The Senate Finance Committee is calling for MA plans to get their provider directories in order with the aim of improving mental health parity in Medicare and Medicaid.
Senators released a discussion draft with policiesto put access to mental health and substance use disorder services on the same level with physical healthcare — the fifth and final legislative draft the committee has released focusing on its bipartisan initiative of advancing mental health.
"Too often the notion of mental health parity falls short of reality," Senate Finance Committee chair Ron Wyden said in a statement. "These policies represent the first step towards addressing the mental health parity and ghost network challenges that I intend to build on in the coming months -- especially the challenges I hear about consistently from families at home who aren't able to find available mental health professionals covered in their insurance networks."
The policies include codifying existing requirements for MA plans to maintain updated provider contact information, whether a provider is accepting new patients, and in-network status changes within two days.
The discussion draft also calls for a Government Accountability Office study on the differences in enrollee cost-sharing and utilization management between behavioral and non-behavioral health services in MA and compared to free-for-service Medicare.
"These proposals will help us gather additional data and increase transparency to ensure Medicare beneficiaries have access to affordable mental health services, on par with their access to physical health services," committee ranking member Mike Crapo said.
A survey of health plans finds prior authorization processes need improvement to become fully electronic.
While the healthcare industry is moving towards automation as a whole, prior authorization (PA) still has plenty of room for growth.
An industry-wide survey conducted by America's Health Insurance Plans (AHIP) fielded responses from 26 health plans covering 122 million commercial enrollees from February to April to better understand PA practices from the perspective of payers.
The survey revealed the top barriers to prior authorization automation for insurers, which were led by providers not using electronic health records (EHR) enabled for electronic PA and the high costs to upgrade EHR.
The top five reasons were:
Provider does not use EHR enabled for electronic PA (71%)
Costly/burdensome for providers to buy/upgrade HER for electronic PA (71%)
Lack of interoperability between EHR vendors (62%)
Costly/burdensome for payers to enable PA rules and information to be delivered electronically (43%)
Lack of electronic PA solutions on market (19%)
Payers reported that a significant percentage of PA requests continue to be submitted manually by providers. The breakdown for prescription medications was 61% electronic and 39% manual, while medical services were 60% manual and 40% electronic.
The use of electronic PA was the most chosen method of streamlining PA for respondents, with 88% automating medical services and 75% automating prescription medications.
On the other side, many providers feel the burden of prior authorization still falls on them.
A survey by the American Medical Association (AMA) revealed that physicians feel payers are not upholding a 2018 voluntary agreement on PA reforms between them, the AMA and other national organizations.
Only 26% of the responding physicians reported that their electronic health record system offers electronic prior authorization for prescriptions.
A study finds variation between rates for insured and uninsured at the same hospital and differences in cash prices across hospitals.
Insured patients have an expectation that their health plan allows them to pay less for hospital services, but that may not necessarily be the case.
According to a study by a Trinity College economist, payer-negotiated rates for insured patients are often higher than self-pay cash prices for the same services.
Ruiz Sánchez examined data on 14 shoppable hospital services that can be scheduled by patients in advance, including office visits, MRIs, and CT scans. Hospitals have had to disclose prices under the price transparency law, which went into effect on January 1, 2021. Data made available through the federal rule was compiled within the Turquoise Health dataset, consisting of records on about 2,200 hospitals.
The research was focused on the payer-specific negotiated rates charged to major insurers Aetna, Blue Cross Blue Shield, Cigna, Humana, and United Health, as well as government-related payer plans like Medicaid, Medicare, Tricare, Veterans Affairs and state agencies insuring state employees.
The findings revealed that 60% of negotiated rates were higher than the cash prices for the same services.
Additionally, there was also significant variation between cash prices across hospitals, with costs for the same service being as much as eight times more expensive depending on the hospital.
"Individuals purchasing private health insurance are paying monthly premiums … under the promise that their insurer is also negotiating the lowest possible rates for services," Sánchez said.
"This raises the question whether it is evidence of poor bargaining by insurers, who are representing consumers, in their negotiations with hospitals."
A recent study also found that some insurers negotiate prices for common radiology services less efficiently than their competitors, as well as across other health plans under their management.
The research, published in Radiology, found that on average, the maximum negotiated price for shoppable radiology services was 3.8 times the minimum negotiated price in the same hospital and 1.2 times in the same hospital-insurer pair.
Another study published in The American Journal of Manage Care found that payers generally negotiate lower amounts for health insurance exchange plans than their commercial group rates and significantly more than their Medicare Advantage contracts at the same hospital.
The health insurer is focused on advancing health equity to address the health needs of all communities.
Twenty-one of Elevance Health's affiliated Medicaid plans have earned accreditation for health equity from the National Committee for Quality Assurance (NCQA), the health insurer announced.
The plans, which serve more than eight million beneficiaries and span 20 states, are the first to receive a full three-year accreditation, according to Elevance. The NCQA health equity accreditation gives organizations, health systems, and health plans an actionable framework for evaluating and elevating the health of the populations they serve.
”Advancing health equity is a priority for everyone at Elevance Health, and we hold ourselves accountable for addressing the root causes that drive poor health outcomes,” said Aimée Dailey, president of Medicaid at Elevance Health.
”Ninety-three percent of our Medicaid members are now served by a health plan that has earned this health equity accreditation, a scale unmatched in the industry. It's an opportunity to continue to address the unique needs and improve the health of the diverse communities we serve.”
Elevance Health, formerly Anthem, states that it has a "health equity by design" philosophy, which allows the insurer to address inequalities and whole health through a personalized approach.
One example of that philosophy in action was when the insurer enrolled 20 Medicaid leaders in a course on advancing health equity through the Harvard T.H. Chan School of Public Health earlier this month.
”While our ongoing work to advance health equity, specifically with this accreditation, is something to celebrate, it is just the beginning," said Dr. Darrell Gray, II, chief health equity officer at Elevance Health. "It's the foundation from which we will continue to innovate in our partnerships and journey towards designing an ecosystem in which all people, regardless of race or ethnicity, age, sexual orientation, gender identity, disability, and geographic or financial access can receive individualized care that optimizes their health and well-being."
The NCQA announced in September that nine organizations had earned the first accreditation as part of its Health Equity Accreditation (HEA) Plus advanced evaluation program.
Those nine entities were part of NCQA's HEA Accreditation Plus Pilot, with the Plus designation building on the NCQA's existing Health Equity Accreditation program by highlighting organizations "further along on their health equity journey."
New customers are flocking to Affordable Care Act (ACA) Marketplace health plans in the early stages of the open enrollment period.
Nearly 3.4 million Americans have chosen an ACA Marketplace plan through the first three weeks of the OEP, the Biden administration announced.
The total number of enrollees represents a 17% increase over last year, with HealthCare.gov experiencing 40% more sign-ups compared to 2021.
"We are off to a strong start – and we will not rest until we can connect everyone possible to health care coverage this enrollment season," said HHS Secretary Xavier Becerra. "The Biden-Harris Administration has taken historic action to expand access to health care, and ensure everyone can have the peace of mind that comes with being insured."
Becerra also highlighted that every four out of five people are eligible for coverage at $10 or less and potential enrollees can explore affordable plans at HealthCare.gov.
The website had 493,216 new enrollees, compared to 354,137 on the same date last year.
Meanwhile, total Marketplace plan selections include 655,000 people (19%) new enrollees and 2.7 million people (81%) who renewed or chose a new plan for 2023.
The early numbers are encouraging for the administration as the OEP continues to run until January 15, 2023.
"Providing quality, affordable health care options remains a top priority," said CMS administrator Chiquita Brooks-LaSure. "The numbers prove that our focus is in the right place. In the first weeks of Open Enrollment, we have seen an increase in plan selections and a significant increase in the number of new enrollees over the previous year."
Earlier this year, on its 12th anniversary, ACA enrollment hit a record-high of 14.5 million people signing up, a 21% increase from the previous year.
The administration is prioritizing ACA growth and the results in 2022 are indicative of that.
Lawmakers take issue with the importance of the qualifying payment amount (QPA) in the independent dispute resolution (IDR) process.
The House Ways and Means Committee is the latest group to call for changes to the No Surprises Act final rule, arguing that the QPA remains too big of a factor in the IDR process.
In a letter to HHS, the Department of Labor, and the Department of the Treasury, the leaders state they are "severely disappointed to find that the August 2022 final rule violates the No Surprises Act in the same ways as before."
The IDR process allows providers and insurers to enter into arbitration when they cannot agree on fair reimbursement. After the government released the interim final rule in 2021, the Texas Medical Association filed a lawsuit alleging the rule required arbitrators to heavily weigh the insurer-calculated QPA in deciding the rate. A federal judge ruled in favor of TMA in February before CMS released a revised final rule in August, which TMA once again challenged and other major medical associations criticized.
Specifically, the committee highlights in the letter the departments' creation of a 'double counting' test, which directs IDR entities to "consider whether the additional information is already accounted for in the QPA."
Lawmakers argue that while the No Surprises Act requires IDR entities to separately consider all of the statutory factors, the final rule prevents entities from considering factors like patient acuity and the item or service unless providers meet the burden of disproving double-counting within the QPA.
"As written, this perpetuates the flaws of the interim final rules and continues to unfaithfully implement the statutory text and intent of the law by skewing the determination of the IDR process toward the QPA," the committee writes.
To stay true to the "Congressional intent" of the No Surprises Act, the lawmakers ask the departments to swiftly adjust portions of the final rule by taking immediate steps.
Research by America's Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association (BCBSA) looks at the effects of the law.
The No Surprises Act (NSA) successfully protected more than nine million Americans from surprise bills in the first nine months since going into effect, according to new data by AHIP and BCBSA.
However, the unintended results of the law have been a boom in claims to the federal independent resolution process (IDR). The survey found that providers have submitted over 275,000 arbitration claims, nearly 10 times more than originally anticipated.
The IDR process is meant to serve as a last option when providers and insurers cannot reach an agreement on fair reimbursement. Excessive use of the process creates unnecessary costs.
"A health care emergency should not lead to a financial crisis. The No Surprises Act has now protected 9 million Americans from receiving costly surprise medical bills from care providers—a huge win for patients," said David Merritt, senior vice president of policy and advocacy for BCBSA.
"However, the tens of thousands of arbitration claims filed by providers clearly demonstrate that more needs to be done to ensure that they don’t abuse the system for their financial gain. We'll continue to work on behalf of patients to protect everyone from surprise medical bills—and lower health care costs with an effective resolution process."
To collect the data, AHIP and BCBSA fielded a nationwide survey to 84 insurers with group health plans and qualified health plans, with 33 payers, making up 57% of the total commercial market, responding.
Using the insurers' commercial enrollment and number of claims between January and September this year, researchers reached a national estimate on the number of NSA-eligible claims (9,367,031) and claims submitted to IDR (275,245).
While the research suggests the NSA is working as intended, another survey by Morning Consult from June found that one in five patients received a surprise bill in 2022. Those bills have been especially costly in some cases, with 22% of respondents saying their chargers were over $1,000.
Meanwhile, the IDR process has continuously been under the spotlight as providers have been unhappywith the rule, claiming it favors payers by heavily factoring in the insurer-calculated qualifying payment amount.
Seven of the 19 Commonwealth facilities surveyed did not have information on discounted cash prices.
Hospitals nationwide have been slow to get up to speed on price transparency compliance and hospital-dense Massachusetts is faring no better, according to a new report by Pioneer Institute.
The survey analyzes 19 facilities on 35 of the 70 shoppable services required by CMS as part of the price transparency law, which took effect on January 1, 2021.
Researchers found that that compliance rates ranged from 60% at Emerson Hospital to 97% at Mass General, while seven hospitals had no information on discounted cash prices — the price for self-pay patients.
Those seven hospitals were Boston Children's, Falmouth, Holyoke Medical Center, MetroWest Medical Center, Mount Auburn, New England Baptist and St. Vincent's.
"Our earlier work found disappointing compliance with Massachusetts' 2012 healthcare price transparency law," said Pioneer executive director Jim Stergios. "And now we find that compliance with the federal law isn't much better. We are not insensitive to the challenges providers are facing, but it is disappointing that compliance with the law has not budged much since 2017, when Pioneer began monitoring hospital price transparency efforts."
The 12 hospitals that did provide some discounted cash prices had pricing discrepancies. For example, the survey highlighted that an MRI of a leg joint was more than $3,400 at Mass General and Brigham and Women's, but $775 at Carney 10 miles away.
"The disparities we observe strongly suggest a market dominated by the systems that are able to maintain prices above competitive norms," said report author Barbara Anthony. "This is why it's crucial that consumers, employers, benefit managers and insurers have ready access to provider prices."
Where the surveyed hospitals did relatively well in was providing prices in machine-readable formats (MRF), which not necessarily for the benefit of consumers due to its lack of user-friendly readability. Only two of the 19 hospitals had no MRF data.
To improve price transparency compliance, the authors of the survey offer recommendations, including: hospitals appoint a single administrator to be in charge of adherence, the federal government provide guidance to hospitals on how to make pricing information more consumer-friendly, CMS enforce the law more strongly, and the Massachusetts state government come up with incentives for hospitals to comply.
After hospitals got off to a slow start with compliance, an October report by Turquoise Health revealed that 76% of facilities have posted a MRF, 65% have posted an MRF with negotiated rates, and 63% have posted an MRF with cash rates.
Nonetheless, the Office of Inspector General recently said it will be keeping an eye on CMS' enforcement of the law after the agency resisted on issuing fines for violations until June.
In a letter to CMS, lawmakers highlight five steps they want the agency to take to counter deceptive practices.
U.S. senators have asked CMS to take action to protect beneficiaries from harmful Medicare Advantage (MA) marketing tactics through further oversight and regulations.
Thirteen senators penned a letter to the agency outlining five changes CMS can make through notice and comment rulemaking and sub-regulatory guidance as soon as possible.
The letter comes after the Senate Finance Committee's investigation into MA marketing practices, which found a "concerning pattern of misleading advertising materials, aggressive marketing tactics, and in some cases flat-out deception harmful to beneficiary access to care and health outcomes," the senators wrote.
Complaints over MA marketing are not new, with the letter pointing to when Congress addressed abuses in 2008 and CMS issued civil monetary penalties to MA plans. However, the senators state that the Trump administration weakened protections and found workarounds to take advantage of beneficiaries.
The letter commends CMS for implementing the changes it already has, which includes a new policy, effective January 1, 2023, which would require CMS approval before running television advertisements for MA or Part D prescription drug plans.
The following five steps would strengthen protections further, the senators argue:
Reinstate requirements loosened during the Trump administration: This includes banning educational and marketing events from occurring on the same day at the same location.
Monitor MA disenrollment patterns and use enforcement authority to hold bad actors accountable.
Provide clear guidelines and trainings to ensure agents and brokers understand and adhere to best practices: Agents and brokers should be accountable
Implement robust rules around MA marketing materials and close regulatory loopholes that allow cold-calling.
Support unbiased sources of information beneficiaries, including State Health Insurance Assistance Programs and the Senior Medicine Patrol.
"We share the same goal to enable the offering of MA plan choices that are valuable to seniors and people living with disabilities," the senators wrote. "Yet, our first responsibility is to protect beneficiaries and the integrity of the MA program from fraudsters and scam artists who look to take advantage of any opportunity to prioritize profits over beneficiary health and well-being."
Housing and food security programs led the way for spending on social determinants of health (SDOH) by payers between 2017 and 2021.
SDOH have been identified as worthwhile investments by health organizations, but insurers are not putting their money where their mouth is, according to a study published in the Journal of General Internal Medicine.
The research, which examines social spending by the top 20 payers in the nation based on market share rankings by the National Association of Insurance Commissioners, found miniscule investment on SDOH by insurers relative to their net income.
Between January 1, 2017, and December 31, 2021, the total spending for the top 20 insurers was at least $1.87 billion, with the top six payers by market share making up 72%. The top six, on average, spent 0.11% of their net income on SDOH in 2017 and 0.67% in 2021. Spending in 2020 peaked at 1.6%, which the researchers attribute to the COVID-19 pandemic.
To quantify social spending, researchers searched news articles and press releases that included insurer name and terms "social determinants of health" or "community health." Social spending was categorized into housing, food security, employment, education, social and community context, transportation, and "general SDOH" for ambiguous reporting.
The researchers acknowledged their method could have blind spots with missed investments by insurers not publicly posted. They also recognize they may have misclassified investments depending on when they were publicized.
Investments in mental health, substance use, domestic violence, natural disaster relief, technological infrastructure, community health workers, and racial equity initiatives without specifically mentioning SDOH were excluded from the study.
The majority of payers' spending was on housing ($1.2 billion) and food security ($238 million) programs, while $247 million was classified as general SDOH.
The areas that saw the least investment were transportation ($13.4 million), social and community context ($49.7 million), education ($57.2 million), and employment ($58.6 million).
The spike in SDOH spending in 2020 coincided with significant profit for insurers, but the researchers posit that the uptick in investment was due to urgency around the pandemic and not necessarily based on an increase in net income.
Regardless, the study suggests that payers have the capability to put more money into SDOH initiatives, though investing more in other areas may be more of a priority.
"Whether insurers should spend more on these programs is unclear considering that these dollars may be instead used to lower patient premiums and cost-sharing," the authors wrote. "The impact of insurer social spending remains equivocal, though practice patterns, such as considering SDoH in hypertension guidelines, will continue to change as payers and providers make more investments."