AHIP to lead Connecting to Coverage Coalition, a one-stop shop for multi-stakeholder redetermination resources.
As many as 18 million people could lose Medicaid coverage after the COVID-19 Public Health Emergency (PHE) ends. April 1 is the deadline for states to start redetermining eligibility of Medicaid beneficiaries.
In response, AHIP has co-founded and will lead the Connecting to Coverage Coalition (CCC), "a national coalition committed to being a single source of trusted information about the Medicaid redetermination process."
The CCC "will also work to convene stakeholders to support information sharing, build on best practices, and develop solutions to ensure Americans are able to enroll in coverage that is right for themselves and their families."
Coverage options range from remaining on Medicaid for those still eligible or transitioning to an employer-sponsored, CHIP or commercial plan, with options for the latter including the individual and ACA marketplaces.
On the new CCC website, AHIP President and CEO Matt Eyles commented: "With the Medicaid redetermination process already underway, millions of Americans will be looking for trusted, reliable information to guide them. The Connecting to Coverage Coalition will be an essential resource to help them through Medicaid redetermination, and to learn more about the health care coverage that is best for them."
New redetermination resources
The CCC website includes the following redetermination resources for Medicaid enrollees, healthcare navigators, industry and community leaders, and other stakeholders:
Background research on knowledge and perceptions surrounding the Medicaid redetermination process.
Redetermination FAQs for Medicaid enrollees and family members.
CMS and other federal agency guidance on redeterminations.
Best practices and toolkits for eligibility pathways.
In its CCC press release, AHIP stated that the coalition is committed to helping people "enroll in affordable coverage choices to protect their health and financial stability."
Combating low awareness and understanding
Help for current Medicaid enrollees will be pivotal. HealthLeaders recently reported that 64% of adults in a Medicaid-enrolled family have no idea that they may lose coverage with the return to regular Medicaid renewal processes. That figure—based on analysis from the Urban Institute, funded by the Robert Wood Johnson Foundation—is only slightly higher than the 62% of beneficiaries who reported being unaware of redeterminations.in June 2022.
The most recent survey uncovers that 16% of adults have heard only a little about the return to regular renewal processes, while 13.9% have heard some, and 5.1% have heard a lot.
Awareness does not differ significantly across the U.S. Lack of awareness is highest in the Midwest (67.6%) and lowest in the West (61.3%). There is also little difference in states that have expanded their Medicaid programs, where awareness is 64.5% versus 63.7% in non-expansion states.
The report—based on analysis conducted by NORC at the University of Chicago with AHIP support—estimates the current Medicaid enrollees who will lose eligibility, what programs they will transition to, and variations across states:
Most enrollees will have access to employer-provided coverage (EPC).
This is true in nearly all U.S. states, with NORC estimating that Georgia will have the lowest EPC transition enrollment (48.9%) and Delaware the highest (57.1%).
Approximately 3.8 million current Medicaid enrollees will become uninsured (21.2%).
This compares to the 18 million originally projected to lose Medicaid coverage.
NORC has determined that uninsured rates due to Medicaid redeterminations will grow the most in South Dakota (26.2%) and the least in Massachusetts (17.7%).
The NORC report includes a coverage-transition modeling dashboard based on two core figures: the Urban Institute's estimate of a state's total Medicaid coverage loss during redetermination and the percentage of the state's population that is currently enrolled in Medicaid and CHIP.
The modeling includes a breakdown of not only EPC, CHIP and marketplace coverage transitions, but those Medicaid enrollees who are projected to receive subsidies on the ACA exchange and those who will transition to other healthcare insurance programs such as military-based and Medicare.
Despite state differences, the CCC hopes to identify best practices that could apply more generally to Medicaid redeterminations for smoother transitions with fewer negative impacts.
On the CCC website, BCBSA CEO and President Kim Keck commented: "Millions of Americans are at risk of losing their Medicaid coverage. Our commitment is simple: Everyone should have access to high-quality, equitable, and affordable care, in times of trouble like the pandemic, and every other day."
Additional members include: American Cancer Society Cancer Action Network, The Arc of the United States, Cystic Fibrosis Foundation, Cancer Support Community, Mental Health America, Catholic Health Association of the United States, Unidos US, American Benefits Council, National Association of Benefits and Insurance Professionals, National Association of Community Health Centers, Federation of American Hospitals, and American Health Care Association.
The Health Affairs Council on Health Care Spending and Value has followed its initial report with an article series.
In February 2023, Health Affairs and the council published its initial A Road Map for Action report, which has now been supported by a series of articles for Forbes, written by council co-chair William Frist, MD, former U.S. Senate Majority Leader.
The council's stated purpose is to "ignite and provide a focal point for discussion, analysis, and action surrounding the topic of US health care spending and value" and to promote a "nonpartisan, evidence-based approach to understanding what we spend on health care, what benefits we receive from that spending, and how the nation can achieve more from its investment in health."
The council's other co-chair is Margaret Hamburg, MD, former FDA commissioner. The council includes 20 leaders from across the healthcare delivery system.
Intersection of council recommendations, goals and associated levers
The council's first four recommendations related to U.S. healthcare are:
Administrative streamlining
Price regulation and competitive supports
Spending targets
Value-based payment
The council report maps each of these recommendations to four levers that can achieve the overall goal of "higher-value health care spending and growth in the U.S.":
Price
Volume
Service mix
Sustainable growth
Price is the one lever mapped to all four council recommendations while value-based payment is the recommendation impacted by all four levers.
Recommendation 1: Administrative streamlining
The council makes two recommendations for administrative streamlining: standardizing key processes and harmonizing quality measures.
Streamlining includes the standardizing of claims processing and also of data collection for provider directories, provider credentialing, and prior authorization.
Characterizing these processes as both "in between" and "seismic," the report notes: "Although some of the reforms detailed here would admittedly produce relatively small savings on their own, the council believes that it is important to start with these actionable steps to build momentum for taking larger steps in the future."
As part of its longer-term proposals, the council recommends that quality measures be streamlined across all payer types and state and federal agencies—including the more than 2,200 metrics included in CMS programs. The report cites a study that harmonizing measures could save up to $7 billion while improving provider and patient experience.
Recommendation 2: Price regulation and competitive supports
This category includes four individual recommendations:
Increased monitoring of markets and mergers
Limited price regulation in non-competitive markets
Performance improvement plans and conditional regulation in potentially competitive markets
Supports for already competitive markets
To support these recommendations, the council report cites the impact of private sector pricing on the public sector and market-specific competitive dynamics, noting: "There is compelling evidence that relatively high US private-sector prices are a key driver of relatively high US health care spending. Also compelling is a lack of evidence linking consolidation-induced higher prices to higher quality of care."
The council adds that while its recommendations "address hospital markets … a similar framework could be applied to physician or insurance markets."
Recommendation 3: Spending targets
As with price regulation and competitive supports, this category also includes four recommendations that stress data support for setting growth targets, monitoring spending growth, and enforcing targets with a call for federal data infrastructure support.
"The missing ingredient in US efforts to moderate health care spending growth is a locus for collective action," notes the report. "The council therefore encourages states, with federal support, to convene stakeholders to engage in data collection, analysis, and discussion about health care spending."
The council cites examples of multi-stakeholder work in Maryland and Massachusetts.
Recommendation 4: Value-based payment
Value-based payment (VBP) includes just one recommendation that should come as no surprise: continue work on models that work. The council cites the 10-year findings of the Center for Medicare and Medicaid Innovation (CMMI), showing that federal VBP models were duplicative and underperformed.
Whereas fee-for-service is still the chassis of healthcare reimbursement, the report states that VBP can be its new chassis, one that supports the council's three other recommendation areas: streaming, pricing, and spending.
Noting that there are "reasons to be optimistic," the council specifically recommends:
Fewer, better aligned VBP models
Incentives that promote patient selection of, and lock in to, accountable care providers
Greater patient responsibility and flexibility
Incentives to address social drivers of health
Assessing confidence
The council rated its 11 recommendations with either Medium or High confidence in their ability to produce savings or slow spending growth, the level of resources/implementation difficulty involved, and the financial magnitude of success.
The report concludes with a statement that resembles that of The Innovator's Prescription, published more than a decade ago: "The level of collaboration and compromise that will be required to implement these recommendations is significant. However, in steering policy makers toward a set of recommendations that has been vetted and supported by a diverse group of experts with divergent interests, the council hopes to provide a strong starting point for action."
In the fact sheet, CMS noted the PHE's widespread impact on "many aspects of health care delivery," including those that allowed for more streamlined and flexible services. CMS notes: "While some of these changes will be permanent or extended due to Congressional action, some waivers and flexibilities will expire, as they were intended to respond to the rapidly evolving pandemic, not to permanently replace standing rules."
COVID-19 updates
Mandatory coverage of COVID-19 services will vary by payer after the PHE expires.
Traditional Medicare beneficiaries will continue to have coverage for vaccines, testing and COVID-19-related treatment. Exceptions include tests that are not ordered by healthcare providers (over the counter) and possible cost-sharing for Medicare Advantage (MA) members.
Among private payers, most must continue to offer no-cost vaccines delivered in network. Mandatory coverage of COVID-19 PCR and antigen tests will expire, will continue at the insurer's discretion, and may involve some cost to members. Treatment coverage and associated cost-sharing and deductibles will not change unless the carrier does so.
For Medicaid members, the American Rescue Plan Act of 2021 (ARPA) required states to "provide Medicaid and CHIP coverage without cost sharing for COVID-19 vaccinations, testing, and treatments." This will expire for treatments and testing by September 30, 2024, and vary by state afterward but will continue for vaccinations.
Telehealth updates
Continued access to and reimbursement of telehealth services will vary by payer after the end of the PHE.
Via the Consolidated Appropriations Act of 2023, original Medicare will retain the following benefits through December 31, 2024:
General access to telehealth, regardless of where they live and not dependent upon residence in a rural area.
Access to home-based telehealth services versus those delivered in a healthcare facility.
Audio-only telehealth services (e.g., telephone) if other resources are not available (e.g., video, smartphone, computer).
Members of Medicare accountable care organizations (ACOs) may have access to telehealth services after 2024 to ensure continued engagement between patients—no matter where they live—and their PCPs. Primary care is central to value-based care models such as ACOs.
Individual commercial payers—including those who offer MA plans—will determine ongoing telehealth access, coverage, and payment for their members. CMS notes that plans are permitted to "impose cost-sharing, prior authorization, or other forms of medical management on telehealth and other remote care services."
Medicaid telehealth services will continue to vary as many states offered coverage prior to the pandemic, with continued delivery of services not dependent on the end of the COVID-19 PHE. In its fact sheet, CMS "encourages states to continue to cover Medicaid and CHIP services when they are delivered via telehealth" and has provided a guidance toolkit.
Hospital-at-home updates
CMS implemented the Acute Hospital Care at Home initiative to allow hospitals to provide expanded at-home care during the pandemic. That initiative will stay in place through the end of 2024 as approved by the Consolidated Appropriations Act of 2023. This will allow new patients to participate and maintain continuing for those already receiving at-home care as a part of the program.
Provider updates
Several PHE waivers expanded provider scope of practice and allowed for more flexible training and supervision. The following waivers will expire in 2023, with varying dates:
Nursing home aides. These providers must once again complete their training within four months of the start of their employment. This requirement will resume with the end of the PHE on May 11, 2023.
Certified registered nurse anesthetists. Practice must return to physician supervision, also effective May 11. States may apply to waive the requirement, allowing CRNAs to practice independently. To be approved, states must "attest that they consulted with the State Boards of Medicine and Nursing … and concluded that it is in the best interest of the citizens of the state to opt-out of the current supervision requirements" in a manner consistent with state law.
Virtual supervision. Physician supervision, where required, must return to direct versus virtual means as of December 31, 2023.
Waiver updates
CMS has issued individual fact sheets for how the end of the PHE will impact waivers related to healthcare providers, settings, and service delivery. Three of note—which CMS states "were intended to temporarily expand health care capacity when needed and generally cannot be made permanent without a legislative change"—include the waiver of:
Three-day prior inpatient hospitalization for Medicare coverage of a skilled nursing facility (SNF) stay.
Limitations for Critical Access Hospitals (CAHs), including the number of inpatient beds (25) and length of stay (no longer than 96 hours on average).
What constitutes an allowable setting for acute care (expanded to ambulatory surgery centers, inpatient rehabilitation hospitals, hotels, and dormitories during the PHE).
Medicaid enrollment updates
Continuous enrollment for Medicaid members will end March 31, 2023. Continuous enrollment allowed members to stay enrolled in the program without a redetermination process due to the shifting socioeconomic landscape that COVID-19 created.
How states will resume redeterminations is an ongoing topic, including flexibilities that will allow members to stay enrolled without processes that add burden to both states and individuals. States have up to one year to resume standard eligibility and enrollment operations.
"It's important to not rely on just one data view," notes Kurt Wrobel, who has helmed the integrated delivery network's payer business since 2020.
"There are a few of us out there," says Kurt Wrobel, referring to the actuaries who now lead U.S. health plans.
Wrobel's trajectory from chief actuary to CFO to president of Geisinger Health Plan (GHP) is fairly unique, making him quick to recognize others in the field. ("There's also Krista Hoglund, the CEO of Security Health Plan.")
But every executive journey is distinct, including Wrobel's leading a Pennsylvania payer that serves approximately 500,000 Medicare Advantage, Medicaid, CHIP, Marketplace, and employer group members.
In an exclusive interview with HealthLeaders, Wrobel detailed leadership transitions during disruption, healthcare reform's impact on actuarial science, and why it's important to question data.
From chief actuary to president
"I started my career in large-group pricing and underwriting for larger insurers [PacifiCare Health System, UnitedHealth Group, and Humana]. It's a great way to get the details on a particular line of business, but a smaller organization can give you a broad vantage point across all lines of business. As an actuary, you touch a lot of details and get a breadth of experience across all lines of business that you wouldn't necessarily get in other professions or organizations."
Leading during disruption
Wrobel transitioned to the top position at GHP at a particularly challenging time.
"I became interim president at Geisinger at the start of COVID when no one was around. The chief sales officer and COO had left and it took a while to fill those roles, including the chief actuary and CFO role I had held," says Wrobel, adding: "I wore those two hats, as well as president, for about nine months. There was a lot going on. The downside is you have to be a little less forward-thinking while you're getting problems solved."
Wrobel is quick to recognize the problems others were solving.
"I'd add that what I went through isn't anywhere near what the nurses and physicians went through during COVID. The way they came together—I have so much respect for them and their connection to one another and the community."
Pictured: Kurt Wrobel, president of Geisinger Health Plan. Photo courtesy of Geisinger.
How healthcare reform changed actuarial science
An actuary since the mid-1990s, Wrobel has an insider's perspective on how the Affordable Care Act impacted not only his profession but the healthcare industry at large.
"Where the profession had historically been focused on life and pension, health insurance has become increasingly more important. The actuary's role in healthcare has grown because the industry is more complex and now more oriented to risk."
Wrobel adds: "I somewhat joke that the Affordable Care Act and value-based care made actuaries too important. The ACA and VBC introduced more uncertainty and increased the need for actuaries in healthcare."
Case and point: risk adjustment.
"Risk adjustment post contract is difficult. It's hard to get a sense of true performance, risk scores, risk payments, and to establish liability—especially in the early years of the ACA. It's good that it's become calmer compared to the early days of the ACA. There's more data."
Data isn't everything
Wrobel identifies himself as a "believer in using wisdom and simple data analysis to answer business questions." He has written extensively on the need for, and power of, simplicity in complex fields—from actuarial science to insurance to healthcare.
It takes more than data, and certainly more than one view of it, to not only arrive at the best decisions but frame the best questions.
"There is the promise of Big Data and the industry that has grown up around it," says Wrobel.
"There are people who have the incentive to push more data on an organization. It's important to not rely on just one data view, but look at different sources, the marketplace and benchmarks."
Wrobel adds: "People can fall in love with a story and then seek the data to support it. It's called narrative bias. It's human nature but there's a real danger—think of Vietnam as well as how data is used incorrectly in elections. You need naysayers who will take a different position. Discipline around this is critical."
Wrobel has written about not only narrative bias but the many other blind spots that leaders can fall prey to—whether they are from technical or nontechnical backgrounds or make decisions in the arenas of war, finance, politics, or healthcare.
Wrobel is aware of this in his role as GHP's president as he balances his actuarial background with the health plan's mission and vision, noting: "You still want to dive into the details, but the worst thing is to get caught up in them. You're the leader of a broad organization who needs to manage people and strategy. I have to catch myself at times and have learned to trust the team to get the details right."
Payers and providers: The state of the union
Many healthcare conversations seem to touch on payer-provider relations. Challenges abound, even for IDNs, but Wrobel is optimistic.
"It's true that at Geisinger, we take a different perspective. We view providers as key partners, very much so, in creating risk-based arrangements and aligning incentives."
Success lies in a common purpose.
"We're all trying to do the same thing: deliver high-quality, affordable care," says Wrobel. "It's in our DNA and is becoming part of the DNA of other payers and providers. There is some thaw in those relationships, especially as payer and provider roles have become more interchangeable and represent more financial challenges."
The GHP president adds: "Anything that moves us from fee-for-service [FFS] and toward greater alignment is a positive."
"Like moving an aircraft carrier"
Wrobel expands on the evolution from FFS to value-based care, noting the need for, yet difficulty, of change to healthcare's reimbursement framework.
"The economic incentive that's important is moving away from traditional FFS. Two of the biggest developments here are the increasing complexity of the individual, group, and Medicare Advantage markets and the move toward value-based care."
Wrobel adds: "Everyone knew we didn't have a great, sustainable system. The move to VBC has been steady but slower than expected because healthcare is complex—like moving an aircraft carrier. You can't change hospital, physician, and payer behavior on a dime."
"Hospitals are important"
As the leader of a health plan closely integrated with its providers, Wrobel holds Geisinger's hospitals in high regard.
"Hospitals are important. I fully understand their challenges but have respect for what hospitals and health systems do. It's not just about saving money or the number of value-based contracts you have," says Wrobel.
He adds: "Hospitals are the jewel of many communities. Yes, we need to become more efficient. But few industries provide something more important than healthcare. There is simply no comparison."
Andrew Toy takes the helm at Clover Health and talks to HealthLeaders about how open networks, early disease detection and management, and health equity are intertwined.
In January of this year, Andrew Toy assumed the role of CEO of Clover Health. It was not only the time but his time. Toy served first as the payer's CTO then president and board member before becoming its chief executive. In this exclusive interview, Toy shares his love of solving ''bigger and bigger problems'' in service of the healthcare industry and society at large.
HealthLeaders: Describe your background and how you leverage it in your new role.
Andrew Toy: I have a varied background but you wouldn't know that from how I grew up. I was a software engineer-computer science person. I got my first computer when I was six years old. I came to the U.S. from Hong Kong to study computer science and got a master's degree from Stanford. All of this helped me as I came into healthcare. I had a startup from 2010 to 2014 that I sold to Google, where I worked on the Google Cloud team. About five years ago in 2018, I joined Clover.
The way I self-identify is that I like to solve problems—business problems, problems for society, and the world hopefully. I use my technical skills as a mechanism to solve those problems and then try to scale up to solve bigger and bigger problems.
HL: What skills does it take to want to solve bigger problems, and what advice would you give young to mid-career professionals who want to do the same?
Toy: I like to encourage myself and others to ''Start with Yes.'' It's easy to look at a big problem or idea and call out why it can't work. The key is, that no problem was ever solved without someone being willing to propose the solution. So, if you are willing to keep proposing ideas and generating answers, you come to realize that rarely does anyone remember how many times you pitched an idea before you found the right one. All that matters is that you reached the solution in the end. The upside of doing that for the business, the world, and your career far exceeds the actual risk. It just takes courage.
HL: Describe your Clover leadership transition and why now was the time?
Toy: My vision has not necessarily been, 'How do I become CEO?' but rather 'How do I deliver the biggest impact?'—for Clover as an organization, our members, and to help society.
I had been the CEO of my own company and knew it would make sense one day to take the CEO chair due to my relationship with the prior CEO (and founder Vivek Garipalli) and our mutual belief that the next generation of health will be deeply enmeshed with technology. The reason I'm taking the helm now is that everything is different coming out of the pandemic. The world reset in lots of ways and in the next few years, healthcare will have to continue to change significantly.
Vivek spoke to this when he transitioned to his new full-time role as executive chair of Clover's Board. [See Vivek Garipalli's post highlighting what Clover strives to deliver through its MA plans—''open, zero [or low] cost-access to any primary care physician,'' and how he sees the company's Clover Assistant for ''a core driver of [the kind of] clinical value creation'' for providers that healthcare will need to deliver in the next decade.]
HL: Talk more about Clover's open network design, PCP and care management focus, and how they both support heath equity.
Toy: There's a degree of futurism to how fast things are changing, but at the end of the day, the CEO's job is the mission and the vision. Clover's mission is to improve the everyday lives of people on Medicare. Our vision is to be a powerful, motivating force in the early detection and management of disease burden. The mission and the vision are simple but the details are complicated.
I describe it as the physics of healthcare.
The utilization of narrow provider networks by payers means that patients may be pushed to engage with a PCP they don't know or trust—and trust between a patient and their PCP is a crucial aspect of successful care management. In addition, there aren't enough doctors in the U.S. as it is. The narrow network approach exacerbates this problem, particularly in lower-income and underserved communities. These networks are implemented for financial reasons.
We believe low- to no-cost open networks will lead the way to a more equitable healthcare system. [See Clover's health equity white paper.] Our PPO-centric approach allows our members to avoid the painful decision of choosing between the insurance they can afford and the doctor they trust. When we present our members with choice, we believe they will visit their PCPs more and be more proactive about managing their own health.
HL: What role does Clover Assistant play in the open network approach and health equity?
Toy: Healthcare's biggest problem is health inequity because it can only be solved by helping everyone. We see a massive opportunity for technology here, and that's why we're so focused on bringing Clover Assistant to the widest network of physicians as possible. For doctors, it provides them with additional resources and support to do what they love to do: practice medicine.
At Clover, we're thinking about how we can leverage software to synthesize data in real time to build machine learning models that we put in the hands of our physicians. It's a totally different way of thinking about how you invest, spend, and get return on investment.
The analogy I use for Clover Assistant is the GPS. It provides useful, specific data that could inform a better route that supplements or complements a provider’s clinical care. Everyone finds that helpful. We're not trying to tell a doctor how to practice medicine.
HL: Did your background as a software engineer lead you to the broader value of open networks?
I have always seen an opportunity for technology to fix large-scale problems, and software engineers like to do that by creating structure and layers of abstraction. That's something networks of all kinds do well.
This idea of breaking free of centralized, siloed hubs is an interesting trend across multiple areas of technology and is becoming more about how we live our lives every day. The trend of decentralizing from the traditional ''networks'' of employment, transport, power, connectivity, etc., is going to be the future.
Healthcare is the only place where we are centralizing more every day, and we need to reverse this trend. It makes sense then that open and inclusive systems are also the future of healthcare. Open networks spur better, more accessible and often, more culturally appropriate care for our members. You can get care when and where it makes sense for you. Open architecture and interoperability allow our technology to seamlessly integrate with other systems, like virtual care.
To advance health equity—to truly help everyone—we need more open, distributed networks with broader care capability.
A Blue Cross Blue Shield of Massachusetts (BCBS-MA) pilot increased rates while signaling a shift to home-based screening.
"This is the beginning of the shift from colonoscopy to home screening."
This from Laura Carr, PharmD, director of Provider Performance at BCBS-MA.
The beginning she refers to is a BCBS-MA pilot with Beth Israel Lahey Health (BILH) and healthcare data analytics company Arcadia. The pilot used shared decision-making (SDM) to help patients choose whether office or facility-based colorectal cancer (CRC) screening was best for them. With SDM, patients, providers, and payers partner on treatment and care decisions for better outcomes.
In an exclusive interview with HealthLeaders, Dr. Carr detailed the goals and results of the pilot, the use of text-based messaging to jump start patient engagement, the role of the EMR in identifying screening gaps, and how SDM approaches support health equity.
CRC screening pilot goals and results
The pilot's goal was to improve CRC screening rates, starting with the patient-PCP visit. In a November 2022 webinar on the pilot, hosted by Arcadia, Carr stated: "SDM was a new approach, overall and for CRC screening options."
She noted that BCBS-MA wanted to:
improve quality outcomes
address disparities
give patients choice
demonstrate the power of tracking and reporting
exceed national CRC screening goals.
From January 2022 to September 2022, completed CRC screenings have increased 10%. Within that group, the number of patients choosing a home-based CRC screening versus a colonoscopy increased from 5% to 20%.
A text-based patient communications campaign was central. During the pilot, BILH sent 17,000 text messages—more than 13,000 in three languages—to patients with a CRC screening gap.
That gap included patients aged 45-49. In 2018, the American Cancer Society recommended that initial CRC screening be lowered from age 50 to prevent emerging, earlier-age CRC cases and deaths—particularly among racial and ethnic minority groups. In 2021, the United States Preventive Services Task Force followed suit, along with multiple cancer stakeholder groups.
"As a provider, your entire patient pop ages into CRC screening. Going back further to catch ages 45-49 is a big group. Pre-pilot, the screening rate for that group was low. So the objective is, 'How can we help get all necessary screening done.' If you're at lower risk for CRC, you have more options."
This from Tim Carey, clinical operations project manager (Performance Network) at BILH, as quoted from the Arcadia webinar.
Identifying patients, selecting outreach methods
BILH and BCBS-MA used the patient data stored on their Arcadia platform to identify the right patients. They set parameters to contact patients within the eligible age range for CRC screening (45-75).
During the first year of the partnership, the group designed the project, educated providers, surveyed patients for baseline, and decided on their patient outreach methods. The group landed on text outreach, paired with a patient SDM decision aid for CRC.
"We decided to send the decision aid in advance of the doctor visit because we want patients to learn about their options so they can have an informed discussion with their provider and then come to a shared decision about which tests to undergo, if any."
That's from Dr. Kim Ariyabuddhiphongs, associate chief medical officer at BILH's Performance Network, in a BCBS-MA article stating that patients and clinicians provided input on the decision aid, which was translated into six languages.
The power of text and the EMR
At a time when digital health is focused on apps and AI, why did the pilot focus on text communication?
"The first phase of the pilot was to demonstrate the effectiveness of SDM," Carr said. "The BILH providers could operationalize text efficiently and create and modify those messages to inform patients of the SDM tool."
In addition, data from the Arcadia webinar shows that younger patients are more likely than older ones to use a cell phone—important to know when you want to improve CRC screening rates among that population.
In the Blues-BILH pilot, 84% of patients aged 40-49 received text messages compared to 55% of patients aged 70-79.
Provider EMR capabilities also play an important role, both for identifying gaps and putting SDM tools at the fingertips of PCPs while they meet with patients.
"EMRs can generally flag for gaps in care including cancer screening. Different EMRs have different capabilities, which impacts the effectiveness of these flags," Carr said.
She added: "Outside the EMRs, providers still have online and paper-based tools for patients in the pilot who couldn't access the tool through the text message. Some EMRs allow the shared decision-making tool to be embedded right in the visit note or a link to it. We're trying to work with providers to get the tool embedded right in the EMR."
Carr notes that the pilot's four-fold increase in CRC screening completion using shared-decision making can help the industry exceed national CRC screening goals—which is currently 80% and largely unmet. In the webinar, she stresses: "The more cases found and found early, the more lives saved and beyond the colonoscopy status quo … This is the beginning of the shift from coloscopy to home screening."
Nina Zelcer agrees. She is senior manager of Life Sciences at Arcadia, which "transforms data from disparate sources into targeted insights and puts them in the decision-making workflow to improve lives and outcomes," per a company representative.
In her company's webinar, Zelcer noted: "Pilots like this shift VBC from facilities to wherever you can get care. It stresses the importance of bringing care into the home that occurred due to COVID."
The power of SDM and its link to health equity
Despite its effectiveness, SDM is still catching on.
"The resistance to shared decision-making comes because not everyone is familiar with it. Another factor is ensuring SDM tools are easy to use and that the best resources are available to enable provider conversations with patients," Carr said.
She added: "Uptake of the model can be slow because the upfront time to implement it can be seen as a barrier. There is some provider hesitation due to the perceived added time that SDM will take. But the BILH provider experience did not bear this out.
"Shared decision-making allows providers to truly operationalize patient-centered care so that patients can understand, make informed decisions, and be empowered. The provider hears the patient's preferences and circumstances and incorporates them. It really is a win-win-win for patients, providers, and health plans."
Carr noted that BCBS-MA plans are working with multiple providers to expand SDM's use. Health equity is a big reason why.
"Shared decision-making is a tool that helps improve equity," she said. "SDM helps patients and providers make choices together that will work better for the patient, which can help prevent delays in screenings. In the case of colorectal cancer, the longer screening is delayed, the poorer the outcomes. Early is better."
provider choice transparency for companies and their employees
market-based payment reform quality initiatives
value strategies
The 2022 survey responses came from more than 100 U.S. small, midsize, and large employers covering from 10,000–100,000 lives each. More than one in four respondents employed staff in 21 or more states. The 174 respondents included HR directors/managers (49%), HR senior executives (14%) and CEO/CFOs (11%). Respondents cited their experience with health plans including Aetna, Cigna, UnitedHealthcare, and BlueCross and BlueShield plans.
Quality is job one
The Leapfrog report stated: "Most notably, the survey findings suggest that when evaluating health plans, employers prioritize quality in care over other factors."
The report added: [W]hile employers generally believe health plans are aiming for quality and value, employers perceive significant room for improvement across all categories surveyed."
In a press release for the report, Leapfrog president and CEO Leah Binder stated: "We were a little surprised at how clearly the findings showed that employers care first and foremost about quality of care. They want results. The report points to specific issues that appear to disappoint employers and what successful health plans do to earn their trust."
Room for improvement: data and value
Leapfrog surveyed employer opinions on the safety, quality, and value of their health plan, with the corresponding report noting: "Most employers agreed their health plan cares about quality (57%), is committed to reducing unnecessary health costs (53%), gives employees easy access to usable data (59%), and demonstrates a commitment to employee health (56%)."
Health plans came up short on employer favorability in two major areas: sharing of quality and safety data (helping members choose the best providers for them) and alternative payment model offerings (steering members to the best providers).
"It is critical that health plans improve transparency of data," noted Binder in the release.
These results were mixed in comparison to 2020.
"While employers were more likely to agree that their health plan shares quality and safety data in 2022 than in 2020," the report noted, "employer satisfaction with alternative payment model offerings appeared to decline in the two years between survey" (from 41% to 30%).
It's quite possible that the pandemic's impact on data and collection and reporting contributed to the decline.
Correlating results to health plan grades and GPAs
The Leapfrog survey asked respondents to also grade their health plans based on their ability to provide their employees with high-quality care. The result? An overall "C" grade, with considerable variation between plans. This corresponds to an average health plan "GPA" of 2.29, a decrease from 2.57 in 2020.
For employers that gave their health plans the highest grades, the results echoed other response percentages. First was the belief that their plan cared about employees' quality of care (89%). Second was plan ability to improve employee health (84%). Health plans that received high grades offered employees easy access to usable data (79%), were committed to reducing unnecessary health costs (76%), and supplied provider quality data (74%).
Implications for employers
These results suggest that employers remain disappointed in many aspects of health plan performance—and at a critical time. As part of the 2020 Consolidated Appropriations Act, which updated the Employee Retirement Income Security Act, employers are on a greater legal hook for delivering high-quality, cost-effective employee health benefits.
With this new accountability comes new employer concerns.
As HealthLeaders reported in September 2022, the Purchaser Business Group on Health (PBGH) debuted new strategic goals to "redirect" member spend and purchasing toward affordable, whole-person, equitable care.
PBGH, which includes nearly 40 large public and private employers, will also launch a Public Purchaser Advisory Committee to "elevate the needs of public members and help further integrate the work of public and private purchasers." In its press release, PBGH noted that its members are "frustrated by uneven quality and out-of-control spending" and that some 90% of large corporate executives "believe the cost of providing health benefits will become unsustainable" within five to 10 years.
An April 2021 survey from PBGH, the Kaiser Family Foundation, and West Health Institute revealed that some 85% "expect the government will be required to intervene to provide coverage and contain costs."
A roadmap for health plans
Leapfrog noted that "dissatisfaction in this report should be an urgent priority for health plans," providing "a road map on how to increase satisfaction with employers and purchasers." Leapfrog identifies quality as a "competitive opportunity for health plans … [which] should look for opportunities to partner with business groups on health and employers and other purchasers to better achieve these shared goals."
CEO Dr. Toyin Ajayi details how her approach delivers innovation for patients and payers: "You just prove it."
"For us, it's very emphatic. We are a healthcare provider."
So answered Cityblock Health co-founder and CEO Dr. Toyin Ajayi in an exclusive interview with HealthLeaders that kicked off with the question: Where does Cityblock operate in the healthcare delivery system?
This in a conversation that included payer partnership models and the company's mission to "radically improve the health of marginalized communities at scale," Ajayi continued.
"Cityblock is in the community, providing primary care, behavioral health services, and social care. We are technology enabled and rely very much on data, analytics, and decision-support tools to provide care in a multimodal way: at the right time, in the right place."
Cityblock offers this care via clinical and non-clinical providers who deliver largely home-based care. The company's aforementioned tools help identify need, meet need, escalate response based on a member's situation, and pivot between virtual and in-person care.
Cityblock's integrated care model
"We focus on folks who struggle with the combination of low income and the clinical, social, and behavioral challenges that layer on to that, as well as disabilities. Making their lives is our sweet spot," the CEO said.
For example, Cityblock improved 2022 utilization as just reported in its Equity In Action analysis, including:
20% of ER visits prevented for members seen by the Mobile Integrated Care team
15% fewer ER visits in Washington, D.C. for members engaged in the Advanced Behavioral Health program
The company's social care services play an important role.
"Social care as a concept is something that we did a lot of work to pioneer in many ways, describing what it looks like to encompass trusted, longitudinal relationships and close gaps," Ajayi said.
"We can't address mental health without addressing physical health, and we can't address either without considering social drivers and social contexts. There's a recognition that care models that carve out mental health may allow expertise and specialization in nuanced provider contracting, they don't align with the ways that human beings actually experience life."
"COVID forced us to relearn lessons we should have known already," Ajayi continued. "When you not only have silos, but also trauma that is particularly concentrated in low-income communities and communities of color, you create the perfect circumstances for it becoming no one's problem with people falling directly through the cracks."
"The majority of what we do is in the community"
Ajayi describes Cityblock's model as progressive and tech-enabled to manage high-risk members, of which:
89% are either Medicaid or dual-eligible
85% experience two or more chronic conditions
47% have behavioral health needs
62% have specific social needs
Cityblock's approach and health plan partnerships have yielded results. From Equity In Action, the company reports 90% patient engagement with mature dual-eligible cohorts.
Across all populations, Ajayi stated: "Frequently, as many as 50% of the highest-risk people in a population cohort haven't seen a PCP in 12 months. And that's not because they aren't attributed to one. They have somebody's name on their insurance card."
"But if they're also trying to figure out where they're going to sleep at night or if they can't afford transportation or don't have a cell phone to manage appointments and get to their care—it's no surprise that these folks are falling through the cracks," she said.
"We know who those folks are. And we task our Cityblock teams with finding them. It's a high-intensity, boots-on-the-ground model that leverages team members who live in the communities we serve."
"They can really engender the trust that is necessary to pull people back into the healthcare system and allow us the privilege of serving them," she noted.
How Cityblock chooses markets and partners
In 2022, Cityblock began serving more members after expanding to Indiana in a partnership with MDWise, which Ajayi describes as the state's second-largest Medicaid MCO.
"They share our values," she said. "We launched with them in Indianapolis and Fort Wayne to serve about 10,000 Medicaid members.
Delivering on Medicaid innovation in general is also a priority.
"There's been a real trend there," Ajayi said. "States aren't just saying, 'We want you to manage the population. Here's the rate book.' They're saying, 'We want you to innovate.'"
That includes closing health equity gaps, being accountable for quality metrics, and creating value-based provider relationships."
Ajayi added: "States want plans to move the ship toward value. Cityblock acts as both a primary care provider in their networks and as a care coordination partner for members."
To meet payer needs, Ajayi noted that Cityblock pursues:
Specific populations in need and in states with Medicaid MCOs
Plans that want to partner beyond managing medical spend and medical loss ratios
Deeper, broader collaborations in existing markets
Expansion to roughly two new markets per year
"One of the things that is so important to us about building this business is that there is a scalable, sustainable model that can really have an impact for people."
Changing the narrative
This impact involves people who haven't been served well by the healthcare system or regularly included in its innovations.
"There are a lot of myths about the way the economics can and can't work, all of which pose barriers. But today, more people are thinking about these populations, and we played a role in helping that happen. If you're going to launch a healthcare business today, you better be thinking about how what you're doing applies to those most in need—the most systemically marginalized among us.
"We need to continue to push that it's possible. It's our moral imperative. It's a moment in time where we as innovators are not looking at the data and seeing that brown people and people with disabilities are the most disadvantaged over and over again. I want that to not be the story anymore. That requires everybody pulling together to change that."
Ajayi added: "Ultimately, the proof is in the pudding. When we deliver, and as we continue to scale this business, we belie any of the other fallacies and narratives. You just prove it. That's what gets me really excited about this."
What it means for Gravie to add its first-ever CMO to the executive team.
The multiple service areas that Gravie has bundled for employers, brokers, and consumers.
How this combination can help offer large-company health benefits to small business.
As CMO, Burrell will "develop and lead Gravie's care strategy, building innovative clinical programs and ensuring that members are happier and healthier as a result." In the announcement, Gravie adds: "Dr. Burrell will work closely with providers and members as he oversees the integrated clinical operations and population health at Gravie, ensuring the delivery of the most effective and affordable medical services to members."
Gravie was founded in 2013 and remains a private startup, raising more than $90 million in July 2022 in its latest funding round.
Gravie offers two core services to self-insured employers—the Comfort health plan and support for the new defined contribution model ICHRA (Individual Coverage Health Reimbursement Arrangement).
Gravie describes Comfort as "the nation's first-of-its-kind health plan that provides zero-deductible, zero-copay, and 100% coverage on most common healthcare services" (e.g., primary care, generic prescriptions, labs). Other services (e.g., emergency, specialty drugs, inpatient care) have defined copays or are available no cost after the employee reaches their OOPM.
To support ICHRA, Gravie offers a marketplace for employees to purchase a health plan using the defined contribution their employer made toward the cost of coverage.
Burrell notes that the company wants to be smart about innovation. Gravie's Comfort plan and ICHRA marketplace reflect three market developments:
More small to mid-sized employers are turning to self-insurance to lower healthcare costs.
More benefit design is focused on wellness and prevention.
Defined contribution is a viable alternative to traditional models where employers offer specific benefits and plans.
HealthLeaders: Sometimes it's difficult to tell what an innovator actually does and how it's different. Gravie sounds like a combination third-party administrator, benefits navigator, and marketplace platform. Is that accurate?
Burrell: All of the above is basically true. Gravie started about a decade ago with the ACA mandate as a Marketplace plan, then moved to ICHRA and saw common challenges. The company then built its own plan, Comfort. This allows smaller employers to be self insured by paying Gravie a premium to administer benefits.
HL: How is the addition of a CMO a selling point for employers and brokers?
Burrell: In many cases, we're already proving ourselves with our offerings. The extra benefit is knowing that there is a medical leader looking at plans, benefits, and the analytics needed for a quality offering and high-quality care. It lets employers know that there is medical oversight through the entire process.
(In its announcement blog for Burrell, Gravie notes: "With this new medical and clinical thought leader on our team, we'll continue to grow and innovate while focusing on improving the quality and efficiency of healthcare delivered to members, and ensuring it's worth the investment for both members and employers.")
HL: What types of employers does Gravie pursue and why?
Burrell: Today we serve about 1,000 employers. Our sweet spot is companies with 50 to 500-ish employees—sometimes a little larger and across a broad variety of organization types. One commonality might be employers that are interested in accessing things that were only previously available to larger employers. This includes more robust, personalized plan design and unique point solutions.
HL: What are some examples of those point solutions and your decision-making process?
Burrell: We offer a couple of point solutions at no cost as part of our Comfort plan. Sword, for example, is a virtual musculoskeletal (MSK) clinic for customers needing physical therapy and/or are experiencing pain or discomfort. We also use Teladoc for mental health and therapy services.
Callout Quote: "Innovations can take different forms. Some are care delivery model innovations, some are technology innovations where we have a new way to meet members where they are (telehealth). In general, we're trying to be smart about it."
Burrell: But when you're thinking about real people, they often have mix of things going on—an MSK component of pain plus depression or anxiety. The question is whether and how to prioritize or to address simultaneously. There is a point at which there can be too many handoffs and we might think about in-house development of our solutions to ensure a good customer experience and care journey. It's a case-by-case decision.
The CMO, an advisor to early-stage health tech companies and former co-founder of Carbon Health, concludes: "Gravie offers no-cost care beyond the annual exam. This is important to me because I'm a primary care physician by training. I'm passionate about patient experience, access, and preventive care."
Positive predictions that (almost) don't mention the pandemic or the recession.
The recession: If we're not careful, we might just talk ourselves into it. While recessions have very real drivers, it's also true that what we choose to focus on can impact outcomes. Talk doesn't get the job done, but a healthy dose of optimistic 2023 predictions might be a welcome change.
From Triple to Quintuple Aim
IHI President and CEO Dr. Kedar Mate and colleagues propose an evolution from the Triple Aim to the Quintuple Aim—adding workforce well-being and safety, and health equity to the existing targets of improved population health, enhanced patient care experience, and reduced costs.
In a February IHI blog, Mate wrote that "the Quintuple Aim is necessary precisely because we have not yet achieved the Triple Aim. My thesis is that the Triple Aim is not achievable without attention to health care burnout and inequity."
The influence of consumerism and HIT
Managed Healthcare Executive offers multiple consumer and tech-driven predictions for 2023. Talkdesk VP Patty Hayward writes that providers will see "competition from consumer-oriented brands" and that "big retail, tech, and payer organizations [will] move further into primary care and invest in delivery systems that look more like a great retail or hospitality experience."
Insightin Health CEO and founder Enam Noor adds: "Personalized services have become table stakes, and health plans that can deliver consumer-centric experiences to their members will have a competitive advantage over plans without the same approach."
Noting technology's role, Noor advises health plans to "design strategies and implement technology solutions that provide data-driven insights to better understand, anticipate, and address their members' needs in real time."
Other Managed Healthcare Executive contributors and industry leaders are equally optimistic that HIT can help:
drive prior authorization automation
link patient homes with traditional care settings for better prevention and outcomes
manage growing data volumes through better interoperability and EHR design
extract and identify more data to address social determinants of health
Turning the corner on value-based care?
Managed Executive also predicts that 2023 will be "a breakout year for value-based care."
Equality Health chief strategy officer Brandon Clark writes: "Across the past two years of the pandemic, we better understand that ground-up redesign is an imperative and not an option." Noting CMS' increased focus on VBC, Clark identifies other drivers: "The fee-for-service model is creating provider burnout at alarming rates, and the pandemic shed a major light on social and cultural health inequities."
Employers own their payer role
As HealthLeaders highlighted throughout 2022, employers appear fed up with healthcare costs. They will continue to take strong actions to counter them. Look for the Purchaser Business Group on Health (PBGH) and its dozens of large employer members to act on new strategic goals. This includes a "redirect" of member spend and purchasing toward affordable, whole-person, equitable care.
PBGH strategies include integrating public and private purchaser efforts. Across the industry, self-insured employers are also exploring direct contracting with providers. They are also taking advantage of new funding models such as ICHRA, or Individual Coverage Health Reimbursement Arrangement. Employers can use ICHRA to give employees a set amount of money to purchase coverage and offset cost-sharing.
Digital therapeutics learns more about commercialization
Consumer-driven healthcare is the rising tide that will lift many boats.
This includes wearables, other personal and home-based software and devices, and DTx, or digital therapeutics. DTx consists of "evidence-based therapeutic interventions that are driven by high quality software programs to prevent, manage, or treat a medical disorder or disease."
One of the biggest hurdles for DTx uptake, including solutions that require a prescription, is reimbursement scale. That can only come from payers and progress has been growing but slowly. But one X predicts that DTx companies will have the confidence to evolve their strategies.
Curavit Clinical Research co-founder and CCO Dave Hanamanpredicts that DTx companies "will focus on the difficult last mile to commercialization." Hanaman forecasts a more even mix (60%/40%) between FDA approval for DTx devices and earlier market access.
"This 'last mile' is completely unchartered territory for DTx companies," he notes, with continued challenges matched by a more optimistic and aggressive approach.
Inspiration-driven innovation
It's easy to be a pessimist in healthcare. But hope often springs eternal in the innovation and tech sectors, despite 2023 market downturns. Just ask Solome Tibebu, founder and CEO of Going Digital: Behavioral Health Tech.
In her BH-focused newsletter, Tibebu acknowledges the field's opportunities and challenges: "Behavioral health care has a lot of problems. But it also does a lot of good. Most of us who work in behavioral health believe in its power to help people while still recognizing that it's far from perfect."
Tibebu adds meat to the bone, citing the "myriad of possibilities for using technology in treatment" that innovators have developed—from artificial intelligence to virtual to wearables.
"These are all promising tools in the 21st-century treatment arsenal," writes Tibebu, adding: "Behind every merger or funding announcement, behind every technological breakthrough —there are human beings who are parents, kids, friends, and loved ones. They have lives and they are struggling. They need to know that there are people who care, who are working to ensure that 'it gets better than this.'"
