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."
Healthcare financial leaders were asked if and when they calculate return on investment (ROI) on revenue cycle management (RCM) automation.
While the use of automation in RCM continues to grow, how its ROI is measured varies heavily depending on the provider, according to a survey from Healthcare Financial Management Association commissioned by revenue cycle firm AKASA.
The survey, which fielded responses from 556 chief financial officers and revenue cycle leaders at hospitals and health systems across the nation between July 8 and August 2, reveals a lack of set standards when it comes to quantifying RCM automation.
Nearly a third of respondents (32.7%) said they calculate ROI on RCM automation in-house, while 7.1% stated ROI is calculated by their RCM automation vendor. More than half (51.9%) answered that instead of calculating ROI, they focus on other key performance indicators, such as accounts receivable days. Finally, a small but not insignificant amount of providers (8%) said they don't measure for ROI at all.
There were also differences among the respondents in how often ROI on RCM automation is measured. More than a third (34.7%) said they measure ROI monthly, followed by quarterly (26.4%), annually (14%), and semi-annually (6.6%). The option of "other – write in", chosen by 18.2% of providers, indicated that ROI measurement will be determined once automation is fully implemented or on an as-needed basis.
"This survey really highlights that healthcare financial leaders are struggling with who or where to turn on ROI measurement," said Amy Raymond, VP of revenue cycle operation at AKASA. "There's a significant gap in the market for guidance and frameworks on how to get ROI right.
"As health systems mature in their automation journey, the current understanding of ROI falls short as a sole measure of success. Part of this is that not all metrics are easy to measure upon implementation — specifically those that examine the impact on the workforce or patient financial experience. There is a clear need for a new form of assessment — one that holistically looks at Total Value."
As ROI becomes more of a focus, revenue cycle leaders are turning their attention to trends and opportunities to develop best practices and evaluate their level of involvement in an array of functions.
The health system and health plan giant saw its bottom line flip in the third quarter compared to the previous year.
Kaiser Permanente experienced a difficult third quarter which included a net loss of $1.54 billion, the company announced.
The operator of hospitals, health plans, and other subsidiaries released its earnings report, revealing a significant fall to the opposite end of the spectrum from last year's third quarter profit of $1.56 billion.
Most of the decline was due to other income and expense totaling a loss of $1.5 billion for the quarter, which the company said was driven by investment market conditions. The operating loss, meanwhile, was $75 million.
Despite the downturn, organization leadership expressed encouragement about the maneuvering through the current financial climate.
"I am proud of our ability to navigate the challenges of the past few years including a global economic crisis, the high cost of goods and services, supply chain issues, labor shortages, and the pandemic while serving our 12.6 million members," Kaiser Permanente chair and CEO Greg A. Adams said in a statement.
"I continue to be inspired by the unwavering commitment and dedication of our Kaiser Permanente teams who through this unprecedented and unpredictable 3-year period continue to provide high-quality, affordable care and service to our members and communities."
The company's membership has experienced modest growth of nearly 40,000 during the calendar year, with the total sitting at 12.6 million at the end of the third quarter.
Kaiser Permanente continues to pour into capital spending, which totaled $820 million for the quarter, compared to $878 million for the third quarter in 2021. Year to date, the company has capital spending of $2.5 billion.
"Kaiser Permanente's integrated model of care and coverage continues to provide long-term stability amid changing market conditions," stated Kathy Lancaster, Kaiser Permanente executive vice president and CFO. "In the third quarter of 2022, we remained committed to our members, patients, and the communities we serve while controlling spending and investing in our capital program."
The American Hospital Association (AHA) finds administrative policies are increasingly overburdening providers.
Some commercial health insurers are using policies that can delay patient care and create burden for providers, causing relationships with hospitals to worsen, according to a survey by AHA.
The association fielded responses from more than 200 hospitals in 2019 and from 772 hospitals between December 2021 and February 2022, creating data that both predates COVID-19 and represents the lasting effects of the pandemic.
With hospitals strained by the challenges of the labor shortage, the survey highlights how insurer tactics are stretching providers even thinner through administrative tasks.
Of the hospitals and health systems surveyed, 95% said there have been increases in staff time spent seeking prior authorization approval, while 84% reported the cost of complying with insurer policies is increasing.
The time and energy spent by providers is unnecessary, however, as 62% of prior authorization denials and 50% of initial claims denials that are appealed are ultimately overturned.
The result is deteriorating relationships with payers, as 78% of hospitals and health systems said their experience with insurers is worsening. Less than 1% said it was getting better.
"These survey results are stark evidence that some commercial health insurers deny care while hospitals and health systems focus on providing care," said AHA president and CEO Rick Pollack. "Patients deserve comprehensive health coverage with the protections they were promised when they signed up. Congress and the Administration need to act now to hold commercial insurers accountable for actions that delay patient care, contribute to clinician burnout and workforce shortages, and increase costs."
Medicare Advantage (MA) has especially come under scrutiny for often unnecessarily denying or delaying care. AHA pointed to a report by the Office of Inspector General from April which found that 13% of MA prior authorization denials met Medicare coverage rules and 18% of MA payment denials met Medicare coverage and Medicare Advantage organization billing rules.
To push for fairer coverage for both patients and providers, AHA wrote a letter to HHS secretary Xavier Becerra and Department of Labor secretary Martin Walsh asking for more oversight of insurers.
