"Being more open will help make treatment plans more accessible for all people who experience menopause," Sarah Chavarria, president and incoming CEO, Delta Dental says.
As payers operationalize responses to social drivers of health (SDOH)—such as food, housing and income insecurity—there are factors that precede and span these challenges: gender and age.
Ignoring these factors can impact outcomes, including for oral health. A first-of-its-kind study from Delta Dental revealed that 84% of women aged 50 and over are not aware that menopause, oral health, and dental discomfort are connected.
In its press release for the study, Delta Dental describes how this lesser-known connection makes dentists "a prime, untapped resource for women navigating it." The release adds that while 70% of women 50 and older have experienced at least one oral health symptom since their menopause symptoms began, few have raised the topic with their dental providers: only 2% with their dentists and only 1% with their dental hygienists.
"With menopause a long-stigmatized topic and symptoms going largely unaddressed or even ignored, these findings are stark but unsurprising," says Sarah Chavarria, president at Delta Dental and its incoming CEO, effective January 2024. "Despite the knowledge gaps revealed in this survey, sentiments about menopause are beginning to shift, and women are eager to break the stigma."
Startling results: Oral health and menopause
The Delta Dental study highlights other "missed connections between menopause and oral health."
Of the 1,000+ women surveyed, 70% have experienced increased oral health symptoms during menopause, including dry mouth (39%) or reduced saliva production (13%), receding (30%) or bleeding gums (16%), tooth sensitivity or pain (28%), decay (20%), and other symptoms.
Most women didn't associate these with hormone shifts, however. Lack of awareness included:
"Saliva is the natural buffer of your mouth, and less saliva means less protection against dry mouth, which is at the crux of all other oral health symptoms related to menopause," says Dr. Jessica Buehler, senior director of Dental Affairs at Delta Dental. This includes increased tooth decay and even altered taste and a burning tongue.
Knowledge means power, resources mean action
The Delta Dental survey found that menopausal women aged 50 and older are either extremely or moderately curious about the menopause-hormone-oral health connection, are motivated to make changes, and believe providers play an important role:
77% say they will prioritize scheduling their next exam/cleaning.
43% say will spend much more time on their oral health care.
39% say healthcare providers can encourage more women to ask questions about the oral health-menopause connection.
In addition, only 26% of women aged 50 and older consult their primary care provider for menopause-related oral health concerns—"the same percentage that look to Google," the Delta press release notes.
"That's a care gap with extensive repercussions," says Buehler.
A patient can't raise a connection she isn't aware of, making the Delta study an important resource for not only prevention and tailored treatment, but provider engagement and downstream benefit design.
The critical role of dental providers
The Delta Dental survey revealed that dentists and dental hygienists are a "prime, untapped resource for women navigating menopause."
"Having open conversations with your dentist about your overall health and potential menopause onset will help your provider make the right treatment recommendations," says Dr. Buehler.
Dr. Daniel Croley, chief dental officer at Delta, recommends that dentists check in with these patients. "As medical professionals, we have a responsibility to ensure our patients are receiving the holistic health care and support they deserve—not only oral health, but whole person health as well.
"We can help ease the burden and break the stigma by creating space for these conversations," adds Croley.
The connection to dental benefit design
Delta Dental provides dental benefits to more than 45 million members in 15 states and the District of Columbia.
The Delta study—and conversations between patients and providers—can influence health plan benefit design. In an exclusive quote for HealthLeaders, Brian Sherman, vice president and chief people officer of Delta Dental, notes:
"The results from this survey shed a lot of light on what knowledge gaps exist on the impacts menopause has on oral health. Our findings emphasized the importance of tailoring oral health care to the unique needs of this population. At Delta Dental, a people-first organization, we are using this opportunity to evaluate our benefits for our female employees to ensure they receive support through every stage of their life."
Delta Dental offers plans with graduated benefits that make it possible for changing coverage to align with changing needs—due to aging in general as well as menopause.
Delta's soon-to-be CEO is particularly passionate about this topic. Chavarria shares that she is of menopausal age herself and understands the importance of bringing awareness to the underrepresented: painful symptoms and conversations about menopause and stigma.
Perhaps more women in the top spot—at health plans and across the industry—will lead to more studies like Delta's and benefit decisions based on them.
"At Delta Dental, we are committed to empowering more whole-person care that incorporates oral health into overall physician care and wellbeing, including in menopause," says Chavarria. "Being more open will help make treatment plans more accessible for all people who experience menopause."
From less loneliness and ED utilization to more screening and CMS equity alignment, "we've got the data to show it," says Papa exec Dr. Ellen Rudy.
The Problem: Loneliness has become an epidemic. This "chronic, unmanaged, and persistent" problem isn't just a social, it's medical—especially among older, lower-income Americans. And the data proves it. For this D-SNP population (dual-eligible special needs), severe loneliness:
Leaves 40-50% of D-SNP with no one to help them in times of need (forthcoming Papa State of Social Health report); and
Contributes to less timely or appropriate use of medical care.
This "silent cry for help"—as Dr. Ellen Rudy calls it—would be challenging enough. But loneliness intersects with other healthcare challenges: post-pandemic financial recovery, stark inequality, and population-specific needs like maternal health and hospital readmissions.
Dr. Rudy should know. She is the Head of Research and Social Impact at Papa, the nation's first curated human companionship platform to address loneliness, key social drivers of health (SDOH) and, increasingly, the medical issues associated with them. From its direct-to-consumer beginnings, Papa now serves payers (Medicare, Medicaid, and commercial health plans as well as employers) and their members.
The D-SNP data above is among the company's newest, which Rudy shared more of in an exclusive interview with HealthLeaders.
Expanding to meet intersectional payer goals
How does the model work? Payers identify their objectives, Papa designs and implements solutions—and their companion reimbursement codes—and Rudy studies their impact. These solutions have expanded from core companionship services ("Papa Pals") to Social Care Navigation (SCN).
Since its founding in 2017, Papa Pals have provided members with companionship, assistance with the Instrumental Activities of Daily Living (IADLs; e.g., cooking, cleaning, transportation, laundry, finances) and care gap reminders for the CMS Stars Program. While these in-home and virtual visits already represent an intersection of social-medical needs, SCN operates behind the scenes with wraparound services.
SCNs assist Papa Pals in these roles and provide health plan clients with on-the-ground support to address their members' unmet needs and advance population health management strategies.
Papa expanded SCN in April 2023, following a limited rollout in 2022. Per the associated press release, SCN is committed to "uncovering and resolving barriers to members' whole health . . . before they escalate into greater issues." Rudy affirms this focus and its Digital Health Literacy Services.
As part of SCN, the company uses its Papa Social Index at enrollment and annually to assess digital health literacy and other unmet social needs. Papa then reports assessment outcomes to health plan clients for measurement.
Scaling to meet upstream and downstream payer needs
Citing internal data, a Papa spokesperson states that Pals have completed more than 1.8 million visits with members since the company's inception. Papa is on track to complete nearly 1 million visits in 2023, a 57% year-over-year increase.
The April press release notes that "more than a quarter of Papa's health plan clients use Social Care Navigation," with these benefits: "As health plans continue to focus on moving care upstream, Social Care Navigation plays a critical role in advancing proactive care measures, like preventive screenings, vaccinations, and health risk assessments . . . The result is a high-touch and differentiated member experience to reduce downstream health care costs. reduce downstream health care costs."
These up- and downstream benefits are showing up in Papa results. One claims analysis shows that Papa has effected an 11% decrease in hospital readmissions while a second demonstrated a 20% reduction in ER visits, and increased cancer screenings (5.4% for breast cancer, 3.7% for colorectal cancer).
"These are incredible results," says Rudy, "given that the people we impact most are often the hardest to reach."
Aligning with CMS equity efforts
Papa's aim to reach even more people in need is timed well with CMS' growing equity goals.
"Papa is an organic solution for health equity," says Rudy.
The pitch to payers is that Papa can provide these solutions more effectively than payers can on their own. With the exception of Pals, Papa and payer staff are similar: registered nurses, case managers, social workers, dieticians. But key differences remain.
"Health plans face staffing shortages and less flexibility in terms of the hours and services they can provide, and at what cost," says Rudy. "Payer nurses and community health workers are often limited in what they can do."
She returns to Papa Pals as a key advantage: "Pals are there, first and foremost, to meet the needs of the member."
There is more work to do, including how to reimburse these emerging services. Many Papa services are reimbursed under the 2018 Chronic Care Act (CCA). The CCA expanded supplemental benefits beyond the traditional (dental, vision, etc.) to chronic and social needs.
"That was a game-changer for all SDOH companies," emphasizes Rudy, citing U.S. Surgeon General Vivek Murthy's 2023 Advisory encouraging payer involvement in loneliness and isolation: "Insurance companies should provide adequate reimbursement for time spent assessing and addressing concerns about social disconnection (e.g., isolation, loneliness, low social support, poor relationship quality), and incorporate these measurements into value-based payment models."
Rudy adds: "If companies want to get more of this work done, we have to have the reimbursement codes."
"We've been given a set of directions by the government and our job is to build this micro ecosystem with sticky floors." — Peter Long, EVP-Strategy and Health Solutions
Peter Long—executive vice president of Strategy and Health Solutions for Blue Shield of California—is a health services researcher by trade. He previously led the Foundation for the health plan, which serves 4.8 million members statewide, and co-authored the 2023 National Academy of Medicine (NAM) paperValuing America's Health: Aligning Financing to Award Better Health and Well-Being.
The following Q&A with Long includes NAM recommendations and how the plan convinced payers across California to follow its hybrid value-based payment (VBP) model.
HealthLeaders: The NAM paper states that "in the absence of a legislative or government-based solution, health care, public health, and other stakeholders are obliged to act to the best of their ability." Can you talk more about that?
Long: Healthcare stakeholders have many constraints. Policy hasn't allowed us to go above and beyond things like basic access, emergency response, and affordability to help people achieve truly better health. We're trying to work on value-based payment models, but there's just so much regulation and how are we supposed to do it for free? The NAM paper was a great thought exercise in asking: If we changed some of the rules, could we actually get to our goal which is the health of the population?
HL:About VBP, the paper seemed to make conflicting statements—that these models had remained financially resilient during COVID but also that the pandemic had renewed interest in them? How do you reconcile those two things?
Long: First, value-based care adoption has been very steady and yet very slow—somewhat like virtual care, and I think these examples are related to COVID. We've known how to do virtual care for 25 years but weren't sure how to integrate it with in-person care, how to document it, how to make it all work. But when COVID hit, we had no choice. It was a very instructive moment for healthcare.
The same is true for VBP. We've known how to do the mechanics of it—the outcomes measures, the per-member per-month [PMPM] payments—for 30 to 40 years. But there has been a low-trust environment. The pandemic showed us that fee-for-service-only providers were in huge financial trouble because there were no services to get fees for. With COVID, they took another look and said, 'If I'd been on a VBP model, I would have received a PMPM payment, even if I had just emailed my members or had a virtual visit. I would have had a continuous stream of revenue for my practice.'
Peter Long, executive vice president of Strategy and Health Solutions, Blue Shield of California.
HL:That's a great explanation.
Long: This is why Blue Shield has chosen a hybrid VBP method that includes three parts. For primary care, providers receive a monthly payment—a steady revenue stream to sustain the practice. On top of that, we pay for services we want to happen as much as possible: immunizations, well-child visits. The third component—and this is part of what the NAM paper stated—is addressing incentives that have been small and conflicting.
Blue Shield has significantly increased the amount of money that practices can earn and for things that are very tangible. Is the patient happy with their experience? If they have diabetes, is their blood sugar under control? By focusing on simple things that are simple and aligned, we've had a very positive response from providers. It's the best of all worlds.
It also can't just be about Blue Shield. We have more than four million members but there are 40 million Californians. We shared our model with all of the other plans, which is uncommon in the industry. We got a memorandum of understanding for this hybrid payment model because we think it makes sense. I think it was the first time health plans have voluntarily agreed to do something like this, and it's a good example of what we can actually create when we put our heads together. As the NAM paper suggests: You achieve bigger things by conducting smaller actions that create alignment.
HL: The NAM paper included multiple recommendations, rated by impact and feasibility. Two payer recommendations that stood out were identifying plan members with social drivers of health needs and holding health systems accountable for whole-person health outcomes via contracting. Can you speak on those?
Long: A health plan can actually get SDOH information more readily compared to providers. At Blue Shield, we are huge believers in addressing social drivers of health. The open question is what does the financing look like? Healthcare spend is already $4 trillion in this country. If we drive housing money through it, we now become a $10 trillion industry and we could become more distracted.
At Blue Shield, we're aligned on social determinants that are related to medical care. It wouldn't be necessary or appropriate to get housing vouching for all of our members, but it does make sense to ensure there is air conditioning in the house and on mold problems for someone with asthma. That makes sense and fits within what health insurance can do.
As for health systems, it's challenging holding then someone accountable if they only see a person once or twice. There are three issues. It can be a long time for patients from the cause to the effect, there are a lot of multi-factorial things involved, and it's been hard to agree upon what the outcomes should be. They are surmountable problems, but they require a fair amount of work and some pretty good levels of trust.
In my mind as a health plan executive, all of this is doable.
As the insurer limits expansion, what will others do amidst premium increases and continued enrollment growth?
Conservative, aggressive, or somewhere in between? Expansion strategies will be revealed as payers announce their Marketplace portfolios for plan year 2024.
Cigna Healthcare is one of the first, falling in the conservative camp despite sizeable Exchange enrollment growth since 2022. Per a press release, the payer will expand its Marketplace plans in 15 counties—all in North Carolina, with a focus on Charlotte and Winston-Salem—while exiting Missouri and Kansas.
What will other payers do? While big Marketplace players will likely make more big moves, expect the needle to move as a whole as subsidies continue and Medicaid redeterminations drive those who lose coverage toward the Exchanges.
Cigna Marketplace trends
Cigna's Marketplace updates for 2024 land the payer in 350 counties across 14 states: Arizona, Colorado, Florida, Georgia, Illinois, Indiana, Mississippi, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas, Utah, and Virginia.
While the new North Carolina counties total up to 200,000 customers, 2024 curbs Cigna's recent expansion—four new states in the previous two years which more than doubled its Marketplace enrollment from 337,000 to 821,000 by the end of 2022.
"We take a thoughtful and deliberate approach to our geographic presence to ensure our plans meet high standards for affordability, network quality, and comprehensive coverage," said Chris DeRosa, president of Cigna's U.S. Government business since January of this year. He previously served as president of National Accounts and COO of US Markets for Cigna Health Benefits.
Cigna cost-sharing and benefits
Zero-dollar (insert benefit here) is a common selling point for Marketplace carriers. Select Cigna plans will offer $0 cost-share on medical deductibles, designated benefit copays, and preferred generics.
Where there is cost-sharing, Cigna reports that its copays range from $0-$70 for primary care and $30-$110 for non-emergency care. Select plans offer first-dollar coverage and "predictable copays" for outpatient lab exams during the deductible period. Cigna's Patient Assurance Program caps covered eligible insulin costs at $25 per month for a 30-day supply.
As noted in Cigna's press release, many customers will have access to 24/7 virtual medical and behavioral healthcare, with a $0 copay for some primary care and minor acute urgent care. The payer will also offer up to $325 in annual wellness incentives for those eligible, and affordable prescriptions including preferred generics and insulin.
"Health and well-being are key to a person's overall vitality, which is why we provide comprehensive medical, behavioral, and pharmacy benefits and a host of other features that make it simple for customers to access affordable care when and where they need it," DeRosa added in the press release.
Payer Marketplace participation as a whole
The Marketplace has seen both constancy and disruption since it launched in 2013. Some carriers, like Cigna, have participated from the beginning.
"Cigna has continuously maintained our presence in the ACA Marketplace over the past ten years, and we are proud to continue using our expertise to help customers have a healthier future," noted DeRosa.
The same is true of other carriers, namely BlueCross BlueShield, Centene, and UnitedHealthcare—all of which either started with or have grown to a robust presence since plan year 2014.
This is not the case for all payers, whether startup or stalwart. Among the former, Oscar Health has continued to grow while Bright Health—which had steadily increased participation since 2018—exited the Marketplace in 2023. Humana also exited last year after a small but brief re-entry since 2017. A company spokesperson noted Humana's focus is its Medicare core (individual, group, supplement and prescription drug plans); Medicaid, Military, and Specialty dental, vision and life plans; and its CenterWell healthcare services business.
Sitting somewhere in between is Aetna. Before 2022, the payer had not offered Marketplace plans since 2017.
Growth by pandemic and subsidy
While no one would wish for a pandemic as a growth driver, COVID-19 was a boon for the Marketplace. Enrollment set records in 2022 (14.5 million) and again in 2023 (16.3 million)
Overall Marketplace premiums are expected to rise but with an influx of new customers due to Medicaid redeterminations, shouldn't adversely affect an overall enrollment that is likely to grow.
KFF reports a 6% median premium increase with insurers citing increased medical and prescription drug costs as well as utilization. "Although most Marketplace enrollees receive subsidies and are not expected to face these added costs, premium increases could result in higher federal spending on subsidies," Kaiser adds.
That spending could change after plan year 2025, when expanded subsidies will end unless Congress extends them. The broader subsidies were enacted by the American Rescue Plan and continued under the Inflation Reduction Act. depend on which political party assumes the White House in 2024.
While it's up to Congress to act, the Executive branch can influence how well the Exchanges are supported and promoted. As The New York Timesnoted in January about the subsidy impact: "The Biden administration has taken other steps to encourage enrollment in the plans, including increasing advertising and enrollment assistance and providing a longer window for sign-ups than during President Donald J. Trump's administration. But it appears the money is mattering more than anything else."
The 2024 Marketplace Open Enrollment Period begins November 1 and ends January 15, 2024.
Execs from diverse organizations share their strategies.
"We have providers all the time saying, 'I want a value-based contract.' But when you ask them why, they have no idea." — Chasity Howell, Vice President of Provider Relations for Indiana Medicaid MCO MDWise
"Value-based care really is a shift in the paradigm. Providers deliver care on an individual patient level. Now, we're asking them to deliver care at a population health level. This is where practices need to change how they operate." — Dr. Nancy Klotz, Chief Medical Officer of third-party administrator Brighton Health Plan Solutions.
These quotes from the HealthLeaders Payer NOW Summit capture the abiding challenge of value-based care: what it actually means, how to deliver it, and how providers can embed preventive care in VBC models. Read on for more highlights from the panel: Preventive Health: Coverage and Reimbursement on the Chopping Block?
HealthLeaders: Preventive care is defined differently across organizations. How does your organization define it, and what flexibility do you have in implementing preventive care protocols and reimbursement?
Chasity Howell, MDWise: As a Medicaid managed care plan, we define preventive care as whole person health. We follow Indiana state guidelines, but we try to think kind of outside the box including how we can impact members with social determinants of health. When thinking about preventive care, we also engage our care managers on issues that interfere with a member having a healthy day-to-day life — things like diabetes and other chronic conditions.
Dr. Nancy Klotz, Brighton:*Preventive care really is a more encompassing type of care that addresses what patients or the population need. Some folks are ill, some folks are healthy.
First, we borrow from the experts in the community: NCQA HEDIS and their guidelines to define what we deliver as far as preventive care. That's divided into preventing disease [e.g., via screenings] and then managing those who have disease and making sure it hasn't progressed. Those are the two main categories. Then there's the category where we don't know we don't know what we don't know. Here, there are things that can help like the Medicare annual wellness exam, functional assessments of the activities of daily living assessments, and pain management assessments.
HL: If this year's federal court decision blocking select no-cost preventive services is upheld, what kinds of coverage decisions will you face and what advice are you providing in light of this uncertainty?
Howell: If for some reason the state of Indiana decided that preventive care was no longer going to be covered at the same level, it would definitely have an impact on us. At MDWise, preventive care is something we've implemented into our mission and our vision of being a health outcomes leader in the state we live in. It really comes down to doing what's best to keep members healthy, understanding their benefits, and educating providers on how best to be reimbursed for those types of services.
Dr. Klotz: There is a lot of concern. There are more than 60 physician-led organizations that are opposed to what's happening right now in the preventive care scenario . . . But even if the Affordable Care Act went away, there are 15 states that have broad ACA-style laws that require individual market insurance to cover prevention without cost sharing . . . At Brighton, we are going to continue to offer these preventive service guidelines and per our client's wishes, but we will strongly urge them to continue with them regardless because make good sense — from a medical perspective, a health perspective, and a financial perspective.
HL: Share a specific, unique solution that your organization has encountered related to preventive services reimbursement that others can learn from?
Howell: The solution that we have tried to shift toward is the value-based care model, reimbursing providers for quality of care and patient outcomes. That really encourages a focus on prevention against costly care on the back end. We also recognize the impact of social determinants of health, and we're trying to find a unique way to reimburse providers for things like housing instability, food insecurity, transportation issues. There's also collecting and analyzing the data so we can work together as provider and health plan, target at-risk populations, and identify interventions that address those specific needs.
Dr. Klotz: With regards to reimbursement, it all depends on the clients that we contract with. That being said, we conduct our financial analysis and find the highest-cost items, including those that might have been avoided if there had been preventive services in advance.
As an example, I spoke with a fund administrator and noticed that cardiology, kidney failure due to diabetes, and dialysis were high-cost items. We designed a program to ensure patients see their nephrologist as part of their dialysis and promote the use of statins. We promote mail-order pharmacy, where there's less of an opportunity for missed dosages. We also have a behavioral health case management team and are contracted at preferential rates with certain organizations to help expedite member appointments and even reserve appointment slots to ensure access to care.
HL: Preventive services should be the secret sauce of value-based care. Why aren't they, what role does reimbursement play, and what do we do about it?
Howell: Moving to value-based care for providers is super important because it stresses preventive care services, the impact on the total outcome for the patient, and the role of the overall care that they provide every day. So, while little Johnny is coming in for his ear infection, does he need a well visit? If he's scheduled for one, will he be able to get back for it. And while he's here, is there anything else we can do to make the most of that visit . . . There are a lot of providers who are shocked when they see their missed opportunities.
Dr. Klotz: Most providers are a little hesitant to take on risk and have skin in the game. If their outcomes are bad, it may be due to their lack of attention to preventive guidelines, but it's also multifactorial because now providers are taking on the burden of addressing social determinants of health.
Another barrier that needs to be addressed is that the definition of value-based care is still a bit vague.
And lastly regarding incentives, they don't always work. I think they work when there is a significant portion of providers practicing and, let's say, 10% of their income is based on incentives.
*Brighton Health Plan Solutions Disclaimer: Contents are for informational purposes and do not constitute legal or medical advice.
Three Blues plan execs share mental health reimbursement strategies.
"We've passed legislation that says you must have mental health parity. That's going to sound so outrageous five or 10 years from now. Why was there ever not parity?"
This quote from the HealthLeaders’ Payer NOW Summit captures where mental health has been, but not where it's going. Just ask the trio of Blues plans executives that participated in the August summit panel: Mental Health: Can Healthcare’s Bridesmaid Lead Reimbursement, Coverage and Treatment Breakthroughs?
HealthLeaders: What has prevented mental health services integration, broadly and as an aspect of value-based care?
Gabriella Gold, CareFirst: We can't talk about mental health integration without first addressing access to care. Adequate and appropriate access to care will look different depending on the type of care the member needs.
Dr. Greg Harris, BCBS-MA: For about 10-plus years, we've had Alternative Quality Contracts that put our large medical groups at risk for mental health. That has helped but not enough. On top of that, we're building a specific model for psychiatric collaborative care management that puts a care manager and a consulting psychiatrist into the primary care setting. There's a coding structure now for this model of care, for reimbursement and incentives, and a big evidence base.
Dr. Tim Law, Highmark: Another part of value-based care is how you attribute a patient to a mental health care expert. Not everyone who provides mental health support submits claims, including some licensed professionals as well as loved ones.
Right now, we chase our tails in this industry trying to fill gaps. If we built the house correctly, there shouldn't be gaps to begin with. And we can't say that once we've filled the gaps, that we've redesigned the system or transformed utilization management.
HealthLeaders: How is your health plan expanding and rethinking access to behavioral health care and what unique solutions you are getting results from?
Gold: Our networks need to be all inclusive. Until very recently, we ran separate networks with distinct populations of providers who served the same membership but with different benefit designs.
The next step is ensuring that access maps to a continuum of care. An example of a technology we've rolled out to all our commercial members is an asynchronous chat function that mimics a coffee conversation with a close friend or family member.
We've also partnered with an organization to bring all of our solo practitioners together and incentivize technology use for charting and appointment scheduling. We're now seeing streamlined appointment bookings in under four days whereas previously, members were calling five to 10 providers and not getting a call back for 30 days. We've seen great strides there.
Dr. Greg Harris: It's great to hear what's going on in different regions, because that's another aspect of the silo.
About 50% of our network is solo practitioners so there's huge friction for our members in trying to figure out who's really accessible. Every interaction becomes very critical very quickly, so we've added three areas of focus: 1) primary mental health groups, 2) sub-specialty groups, and 3) navigation with three layers of customer service. A key element of the navigation is a QR code with a survey at the digital front door that allows members to directly access promoted groups. There is also a mental health advocate and a case manager, so there is this pathway.
One of our network innovations is to reimburse groups on a bundle based on access and outcome metrics. Most groups have agreed to two-day and five-day access standards and data reporting.
Dr. Tim Law: I wish we got together like this more often and talked about what programs are doing in different regions. There's no sense reinventing the wheel, right?
There is an unfortunate stigma attached to a mental health visit, so we've started to rethink the options. Our medical directors review mental health cases and we've started reaching out to physicians proactively on residential and inpatient hospitalizations that we might have previously denied. It has helped create such a collegial attitude between the payer side and the provider side. In the intensive outpatient therapy realm, we've also found ways for our smaller, self-funded, administrative-only accounts to buy up on programs that lead to better health outcomes.
HealthLeaders: What impact has digital health had (including consumer-driven tools) on mental health reimbursement strategies?
Gold: We expect our providers to update us on their practice regularly and to be accessible to members via online and in-person platforms. We need to be able to pay for one-click solutions like that.
Dr. Law: Highmark was the first payer in the country to cover prescription digital therapeutics, and we gained a lot of backlash and kudos. Once we vet something scientifically, we then send it to reimbursement to have them assess the company. We don’t want a scenario where, three months after a member starts using a digital health product, we yank the rug out from under them because the underlying business model was so poor that the company no longer exists.
Dr. Harris: There are apps that are consumer focused, there are digital therapeutics, there are technologies that support providers. As a strategy, we structure and prioritize solutions that center on a service as opposed to something that's more ancillary.
Next week, HealthLeaders will spotlight its second panel from the August Payer NOW Summit: Preventive Health: Coverage and Reimbursement on the Chopping Block?
It will be difficult for the patchwork that is U.S. healthcare policy to bridge the gap.
"We may be on the cusp of an era of astonishing innovation," notes a June feature from New York Times Magazine. "[T]he limits of which aren't even clear yet."
One limit is clear: insurance can't keep up with these innovations.
The ACA has provided new coverage options for a now record-breaking 16.3 million Americans. This includes people who are without an employer-sponsored plan, gig workers and the self-employed, and those who are between coverage. That is a near-miraculous innovation in itself, given today's political climate.
Times author David Wallace-Wells cites multiple examples, leading with coronavirus vaccines and:
Gene and immunotherapies, including for cancer;
New drug-development pathways driven by machine learning; and
Off-label uses of the diabetes drug Ozempic, whose potential has expanded beyond weight loss to Alzheimer's, Parkinson's, polycystic ovary syndrome, addiction and alcohol use disorder, even cancer.
But how many innovations will be affordable, even for the insured? Wells reports that drug development costs "have doubled every decade since the 1970s." As for gene-based therapies, he adds that 400 million people worldwide have single-gene mutation diseases that Crispr gene-editing could fix. The two newest (sickle-cell anemia) would cost an estimated $2 million per patient.
"The deep-seated rot in US health insurance coverage"
Two days after Wells' article appeared came We've Got You Covered: Rebooting American Health Care. Authors Liran Einav and Amy Finkelstein start their book with a bang, citing the "deep-seated rot in US health insurance coverage." The source of the rot? The patchwork that is U.S. healthcare policy, forged from crisis response and plugged coverage gaps versus a unified approach. Other rots they cite include exorbitant consumer cost-sharing that deters treatment and can bankrupt even the insured users of care.
"When patients have to pay more for medical care, they use less of it . . . If cost sharing is large enough to have a meaningful impact on medical spending, it interferes with the primary function of health insurance, which is to protect people against the risk of having to pay large medical expenses."
The Covered authors note that collection agencies hold $140 million in unpaid U.S. medical debt—60% from people who have insurance. But the cost burden starts long before that. Half of U.S. adults can't cover a $500 surprise medical bill.
What would their Golden Age of Coverage look like?
The We've Got You Covered blueprint
Covered's authors, Einav and Finkelstein, propose that people should be auto-enrolled in free, basic coverage: all essential care for critically ill patients but only primary and preventive care for those who are healthy. "The rest is gravy"—separate, optional insurance that sits "on top of existing basic coverage" and allows consumers to pay the difference and only for the extra supplemental benefits they want.
Insurance innovation won't be cheap either. The authors call for a "binding budget for basic coverage, just like all other high-income countries have." They add that the budget "would come out of taxpayers' pockets [which could] plausibly be financed out of existing tax revenue."
What about cutting costs? Einav and Finkelstein are clear it is needed but acknowledge the consequences and the "large body of evidence that when physicians are paid less, patients get less care. And when drug prices are lower, fewer new drugs are developed."
The authors' final proposal is to eliminate unnecessary care. Again, they cite the evidence, that "the tools we currently have at our disposal tend to throw the baby out with the bathwater — cutting high-value and low-value care alike."
Healthcare value originates from many places
Returning to COVID vaccine development in his Times article, Wells notes: "It is sometimes hard to see the silver lining for the cloud, particularly when it's as dark as the last three years have been."
"But the mRNA sequence of the first shot was designed in a weekend, and the finished vaccines arrived within months, an accelerated timeline that saved perhaps several million American lives and tens of millions worldwide."
This highlights that the Golden Age of Medicine and the Golden Age of Coverage must share: speed, innovation, collaboration, and new regulatory pathways. In addition to being a patchwork, U.S. healthcare policy also can't keep pace with innovation. Because policy can't keep up, coverage can't either.
Hype and hope, boom and bust
Wells writes that hype springs eternal in medicine, right beside the hope. It's important to acknowledge both. He also details that decoding the human genome "unleashed a venture-capital-like boom-and-bust biotech hype cycle that sputtered out before most Americans had seen any real gains from it." There is only one U.S. Crispr gene therapy, the others focus on testing and only two companies have submitted FDA applications for associated treatments.
The Affordable Care Act has generated a similar cycle. In 2016, Inc. Magazinedeclared the ACA a "gazillion-dollar startup machine." It was and is, with its own booms and busts. Perhaps the greatest venture would be to achieve the coverage Einav and Finkelstein describe.
"[O]ur reading of the historical record — both at home and abroad — leaves us sanguine about the possibilities for universal health care in the US . . . but we're confident it's not impossible either."
As Wells concludes: "Sometimes these things just take a little time."
"One value-based care premise is that better primary care should mean less reliance on specialists. It's too simple a story but the idea is out there." — John Barkett
In June, CMS launched Making Care Primary (MCP). The agency designed the model to "improve care management and care coordination, equip primary care clinicians with tools to form partnerships with health care specialists, and leverage community-based connections to address patients' health needs," including related social needs.
In this exclusive interview with HealthLeaders, former Senior Biden Administration Policy Advisor John Barkett unpacks MCP. Barkett—now a healthcare group managing director at Berkeley Research Group—served as a VBC portfolio advisor on the White House's Domestic Policy Council.
HealthLeaders: MCP applies lessons learned from two prior primary care models and the Centers for Medicare & Medicaid Innovation [CMMI] strategic refresh. What does CMS hope that the new model will accomplish that others haven't?
Barkett: The background here is important: the CMMI strategy refresh and CMS' goal of getting 100% of Medicare beneficiaries into value-based arrangements by 2030. The feedback during the first year of the Biden Administration was that the previous models were not easy to participate in for every provider.
The 10-and-a-half-year length of the MCP model responds to feedback from primary care providers who have said, 'We support value-based primary care, but we need a longer time horizon to realize the benefits of it as we help patients manage their chronic conditions.' You need more time to really bear that out.
HL: Can you unpack why MCP is launching with State Medicaid agencies but also includes Medicare requirements and an invitation for private payers?
Barkett: That ties to the second part of this: the importance of getting the vast majority of Medicaid patients into value-based care as well. MCP starting with Medicaid too helps ensure a multi-payer model. If you start with Medicare only, it's harder to convince practices to participate, especially if they have large Medicaid patient panels.
The Federal government can only control what they can control. With MCP, they're talking to states early on and I suspect that the efforts to bring along commercial payers will also be swift here, because they want as much alignment as possible.
HL: Just how bad is primary care integration and coordination with specialty care?
Barkett: You raise a good point; we should better understand exactly how bad it is. That is something we don't really have yet—a metric that measures how bad or good it is. We know who has insurance and who doesn't. We don't get the same type of data as to who gets value-based care and who doesn't.
With MCP, a question I have is how will practices partner with specialists. One VBC premise is that better primary care should mean less reliance on specialists. It's too simple a story but the idea is out there. This model could go a long way toward providing an initial set of answers to this question as it encourages partnership between primary care and specialty providers. Encouraging primary care practices to engage in coordinated care efforts is something CMS hasn't done much of in previous models.
HL: Given the diverse participants in MCP, who will be in the driver's seat?
Barkett: That's a loaded question. MCP is as public-private partnership-y as it gets.
There's always a tension: payers pushing the practices to transform while making sure the model is attractive enough to make it worth the effort. You've got several people with their hands on the wheel here—maybe two or three with their feet on the gas pedals, others on the brakes. It's almost like a three-legged race with either state or federal governments or payers generally each putting a leg in the sack. The first couple of years, it's, 'Can we walk?' with the goal to be running by year two or three.
HL: It's like we wanted it to happen in dog years—seven years of progress for every one.
Barkett: There was never any question that the administration's Domestic Policy Council would have a subject matter expert tracking value-based care. It really took off under Obama, continued under Trump and now the Biden Administration—the idea that there is an alternative to fee-for-service medicine that gets you better patient health provided at lower costs. But it's not as simple as, 'We can reform the way we pay, and providers will transform their practices.' It's not something you can do overnight.
It takes change management. It takes leadership. It takes learning. It takes sharing best practices. It takes technology. It takes data. Everyone would have hoped that all of these things were slam dunks. Instead, we're probably where we were always going to be, which is having learned a lot and now working on the next generations of these payment models.
As noted in the AHIP press release, the playbook seeks to grow private-sector VBC arrangements that increase quality, equity, and participation; are sustainable for all stakeholders; and use valuable, real-world insights to design, implement, and evaluate these arrangements.
The release notes that the playbook "marks the beginning of an ongoing partnership between three prominent industry leaders, united in their efforts to foster broader participation in value-based care arrangements, thereby enhancing the lives of patients and families across the United States."
The three-organization workgroup that developed the playbook included participants from national and regional health plans, diverse physician practices, and multiple VBC entities, including but not limited to ACOs.
AHIP, AMA, and NAACOs released its first playbook in conjunction with a webinar featuring leaders from all three organizations:
Danielle Lloyd, SVP-Private Market Innovations & Quality Initiatives at AHIP
While these three stakeholder groups have unique needs, focusing on five best practices for data-sharing — quoted directly from the playbook with webinar quotes highlighted throughout:
Create an Interoperable Data Ecosystem: Adopt consistent content and exchange standards to simplify and expand data sharing.
On this best practice, AHIP's Lloyd noted: "Both plans and providers have different levels of experience and capabilities. We talk about alignment but there is no uniformity. We have to meet our partners where they are. For example, some provider offices don't have access to certified EHRs, so we have to think about how to incrementally implement some of these best practices."
Pittman with NAACOs echoed these points: "EHR interoperability is still a challenge that ACOs are facing. Some workarounds are using third-party applications to combine data where feasible, but more work is needed to better align and combine data elements."
Share More Complete, Comprehensive Data: Empower value-based care participants with complete, accurate, and consistent data that paints a more comprehensive picture of a patient or population.
Speaking to this best practice, Pittman asked: "What do you do when complete information cannot be shared?" The NAACOS SVP further cited the need for "aggregate or contextual data to promote and build transparency and ultimately trust."
Improve Data Collection and Use to Advance Health Equity: Collect and share data to identify and address health disparities as well as barriers to care beyond the clinical setting, while ensuring transparency, appropriate use, and confidentiality.
Examples provided by Lloyd include stratification around demographics, more granular options, national standards, and the ability to act on individual and shared data.
Share Timely, Relevant, and Actionable Data: Prioritize sharing focused insights and data early, often, and in accessible ways to improve care.
For this best practice, Pittman noted that data must be "presented in a way that can be leveraged to help make decisions. Clinical data needs to be available at point of care … [with] adequate attribution data available frequently."
Make Data Methodologies, Calculations, and Context Readily and Easily Available: Share detailed information on how and what data were derived from to foster trust among value-based care participants in the data they receive, use, and by which performance is measured.
A phase two playbook on payment methodology will follow these data-sharing best practices.
Obstacles to implementation
Best practices are one thing. Implementing them successfully is another if more providers are to participate in VBC arrangements.
Largo, VP with the AMA, noted that physicians need three things to participate: infrastructure, including data analytics); stable and transparent reimbursement, including a stemming payment rate erosion; and less administrative burden.
"Many practices have 10+ payer contracts. These should be aligned to aid VBC participation and create a better on-ramp."
Pittman and Lloyd agreed, adding that the impact of turbulent provider finances and workforce issues has sparked interest in achievable VBC arrangements. Lloyd stressed "the importance of the upfront investments" needed for VBC, that providers have looked to acquisition for these resources, and that that represents real risks.
"We've seen a lot of new entrants into the market [acquiring practices] that aren't necessarily interested in value. Our goal is to really ensure that physician practices are able to participate and stay independent if they want because I think some of the consolidation issues that we're seeing are troublesome."
The Purchaser Business Group on Health executive signals how far employers are willing to go to tame out-of-control healthcare costs.
In 2008, America's financial institutions were deemed Too Big To Fail. In 2023, does healthcare have the opposite problem: Too Big To Succeed? Can a delivery system dominated by a small group of for-profit players deliver reform and customer value?
Many employers would say no, and Elizabeth Mitchell is a leader among them. As president and CEO of the Purchaser Business Group on Health, Mitchell helms a nonprofit coalition of nearly 40 private employers including those who self-insure to provide employee health benefits.
"United Healthcare, the big three PBMs—they are so large and so well resourced and so profitable that they have very little incentive to change course. And in many cases, they are larger than my even my largest member."
In an exclusive interview with HealthLeaders, Mitchell dispels multiple myths:
That mergers and acquisitions improve care
That payers listen to large employers
That employers want health plans to coordinate care
That employers will continue to accept the status quo without a fight
To this myth-busting, Mitchell adds PBGH's mission: "Our focus hasn't changed. It's quality, experience, affordability, and equity."
M&A is DOA
"We are seeing a growing access crisis, particularly for primary care and maternity care. I believe mergers and acquisitions are playing into that," says Mitchell.
"All of the evidence shows that M&A has had no positive impact on quality but a clear impact on prices because the larger entity then has more leverage in negotiations, which is typically the point. Mergers and acquisitions are not generating the results that our employers would like to see in the market."
Being a larger entity doesn't benefit everyone, including what Mitchell calls jumbo employers.
"There is this myth that these entities [payers, PBMs] are responsive to jumbo employers when in practice, they're just not. Employers are clear about what they would like to buy, and the suppliers just don't care," she says.
Elizabeth Mitchell, president and CEO, Purchaser Business Group on Health.
"It's increasingly challenging to shape the healthcare system in the way that purchasers want."
And what do they want?
"What we are seeing among my members is a growing trend to want to go direct, to not go through these entrenched middlemen, and to find other ways to buy the healthcare that they want to buy for their employees."
Mitchell is referring in part to direct contracting, where employers contract with providers and accountable care organizations to deliver employee healthcare versus contracting with health plans or third-party administrators (TPA).
But how prevalent—and successful—are these approaches?
Mitchell reports that "about 20%" of PBGH members direct contract, have done so for years, and with notable success.
"They all have data that shows that when they go direct, they are saving 10-20% of total cost—and in many cases, getting the quality and experience and access results that they're looking for."
The challenge is replicating those results more broadly.
"Going direct at scale is very challenging for jumbo employers with headcount all over the country. They tend to direct contract in regions where they have concentrated headcount [e.g., an ACO contract where they're headquartered]. But they may not have the volume to make it work in other regions where they have employees."
Mitchell adds: "It's just not feasible to negotiate hundreds of contracts with different providers, especially when you're a small benefits team that isn't resourced to do that. Taking that strategy to scale is what we're working on now."
"Employers are able to have a different type of relationship with their provider partners. And they both understand what the other is looking for," says Mitchell.
While employers may be telling providers "We heart you," the message to TPAs and health plans is very different message: "Stay in your lane."
"Our members don't want health plans to be doing any form of medical care. They want those resources to be with the providers, particularly primary care and maternal health," says Mitchell. "Let them do the care coordination and the social needs screening and all of the things that patients frankly want from their doctors, not from their health plan."
And what about health plans?
"They need to get the basics right: customer service, claims processing."
She has similar advice for TPAs, who may start out offering administrative services but often expand until they look like the very health plans that self-insured employers sought to avoid. And the more they resemble a health plan, the more likely they are to be acquired by one—another example of M&A's negative impact on healthcare.
"There is a significant gap in the market to enable the types of programs that jumbo employers want. When I say gap, I want to be clear that there are plenty of TPAs out there and even some that are still independent. What our members are looking for is a TPA that is not just fee-for-service based, but one that can pay prospective or alternative payment models. That is a very small subset."
May you live in interesting (fiduciary) times
If all of that wasn't intriguing enough, enter the Consolidated Appropriations Act (CAA) and new hospital pricing transparency regulations.
Employee benefits consultancy Bolton notes: "With the CAA now mandating access to the prices of health care services, employers have greater accessibility to carrier transparency. Additionally, CAA requires plan sponsors to demonstrate that their purchased health care services are cost effective, high quality, and meet mental health parity and pharmacy benefit requirements for their members."
Expect employers to use the data that TPAs, health plans, and PBMs have historically withheld.
"I would just underscore the fact that the CAA actually obligates jumbo employers to audit their vendors and partners, to test that there are no conflicts," says Mitchell. "That is going to require access that employers have not always had, like data that PBMs are loath to provide."
"Employers are obliged to ensure that they are paying a fair price, that they're getting the best quality. That is not necessarily something they can achieve with the current vendors and partners they have."
"I believe all of this is going to force some very different dynamics and make it a very interesting time," says Mitchell.
Or as her LinkedIn profile banner reads: "It's long past time we take action to foster meaningful, widespread change in health care to the benefit of those the system should be serving — American businesses and the workers."