Higher premiums and deductibles but lower out-of-pocket maximums were revealed in the exchange giant’s application analysis.
eHealth’s fifth annual Medicare Index Report showed a mix of cost increases and decreases for 2022 private Medicare plans. Just as customer development theories stress the value of what consumers do and actually pay for—not just what they say—eHealth’s analysis is based on submitted applications to its exchange, the first and one of the largest in the U.S. eHealth’s Index Report includes data on Medicare Advantage (MA), Part D standalone (PDP), and Medicare Supplement (Med Supp) plans.
The following are highlights from the more than 260,000 applications submitted via eHealth for plan year 2022:
87% of customers chose plans with a $0 premium. This percentage has risen annually as more insurers offer more $0 premium options. In 2018, the first year of eHealth’s annual Index Report, only 63% of the exchange’s customers enrolled in $0 premium plans.
Despite the prevalence of $0 plans, average monthly premiums rose overall from 2021—although only slightly. This includes: $6 monthly for MA plans (up from $5), $22 monthly for PDP (up from $20), and $178 monthly for Med Supp.
Med Supp monthly premiums have increased the most. Average monthly premiums from eHealth Med Supp enrollments were $142 in 2018 (a 25% spike). MA and PDP average monthly premiums have decreased over that same period. MA premiums are more than half of what they were in 2018: $6 versus $17.
2022 annual deductibles were higher, with Med Supp showing the largest increase over time. Med Supp deductibles were nearly 14% higher ($181 versus $159), PDP 7% higher ($427 compared to $400), and MA 4% higher ($121, up from $116).
MA enrollees are paying less out of pocket. Plans’ annual maximum out of pocket (MOOP) average was $5,108, down 5% from $5,367 the prior year. MOOPs analyzed from eHealth applications have fallen just over 10% since 2018, when they were $5,694.
The National Association of ACOs is the latest to respond to CMS electronic quality measure goals.
Which challenge to tackle first in digital quality reporting?
The National Association of ACOs (NAACOS) is one of many posing the question as CMS aims to "[t]ransform measures to fully digital by 2025." NAACOS announced that it "has launched a new task force, aimed at developing recommendations for how to successfully collect and electronically report on ACOs' quality of care through disparate health information technology (IT) systems."
In its press release, NAACOS noted the following digital quality measure challenges for the Medicare Shared Savings Program (MSSP) and other stakeholders:
Interoperability. An abiding industry challenge requiring the collection, integration, and analysis of data from dozens of disparate EHR systems.
Standardization. A key part of interoperability applies not only to data but quality measures themselves. Electronic clinical quality measures (eCQM) were a component of CMS' final Rate Announcement.
Streamlining. CMS' Meaningful Measures program, now in Phase 2.0, will continue to target measure reduction and consolidation. Some ACOs have already done this work. A consolidated value-based care Star Rating from one MSSP—the Baylor Scott & White Quality Alliance—spans 50+ multipayer contracts and was featured in a January 2022 NAACO webinar.
Unique ACO challenges. NAACOS reports that more than 75% of ACOs must navigate at least six EHR systems, with 37% managing 15 or more. NAACOS also cited the "unintended implications and consequences of mandating data reporting on total patient populations instead of just the MSSP," which has been the decade-long standard.
Financial and operational changes. Achieving all the above by 2025 will require time, resources, and money, what NAACOS terms "significant investment by vendors, practices, and ACOs."
The NCQA response
NAACOs is not alone. In mid-2021, the NCQAresponded to CMS' Meaningful Measures 2.0 announcement and Request for Information (RFI). Placing eCQM needs within the context of a pandemic that revealed just how vulnerable we are, NCQA Federal Affairs Director Eric Musser wrote:
"Now imagine this: It's 2025, and there's another pandemic—but this time, there's a solution to those issues. There's a solution because the federal government, with support from private industry, looked at the how the system failed in 2020 and asked, 'How do we build an infrastructure that ensures we'll never be caught flat-footed again?' "
NCQA's digital quality measures priorities include a "digital first" portfolio and measures that are "configurable, modular" and can be accessed and integrated via API and standards such as Fast Healthcare Interoperability Resources (FHIR).
Returning to NAACOS' response, Katherine Schneider—Digital Quality Measurement Task Force chair—noted: "[W]e know digital quality reporting in general is the direction we need to move in, but we need to get it right, ultimately for the benefit of the momentum of value-based care and for patients, including those cared for by safety net providers."
Two decades of innovation reveal mixed findings for quality, cost, and utilization—and unclear ways to resolve.
The results are in on the impact of value-based payments (VBP) and once again, they're mixed.
In what Health Affairs calls "the first-systematic review" of commercial VBP models, the study has yielded mixed results. The review, based on 59 studies published since 2000, found "mixed and modest effects" and that commercial VBPs were far more likely to improve healthcare quality then lower costs or steer utilization.
The conclusion? "Given the … nature of the findings, commercial insurers should identify ways to strengthen value-based payment programs or leverage other strategies to improve health care value."
What are these new ways and other strategies? Read on for the summary and HealthLeaders' analysis.
The results
Health Affairs analyzed 20 years of commercial VBP studies (2000–2020) to assess quality, spending, and utilization. Studies for each category demonstrated either clearly positive/negative outcomes or mixed-to-no effect. The studies spanned VBP commercial models (P4P, bundled/episode-based payment, shared savings and risk, and population-based payment) with the following results:
There were more positive outcomes for quality (81%) than for spending (56%) or utilization (58%).
Shared risk was studied the most, bundled/episode models the least.
Only P4P had positive outcomes across all three dimensions (quality, spending, and utilization).
P4P and bundled/episode models aided quality; most other models either improved or did not.
Spending studies were slightly more prevalent and their results the most mixed.
Shared risk outcomes were the most conflicting:
More positive/mixed-positive studies across all dimensions.
The most mixed-to-no effect on spending.
One of the only models with clearly mixed-negative results.
Five study conclusions
The Health Affairs results are important for three reasons. First, less is known about commercial VBP versus other payer models. In addition, commercial coverage is responsible for higher spending and more quality variation compared to traditional Medicare. Finally, VBP evaluation methodology is often as inconsistent as VBP results. Key findings include:
Something's got to give. After 20 years, the question remains: Can commercial VBP make a difference?
Don't abandon benefit/delivery system innovation. Combining narrow networks with shared savings/risk models could prove effective.
Providers need support, not just data. Payers should offer technical assistance, reporting tools, and shared learning.
Streamline for success. Private and public payers may benefit from aligning VBP strategies.
Hospitals, where are thou? How can VBP impact the high-cost and -utilization services that drive revenue?
In an interview with HealthLeaders, study co-author Roslyn Murray noted: "I don't necessarily think that VBP is the silver bullet to our healthcare spending problem." Citing commercial VBP's mixed results, underestimated costs, and the lack of significant quality improvements, Murray—a PhD student in the University of Michigan's Health Services Organization and Policy program—added: "It makes it a little concerning as to whether to spend more time, money, and energy on these models."
Murray cites pricing as the primary driver of healthcare cost, one that VBP may lack the levers to affect.
Additional HealthLeaders analysis
Health Affairs suggests that payers must either strengthen their commercial VBPs, look to other strategies, or both. How?
Don't leave tools on the table. The VBP studies are unclear on whether payers align "demand-side benefit designs with supply-side payments." But insurers definitely use this strategy. Anthem is tackling market and VBP challenges simultaneously by linking high-performing providers to its best plans and giving them added marketing support.
When healthcare moves forward, it often leaves things behind. The Health Affairs analysis shows that VBP strategies have been more sequential than concurrent. As new models emerge, others fade. Pure-play P4P has been eclipsed, yet its studies yield higher quality. Meanwhile, many cost-focused studies exclude net savings after incentives.
The industry may repeat this history with health equity. Health equity is the latest "add-on" to VBP model design. Understandably, there is little consensus on how to integrate equity: should it be assessed independently or as a component of other dimensions? Just as cost and utilization followed quality, heath equity is a trailing consideration looking for its place. Murray notes that as healthcare spending becomes an even-larger part of GDP, it compromises investment in the areas associated with social determinants of health (e.g., housing, education).
Find the balance. Many of CMS' VBP goals stress either cost or quality gains, and that one does not stifle the other. Among Health Affairs studies, only the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract improved all dimensions, though inconsistently. Murray notes that the AQC studies "were by far the most methodologically rigorous and incorporated provider payouts to assess net savings."
The Announcement—otherwise known as the Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies—also included plan risk adjustment and coding intensity; health equity; Star Ratings and overall quality; and end stage renal disease (ESRD) guidance. For each issue, HealthLeaders has analyzed Avalere's key quotes, surprises, and predictions to help payers prepare for another wait-and-see pandemic year.
The big picture
"This year's rule reads more like a first-year announcement," noted Avalere Managing Director Revenue Sean Creighton. This refers to the relative lack of risk and other adjustments that plans were expecting.
"The major lever that everyone expected to be pulled was taken off the table, so I can't describe the Final Announcement as anything but positive, but it depends on what happens with legislation," Creighton added.
Federal legislation could impact plans beyond the rate notice, along with the decisions CMS has left to health plans and the additional technical levers it can pull via other regulations. About these levers Creighton noted that while CMS has many, they must apply them while assessing beneficiary impact—a kind of Hippocratic Oath for payment policy.
Three top-line payer recommendations for next year were:
Keep COVID-19 central to strategy (even after the public health emergency ends) as it pertains to care access, delivery, and quality measurement.
Look for legislation that addresses what the Rate Announcement didn't.
Expect more specificity related to equity, including closer collaboration between CMS and the Center for Medicare & Medicaid Innovation (CMMI).
Coding intensity and plan risk adjustment
"There was a possibility of significant downward rate adjustments, and they weren't there," noted Creighton.
While CMS did not change how it calculates risk scores, the Rate Announcement and other CMS rules signal the agency is assessing its risk methodology across plan types. It must also consider the role of social determinants of health (SDOH) in risk adjustment as well as long-standing concerns over MA plan upcoding practices that increase reimbursement by teasing out patient risk.
In addition to the lack of any real rate adjustment, CMS also did not tinker with its normalization factors and coding intensity adjuster. As a result, Creighton adds: "There is a huge risk of CMS doing something on coding intensity adjuster next year; they haven't done anything for years, even though MedPAC has been beating the drum."
Creighton said CMS may be leaving coding intensity as a legislative activity as it tries to leverage other changes related to benefits and drug costs.
Star Ratings and quality
Some 90% of MA plans had a 4+ Star Rating in 2021. These gains rode the back of pandemic losses and anomalies. Continued COVID-19 impacts are an area of concern, including the CAHPS response rates and results that will factor heavily in CMS' new patient-experienced-focused Stars program.
Related to CMS' broader quality approach, Avalere Associate Principal Taylor Musser noted the intent to not only stratify but evaluate measures based on social risk, in part to create a Health Equity Index that would impact a plan's overall Star Rating. The Rate Announcement also addressed SDOH screenings, manual versus electronic measure reporting, and CMS' intent to "begin sharing confidential stratified reports with contracts this spring."
Health equity
Quality and equity were intertwined in the Rate Announcement takeaways, with Avalere analysts surprised at the level of health equity program detail but advising that CMS will introduce health equity measures "in a fairly careful way."
Creighton said that current risk models "already take into account" some aspects of health equity and SDOH. He added that MLR may be a better place to look for payment-equity gains (e.g., shifting equity outreach costs to clinical).
ESRD
One plan year into MA ESRD eligibility, CMS finalized two expected changes—risk modeling and network adequacy—but left a widely desired rate change off the table. "Leaving it to the plans for now" was the ESRD theme, at least for now.
Creighton noted: "If I had to look at the tea leaves, there is probably a belief at CMS … that plans can bring down costs without doing damage." Explaining CMS' rationale, he cited the looser network adequacy rules and plans' power to negotiate with providers, including large dialysis providers.
Case management was the other ESRD hot topic, yielding some of the strongest warnings and predictions for plans.
Medicare Advantage plans collaborate with companionship companies to meet non-medical needs and collect data that grows member trust and revenue.
Let the word "lonely" sink in for a minute—really sink in.
We’ve all felt its sting, even in the middle of a crowded room or in a loving home where no one seems to want for anything.
But COVID-19 cleared those crowded rooms, especially for people experiencing what has become a companion to the pandemic: more isolation paired with greater need. Two companies want to change all that by partnering: Aetna and for-profit Papa. Together, the companies are achieving double-digit reductions in loneliness among Aetna members through a new brand of caregiving.
Such partnerships help expand the lead Medicare Advantage (MA) plans have over traditional Medicare as supplemental benefits and SDOH gains importance.
HealthLeaders spoke with Dr. Jamie Sharp, VP and CMO of Aetna Medicare (Aetna is a CVS Health Company), and Andrew Parker, founder and CEO of Papa, about how and why their partnership works.
Severe need meets significant improvement and program expansion
A recent eHealth survey found that 39% of nearly 4,000 Medicare beneficiaries said the pandemic has increased their sense of loneliness and isolation.
Through Aetna and Papa's partnership, this gives the insurer a more complete picture of how their members are doing. Papa clients can sign up for the free service through their health plan or employer. More than 65 MA payers—from state plans like Ohio’s SummaCare and Michigan’s Priority Health to national players like Aetna—are Papa customers.
Aetna’s partnership with Papa began in 2020 but that wasn’t the start of what the payer saw was a significant problem.
"Even before the pandemic, we knew social isolation was a big issue for our seniors," says Sharp.
How big? Aetna reports that during 2020, 80% of its eligible Florida members reported feeling severely lonely and depressed. "These are astounding numbers," says Sharp. "These statistics on social factors rival smoking and heart disease."
After using the Papa companionship benefit, 86% of Aetna’s participating members in Florida noted improvements in their feelings of loneliness. Following the positive pilot, Aetna expanded its Papa partnership to seven more states—Nevada, California, Illinois, Michigan, North Carolina, Pennsylvania, and Indiana—and with comparable results.
In 2021, 62% of Aetna PPO members and 52% of Aetna Dual Eligible Special Needs Plan (D-SNP) members reported feeling much less lonely and happier overall after using the companionship services. This included a reduction in reported "unhealthy days," the number of days in the last month where a member reports their physical or mental health was not good.
New regulations create new customers
Before 2019, MA plans would not have been a Papa customer segment. New Medicare regulations that allow private payers to offer non-medical services have created a value-added and supplemental benefits boon that adds complexity to an already competitive MA market.
"We knew we had to prioritize benefits to address social determinants of health," says Aetna’s Sharp. "Things like our Healthy Food Benefits Card and Utilities Debit Card," which help people pay for groceries and their electric bill and which many MA plans are now offering—often in high-need pilot markets first, followed by expansion.
"Health plans love providing great experiences and value to members," notes Parker, of Papa. "A focus on wellness and customer experience aligns with a health plan’s brand, while helping them address needs proactively versus reactive."
Capitation is part of the model, with Papa receiving a per-member per-month fee to provide a host of services that may reveal additional member needs over time.
An SDOH focus
This partnership is an example of the growing people-and-platform needs that health plans meet by contracting with companies like Papa. Parker adds: "With the plans, we identify member needs looking at markets, counties, and ZIP codes. Our algorithms help us make better decisions and partner with plans on what their gaps are. This also creates best practices for enrollment, targeting, and communication."
The data Papa collects is added to broader social data that the company already has or acquires from its health plan partners. "Social determinants of health are something we’re all focused on, all health plans," says Aetna’s Sharp. "We know how important it is to get the information we have to Andrew and his team."
And for plans to get information back.
Good for people and business
One of Parker’s observations (that "healthcare is becoming real health care") speaks to the greater reach payers have into members’ lives—and will be expected to have as federal SDOH requirements take shape.
The payer and companionship services relationship is good for people in need and good for business, impacting the risk coding and screening numbers that increase reimbursement and incentives tied to the MA Star Ratings program. Providing these types of services expands the growing advantage MA plans have over traditional Medicare, which does not generally cover them. It may also address growing caregiver challenges. Caring for caregivers while expanding and directing their capacity is a critical need.
Editor's note: This story was updated on April 8, 2022.
Healthcare leaders must manage health equity measures as part of strategy and profit and loss.
How do you make a metric that matters?
Measure twice, cut once.
It turns out that the home repair adage also applies to…well, measures. This includes the health equity measures that a growing number of healthcare leaders must manage as part of both strategy and profit & loss (P&L).
Measuring a health equity metric twice means assessing and reassessing whether it is worth developing, no matter how compelling the subject. Once that decision is made, cutting once means delivering a well-designed measure that delivers value quickly. Over time, metrics must also be optimized as everyone learns more about what they reveal.
Trenor Williams—founder and CEO of Socially Determined—detailed for HealthLeaders in five steps how to create effective measures for social determinants of health (SDOH) that improve health outcomes and business performance. Socially Determined's newest metric is Social Connectedness.
Step 1: Ruminate
"Social connectedness has been on our radar since 2016. But what's important with developing any metric is the ability to get consistent quality data," says Williams.
Socially Determined conceptualized the Social Connectedness metric for several years before developing and refining a model that would work for every healthcare sector, including the P&L leaders who must deliver profits that don't leave people behind.
"Net new data sources, COVID-19's impacts, and several years that highlighted the lack and importance of social factors—these factors plus market pressure and interest allowed us to prioritize."
Step 2: Make sure you have the data
In developing Social Connectedness and other equity metrics, Williams stressed the need for data that can assess both individual and community risk.
"Our model is to have individual data sources that consistently feed the algorithms for reliable, thoughtful insights," says Williams.
To deliver value, health equity intelligence should include geospatial, migration, and other open-source and proprietary datasets. Rich sets are those that can be collected consistently and across the entire country.
Step 3: Determine whether the metric achieves something
Data needs to do something, especially in healthcare. And metrics—aided by advanced analytics—exist to not only measure outcomes but improve them. Applying social risk analytics to SDOH data helps organizations understand what Williams calls the "contours" of need. The result is tailored solutions that are more likely to meet community, organizational, and systemic goals while not leaving people behind.
"You have to think of metrics in a longitudinal way," says Williams. "Upstream is only half the story. Data frequency and validity are critical, too."
Giving healthcare decision-makers the ability to act on data is why some equity metrics may not make sense. Crime and violence are one example.
"This data has a real impact on the social determinants of health," says Williams. "But crime data is not consistently reported, which impacts the ability to use it to assess risk and deal with gaps."
Williams adds that the best metrics give organizations the "action arm" to respond to elevated risk.
Step 4: Ask if it can solve more than one problem
The best health equity metrics navigate multiple needs.
For his company's Social Connectedness metric, Williams notes the need to design targeted interventions at the personal level that also inform broader strategic goals: "You have to think about where the dollars, the partnerships, and the organizations are."
The example he gives is how the observations of a health plan's case managers can help direct supplemental benefits to meet individual and market need.
Strong metrics and social risk analysis straddle personalized medicine and population health, just as payers and providers do.
Step 5: Don't stop improving and don't hand over the keys
Even the best-designed metric needs adjustment. "Our job is to optimize and continually enhance SDOH metrics to deliver more value to the organizations we partner with."
On the payer side, those organizations include CareFirst Blue Cross Blue Shield; Aetna—whose Medicaid team is "investing heavily" in social determinants, according to Williams; and the fast-growing Priority Health, the Michigan health plan that is part of Spectrum Health, a leading regional IDN.
"We believe in long-term sustainable relationships and have a disciplined process. We're not just handing over the data. We're spending a lot of time with our partners—how they act, who they're supporting," says Williams. "This gives us a consistent view," a value for optimizing metrics and assessing social risk long term.
Finding the balance with health equity ROI
The last two years have exacerbated social isolation, loneliness, depression, and anxiety.
Williams—a former family physician and the son of a social worker—agrees, adding:
"At the end of the day, what I get most excited about is the impact that changes people's lives. ROI isn't just about avoidable utilization and preventable cost."
Simultaneously, there isn't a single healthcare decision-maker who isn't thinking about how to link SDOH to traditional ROI. The pandemic wouldn't be revealing long-standing disparities if addressing them wasn't already ingrained in the deepest levels of business strategy and prioritized at scale.
In healthcare, suffering is both a human problem and a business one—with well-designed metrics critical for addressing both.
Photo credit: This image of Baltimore City, Maryland, Socially Determined’s SocialScape platform processes dozens of elements, including geospatial data from SafeGraph, migration data from the IRS, and other open-source and proprietary datasets, to identify populations. Photo courtesy of Socially Determined.
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.
