At the Inspire Recovery conference, payers and providers align on needed substance use disorder strategies.
In the healthcare industry, if mental health lags behind medical care, then substance abuse disorder (SUD) lags behind both.
Payers and providers alike acknowledge this. They're also coming together to do something about it. One example is the Inspire Recovery conference, held April 5, 2023, in Nashville, Tennessee, at the Country Music Hall of Fame.
Across four sessions, common and critical SUD themes emerged:
The importance of evidence-based treatment and outcomes measurement
Infrastructure, funding, and reimbursement, all of which are lacking
SUD strategy and treatment for future decades, not past ones
Patient access, engagement, and the value of peer support and lived experience
The importance of multi-stakeholder commitment
All form the patchwork that is SUD treatment in the United States. Technology and collaboration are working to connect the pieces without leaving the most important one behind: the human beings struggling with addiction who don't know where to turn, who may believe the only treatment option they have is leaving their lives for 30 days of inpatient care, and who may be addicted to substances they don't even know they're taking due to the rise of synthetic drug lacing.
Conference and session details
The Inspire Recovery conference included panelists and audience members from payer, provider, startup, and venture capital organizations. The event included three sponsors, whose executives served as panel participants:
Wayspring, which provides SUD, behavioral health, and primary care services in partnership with health plans
Groups Recover Together, which also provides SUD treatment, including group and custom support also in concert with payers
Specific panels addressed SUD treatment access, State and MCO collaboration in Medicaid SUD care, the role of payers in SUD, and the role of lived experience in engaging hard-to-reach members.
Nationally prominent panelists included former U.S. Representative Patrick Kennedy—founder of The Kennedy Forum and lead sponsor of the landmark federal mental health parity legislation that became law in 2008—and Tom McLellan—founder of the non-profit Treatment Research Institute.
SUD from the payer perspective
Inspire Recovery included an all-payer panel—"The Health Plan's Central Role In Driving Innovation"—with executives from CareSource, Elevance Health (formerly Anthem), Magellan Health, and Optum participating.
The payer panel themes included:
Digital health and how individual tools must fit with broader investment strategies
Evidence-based treatment and outcomes measurement in SUD
Total cost of care and ROI
Provider support that includes both education and gatekeeping when necessary
"We're always looking for innovation that supports the evidence and what we can cover"—a good summation of topics from panelist Debra Nussbaum, senior director of Behavioral Health at Optum.
Closely linked to evidence-based treatment is outcomes measurement, nearly non-existent in the SUD field, but with payers having a growing role to play.
"There is a health-plan centric role in measurement: pay for what works and what consumers demand and expect." This from Eric Bailly, Business Solutions director at Elevance Health, who also noted that "we [payers] can't move fast enough" and that all stakeholders need to "let the science speak."
Another SUD mantra? "Let the data speak." So noted Dr. Caroline Carney, president and CMO of Magellan Health, who stressed where the ROI needs to be: in the outcome for the individual and the cost of care for the payer.
Nussbaum added the importance of standardization when it comes to SUD outcomes measurement.
"People think of SUD as the Wild Wild West."
Everyone in the field wants to change that perception—and bring alignment in two other key areas. The first is providers.
Carney added: "We need to support providers who are not on board yet … to define what evidence based is. Behavioral health includes lots of different kinds of providers and we need to hold all of them to the same standard"—possibly through a team-based approach to metrics.
"Providers may say they are following evidence-based treatment, but payers need to make sure they are sticking with the model, maintaining fidelity" said Jessica Johnson, director of Behavioral Health and Wellness at CareSource. "To make something evidence-based, you need data and you need time and pilot opportunities."
The second area needing standardization is digital health investment.
For Nussbaum, this translates to cautious optimism about telehealth. Quoting "Jurassic Park", she asked: "We can do it, but should we?"—noting the importance of environmental cues in in-person SUD treatment settings. "How do we do virtual care safely in the SUD space, keeping the member safe and not moving too fast?"
Bailly echoed the sentiment: "There's some level of the pendulum swinging back that we need to be prepared for … Telehealth in the digital health space is so much more than a forklift"—in other words, not simply a unidimensional alternative to in-person care.
Carney broadened the view.
"I love this space because the control tower that the health plan often is is important."
Being a control tower requires tech investment discipline.
Johnson recommends digital health paired with predictive analytics and multiple external data sources that wraparound to forma a digital approach that works.
Carney agrees.
"If a technology isn't tied to the rest of what you do, it's almost dead on arrival for consideration. You can't have parallel processes in the realm of SUD-mental health treatment," she said, adding: "How are you going to use the tool you're paying for? There must be a high level of discernment on the data."
During the panel's Q&A, Colleen Nicewicz, CEO of event co-sponsor groups Recover Together, capped off the discussion.
"You have to be able to hear the signal through the noise because there are only so many bets you can make."
Carter Paine, CEO of co-sponsor Wayspring, ended the conference with this: "Stigma is still very pervasive, but I think it's lifting a little. A lot of people were in this area [SUD] before it was cool. We all should feel really good about what we do, getting payers and providers together in coming up with new approaches to treat and manage SUD. I think our society has become much more supportive of this good work."
That made HealthLeaders' exclusive interview with Pieninck a balance of the personal and the professional. Topics ranged from critical pandemic lessons that the healthcare industry can't afford to leave behind, to broader regional investments that make CareFirst and its executive a leader in areas that reach far beyond traditional healthcare.
The conversation started with the social determinants of health (SDOH), a term as problematic as the challenges it hopes to spotlight.
Reframing healthcare's language and focus
"The way we talk about SDOH feels so far from how people wake up every day in their own lives," said Pieninck. "A determinant feels like something that's destined to happen, and I don't think that's right. We need to make choices—as a society, as an industry—that help us intervene in better, more thoughtful, more effective ways."
Focusing on supply over demand—i.e., putting healthcare's consumers first instead of its delivery mechanisms—is another area the industry should reevaluate, said Pieninck.
"I would argue that if we're going to get this right, we need to start with the demand side, the people whose lives we're trying to impact."
Critical learnings from the pandemic
Nothing changes paradigms quite like a pandemic. The question is, will those changes last?
Pieninck hopes so, noting that "a global health crisis is something that most of us professionally had never seen" and the few simple lessons that he now reflects on often.
"One is humility. Most of the things we'd been doing in healthcare delivery were not really effective in the early days of a rapidly progressing pandemic. All of us were forced to confront that. The humility of that is something I'm desperately hoping will continue in healthcare as we go forward."
"The second is collaboration. I saw so many organizations across healthcare being willing to sit down in new ways, to connect and ask questions: How can we set aside the historical definitions of who we are and the roles we play and look at things more practically? What's going to drive the best progress? What can we do in partnership with the hospital, the health department, with local resources and communities that will create the change we so desperately need under these difficult circumstances?" said Pieninck, illustrating the "leading with questions" approach that characterized his discussion with HealthLeaders.
"That thoughtfulness—that we're all connected in this ecosystem that is healthcare—was a critical learning that I'm really hoping we don't lose sight of."
A third lesson from the CareFirst executive? That "healthcare interventions are not limited to healthcare resources."
"What worked out of necessity during COVID is, more often than not, what works when we're trying to reach people every day. There's a level of thoughtfulness and personalization that so often gets missed in trying to deliver in a healthcare system," said Pieninck, adding: "I would really love to see us continue to invest, scale, and stretch impact in areas that we have traditionally thought of as being outside of the healthcare ecosystem."
Brian Pieninck, president and CEO, CareFirst BlueCross BlueShield. Photo courtesy of CareFirst BlueCross BlueShield.
How a leader shows up
Pieninck on how he leads, as a professional and as a person: "For me, I really can't separate the two. Regardless of where I am in the community and given the role that CareFirst plays in the city, in the state, in the region, there isn't a moment in my life where I'm not the CEO of CareFirst. There really is no separating Brian at home and Brian at work. That's opened up more opportunities to extend our reach."
CareFirst BlueCross BlueShield is the largest not-for-profit health plan in the Mid-Atlantic region. It serves 3.6 million commercial, group, government, and students members across Maryland, Washington, D.C. and Northern Virginia.
"People may look at CareFirst and say, 'Hey, you're a health benefits company. Why are you personally committed to transportation in this region?' But when you start to speak in terms of, 'Yes I'm a representative of CareFirst. But I also work here and live here, and my family is growing up here.' So what's happening here affects me not just professionally, but personally."
Regional health, growth and prosperity
CareFirst's role in regional transportation improvement brought the discussion back to equity—health and otherwise.
Pieninck said: "I'm sitting here today in Baltimore City. If you live in the greater Baltimore region and you want to get to pretty much any job and you own a car, you're in luck. You can get there within one hour, no problem."
"But if you're relying on public transportation, you can only get to 9% of those opportunities," he noted. "You look at that and say to yourself, 'Here we are as an industry, trying to have a conversation with someone about managing their diabetes, and that person might be waking up every single day already behind the rest of the people in the community because they can't get to 91% of the opportunities.'"
Balancing short and long-term solutions
Expanding the discussion from transportation to pandemic work changes, Pieninck added: "There's so much conversation about this idea that we moved to remote work during the pandemic. And the reality is that for a huge percentage of people, that was never true."
"If we design things in healthcare that only serve the needs of a small number of people, we are not going to get to the right structure and solutions for broader populations and the public at large. That is the thing that healthcare needs to confront."
Pieninck added more detail on his plan's approach to regional growth.
"CareFirst is heavily invested in a multisector transportation investment initiative for the mid-Atlantic region—from Richmond north to Baltimore and everything in between. That's likely going to take a decade or more to mature, and those options are critical to getting it right into the future. But they don't necessarily help people right now.
"As a company, what we've said is: How do we advocate for the long term—making sure that we get things increasingly right structurally and what are some things that we can also do differently right now that begin to change the trajectory of people's lives and local communities? From that perspective, large anchor institutions like ours start to solution differently."
Making a broader impact
Pieninck concluded the discussion with a broader look at what healthcare needs to improve.
"I see this as a really critical moment where, as an industry and as society, we're pressing toward the convergence of doing what's right and doing what's smart," said the CareFirst exec.
"The trajectory that healthcare has been on is just not sustainable. We have a $23.3 trillion economy in the United States and 18.3% of that is healthcare spend. We have to reconcile that we're not getting the outcomes, impact, and benefit based on the level of investment. Most other industries would be maniacally focused on that.
"We've got to reorient that spend. We've got to get upstream. We can't just think about what we do as symptomatic relief for the manifestation of disease. We've really got to think about the health, quality of life, and economics of this country."
Redeterminations are among the many significant changes and challenges that State Medicaid agencies are facing.
"Existential threat." Those are the words the National Association of Medicaid Directors (NAMD) has used to describe the workforce challenges faced by State Medicaid agencies.
While employees in other economic sectors face mass layoffs, State Medicaid programs are struggling. And they will need help now more than ever as they engage in the Medicaid redeterminations that could cause millions to lose the coverage they gained or retained during the pandemic.
These are just a few of the challenges Medicaid programs face as the NAMD names new leadership and the association responds to new proposed rules and recommendations at the federal level.
Medicaid workforce challenges
Workforce shortages and vacancies may create significant barriers for Medicaid agencies as they work on redeterminations. Turnover is common in the Medicaid workforce, including for State Medicaid Directors who often serve just a few years. In a March blog on the topic, NAMD noted the challenges workforce shortages represent and what states are doing about them, including:
The State Medicaid agency vacancy rate is between 17–40%.
Skilled workers are required to conduct the "detail-oriented, pressure-filled, and time-sensitive" work that redeterminations represent.
State workforce strategies range from who can fill the needed roles (temporary or borrowed staff, contractors, and former employees) to how the work is supported (funding, training, complex case triage, tech tools and remote work).
The NAMD blog concludes: "State workforce shortages are another reason for states to 'strike a balance' on the speed with which they do the unwinding" (e.g., an approach that prevents unintended administrative costs/burdens downstream while adopting timelines that reflect unique State challenges).
NAMD response to CMS rules and MACPAC concerns
The NAMD recently weighed in on CMS's proposed rule, Advancing Interoperability and Improving Prior Authorization. The rule would require Medicaid agencies to "expand the Patient Access API, implement three additional APIs, and meet new timeframe requirements for prior authorization decisions." NAMD supports the proposed rules but recommends longer implementation deadlines.
NAMD also weighed in MACPAC's annual March report to Congress. MACPAC—the Medicaid and CHIP Payment and Access Commission—is a "non-partisan legislative branch agency" that makes policy and data analysis recommendations to Congress, HHS, and State Medicaid programs. NAMD supports MACPAC's recommendation for a national coverage determination that aligns select Medicaid coverage with the Medicare program to help protect those that are dually eligible for both programs. MACPAC also recommends that new questions on race and ethnicity be added to the Medicaid model streamlined application.
Changes in NAMD executive leadership
In the midst of multiple Medicaid program challenges, the NAMD named a new executive director, Kate McEvoy, in October 2022. In her monthly public message, McEvoy—who assumed her role in January 2023—addressed the "active, iterative process" that Medicaid redeterminations represent and announced upcoming technical assistance for long-term services and supports as those programs are impacted by the end of the public health emergency (PHE).
McEvoy also made note of the current federal budget impasse, its impact on Medicaid, and separate proposals made by the Biden administration in its March proposed FY 2024 budget. The proposal includes "sizeable investments in behavioral health services, the health care workforce, long-term care, and maternal health" and a plan to offer "Medicaid-like coverage" in non-expansion states.
Nearly a year ago, NAMD also welcomed a new Board president, Allison Taylor. She continues to serve as Indiana's State Medicaid Director, a role she assumed in 2017. As part of Taylor's work in the Hoosier state, her agency has shared reimbursement and managed care innovations with other programs in an attempt to align the actions of multiple state human service agencies as well as insurers.
State-level leadership changes
In addition to executive-level shifts, two states have new Medicaid directors: Janet Mann in Arkansas, who was previously with Mississippi Medicaid, and Jay Ludlam, the new Deputy Secretary for North Carolina Medicaid, who was promoted from within. A complete listing of State Medicaid directors is available here.
Medicaid's "new normal"
In the middle of multiple changes, Medicaid agencies must also make annual projections. In another blog on the topic, the NAMD notes "the key factors states are taking into account" as they face a possible 20-million-member reduction in their programs. These factors include:
Historical "churn" in Medicaid and its relationship to overall economic health, including unemployment rates and the incomes of those who are typically eligible for the program.
How cost and utilization will be affected by both standard churn and the redeterminations, particularly among older adults and those who are disabled.
The NAMD notes that these populations represent the "highest and most costly users of Medicaid services" but "typically make up only 10 percent to 15 percent of the overall population of members."
While these members are not as subject to Medicaid churn, children are—due to the eligibility changes of their families.
This is particularly important given the NAMD's note that "some people who do in fact remain eligible for Medicaid may lose coverage due to lack of awareness or administrative error. Individuals may not realize they have lost Medicaid coverage until they need to use the health care system."
The heath plan executive and Forbes contributor talks growing nonprofit scale, the industry's "toxic positivity," and why healthcare needs a new kind of leadership.
Dr. Sachin Jain is on the cusp of a new leadership role, something he's used to.
Jain—the current CEO of SCAN Health Plan and its parent company, The SCAN Group—will become the CEO of HealthRight Group. HealthRight is a new nonprofit healthcare organization that will combine the California-based SCAN Group and CareOregon to serve nearly 800,000 Medicare and Medicaid members in five states, provided regulators approve the merger.
In a press release on the merger, Jain noted: "For far too long, America's not-for-profit managed care organizations have operated at a scale disadvantage to their larger for-profit competitors."
In an exclusive interview with HealthLeaders, Jain had more to say—about the HealthRight merger, the unique role nonprofits play in the industry, and the state of the industry itself.
"Our distinctive approaches to duals will allow us to learn from each other, but our shared culture is service to the member," he says. "It was super obvious when we were meeting, like we were siblings separated at birth around mission, purpose and goals."
Sachin Jain, CEO SCAN Health Plan. Photo courtesy of SCAN Health Plan.
Jain on scale: Competing with the for-profits
Jain sees an important advantage in how HealthRight can care for vulnerable populations.
"These are two renowned not-for-profits coming together as a viable alternative to for-profit plans in the government space … We want to be able to scale to meet challenges at the level of for-profits and private equity organizations."
"Not-for-profits have the edge in making pro-patient decisions and can do more here on the margins. Before the current insulin pricing drama, for example, SCAN already covered insulin in the gap."
Jain adds that the way for-profits operate can generate self-limiting prophecies: "A world where the focus is quarterly targets leads to behaviors that are anti-patient and pro-profit."
But the CEO also cautions against a fixation on operational designations.
"We should be talking more about right and wrong."
Jain on healthcare: We are not Uber
Jain's belief extends to many aspects of healthcare, including how it stacks up against other industries.
"Healthcare has an extra set of obligations that are far greater. I think we sometimes rush to equate healthcare with other industries and forget that—when we're dealing with life and death, sickness and health—the rules are different than Amazon and Uber."
Jain adds: "We're all too quick to abstract obligations away. We need to be more thoughtful as a country, a society, and an industry."
Jain on providers: Leveraging the long term
With multiple organizations operating across multiple states, the potential for negative impact on providers is a factor, but not one Jain is concerned about.
"Provider-payer relationships are usually quite frayed. The stereotype is one of conflict and obfuscation," says Jain. Returning to HealthRight, the CEO adds: "We have stable management teams on all sides, people who have been with their organizations for a long time. Providers are engaging with leaders oriented to the long term."
Jain on the industry: No holds barred
If you've read Sachin Jain's Forbes articles, you know what he thinks about the industry's approach to things like high-profile mergers and value-based care (VBC). He added to those views for HealthLeaders.
For example, Jain expands the idea of "never events" beyond medical errors to healthcare's first harm: lack of access.
"In healthcare, we try to guide and manage as best we can, but some things should just never happen. Like cancer patients not having rapid access to expert medical opinions or stroke patients waiting in the ER. We've normalized waiting and suffering as an inconvenience. We have an obligation as industry to change this."
Another obligation is the industry's transformation from fee-for-service to VBC—one that cannot occur with the industry's current mindset.
"Toxic positivity or believing in a magic bullet occurs in healthcare because we're so desperate for solutions that we stop being critical. Being critical is not the same as not being optimistic. It's about applying a realistic lens."
Jain on leadership: Beyond CEO to MLK
HealthLeaders asked Jain how other industry leaders react to his unvarnished views—and how much that matters.
"I'm now 20 years into the work of making healthcare better. First, we thought the answer to healthcare reform was policy, then technology. The missing element is actually leadership. If I as a leader am not able to talk about uncomfortable truths, who is?"
Jain has been consistently recognized as a leading healthcare executive. In 2022, Modern Healthcare named Jain a Diversity Luminary as part of its Top Diversity Leaders in Healthcare awards. But his own model of leadership extends far beyond the industry.
"The kind of leadership I'm talking about is leadership with a capital L: people like MLK, Gandhi and Malcolm X, who really changed society. There's not enough iconoclastic energy in healthcare because most people aren't comfortable with it. In an industry as broken as ours, we have to ask ourselves hard questions about what leadership is and be willing to change our view of it."
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.
Editor's note: This article appears in the June 2023 edition of HealthLeaders magazine.
"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.
Editor's note: This article appears in the June 2023 edition of HealthLeaders magazine.
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."
