Highmark Health's new executive vice president and market president for Western Pennsylvania discusses his unique role bridging two sides that don't always see eye-to-eye.
Editor's note: This conversation is a transcript from an episode of the HealthLeaders podcast. Audio of the full interview can be found here and below.
That proverb should be on the minds of payers and providers alike as both sides continue to battle economic challenges in the wake of the COVID-19 pandemic from their respective positions.
Putting aside differences and working together is the best path forward, says Dr. Bruce Meyer, Highmark Health's new executive vice president and market president for Western Pennsylvania.
In his new role, Meyer is bridging the payer side of Highmark Health and the provider side of subsidiary Allegheny Health Network, giving him a unique perspective on the issues facing the two groups.
Meyer recently sat down with HealthLeaders for a podcast interview to talk about the opportunity at Highmark Health, what specific challenges payers and providers are grappling with, and why the "adversarial relationship" between the sides needs to be left in the past.
This transcript has been edited for clarity and brevity.
HealthLeaders: What is your new role affording you and how are you finding it so far?
Meyer: It gives me the opportunity to really think about how we have to redesign the economics of healthcare from the payer and provider perspective to create a sustainable model. Because right now, we are pretty much in a semi crisis mode, particularly for hospitals and healthcare systems in terms of the economic dynamics of the significant increases in expenses and a flattening of the revenue stream over the last 18 months or so as we've been through the pandemic. We've seen these dramatic changes in economics for hospitals and health systems that is an unsustainable situation. So I feel like I'm in a unique opportunity to try to find a much better future that gives us an opportunity to create more sustainability.
HL: You mentioned that hospitals and health systems right now are in a semi crisis mode and the economic challenges are plenty. What specifically have you found to be of the most concern?
Meyer: I think the biggest concern is really workforce. Between burnout issues and the rise of the nursing workforce shortage, that's profound. And what that has led us to is to have a significant increase in travelers and even foreign nurses coming in just to be able to provide the appropriate care at healthcare sites, particularly in hospitals and health systems. And that's led to very significant increases in costs in patient settings and facility-based settings, but also in doctors' offices because you just have to pay a premium in order to get the staff to be able to take care of patients.
I think second to that is supply chain. Inflationary costs in the supply chain are no different and actually at some level worse than what we've seen in food and housing and other kinds of pricing in this country. In terms of inflation, we've had double-digit inflation in those arenas over the last three years. In healthcare, the same kind of thing with pharmacy costs having had double-digit inflation over the last three years. And those three things combined have just led to a dramatic rise in the expense equation for the facility-based side of the healthcare world.
Pictured: Bruce Meyer, executive vice president and market president for Western Pennsylvania, Highmark Health.
HL: On the payer side, how do you see these problems trickling over?
Meyer: On the payer side, we face a similar dramatic issue, which is that employers and the federal government pay for the vast majority of care in this country. And we've been shifting costs of care onto employers in one way or another, whether they're self-insured or commercial. Employers have reached a point where that continuing inflationary cost of healthcare has simply become unsustainable for them. Employers have said 'I can't sustain this continued increase' and so there is incredible pressure on plans to find ways to plateau the inflationary increase or just cap off increased costs in terms of healthcare.
That's why we've seen a dramatic shift from commercial insurance to self-insured insurance because that's a way for people to help control their costs a little more. Then the onus entirely becomes on the individual and health literacy in this country has not reached a point where individuals really understand cost of care and can make good decisions on their own. Yet that's obviously a goal for us.
HL: What strategies do you feel payers can utilize right now to deal with these challenges?
Meyer: Without tooting the horn of Highmark and what Highmark is trying to do in our catchment area, I think there's got to be a much better partnership between payers and providers. We, for the most part in this country, have had relatively adversarial relationships between payers and providers in which payers kind of view providers as folks who are just spending money unnecessarily and providers look at payers as folks who have a giant pool of money sitting somewhere in a vault somewhere that they're simply not giving to providers for the work that they are doing. And although that's simplistic, it's very real. And that adversarial relationship has been going on for 40 years in this country. It's just accelerated significantly through the pandemic because with significantly less spending for healthcare, payers were able to do well because they still received the payments from the government and from the businesses, but providers struggled mightily because they weren't seeing volumes and getting revenues in.
I think that the solution is that we've got to find a way to partner. We've got to find a way to work together to find a better future for the economics of healthcare in this country. Because our current economic trajectory is truly unsustainable. And what we cannot do is say that there's a winner and a loser in that economic equation. Because ultimately, the loser is the public who need healthcare, and particularly the disadvantaged among us who have poor access or poor health literacy in terms of being able to live their best lives.
A KLAS report examines purchase decisions to better understand what organizations value when it comes to claims management.
When choosing vendors for their claims management, healthcare organizations look for functionality first and foremost, according a report by KLAS.
The research compiles claims management purchase decisions of 24 organizations between February 2020 and November 2022 to assess what factors are at play in the search for vendors.
"The financial well-being of healthcare organizations is critical, especially given the macroeconomic pressures they face today," the authors wrote. "Many are looking at claims management and clearinghouse technology to maximize cash collections and reduce administrative burdens."
Functionality was far and away the top reason for consideration or selection of a claims management vendor, chosen by 83% of respondents.
More specifically, 55% of organizations said the functionality they value the most is a solution that saves time and simplifies claims processing. That was followed closely by claims scrubbing, or full control over editing and customizing rules (50%), and reporting/analytics that provide visibility into outcomes and denial prevention (45%).
On the lower end of desired functionalities were help with provider credentialing and payer enrollments (10%), notifications about payer updates (10%), and coordination of benefits and real-time eligibility (7%).
After functionality, "other" was chosen the most often among reasons, selected by half of respondents. "Other" includes consolidation, expertise, reputation, road map, sales experience, and user experience.
Organizations also showed a preference for existing vendor relationship (46%), cost (42%), and integration (33%).
The report also revealed overall performance scores for vendors, based on customer respondents:
Experian Health: 90.1
Olive: 89.2
Quadax: 88.0
Waystar: 87.3
SSI Group: 87.2
Availity: 87.0
FinThrive: 84.0
Change Healthcare: 76.6
A recent survey conducted by Experian Health looked at the state of claims and solutions organizations can utilize.
Among 200 healthcare professionals surveyed, nearly all indicated they had technology in place to help improve claims and reduce denials, with more than half (52%) having updated or replaced their existing claims process technology, and 45% saying they automated tracking of payer policy changes. Providers also invested in patient portals (44%), accurate estimates (40%), and digitizing the registration process (39%).
The federal agency will likely claim back billions of dollars in overpayments from health insurers that operate Medicare Advantage plans.
Payer organizations have expressed their disappointment for the Medicare Advantage Risk Adjustment Data Validation (RADV) final rule released by CMS, claiming the auditing standards will have the "potential unintended consequence" of harming beneficiaries.
The rule, which will allow the federal agency to collect billions of dollars in overpayments, eliminates the fee-for-service adjuster in RADV audits, a method to assess for a permissible level of payment errors.
However, the rule will only apply to audit findings beginning with the payment year 2018, rather than 2011 as previously proposed, absolving payers of significantly more in overpayments.
"CMS has a responsibility to recover overpayments across all of its programs, and improper payments made to Medicare Advantage plans are no exception," HHS secretary Xavier Becerra said in a statement. "For years, federal watchdogs and outside experts have identified the Medicare Advantage program as one of the top management and performance challenges facing HHS, and today we are taking long overdue steps to conduct audits and recoup funds."
Health insurer groups have bristled at the rule, insisting that it will raise costs for plan members and limit their access to care.
Matt Eyles, president and CEO of AHIP,stated: "Our view remains unchanged: This rule is unlawful and fatally flawed, and it should have been withdrawn instead of finalized. The rule will hurt seniors, reduce health equity, and discriminate against those who need care the most. Further, the rule would raise prices for seniors and taxpayers, reduce benefits for those who choose MA, and yield fewer plan options in the future."
Mary Beth Donahue, president and CEO of Better Medicare Alliance, a Medicare Advantage advocacy group, echoed the sentiment.
"While our review of the rule is ongoing, we are focused on the potential unintended consequence of creating an environment of higher premiums and fewer benefits for the more than 29 million seniors and people with disabilities who choose Medicare Advantage," Donahue said.
Meanwhile, David Merrit. Blue Cross Blue Shield Association senior vice president of policy and advocacy, stated: "CMS should have implemented a narrower solution aimed at a few bad actors, but instead this overreaching regulation will raise costs, reduce choice and make it more difficult for seniors and those with disabilities to effectively manage their health."
New research investigates the financial impact of reimbursing telehealth services at parity with in-person care.
Private health insurers were reimbursed similarly for telehealth and in-person visits in 2020, according to analysis from the Peterson- Kaiser Family Foundation Health System Tracker.
The research used data from the Health Care Cost Institute for the 2020 calendar year to examine the cost benefit to payers for reimbursing services provided through telehealth.
After looking at the average paid amount for evaluation and management claims and mental health therapy claims controlling for variation across providers, regions, and the severity of the claims, researchers found little difference between telehealth and in-person services.
"Telehealth use surged with the COVID-19 pandemic as patients sought access to services while providers implemented social distancing protocols," the researchers wrote. "Early in the pandemic, many payers eased restrictions on the use of telehealth and increased reimbursement rates to encourage its use."
For established patients at severity level one, payments were $34 for telehealth and $33 for in-person. At the highest severity level (five), the gap was $143 for telehealth and $137 for in-person.
For new patients, the difference in payments was also negligible—$61 for telehealth and $63 for in-person at severity level one, while severity level five was $273 and $267, respectively.
The trend held true for mental healthcare as well. The researchers found that 52% of mental health therapy claims for people with private plans were delivered over telehealth, with both the lowest (30 minutes of psychotherapy) and highest (psychiatric diagnostic evaluation with medical services) claims dead even in payments for telehealth and in-person.
Additionally, the analysis looked at how paid amounts varied within each provider. Among most of the providers offering the same service by telehealth and in-person, the average paid amount for claims delivered over telehealth was within plus or minus 10% of the payment for in-person claims.
Telehealth serves to increase access and convenience for patients, but if it encourages more utilization of services, it could mean greater spending for payers.
The key factor for the evolution of telehealth is how insurers reimburse services, the researchers concluded.
"We do not know at this point if private insurers continue to pay for telehealth in parity with in-person care," they wrote. "However, if telehealth payments continue to be the same as those for in-person care, then this raises questions as to whether telehealth will reduce the spending on common health services, as some have predicted."
A study finds integrating medical, pharmacy, and behavioral benefits reduces total costs, benefiting both employees and employers.
Focusing on health outcomes and affording employees a more personalized healthcare journey can save employers money, according to a study by Cigna.
Aon, the firm that conducted the study, analyzed medical claims of over two million Cigna members who receive coverage through their employers from 2020 to 2021.
The findings showed that Cigna's integrated employer clients saved $148 per member per year in 2021.
Cigna then used a similar study method to determine the financial impact of having employees participate in health improvement programs, such as wellness coaching, and found increased savings of over $1,400 per member per year.
When members with specific high-cost conditions and therapies were enrolled in a triple-integration plan and needed speciality medicines, the savings were nearly $9,000 per member per year. That increased to more than $11,000 when the speciality drug was for an inflammatory conditions like rheumatoid arthritis and nearly $17,500 for members who took speciality drugs and have a confirmed depression diagnosis.
"Integrated benefits provide a real-time, connected platform that enables us to anticipate our customers' unique health needs and support them as they make important health care decisions – driving lower costs over time," said Katy Wong, chief pharmacy officer of Cigna Pharmacy.
"There is tremendous value for employers in having this holistic view across the continuum of care for their workforce. It produces significant savings on health care, which they can pass along to their employees, and it also improves the health of their workforce, which fuels productivity and business growth."
Additionally, the study found that integrating benefits can help lower the costs of chronic conditions. When members were enrolled in a triple-integrated plan, nearly $400 were saved per year for members with a musculoskeletal diagnosis, more than $1,400 saved per year were when an individual with a musculoskeletal diagnosis was engaged with a health coach, and almost $2,500 saved per member per year with a diabetes diagnosis.
Members with integrated benefits and support from health improvement programs also needed fewer emergency room visits and fewer costly invasive in-patient procedures, the study revealed.
Members with diabetes had a 17% lower rate of avoidable emergency room visits, while members with musculoskeletal conditions experienced 133% lower rate of surgeries in an in-patient setting, 26% lower rate of opioid overdoes, and 16% fewer interventional procedures.
Todor Penev, commercial analytics leader at Aon, said: "Employers should feel confident that integrated benefits deliver on the promise of improved health outcomes and ultimately lower the financial risk to the employer, helping build a more resilient workforce."
Findings from a survey reveal shared negative experiences with surprise billing, billing estimates, and medical debt.
As more and more people continue to choose high-deductible health plans (HDHPs), the patient financial experience is likely to include issues related to medical billing, according to a YouGov survey commissioned by revenue cycle firm AKASA.
The survey fielded responses from 2,206 individuals, including 179 with employer-sponsored HDHPs, between March 9 and March 14, 2022.
When asked if they had ever received a surprise medical bill, 50% of the individuals with employer-sponsored HDHPs said they had.
Respondents were also asked if they had ever received a bill that did not match the upfront price estimate for care or services. More than half (53%) with employer-sponsored HDHPs answered yes.
Negative experiences among the respondents during the billing process didn't just end at receiving the bill but extended into medical debt.
More than a third (34%) of those with HDHPs said they had been harassed by a medical debt collector before, while 44% of individuals with HDHPs stated they had experienced financial hardship from bills.
"Enrollment in high deductible health plans grew 43% from 2014 to 2019, and with it has come a similar rise in patient responsibility for payments," said Amy Raymond, VP of revenue cycle operations at AKASA.
"With high health insurance premiums, deductibles, and cost of care, patients are shouldering more of the financial burden of healthcare. This has led to increasing rates of bad debt for hospitals and health systems. Providers must modernize their systems with options that drive more consistent patient behaviors in paying for services."
Another survey commissioned by AKASA found that medical bills are more likely to come across as confusing than straightforward to patients.
In that survey, more respondents either found bills extremely confusing (19%) or somewhat confusing (19%), compared to those that said bills are not confusing (11%) or leaned towards bills not being confusing (14%).
A survey of privately and publicly insured individuals highlights the need to improve the healthcare financial journey.
Many patients are at their wits' end when trying to correct a billing error—an issue that crops up far too often, according to a study from Zelis and Hanover Research.
The findings were gathered through an online survey to 800 privately and publicly insured adults who had found at least one medical billing error in the last five years.
More than two in five respondents (41%) said they are significantly frustrated trying to address billing errors, with only 30% expressing extreme confidence in their ability to identify an error in their bill.
Knowing who to contact and how to find the right contact information were identified as the two biggest hurdles during the bill correction process, suggesting that the patient financial experience is too complicated.
When patients did notice an error, it was either by comparing charges with estimated costs (32%), comparing charges to explanation of benefits (29%), or noticing items on the bill that differed from their care experience (29%).
Most of the respondents (62%) said saving money is the primary motivator for correcting a billing error, with half the respondents reporting incorrect charges of at least $200 and a quarter experiencing a difference of more than $500 in the past five years.
The bill resolution process can not only be confusing, but time-consuming as well. Forty three percent of respondents spent up to one month getting bills corrected, while 70% spending more than two hours on the process.
As such, 80% of patients believe their health insurance plan could have a more well-defined process to deal with billing errors, as well as better service, clearer options, and more efficient resolutions.
"Our research reinforces that healthcare billing systems are complicated, and bills can be complex and with the potential for errors," Michael Axt, chief member empowerment officer at Zelis, said in a statement.
"This negatively impacts healthcare consumers, particularly those with lower incomes or less health literacy. Healthcare organizations have an opportunity to reduce friction in the billing process to support consumers and create a more seamless healthcare financial journey."
A separate YouGov survey commissioned by revenue cycle firm AKASA further establishes how befuddling medical bills can be for patients.
More respondents either found bills extremely confusing (19%) or somewhat confusing (19%), compared to those that said bills are not confusing (11%) or lean towards bills not being confusing (14%).
Being able to understand what they're being billed for (29%) was chosen as the biggest source of frustration, while uncertainty on if they can pay the bill (27%) was a close second.
More people than ever have enrolled in the program, which makes up nearly half of all Medicare beneficiaries.
Medicare Advantage (MA) plans now have a record-high 30 million enrollees, according to new data released by CMS.
The numbers, as of the January 1 payment which reflect enrollments accepted through December 2, 2022, illustrate MA's continued growth in reaching the milestone and beyond.
In 2022, MA had more than 28 million enrollees, which accounted for 48% of the eligible Medicare population, according to analysis by Kaiser Family Foundation.
"With more than 30 million seniors and people with disabilities now enrolled in Medicare Advantage - nearly half of all who are eligible for Medicare – it is a huge endorsement of the value of this program," Matt Eyles, president and CEO of AHIP, said in a statement.
"This milestone shows that people are choosing MA for better affordability and health outcomes. The continued growth of the program is a testament to the tremendous value MA offers to all enrollees, and especially those with chronic illnesses who require care coordination and management, as well as those with low incomes who rely on MA's access to additional benefits at little or no cost."
Much of the new MA enrollment growth can be traced to members switching over from traditional Medicare, research published in JAMA Health Forum found.
A higher rate of members switched from traditional Medicare to MA than in the opposite direction from 2017 to 2020. The switching rates contributed to new MA enrollment growth, rising from 49% in 2016 to 67% in 2020.
A report by the Commonwealth Fund revealed that more benefits and a limit on out-of-pocket costs are the main drivers of older adults choosing MA plans.
About one in four (24%) respondents surveyed cited additional benefits as their reason for choosing MA, followed by out-of-pocket cost limits (20%).
High volume has created a backlog that federal departments have to sift through to review and process disputes.
The No Surprises Act may be preventing unexpected bills, but the law's independent dispute resolution (IDR) process is being used significantly more than the federal government anticipated, according to a government report.
HHS, the Department of Labor, and the Department of the Treasury released statistics on the IDR process from April 15 to September 30, 2022, detailing how often providers and payers utilized arbitration to resolve disagreements over payment for items and services after an unsuccessful negotiation period.
The IDR portal was opened on April 15, 2022, just over 15 months after the No Surprises Act was signed into law to protect patients from surprises out-of-network bills. The Departments estimated that 17,333 claims would be submitted in the IDR process annually.
In reality, the IDR process saw 90,078 disputes over the aforementioned period in the report, far and away outpacing expectations.
The Departments state that disputes reached 18,163 in the second quarter (April 15 to June 30, 2022), including disputes over items and services that would have been eligible for the Federal IDR process beginning January 1, 2022, when the surprise billing protections became effective.
The third quarter (July 1 to September 30, 2022) saw nearly four times as many disputes as the second quarter, totaling 71,915.
Most of the disputes in the second and third quarters were for emergency or non-emergency items or services and most of those disputes were submitted by out-of-network providers and facilities.
Of the total disputes initiated, 23,107 were closed, 3,576 reached a payment determination, and 15,895 were found ineligible for the IDR process. The remaining closed disputes were either withdrawn by the disputing parties, were closed because the parties reached an outside settlement, or were closed for other reasons, such as incorrect batching, data entry errors, or unpaid fees.
The backlog of disputes is due to the review and processing time needed to determine the eligibility of disputes.
"It is within this context that the Departments are working to enhance the Federal IDR portal's ability to intake and process disputes and associated data," the report stated.
Providers and payers have struggled to get on the same page on how the IDR process should be settled, with medical associations filing multiple lawsuits contending the emphasis on the qualifying payment amount, or the median in-network rate.
According to analysis by the Commonwealth Fund, providers are favored in some states' IDR process compared to the federal system, which could lead to higher payments for providers.
Marketing practices have caused CMS to put rules in place to curb deceptive or inaccurate ads.
Medicare Advantage (MA) marketing has come under scrutiny for unscrupulous tactics, but where exactly is it coming from?
According to a report from the Commonwealth Fund, non-government entities account for one-third of all Medicare-related search records and 87% of all search engine ads, creating confusion for beneficiaries and consumers struggling to select an appropriate health plan.
"Medicare Advantage plans are promoted through direct mailings, telemarketing, and advertising on radio, television, websites, and social media channels," the researchers state. "No organization, including the federal government, directly 'markets' traditional Medicare, although commercial insurers sell supplemental Medigap and Part D plans for people in traditional Medicare. Thus, nearly all beneficiaries are subject to some form of marketing effort."
When users search for information on Medicare, 20% of the records are from agents, brokers, or partners, while 16% are from health plans. CMS is responsible for the largest share of search records at 27%.
When it comes to search engine ads, agents, brokers, and partners make up 55% and health plans an additional 32%. CMS only has 7% of the ads, tied with other for-profit organizations.
While 40% of Medicare beneficiaries do not receive any help with their plan choice, the ones that do most often turn to brokers and agents for guidance – 30% in traditional Medicare and 31% in MA.
As brokers and agents are paid commission by insurers, beneficiaries can be negatively influenced. Researchers for the Commonwealth Fund highlight that CMS has reported more than 41,000 complaints in 2021 about Medicare private plan marketing, which was double the number in 2020 and up from about 6,000 in 2017.
To alleviate complaints and combat misleading marketing practices, CMS has proposed a ruleto prohibit ads that don't mention a specific plan name, as well as ads that use words, imagery, language, or logos that can be confusing and deceptive.
It is unclear, however, if the restrictions put in place will affect outcomes. Researchers believe more needs to be done to better understand what information is accessible for Medicare beneficiaries.
"Additionally, more information about agent and broker compensation — including overrides and payment for other services such as health risk assessments, as well as more transparency around the relationships between health care providers, TPMOs, and insurers — could help CMS ensure a level playing field and assess whether compensation and other financial arrangements are aligned with beneficiaries' interests," the researchers concluded.