chronic illnesses who tell us that insurance is worthless when their insurance providers withhold coverage of essential treatments prescribed by a doctor.”

The Project highlighted that the survey found:

  • Insurance plans denied treatment coverage 24% of patients with a chronic or persistent illness or condition
  • 41% of these patients denied coverage were denied once, while 59% were denied multiple times.
  • 55% of those denied treatment said they were denied a prescription medication
  • 41% of those denied treatment said they were denied a diagnostic or screening test
  • 24% of those denied treatment said they were denied a medical procedure
  • 53% of those denied coverage for a treatment of a chronic or persistent illness appealed the denial
  • 49% of those appeals were ultimately successful
  • 70% of the denied treatments for chronic or persistent illnesses were for conditions described as “serious
  • 43% were for treatment of patients described as “in poor health”
  • 29% of patients initially denied coverage reported that their condition worsened
  • 34% denied coverage had to put off or forego treatment altogether

What isn’t clear at all in the report, is what the overall denial rate was for the 1,500 consumers surveyed. One wonders why that information wasn’t shared. The report focuses on denials for those responding that they had a chronic or persistent medical illness or condition, or on types of denials for the overall population surveyed.

The report tells us that 55% of the denials were for prescriptions, with 37% of these for formulary exclusions, while 12% required prior authorization, 9% required step therapy and 5% involved therapeutic substitutions. It becomes less clear from the report what portion of these denials still resulted in an alternative covered prescription, or ultimate coverage of the requested prescription after qualifying conditions were met.

The health insurance industry counters that runaway prescription costs are what we should be focusing on. The Blue Cross Blue Shield Association, AHIP and others have regularly produced reports highlighting the prescription cost problem. AHIP, for example one month ago posted Myth vs. Fact: What’s Behind Drug Prices on their website, in which AHIP goes about “fact-checking some of the pharmaceutical industry’s main arguments for why they have to charge hundreds of thousands of dollars for a course of treatment.” They cite reports and articles to support statements including: “High prices have little or nothing to do with drugs’ innovation or efficacy for patients”; “Pricing is based on what already exists, and competitors use shadow pricing to drive each other’s prices higher”; and “Instead of promoting true medical advances, a common business strategy in the pharmaceutical sector is to buy the rights to older drugs and then immediately jack up the prices.”

Morning Consult wrote about the dustup between the two sides this week, stating that health insurers are “alleging it [the Project Report] is part of a campaign by the pharmaceutical industry to distract the public from rising drug prices,” and that “Insurers say the coalition [Project] is tied to pharmaceutical companies.” The article quotes AHIP: “Big Pharma initiated another long-rumored political ad campaign in its attempts to distract from skyrocketing drug pricing, AHIP spokeswoman Cathryn Donaldson said in an email Monday, adding that instead of spending money on advertising campaigns, pharmaceutical companies should address high prescription drug prices.”

The article also quotes the other side punching back: “PhRMA spokeswoman Holly Campbell said pharma companies spend 20 percent of their revenue on research and development, fueling economic growth and bringing patients new treatments. In contrast, the insurance industry invested $0 in R&D and instead spend nearly 20 percent of premium dollars on administrative costs, she said in a Monday statement.”

Friday
Aug182017

Medicare Advantage plans are rethinking member experience

Kristin Rodriguez, Health Plan Alliance. August 18, 2017

One of my favorite moments during our Medicare Advantage Value Visit, July 19-21 was when Melissa Smith, Vice President, Stars & Quality Innovations with Gorman Health Group said the highest performing health plans are the ones “making old school new again.” The point she was making? That which sets high performing health plans apart is the ability to execute at the member level.  The flavor of how health plans are tackling that member-level execution differed with each case study we explored during our time together last month, and yet the same theme presented again and again, with every conversation.  Elevating and protecting the member experience is paramount to ensuring strong market position, better outcomes and higher star ratings.

The “member experience” is a relatively new, hot topic for MA plans, though really it’s just a consolidation of the efforts we’ve been making for a long time, reframed into a global strategy that is bringing leaders from across the enterprise together to tackle challenging issues like these: making member facing materials more palatable, leveraging digital channels to enhance engagement, evaluating our MA portfolio with an eye on social determinants of health and guarding against chronic loneliness, building dashboards our provider partners actually care about, so they can deliver the care to those members that need it most, and, finally, ensuring appropriate payment so that we can finance that care.

 

The challenge facing all Alliance member health plans and our provider partners as we seek to “execute at the member level” are the barriers we and our members face, which have traditionally been outside any health plan’s influence or control.  With the industry transformation to value based purchasing and the steady march of quality ratings programs’ focus to outcomes and experience, health plans must drive care from the clinic to the community, and forge partnerships that empower care for the “whole person.”  Our MA members face crippling chronic conditions like depression and diabetes, not to mention persistent loneliness.  And even for our healthy senior population, ensuring a benefit mix that supports long term health and happiness can be challenging when it comes time to submit a bid that both differentiates your plan and is sustainable.

Experts like John Gorman agree that Medicare Advantage is a sound investment for health plans, with strong market growth providing solid opportunity for health plans looking to diversify and perhaps stabilize their portfolio.  To become a high performing MA health plan, however, organizations must be willing to identify and remove barriers preventing them from executing at the member level.  No matter what’s potentially holding you back, you can bet another Alliance member health plan is facing a similar challenge, or perhaps has even found a way to solve it. Through ongoing networking in-person and virtually, and by sharing our tools and lessons learned, we can help one another make “old school new again.”

Friday
Aug182017

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition
 

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week:

 

Time Crunch Among Hurdles for Bipartisan Senate Push to Bolster ACA

The leaders of a key Senate committee say they are cautiously optimistic about reaching a deal to shore up the Affordable Care Act’s individual marketplaces, but even with a bipartisan effort, it is far from certain whether they can hash out an agreement in time.

Morning Consult

Friday, August 18, 2017

EpiPen maker to settle on claims it overcharged taxpayers, agrees to have pricing practices reviewed

Mylan will pay $465 million to settle claims that it overcharged states for its signature EpiPen, according to a Thursday Department of Justice press release. The company also signed an agreement with the federal government to enter into a review of its pricing practices.

Stat News

Thursday, August 17, 2017

Express Scripts to limit opioids, concerning doctors

The nation’s largest pharmacy benefit manager will soon limit the number and strength of opioid drugs prescribed to first-time users as part of a wide-ranging effort to curb an epidemic affecting millions of Americans.

Stat News

Wednesday, August 16, 2017

Federal deficit will soar to $194 billion, premiums spike 20% if Trump nixes cost-sharing subsidies, CBO report says

The federal deficit will soar by $194 billion over the next nine years and gross premiums for silver plans, the most popular, would spike 20 percent higher in 2018 and 25 percent higher by 2020 if President Trump follows through a proposal to eliminate the cost-sharing subsidies that allow low-income consumers to purchase and afford health plans on the individual ACA insurance exchanges, a report from the Congressional Budget Office said.

Healthcare Finance News

Tuesday, August 15, 2017

CMS cancels two mandatory pay models and scales back a third

The CMS on Tuesday said it will toss two bundled payment models and cut down the number of providers required to participate in a third, citing providers' requests to have more input in the models' designs.

Modern Healthcare

Tuesday, August 15, 2017

These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.
 
Friday
Aug112017

Employer Surveys Project 2018 Cost Increases in the Five Percent Range

Employer Surveys Project 2018 Cost Increases in the Five Percent Range
 

by Clive Riddle, August 11, 2017

 

The National Business Group on Health has released results from their Large Employers’ 2018 Health Care Strategy and Plan Design Survey, which projects the total employer cost of providing medical and pharmacy benefits to rise 5% for the fifth consecutive year in 2018. The total cost of health care is estimated to be $13,482 per employee in 2017, and is projected to increase to $14,156 in 2018, with employers funding 70% of these costs. What is driving cost increases? The most often listed top driver was specialty pharmacy (26%) and 80% of employers ranked this among the top three cost drivers.

 

Similarly, last week Willis Towers Watson released preliminary findings from their 22nd annual Best Practices in Health Care Employer Survey, which found that "Employers expect health care costs to increase by 5.5%* in 2018, up from a 4.6% increase in 2017."

 

The NBGH 2018 survey also produced this grab-bag of interesting employer survey responses regarding health benefit strategies, regarding telehealth, onsite care, value based care, and CDHP:

 

·         96% will make telehealth services available in states where it is allowed next year

·         56% plan to offer telehealth for behavioral health services

·         20% of employers are experiencing employee telehealth utilization rates of 8% or higher

·         21%s plan to promote ACOs in 2018, and another 26% are considering offering them       

·         54% will offer onsite or near site health centers in 2018        

·         88% expect to use Centers of Excellence in 2018 for certain procedures        

·         40% of employers have incorporated some type of value-based benefit design

·         18% will use value-based benefit design to steer employees toward telehealth in 2018 (16% in 2017)

·         66% of companies will offer medical decision support and second opinion services in 2018

·         90% will offer at least one Consumer Directed Health Plan (CDHP) in 2018.

·         40% of employers will offer a CDHP as the only plan option in 2018, compared with 35% this year

·         28% pair a HDHP with a Health Reimbursement Arrangement
 

 
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