Mental healthcare is finding its place in health systems. Here’s what three executives are tackling to make mental healthcare more accessible.
While mental healthcare integration remains a challenge, innovation is on the horizon.
Three executives: Gabbriella Gold, Director of Network Strategy and Innovation, CareFirst BlueCross BlueShield; Dr. Greg Harris, Senior Medical Director, BlueCross BlueShield of Massachusetts; and Dr. Tim Law, Chief Medical Officer, Highmark, Inc. share their strategies for incorporating a functional, beneficial system for mental health.
From paving an accessible path to care, to utilizing tech tools that extend value-based care coordination, check out what these three executives are implementing in their health systems. Read the full story by Laura Beerman here.
Medicare Advantage has gained substantial popularity over recent years, but its growth may prove to not be the best trajectory for consumers.
Medicare Advantage (MA) already holds about 30 million beneficiaries, and that number is only expected to grow. A new report by the New England Journal of Medicine is raising some concerning questions about the quality of care, cost considerations, and general strain of an overpopulated program.
The study shows that since 2010 MA has been slowly catching up to traditional Medicare enrollment numbers and is now on track to surpass it in 2024.
Why the Growth?
The attraction of MA plans stems from a few items. Beneficiaries consistently cite that these plans have lower cost-sharing, support generous supplemental benefits, and put limits on out-of-pocket spending. Another attraction is the increasing rebates, as well as the supplemental benefits they fund, which are also expected to grow over the next decade.
But outside of the attractive benefits and costs, aggressive broker marketing is also at play here, and it is prone to abuse. Brokers are offered higher commissions and other financial incentives by insurers to enroll consumers in MA plans, versus private insurance plans that supplement traditional Medicare.
Another reason? The simplicity in the plan. While traditional Medicare forces patients to split up their plan in various different parts to receive comprehensive coverage, MA plans keep it short and sweet with one comprehensive plan and one deductible.
The Current and Rising Issues
The Cost
The issues the system is seeing emanate from its overpopulation and costs. Can Medicare afford MA?
According to the Medicare Payment Advisory Commission (MedPAC), MA plans will cost Medicare approximately $27 billion more for 2023 than for the same patients in traditional Medicare. The program costs the Federal Government 6% more per enrollee, and that’s before we even account for the general favorability of MA. This hike in cost results in higher federal expenditures and deficits and higher costs to all beneficiaries.
Solutions? There’s the option to trim Medicare benefits and increase federal taxes, but these aren’t exactly favorable discussions. Problems will inevitably arise.
The Quality
While the quality of MA plans seems to be neck and neck with traditional Medicare, there are a few areas of concern, the NEJM study said. On the whole, in some parts of the country MA has shown less disparities in quality, but the quality of care for some medical services may be poorer than traditional Medicare. However, the data here is limited.
Concerns have also arisen about provider networks, specifically for top tier providers of cancer care. Evidence shows that accessibility to behavioral and mental health is also an issue for both MA and traditional Medicare, many psychiatrists will opt out of traditional Medicare and very few remain in networks of MA plans.
Although MA beneficiaries seem to be using fewer services and running into fewer costs, care quality is somewhat unclear. The NEJM study reported, “[...] recent evidence suggests that beneficiaries in Medicare Advantage plans who use postacute services have less favorable outcomes than those in traditional Medicare.”
Keep in mind this data is limited, unclear, and shows that quality of care is an area that will need to be further examined for comparison.
The Road Ahead
MA has presented a few major problems for an important national program, and working to change them may not be the easiest path. MA holds a massive number of older voters that might make it politically difficult to change the course of the program.
However, as the study suggests, as the program continues to grow, federal authorities and MA plan stakeholders must rise to the challenge of creating a program that is affordable, high-quality, free-of-abuse, meets the needs of consumers, and truly benefits them.
An AI driven tool used by Mercy and called the Chen Chemotherapy model is helping patients steer clear of complications after chemotherapy
With the potential to reduce workloads, streamline services, and aid in patient care quality, AI is rapidly becoming a popular tool in healthcare.
The technology has now entered the cancer care unit. The Mercy healthcare system is using AI to help cancer patients - by texting them.
Often, chemotherapy patients find themselves struggling with side effects such as general pain, fever, diarrhea, fatigue, and vomiting; these are red flags that frequently lead to hospitalizations. According to a study by the National Institutes of Health, “of 18,486 patients who received chemotherapy for metastatic cancer, 92% were hospitalized at least once for any reason, including 51% hospitalized for a likely toxicity.”
Care units need a way to track these symptoms before they lead to patient hospitalization. Enter the Chen Chemotherapy model.
Named after lead data scientist Jiajing Chen, who lost their own battle with cancer in 2023, the model notifies doctors before these symptoms become severe, keeping patients out of the hospital.
The program works by creating a risk score for non-leukemia chemotherapy patients over 18 years old. As the program learns, it’s able to predict how likely it is that a patient who is experiencing symptoms will be hospitalized within 30 days after their chemotherapy treatment.
Once patients are opted into the smart texting platform, they will receive a text each day for seven days, minus weekends and holidays, to monitor their symptoms. When a patient selects a symptom, they rate it and, based on their answers, the information may be sent to their provider.
Prior to this model, providers were oblivious as to which patients were experiencing problems until patients called or showed up at the emergency room.
This tool allows providers to be more involved in the process of chemotherapy recovery.
“The Chen Chemotherapy Model and smart texting allows us to proactively manage these patients and identify when they are having problems earlier in the journey,” Jay Carlson, DO, medical director of Mercy oncology service line, said in a press release. “This means they may be able to be treated in the office, recover faster and feel better overall.”
The success of AI in cancer care has led to the development of several other tools by different creators. Last year a neurobiology and human genetics professor at the University of Utah, along with a 20 person team, created an AI algorithm to help identify more than 200 ‘micro-symptoms’ for cancer patients, such as behavior, speech, and vocal patterns. These range from abnormal neurological phenotypes and eye movements to sadness in the vocal tone. A clinical trial of the tool is scheduled to start in January 2024 at the Moffitt Cancer Center. Identifying these small changes can help assess how patients are handling the treatment and can even predict changes in future symptoms.
Healthcare providers have also been using AI to improve breast cancer screenings. According to The Lancet Oncology, a recent survey of 80,000 women in Sweden found that, when put up against two experienced radiologists, AI-enabled breast cancer screenings outperformed their standard readings.
Cancer is the second leading cause of death in the U.S., compelling the need for new innovations and screening technology. In recent years the U.S. Food and Drug Administration has approved more than 500 AI and machine learning-enabled medical devices, ranging from imaging software to remote cardiac monitoring devices.
The use of EHRs has grown substantially over the last decade, but patients still face problems getting to their health data
EHRs may be commonplace in healthcare, but that doesn’t mean everyone can access them, according to a new report from the Health and Human Services Department’s Office of the National Coordinator for Health IT.
Now that patients have had a taste for easy access to their health records, they’re demanding more. During the pandemic, patients wanted access to their records following a telehealth visit and to obtain COVID 19 test results. More patients also wanted to message their providers following the pandemic, at a rate of 53% in 2018, and climbing up to 64% in 2022.
Healthcare apps have made access to records even easier, and by 2022 more than half of patients were using apps to access their EHR data. They were also looking at their records more frequently than web-based portal users. In 2020 the ONC’s Cures Final Rule Act required certified health IT developers to create broader patient access through apps with standards-based application programming interfaces (APIs).
According to the ONC, healthcare organizations are seeing three barriers to patients being able to access their data:
Not All Apps Are Created Equal
Currently, a majority of patients are not using emerging third-party apps that have adopted APIs; Instead, they’re using apps provided by their healthcare provider or an online patient portal. APIs make information more widely available across smartphone apps, and they do so in a more secure method than other apps and web-based portals. By encouraging patients to use these API based apps, healthcare providers can ensure their patients are easily accessing their data in the most secure manner.
But What Does It Mean?
Another problem with EHR technology is that they don’t offer detailed explanations of diagnoses or test results. Patients may have access to their health records, but that doesn’t mean they understand them, especially complicated diagnoses. Research shows that patients like having timely access to their test results on their patient portal, rather than waiting for a call from their doctor. Going forward, health IT developers will need to monitor this and evolve the technology to add more context for patients.
Disparities and Barriers
Lastly, certain populations still face barriers to accessing their medical records. There are “disparities in patient access by race and ethnicity, education, income, and other socio-demographic factors,” according to a study by the Health and Human Service Department’s Office of the National Coordinator for Health IT. Other barriers include internet access, health literacy, and language. Although the ONC provides resources for patients to access and manage their health records through different methods, this issue persists.
The healthcare industry’s rocky relationship with EHRs will continue as long as patients have problems accessing their information. Providers need to step up and take action to ensure all patients have access to, understand, and can manage their health records
Delta Dental CEO Sarah Charvarria shares how she is stepping into her new role with confidence, armed with strategies for success in her back pocket.
Chavarria first started as Delta Dental’s chief people officer, since then she has facilitated collaboration and built organizational designs as a part of the company's transformation. Charvarria’s mission in her new role as CEO is to reshape the culture and transform an established brand through a few specific strategies.
With a focus on preparedness, curiosity, and people centered operations, check out her three approaches to creating a thriving system below. Read the full story by Laura Beerman here.
Where healthcare’s future leaders convene, fresh ideas and shared viewpoints emerge to tackle industry challenges.
Operational success and decision-making doesn’t start and end at the top, but needs to grow from new and emerging leaders.
This sentiment held true at HealthLeader’s recent UpNext Exchange where participating leaders shared their personal views and experiences dealing with the same pain points that are keeping CEOs, CFOs, and other c-suite executives up at night—but with a fresh outlook steadfast in its belief that the status quo is no longer enough.
The approach to solving healthcare’s biggest issues must change to keep up with healthcare itself being ever-changing, the attendees said. And below are the three main takeaways to do just that. Read the full coverage from Jay Asser here.
As insurers design a healthcare market that is evermore concentrated, where does that leave Americans looking for a competitive plan?
Nearly 73% of markets were highly concentrated in 2022, a new study says. This poses major problems for both consumers and healthcare providers.
The 2023 edition of Competition in Health Insurance: A Comprehensive Study of U.S. Markets looked at 381 metropolitan statistical areas (MSAs), across 50 states and Washington D.C. To be considered "highly concentrated," markets had to exceed a regulatory threshold set by federal guidelines.
Focusing on data ranging from 2014 through 2022, the study found that 73% of commercial markets at MSA levels were highly concentrated in 2022, an increase from 71% in 2014. The study also found that concentration was on the rise, with more than half (53%) of the markets that were already highly concentrated in 2014, becoming even more so by 2022.
Moreover, with current proposed federal guidelines, 95% (363) of MSA-level markets would be highly concentrated.
The study shows that over time not much has changed for the biggest names on the list. In fact, the top four insurers had identical rankings in both 2014 and 2022. In both years, UnitedHealth Group had the largest market share: 16% and 14%, while Elevance Health (formerly Anthem) came second with shares of 13% and 12%.
The study also found that of 48% MSAs, just one health insurer held a market share of at least 50%.
Nationally, the top ten largest health insurers by market share were:
The study examined exactly how these anticompetitive practices lead to harmful effects in the system. "When an insurer exercises market power in its output market (the sale of insurance coverage), premiums are higher and quantity of coverage is lower than in a competitive market… When an insurer exercises market power in its input market (e.g., physician services), payments to providers and the quantity of health care are below competitive levels," the study stated.
AMA President Jesse M. Ehrenfeld, M.D., M.P.H. wrote about how the high concentration of the markets is detrimental to both providers and consumers. "Reversing the trend toward consolidation in health insurance markets is the right prescription to cut exorbitant health care costs, improve outcomes and boost the quality of care," Ehrenfeld wrote.
Ehrenfeld went on to state that the AMA supports guidelines that were proposed earlier this year by the Federal Trade Commission and the Depart of Justice to limit mergers amongst payers. These guidelines would call for more careful examination of mergers and acquisitions and would work to limit future consolidations.
Overall, this study presents evidence to confirm that insurers are creating a highly concentrated market with their anticompetitive behavior and exercise of market power, which is in turn, causing great harm to consumers and care providers.
RTLs has been able to boost Aurora’s patient visits, streamline provider and staff workflows, and more.
RTLs have a long history with health systems to keep track of supplies, devices,and patients. With Healthcare executives now applying the tech to chart patient and provider workflows and improve care coordination, here’s how one healthcare provider is making them work.
Aurora Health Care spans just under 30 hospitals and 600 care sites, now they are using RTLs in new clinics to direct patients to their exam rooms, coordinate care teams, and reduce wait times.
Aurora’s manager of clinic operations Elise Dieringer talks about how making use of the RTLs has been able to boost Aurora’s patient visits, streamline provider and staff workflows, and overall improve care quality and coordination.
Learn more about how Aurora Health Care is making use of the technology to enhance workflows below. You can check out Eric Wicklund’s full story with Dieringer here.
One leader at Blue Shield California shares the company's strategic priorities.
Dr. Pushwaz Virk serves as the Medical Director of Clinical Product Development, Care Innovation, and Technology Integration at Blue Shield of California.
With 4.8 million members in individual and family, Medicare Advantage, Medicaid, and group employer plans across California, Virk has no shortage of pressure when leading out strategic initiatives for the company.
Not only is Virk a practicing physician, he also leads plan iteration efforts in the face of technology challenges and opportunities.
Read his top three strategic priorities across members, providers, partners, and communities. You can also catch up on Laura Beerman’s full story with Virk here.
By the end of 2023 Clover Health will exit the program after inadequate results in Medicare direct contracting.
After two years of poor performance within the ACO REACH program, Clover Health is exiting.
While the company will fulfill its obligations to the program for the rest of the performance year, after that it will move on in search of sustained profitability. The decision will have no impact on its ACO REACH beneficiaries, according to the Clover’s news release.
Clover’s decision to join the ACO REACH program in 2021 came as a way to expand the company in the traditional Medicare sector; they hoped to expand their number of lives under their AI program Clover Assistant, and to generally increase the number of physicians they worked with.
However, under ACO, the company saw millions in disappointing losses.
According to Clover’s 2022 earnings report, the insurer saw $84 million in loss in Q4 of 2022, albeit a sizeable improvement from the $187.2 million loss incurred over the same period in 2021. For the full year, losses were $338.8 million in 2022, compared to $587.8 for 2021.
At the time, Clover Health CEO Andrew Toy said the company was focused on continuing to make gains to quickly turn losses into profit.
"In 2023, accelerating our path to profitability is our top priority, and I am excited by Clover Assistant's role in helping physicians identify and manage chronic diseases earlier, which improves care for Medicare beneficiaries," Toy stated.
What went wrong?
Clover attempted to counteract their poor 2021 results by cutting back their number of physicians they had in the program by two-thirds, but still weren’t able to recover.
Despite the repeat losses, Toy remains optimistic about the company’s future into 2024 and beyond.
Toy mentioned in a statement that while Clover did see the benefits of joining ACO REACH, the insurer is choosing to stick with its Medicare Advantage (MA) plans, which have proven more profitable.
“We remain extremely excited about the success of our Medicare Advantage insurance business in 2023 and intend to focus our resources on building that business and continuing to invest in Clover Assistant as part of our path to profitability,” Toy said in a press release.
Toy went on to say that the company expects “meaningful tailwinds” in 2024 from a number of factors including their partnership with UST HealthProof to outsource their administration workload, which saved them $30 million.
“Overall, this narrower focus gives us even greater optimism that Clover Health can deliver profitability on an Adjusted EBITDA basis for full-year 2024,” Toy said.
Art Gottlieb, principal for A2 Strategy Corp, called Clover’s exit one in a series of “wise moves” by the company, in addition to their UST partnership.
Gottlieb went on to say in a LinkedIn post: “Now if they were to shut down the Clover Assistant and just focus on the MA plan and semi-quarterly, critically acclaimed Clover Living print magazine, they might actually have something of value that another company would be interested in buying. It won't be worth billions of dollars, but it certainly is better than the alternative…”
Currently, Clover falls in average ratings for Medicare. In 2022 the company received 3 out of 5 stars from CMS, and 2023 3.5 stars. The 10-year-old company is currently valued at $457.8 million.
