A multi-organization response to CMS' proposed Physician Fee Schedule seeks to build off strong program savings but flat participation growth.
The National Association of ACOs (NAACOS) is calling for the strongest possible accountable care design as the program posts significant annual savings and quality.
In a comment letter to CMS' proposed 2023 Physician Fee Schedule, the association and 10 other provider groups called out the following rule components—expressing support for some and changes to others.
As summarized in the NAACO press release: "The regulation, if finalized, would bring several positive changes to [MSSP] … including giving ACOs more time before advancing to the highest levels of risk, providing fairer, more accurate financial benchmarks, making positive changes to quality scoring approaches, and providing advance shared savings payments to smaller ACOs that serve underserved populations."
Continued and expanded funding
Launching and maintaining successful value-based care (VBC) models requires significant funding. As such, the NAACOS group letter supports advanced payments to all ACOs with health equity objectives. The group also wants to see incentive payments continue for Quality Payment Program participants that are part of Advanced Alternative Payment Models. The annual 5% bonus expires in 2022 and can only be renewed via legislation. House Democrats introduced the Value in Health Care Act in July 2021 to extend the incentive program while making other MSSP changes.
Greater stakeholder voice and flexibility on ACO benchmarks
Support for CMS benchmark changes is varied from the NAACOS group, with their letter applauding the administrative benchmarks to support reimbursement and health equity but wanting stakeholders to have adequate opportunities to shape these changes and participate in them in a timely way.
The NAACOs letter calls for CMS to eliminate the identification of high and low-revenue ACOs, noting that these distinctions are arbitrary (e.g., Federally Qualified Health Centers, Rural Health Clinics, and safety-net hospitals are considered high revenue) and should be made instead based on an ACO's patient characteristics.
Innovation, fast and slow
CMS wants 100% of original Medicare beneficiaries to be in VBC by 2030. This will require continued innovation. The NAACOS group letter urges the agency to use "MSSP as an innovation platform … to test new concepts typically reserved for CMS Innovation Center models such as a full-risk track, primary care capitation, and other public health emergency-era waivers." In other areas, including electronic quality reporting, the group urges CMS to slow its timeline to ensure a smooth transition.
The organizations that signed the letter, in addition to NAACOS, included: America's Essential Hospitals, American Academy of Family Physicians, American Medical Association, AMGA, Association of American Medical Colleges, Federation of American Hospitals, Health Care Transformation Task Force, Medical Group Management Association, the National Rural Health Association, and Premier, Inc.
The recent acquisition will convert HCSC from customer to owner of the ninth largest third-party administrator (TPA) in the U.S in a bullish and rapidly changing TPA market.
Member lives.
While health plan business diversification means that enrollment is not the only way that payers turn a profit, capturing member lives is still a primary objective. And there are many ways to do it: organic growth, partnership, or acquisition, and by direct enrollment, health services contracts—or acting as a health benefits TPA for self-insured employers.
"With this acquisition, we're making it easier for employers of all sizes to have access to our expansive provider networks, our data-driven insights and coordinated approach to care that focuses on quality and value," states Kevin Cassidy, HCSC's president of national accounts.
"Of all sizes" refers to the growing number of smaller companies opting for self-insured benefits. It's good for payers. But are these companies really getting the best deal as health plan, TPA, and employer dynamics shift?
Payers 2.0
"Increasingly, large health plans aren't referring to themselves as just insurance companies. They rent their networks and sell disease management and population health programs. A larger percentage of their revenue is toward selling services."
This from HealthLeaders' interview with Ken Janda, a consultant, adjunct professor at the University of Houston College of Medicine, and 40-year insurance industry veteran.
But don't take only Janda's word for it. In 2021, America's Health Insurance Plans updated its trade association name to just "AHIP"—noting that payers are more accurately providers that "play a critical role in making health care better."
That role includes the big business of TPA contracts.
Speaking last fall to TRADEOFFS for another TPA analysis piece, Janda noted: "The large insurance companies like Aetna, Cigna, UnitedHealthcare … all love to act as a third-party administrator. It's safer than being in the insurance business."
For these insurers, TPA contracts represent the bulk of their covered lives: Cigna at 76%, Aetna at 59%, and United at 42%—representing a collective $20 billion in TPA services in 2020.
This is more than the 10 largest TPAs combined (inside and outside of healthcare). These numbers make TPA contracts not just a payer side hustle but a main gig.
"From an insurance company standpoint, if you can get a TPA contract that pays $50 per employee per month and have the employer take the risk, why wouldn't you do that? Even though the revenue is less, it's less risky revenue."
TPAs 2.0
TRADEOFFS notes that the percentage of workers covered by self-funded plans has risen consistently, for all employer sizes, from 1999–2020:
Small (3–199 employees): from 13% to 23%
Mid-size (200–999 employees): from 51% to 59%
Large (1,000+ employees): from 62% to 92%
As smaller organizations turn to self-insurance with the help of deals like the HCSC-Trustmark acquisition, this trend is likely to continue.
Until it doesn't.
If and when things change, a new generation of TPAs may cut into payer profits, but likely on their way to being acquired. A November 2020 report from FCA Venture Partners stresses the opportunity: "Since 2015, the TPA market size in the US has risen by over 4.8% per year … The TPA industry is $240.5 billion in revenue per year and is the 35th largest market size in the US … [C]oncentration is quite low, however, with the top 10 TPAs accounting for only 3-5% of the total."
FCA adds that it is "bullish on the potential for innovative TPA solutions to have a meaningful impact on runaway healthcare costs and be an attractive driver of value in the healthcare ecosystem."
FCA brands these solutions "TPA 2.0 … because of their superior tech, patient-focused care, and simple user interface," adding: "Realizing this, larger insurance companies have begun buying up both large and small TPA 2.0 tech startups to modernize their claims process."
But does this outweigh the risks, challenges, and the benefits of emerging options?
Employers 2.0
Payer TPA upsides are matched by a growing number of employer downsides. As TRADEOFFS notes, these include insurer contracts that may conflict with the best interests of their employer clients—who may also be restricted from accessing their own claims data and end up spending more on TPA as payers charge additional fees for bolt-on services.
"The original idea of a TPA was to save employers money," says Janda. "Most employers still believe they are doing the right thing by being self-insured because they don't have to worry about a risk pool made up of other employers or about the risk margins of pricing insurance."
Drawing from his prior experience with Aetna, Community Health Choice, Humana, Prudential Health Care, he adds that employers have a role to play as well in building a better mousetrap.
"Most large employers have not asked their insurance companies or their TPAs to go out and get them a better deal, so they are complicit in this as well."
Value 2.0
Today, however, employers have more options, including direct contracting with providers as well as ICHRA—the Individual Health Coverage Reimbursement Arrangements enacted in 2020 in which employees buy their own coverage with the help of employer subsidies.
eHealth, for example, is now offering ICHRA "products and services" on its private insurance exchange, noting that smaller businesses may find the option less risky and more affordable.
The confluence of these alternatives with TPA 2.0 will drive both more M&A activity and an employer market that looks very different in the next five to 10 years.
"Right now, employers will continue to look to self-insurance with insurance companies to support them," says Janda. "In the end, however, this will not drive better value. That will come from VBC models that are more conducive to their goals."
From the importance of composability to buy-versus-build decision paths, there is a common takeaway regarding healthcare platforms: the need for nuanced strategies executed with unrelenting focus so payers can make the most of digital disruption.
No single answer for buy versus build
The best platforms—bought or built—reflect a mature vendor API strategy and user interface, paired with openness and integration and the underlying characteristic that maximizes every opportunity: composability, the capacity for modular components to work together to form more complex systems.
Says Jesse Horowitz, chief product officer for Oscar Health: "You may say that we're going to become the best-in-class algorithmic, medical, clinical, coding, AI company, and so we want all this in house. Most payers probably are not saying that and so really what you want to have is the easiest plug-and-play with any vendor on the planet."
Horowitz adds: "What has already become very universal is the improvement of economics. The need now, more than even six to 12 months ago, is to show a tangible result. I think it's been easy over the past number of years to talk about buying capabilities, but capabilities don't translate to results."
Alex Zavgorodni, VP of Enterprise Architecture at Healthfirst, notes: "You've got to be in a position to take advantage of what's to come. If you don't have a composable way to participate in the evolving ecosystem through digital channels, you will miss out."
Integrating the three-legged stool
Just as platforms cannot be monoliths, neither can approaches to meeting payer, provider, and customer needs.
"Our platform decisions are driven by our need to ensure the connections between all three are well thought out and allow for easy integration," says Tom MacDougall, CITO for L.A. Care Health Plan. "As a payer we are accountable to the member first, followed very closely by our commitment to the provider. We have begun to place an increased focus on the data we as a payer maintain which is utilized to assess the health of our members."
Data is the tie that binds stakeholders, with Zavgorodni adding: "I would argue that any plan that is looking to build a better consumer experience based solely on the information they control within their four walls will result in a very short journey."
The Healthfirst VP adds: "Melting away administrative efficiencies on the part of providers and payers is what's going to allow us collectively to focus a more intentional and cohesive consumer experience. That's a very interesting kind of dynamic in how you think about what issues platforms can solve."
Innovation accelerators and detractors
Regulation and process approach can either help or hinder platform-driven progress.
"I think that regulation is the catalyst for other significant change, but I think there are also two other factors. Who can come up with good, useful applications that are going to play into either the consumerization aspect or drive extreme amounts of efficiency," says Oscar's Horowitz.
Zavgorodni agrees. "The shift that's unstoppable is the digital disruption around consumer experience in everyday life. What's holding us back is the notion of a human wrapper in how companies operate. An enormous amount of money is spent on administrative functions."
MacDougall added the importance of iteration. "To not stall innovation, the focus must remain on 'the need,' 'the benefactors,' and 'the delivery of V1.' There needs to be an understanding of who owns the product, what the regulations are that shape its functionality, and who makes the call. It's okay to go out early and a bit ugly as that's where the rubber hits the road and true progress begins."
Stakeholders from five countries identify critical digital transformation connections in the 2022 HIMSS survey.
"Most providers, payers and clinicians [understand] that traditional healthcare will give way to a different patient experience … When a doctor visit is warranted, they will more likely seek medical centers with digital front doors, retail based urgent care and big tech companies moving into the healthcare arena."
The implications from an August 2022 HIMSS Future of Healthcare report signal just how secondary in-person care could become before decade's end—with trackers and apps driving prevention and wellness, and advanced telehealth and remote monitoring subbing for acute care and preventing hospital readmissions.
Highlights from the HIMSS report follow, with a focus on payers but based on healthcare leader responses from five countries: the U.S., United Kingdom, Germany, Australia, and New Zealand.
A new confidence in navigating disruption?
"Almost every US and international healthcare system intends to be in some stage of digital transformation by 2026-2027." So begins the HIMSS report, adding: "[R]esponses make clear that a transition toward digitally enabled and personalized care is well underway, even as adoption rates vary."
Health systems: Roughly 90% are preparing to deliver "digital-first primary care within the next five years." For specialty care, the number is nearly 50%, up 30% from the prior HIMSS report. These numbers—this year and last—are similar for "digitally enabled contact/service centers."
Clinicians: Some 76% of providers globally and 62% in the U.S. believe patients' willingness to use digital health tools will increase in the next five years.
Payers: With big gains in their belief that nontraditional approaches will drive personalized care delivery, U.S. health plans are catching up to their global counterparts—with mental/behavioral health, retail clinics, and online-only services leading the way.
There is something about inevitability that breeds confidence.
Look back five years and fewer than half of companies felt ready to respond to digital disruption. Fast forward five years and a similar amount of health systems expect to be implementing "core clinical and enterprise digital initiatives."
While the what and the how of transformation may differ by stakeholder, HIMSS adds: "Every group in the study was encouraged by the potential for digitally transforming health systems to greatly improve current health access disparities, rather than to further isolate patients located in digital deserts."
The Garmin will see you now
The best way to combat digital deserts is to create an oasis of digital doors, consumer-friendly entry points that marry trackers and apps to telehealth and remote monitoring on the care side and to diverse digital communication on the service side.
Despite multiple advances, clinicians are confident of their place in the digital landscape. HIMSS notes: "Fewer than 15% of clinicians across different countries believed they would be working in a fully digital work environment five years from now. This reflects growing understanding that digital transformation is ongoing, and that technology's role is to augment and not fully replace human interaction."
Clinicians are bullish on general tech enablement, including "workflow improvements that free up time to spend on complex cases," as well as better personalized care in three leading areas: cardiovascular disease, mental and behavioral health, and respiratory conditions.
How payers view the path to 2027
Predictably, the HIMSS report notes that "payers are excited by digital transformations' potential cost savings," adding that they "intend to improve incentives to push both plan holders and healthcare partners toward adopting digital tools that keep patients healthy and out of hospitals."
Payers are also confident that, post pandemic, "financial and technical barriers will ease" in the coming years and that "big tech innovation will be a major driver of digital transformations." However, compared to the 75% of U.S. payers that see tech innovation as the driver, only 64% believe tech companies will take command, particularly when it comes to personalized care innovation.
Bigger and techy-er may indeed be better
There is some but not total agreement on who will lead innovation
As noted previously, providers, payers, and clinicians all understand that big tech companies will continue their healthcare power plays. The HIMSS report states that "large national plans are expected to lead the way in supporting nontraditional approaches for care delivery."
Analysis from Tom Kiesau, chief innovation officer for The Chartis Group—a HIMSS Trust Partner—notes: "Given the increased reliance on technology companies, health systems should anticipate big tech companies becoming rivals for patients.
Kiesau adds: "These new market entrants are hyper-focused on meeting consumers' needs, which has effectively raised the level of expectations for how easy and satisfying care should be to access and receive."
Value-based anchors are among the company's expansion strategies.
As the ACA marketplace grows, so does Cigna's nearly decade-long presence in it. For plan year (PY) 2023, the insurer will expand its geographic and $0 footprints along with increased affordability and accessibility for labs, prescription drugs, virtual care, and wellness incentives.
Products expand to three new state and 50 new counties. Cigna's new markets will include Indiana, South Carolina, and Texas, putting the payer in 16 states total. This growth is rooted in Georgia, Mississippi, and North Carolina and brings Cigna's county total to 363.
Growth anchored in local, value-based care (VBC). In a comment to HealthLeaders regarding its expansion strategy, Cigna representatives said: "We choose new markets based on where we have strong provider partnerships that enable us to offer local plans that meet our customers' unique needs and deliver affordable care and superior health outcomes."
The company added: "In those areas, a majority of our anchor providers are in value-based arrangements that truly connect care for those we serve. This approach has enabled us to maintain a continuous presence on the individual exchange since inception in 2014–one of the few national carriers to do so."
Anytime virtual PCP visits, plus other telehealth specialties. In its press release, Cigna notes: "New for 2023, members will have access to MDLIVE's primary care physician network for routine visits via video at any time." MDLIVE also includes virtual dermatology, behavioral health, wellness screenings, and even urgent-acute care—the latter two for a $0 copay.
Zero-dollar and first-dollar benefits continue to grow. Cigna will offer more $0 options for deductibles, copays, and select preferred generics while offering "first-dollar" coverage for outpatient lab exams independent of deductible requirements.
Walgreens anchors the plan's retail prescription drug network. Through the Walgreens Advantage Network, most members can fill 30 and 90-day prescription quantities.
Cigna among the plans capping insulin costs. Cigna's Patient Assurance Program offers insulin at $25 per month for a 30-day supply.
Up to $325 in annual wellness incentives. For customers 18 and older, Cigna is offering a Take Control Rewards program.
About the company's 2023 ACA Marketplace offerings, Cigna's president of Individual and Family Plans, Lisa Lough, states: "From anytime-access to virtual care to $0 wellness screenings and personalized support for chronic condition management, Cigna's plans are designed to meet customers wherever they are on their health care journey and provide the care and coverage they value most."
Lough adds: "By continuing to expand and enhance our individual and family plans, more people will have access to quality, affordable care that supports whole-person health."
Open Enrollment for 2023 ACA Marketplace plans is from November 1, 2022 through January 15, 2023.
These unique Medicare Advantage services align with equity, outcome, and value-based objectives. Can they unlock all three?
A skeleton key is designed to fit multiple locks. In the case of MA, one such key is expanded supplemental benefits, non-medical services that—per CMS' definition—"diagnose, prevent, or treat an illness or injury, compensate for physical impairments, act to ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and health care utilization to all beneficiaries."
Introduced pre-pandemic, these services present a way for MA health plans to address social risk via good old benefit design, versus philanthropy or ancillary programs. But can they?
CMS RFI seeks answers
While supplemental benefits aren't new, CMS questions about their use and effectiveness are. How MA plans leverage, partner on, and prove the value of supplemental benefits was included in CMS' June 2022 RFI, which seeks to strengthen the MA program.
And why wouldn't the agency want to strengthen the program that is poised to replace its current model?
By plan year (PY) 2023, MedPAC predicts that MA enrollment will overtake that of original Medicare and reach 69% of beneficiaries within the decade. In addition, The Commonwealth Fund (TCF) reported in February 2021 that a growing number of MA enrollees have both social risk factors and complex medical needs. And with every federal healthcare initiative embedding equity goals, CMS appears to be all in on MA—bolting on every manner of benefit and cost flexibility to the private market chassis to help drive value-based care.
But many questions remain:
At what velocity will MA plans grow their expanded supplemental benefits?
Will members not only enroll in but use what they've signed up for—and how can utilization barriers be overcome?
Can supplemental benefits targeting social risks actually improve health outcomes?
What answers are available must be teased from MA plan data and the RFI responses (due August 31).
But first, a brief history of supplemental benefits.
How supplemental benefits expanded beyond the medical
Dental, vision, and hearing benefits were among the first supplemental benefits MA plans could offer to differentiate themselves from one another and traditional Medicare. Since PY 2018, their presence has flourished. TCF analysis of CMS data shows that between 93%-98% of plans offered vision and hearing in PY2020, with another 87% offering dental.
For PY2109 and per TCF, CMS expanded these options to include "nonmedical benefits." For PY2020, CMS introduced another expansion, Special Supplemental Benefits for the Chronically Ill (SSBCI). Again from the TCF: "Plans may choose to offer these benefits to enrollees with certain chronic conditions, and the benefits do not have to be primarily health-related, as long as the item or service can reasonably improve or maintain health or function of the enrollee."
Even before these expansions, MA plans could offer supplemental benefits that began to touch on the social determinants of health (SDOH), albeit narrowly. These benefits and their uptake as of PY2020 include:
Transportation – 35% of plans offer, 34% of beneficiaries enrolled
Meals – 46% offer, 45% enrolled
Home modifications – 10% offer, 2% enrolled
There is much room for growth. But it will take ROI confidence on the part of health plans and more robust customer utilization to achieve.
Customers pay for benefits they don't use
For health plans to know if supplemental benefits can impact equity, outcomes, and value, customers have to use them.
A November 2021 study on OTC benefits from the Consumer Healthcare Products Association (CHPA) showed that medical costs and hospital admissions were 8%–62% lower for select groups that used their OTC dollars. Most members, however, don't take full advantage of their benefit, leaving 30% annually—$5 billion aggregate—untapped.
"There's a lot of benefit left on the table," says David Spangler, senior vice president for legal, government affairs and policy at CHPA, in the agency's news release for the study. "When we see so many advantages in terms of real cost to health plans and systems, like reduced per member per month medical and utilization costs, health plans should do all they can to get enrollees to use this benefit."
The investment requirement
There are many reasons why MA payers are lagging on select expanded supplemental benefits. First, these benefits are coming of age just before and during the pandemic. And while quarterly plan profits have rebounded, COVID-19 costs have been unexpected and massive. Health plans are making significant new investments with care.
As TCF notes: "Supplemental benefits may help plans improve health outcomes and address unmet patient needs. However, to offer these benefits, plans must decide the best way to allocate resources among different types of services, some of which may require significant investment and infrastructure."
The study adds: "Some plans may not offer these additional benefits in the early years because of a lack of evidence on these benefits' impact on health outcomes."
Exactly what kind of evidence will it take? Therein lies the rub of the SDOH business case.
The million-dollar question
The industry now widely accepts that 80% of health outcomes depend on nonclinical factors. The industry OTC data previously cited establishes a connection between supplemental benefit use and better outcomes.
But the gap must be closed between industry-level data and the native intel that health plans need to make investment decisions.
TCF notes that "[i]ncreases in 2021 offerings suggest that plans are beginning to make these investments." A 2022 Milliman study—also based on CMS data and commissioned by the Better Medicare Alliance—supports this with growth areas such as home and community-based nonmedical services (e.g., in-home support, palliative care, caregiver support and adult day care).
There is also the CMS RFI. If MA plans cannot yet justify larger supplemental benefit investments, how much data will they be able (or willing) to provide CMS on use and outcomes? Other MA RFI questions target:
How supplemental benefit outcomes are evaluated;
How MA plan partnerships with CBOs and other third-party providers impact service delivery; and
What data CMS should collect to provide these and other answers.
Watch for the RFI responses after August 31 to see whether MA plans are beginning to realize more advantages from supplemental benefits or if the skeleton key is still only a quarter-turn through the lock.
Don Rucker and Joe Gagnon detail the power of computational quality for the NCQA's new pilot and far beyond.
How much could and should we have done without a pandemic to spur us?
For years to come we'll be asking ourselves that question about everything, from personal choices to industry practices. Sometimes, however, change does require a confluence of innovations—that "perfect storm," in the words of former ONC chief Dr. Don Rucker—to transform the slow, fragmented, and undiscoverable into the real-time, unified, and actionable.
The nascent field of digital quality measurement (dQM) is now harnessing that storm, which combines cloud computing, new FHIR-based API requirements (Fast Healthcare Interoperability Resources), and more modern data storage and transmission formats.
The NCQA is leveraging these advances for its Digital Quality Solutions (DQS) Pilot, which will convert the agency's printed quality measures into a software solution. In the second of a three-part series on DQS (part one here), HealthLeaders spoke in depth with Rucker—an executive lead for the pilot and now chief strategy officer for 1upHealth—and his colleague CEO Joe Gagnon about the coming dQM transformation.
With FHIR, says Rucker: "For the first time ever, payers and providers can have a formal computational discussion about performance." He adds two related firsts: the ability to "compare providers and patterns of care robustly, rather than doing a specific study" and the ability to "match up computationally what you're paying for, which amazingly enough has not really been possible in a robust way."
Robust is the key word.
"We want to look at populations and performance. Modern medicine should be able to pull out data on a population of patients, not just one at a time," says Rucker.
By leveraging FHIR for dQM, he adds: "We'll be able to look at populations in a computational apples-to-apples type of comparison. Historically, all we've ever had in American medicine or any other medicine, is apples to oranges."
Those apples and oranges are the clinical and claims data that have been firewalled, preventing the optimal integration and use of both.
"Almost all health services research is done on claims data while trying to answer clinical questions. It's like using a hammer instead of a screwdriver," says Gagnon.
Achieving terminal velocity
Rucker notes that 1upHealth has "built a FHIR-native architecture that we think will perfect for complex performance and quality measurements benefiting from both clinical and claims data that is provided by both providers and payers in varying combinations."
Aiding this data integration is more automation.
"The challenge of quality measurement over the last 20 years is that for every single program, we've had to manually curate data," says Rucker.
Gagnon also notes: "The thing that's different now are these sort of real-time protocols. Healthcare has a lot of very important decisions to make about quality, cost, and value, and when you're doing things more manually, that is a very long distance in the rearview mirror."
The CEO adds: "Allowing for computation in near-real time has, in every industry, changed the dynamics of those industries … We've hit a point where I think the terminal velocity is going to increase at a rapid rate. This is the sort of transformation that healthcare needs to go through because we can't accept how the performance and cost structure is anymore. I think everyone is for that."
Linking real-time data with long-term strategy
The NCQA pilot includes two payer organizations: Aetna, a CVS Health company, and Health Care Service Corporation. Rucker notes that FHIR and dQM will "materially change" how these and other payers operate.
"Payers have been really a more claims processing type of operation that now are effectively supervising clinical care," says Rucker. "Historically, they've had to rely on claims data, and it's been a very jury-rigged system," adding that "the way payers manage care through a combination of network contracts, network contract incentives, quality measures, and prior authorization … has been a huge dissatisfier."
So what will early transformation look like and how will it evolve?
Through FHIR and dQM, says Rucker: "We anticipate early payer analytics will be around typical questions such as risk management, patterns of care, network design, and various other forms of cost management.
He notes, and Gagnon agrees, that these will "soon involve richer calculations supporting appropriate care, personalized prior authorization, and digitally native quality measurement. Eventually the ability to power real-time analytics and APIs will allow more direct communications between providers, patients and payers that are possible today."
Gagnon agrees.
"The environment has not been pro-sharing and consumers aren't ultimately in control" as they are in other industries. "We don't need to accept that a proprietary focus is the best we can get, which is what we've been stuck with in healthcare for so many years."
The CEO adds: "How we use the data is where the difference is made and that's where a market economy can really make strides on behalf of both innovation and consumerization."
CDC to stakeholders: It's time for us to take our place at the data table.
What stakeholders already know: COVID affected some populations more severely and disproportionately than others.
What stakeholders have been reminded of: The pandemic was a redux wake-up call that non-clinical drivers of heath (also known as the social determinants of health, or SDOH) impact 80% of health outcomes.
What the government is doing about it: A CDC workgroup dedicated to SDOH has identified three specific SDOH data use cases.
The CDC acknowledges its lags
A February 2022 article from HealthLeaders highlighted: "Most state HIEs have, from the get-go of COVID, been able to answer all of the major questions that have somehow befuddled [the Centers for Disease Control and Prevention]. Who's getting affected? What is recovery? What is immunity? What are comorbidities? What things work? We have vast data stores on that, and huge statistical significance over all populations."
As Don Rucker, former chief of the HHS Office of the National Coordinator, notes in the article: "By contrast, the CDC has been unable to use huge silos of its own data to answer these questions in a timely fashion."
As the primary public health authority in the U.S., the CDC should be at the data forefront and has now stated: "[W]e felt that it was important to be at the table, and to be developing the public health use cases about how this information on social determinants of health on social needs could be interpreted by public health and used by public health for decision-making."
This quote from Karen Hacker, MD, MPH, director of the agency's National Center for Chronic Disease Prevention and Health Promotion, marked the April launch of the CDC SDOH Public Health Use Case Workgroup.
The three CDC use cases
Beyond the pandemic, there is not a healthcare stakeholder in the U.S. that is not thinking about, talking about, and—best case scenario—attempting to integrate SDOH as part of its outcomes strategy and business model.
It's fair to say that cloud computing, 5G, and Fast Healthcare Interoperability Resources have been the missing link for efficient data exchange. Maybe that's why the CDC is now in a position to target use cases based on "the functionality and interoperability required to allow an end-user to send and exchange coded SDOH-related data." Those use cases are:
Community Health Needs Assessment [CHNA] Leveraging Individual Level Social Care Data
Assessment of State, Local and Territorial Health Department Diabetes Programs
Monitoring Federal Program Successes for Individual, Program, and Population Health Advancement
Why these three? The prevalence and high-cost of diabetes, and the government's need to improve federal program outcomes—including value-based care models—are obvious.
But what about the CHNA? The assessment—which hospitals are required to complete the assessment every three years, uses community input and multiple data sources, including and increasingly third-party SDOH data—helps prioritize community need on the road to effective interventions. And while a robust CHNA is not the same thing as an overall health equity strategy, the assessment has new importance in the SDOH era.
Systemic focus
SDOH priorities often focus on food, housing, and transportation. Other target areas include finance and literacy (both health and digital). The CDC's five SDOH domains include Food and Nutrition Security but are otherwise, and logically, more systemic:
Built Environment. The human-made surroundings that influence and drive community and individual health.
Community-Clinical Linkages. Connections between "health care systems and services, public health agencies, and community-based organizations to improve population health."
Social Connectedness. "[T]he degree to which individuals or groups of individuals have and perceive their desired number, quality, and diversity of relationships that create a sense of belonging and being cared for, valued, and supported."
Tobacco-Free Policy. Policies that are "population-based, preventive measures to reduce tobacco use and tobacco-related morbidity and mortality."
The CDC focus areas highlight the distinction between individual, community, public, and population health, with some emphasis on industry and interpersonal system support. For example, Community-Clinical Linkages is more about how stakeholders work together to achieve SDOH goals. Social Connectedness seems unique among the CDC's defined SDOH objectives, and yet combating loneliness—particularly for seniors—has been a priority for multiple stakeholders during the pandemic.
Bringing stakeholders together in an efficient way is on the CDC's radar and was part of its SDOH Public Health Use Case Workgroup announcement. The agency's director of the Office of Informatics and Information Resource Management, Timothy Carney, PhD, MPH, has stated:
"We recognize that there are a lot of organizations, entities, activities, and individuals who are doing front-line work on social determinants and health equity … [M]any of us are building systems, solutions, technology applications, strategy, policies, etc. The hope however, is that we can identify a common framework, a future state diagram that all of us can begin to point to."
CMS announces remaining provisional awardees in stealth mode.
If you weren't looking closely, you might have missed CMS' announcement of the 110 participants that have been provisionally accepted into the ACO REACH program for 2023.
The agency released the names via an updated letter in a list of other ACO REACH documents—noting, with no plans to name, the 18 applicants that have withdrawn since late June. CMS will also not announce the 142 organizations that applied but were not selected.
Perhaps the low acceptance rate—47%—shouldn't have been a surprise. As Juliette Price, chief solutions officer at HSG, noted in July: "CMS had a cleverly-phrased portion of the ACO REACH request for applications that gave them the right to limit the total number of ACOs accepted into the program based on the volume of applications received. This tiny but significant sentence has been talked about in many conference hallways since it was released."
How the numbers may change
The 99 groups currently participating in the Global and Professional Direct Contracting model—GPDC, or Direct Contracting—may transition to ACO REACH with no added selection process, raising the total participants from the conservatively sized freshman class from 110 to 209.
While this would turn ACO REACH into a sizeable CMMI model, the numbers will only go down. CMS has signaled that the freshman class will be the only class, announcing in an August 15 companion FAQ: "At this time, CMS is not planning any other application opportunities for the ACO REACH Model."
The chosen ones
What do we know about the 110 organizations that were chosen and why, including the "provisional" designation? The latter simply means that more organizations have the option to withdraw before ACO REACH model year one begins January 1, 2023.
The only organization clearly linked to a current GPDC participant is agilon health, which plans to participate in ACO REACH in the Tennessee and Toledo, Ohio, markets. As a GPDC participant, agilon health links to four provider management organizations with multiple participating physician groups. In its FAQ, CMS states that it "will include supplementary
information on the participating ACOs in these announcements as available, including ACO type, risk sharing option, state(s) where the ACO operates, and ACO website."
What's in a name? Not much
Until then, the only safe speculation is that multiple health plans lurk beneath less-than-illuminating legal entity names like ACO REACH (in California, Washington, DC, Florida, Nevada, and Texas) and less-than-inspiring names such as "Dedicated US Holdings, LLC." The ability of health plan-linked organization to become direct contracting entities within original Medicare was part of the GPDC model controversy, at least among some circles.
HealthLeaders will continue to investigate the organizations behind the curtain as provisional participants wade through the methodology papers that detail the "financial, quality, and alignment policies under the redesigned ACO REACH Model." Per CMS, these will be published late summer 2022 on the ACO REACH Model website.
"We do compete against the for-profit nationals and have proven we can win against them," says the executive, who applies her diverse background to advance affordability, provider collaboration, and health equity.
As Dana Erickson approaches her one-year mark as president and CEO of Blue Cross and Blue Shield of Minnesota (Blue Cross MN), she shared with HealthLeaders her vision for better healthcare in Minnesota and the just-minted strategy that is designed to deliver place, plan, and industry-based solutions against healthcare's most persistent problems.
"Was it always my goal? No, I don't think so."
Erickson wasn't gunning to be CEO, but a combination of service, experience, and opportunity—and positions with Optum Health—positioned her for the role.
"I think it was something that did emerge over time," says Erickson, who served in four prior roles with Blue Cross MN before taking the top position.
"What I love about the organization from my whole development perspective—there are many things that I love—was the ability to be involved in so many parts of the enterprise."
She adds: "Certainly [the CEO role] was a part of the conversations I had with leaders throughout my time. It's always that mix of opportunity and preparedness. By nature, I'm a curious person so I've always taken every opportunity I can to learn different parts of the healthcare system. I've worked on the provider side as a nurse, I've worked in public health and home care. All of that work prepared me for a role that brings all of those pieces together."
That background included progressive roles with Blue Cross MN since 2015, including director of Integrated Health Management, senior director then VP of Care Management, and SVP of Health Services.
A first look at the Blue Cross MN strategic plan
Continuity combined with new strategic initiatives are the language of a leader who has spent seven years with a not-for-profit plan—and another decade as a nurse, home health provider, and executive with Optum Health, the health services arm of for-profit UnitedHealth Group.
"I was on the executive leadership team [at Blue Cross MN] and was well aware and very involved with the strategic work that had been done to date," says Erickson. "There are several things in our new strategic plan that were already been in motion. Payment base rate, for example, was part of my prior role. That's certainly something that will continue along with affordability, customer experience, and health equity."
Blue Cross MN shared its new three-year strategic plan, which is focused on five interlocking areas that will advance short-term and long-term goals:
Expanding overall market leadership with growth in all segments.
Growing affordability initiatives to lower the cost of care, including optimization of clinical programs and increasing the level of at-risk claims going through VBC contracts within our provider network.
Advocating for members at every step of their health journey and earning top rankings in industry benchmarks for customer experience.
Paving the way for everyone to achieve their healthiest life by ensuring that company initiatives and priorities are developed, designed, and deployed through the lens of racial and health equity.
Ensuring that the workforce will mirror the diverse membership, with a high-performing, inclusive environment that strengthens their position as a top place to work.
Detailing strategic objectives—starting with affordability
In her conversation with HealthLeaders, Erikson spoke often of affordability—the innovation that, for the most part, has eluded industry progress.
"We are fundamentally, unabashedly focused on affordability because that's what's keeping people from even entering the door," stresses Erickson. "I feel strongly that part of our work on the payer side is getting people access to care."
Erickson adds: "I know that we all love to talk about innovation and advancements, and we need to. But even with the most innovative solution, if it's not affordable, people won't have access to it."
Pictured: Dana Erickson, president and CEO, Blue Cross and Blue Shield of Minnesota.
Working shoulder to shoulder with providers
Erickson identifies to key targets to affordability—deeper, more strategic collaboration that Blue Cross MN calls its joint accountability model, which transcends contracting and financials.
"How do we not just financially collaborate with providers but also find other areas of commonality and strategic alignment that we can work on together. [Access to care and health equity] are a huge driver for me personally, and for the organization."
Erickson adds: "We can help providers be successful in those types of models, but they also have a responsibility and a role to play to be a part of the solution."
A new era of plan-provider collaboration
Perhaps more than ever before, health plans seem keen on provider collaboration. With news that prior authorization practices contribute to workforce burnout and shortages, payers are wise to treat providers as partners.
Noting pervasive and increasingly high-cost workforce challenges, Erickson adds: "We're at a point where we don't have enough clinicians to sustain the prior model. We have to move away from contractual relations and toward strategic partnerships—having like-minded providers that want to help us collectively address these systemic issues."
For Erickson, enhanced collaboration is personal.
"Collaborating with providers is a focus of mine. It's really driven out of my background of actually providing direct patient care and working in public health. Providers are a key part of the ecosystem, but they can't solve healthcare's issues alone."
Access to care: the first customer experience threshold
Innovation is irrelevant if you can't afford a health plan's gateway offering: coverage.
"I believe that part of our mission is getting people access to care," says Erickson. "So many people have a barrier to even accessing care and knowing where to go. The advocacy piece becomes critical."
Once people are in the door, a combination of customer experience, provider collaboration, and technology help create a loyal health plan member.
"A personalized approach to healthcare is an expectation that consumers have now," says Erickson. "Probably 10 years ago, it was about customization. Now it's about personalization. How do we how to make that experience personalized and specific to them to get the best outcomes possible?"
The CEO adds: "The use of technology has changed the expectation. Our ability to partner with providers on that type of care is critical. All of that has to be done within a payment model that supports that. Then ask, 'How can we provide better data and analytics? Where are we duplicating efforts and working against each other?'"
Erickson ends the topic with: "You have to really remember that the patient is the goal here."
Serving at ground zero
Even with the patient as the goal, not all patients facing life's storms are in the same kind of rowboat.
"It's something that motivates me on a daily basis," says Erickson. "I pull on the experiences I had as a home health nurse, of walking into people's homes and seeing that all of the equipment that we thought was going to change their life that was ordered in the doctor's office was sitting in the bathtub. And that happened on multiple occasions. Or refrigerators that were empty when I opened the door."
Flash forward to 2020. As the pandemic was emerging, Minneapolis was in the spotlight for a different kind of inequity—the treatment of black Americans by the police.
"We came out of ground zero for George Floyd's murder," Erickson makes it a point to discuss. "It was important for the whole community to come together out of that crisis."
That wasn't the last crisis. As The Independent wrote in April 2021:
"George Floyd and Daunte Wright never met but there's a chilling overlap between the two men. They died within 11 miles of each other. Mr. Floyd on the south side of Minneapolis and Mr. Wright in Brooklyn Center to the north of the city." Brooklyn Center, the "first-ring suburban city … in the Minneapolis-Saint Paul metropolitan area," became a priority response site for Blue Cross MN.
"We in the Twin Cities came out of ground zero for George Floyd's murder," says Erickson.
"It was important for the whole community to come together out of that crisis. Then there was another police-involved shooting, Daunte Wright. We then specifically had a call with city officials in Brooklyn Center and our leaders jointly determined a strategy that we call place-based initiatives."
Erickson adds: "Solutions come from communities. That's our belief. We need to listen to the community tell us what they need versus us coming in an applying what we think."
Those solutions include TurnSignl, a new app providing on-demand and real-time legal services to de-escalate encounters between motorists and law enforcement, as well as no-cost access to culturally responsive and trauma-informed teletherapy through Hurdle Health.
Regarding equity, Erickson ends with: "It is the right time for the healthcare system. Collectively it's about combining our efforts around a common pain point."