Elevance Health announced at CES that it will give free smartphones to Medicaid program members to help them access healthcare services
Elevance Health is addressing a critical care gap for its underserved members by giving them a smartphone to connect with healthcare resources.
The Indianapolis-based insurer formerly known as Anthem, which announced the program at CES 2024 this past week in Las Vegas, is targeting a Medicaid population that faces barriers to accessing the care they need. According to Elevance, roughly one quarter of American households making $30,000 or less a year aren’t using a smartphone, and 43% don’t have home broadband internet access.
"The lack of sufficient internet connectivity and technology access remains a significant barrier for many – increasing health inequities," Kurt Small, president of Elevance Health’s Medicaid business, said in a press release. “This program aims to directly address this challenge and helps improve the health of the people we serve.”
The program targets a glaring care gap that both payers and healthcare organizations are trying to address through digital health and telemedicine. Consumers who have trouble accessing care often end up in a clinic or hospital later on with a serious health issue that could have been prevented, and which now will cost more to treat and affect long-term clinical outcomes. That, in turn, puts stress on Medicaid and Medicare programs that support those populations.
CES, through its Digital Health Summit, often focuses on using consumer technology to close gaps. This year’s summit track and exhibit halls featured a wide variety of strategies and technologies aimed at helping consumers monitor their health and connect with care providers at the time and place of their choosing.
Elevance Health is targeting the root of the problem: Communication. The company is offering qualified members on Medicaid programs a smartphone with unlimited data, talk, and texting services, as well as customized access to healthcare resources, both digital and virtual, and instructions on how to use the phone.
“Increased availability of digital technologies, such as a smartphone, as well as fast, reliable internet is critical to supporting a person’s health journey," Omid Toloui, Elevance Health’s vice president of innovation, said in the press release. “We believe the digital tools and the custom, curated experience offered through this program can help improve health, make healthcare more affordable, and serve people more equitably.”
The program is supported with funds from the Federal Communications Commission’s Affordable Connectivity Program (ACP) and offered through partnerships with Verizon, Samsung, AT&T, and T-Mobile.
Two leaders share their insights and strategies to help CNOs work together with staff and problem solve.
Nurses everywhere are going on strike.
Right now, it seems like every day there are new cases of nurses striking or unionizing at health systems all across the country.
Nurses are frustrated, and the recent union activity is indicative of large, widespread problems in the nursing industry with staffing, work environment, and nurse wellbeing. While it is the CNO’s responsibility to address those issues and to facilitate those conversations, it can be quite difficult.
Underlying causes
According to Katie Boston-Leary, Director of Nursing Programs at the American Nurses Association, there are several reasons that nurses have been going on strike, starting with the staffing crisis and its impact on overall nurse wellbeing. Workplace violence, unmanageable workloads, exhaustion, and the feeling of not being heard are also contributing factors.
“There is a generalized dissatisfaction of the current state [of the industry] from nurses,” Boston-Leary says, “and I think that the phenomenon that’s happening right now is nurses are really saying ‘no more.’”
Due to staffing shortages and heavy workloads, nurses are not able to spend as much time with their patients as they want to, and according to Boston-Leary, they often leave work feeling like they did not provide the best possible care.
“We have unintentionally set up a system that pulls nurses away from what matters most to them,” Boston-Leary says, “which is spending time with their patients.”
COVID-19 exacerbated the issue. It forced nurses and other healthcare professionals to be introspective, and to reassess what their priorities were in terms of job structure and how work should balance with their personal lives.
“I think COVID is an accelerator and illuminator,” Boston-Leary says, “and it just adds fuel to everything that we [already] knew.”
Boston-Leary believes that nurses are using unions as a last resort to find their voices in health systems, and that they are voting to make sure that things are changed for the better, for themselves and for new nurses. If they do not see the issues being addressed, nurses might feel a need to turn toward the more compulsory, structured approach.
Boston-Leary also states that in all her experience leading and working in unionized hospitals, the unionized environment does not impact the dedication that nurses have to their profession.
“Nurses have a right to voice their concerns,” Boston-Leary says, “and [they] find a number of different ways to do that through shared governance, through leadership, and in some cases through unions.”
Are strikes avoidable?
Last year, Temple Health was close to a nursing strike, and the issue up for negotiation was staffing. According to Dr. Chaudron Carter, Executive Vice President and Chief Nurse Executive at Temple Health, they were able to avert the strike by sitting down with the nurses and adjusting staffing based on acuity and many other criteria.
“We essentially averted a strike by really just getting together and agreeing to some changes in our staffing guidelines,” Carter says.
Temple implemented a new set of staffing guidelines that do not include ratios, and they developed a process where the guidelines are looked at on a monthly basis, and any necessary adjustments are made. Leadership focuses on a different unit each month, and they provide the union with updates about new staff and other information. The meetings last for eight hours, four are dedicated to discussing topics on a shared agenda, and the other four are spent assessing the staffing guidelines and making changes if needed.
To Carter, it is crucial that the nursing staff show up for these discussions, and that they continue to deliver on quality of care, as part of the effort to foster shared governance.
“Leadership can make decisions,” Carter says, “however, if it is not the right decision to drive the change that we want, it won’t work.”
Communication and action
With the principles of shared governance in mind, the responsibility falls on CNOs and other nurse leaders to be able to strike a balance between the unions and health systems in a way that is beneficial for everyone.
According to Boston-Leary, the nurses will know that the CNO is listening when their questions and concerns are answered and addressed.
“I’ve learned the hard way that it’s not enough to have an open door,” Boston-Leary says. “You have to walk the walk and talk the talk and really show people that you’re listening.”
CNOs can find out what their nurses are going through by asking them directly. Boston-Leary recommends setting up a shadow board in the department so that nurses can give feedback in a structured way. It is also vital that leaders give feedback to nurses about actions being taken to make progress and to keep them updated on that progress.
“We have to get to a point of resolving a lot of these issues and managing these pain points, because it’s at the point of being unbearable for nurses,” Boston-Leary says, “which is why we’re seeing all the [union] activity that we’re seeing.”
Additionally, CNOs can maintain relationships with their nurses without always involving the unions. Boston-Leary states that nurses are a part of a CNO’s team regardless of union presence, and it’s important to still have conversations with them.
“You should have relationships with the people that are under your leadership because those relationships are important,” Boston-Leary says, “and the unions don’t necessarily have to come between [those] relationships.”
For Carter, communication is also key. She recommends stepping onto the hospital floor and spending time listening and talking to staff to better understand the pain points that might arise in union discussions. That way, CNOs can get ahead of the curve and develop strategies before negotiations that will help move the problem-solving process along.
“If you could develop a strategy before you get to go into negotiations around what those topics may be, and the organization develops a strategy on how to combat those issues,” Carter says, “I think you’ll position the organization better as it relates to going into negotiations and averting a strike.”
Trust is another important ingredient. Carter believes that open dialogue and transparency can help create a trusting relationship between the two parties, so that even when there are disagreements on approach, there are still shared goals.
“We don’t always see eye to eye,” Carter says, “[but] we’re here for the same reason, we’re here for safe patient care, [and] to make sure that the staff is taken care of as well.”
Have a contingency plan
For CNOs working in union environments, preparation is essential.
Carter highly recommends that any organization embarking on contract negotiations should have a contingency operations plan in place. The plan should detail how to continue operations at the hospital if the nurses go on strike.
Carter suggests that this could involve pulling from other departments within the health system, such as housekeeping or radiology, or hiring an agency to bring in a contingency workforce. CNOs should determine where and how to downsize and distribute staff so that they can still provide the same quality patient care.
“The plan is huge because nursing touches all aspects of an organization,” Carter says, “and so you have to think of the most minute things to the larger scale items.”
At the end of the day, unions are an inevitable part of dealing with the workforce.
In her time leading in a unionized environment, Boston-Leary took the approach of enlisting the support of the unions and keeping them informed in order to help tackle nursing issues. She found it important for nurses to see their leaders working together for their benefit, rather than an adversarial relationship where no progress is made.
“I learned that I cannot treat unions as if they were the bad guys, because that was a non-starter,” Boston-Leary says. “If they’re here, they’re here, and you have to work with them and partner with them.”
Mark Cuban and Glen Tullman are two of the many disruptors aiming to make healthcare more convenient for consumers. Their advice to healthcare execs: Do more by doing less
As CES 2024 winds down, the message to healthcare executives is simple: Do more by doing less.
The healthcare industry has become too complicated, frustrating patients and stressing out doctors and nurses. As a result, consumers are looking elsewhere for their healthcare, to retail companies, pharmacies, and online companies that promise convenience and transparency.
“You need to start questioning the long-held beliefs of the way you thought things needed to be done,” billionaire investor and businessman Mark Cuban said during a closing session of the two-day Digital Health Summit.
In other words, healthcare executives need to find a way to cut through the complexity and return to the simple process of health and care. And technologies like digital health and AI will help them make that transformation.
Cuban, who launched the Cost Plus Drug Company in 2022 to give consumers access to generic medications, shared the stage at CES with Glen Tullman, the former Allscripts executive who now heads the integrated healthcare benefits company Transcarent. The two are part of the growing ranks of disruptors aiming to make healthcare more consumer-friendly.
Their appearance capped two days of sessions on the value of consumer-facing digital health technology to address a healthcare ecosystem that many say is broken. Advocates say digital health tools like AI can take on some of the industry’s biggest pain points by automating tasks, improving workflows and boosting clinical outcomes.
The challenge is in getting health system executives and payers to take notice. Few made it to Las Vegas this week, giving attendees just a few examples of how health systems are using technology to improve operations and little evidence that payers will pay for it.
Tullman, who launched the successful digital healthcare startup Livongo prior to developing Transcarent, said the industry needs to focus on the consumer experience, embracing new technologies and ideas that make it easier for the consumer to access healthcare at the time and place of their choosing. Technology, he said, should be the foundation of that experience.
“But if people are talking about the technology, that’s a problem,” he added. “Look for technology to simplify things rather than [produce} complications,”
That’s one reason that AI is such a hot topic, at CES and elsewhere. Health systems and hospitals are embracing the technology as a means of reducing administrative and data-intensive tasks, giving clinicians more time to focus on healthcare delivery and giving consumers an easier path to that care.
“There are many practical uses,” said Tullman, whose company has developed an AI tool called 10X—designed, he said, “to make physicians 10 times more proficient.” He predicted AI would “simplify the paperwork” and “improve the quality of the experience.”
Cuban said AI will change the entire healthcare industry, and he predicted “millions” of models and applications. It will, he said, democratize healthcare.
Both said the key to the transformation of healthcare lies in putting healthcare in the hands of the consumer. If health systems and hospitals are slow to make that adjustment, they’ll lose patients to the disruptors who are making the experience more convenient and less costly.
Cuban told a story about his son needing an MRI. Through their health plan, that MRI would cost roughly $2,000. Cuban called the doctor’s office and asked for the cash price, and was told the MRI would cost $470. Some providers, he pointed out, would prefer cash in hand rather than going through the process of scheduling and billing.
“Healthcare is more confusing, more complex, and more costly than ever before,” Tullman added.
Allina Health's new chief nursing executive has a background that includes leadership positions at Jefferson Health, Baylor Scott & White, VCU, and UnityPoint Health.
D'Andre Carpenter, DNP, RN, knew he wanted to be a nurse at age 13. For a while, he was convinced not to go into nursing, and worked in computer science and software engineering instead. However, he never stopped thinking about his dream of being a nurse, and so he decided to pursue becoming a registered nurse full time while working and raising a family.
Carpenter has held leadership positions at Jefferson Health in Philadelphia, Baylor Scott & White Health in Dallas, and the Virginia Commonwealth University Health System in Richmond, Virginia. He also served as senior vice president and chief system nursing officer for UnityPoint Health in Iowa.
He was recently appointed senior vice president and chief nursing executive at Allina Health, where he will be developing strategies to improve retention rates and patient satisfaction.
For our latest edition of The Exec, we sat down with Carpenter to discuss his thoughts on recruiting and retention strategies, diversity, equity, and inclusion (DEI), technology in nursing, and how to prevent workplace violence. Tune in to hear his insights.
As health system execs attending CES 2024 talked of using AI to address specific challenges, the FDA commissioner pointed out that the technology will fundamentally change how healthcare is delivered in the future.
Healthcare executives are in uncharted territory, due to the speed at which AI is evolving. And with that progress, health systems and the federal government are going to have to continually adjust how the technology is governed.
“The assessment of the algorithms needs to be continuous,” US Food and Drug Administration Commissioner Robert Califf, MD, told a packed room during a session Wednesday at the CES 2024 show in Las Vegas. In fact, he added, post-market evaluations of new tools may be more important than pre-market evaluations.
“It’s a different world,” the FDA commissioner added. “The changes are dramatic. … We can see the time when [healthcare] is going to be guided and assisted so much more by algorithms and AI.”
As the massive consumer technology show continues this week, AI is dominating the many exhibit halls and the discussion around the two-day Digital Health Summit, which runs through today. Aside from getting a glimpse at new advances in smart health technology—from smart toilets and bathrooms to smart beds and pillows to more refined wearables and sensors—healthcare execs who braved the typical Las Vegas chaos talked of how AI is already being used to address key pain points like administrative overload, stressed out providers, and siloed care.
“This stuff is so powerful,” Lee Schwamm, MD, chief digital health officer at the Yale New Haven Health System and associate dean of digital strategy and transformation at the Yale School of Medicine, offered during a panel discussion. “Health systems are just now trying to figure out what the business model will be.”
Sara Vaezy, EVP and chief strategy and digital health at Providence and a panelist at the upcoming HealthLeaders AI NOW Virtual Summit later this month, said her health system is working on four distinct AI demonstration projects in a partnership with Microsoft, primarily around automating tasks that affect the clinician workload and improving self-service options for patients.
“It’s just too expensive to deliver care in the way that we normally have,” she said.
Both she and Schwamm pointed out that the use of AI in healthcare will be different than in other industries, primarily because of the inclusion of patient data. Health systems and hospitals need to plan carefully to protect that information, since so much of AI depends on using data to make decisions and advance processes.
“This is a very special space,” Schwamm pointed out.
Califf, whose appearance at CES was as part of the government and policy track, also pointed out the intricacies of healthcare. He noted the industry is gradually shifting from episodic to value-based care, where not just immediate outcomes but long-term outcomes are valued.
“In order to make it work you’ve got to [focus on] complete outcomes,” he said.
Califf said he’s excited about how AI will factor into healthcare in three distinct venues: The home, where more care is being delivered and more patient data is being collected; the operating room, where robotics and digital health are changing how surgical procedures are done; and the clinic, where providers are learning how to use technology to develop care management and coordination plans that surround the patient and become part of his or her journey.
He also noted the advance of wearables, which are becoming more sophisticated, and the rapid pace of development for adaptive AI models such as ChatGPT.
“The chance to learn through algorithms is the basis for so many things we take for granted in life,” he said.
Health Condition Programs gives consumers convenient and virtual access to care management and other services to address chronic health conditions like diabetes and hypertension
Amazon has launched a new service aimed at helping consumers manage their chronic conditions.
Health Condition Programs, which was unveiled on January 8 during the JP Morgan Conference, gives the online retail giant a significant platform in the healthcare space—and another reason for healthcare executives to fret about competition from disruptors. The service gives consumers a virtual link to a personalized care team to help manage their health.
“Amazon wants to make it easier for people to get and stay healthy, and part of that is making it easier to discover the products, services, and professionals that can help them do that,” Aaron Martin, Amazon’s vice president, said in a press release issued by Omada Health, a digital health company that is partnering with Amazon to offer diabetes prevention and care and hypertension care services through the new platform. “Many aren’t aware of the healthcare benefits they are eligible for, that are typically no cost or subsidized by their employer or insurance plan. When customers are shopping for health-related products on Amazon, we can surface these benefits to provide even more support in improving their health, at no additional cost.”
Amazon will partner with companies like Omada Health to cover a wide range of chronic health conditions, creating a care management path that would traditionally be handled by one’s primary care doctor or health system.
The company matches consumers to the appropriate care team based on their online searches and shopping history. Consumers accessing the program can first find out if their employer or health plan covers the Health Condition Program; if the program is covered, the consumer can then access services such as virtual visits, health coaching, remote patient monitoring, and access to online forums and other resources.
The program gives consumers convenient and virtual access to care management, an option to the often complicated task of scheduling appointments with primary care doctors and specialists and visiting doctors’ offices or clinics.
“This partnership is pivotal for Omada, as we are leveraging Amazon’s wide reach to literally meet consumers where they are, just as we do for our members as a virtual-first care provider,” Omada Health CEO and Co-Founder Sean Duffy said in the press release. “Ultimately, the more people we’re able to reach, the larger impact we can have on the rising prevalence of chronic disease.”
The platform gives healthcare executives yet another reason to develop virtual care programs to compete with the disruptors, focusing on convenient access to a trusted healthcare provider or health system.
While much of the focus at CES is on innovative technology, a policy panel on the first day of the event discussed how the government can shape AI standards
With innovation on full display at CES this week, one of the more compelling panel discussions on the first full day focused on the intersection of technology and policy. And the general consensus was that collaboration is best.
“We’re definitely seeing the right incremental steps being taken,” said Matthew Hine, a senior international trade specialist in the Office of Health Industries, part of the U.S. Department of Commerce’s Industry and Analysis business unit.
To wit: The Biden Administration has been focused so far on working with the healthcare industry to develop AI policy, particularly around standards and guidelines. And health system executives have so far said they’re moving cautiously but firmly forward, using the technology where they can but making sure a human still makes the final decision when clinical care is concerned.
Congress isn’t in the loop on developing policy, though some lawmakers have called for more of a say on the matter. And that’s OK with Conor Sheehy, a senior health policy advisor for the minority staff of the Senate Finance Committee.
“It’s not an area where Congress, to my mind, has shown a great deal of expertise … or understanding,” he pointed out.
Both Sheehy and Marisa Salemme, a senior health policy advisor for the majority staff on the Senate Finance Committee, agreed that lawmakers on both sides of the aisle have been in agreement on supporting the use of innovative technologies, such as virtual care. The hope is that Congress will push through a logjam of healthcare-related bills this year, giving health systems more opportunities to use technology.
But the challenges remain. Healthcare is still focused on reimbursing providers for episodes of care, and is only moving slowly towards outcomes-based care. And providers won’t embrace new technology if they’re not incentivized to use it. To that end, both the government and Congress need to come together on incentives that will spur the use of innovative technology.
How or when that happens remains to be seen. And some parts of that conversation are expected to be picked up on Wednesday with the opening of the Digital Health Summit, as well as in a special panel session featuring FDA Commissioner Robert Califf, FTC Commissioner Rebecca Slaughter, and FCC Commissioners Brendan Carr and Anna Gomez.
That’s also why health system executives aren’t flocking to CES to take in the latest innovations in consumer technology, and are instead keeping tabs on the technology from afar. New technology and ideas need room to grow into healthcare, and that isn’t happening at a time when operating margins are thin and hospitals are struggling to stay afloat.
Many of the companies exhibiting in the digital health space at CES have said they’re talking with health systems about small pilot programs, but the key to adoption lies in support from the payers, especially the Centers for Medicare & Medicaid Services. CMS has been traditionally hesitant to embrace new technology like telemedicine and digital health, thougn the gradual move toward reimbursing for remote patient monitoring tools and services has spurred some hope.
“Medicare reimbursement would be huge,” said Aaron Labbe, co-founder and chief technology officer for LUCID Therapeutics, a company that develops music-based treatments for providers and is talking to health systems about using the technology in everything from pediatric care to the ICU. “We need their support.”
This CNO has advice for the huge challenges facing nurse leaders as we enter the new year.
As we dive into the new year, CNOs must be prepared to deal with the new and ongoing challenges facing the nursing industry.
Lisa Dolan, Senior Vice President and Chief Nursing Officer at Ardent Health Services, has laid out what she thinks are the five biggest issues that CNOs will face in 2024.
For more information, check out the full article here.
The great termination? More organizations are terminating payer contracts amid heated negotiations, and Medicare Advantage is in the hot seat.
The payer/provider battle is raging, and signaling what may be an emerging trend: More organizations are fighting back against payers by terminating their contracts completely, and Medicare Advantage (MA) has seemingly been the focus.
Thanks to record inflation and operational challenges, hospital and health systems find themselves with their backs against the wall in negotiations, leading CFOs to initiate contract terminations.
But what exactly has led to the turmoil? CFOs say the reasons are vast.
“Bad behavior.”
More organizations are now considering contract terminations due to dissatisfaction with reimbursement rates and overall bad payer behavior.
Healthcare providers have been arguing for years that insurance payers often set reimbursement rates at levels that are lower than the actual cost of providing care. Couple this with skyrocketing inflation costs and labor expenses, and providers can be left with no other choice.
When reimbursement rates are significantly lower than the cost of care and the administrative burdens are so high, healthcare providers may experience unsustainable financial losses. These underpayments along with egregious denials are pushing providers to the limit.
In such cases, CFOs may weigh the option of contract termination as a last resort to protect the financial stability of the organization.
“There is rarely one final straw, but rather, a cumulation of events that negatively impact the fiscal viability of the relationship,” Britt Berrett, managing director and teaching professor at Brigham Young University and former CEO with HCA, Texas Health Resources, and SHARP Healthcare, explained.
“Long before rates become contentious, hospitals are dealing with bad behavior and payer shenanigans,” Berrett said.
For example, he says, payers are rejecting claims based on utilization review criteria. Many healthcare leaders consider these rejections to have little to do with utilization but rather an attempt to refuse payment.
Luckily for providers, organizations are becoming more capable of cost accounting and utilizing analytics to determine the actual cost by patient and payer.
Why Medicare Advantage?
Why has MA been in the hot seat of terminations? While not the only culprit of the turmoil, organizations have been fighting back against MA’s low reimbursement rates for years, and as Berrett said, maybe CFOs are finding no fiscal viability in the relationship with the payer.
One case in point is Scripps Health. Two medical groups within the system canceled their MA contracts for 2024 because of low reimbursement rates, denials, and administrative costs to manage high utilization and out of network care.
“We’re unfortunately on the vanguard of what I think is going to be a very ugly few years between hospitals and commercial insurance companies,” Chris Van Gorder, president and CEO of Scripps, told USA Today.
And Scripps has the resources to better manage these burdens, meaning these burdens are even more exacerbated for smaller systems.
An example of this is Samaritan Health Services. It recently terminated its commercial and MA contracts with UnitedHealthcare.
The five-hospital, nonprofit health system cited slow processing of requests and claims that have made it difficult to provide appropriate care to UnitedHealth's members, according to a news release from Samaritan.
“This, along with other factors, is not in alignment with our mission of building healthier communities together,” the health system said.
Another example is St. Charles Health System, a four-hospital network and healthcare company in Central Oregon, which terminated its MA contracts in 2023.
Steve Gordon, president and CEO of St. Charles, said great thought went into the decision to reevaluate MA participation, and it was done only after years of concerns piled up not just at St. Charles, but at health systems throughout the country.
“The reality of Medicare Advantage in central Oregon is that it just hasn’t lived up to the promise,” he said in a press release. “A program intended to promote seamless and higher quality care has instead become a fragmented patchwork of administrative delays, denials, and frustrations. The sicker you are, the more hurdles you and your care teams face. Our insurance partners need to do better, especially when nurses, physicians and other caregivers are reporting high levels of burnout and job dissatisfaction.”
It's also worth noting that Memorial Hermann Health System, the largest hospital system in the Houston region, terminated its agreement with Humana's MA networks at the beginning of the new year. Memorial Hermann has not yet publicly cited why, other than saying the contract negotiations hit an impasse.
OK, but what’s the outcome of termination?
But what is it like on the other side of an MA termination? It hasn’t been so bad for some.
Hamilton Health Care System, a not-for-profit, fully integrated system of care serving the northwest Georgia region, has been out of network with MA for years.
“We are not currently in network with any Medicare Advantage plans. We would end up netting less than traditional Medicare because of denials and administrative hassles,” said Julie Soekoro, EVP and CFO at Hamilton Health Care System.
In addition to a lessened administrative burden, being out of network hasn’t affected Hamilton’s bottom line or patient experience.
“Since we are out of network, the MA plan should be paying us as if the patient were a regular Medicare patient, so it has not affected the patients adversely,” Soekoro said.
All the time and money spent on takebacks, pre-authorizations, and denials add up. Coupled with the aforementioned low reimbursement rates, CFOs can find it doesn’t make business sense to continue with the payer.
MA isn’t the only difficult payer, though; the challenge is universal.
For example, Hamilton Health Care has spent a lot of time going back and forth on a contract with a national payer that wanted to bring them in network, only for Hamilton to walk away from the negotiation table.
“After spending a great deal of time and effort modeling the contract, we learned the payer will require all diagnostic imaging business to go to a freestanding competitor, while building in very attractive looking rates for imaging,” Soekoro said. “This is misleading in that they never intended to allow their subscribers to come to us for imaging.”
“This was discovered incidentally by our contracting director, rather than fully disclosed by the payer,” she added. “Also, certain provider-favorable terms that we built into the language have mysteriously fallen out of the most recent version of the language.”
As stated, Hamilton walked away from that particular negotiation.
Another example comes from Berrett and his time at Texas Health Resources.
While Berrett didn’t specify the type of plan (MA or otherwise), the organization terminated a payer contract because its patients had significantly higher CMI, resulting in losses for their patients.
“The impact [of terminating the contract] was very positive for the hospital. We lost volume but improved margins,” he said. “The payer was able to promote a significantly lower premium for companies because their rates to the providers were so low. When we terminated the agreement, they could no longer sell lower premiums and their market share dwindled. They eventually retreated from the market.”
What does the future hold?
It’s worth noting that the trend of MA terminations is not a common occurrence with the nation's health systems—yet. In fact, several health systems expanded their own 2024 MA subsidiaries.
But that hasn’t stopped the critiques of the program from growing louder.
The Health and Human Services Department’s inspector general reported last year that some MA plans have denied coverage for care that should have been provided under Medicare's rules. On top of this, CMS and the Biden Administration have both proposed rules to address certain aspects of the plan’s requirements.
Even so, the payer/provider relationship is sure to remain heated in the coming year—even beyond MA.
“At the same time that community hospitals are struggling to stay out of the red, the national payers are reporting profits in the billions in their quarterly earnings reports,” Soekoro said.
“It feels to me like the payers became accustomed to taking in premiums during the volume downturns of the COVID years when patients shied away from seeking follow through on regular—and sometimes even urgent—healthcare needs,” she said. “Now the payers seem to be looking for ways to sustain those increased quarterly earnings.”
As for the providers, CFOs could have more leverage in negotiation talks than they think, but it requires willingness and preparation to pull levers that may be uncomfortable yet necessary for financial survival.
Dropping a payer is “absolutely an important strategy,” Berrett says. “Providers are becoming more capable in measuring the impact of the slow or rejected payments, and providers are looking at the actual cost of care by patient. Payers need to be aware that.”
There are two important considerations for providers, Berrett says.
“Are we able to collect our negotiated rates, and are the patients covered by this payer more expensive to treat?”
A study released today by researchers at Mass General Brigham focuses on the safety and quality of care in the Hospital at Home program, which will be discussed in at least one panel session at this week’s CES 2024 show in Las Vegas.
Advocates are touting a first-of-its-kind national study of Hospital at Home outcomes to convince the Centers for Medicare & Medicaid Services to make reimbursements permanent.
The study, led by researchers at Mass General Brigham and funded by the National Institutes of Health, analyzed clinical outcomes for almost 5,900 patients who were treated in CMS-approved Acute Hospital Care at Home (AHCaH) programs across the country. The research, posted today in theAnnals of Internal Medicine, found that those patients saw a lower mortality rate than if they were hospitalized, incurred fewer rehospitalizations, and spent less time in a skilled nursing facility (SNF).
More than 300 health systems and hospitals have launched Hospital at Home programs since CMS created a waiver for the program in 2020, enabling health systems who follow the agency’s guidelines to qualify for Medicare reimbursements. Other health systems have developed their own acute care at home programs, aimed at reducing stress on inpatient services and giving patients an opportunity to recover more quickly and effectively at home.
The study helps advocates who are lobbying CMS to make the AHCaH waiver, which is scheduled to expire at the end of this year, permanent. Many health systems are dependent on the waiver to sustain their programs, and are struggling to expand or develop long-term plans with the threat of losing that reimbursement.
The Mass General Brigham study was led by David Levine, MD, MPH, MA, clinical director for research and development for Mass General Brigham’s Healthcare at Home, one of the first to develop an acute care at home program and study its benefits.
“For hundreds of years, since the inception of hospitals, we’ve told patients to go to a hospital to get acute medical care,” Levine said in a Mass General Brigham press release issued today. “But in the last 40 years, there’s been a global movement to bring care back to the home. We wanted to conduct this national analysis so there would be more data for policymakers and clinicians to make an informed decision about extending or even permanently approving the waiver to extend opportunities for patients to receive care in the comfort of home.”
Levine and his colleagues analyzed Medicare fee-for-service Part A claims filed between July 2022 and and July 2023 for 5,858 patients across the country who had been treated in AHCaH programs. Of that group, roughly 42.5% were being treated for heart failure, 43% for COPD, 22% for cancer, and 16% for dementia. The mortality rate for that group was 0.5%, the escalation rate (returning to the hospital for at least 24 hours) was 6.2%, and within 30 days of discharge, 2.6% used an SNF, 3.2% died, and 15.6% were readmitted.
“Home hospital care appears quite safe and of high quality from decades of research — you live longer, get readmitted less often, and have fewer adverse events.” Levine said in the press release. “If people had the opportunity to give this to their mom, their dad, their brother, their sister, they should.”
Levine also noted that the study found no differences in outcomes for underserved patients, indicating the program could help address some of the barriers that patients face in accessing care.
“There are a number of reasons we think hospital-level care is better at home,” he said. “For one, the discharge process is smoother since we show patients how to take care of themselves right in their homes, where they are also more likely to be upright and move more. In addition, the clinical team has a greater ability to educate and act on the social determinants of health that we see in the home. For example, we can discuss a patient’s diet right in the kitchen or link a patient with resources when we see the cupboards are bare.”
Levine’s colleague, Jared Conley, MD, PhD, MPH, associate director of the Healthcare Transformation Lab at Massachusetts General Hospital, said during a HealthLeaders virtual summit in 2023 that the Hospital at Home program could eventually surpass inpatient care as the highest quality acute care program. The challenge, he said, lies in balancing in-person care with virtual and digital health technology to achieve the best results.
"Think of this as building another brick-and-mortar hospital," he said. "It is very challenging work, but it is so beneficial."
The Hospital at Home concept will be discussed during a panel at this week’s 2024 CES event in Las Vegas. Conley will be taking part in a Thursday panel titled Revolutionizing Health Through Smart Home Innovation, which will be moderated by HealthLeaders Senior Editor Eric Wicklund.
