States will have the opportunity to give additional benefits through the use of "in lieu of services and settings."
HHS is offering states greater flexibility to address health-related social needs for people enrolled in Medicaid, the department announced.
As part of the Biden administration's efforts to bolster Medicaid, the initiative gives states an opportunity to provide alternative benefits through the use of "in lieu of services and settings" in Medicaid managed care.
The benefits focus on a range of unmet social needs, such as food insecurity and housing instability, to help beneficiaries maintain their coverage as well as improve their health outcomes.
"We are deeply committed to strengthening Medicaid for the millions of Americans covered by it," HHS secretary Xavier Becerra said. "Today's step ensures people with Medicaid receive the broader care they need to live safe and healthy lives. We call on all states to leverage these innovative options and stand ready to partner with them in providing essential health care services."
CMS administrator Chiquita Brooks-LaSure said: “Today’s announcement is the next step in CMS' effort to use every lever available to protect and expand coverage for all eligible individuals as we work with our state partners to offer whole-person care.”
HHS stated that the initiative also allows states to adopt in lieu of services and settings to provide tailored meals for people with severe, chronic conditions that are worsened by poor diet, living in "food deserts," or not having access to nutritional choices.
The announcement additionally establishes the requirements and guardrails states must meet to ensure the actions are medically appropriate, cost effective, preserve enrollee rights and protections, and fulfill Medicaid objectives.
Most of the new Medicare Advantage enrollment growth can be attributed to members switching over from Medicare.
A higher share of beneficiaries switched from traditional Medicare to Medicare Advantage (MA) than vice versa in 2020, contributing to recent MA growth, according to research published in JAMA Health Forum.
MA share of overall Medicare enrollment skyrocketed from 19% in 2007 to 46% in 2021, the study notes, and is expected to surpass the 50% threshold by 2023. Key to that larger share is enrollees in traditional Medicare migrating to MA.
The study, which used the 2014 to 2020 CMS Master Beneficiary Summary File Limited Data Sets, found that switching rates from MA to traditional Medicare exceeded those from traditional Medicare to MA from 2017 through 2020.
In 2020, traditional Medicare to MA switching rates were nearly four times higher than MA to traditional Medicare for Medicare only and 2.5 times higher than MA to traditional Medicare for Medicare-Medicaid enrollees.
Switching accounted for new MA enrollment growth, increasing from 49% in 2016 to 67% in 2020.
Researchers also found switching rates differed by population group. Rates generally declined with age, while mortality status played a factor as well. Beneficiaries in the last year of their life were more than twice as likely to disenroll from MA than from traditional Medicare in 2016 (5.4% vs 2.6%). By 2020, that flipped the other way to the tune of 3.1% vs 5.1%.
The study discovered that Black and Hispanic beneficiaries generally switched at greater rates than White enrollees. By 2020, Black and Hispanic beneficiaries were more than twice as likely to disenroll from traditional Medicare as White enrollees (13.4% and 13.5%, respectively, vs 5.9%).
"Switching may be associated with changes in health status, inclusion of additional services in MA, cost considerations, and access to specialized health care clinicians," researchers wrote.
"The observed trends may reflect a growing importance of access to non-TM benefits in MA, cost considerations among beneficiaries, and divergence in the enrollment preferences of Black and Hispanic beneficiaries compared with White beneficiaries."
More benefits and out-of-pocket cost limits are at the top of the list for reasons why enrollees are selecting MA plans, a survey by the Commonwealth Fund found.
The survey fielded responses from older adults aged 65 and above who were enrolled in Medicare to better understand why they opt for MA or Medicare.
The Inflation Reduction Act has played a role in making health insurance on the Marketplace more affordable.
The ACA Marketplace has seen 11.5 million people enroll in a health plan this year, marking an 18% increase from 2021, HHS announced.
In total, that increase represents about 1.8 million more people as of December 15, which is the deadline for coverage starting January 1, 2023.
The boost in enrollment signals the Biden administration's commitment to making health insurance more affordable and accessible.
"Unprecedented investments lead to unprecedented results. Under President Biden's leadership, we have strengthened the Affordable Care Act Marketplace with continued record affordability, robust competition, and historic outreach efforts – and today's enrollment numbers reflect that," said HHS secretary Xavier Becerra.
"Thanks to the Inflation Reduction Act, four out of five customers will be able to find a plan for $10 or less. As we head into the new year, there is no greater gift than the peace of mind that comes with having high-quality, affordable health care."
Through the Inflation Reduction Act, individuals will continue to receive enhanced tax credits to purchase health insurance.
Meanwhile, 92% of HealthCare.gov enrollees will have the option to choose from three or more insurance companies they shop for plans, HHS stated.
Marketplace Open Enrollment is still open until January 15, 2023, with coverage options made by that deadline going into effect beginning February 1, 2023.
The second Marketplace snapshot by CMS showed 5.5 million plan selections, an increase from 4.6 million year over year. Those selections included 1.2 million new enrollees and 4.3 million who had renewed coverage from both HealthCare.gov and the state-based Marketplaces.
A survey examines how Americans view their health coverage and other workplace benefits.
Health insurance isn't just a perk, but one of the main draws of employment for nearly all American workers, according to a new poll.
The survey, from Seven Letter Insight for the Protecting Americans Coverage Together campaign, fielded responses from 2,334 workers with employee-sponsored health coverage with from November 14 to November 19, 2022.
Respondents overwhelmingly highlighted the significance of receiving insurance through their employer, with 83% saying it is important that a job offers coverage, while 13% say it is very important.
Americans would rather get their insurance through their employer than on the individual market, as 89% of respondents expressed their preference for employer-sponsored coverage.
Over 75% of workers surveyed said they believe insurance through employers is higher in quality than open market plans, while 95% said employer-sponsored coverage is more convenient, and 83% said it is more affordable.
Overall, 93% of respondents are satisfied with their insurance. More than half (54%) are highly satisfied, more than 70% agree their health insurance is worth what they pay for it, and 87% call their plans affordable.
Speaking of affordable, that topped the provided list of words for respondents when asked to describe their coverage. The other top choices were "high-quality" and "comprehensive." Meanwhile, the least chosen descriptions were "lacking," "confusing," and "low-quality."
Nearly all workers (97%) feel that "quality health coverage is an important way for companies to retain their valued employees," and 80% named health insurance as one of the most important benefits for an employer to offer.
"Employees value their employer-sponsored health coverage, and they believe it is fundamentally important for employers to offer it," said Katie Mahoney, vice president of Health Policy at the U.S. Chamber of Commerce. "ESI is working for the people with access to it, and the goal of policymakers should be to strengthen and bolster the system to help more people."
The payer giant has signed contracts with four health systems in a milestone initiative.
Blue Cross Blue Shield of Massachusetts (BCBSMA) announced value-based contracts with four health systems with the aim of reducing racial and ethnic inequities in care.
The health insurer said the agreements are the first in the state of Massachusetts, as well as among the first in the nation, to create a financial payment model that rewards providers for improving equity measures.
The four Massachusetts health systems to sign on are Steward Healthcare Network, Beth Israel Lahey health, Mass General Brigham, and Boston Accountable Care Organization. In total, the health systems provide care to more than 550,000 Blue Cross members.
"For more than a decade, we've collaborated with physicians and hospitals via our Alternative Quality Contract, which replaced the fee-for-service model and instead rewards clinicians' efforts to improve the quality and value of the care they deliver," Andrew Dreyfus, CEO of Blue Cross, said in a statement.
"We're now building on that model to help health systems in our value-based payment programs improve equity. As a health plan, this is the most important tool we have to work toward a health system that provides affordable, quality and equitable care to all our members."
At the start, the agreements will focus on measuring and rewarding equity in care in multiple clinical areas with inequities, such as colorectal cancer screenings, care for diabetes, and blood pressure control. As the payment model evolves, more categories will be included.
The Center for Healthcare Organization and Innovation Research at the UC Berkeley School of Public Health will conduct an independent external evaluation of the contracts and publish the effects of their effectiveness.
Whopping statistics show how quickly payers responded to the price transparency rule this year, compared to hospitals.
When it comes to price transparency rules, the hospital regulation has been in place four times longer than the payer version, yet the difference in the data available for the two is miles apart.
More specifically, enough miles that it would be the equivalent of traveling from Earth to Neptune and back 14 times, according to Turquoise Health. The price transparency data company put together numbers that illustrate how much payer pricing information is out there in its 2022 year in review.
Since the hospital price transparency rule went into effect on January 1, 2021, Turquoise Health has collected about three terabytes of hospital data. That figure pales in comparison to the 630 terabytes of payer data since the payer rule arrived on the scene July 1, 2022. If you're calculating at home, that's a gargantuan 20,090% increase in size from the hospital data.
Those 630 terabytes consist of 78 billion payer price records, with 163 total number of payers in Turquoise Health's database. If you decided to manually count the rows of data after payers refresh their data monthly, the company says it would take a mind-boggling 76,104 decades.
Despite the size of all that data, payers haven't yet figured out the best way to display it for consumers. Turquoise Health found payer machine-readable files that varied 50-100 times in size.
"The takeaway: payers can drastically reduce their file sizes by taking measures to ensure smart architecture," Turquoise Health said. "For example, using references to provider groups within rates, as opposed to duplicating the provider group data within each rate shrinks the overall file sizes."
A survey reveals what frustrates Americans about the financial experience after receiving care.
Medical bills are more likely to come across as confusing than straightforward to patients, according to a YouGov survey commissioned by revenue cycle firm AKASA.
Responses were fielded from 2,206 Americans between March 9 and March 14, 2022, to gauge patient burden with the billing experience. The results show that patients are confused by bills in general and have frustrations with specific parts of the billing process.
Nearly one in five respondents (19%) said bills were extremely confusing, while another 19% found bills somewhat confusing. On the other end of the spectrum, 11% answered that bills were not confusing at all and 14% leaned towards bills not being confusing. The most chosen answer, by 37% of respondents, was neutrality on the confusion of bills.
Amy Raymond, VP of revenue cycle operations at AKASA, said of the findings: "The rise of high-deductible health plans, the uncertainty of what's being billed, the complexities of in- and out-of-network charges, and how much patients are on the hook for makes understanding and managing medical bills challenging for many families."
Additionally, the survey asked respondents what parts of the financial experience after seeking medical care frustrates them the most.
Most of the respondents (29%) identified being able to understand what they're being billed for as the biggest source of frustration, while 27% chose uncertainty on if they can pay the bill. Not getting the bill until weeks after they received service (24%) and uncertainty if the final bill will be consistent with the estimate of responsibility (20%) rounded out the selections.
Finally, the survey asked respondents what would be most helpful in allowing them to understand how much they are expected to pay for care or services. More than a quarter (27%) chose a call before the procedure from the provider to walk through what's expected and payment plan options as the most helpful.
That option was followed by an online calculator to help determine cost ranges for care or procedures (12%), an email from the insurance company to walk through the bill after receiving care or services (11%), a call from the insurance company for the same assistance (9%), access to live online customer service through their insurer's website (9%), and a call from the provider to walk through the bill after receiving care or services. Nearly another quarter (24%) of respondents chose none of the above.
"These results show that medical billing is still a black box to patients," Raymond said. "The onus is on healthcare organizations—both providers and insurers—to make medical billing less painful for patients, who may fear going into debt and avoid seeking out care. One critical tool healthcare leaders can leverage to course correct on medical billing and make it more seamless for patients is automation."
The American Hospital Association (AHA) and Better Medicare Alliance (BMA) both support the agency's effort to improve Medicare Advantage (MA).
In an attempt to reform MA, CMS released a proposed rule that aims to streamline prior authorization, promote health equity, and curb deceptive marketing.
The Biden administration has shown a commitment to increasing oversight of MA plans and the proposed rule would better align MA with traditional Medicare with new provisions and policies.
Building on a separate proposal by CMS, the new rule strengthens prior authorization protections for patients and makes the administrative process more efficient. It would require that a granted prior authorization approval remain valid for an enrollee's entire course of treatment, require MA plans to annually review utilization management policies, and require coverage determinations be reviewed by professionals with relevant expertise.
The rule would also tackle misleading marketing by MA plans by prohibiting 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. MA marketing has been scrutinized by lawmakers for using tactics that are harmful to beneficiaries.
Additionally, the proposed rule would put forward a health equity index for MA star ratings and implement a key provision of the Inflation Reduction Act to lower prescription drugs costs for low-income Medicare beneficiaries.
"From streamlining prior authorization to cracking down on misleading marketing, we are committed to ensuring that everyone can have peace of mind and get the health care they need," HHS Secretary Xavier Becerra said.
The AHA commended CMS for taking steps to increase oversight of MA plans.
"The AHA has previously raised concerns about the negative effects of certain Medicare Advantage practices and policies that have the potential to directly harm patients through unnecessary care delays or outright denial of covered services," the AHA stated. "CMS' proposed rule includes helpful provisions to ensure more consistency between Medicare Advantage and traditional Medicare by curtailing overly restrictive policies that can impede access to care and add cost and burden to the health care system."
Meanwhile, the BMA, an MA advocacy group, also showed their support for the proposed rule.
Mary Beth Donahue, president and CEO of BMA, said in a statement: "Better Medicare Alliance commends CMS's work on delivering a thoughtful, comprehensive proposed rule and appreciates the agency's engagement with stakeholders across the health care spectrum ahead of the rulemaking process."
New research finds that a significant rise in high-intensity billing since 2006 isn't solely due to coding practices.
High-intensity billing for treat-and-release emergency department (ED) visits has increased notably over the past 14 years, according to a study published in Health Affairs.
Researchers used the Nationwide Emergency Department Sample to examine treat-and-release ED visits and found that 19.2% of those visits exhibited high-intensity billing in 2019—a sharp rise from 4.8% in 2006.
However, the authors state that 47% of the growth in high-intensity billing was expected due to the changes in administrative measures for patient case mix and care services as data of later years showed higher proportions of older patients and those with more serious conditions.
While the researchers admit that the remainder of the growth may involve upcoding, the study highlights that coding practices alone aren't to blame. Providers have taken criticism from payers for their role in inflating high-intensity billing over recent years.
"Coding practices have become one element of an ongoing tug-of-war between payers and providers," the authors wrote.
The study also points to there being more clinical pathways and observation care for patients with more common but potentially serious issues, while more urgent care clinics are claiming low-acuity patients. With hospitals facing pressure to reduce spending, they have greater incentive to emphasize ED visits over low-value admissions.
The authors conclude that "future policy work must address controversies around high-intensity billing" given the context of shifting emergency care landscape, but payers must also recognize that patients are getting older and have more chronic conditions.
"In addressing potentially inappropriate billing practices, payers must acknowledge the increasing complexity of care for a treat-and-release ED patient population composed of older, more comorbid, and clinically undifferentiated patients, to avoid hospitalization, ensure safe discharge, and improve acute care outcomes," the study states.
Multiple payers are the target of concern in a letter to CMS urging for an investigation into program participants.
A group of House and Senate Democrats are asking CMS to boot organizations that have committed fraud out of the ACO REACH program before they "further encroach on the Medicare system."
In a letter to CMS administrator Chiquita Brooks-LaSure, the lawmakers, led by Senator Elizabeth Warren (D-Mass.) and Representative Pramila Jayapal (D-Wash.), express their concern that payers will continue "ripping off taxpayers" with their participation in the new payment model, which will start on January 1, 2023.
The ACO REACHprogram is replacing the Global and Professional Direct Contracting (GPDC) model, with participants of GDPC allowed to enroll as ACOs if they maintain a strong compliance record and agree to meet the requirement of the model. However, the lawmakers point out that participants have troubling records, including notable health insurers Centene, Humana, Cigna, Clover Health, and Bright Health.
A preliminary review of the direct contracting entities (DCEs) by Physicians for a National health Program (PNHP) found that at least 10 current GPDC participants had documented cases of fraud and abuse.
Centene, for example, paid $97 million in 2021 to settle allegations of "duplicated and inflated claims" to the Department of Veterans Affairs. The payer giant's pharmacy benefit managers also allegedly overcharged state Medicaid programs on prescription drugs last year, resulting in settlements that totaled more than $260 million.
"The ability of organizations with known histories of fraud and abuse to take part in the program increases the risks for Medicare beneficiaries, and raises concerns that CMS screening procedures for participants are inadequate, putting taxpayer dollars at risk" the lawmakers write.
The letter calls on CMS to address these issues and protect patients before the ACO REACH program begins by stopping the participation of the organizations with histories of fraud and removing DCEs that do not meet the new standards for the program.
In addition, the lawmakers want written answers to multiple questions by January 16, 2023, such as how organizations that have been accepted into GPDC been screened for acceptance into ACO REACH, and what methods CMS will use to screen ACO REACH participants.
