A Georgetown University study finds that policies limit already narrow networks.
Between government regulations, missing mandates, and health plan policies, narrow networks can get even slimmer for some consumers.
A recent Georgetown University study found that adequate access to care is a significant threat for many marketplace and Medicaid enrollees. Why? Because the standards designed to protect these consumers vary significantly and often lack the protections to enforce provider network adequacy and choice.
Study highlights
Details from the study findings include:
Diverse state network standards make geography a differentiator. The study notes that there is "dramatic variation in standards for health insurers' physician networks across states and among Medicaid and marketplace plans in the same state." This can limit in-network access based solely on where someone lives.
Marketplace plans lack key protections. Qualified marketplace plans are not subject to the same payer network oversight as managed Medicaid plans.
States could protect access, but often don't or can't. The study found that while states have "considerable flexibility" to help protect access to essential providers, most "do not enforce standards stronger than baseline requirements."
Cultural and linguistic access compounds geographic issues. The Georgetown research further noted: "There are no federal requirements that individuals be able to access healthcare that meets their language or cultural needs."
The Georgetown study was published by the university's McCourt School of Public Policy, Center on Health Insurance Reforms, and its Health Policy Institute Center for Children and Families.
Funding was provided by the Robert Wood Johnson Foundation, whose senior program officer, Andrea Ducas, commented: "One important dimension of that is having enough providers that accept your insurance. Policymakers can bring greater peace of mind to more people by ensuring that provider networks are adequate in size and scope of coverage."
Coverage without care
The Georgetown findings pair with other access limitations. These include longstanding and widespread provider shortages and the baked-in inequalities of markets that are more rural with more dispersed populations, and longer distances to travel for any kind of care—in-network or otherwise.
The sum total is that geography is often destiny when it comes to healthcare, and that coverage without care remains a reality. While narrow networks are a design innovation that theoretically lower costs for members and health plans alike, they can have unintended adverse effects in markets that are already disadvantaged.
CQMC has also published a measurement gap and alignment analysis that calls for new health equity measures and digital approaches to speed outcomes tracking.
The Core Quality Measures Collaborative (CQMC) has updated five of its measure sets to improve physician performance and patient outcomes under value-based contracts. New and deleted metrics—in addition to telehealth-related updates across multiple measures—were part of the periodic refresh by the CQMC, a public-private collaboration between AHIP and CMS with guidance from the National Quality Forum (NQF). With the update, the CQMC also published a measurement gap and alignment analysis that called for new health equity measures and digital approaches to speed and strengthen outcomes tracking.
In the related press release, AHIP notes that the CQMC core measure sets are consensus- and evidence-based "to promote alignment across public and private payers within value-based contracts." Highlights from the five measure set changes include telehealth-applicable updates and the following:
1. Accountable Care Organizations/Patient Centered Medical Homes/Primary Care (ACO/PCMH/PC). Refined and enriched Comprehensive Diabetes Care metrics to focus on HbA1c control over testing. Align kidney health assessment with current clinical guidelines and other measurement programs.
2. Behavioral Health. Added diabetes screenings for people who have schizophrenia or bipolar disorder and are taking antipsychotic medications.
3. Cardiology. Added measures for assessments of congestive heart failure functional status assessments and ischemic vascular disease monitoring. Removed measures related to youth cardiac catheterization and cardiac stress imaging that are either no longer NQF endorsed or have consistently high performance.
4. Obstetrics & Gynecology. Added measures for postpartum depression screen and follow-up, prenatal immunization status, and birth control counseling. Removed metrics that are either retired or no longer maintained.
5. Orthopedics. Added metrics to address previously identified gaps related to ambulatory care treatment and patient outcomes related to neck/low-back impairments and hip/knee arthroplasty.
The CQMC's five additional data sets include: Gastroenterology, HIV & Hepatitis C, Medical Oncology, Neurology, and Pediatrics.
"With these changes," says AHIP SVP Danielle Lloyd, "the CQMC is furthering its goals of ensuring patients are receiving patient-centered, evidence-based, high-quality, and coordinated care while reducing provider burden through aligned measurement in key clinical areas." Lloyd helps lead AHIP’s private market innovations and quality initiatives and is the CQMC's Steering Committee co-chair.
Reducing burden means providing physicians with the information they need—when and how they need it—to pivot their performance. This could include expanding the data sources for digital quality measures beyond claims records and the technologies used to collect and analyze them.
About this, Lloyd adds: "As we expand performance measurement, it is critical that we move to digital measurement to reduce the resources required and get the information in front of the physicians when it counts."
Digital reporting recommendations were included in the CQMC's annual Analysis of Measurement Gap Areas and Measure Alignment report. The analysis identified gaps related to specific measures and common to multiple ones, opportunities to align metrics, and areas under development. The CQMC described the need for:
More advanced outcome measures, including those informed by patient self-reporting
Measures that span multiple conditions and care levels, as well as episode, population, and provider types
ACO-specific measures that align with other measure sets, such as behavioral health and cardiology
The annual report also recommended health equity improvements, including defining new measures, stratifying existing ones "to identify where healthcare disparities may exist for vulnerable populations" and defining areas in which inequity is persistent.
A recent survey captures physician telehealth utilization.
New survey results indicate that "telehealth use will outlive the pandemic," reported by Optum, UnitedHealth Group’s health services division, conducted fall 2021, which captured physician telehealth utilization including opportunities and frustrations. Below are four highlights from the survey.
1. Very few providers plan to stop using telehealth post pandemic.
In a survey of 240 providers, mostly primary care physicians (PCP), 93% intend to keep using telehealth. Most common uses include primary and chronic care visits as well as prescription refill needs (75%, 72%, and 64%, respectively). Urgent and post-procedure care represented 38% and 28% of visits. PCPs also used telehealth to support patient mental health needs (36%).
2. Telehealth preferences vary.
Provider responses indicated that older technologies have given way to new telehealth preferences when it comes to visits and communication, but not scheduling. Video was used in 88% of visits while pre-pandemic communication channels such as secure messaging (30%), email (12%), text messaging (7%), and chatbots (3%) lagged. The telephone remained highly favored for both visits and scheduling at 80% and 86%, respectively.
3. Virtual care both convenient and frustrating.
Like patients, providers have benefitted from telehealth with 69% emphasizing its convenience. Nearly 30% of providers, however, also find it frustrating—citing not only telehealth’s technical difficulties (50%) but the added challenges it presents for delivering quality care (58%) and managing patient expectations (55%).
4. Providers see need for "bridging digital divide."
The survey notes that most stakeholders "adopted virtual care as recently as the start of the pandemic." As such, it comes as no surprise that providers and patients alike needed a crash course in navigating virtual medicine. While providers see a need for ongoing digital training for patients and staff, Optum’s DocASAP co-founder and CEO Puneet Maheshwari states: "The innovations utilized over the past two years and the convenience they have brought to providers and patients should not be left behind." DocASAP is Optum's patient access and navigation enablement platform used by health plans, health systems, and physicians.
Health systems are brokering arrangements for not only themselves but other employers looking for direct contracting gains.
A growing number of providers are disintermediating the payer space through direct contracting with employers.
In a search for significant savings and a strategic game-change, hospitals and health systems are brokering arrangements for not only themselves but other employers looking for direct contracting gains. New York–based Northwell Health is one of those systems, moving all 75,000 plus of its employees to coverage managed by its contracting arm, Northwell Direct, and benefits administrator Brighton Health Plan Solutions.
A few months into implementation, HealthLeaders spoke with executives from both companies—Nick Stefanizzi, VP and CEO of Northwell Direct, and Michelle Zettergren, president of labor and chief sales and marketing officer at Brighton Health Plan Solutions—on their partnership and its broader industry impacts and implications.
HealthLeaders: Describe the decision-making and implementation processes that led to your new model.
Nick Stefanizzi: We made the decision last year to move forward with Northwell Direct Network, a separate but affiliated company with benefits administered by Brighton. We have a tight partnership and that has allowed us to move quickly in a few short months. Frequent, multi-channel communication is key. We were willing to work with employees, surface issues, recruit providers—everything that needed to be done. And we believe in this model; it's the way of the future.
HealthLeaders: How does direct contracting differ from what self-insured (SI) employers already do to craft provider network and member programs?
Stefanizzi: Direct contracting puts the patient-provider relationship at the center of how care is organized, how decisions are made, and is focused solely on best outcomes—not shareholder returns. The fact that there is no intermediary allows us to curate programs and interventions that drive savings and engagement. Another thing that's different is that employer/provider contracting normally revolves around a center of excellence based on specific conditions. Our approach involves a robust, clinical network that is local, can provide all care, and that meets employees where they are.
Michelle Zettergren: Some large SI employers have been doing this for a while—Boeing, General Motors—but smaller SI employers haven't been able to engage in things like direct rate setting and experimenting with reference-based pricing.
HealthLeaders: Can you talk more about the pricing and value aspects?
Zettergren: Employers have historically chosen the traditional insurance model by default. But the price for that status quo is unsustainable. The average premium for family coverage has increased 22% over the past five years and 55% over the past 10 years, according to the annual Kaiser Family Foundation survey.
Direct contracting with a health system—with no middleman—is a viable alternative in part because of the value integrated delivery networks [IDN] bring to the market: patient care coordination, shared EMR, health and wellness engagement strategies based on real-time data, and provider collaboration on patient outcomes.
Employers are increasingly interested in achieving value for the money they spend on employee health benefits in the same way they analyze value for any other contractual relationship. Because direct contracting is a partnership between a health system and an employer where they agree on costs, transparency, data sharing, and how to share savings, the potential for both parties to benefit is substantial. As an example, in Northwell Health's new direct contract offering, Northwell Direct, where Brighton serves as a TPA [third-party administrator] partner, rates are as much as 20% lower than the best traditional rates.
HealthLeaders: What is your plan for bringing other employers into this model?
Stefanizzi: We talk to employers all day every day. We tell the story of how this has been value-additive for us, and a savings opportunity based on repricing analytics and disruption in adequacy analysis. There are also clinical and quality opportunities to offer programs that are different and better. We bring data to the table whenever we can and stress that building relationships between organizations is the key.
Zettergren: There is also a level of credibility when a provider makes this choice for themselves, their employees, and their dependents. It speaks volumes.
HealthLeaders: What are the key market factors at play, including IDN selection, where direct contracting will emerge?
Stefanizzi: Even a strong IDN may not be enough to meet complete need without looking to others to fill gaps. For Northwell specifically, serving New York, our network has to stretch into New Jersey, Connecticut, and the Hudson Valley.
Zettergren: We've seen a lot of M&A activity in the provider space over the past decade. Today few community hospitals remain—67% are now part of a health system, according to the American Hospital Association. We'll see direct contracting emerge across the country but initially in markets where there has been a lot of consolidation and where there is a TPA partner like Brighton to enable the partnership.
HealthLeaders: How do IDN-affiliated providers view the shift to direct contracting?
Stefanizzi: In general, physicians and providers view direct-to-employer relationships favorably … There are generally reduced administrative burdens for physicians since they work collaboratively and directly with the network as opposed to a traditional carrier … The volume and frequency and denials are also greatly reduced in these direct-to-employer relationships, which leads to greater physician satisfaction.
HealthLeaders: What impact, if any, has the pandemic had on direct contracting?
Zettergren: Employers across the nation have been proactively reaching out to their local health system for support on COVID-19 safety protocols, on-site testing, and on-site vaccinations. We've observed that pandemic and workforce changes have been drivers and have accelerated interest in employer-health system partnerships.
"A lot of SNP members have had challenges related to health equity barriers for the majority of their lives. We saw a need to strengthen caregiver support as an extension of providing member support," says one MoreCare leader.
MoreCare—a Medicare Advantage (MA) plan for residents of Cook County, Illinois—has reported significant results from its expanded caregiver support partnership with Carallel. In a recent pilot, 62% of members and their caregivers signed up for MoreCare's Advanced Care Planning (ACP) program with 100% going on to complete the program. ACP, which facilitates end-of-life conversations, reflects a "human-led and tech-enabled" approach that starts with empathy and continues with a scalable care management platform that will help the plan expand ACP and other Carallel services to all members.
A growing partnership
MoreCare's enrollees include many Special Needs Plan (SNP) members, including those dually eligible for Medicaid (D-SNP), those with chronic conditions (C-SNP), and those living in long-term care (LTC) institutions (I-SNP). These specialized member needs are the foundation of MoreCare's partnership with Carallel, which began in 2021 and grew to include ACP. The engagement rate for the innovative ACP pilot was, according to Carallel, "nearly six times higher than the industry average for comprehensive care management programs."
These results apply to members of a single LTC facility, with MoreCare working with Carallel to prioritize more members. Abby Sibley, MoreCare's associate director of clinical initiatives and product, describes the pilot and plans for expansion. "Our first program was in a specific facility. Turnout was beyond even what we thought it would be."
Sibley adds: "Our goal is to go to every facility where we have members. It doesn't matter how many members are there because these are individualized conversations."
Challenging but important conversations
Those conversations with members, caregivers, and loved ones include the well-known Five Wishes document and help establishing powers of attorney and living wills.
Scott Sarran, MD, CMO at MoreCare, notes: "There are no more difficult or important conversations to have than those around the end of life." He adds that these conversations can be particularly difficult for members with long-standing, unmet needs tied to nonclinical factors such as social determinants of health. His colleague Sibley agrees.
"A lot of SNP members have had challenges related to health equity barriers for the majority of their lives. We saw a need to strengthen caregiver support as an extension of providing member support."
Through the MoreCare-Carallel partnership, this support is diverse, notes Carallel CEO Shara Cohen.
"It started with broad support, with our experts acting as extensions of the care management team. MoreCare then saw the opportunity to tackle specific challenges like ACP."
Cohen continues: "Unpaid family caregivers are part of the healthcare workforce and like the rest of that workforce, they are overwhelmed. They need support for a broad range of responsibilities. We also recognized that caregivers provide key opportunities for improving patient care. They are one of the most important influencers in a loved one's outcomes."
A human-led approach
Both MoreCare and Carallel attribute the program's initial success to their approach.
Says Carallel’s Cohen: "These are complex topics to confront. By investing time upfront to facilitate empathetic conversations with real people, we get tremendous results."
Sibley adds: "Our approach was to hold meetings prior to the ACP introduction to help members understand. But what had largest impact was Carallel going the extra mile—taking the time to come back and have one-on-ones after the information sessions and walk members and caregivers through the Five Wishes document."
Tech-enabled scalability
As with nearly all healthcare solutions, the MoreCare/Carallel offering includes a tech platform component. Carallel helps facilitate monthly case reviews and documentation needs.
"Advanced care planning documentation is fairly straightforward, but technology can add speed [to the process]," says Cohen. "It must be accessible to the PCP and the assisted living facility. The platform adds structure to unstructured information and, for broader needs, helps create segmented datasets to identify needs and match people to programs."
Preceding the documentation is how to identify and prioritize members and their caregivers for ACP and other programs. Cohen notes: "We are starting with the I-SNP population, then looking at secondary and tertiary identifiers." These include high-cost D-SNP and C-SNP cases, as well as member diagnoses, age, and other factors.
A human/tech solution for plans of all sizes
MoreCare and Carallel see even more opportunities for their partnership and for other payers.
Cohen says larger MA plans can benefit from its platform and programs just as much as local plans like MoreCare. "While the program for MoreCare was specialized, larger plans also have high-cost, complex members and a need to focus on them," says Cohen. "The ability to provide broader caregiver support at scale is important, especially as there are more MA age-ins."
MoreCare’s Sarran identifies multiple examples of the better outcomes caregiver support can help deliver for patients and health plans: "Avoiding hospitalization and overmedication, but also addressing earlier—through physical, social, and cognitive support—what is causing symptoms." A press release regarding the MoreCare-Carallel partnership notes that "[t]he support highly engaged caregivers provide is linked to significantly better outcomes for those in their care, including 30% lower rates of emergency department utilization and 50% lower hospital utilization."
Regarding payment and benefit design, Sarran adds: "This is an allowable supplemental benefit that is a way for plans to differentiate."
Carallel’s Cohen identifies additional benefits that are emerging through her company's partnership with MoreCare: "As we continue the program, we are looking at other key metrics where there is opportunity for improvement."
Sarran sums up one of the biggest opportunities of all: "Our goal is to help people go through this last phase of life in as productive, sensitive, supportive, and high-quality a way as possible. It takes a village to make that happen."
Analysts say HHS favors "models that make accurate predictions at the enrollee level within a sample population... that tend to miss the ranges of severity and spending within specific conditions like diabetes."
In its annual marketplace rule, HHS proposes a new "two-stage weighted approach to … [risk] model recalibrations." While some support the change announced in the Notice of Benefit and Payment Parameters (NBPP), most payers, their affiliation groups, and key policy analysts do not. The following are four key oppositions to HHS' proposed change.
The proposed two-weighted model is not appropriate for risk adjustment.
In its comment letter to the proposed rule, the Blue Cross Blue Shield Association (BCBSA) noted that "a two-stage weighted approach is not a standard procedure for risk adjustment and actually worsens the fit [predictive capability], although the effect is small." In making this claim, BCBSA further notes that the model's interaction with other factors that influence risk payment transfers (several noted below) should be considered.
Current risk adjustment predictions are already accurate.
The opposition of multiple payers—Anthem and Health Care Services Corporation in addition to BCBSA—suggests that there isn't anything substantially flawed with HHS' current risk-adjustment model given the relative health and competitiveness of the exchange market. Even so, payers support the continued discussion of possible risk-adjustment model changes that HHS introduced in an October 2021 Risk Adjustment (RA) Technical Paper that predated the 2022 NBPP.
Current administrative adjustments are also sufficient to achieve HHS's goal
BCBSA suggests that an existing administrative adjustment designed to "reduce … transfers from low-risk enrollees to higher-risk enrollees … already addresses some of the under-prediction" that HHS seeks to correct.
It will have the opposite effect and increase adverse selection.
Echoing other payers, BCBSA states: "The first priority for the risk adjustment model should be that issuers have no incentives to avoid higher-risk enrollees." HHS believes that its new two-weighted model will correct under-estimates of low-risk enrollees, BCBSA—in addition to multiple payers and the Brookings Institution believe that HHS' new model will do the opposite.
The result could be increased adverse selection.
Brookings Institution analysts Matthew Fiedler and Timothy Layton note: "Economic theory implies that these changes would have three types of effects:
In an interview with HealthLeaders, Fiedler notes that the HHS approach "is to prefer models that make accurate predictions at the enrollee level within a sample population." He adds that while this result may result in estimates that are "perfectly accurate on average," they tend to miss the ranges of severity and spending within specific conditions like diabetes.
In summary, Fiedler notes: "The core issue is that the agency is misreading what's happening under the current risk adjustment system so in thinking about changes, they're moving in the wrong direction."
The question all payers must decide is the role that member need will continue to play as the cost-benefit of telehealth parity is weighed for post-pandemic operations.
Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will continue payment parity for telehealth services through September 2022. The policy includes physician video and phone visits. It applies to commercial, Medicare Advantage (MA), and State Health Plan members as well as Federal Employee Program members who are covered "until further notice."
Via company press release, Blue Cross NC CMO Roberta Capp, MD, commented: "As we have seen throughout the COVID-19 pandemic, patients and physicians have relied on telehealth. Blue Cross NC has covered telehealth at parity with in-person visits since the start of the pandemic in March 2020. Extending this policy helps our members access the care they need, when they need it."
The question all payers must decide, however, is the role member need will continue to play as the cost-benefit of telehealth parity is weighed for post-pandemic operations.
Two types of parity
There are two types of telehealth parity: coverage (or "service") and payment, and they apply to video and/or audio service delivery. The Center for Connected Health Policy (CCHP) describes service parity as that which "requires the same services be covered via telehealth as would be covered if delivered in-person … [but] does not guarantee the same rate of payment." Payment parity, conversely, "is a requirement for the same payment rate or amount to be reimbursed via telehealth as would be if it had been delivered in-person."
The CCHP tracks telehealth parity policy, including state laws affecting private payers. As of March 2022, only Florida, Kansas, and Louisiana have passed payment parity laws with many more debating the matter. Even those states that have passed some kind of payment parity legislation don’t necessarily prohibit it. Florida allows telehealth providers to initiate reimbursement differences. Kansas law states that stakeholders, including payers, may establish equivalent payments, while Louisiana allows telehealth reimbursement at 75% of an in-person office visit.
Continuing payment parity
There are multiple arguments against and for payment parity. In October 2021, Health Affairs examined and refuted the four most common oppositions: that telehealth service delivery is easier and less expensive for providers, has less value, and may drive overutilization. While article author and physician researcher Chad Ellimoottil, MD, notes that "there are several reasonable arguments against payment parity for telehealth," he refutes claims that "mode of delivery" should not be a deciding factor when assessing "the amount of clinical effort" and making "a blanket distinction between high- and low-value care." Ellimoottil adds that
"Policies that prematurely reduce or eliminate payments for telehealth, including audio-only telehealth, will only diminish its use and its potential," notes Ellimoottil. Citing data from another Blues plan (BCBS of Michigan), Ellimoottil adds that "there is little compelling evidence to suggest that continuing payment parity following the pandemic's end will lead to runaway health care spending"—further noting that '[w]hile in theory it may cost less for clinicians to deliver telehealth compared to in-person care, in reality, telehealth does not always reduce practice expenses."
Beyond a crisis response
Ellimoottil recommends that "organizations should temporarily continue payment parity for video and audio-only telehealth after the public health emergency to allow telehealth to flourish outside of the pandemic." He adds that research and data should prove whether "investment in telehealth improves care for beneficiaries and whether or not payment rates are aligned with the costs of delivering telehealth."
In its press release, Blue Cross NC notes that it "will continue to monitor trends going forward," citing 2020 data that 92% of telehealth visits were for primary or mental healthcare.
Regardless of where payers and other stakeholders fall when the public health emergency officially ends, there is a broader question: Why parity—from mental health to telehealth—should function as a crisis response versus a permanent approach to the industry's delivery system challenges?
Evidence-based prior authorization automation is on the rise as physicians and payers look for better ways to do business with one another.
Recent physician surveys show that nearly 80% of physicians have experienced an increase in payer prior authorization (PA) requirements, with more than a third of delays resulting in adverse patient outcomes. These were among the results from a MGMA poll and an American Medical Association (AMA) survey. Countering this, evidence-based PA automation is on the rise as physicians and payers look for better ways to do business with one another while Congress reintroduces related mandates.
3 PA facts
1. PA is rising and falling.
Seventy-nine percent of MGMA medical groups responded that payer PA requirements increased in the past year. This is lower, however, than pre-pandemic years including 2019 when 90% of association members reported increases.
While 93% of physicians stated that PA slowed needed care, this result consisted of 14% responding "Always" and 42% "Often." The type and seriousness of care delays matters when considering these numbers but so do the negatives outcomes which deserve lower thresholds. In the same AMA survey, 34% of physicians reported that PA led to "a serious adverse event," including hospitalization (24%) or a life-threatening or serious intervention (18%). Some 8% reported that PA contributed to disability, permanent negative events, or death.
3. Other AMA survey results show significant PA burden on medical staff.
The pandemic put increased resource and revenue pressure on physician practices, with some staff members working only on PAs (40%). In the same survey, 88% of physicians report this burden is high or extremely high.
3 PA predictions
1. As PA automation increases, burdens decrease.
PA automation has also doubled. In 2021, some 26% of plans had a fully electronic PA process compared to 13% in 2019—a pandemic-driven increase. These results are from the ninth annual report from the Council for Affordable Quality Healthcare Inc. (CAQH), which reported a corresponding 21% decrease in PA volume in 2021. In 2022 and beyond, expect payer PA automation pilots to expand among smaller plans and larger players alike.
2. Providers demand more evidence.
Given that 35% of payer PA is still fully manual per the CAQH Index, more automation is needed and based on evidence. In the AMA survey, 29% of physicians reported that PA criteria are rarely (25%) or never (4%) evidence-based. In addition to PAs rooted in proven clinical guidelines, physicians want plans to consider their own history of following such guidelines and securing high PA approval rates.
AMA president-elect Jack Resnick Jr., MD, told HealthLeaders that PA must be "right-sized." Resnick adds: "Requiring prior authorization for drugs or medical services with consistently high approval rates—what many would call 'low-value' prior authorizations—is wasteful for physicians, patients, and health plans."
If payers can deliver and partner with providers on the data, automation implementation can be more efficient and cost-effective.
3. Congress reconsiders legislative mandates.
In its poll reporting, the MGMA calls for Congress to pass the Improving Seniors’ Timely Access to Care Act. The House and Senate introduced companion bills in 2021 that would "establish an electronic prior authorization process to streamline approvals and denials." Focused on MA plans—and in response to an HSS Office of Inspector General finding that 75% of MA PA denials were reversed—the legislation would also help create national standards and processes to improve transparency and communication. Predictions on passage are uncertain but multiple signs point to a federal agenda that will continue the innovations the pandemic accelerated.
"Collaborative work between providers and payers helps define the facilitators and limitations of real-world applications … so that evidence becomes standard practice," says one executive.
Health systems and provider-affiliated health plans are now eligible for $50 million in funding through the Patient-Centered Outcomes Research Institute (PCORI)'s Health Systems Implementation Initiative (HSII). The five-year program expands PCORI's focus on practical research application, "this time by directly funding organizations responsible for healthcare delivery," according to a recent institute blog. PCORI adds that HSII will "lay the groundwork for future, nationwide scale-up through demonstration of successful implementation approaches." Here are five things to know about this opportunity and how it relates to other PCORI objectives:
1. In addition to health systems, provider-focused health plans are eligible for HSII funding.
"Provider-aligned health plans are natural innovators and will find PCORI's HSII initiative an exciting opportunity to accelerate what they are already doing, says Eva Powell, MSW, associate director of clinical innovation at the Alliance of Community Health Plans (ACHP). Powell adds: "Collaborative work between providers and payers helps define the facilitators and limitations of real-world applications … so that evidence becomes standard practice."
2. HSII reflects the continued call to operationalize evidence-based practices.
As healthcare costs continue to rise—within the industry and as a growing percentage of U.S. GDP—there is mounting pressure to implement proven practices to curb waste. Responses range from PCORI's programs to proposed CMS marketplace guidelines that would require health plan benefit design to be evidence-based.
3. HSII is but one part of PCORI's ambitious funding goals.
Since January, the organization has announced opportunities totaling $262 million through eight PCORI Funding Announcements. These programs are part of the organization's three-year, $1.8 billion funding goal.
4. HSII is part of PCORI's proposed Research Agenda spanning six focus areas.
The agenda will guide funding that closes evidence and equity gaps, relieves system and consumer burden, deploys data and partnership to create evidence-based interventions, integrates science, focuses on social determinants of health, and makes evidence accessible and actionable.
5. Key HSII deadline begins in March, with awardees announced in February 2023.
Eligible health plans and health systems must file their Notice of Intent to apply for HSII by March 29. Final applications are due July 26.
"Our goal is to help people navigate to the right care; that’s where we are focused," says Evernorth behavioral health CMO Dr. Doug Nemecek.
Evernorth and Monument have launched a partnership for online alcohol treatment that both companies hope to expand post-pandemic. Monument’s contract with Evernorth, the health services division of Cigna, represents a significant expansion of its payer relationships in what had been a self-pay consumer service. In addition to improving affordability, access, and individual outcomes, virtual substance abuse provides multiple opportunities to address stigma, the mental health provider shortage, and to reimagine benefit and network design post-pandemic.
Monument’s program combines virtual peer and professional therapy with specialized treatment from licensed physicians and specialists, including medication support. Monument’s online platform broadens treatment options for people who might not otherwise be able to get into a treatment program or have access to one.
The payer piece
Increasing alcohol treatment access and affordability are primary goals for Evernorth and Monument, as well as other payers. Monument began offering coverage options at the end of 2021 and is in-network with more than 20 commercial payers and Medicare. This includes national payers such as Aetna and Optum/United Healthcare as well as large multi-state plans like Anthem, multiple Blue Cross Blue Shield plans, and local/regional players.
Monument coverage is available to all Evernorth behavioral health customers, including Cigna employer group and marketplace members in 20 states. In seven states—Iowa, Ohio, Maryland, Mississippi, South Carolina, Texas, Washington—Cigna is the only payer partner besides Medicare.
Speaking with HealthLeaders, Evernorth behavioral health CMO Dr. Doug Nemecek notes: "As we look at increasing needs, we want everyone who has a condition to have access to high-quality, evidence-based treatment. Our goal is to help people navigate to the right care; that’s where we are focused."
While Monument notes that its program is "price competitive with or without insurance," adding payers is a priority. In a recent press release, Monument CEO and co-founder Mike Russell stated: "Delivering on our vision requires increasing affordability and reach of effective treatment. Payers play a crucial role in that ..."
Monument’s plans range from no-cost support via therapist-led or community-driven groups to $249 per month, which adds unlimited physician appointments and therapist chat, weekly appointments, and medication options. Customers can send their insurance details directly to Monument for available coverage options and costs.
Significant need
Whether as a self-paid or covered service, online alcohol treatment may help address multiple challenges. The National Center for Drug Abuse Statistics has reported that 60% of people drank more in pandemic isolation. This occurred against a backdrop of newly limited in-person treatment options, ongoing stigma, and existing substance abuse provider shortages—until virtual options emerged and became popular.
Unlike other telehealth services, mental health utilization has remained high: increasing from 30% in January 2020 to a pandemic high of nearly 63% in October 2021. This according to FAIR Health, whose latest figures show usage at 55% (December 2021). Payers like Cigna remain committed to not only telehealth but virtual-first services and benefit designs, not only for routine needs but chronic conditions.
"In all the talk of how the pandemic has accelerated innovation,” says Nemecek, "it’s important to remember as it fades, that all of these mental health and substance abuse [MH/SUD] conditions are still there."
The stigma symptom and online treatment ethics
In many ways, virtual mental healthcare is a consumer-driven phenomenon. Self-downloaded free or subscription-based mobile apps have become part of a delivery system that looks less traditional every day. The benefit of apps, mental health virtual visits, and digitally based addiction treatment are reflected in Monument’s value proposition: "Online alcohol treatment on your terms."
Addressing stigma is one of the benefits. Evernorth’s Nemecek notes: "The stigma around substance abuse is still high. A solution like Monument could mean not having to be worried about taking time away from work, what people are thinking, and getting treatment sooner." While there is no guarantee that more accessible and affordable treatment will reduce stigma, more options and greater uptake can certainly help. And help is needed. In 2020, Mental Health America reported that while mental illness affects 20% of the U.S. adult population, fewer than half receive treatment.
There are also ethical issues surrounding digital mental health, particularly for serious and persistent illnesses. As online solutions grow, there is a corresponding call for "responsible innovation for mental health care . . . to strengthen the positive role of novel technological solutions, and recognise and work to manage both the real and potential risks of using digital platforms."
These risks include privacy, and it is an irony that the greater confidentiality that online versus in-person treatment affords can be compromised if the data generated is not kept private and secure. In addition to these new considerations, progress on long-standing issues like coverage and reimbursement parity for mental health and telehealth must be made.
Progress measured by outcomes, not speed
COVID-19 is the best and worst thing that could have happened to MH/SUD prevalence and treatment—exacerbating existing need while generating the much-needed attention that helps create better solutions.
About the Monument solution, Nemecek notes: "Alcoholism is a chronic condition. We don't expect results in 30 days. We want to look at who engages, how many, and who stays engaged over months and or a year before we can assess outcome data."
The Evernorth executive adds: "It’s important to give support around alcohol use. Alcohol is the most common substance abuse. We don’t spend enough time on it because issues like opioids get more attention."