"[W]e recognize that the Administration’s guidance takes steps to mitigate the real risks of price gouging, fraud, and abuse, which would limit access and reduce affordability for everyone." — Matt Eyles, AHIP president and CEO
COVIDTests.gov went live on January 18: one day before its official launch and roughly one week after the Biden administration's requirement that insurers cover test costs for their members. The mandate, its timing, and how payers are responding reveal a delivery system in motion. Payers must calculate new priorities against existing financial performance and strategy, which the pandemic has already impacted in the billions.
Anyone can order from COVIDTests.gov and receive up to four free tests. Under the mandate program, insurers are required to pay for up to eight eligible tests per month for their individual and/or group members. Eligible tests must be FDA authorized, cleared, or approved. Carriers must also pay for tests that exceed the monthly limit that are "ordered or administered by a health care provider following an individualized clinical assessment, including for those who may need them due to underlying medical conditions."
While four free tests total versus eight monthly represents a coverage gap between the insured and uninsured, both strategies help ensure that testing costs are less of a burden. This is particularly important now that the highly contagious Omicron variant is causing schools and businesses to shut down voluntarily due to staff illness, with negative test results required to return to work following a now-shorter, five-day isolation period.
One website, one mandate, many reveals
There are many ways of looking at these dynamics and their parallel impacts.
COVIDTests.gov and the payer testing coverage mandate are examples of a delivery system working the right way. Both steer consumers toward the most cost-effective service and setting: free tests available online or at a preferred pharmacy/retail settings versus tests with wildly variable price tags, delivered by overburdened providers in higher-cost settings.
Health plans and their national association, AHIP, appear to agree. AHIP president and CEO Matt Eyles has commented: "[W]e recognize that the Administration’s guidance takes steps to mitigate the real risks of price gouging, fraud, and abuse, which would limit access and reduce affordability for everyone."
Despite this, however, costs, reimbursement, and processes are wildly divergent. Under its new mandate, the Biden Administration wants insured consumers to be able to walk into a designated pharmacy or retailer and walk out with a test at no charge. Additionally, it is incentivizing payers to make tests available in this way—or online—to cover costs upfront and eliminate member claims submission. For members who chose not to go this route when the preferred provider option is available, the cost of a test is essentially no longer free, with the government setting a reimbursement limit of $12 for OTC test purchases.
For their part, and to defray some mandate costs, many carriers are using their websites to steer members toward COVIDTests.gov for their first four OTC kits. In addition, not all health plans are offering the most expedient options. In a recent press release, AHIP summarized multiple insurer approaches ranging from tests that are immediately available for online ordering through a preferred vendor link (Virginia-based OptimaHealth) to descriptions of the manual claim reimbursement process—either paired or not with the plan's intent to make online or no-upfront-cost ordering available (Highmark, in Pennsylvania and the mid-Atlantic). For the latter, plans are either leaving it at that or informing members that their approach is evolving.
Payer choices
AHIP has been tracking payer COVID-19 response during the pandemic, highlighting the coronavirus treatment cost-sharing waivers of its members. Well before the free OTC test mandate, however, there was evidence that things were changing according to an August 2021 study by the Kaiser Family Foundation (KFF) and the Peterson Center on Healthcare.
"Earlier in the pandemic, we found that the vast majority (88%) of people enrolled in fully-insured private health plans nonetheless would have had their out-of-pocket costs waived if they were hospitalized with COVID-19." Following vaccine availability and by the fall of 2020, the study found that "72% of the two largest insurers in each state and DC (102 health plans) … [were] no longer waiving these costs," with another 10% planning to do the same.
About these waiver decisions, the study authors add: "At the time, health insurers were highly profitable due to lower-than-expected health care use, while hospitals and health care workers were overwhelmed with COVID-19 patients." A May 2021 analysis from the National Academy of Medicine (NAM) concurred: "Payers initially experienced cost reductions due to care delays, but then experienced a subsequent increase in operating expenses due to the growing volume of COVID-19 patients and the resumption of deferred health services."
The shifting landscape
The NAM study further highlights that "as insurance is an industry premised on forecasting and risk assessment, the fundamentally unpredictable nature of a pandemic created significant challenges for payer operations in 2021 (e.g., pricing, enrollment)." While numerous payers reported significant losses throughout most of last year as members no longer deferred care, some have begun to rebound.
With this, payers appear to be applying the above-mentioned forecasting and risk assessment to the new OTC mandate—balancing the speed of test and reimbursement against the pace of the Omicron variant, whose highly infectious yet less severe nature suggests the virus may be transitioning from a high-cost pandemic to a lower-cost over time endemic. The image is one of multiple cost and operational levers turning at once to balance response and financial stability.
The best of a bad (but improving) situation
There is no doubt that the pandemic has created wins in the face of tremendous losses. The NAM study notes: "The pandemic has both provided momentum to implement long-overdue changes in health care delivery (e.g., flexibilities for virtual care) while highlighting the need to accelerate ongoing efforts to transform payment systems (e.g., the transition to APMs). Notably, COVID-19 has also fostered new, innovative partnerships between payers and other sectors …" It adds, however, that "COVID-19 has illustrated how misaligned financial incentives and the fragmentation of services across sectors contribute to inefficiencies and inequities in the American health system."
Even with the delivery system gains illustrated by COVIDTests.gov and the payer coverage mandate, it is difficult to ignore that free OTC tests have been available in the UK since the spring of 2021. And consumers are still at risk for surprise bills, particularly if they seek tests from expensive sites like hospitals where testing costs have ranged from $20–$1,419—"not including the price of a provider visit, facility fee, or specimen collection," as reported by KFF and the Peterson Center in April 2021. While consumers are far less likely to go this route when they can get multiple tests for free, it is an example of a delivery system that still has many wrong doors.
'The entire country is going to be watching CalAIM,' says one California Medicaid MCO executive.
Medi-Cal, California's Medicaid program, is on a five-year path to innovating what it can offer and how, who will be involved, and what it will expect of its managed care plans. In December 2021, CMS approved the state's CalAIM proposal to make Medi-Cal "integrate more seamlessly with other social services … especially for those with the most complex needs."
This includes non-medical benefits, delivered with the help of community-based organizations (CBO) and in a way that makes navigation to the right care easier. Technology and infrastructure support will not only be needed but required as MCOs are charged with balancing population health and new levels of individualized care.
CalAIM key components
CalAIM's allows the state to offer expanded non-medical services, integrated with clinical care, through Enhanced Care Management (ECM). The objective is to help plans be more proactive, deliver a "no wrong door" approach, and offer more outcome-based reimbursements.
Services linked to social determinants of health (SDOH) will include housing, meal, and peer supports as well as medical respite and personal care. CalAIM applies to all Medi-Cal members but seeks to help those most in need:
Individuals who need care for serious persistent mental illness and/or substance abuse
Seniors and those living with disabilities
Special populations with complex physical and/or mental health conditions, including children and people who are homeless or returning to the community after jail time
Young people in foster care.
Supporting vulnerable populations in new ways will require new types of partnership and accountability, and the technology to scale them both.
Converting patchwork to whole cloth
The California Health Care Foundation (CHCF) highlights the CalAIM goal of "bringing consistency to the current patchwork of programs that vary by county." Some of this patchwork is endemic to Medi-Cal. The program includes multiple managed care models that vary by county, each one with its own unique needs in a state that is home to massive urban centers and small agrarian communities.
But this patchwork is marked by other factors as well.
“For years, local plans have initiated pilot programs and community-based initiatives that marry social supports with Medi-Cal’s robust health and medical benefits." This fromLinnea Koopmans, CEO of Local Health Plans of California (LHPC), which represents the state's 16 nonprofit local health plans. "CalAIM allows us to bring those to scale and offer more comprehensive care to enrollees. We believe through CalAIM we can address long-standing disparities to support equity and better health for all."
For examples and discussion of this pilot-to-programmatic transition, see HealthLeaders' interview with CalOptima.
MCO opportunities and requirements
"Health plans in California have been looking for the flexibility that CalAIM will provide for a long time," says Yunkyung Kim, COO of Orange County Medicaid MCO CalOptima.
But with new flexibility, and funding, come new mandates—nearly all of which will need enhanced infrastructure and technology supports. CalAIM will require that Medi-Cal MCOs:
standardize select benefit and population offerings
create and submit population health management strategies
expand data-sharing, including with CBOs
become NCQA-accredited (National Committee for Quality Assurance)
Technology as the tie that binds
A word that appears repeatedly in conjunction with CalAIM is scale, which the state hopes to achieve through CalAIM's PATH component (Providing Access and Transforming Health). PATH acknowledges that many of the CBOs that are vital to CalAIM may have "never contracted with managed care plans … or interacted with the Medi-Cal program." In addition to contracting, data-sharing is a big first step—and for all stakeholders.
The CalAIM plan is focused on interoperability to support overall reform, an objective many of the nation's providers and health plans are still struggling to achieve. The state's Medicaid administrator, the Department of Health Care Services (DHCS), says: "An overarching goal … [is to ensure] that relevant data (including clinical and non-clinical) can be captured, analyzed, and shared to support provider integration of behavioral health and medical services, case management oversight and transitional planning, value-based payment models, and care delivery redesign."
"We really have to figure out how to share data and it's not easy," adds CalOptima Interim CEO Michael Hunn.
CalAIM includes several CBO data-sharing prerequisites for Medi-Cal plans, including privacy-compliant protocols for behavioral health, claims, pharmacy, advance directives, and care plan and management information. Hunn agrees that data sharing will be vital to CalAIM's ECM component.
"We know that some of our members with complex physical health and behavioral health needs traverse the healthcare system and fall in and out of Medi-Cal. CalAIM provides the opportunity to better track them and their individual needs throughout the healthcare system."
Hunn reports that his plan is "currently building out the CalAIM connect system so everyone on an individual’s care team may communicate together immediately, and that is just to start."
In the end, Hunn adds that there must be demonstrated outcomes.
"We must have metrics of success. One of the questions for CalOptima and other plans would include: 'What [has to be] done over the past 12 months for you to say I had a successful year?' "
Technology requirements for population health and later-stage outcomes
In addition to ECM and CBOs, the CalAIM platform will support "aggregate use by plans" and the new requirement that they develop "comprehensive population health management programs." Specific details include:
equitable assessment of member risk
services—clinical and non-clinical—that address SDOH factors
service coordination that remains intact at care transitions
Another significant CalAIM objective is the state's plan to "test the effectiveness of full integration of physical health, behavioral health, and oral health under one contracted managed care entity." Under the current delivery system, MCOs manage physical and up-to-moderate mental health benefits while separate entities oversee serious mental health and substance abuse (MH/SA) and dental care.
This plan is represented by a single "X" in the last year of the CalAIM implementation calendar. By 2027, the state hopes to achieve this full integration as well as the consolidation of its serious MH/SA disorder programs and a transition from county-based to statewide administration of long-term services and supports.
Data sharing and interoperability will be a vital component—a long-term goal that will be achieved one day at a time. Hunn reports that this work has already begun.
"There is a daily CalAIM-related standup," says Hunn. "Administrators from many different entities are participating and working to improve navigation through the system."
Whether healthcare reforms meet with support or opposition, all represent an effort to control the direction of the delivery system.
Attempts to alter healthcare's value chain are marked by money and power. Whether reforms meet with support or opposition, all represent an effort to control the direction of the delivery system—whether at the national level, local, or both.
This is particularly true in California, which is the birthplace of not only U.S. managed care and venture capital but some of the most robust, state-based attempts to establish universal coverage. In addition to new legislation that proposes the latter, the November 2022 ballot could feature multiple, additional, healthcare-focused measures.
Five proposals
Kaiser Health News recently reported on the following California ballot proposals:
Banning flavored tobaccos
Increasing medical malpractice award limits
Regulating dialysis clinics
Legalizing psychedelic mushrooms
Advancing public health emergency (PHE) response
As Kaiser adds: "Although the election is about 10 months away, money is already pouring in from deep-pocketed interests eager to defeat measures that would eat into their profits."
Opposition to tobacco and malpractice measures
Only the tobacco ban has officially qualified for the November ballot. Big Tobacco has raised $21 million and is sure to invest more to block any bans of its products. State filings indicate the malpractice measure has the required signatures—as well as $43 million in funding raised to oppose it, primarily from the California Medical and Hospital Associations. If passed, malpractice award limits would increase from $250,000 to $1.2 million and give judges and juries the authority to grant larger settlements.
Greater dialysis clinic and PHE oversight
Like the malpractice proposal, attempts to regulate dialysis clinics have been defeated in the past, in part due to more than $200 million in opposition funding. The current measure, if it makes the ballot, calls for more scrutiny of clinic ownership and staffing qualifications.
The state, which has implemented some of the nation's most rigorous lockdown measures, does not want to miss the opportunity to define ongoing response, to the current pandemic or any future ones. If approved, the PHE-related measures would increase personal income taxes for the wealthy to raise $15 billion over 10 years to track and combat disease outbreaks and support safety, infrastructure, and workforce needs in schools and public health entities. Schools and local businesses are the focus of another PHE measure, specifically efforts to limit closures.
Timelines for collecting sufficient signatures for ballot inclusion range from March to May.
"We cannot put the burden of the healthcare system's complexities on the member," says CalOptima Interim CEO Michael Hunn.
"I want to start with this," said says Michael Hunn, Interim CEO of the California Medicaid plan CalOptima.
The "this" was two-fold: the MCO's strategic plan, which Hunn held in hand throughout his recent interview with HealthLeaders, and the mission, vision, and partnership behind it. Joined by CalOptima COO Yunkyung Kim ("YK"), the two leaders detailed CalOptima's approach, new funding commitments, and the initiatives they will support—including those tied to the state's innovative new Medicaid demonstration.
As a Medicaid plan, CalOptima has a bird's-eye view into the social determinants of health (SDOH) that impact its more than 862,000 members. This includes individuals enrolled in Special Needs and Medicare-Medicaid Plans (SNP and MMP) as part of Medicare Advantage and PACE (Program of All-Inclusive Care for the Elderly).
Among the individuals with low incomes, disabilities, and special needs that CalOptima serves in Orange County are not only children, families, and seniors but those looking for a new life after incarceration. It is with these vulnerable populations that Hunn began.
Michael Hunn, Interim CEO of CalOptima. Photo courtesy of CalOptima.
Michael Hunn: I want to start with the mission and vision of CalOptima. It reflects the fact that our membership is multicultural, multilingual, and multigenerational. People who need services need to know where to get them and how to sign up. We cannot put the burden of the healthcare system's complexities on the member.
CalAIM is important here. It's about providing for clinical and the nonclinical needs. It's meant to help touch the individual, build equity in the community, and zero in on how we can better understand your needs and help you better.
(Editor's note: CalAIM is a five-year demonstration program authorized by CMS-approved 1115 waivers and State Plan Amendments. Its components include Enhanced Care Management to improve care integration and navigation, nonclinical community supports (e.g., housing, recovery and recuperation care), and technical and infrastructure support for the agencies that provide them. Plans will also be required to create and implement population health management plans and support data sharing.)
Hunn: We're already reaching out to hospitals, physician networks. I'm personally engaging with provider CEOs and executives to talk about what we can do together to be successful.
Yunkyung Kim: It's something we feel every single day. And CalAIM will help. It builds from a lot of other programs that were moving toward more integrative, whole-person care. The learnings from county pilots are allowing the state to expand these efforts.
CalOptima historically has led the way in raising our hands early and proactively to participate in statewide pilot programs such as the Coordinated Care Initiative, Whole Person Care Pilot, and Health Homes. We will use the same "early adopter" strategy when it comes to CalAIM, which will facilitate more diverse, collaborative partnerships and provide more funding.
Yunkyung Kim, COO of CalOptima. Photo courtesy of CalOptima.
HealthLeaders: Speaking of funding, can you also talk more about the additional $45 million investment in the community? I understand there are three main programs to combat homelessness, increase vaccine rates, and pay providers more for better care coordination.
Hunn: The money will help start some initiatives while also improving the existing delivery system infrastructure. We're funding free, multilingual vaccination clinics, which we locate based on county COVID-19 prevalence data. [The current vaccination rate for members aged five and older is 58%.] Members will receive gift cards. YK and I will both be at these clinics. If you're going to work with the community, you better be in the community.
Our homeless effort is another area receiving added funding. After leaving a facility, someone who is homeless is often not ready to go back to the street or a shelter. They need a place to recuperate outside the hospital.
(Editor's note: These efforts build on an existing CalOptima homelessness program that includes shelter-based services and roaming Clinical Field Teams. With CalAIM help, the program will link to housing vouchers and supports.)
Kim: Recuperative care for people who are homeless is another big example of the flexibility CalAIM will provide. Before, we could pay for hospital or SNF care but nothing in between.
Hunn: Housing navigation is also part of this. We had someone in need over the holiday who was authorized for a voucher. CalAIM will add to this, putting deposits down to help people get into housing.
HealthLeaders: Partnership is another thing that it sounds like CalAIM will amplify.
Hunn: I'm already socializing our strategic plan with other CalOptima executives and our board, then key stakeholders. We have a very supportive board.
We also need to figure out and start working on co-creating interagency strategic plans. We have a stellar relationship with Dr. [Clayton] Chau and Dr. [Veronica] Kelley.
(Editor's note: Chau is director of the Orange County Health Care Agency, where Kelley serves as chief of Mental Health and Recovery Services. Chau is also a CalOptima board member.)
We're thinking about things like, how can we co-locate staff so we have the synergy and the collaboration of a team? The same is true for the Community Health Needs Assessment: why can't we take common things and do it together instead of duplicating outreach? The health plan and the county are often not aligned but we are.
Noting his love for operations and strategy, Hunn concluded by adding: "I am blessed to be a leader, and I'm entitled to nothing. I am a CalOptima employee just like everyone else and serving the same mission. We're here for the member. I don't forget that. I’m standing on the shoulders of a lot of people who were at CalOptima before me."
Editor's note: This story was updated on January 18, 2022.
'While nontraditional venture investors have pulled back investment activity in the past … incumbents and their corporate venture capital (CVC) units have remained committed.—PitchBook 2022 Emerging Technology Outlook
In its 2022 Emerging Technology Outlook, PitchBook made three major predictions for healthcare technology investment, spanning enterprise tech, insurtech, and retail health tech. While venture capital (VC) firms are still the primary funders of the healthcare startups, the company notes that healthtech VC deal activity "has spiked" and is expected to grow to $1.3 trillion by 2025—due in part to payer- and other healthcare stakeholder-led investments in the areas noted below. Within PitchBook's predictions are important caveats discussed at this article's end, the cautionary tales that inevitably and necessarily shadow innovation headlines.
Top three healthcare predictions
1. Precision and personalized medicine to receive record funding.
The right mix and maturity of supporting technologies, market drivers, and opportunities may make 2022 a significant year for precision and personalized medicine. The intersection of the two is but one example of enterprise heath tech, which PitchBook defines as B2B services that focus on improving care quality while decreasing cost of care. Enterprise health tech is divided into five categories:
Prescription tech
Customer acquisition tools
Clinical trial tech
Insurance tech (insurtech)
Operations and care management
While noting that "precision medicine has been a talking point for several years" and that "it may yet take several years to become fully commercialized," PitchBook's Outlook adds that "we expect VC interest to ramp up."
Payer-driven VC companies are among the investors in health tech. UPMC Enterprises for example, the venture capital arm of payer-provider UPMC, was a co-lead investor in a $20 million funding round for Smile CDR, a data and platform company focused on increasing interoperability for payers and providers.
This is increasingly possible, adds PitchBook, through a "confluence of technologies" that range from sensors and remote monitoring to EHRs and genetic databases. The caveat, however, that the very capabilities that fuel growth are enmeshed with the "medicolegal" issues that may slow its growth, including ongoing issues related to data privacy and security.
2. Insurtech to see more M&A, driven by established players.
PitchBook expects established payers to continue acquiring startup insurtech competitors, many of whom are advanced tech native from inception and offer incumbents the opportunity to buy the innovations they lack in-house. Insurtech companies have disrupted the market, offering plan comparison and enrollment platforms in addition to new coverage options. Devoted Health and Clever Care Health Plan are examples of the latter, attracting two of the largest insurtech investments ($1.2 billion and $71 million, respectively) as 2021 drew to a close.
Insurtech is another area where traditional payers are escalating market investment through mergers and acquisitions (M&A). According to PitchBook: "While nontraditional venture investors have pulled back investment activity in the past, especially during volatile market conditions or downturns, incumbents and their corporate venture capital (CVC) units have remained committed to insurtech investments in recent years." That commitment totaled $2.7 billion in 2021, nearly double 2020 figures. Optum Ventures, the VC enterprise of UnitedHealth Group, is one of the largest players in this space.
3. Retail health tech seeks to disrupt entrenched approaches.
Like precision medicine, retail health is another area whose growth has been slower to materialize than eager analysts predicted nearly two decades ago. But as with so many facets of healthcare since COVID-19, telehealth, "[n]ew technologies and the proliferation of mobile devices have enhanced providers’ ability to provide care via video chats and chatbots." PitchBook predicts that "[r]etail healthtech startups will increasingly focus on building technology that increases the frequency of low-touch interactions between patients and providers." This may occur virtually or in person.
Existing players are seeking the same outcomes, through a proliferation of virtual-first health plans and, for CVS Health-Aetna, a deepening integration that makes CVS MinuteClinics and HealthHUBs central to more plan designs.
The interplay of caution and innovation
PitchBook balances its predictions with important counterarguments that demonstrate what payers and other investors already know: that success is never guaranteed. Traditional healthcare practices continue to vex innovation. These include the:
"technical, ethical, and legal" concerns that remain as data, analytics, and interoperability advance.
"increased competition, evolving risks, and heightened customer expectations" that can make insurtech investments high risk.
long-standing workflows, interaction patterns, delivery mechanisms, and fee-for-service reimbursement that are deeply entrenched.
On this latter point, PitchBook identifies "one of largest obstacles facing the industry … how to shift the interaction patterns between providers and patients."
"The risk is much lower for participation now, as payers have learned how to price for exchanges," says one industry analyst.
Marketplace Open Enrollment, aided by a Special Enrollment Period (SEP) in early 2021, has reached its highest numbers since the Affordable Care Act (ACA) launched health insurance exchanges in 2013. CMS reports that 13.6 million people have signed up through HealthCare.gov or State-based Marketplaces (SBM). This surpasses numbers from the final year of the Obama administration and includes additional records for the traditional Open Enrollment period and the number of people with first-time marketplace coverage.
A breakdown of the nearly 14 million now enrolled includes:
9.7 million people selected plans on HealthCare.gov during Open Enrollment (November 1–December 15, 2021).
Of these, more than 1.6 million represents new consumers.
An additional 3.9 million enrolled via SBMs, which operate in 18 states.
CMS published these numbers in its Marketplace Weekly Enrollment Snapshot and will provide a final update that includes a one-month extension (December 16–January 15, 2022), with coverage on those plan choices beginning February 1, 2022.
The impacts of COVID-19—including unemployment and the Great Resignation—as well as new marketplace supports and increased health plan participation have combined to boost enrollment. Subsidies from the American Rescue Plan have helped make coverage more affordable and for a larger group of people. Commercials for HealthCare.gov returned to the airwaves during the SEP and Open Enrollment, and $10.2 million in new funding for enrollment navigators was designed to improve the HealthCare.gov experience.
This is in stark contrast to the Trump administration, during which enrollment declined by more than 1.2 million. Additionally, in 2020, the federal government did not create a COVID-driven marketplace SEP as it did for Medicare Advantage. It should be noted, however, that enrollment dips did grow smaller between 2017–2020, with the pandemic driving the lowest declines.
The question now is whether the temporary marketplace subsidies will continue, to what degree, and the impact of the mid-term 2022 elections. The good news is today's marketplace is far more stable. As Clarivate principal analyst Bill Melville noted in a prior HealthLeaders article: "The risk is much lower for participation now, as payers have learned how to price for exchanges." If Congressional support wanes, overall marketplace health may provide a critical counterbalance for steady enrollment or continued growth—particularly if COVID's impacts on the economy and workforce continue throughout 2022.
"With this proposed rule, we are working to ensure the Marketplaces are a model for accessible, affordable, inclusive coverage—particularly for eligible individuals who have thought comprehensive coverage was out of reach."— CMS Administrator Chiquita Brooks-LaSure
On December 27, 2021, CMS released its annual proposed rule governing Marketplace plans. The agency states that this notice of benefit and payment parameters is intended to "improve shopping for healthcare coverage, establish rules to ensure people can access care, and advance health equity for consumers purchasing Marketplace coverage … particularly for eligible individuals who have thought comprehensive coverage was out of reach.” To achieve these aims, the rule includes the following four proposals below as well as others designed to further stabilize the exchanges.
CMS also states that the proposed rule "minimizes the number of significant regulatory changes to provide states and issuers with a more stable and predictable regulatory framework that facilitates a more efficient and competitive market." Established payers and startup plans should welcome the news, if they agree with the agency's assessment.
Equity reinstatements, requirements, and requests
The proposed rule would once again prohibit discrimination on the basis of sexual orientation or gender identity, an established provision reversed during the Trump administration. The provision applies to covered services
Another equity-related measure would give HHS access to more granular data related to social determinants of health (SDOH). This includes ZIP code, race, ethnicity, and subsidy information. The rule would require that plans collect this data—many of whom already do or plan to improve their efforts—and report it to HHS. The agency has signaled it will use the data for risk assessment and adjustment and broader equity study—including, for example, "conducting analysis on whether there are any cost differentials for certain conditions based on race, ethnicity or subsidy indicator."
CMS has also requested comments on how it can incentivize plans for their health equity programs while also requesting that insurers include equity approaches in their quality improvement (QI) strategies.
Standardization for ease and stability
Carriers on select platforms will be required to offer standardized plans. This includes plans sold on HealthCare.gov and states that manage most exchange functions except enrollment ("facilitated State exchanges"). Standardized plans are to offer identical deductibles and cost-sharing for every network, metal, and plan type and for every plan service area. Some State-based Marketplaces already offer standardized plans as reported by HHS and its Office of the Assistant Secretary for Planning and Evaluation (ASPE). The office notes the impact of "choice overload": nearly 73% of HealthCare.gov consumers encountering more than 60 plan options and the average is 100.
Clinically based benefit design
Equity is also aided by evidence. CMS wants to require plans to design essential benefits that are evidence-based. Benefits include equally accessible care for people with chronic conditions and a possible de facto medical necessity standard across essential benefits. The latter insight is credited to Katie Keith, a Georgetown University adjunct law professor and industry consultant.
Network adequacy, in size and type
The proposed rule would reinstate federal network adequacy reviews for facilitated State exchanges with a companion requirement that 35% of a service area's essential community providers (ECP) be in network.
Other provisions of the proposed rule include: maintaining consumer exchange user fees at current levels; eliminating most pre-enrollment SEP certification requirements; and defining how QI incentives, bonuses, expenses, and activities apply to medical loss ratio calculation.
Rule comments are due January 27, 2022, and the final rule is published in May.
"Many community-based organizations lack sustainability. It is up to payers—or the holders of the financial and outcomes risk for the individual—to create the infrastructure and processes to add CBOs to their VBC models and pay them for their services," says one health tech executive.
Like politics, it's been said that all healthcare is local. But when it comes to the role of community-based organizations (CBO) in supporting health, payers and other stakeholders haven’t quite known how to include their closest neighbors. Add to this the rising importance of social determinants of health (SDOH), which CBOs may be qualified to identify and meet but also disadvantaged to address from a healthcare system perspective, including value-based arrangements.
The challenges CBOs, health plans, and state Medicaid programs face in working together range from data and technology to contracting and payment capabilities. "Many CBOs lack sustainability," says Lynn Carroll, COO and head of strategy for HSBlox."It is up to payers—or the holders of the financial and outcomes risk for the individual—to create the infrastructure and processes to add CBOs to their VBC models and pay them for their services."
And yet it is these very organizations that can often make the most immediate and personal contact with someone in need. "The organization providing care in the home or community is going to be the first one to see when a change in a person's health status has occurred," adds Carroll. There are a growing number of health plans, Medicaid- and Medicare-focused programs, and tech solutions that are emerging to include CBOs and maximize their role in whole-person health.
State and Medicaid responses
The Kaiser Family Foundation (KFF) summarizes well the challenges states face in creating SDOH-focused programs, which "require working across siloed sectors with separate funding streams, where investments in one area may accrue savings in another." KFF adds that: "The capacity of community-based organizations and local programs may not be sufficient to meet identified needs and data infrastructure may need to be improved to allow for data sharing across health care and social services settings."
KFF identifies, however, that "state Medicaid programs have been developing strategies to identify and address enrollee social needs both within and outside of managed care." Before the pandemic, states were already using Affordable Care Act provisions, 1115 Medicaid waivers, and demonstration programs and funding through Centers for Medicare & Medicaid Services Innovation Center (CMMI) to include CBOs in SDOH initiatives. For example, Washington State’s 1115 demonstration, Accountable Communities of Health (ACH), has included CBOs and value-based payments over its five-year term (2017–2021).
One of the challenges is how states include SDOH-related services, which are considered "value-added services" and not generally included in capitation formulas. KFF notes: "States can direct that managed care plans make payments to their network providers using methodologies approved by CMS to further state goals and priorities, including those related to addressing social determinants of health."
Some states are requiring that CBOs be part of this formula. Beginning in 2021, Pennsylvania began requiring its Medicaid MCOs to "incorporate CBOs into moderate and high-risk value-based purchasing arrangements, as an effort to address the social determinants of health." In an FAQ, the State outlined the mechanisms MCOs can use to fund, contract, and track CBO participation and activities including:
MCOs may direct contract with CBOs or use providers who contract with these organizations as a pass-through mechanism
These same options can be used to pay CBOs (via MCO or provider systems)
MCOs may use "medical, administrative, or excess revenue dollars" for CBO contracting
The Pennsylvania Medicaid MCOs working through these challenges include Aetna at the statewide level; UnitedHealth Group, UPMC, Gateway, and AmeriHealth at the regional level; and Health Partners, Keystone First, and Geisinger Health Plan in single regions.
Improving social needs data reliability and integrating it into clinical programs
Facilitating CBO service connection and delivery
Tracking results, from health outcomes to program return on investment
Humana’s Bold Goal involves more intensive SDOH investment and resources in select communities such as San Antonio while Blue Cross and Blue Shield of Kansas City and Illinois have launched similar initiatives.
Turning to third parties
The 2021 CIMA study conducted by the NORC research organization at the University of Chicago, reports: "While every health plan employs personnel dedicated to building and maintaining contracts and relationships with health care providers, health plans have largely had to start from scratch in figuring out how to contract with CBOs for non-health services."
Enter a variety of third-party technology solutions that have emerged to help payers of all types address these challenges. "The contracting piece is something that health plans are saying they don't want to own," says Manik Bhat, CEO of Healthify. Bhat reports that his company has helped payers reduce CBO contracting time from more than a year to less than a month. Several Blue Cross Blue Shield companies are among Healthify’s clients.
The previously mentioned Humana Bold Goal uses a Signify Health platform to help CBOs with communication, tracking, and referrals for MA members. In one Medicaid example, Rhode Island announced in May 2021 that it would launch a statewide Community Referral Platform that KFF reports "will allow health care providers to initiate referrals and enable CBOs to inform the provider of the status or outcome of the referral."
Another company, HSBlox, has launched a new version of its CureAlign platform to make it easier for payers to bring CBOs into the VBC fold while shortening the timespan between care event and reimbursement. CureAlign converts the often-unstructured format of community-based patient care notes into discrete care events that can be confirmed as complete and ready for payment. The platform also operationalizes the complex hierarchical contracting that has made it difficult for payers to include CBOs into VBC.
The role of CBO differences: Local versus larger
Hyper-local referrals and care are what HSBlox’s Carroll terms "the edge," which comes with unique challenges: "Traditional care management doesn’t work well at the edge—in the home or community with things like documenting ADLs [activities of daily living]). For CBOs, the process needs to be something that doesn’t require a lot of steps or supplant other processes. The goal is being additive, not disruptive."
Meeting these challenges is naturally more difficult for smaller CBOs than those connected to regional, state, or national networks. The NORC CIMA study reports: "Some health plans report that it is easier to contract with national umbrella organizations because they can scale benefits more effectively, take advantage of more advanced contracting capabilities, or ensure high levels of liability coverage required under corporate risk management policies. Larger regional CBOs are often able to play similar roles …"
It's understandable but not enough, and payers understand this. From the NORC CIMA study, Andrew Renda, Humana’s vice president of Bold Goal and population health strategy, notes that "to address social needs that almost always are very localized, we do need to figure out how to work with smaller organizations."
"We don't want to wait for symptoms. We can be proactive, before a full exacerbation of a chronic disease," says one ACO executive.
Editor's note: This article is part of HealthLeaders' Mind the Gapseries, a three-part exploration of how healthcare is bringing information, patients, care, and payment closer together. Read the other articles on automated prior authorizations and real-time drug benefits checks.
Yet another benefit of the pandemic's telehealth expansion is more hospital-at-home (HAH) and remote patient monitoring (RPM) programs. Integra Community Care Network, the accountable care organization (ACO) for Care New England Health System, is launching both in partnership with tech company Biofourmis. And with the Centers for Medicare & Medicaid Services (CMS) expanding HAH waiver eligibility and reimbursement parity beyond the COVID personal health emergency, look for more payviders and health systems to deliver at-home solutions.
Two programs for at-home care
The Integra HAH waiver program, per the Biofourmis press release, will " 'admit' patients to their homes instead of a medical facility for inpatient-level care." Data from wearable sensors connects with the company's FDA-cleared Biovitals Analytics Engine to monitor the status of Medicare patients, who will also be connected via tablets, video, and in-person home visits as needed.
"This enables us to be just so much more connected to patients and better able to help people feel comfortable 24/7," says Ana Tuya Fulton, MD, MBA, chief medical officer at Integra and executive chief of Geriatrics & Palliative Care at Care New England.
Integra's second program for remote monitoring applies to its entire ACO population—Medicare, Medicare Advantage, Medicaid, and commercial—with a focus on patients with congestive heart failure, COPD, asthma, and other chronic conditions.
"Integra ACO has remote monitoring for multiple populations," says Fulton "with a focus on improving outcomes, decreasing costs, and improving patient/member satisfaction." From the Biofourmis release, Fulton added: “From a clinical and cost standpoint, safely keeping patients out of the hospital is certainly one of our goals as a risk-bearing ACO …"
A little help from CMS
The HAH program from Integra/Care New England and a growing list of hospitals was made possible by CMS' Acute Hospital Care at Home waiver. Announced in November 2020, the program is part of the agency's broader Hospital Without Walls initiative. While the program is strictly for Medicare beneficiaries, Fulton notes that some states may be working toward a similar solution for people enrolled in Medicaid. In December 2021, CMS issued a revised Fact Sheet to help state and local governments develop "alternate care sites with information on how to seek payments through CMS programs."
Integra's foundations
Fulton cites Integra ACO's foundations as a strong one for their current work. "We've been learning the care pathway with our patients," she says. "We started as an early ACO in community-based, complex care management with interdisciplinary teams taking care of the highest need, typically older patients. Noting that "we wanted to build a continuum to give options," Integra expanded from nurse practitioner and nurse care manager home visits to a
Community Care Medicine program in 2018 that added rapid-response acute care to the home. In 2021, Fulton says that Integra added to their remote-monitoring capacity with one goal: "We don't want to wait for symptoms. We can be proactive, before a full exacerbation of a chronic disease."
The role of patient identification
As to the other ways that an ACO can grow itself operationally? "Correct patient identification is everything," says Fulton, adding: "No one has it nailed down 100% and everyone is looking for the secret recipe. Utilization and cost data to stratify risk is not enough."
Fulton continues: "We spend a good chunk of our time digesting data from claims-based payer reports, including Medicare. Who are our patients, what are their conditions, what claims do they have?" She adds: "We look at their clinical needs, our medical programing, community resources, social determinants of health. We spend a great deal of time in an ACO analyzing data, honing programs—and it changes every year. I spend so much time living in the patient EHR."
While Fulton is living the patient's EHR, she is helping to create a situation where more patients can do their living at home. Integra's HAH and RPM programs seek to transfer elements of care from a hospital setting to one where convenience and familiarity may help speed healing.
"This is a much-needed conversation, at the point of care," says plan executive Martin Burruano.
Editor's note: This Q&A is part of HealthLeaders' Mind the Gap series, a three-part exploration of how healthcare is bringing information, patients, care, and payment closer together. Gaps abound in healthcare: in data, coverage, and equity. There are equally fundamental spaces between information and patients, patients and care, and care and reimbursement. The degrees of separation between these elements are often excessive and unnecessary. Payers and their partners are helping to close these gaps—and ensuring the value in healthcare's value chain is linked throughout. Read the other articles on automated prior authorizations and hospital-at-home care.
Independent Health is one of many health plans gearing up to offer real-time prescription benefits checks for patients at point of care, following a January 2021 final rule from the Centers for Medicare & Medicaid Services (CMS) requiring Part D plans to provide this information to enrollees.
HealthLeaders spoke with Martin Burruano, vice president of pharmacy services at Western New York's Independent Health, about how smaller, regional plans are implementing real-time benefits checks.
HealthLeaders: What does Independent Health's tool include?
Martin Burruano: The myBenefitCheck solution from DrFirst will include up-to-date, patient-specific drug coverage information for nearly 400,000 members, including required prior authorizations and out-of-pocket costs for prescribed medications and therapeutically appropriate alternatives.
HealthLeaders: How long has Independent Health been working on this, and what impact did the CMS requirement have?
Burruano: While implementing a real-time prescription benefits check is CMS-driven, Independent Health had been looking at cost transparency as a part of our business plans for a long time, as well as improving member and provider experience.
It's hard for prescribers. They deal with multiple plans, PBMs, and dozens of formularies, drug coverage criteria, and polices. And clarity around member cost share is especially important given the growing number of high-deductible plans. This is a much-needed conversation, at the point of care that includes lower-cost alternatives, prior authorization, quantity limits.
It was one of those welcome requirements. What currently happens is that a claim rejects from the PBM at the pharmacy and slows things down. Efficiency in the system, up front, is better administratively and for the member and provider. CMS recognized the need, including for interoperability of platforms. It's a win-win for providers, members, and the health plan.
HealthLeaders: What are the unique implementation challenges and opportunities for regional plans?
Burruano: Really, all plans are kind of in the same place. It may even be easier for regional plans because we have strong relationships and mutual trust with our providers already. This is giving them another tool in their toolbox, which makes adoption easier.
HealthLeaders: How are you rolling this out to your physicians?
Educating providers on the benefits of what this means for their total cost of care and greater member satisfaction is huge. Most of our PCPs are in value-based models, so total cost of care really matters. Specialists are included also and there is just less administrative burden for everyone.
HealthLeaders: What is the scale of your rollout?
Burruano: This will be one big bang for all lines of business at once. There's no real advantage to pilot in this situation, even leading up to a CMS requirement. Physicians don’t practice by lines of business and at point of care, they may not even know who the patient's specific payer is.
HealthLeaders: What role did your PBM play?
Burruano: We own and operate our own PBM, Pharmacy Benefit Dimensions, and they were part of the implementation process from day one. It makes designing for flexibility much easier.
About its final rule, which is effective January 1, 2023, CMS stated: "With this tool, enrollees will be better able to know what they will need to pay before they are standing at the pharmacy counter." Independent Health is one of many plans working toward full implementation by that date to improve member and provider experience.
