The first look at a preview of HealthLeaders Payer Week, five days of in-depth coverage and exclusive interviews.
“In quantum mechanics, a particle can exist in multiple states at the same time. Once the particle is observed it ‘picks’ one of these states . . . [and] the results change” — Mindful Leader.
Healthcare is not quantum mechanics. But multiple states do exist simultaneously across the industry, guided by competing groups: providers, pharmaceutical companies, government, tech startups—and payers.
Payers have not “picked” a single state in which to operate. They are also providers, third-party administrators, health services companies, pharmacy benefit managers, data and analytics firms, innovation incubators and investors. The list goes on and it has resulted in a changing healthcare landscape.
Medicare Advantage in the Hot Seat: Challenges and Opportunities
Payer operational diversity will be on display during HealthLeaders Payer Week—five days of in-depth coverage spotlighting the significant roles and contributions of insurers. Our week-long exploration, Medicare Advantage in the Hot Seat: Challenges and Opportunities, will include:
Medicare Advantage's tremendous market growth and expansion
The sticky business of Medicare Advantage prior authorization and marketing
The intersection of benefit design and provider performance
Rising drug costs and Medicare Advantage health plan counter-moves
The Star Ratings program evolution
Below is some of what you can expect for Payer Week.
Preview 1: Drug cost controls, payer shell games, and market collapse
“Meet the IRA,” writes Dr. Adam Fein, CEO of Drug Channels Institute. It’s an innocent enough introduction to the Inflation Reduction Act, which requires manufacturers to negotiate drug prices with the Medicare program and MA payers.
But Fein believes lower drug prices will come with a high price tag. This includes the potential collapse of the standalone Part D market. The cause? Payers steering members toward plans with combined medical-pharmacy benefits and integrated cost management advantages.
The Payer Week drug pricing brief will include an exclusive interview from CareFirst BlueCross BlueShield VP of pharmacy management, Mandi Poplawksi.
Preview 2: The Star Ratings he said, she said
The performance-benefits mashup isn’t the only marketing strategy that Medicare Advantage payers use. CMS’ Star Ratings are another. And a lucrative one, if you know how to play the game and have a five-star plan you can market year round.
Some believe star ratings genuinely reflect Medicare Advantage plan quality. Others believe the program “harbors an arbitrage game in which CMS consistently overpays MA plans with no demonstratable clinical benefit to patients.”
One fact spans both views: 2023 was a tough year for plans as a trifecta of CMS methodology changes sank Star Ratings.
The Payer Week feature will spotlight winners and losers, why a Medicare oversight group can’t stop ringing Star Rating alarm bells, and top tips from industry experts on how payers can improve performance.
Preview 3: What you don’t know about the Medicare Value-Based Insurance Design program
Only a few CMS alternative payment models have included Medicare Advantage plans and the value-based insurance design (VBID) program is one of them. From 2017-2023, VBID has grown from eight to 50 states and all U.S. territories and from nine to 50+ MA Organizations as of 2023.
Among value-based care (VBC) models, VBID is less controversial than direct contracting and has maintained a lower profile than the Medicare Shared Savings Program that put ACOs on the map.
Many Medicare Advantage plans have participated since the beginning (or as early as they could) while others—large players like Centene—have just entered. Why? How does VBID compare to home-grown payer models? How do plans balance the demands of multiple VBC programs? And what’s the status of the VBID-X plan design template?
The HealthLeaders Payer Week brief will address and feature an exclusive interview with Healthfirst’s SVP of Medicare, Jen Cohen-Smith.
More special coverage
Outside of Payer Week, HealthLeaders features exclusive leadership profiles for our series The Exec. Recent payer interviews have included:
Leading industry voice Dr. Sachin Jain, CEO of SCAN Health Plan and its parent company, The SCAN Group
Geisinger Health Plan president Kurt Wrobel, whose plan and parent company Geisinger Health will be acquired by Kaiser Permanente if the deal is approved
The president of Care Solutions for Evernorth Health Services, Joan Harvey. The industry veteran shared the top strategic priorities for Cigna’s health services division.
Clover Health CTO-turned-president-turned CEO Andrew Toy. Struggling of late, Clover represents a new breed of payers leading with tech and business model innovation.
See HealthLeaders’companion article for previews of other Payer Week features and briefs on the state of Medicare Advantage expansion, prior authorization, marketing, and benefit design.
Pushback on DEA regulations is measured by medication coverage trends that are improving but still lag in many areas.
It was the early days of the AIDS epidemic, and the government wasn't responding fast enough. As depicted in the HBO Films version of And the Band Played On—based on Randy Shilts' poignant account of HIV inaction in the 80s—CDC researcher Dr. Don Francis exclaims that when a house is engulfed in flames, you don't wait. "You grab the first hose and start putting out the fire."
Opioid use disorder (OUD) is also burning out of control—an epidemic that the pandemic exacerbated but also lent relief to. How? By expanding telehealth access to OUD treatment and medications, including buprenorphine.
This year has brought more threats and opportunities for those suffering from OUD. And while some outcomes are uncertain, others are clear, based on a new payer buprenorphine coverage study from Health Affairs.
The common thread is access.
The DEA flinches
The US Drug Enforcement Agency (DEA) has had a change of heart.
In response to "a record 38,000 comments," the agency will continue waivers that allow provider to prescribe controlled substances via telehealth (v-prescribing) and without a prior in-person visit. This gave millions increased access to buprenorphine and other drugs. Buprenorphine helps reduce opioid cravings and withdrawal symptoms.
But in the February 2023 rule that received so much criticism, the DEA proposed to end the waiver with the end of the COVID-19 public health emergency. If it had finalized the rule, in-person visits would again be required for initial controlled substance prescriptions and for buprenorphine refills, effective May 11. Amid backlash, the DEA has extended that date to November 11.
HealthLeaders has covered the proposed rule, its pause, and the broader, dismal state of OUD and substance use disorder (SUD) treatment and reimbursement in the U.S.
AHIP's response to proposed rule
AHIP's response was among the 38,000 that the DEA received.
In its letter submitted during the proposed rule comment period, the national payer advocacy group noted: "While we appreciate the Drug Enforcement Administration's (DEA's) efforts to balance patient access with patient safety, we are concerned that the proposed rule may erect barriers to further innovation in health care and offer several recommendations for consideration."
The AHIP letter, signed by organization SVP Kate Berry, continued that "telemedicine played an outsized role in behavioral health during the pandemic, with nearly a third of behavioral health outpatient visits delivered over telehealth for opioid use disorder and substance use disorder (OUD/SUD) conditions, and with rural residents even more likely to use telehealth for behavioral health conditions. That high level of telemedicine utilization for behavioral health continues even as the public health emergency comes to an end."
Payers step up—and are advised to keep going
While AHIP's response signals payer support for buprenorphine v-prescribing, insurance coverage for the OUD treatment has been a work in progress with more to be done.
Coverage for buprenorphine is the subject of a new Health Affairs study. The results were mixed. On one hand, there was a notable increase in coverage for the immediate-release formulation of buprenorphine from 2017-2021:
Formulary inclusion — The number increased from 95.4% to 98% among Medicaid payers, 91.3% to 94.7% among Medicare Advantage (MA) payers, and 93.4% to 97% among commercial payers.
Prior authorization (PA) — The percentage of formularies without PA requirements increased to 74.4%, 84.9%, and 94.6% among Medicaid, MA, and commercial payers, respectively.
Quantity limits (QL) — Most Medicaid (97.2%) and commercial (91%) formularies do not impose QLs, but MA is the exception with more than 50% retaining QLs as of 2021.
But this is for the older, immediate-release formulation. Coverage of the newer, extended-release buprenorphine has also increased but lags well behind. The Health Affairs study notes that "only 46 percent of commercial plans and only 19 percent of Medicare Advantage plans cover the extended-release formulation." In contrast, most Medicaid formularies do include it but with 37% requiring PA.
Benefits of the extended-release version include fewer doses (monthly injection versus a daily prescription) and clinician involvement, which can address adherence barriers and medication diversion/misuse, per the study authors.
"Almost all plans covered immediate-release buprenorphine in 2021, with a general trend of decreasing prior authorization requirements and quantity limits since 2017. In contrast . . . only 46 percent of commercial plans and only 19 percent of Medicare Advantage plans [are] covering this formulation."
Shifting access burdens to patients
The Health Affairs authors advise policymakers to "shift their attention to extended-release buprenorphine," adding: "State lawmakers could help address these barriers by mandating that insurers include extended-release buprenorphine on their preferred drug lists."
AHIP expressed a similar concern over OUD buprenorphine and broader treatment barriers in its DEA rule response.
"Our collective experience has demonstrated that telemedicine is an important health care innovation. Telemedicine's value as a modality is supported by recent data—it is a cost-effective, convenient means of delivering high quality care, particularly to traditionally underserved areas and can expand access to care and reduce disparities, especially for rural populations where there is limited access to in-person care."
AHIP continued: "We are concerned that the proposed rule shifts the burden of seeking care to the patient, which is counter to the goal of increasing access to needed care for underserved populations, especially given health care workforce shortages which can result in longer times to get in-person appointments."
The healthcare industry veteran reveals Evernorth's top three priorities and how her unique experiences inform her leadership.
Harvey's focus? Service, community, and whole health—lessons she learned from an early age.
Joan Harvey's leadership stretches forward and back. President of Care Solutions for Evernorth Health Services, she comes from a long line of pioneers and stands ready to support the next generations.
With HealthLeaders, Harvey shares Evernorth's unconventional collaboration tactics. She also explains how her multi-entrepreneurial family and 20-plus-year career in healthcare helped her understand community networks and the people who rely on them.
Health services: Translating point solutions to value
We started with the basics: How does Evernorth define a health services organization?
"Our definition would be, how do we create an integrated, seamless solution for our customer so they understand how the different services work together for their specific journey? That customer includes that traditional healthcare consumer, employers, and other health plans."
For Evernorth—the health services division of The Cigna Group, created after its merger with pharmacy benefit manager Express Scripts—integration means putting pharmacy at the front end of managing chronic illness. And asking the right questions.
"How do I get access to care? How do I understand my condition? How do I work with providers from a holistic approach?" poses Harvey. The answers include proactivity, client needs clarity, and value delivery.
"In our fragmented world, you can have lots of point solutions. It's very difficult for a client to understand the overall value."
Evernorth today: "We really do have a philosophy and an open approach to partnering"
"What we want to get at, in an integrated fashion," says Harvey, "is to try to solve some of the biggest challenges in healthcare."
Here, Harvey details Evernorth's assets, including: pharmacy care solutions, analytics and insights, benefit management, and care services. The company seeks to "bring them together to predict, prevent, and support complex treatments while making access to care easier."
Harvey adds: "At the highest level, we really do have an open approach to partnership. It allows us to bring together the best minds to accelerate innovation."
These partnerships include Kaiser Permanente and Oscar Health—payer collaborators that historically were strictly competitors. Is there a degree of difference in how Evernorth navigates these new relationships? Harvey says yes.
"To solve the big problems in healthcare, we have to work together. Large organizations are starting to think about how we align our knowledge, our assets, and our understanding of consumers to solve not only fragmentation but access."
Evernorth's big three
Harvey gives the impression of a team that has its eyes on the same prize.
'We look at what is really front and center for our customers, our employer health plan clients and our government support areas," she says.
Evernorth's three front and centers are:
Accessible, affordable high-quality care;
How that care functions in an environment of fragmentation; and
How outpatient mental health can yield overall savings
Take the latter, mental health. A 2022 Evernorth study of 200,000 customers published in JAMA Network Open found that even a few routine outpatient behavioral health sessions can impact total cost of care.
Patients with newly diagnosed mental health and substance use disorders who completed at least one outpatient visit saved up to $2,565 in medical and pharmacy savings in the 15 months after diagnosis (e.g., via preventable inpatient stays and ER visits). Results continued 27 months post diagnosis with savings up to $3,321 compared to those without treatment.
An Evernorth spokesperson notes that this is a great example of how the health services company links a specific high-cost condition to a seamless, connected solution across the entire spectrum of care.
Family history part I: Colorado steakhouses and OPEC
"My father was a restauranteur, and I grew up working in his restaurants," shares Harvey.
"He had quite a command and was also very, very involved in the community. Understanding what kind of experience customers wanted was one of the biggest lessons I learned from him."
She adds: "In healthcare, people are the service. Every day, our clinicians are executing and delivering programs that are helping millions of people live better lives. If we can create a better environment where people understand their network, their benefits, then we can ensure that they are maximizing the financial opportunity to get access to care."
Harvey's lessons come from a unique corner of America and at a very specific point in time.
"We were in the western part of Colorado in the 80s—the OPEC, when Exxon brought in tens of thousands of people and created these mini cities around Grand Junction to build the first phase of oil shale extraction [fracking]. And so, my father built up all different kinds of restaurants."
It didn't last. Exxon abandoned its Colony oil shale project in 1982, stating it could not "prudently continue the Colony project alone."
"Within six months, all of those people left," says Harvey. "The infrastructure that was there to support them dried up and a lot of people went bankrupt."
But not Harvey's father, who had no intention of continuing alone either. He pivoted with his community.
"Because he had spent so much time understanding the community and supporting the businesses there, we were able to shift the business and say, 'Okay, we're not going to be serving executives anymore. We're going to focus on what the people here need and what we can provide.'"
Family history part II: Heart surgery and mental health
"The big lesson for me," says Harvey, "was on the dynamics of economics and the outside world: how you can be resourceful to support teams and partners inside your community, how you can do good by them as you adjust your business."
And her family's entrepreneurial lessons weren't limited to restaurants.
"I grew up in a very medical family. My grandfather and grandmother were big in the founding of open-heart surgery and in mental health," says Harvey. She's referring to Dr. Henry Swan, who pioneered heart surgery using hypothermia—an innovation that expanded the types of cardiac procedures that are now available. And to Mary Fletcher Gaylord, a mental health advocate at the local, state and national level, dating back to the 1950s.
"I have been into whole-person health my entire life. You have to bring the mind and body together," says Harvey, adding: "So in terms of how to run a business, I think about communities. I knew I didn't want to be a doctor but I really wanted to give back."
Like her father. Like her grandparents.
"Your job is to pay it forward—to do something better and make it a better system. My grandparents did that and that passion has been a driver for me since I first started in healthcare."
The study was based on new data made available through the federal Hospital Price Transparency initiative. While the study authors note that this data could help employers bargain for premium savings from their health plans, others—including HealthLeaders—see broader possibilities.
How employers can use price transparency data
"Employers can also use this new research to better understand the total cost of care across various plans and markets and determine where they might have opportunities to control costs."
Azar mentions total cost of care [TCC] with caution: "It is not accurate to evaluate the price of anything by looking at the individual parts."
To TCC management, HealthLeaders adds other cost-control strategies that could make of use transparency data—part of our ongoing coverage of the employer as healthcare payer. The strategies include direct contracting with providers or ACOs and defined contribution tools like Individual Coverage Health Reimbursement Arrangement (ICHRA), where companies give their employees a pot of money to buy their own coverage and help pay for deductibles and coinsurance.
The challenge and opportunity of more data
"There is a lot of work yet to do with these data," says Azar and every professional who has ever tried to turn Big Data into Big Solutions.
Other insights from the Health Affairs study include:
Health plans with more than 71% commercial lives share pay hospitals nearly 15% less than in other markets.
The difference is lower—7%—in less-concentrated markets.
In the most competitive health plan markets, the difference is higher with for-profit hospitals versus nonprofits and government-owned hospitals.
In some markets, providers are more concentrated and have the upper hand in contract negotiations. In addition to cost transparency and other data, employers can use the Herfindahl–Hirschman Index (HHI), which measures how concentrated markets are in general based on who does business there.
Market realities and myths
The HHI definition and other Health Affairs analysis include tidbits worth paying attention to.
HHI is based on "the market share of each firm competing in the market," emphasis added to highlight healthcare's worst-kept secret: payers and providers are competitors. The prize? The healthcare dollar. Employers compete too, making the impact of market concentration on price and the use of cost transparency data even more vital.
As the Health Affairs study noted, the data "revealed considerable variability in procedure pricing across the country…Large employers have been aware of this for a while as they see the differences in employee health costs across the country."
Health Affairs Forefront has noted that "well-functioning markets should not have the amount of price variation observed within and between commercial markets in the US.
As employers search for new tools, the question looms: where exactly are these well-functioning markets in the U.S. economy, past or present? Banks continue to fail due to oversight errors, just as failed IPOs spring from valuation errors.
"Employers do not purchase health care services in an efficient market," says Azar. Another reason why new pricing transparency data will help them parry-and-thrust with their other "healthcare competitors."
The passing of the healthcare buck
If all of this sounds like a game of hot potato, it is: when the healthcare buck gets passed, who pays the bill and how much?
Some interesting moves by employers include the fees they charge the general public to help pay for their employees' healthcare (e.g., restaurants that add an extra charge to your avocado toast bill). Some interesting moves upon employers include directing insurance members to their Employee Assistance Programs before their paid benefits to direct resource use.
There are just a few additions to the already complex chain of supply and demand.
Returning to the Health Affairs study, Azar notes: "Employers have long desired an ability to impact the supply-side of health care services.
In addition to tacked-on fees and data-powered negotiations with payers, employers can also use the new transparency data to negotiate prices directly and at the point of care.
Darrell Moon, a Forbes Business Councils Member, suggests that employers pay providers upfront to get the cash-discount for their employees' procedures .
All of that is visible is the new data, says Moon. He downloaded the gross and negotiated prices for a procedure at one of his large local hospitals and reported the following: "If I'm admitted to that hospital for that procedure and present my employer-provided insurance card, the average price is discounted by 30%. On the other hand, if my employer pays up front through a cash pay strategy, the discount is 75%. By studying the hospital's chargemaster across all procedures, I found this same level of discount applied to almost all procedures."
Moon adds: "The point is, we live in a new world thanks to new regulations. Employers can now hold the healthcare system accountable and, even more importantly, be better stewards of their employees' money."
Addressing data surprises is part of CVS's mental health support strategy for customers, including its Aetna health plan members.
You know an issue needs attention when it has a designated month.
May is Mental Health Awareness Month and viewing it that way may sound pessimistic. But a realistic picture of American behavioral health is needed to improve it.
CVS Health adds to that picture via its recurring survey of mental health perceptions. The retailer's sixth survey since April 2020 reveals nuances across age groups, treatment preferences, and between providers and their patients.
In an exclusive interview with HealthLeaders, CVS Health's Cara McNulty, DPA, president of Mental Well-Being & Behavioral Health, added insight to the data and its biggest surprises.
Topline results: Perception versus reality
The latest CVS Health data is based on a national online Harris survey conducted March 7–24, 2023. Harris polled 3,400 people over the age of 18, as well as physicians and pharmacists. Respondents were those who had previously agreed to participate in CVS surveys. Age breakdowns included: Gen Z/Young Millennials (18-32 years), Older Millennials (33-40), Gen X (41-56) and Boomer+ (57+ years of age).
Gaps between Boomers and Gen Z are no surprise. But individual differences might be, such as how accurately individuals perceive their own mental health needs at any given time.
Gen Z concerns are higher than the national average. While more than two in five Americans (42%) expressed concern about their mental health, that number increased to six in 10 (60%) among respondents aged 18-32.
Physicians report 4x greater declines in patient mental health than their patients. One in 10 Americans (14%) said their mental health had declined since 2022, but their providers don't agree. Nearly six in 10 physicians (56%) believe their patients' mental health has gotten worse.
Worried for others, but not seeking self-help? Two-thirds of survey respondents (67%) said they knew a lot of people with mental health struggles. But only 12% regularly see a mental health professional themselves.
The reasons for the disconnects—between providers and patients, patients and "other people"—are likely varied but perhaps not as unexpected as they seem.
McNulty—a 25-year healthcare veteran—shares her own experiences.
"Often we assume that people know what they're thinking and feeling. But most of us have no clue. Even with my own anxiety, I didn't have a clue."
She adds: "We are feeling the impacts of COVID, of pandemic socialization over the past three years. We're perhaps even immune to it. But physicians continue to see the impact and disruption when patients come in to see them and for reasons other than mental health."
Generational data differences
The CVS Health/Harris poll data showed that 95% of Boomers believe society should take mental health and mental illness more seriously. This is compared to 83% of Gen Z.
This also surprised McNulty.
"The Boomer age group felt that mental health was as important as physical health, which in the past hasn't been case," she notes. "This is not a population that grew up talking about this, but they see with the pandemic how their own mental health and that of their family and loved ones has been affected."
Other generational gaps involved technology, with notable contrasts between Gens Z and X:
Technology for mental health information. Nearly 30% of Gen Z respondents stated they rely on technology for mental health information, the most of any age group.
Technology for mental health access. More Older Millennial respondents, however, appear to use technology to actually access care—85% agree that digital health has made mental health services more accessible.
The social media effect. Gen Z and Boomers also differ in the belief that social media has negatively impacted their mental health—58% versus 22%, respectively.
How CVS applies the data, including for Aetna members
CVS applies the Harris poll data to understand and address the country's diverse mental health needs—for all its customers and for the subset who have Aetna coverage. CVS Health acquired Aetna in 2017.
"We are casting a wide net to ensure people get help at the point of care," says McNulty, who detailed CVS' mental health services in a press release associated with its survey data.
CVS' mental health virtual visits have exploded, from less than 200,000 in 2019 to approximately 30 million by the end of 2022. More than 1,100 CVS MinuteClinic locations also offer depression screenings.
The screening includes the two-item Patient Health Questionnaire (PHQ-2), which asks: "Over the last 2 weeks, how often have you been bothered by the following problems? 1. Little interest or pleasure in doing things. 2. Feeling down, depressed or hopeless."
Based on the results and the person's health plan, CVS Health offers support at the individual and population health levels. CVS' Resources for Living Team connects Aetna members to their employers' resources first, then to plan benefits—a triage approach that reflects shifts in who pays and provides services and in what order.
"For Aetna members," McNulty notes, "we can go a step further. Taking what we are seeing in claims, trends, and environmental factors as an overlay and then looking at predictive factors to deploy services that are age specific, clinically sound, and culturally appropriate."
As a specific example, McNulty returns to that surprise Boomer belief in the importance of mental health and its implications.
"With this population, we make sure that Aetna solutions include mental health needs during situations like joint replacement. We're not waiting for someone to be in crisis."
She adds: "If a customer is not an Aetna member, we still support them. We just don't have details on what their plan sponsor resources are. If they are uninsured, we help connect them to local resources."
"As an industry, we haven't always felt comfortable addressing the mental health side. At CVS Health, we take it as an imperative. That some people are half served, half supported—that's absolutely not good enough. No one needs to suffer, no one needs to do this alone."
"Focusing on this work every single day is the right thing to do."
From accrediting organizations to payers, stakeholders seek often-illusive intel on healthcare's most vulnerable populations.
The National Committee for Quality Assurance (NCQA) has announced its new Race and Ethnicity Stratification Learning Network — “a free, interactive, online tool that offers data and best practices to help health plans improve how they collect race and ethnicity data on their enrollees” with the ultimate goal to “advance health equity through measurement.”
A spokesperson for NCQA stated that the Network provides a first-time look into health plan performance variation trends based on race and ethnicity, and best practices for plans to collect, measure, and report health equity data. The trend data originates from 20 million enrollees of 14 health plans that reported select HEDIS measures results stratified by race and ethnicity.
In a press release for the announcement, the NCQA’s Dr. Eric Schneider — EVP of the organization’s Quality Measurement and Research Group — stated: “Organizations are devoting substantial resources to support health equity, and many are eager to learn how to collect and leverage data to narrow health disparities.”
In an exclusive quote for HealthLeaders, Keirsha Thompson, MSW — NCQA Manager, Performance Measurement of NCQA — added: “What’s exciting about this is that no one has ever seen these data in one place before, and it’s inspiring that the information can be used to support quality improvement to data and help reduce health disparities.”
Thompson adds: “Network findings reflect over 100 contracts across Commercial, Medicaid, Medicare, and Exchange insurance plans. We want health plans to use the Network to feel empowered and know that they can make tangible changes to improve the data they rely on and ultimately work toward narrowing health disparities for their member populations.”
The NCQA is a private, nonprofit organization that accredits, certifies, and recognizes the performance of multiple stakeholder groups including health plans and physician practices. The organization’s Healthcare Effectiveness Data and Information Set (HEDIS®) is the healthcare industry’s most widely used measurement tool.
Just over 10% participation
The 14 health plans and 20 million members reporting race and ethnicity-stratified data for five HEDIS measures is a start. But there is still a long way to go for race and ethnicity data collection to become part of how healthcare does business.
More than 190 million members are represented by plans that report HEDIS overall. Those that report stratified data represent just 10%.
Heath plans have sought to improve their race and ethnicity data collection for years, a chronically difficult task. People of different races and ethnic groups can feel that this data will be used against them by a healthcare system that they already distrust — one that underserves them and even contributes to their poorer health outcomes.
Attacking the problem from multiple angles
Multiple efforts are underway — through data and measurement — to create a healthcare system that at the very least provides equal care for everyone, with the highest aim of producing equal outcomes.
In addition to its new learning network, the NCQA introduced new Health Equity Accreditation (HEA) and HEA Plus programs in recent years — also focused on HEDIS race and ethnicity reporting and adding standards for “organizational diversity, equity, inclusion and reducing bias” as well as data collection for sexual orientation, and gender identity (SOGI).
Payers have launched their own efforts, including plans in the Blue Cross Blue Shield Association (BCBSA). The BCBSA has launched a National Health Equity Strategy, in part to grow self-reported patient data that is more granular and regularly updated on race, ethnicity, and language (REL) as well as social needs and SOGI.
Blues plans are embedding these efforts in their Alternative Quality Contracts (AQC), one of the first — and it could be argued more successful — commercial value-based reimbursement models in the U.S.
In a prior exclusive with HealthLeaders, BCBS-MA CMO Sandhya Rao noted that "data gaps and the lack of race data have been a challenge for years." The plan is now nearly 18 months into an equity initiative that incentives physicians to close care gaps and uses HEDIS data to identify the most critical disparities among members who are Asian, Black, and Hispanic.
All payers must participate
In addition to commercial payers, CMS is doubling down on health equity as a component of not only data collection and measurement but payer and provider reimbursement.
Encouraging and incentivizing health equity have been a part of every annual CMS rule governing Medicare, Medicare Advantage, Medicaid, and ACA plan operations and payment.
The agency’s annual proposed marketplace rule (Notice of Benefit and Payment Parameters) seeks to improve disparities through expanded access and coverage and builds on last year’s rule which had specific proposals for health equity-related data collection and standardization.
In its annual Medicare hospital inpatient prospective payment system (IPPS) rule, CMS has proposed 15 new health equity categories that would impact fiscal year 2024 hospital payments. The agency also wants to add social drivers of health (SDOH) factors to three ICD-10-CM diagnosis codes that would incorporate homelessness as a complication or comorbidity.
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."
