– Today, CVS Health announced Symphony, a medical alert
system designed to keep seniors safe and connected at home.
– Symphony consists of a collection of in-home and wearable devices that offer a new at-home experience by connecting a suite of sensors that can monitor for falls, motion, and room temperature while also providing a 24/7 personal emergency response platform for use when needed.
CVS Health, today announced the release of Symphony medical
alert system to help caregivers monitor the safety and well-being of loved
ones, even from afar. This collection of in-home and wearable devices offers a
new at-home experience by connecting a suite of sensors that can monitor for
falls, motion, and room temperature while also providing a 24/7 personal
emergency response platform for use when needed. Symphony is designed to support
the growing number of seniors choosing to maintain an independent lifestyle at
home, as well as those involved in their care.
Spurred in part by COVID, as you may know, an increasing
number of seniors are choosing to “age in place.” But COVID has also
highlighted major challenges in staying connected to loved ones while socially
isolated. Enter Symphony…a collection of in-home and wearable devices that
are now available in approx. 650 CVSH HUBs and online.
Unlike other systems that require a wearable alert device,
Symphony includes a voice-activated Smart Hub that lets seniors call assigned
caregivers or emergency responders hands-free 24/7. Sensors placed around
the house can monitor motion, temperature, and air quality and alert caregivers
of anything out of the ordinary through a free caregiver smartphone app.
Symphony system also provides alerts for falls or other emergencies and can
assist with facilitating care coordination when needed.
Symphony is the latest example of ways in which CVS Health is supporting seniors at home. Organizations like SilverSneakers® are providing virtual exercise classes to help seniors stay active from the comfort of their homes. And Aetna partnered with the companionship benefit company Papa, Inc., to connect Medicare Advantage members with college-age individuals who can provide remote companionship through the telephone. These are in addition to more traditional services, like virtual care, and SDOH resources like grocery delivery, housekeeping, and others.
Designed to fit a family’s specific needs and adapt to a variety of homes, two easy-to-use Symphony device options are available: the Basic Bundle and Essential Bundle. While both systems come equipped with the Smart Hub and a wearable care button, the Essential Bundle also includes motion sensors and a voice-activated Fall Sensor to automatically detect falls in the bathroom, where the majority of accidents occur. Complementary devices are available for both bundles if desired, including additional motion sensors to extend the range of coverage in larger homes, and entry sensors for use on doors, cabinets, or windows.
Pricing starts at $149.99 for the Symphony Basic Bundle and
$249.99 for the Essential Bundle. A monthly service fee is required, although
no long-term contract is needed to activate. Once activated, each Symphony
bundle can help support safety at home as well as in the event of an emergency.
“We’re committed to helping consumers on their path to better health and new consumer health innovations like Symphony can help give caregivers peace of mind as they monitor a loved one’s safety and well-being through a truly differentiated connected health approach,” said Adam Pellegrini, SVP of Enterprise Virtual Care & Consumer Health at CVS Health.
As healthcare spending continues to rise, so too does the inherent risk for bad actors to take advantage. Today, the United States is estimated to spend nearly 18 percent of its GDP, or $3.6 trillion, on healthcare, and is expected to increase to one-fifth of GDP within the next decade, according to the latest data. This alone provides ample motivation for fraud and abuse. While the full extent of healthcare fraud is difficult to measure,
The National Health Care Anti-Fraud Association (NHCAA) conservatively estimates that 3 percent – $68 billion – of all healthcare spending is lost to fraud each year. Others, such as the Federal Bureau of Investigation (FBI), estimate fraud accounts for up to 10 percent of healthcare expenditures.
Unfortunately, the COVID-19 pandemic has only accelerated the motivation for fraud and abuse amid the increased fear, confusion, and a relaxed regulatory environment. From fake cures to malware and illegitimate charities, fraudsters are taking advantage. Telehealth, which has experienced exponential growth aided by regulatory accommodations to facilitate its widespread adoption, is an area of particular concern. In turn, states and healthcare organizations must optimize their program integrity operations and telehealth strategy to stay protected amid healthcare’s new normal.
Greater Access Brings Greater Risk
The pandemic-driven expansion of telehealth has been profound in terms of enabling care access and continuity while reducing the risk of infection. When the Centers for Medicare and Medicaid Services (CMS) temporarily expanded telehealth coverage at the start of the pandemic, adoption soared to unprecedented levels.
According to a McKinsey report, providers have seen 50 to 175 times more patients through telehealth appointments compared to any year prior. At the same time, once-strict regulations governing telehealth services have been relaxed during the COVID-19 emergency, and the federal government has proposed to make permanent many of the regulatory changes initially meant to temporarily increase access to telehealth.
In parallel and perhaps unsurprisingly, there is a growing sentiment that telehealth is here to stay. According to a recent CynergisTek survey, 70 percent of consumers plan to continue using telehealth post-pandemic. From a provider perspective, new research from Bain & Company found that more than 80 percent of providers will continue to use telehealth as much or more than they do now.
All this considered, we must acknowledge the inherent risks of this technology. Telehealth has a poor track record for fraud, waste and abuse, with some of the largest healthcare fraud schemes involving telehealth providers. This September, for example, the Department of Justice announced the largest case of healthcare fraud in history, involving more than 300 individuals who submitted over $6 billion in fraudulent claims, with telehealth accounting for $4.5 billion of those claims.
With providers struggling to meet fluctuating demand amid unprecedented revenue shortfalls, improper billing practices — both intentional and inadvertent — are, to some degree, inevitable. Factor in hundreds of new telehealth codes and coding considerations as well as the overall stress on the healthcare system, and it is clear we must examine existing risk mitigation measures through a new, post-pandemic lens.
Strategies for Mitigating Telehealth Fraud & Abuse
For healthcare organizations and, specifically, special investigation units (SIUs) tasked with combatting fraud and abuse, the shift to telehealth adds an additional layer of complexity. Fortunately, there are strategies healthcare organizations can implement to successfully navigate the evolving landscape while strengthening the integrity of their operations for healthcare’s new normal.
Data visualization is a key component of an effective fraud investigation. Charts and graphs provide a clear representation of trends and outliers, including connections that could indicate a kickback or collusion scheme. Critical to the success of these tools, however, is the quality of the data that underlies them. Collecting sample data based on the appropriate modifiers and conducting thorough background research provides an accurate portrayal of events from which SIUs can clearly identify and pursue potential fraud schemes.
Integrating qualitative research into telehealth strategies is a great way to capture fraud at the source. When appropriate, conducting interviews with patients can validate whether services were in fact rendered as billed. For instance, a provider may bill for audio-only services as if they were delivered in an audio-visual capacity, resulting in an unjustifiably higher reimbursement rate. Similarly, using data visualization techniques to identify suspect trends, such as blanket billing or an implausibly high volume of services during a known low-demand period, can inform pointed questions for patients.
As we traverse this unprecedented territory, being on high alert for potential indicators of fraud and abuse is critical to protecting healthcare organizations and consumers. If something doesn’t make sense, whether clinically or in the context of the larger healthcare landscape, it is worth investigating. Understanding the limitations of telehealth and other key considerations surrounding its use will help to ensure we are maximizing the benefits of these services while mitigating their inherent risks.
Healthcare providers and patients alike have embraced telehealth during the COVID-19 crisis and, in doing so, confirmed what advocates have been saying for years — that telehealth promotes greater access to care. While ultimately good news for stakeholders across the healthcare spectrum, the environment we find ourselves in today has also created new avenues for fraudsters to take advantage. As telehealth becomes an inseparable part of the healthcare ecosystem, we are quickly learning how to identify telehealth fraud schemes, and, more importantly, strategies to mitigate the risks they post to integrity and security in the space.
About Gary Call, M.D.
Gary Call, M.D., is senior vice president and Chief Medical Officer at HMS, where he leads the company’s clinical program development and execution. Dr. Call has more than 25 years of experience in the practice of medicine and managed care. Dr. Call graduated from the University of Washington School of Medicine and completed his residency training at the University of Utah. He is a board-certified family physician.
The agency has finalized a rule that allows it to provide immediate Medicare coverage for FDA-approved products that are deemed “breakthrough devices.” The new coverage process would enable seniors to get access to these devices more quickly, but some provider and payer groups are concerned that this could cause patient harm.
Medicare Advantage enrollment has grown rapidly over the past decade, and Medicare Advantage plans have taken on a larger role in the Medicare program. More than 24 million Medicare beneficiaries (36%) are enrolled in Medicare Advantage plans in 2020. This data analysis provides updated information about Medicare Advantage enrollment trends, premiums, and out-of-pocket limits. It also includes analyses of Medicare Advantage plans’ extra benefits and prior authorization requirements. The analysis also highlights changes pertaining to Medicare Advantage coverage that have occurred in 2020 in response to the COVID-19 crisis.
In a wide-ranging discussion at J.P. Morgan’s Annual Healthcare Conference, former CMS Administrator Andy Slavitt talked about the future of the ACA, telehealth and Medicare Advantage with a Democrat-led House, Senate and presidency.
– Net Health acquires post-acute market analytics platform PointRight to deepen the company’s analytics capabilities, post-acute presence, and support for SNF networks.
Health, a provider of cloud-based software for specialty medical providers
across the continuum of care, today announced that it has acquired PointRight Inc., a leading provider of
analytics and data-driven tools for the post-acute market. The acquisition adds
to Net Health’s expanding investments in analytics capabilities, which include
the recent acquisition of Tissue Analytics in April 2020 and the earlier
acquisition of Focus on Therapeutic Outcomes (FOTO).
Unlock the Power of Advanced Analytics for Post-Acute
Founded in 1995, PointRight provides analytics that shows a 360⁰ view of long-term and post-acute (LTPAC) facility performance and clinical outcomes. Equipped with these insights, LTPAC Provider and Payers can lower rehospitalization rates, improve clinical outcomes, and build and manage high-performing networks. Today, close to 2,400 SNFs use PointRight’s advanced analytics and data-driven decision support tools to further their clinical, financial, and operational objectives.
SNFs use PointRight to improve the accuracy of their reimbursement and regulatory submissions and to enhance overall performance in readmissions, quality, and outcomes, including more accurate and compliant patient assessments, reduced rehospitalization rates, and optimized care transitions.
More recently, health systems, ACOs, payers, and real estate investment trusts (REIT) have relied on PointRight to provide insight into the health of their SNF networks and to identify areas for improvement.
Acquisition Expands Net Health’s
Market Share in Growing Post-Acute Market
acquisition of PointRight expands Net Health’s position and scale in the
growing post-acute market. Additionally, the acquisition will enable Net
Health’s broad roster of hospital clients to better manage their skilled
nursing facility (SNF) networks and support outcomes measurement and performance
improvement in Medicare Advantage and managed Medicaid programs. As part of the
acquisition, Net Health
plans to fully integrate PointRight staff to accelerate the delivery of new
analytics solutions and expand the availability of PointRight to Net Health’s
customers and markets.
“Through PointRight, Net Health will significantly expand how we support SNFs and their health system, accountable care organization (ACO), payer and REIT partners,” said Josh Pickus, Net Health’s Chief Executive Officer. “It also strengthens our growing analytics capabilities by providing insights into post-acute performance, which enables providers and payers to align around value-based care initiatives.”
Financial details of the acquisition
were not disclosed.
Keely Connolly thought she would be safe once the ambulance arrived at Hutchinson Regional Medical Center in Kansas.
She was having difficulty breathing because she’d had to miss a kidney dialysis treatment a few days earlier for lack of child care. Her potassium was dangerously high, putting her at risk of a heart attack. But she trusted she would be fine once she was admitted and dialysis was begun.
She panicked when a nurse told her that no beds were available and that she would have to be transferred — possibly more than 450 miles away to Denver. She had heard a rumor about a dialysis patient who died waiting for a bed at a hospital in Wichita, about an hour down the road.
“‘I don’t want to die in the ER,’” Connolly, 32, recalled thinking. “I just wanted them to fix me, but then the woman came in and said, ‘There are no beds.’ I got really scared and I didn’t know if they had time to get me anywhere else.”
When a bed was finally located 65 miles away in Salina, Connolly, who has kidney failure, was relieved but worried: How long would she be gone? Who would care for her young daughter? How would she get home? What would it all cost?
Connolly was caught in a situation experts have warned about since the beginning of the coronavirus pandemic: Covid-19 patients are overwhelming hospitals, squeezing space and staff needed to treat emergencies like Connolly’s.
“This is the first time since I have been here that we’ve had a scenario where multiple hospitals, for longer periods of time, are experiencing some kind of shortages,” said Cindy Samuelson, a senior vice president of the Kansas Hospital Association.
And it got worse after Connolly’s emergency in mid-November. The 14-day rolling average positive test rate in Reno County, where Hutchinson is the county seat, reached 46% on Dec. 22, though it has since come down to 24% as of Jan. 4, said D.J. Gering, data analyst for the Reno County Health Department. The results did not include inmates from the Hutchinson Correctional Center, the local state prison.
By Oct. 1, four covid deaths had been recorded in the county of about 62,000. By Jan. 4, the death toll since the pandemic began had jumped to 105. For comparison, Gering said, Reno County had 19 deaths attributed to pneumonia and influenza combined in all of 2019.
Hospitalizations at the 190-licensed-bed Hutchinson Regional Medical Center increased 800% from mid-October to mid-December then started to temper at the end of the month, said Chuck Welch, vice president of Hutchinson Regional Medical System.
“I hate to be overly optimistic until we are well past the possible holiday surge from Christmas and New Year’s,” he said in an email.
Operating between 90% and 95% capacity, the hospital is providing care to patients with a multitude of needs and still has room to expand. The problem, Welch said, has been staffing.
Competing for traveling nurses and specialists against larger hospitals to backfill positions open from sick or quarantining staffers has been challenging. When the hospital has been faced with increasing numbers of covid patients seeking emergency care, handling “normal” emergencies like Connolly’s has been much more difficult, Welch said.
While staffers work to transfer patients as close to home as possible, with so many hospitals in Kansas beyond capacity, it has become more common than before to transfer as far away as Colorado and Nebraska. Such transfers require medical flights, which are typically not covered by insurance and can cost patients upward of $50,000, Welch said.
“It is collateral damage,” he said. “It is something that has sort of been lost out of the narrative of these folks where everybody is relieved when we find them a bed. Everybody forgets about the downstream impact of the cost of those transports.”
Connolly recovered after three days in the Salina hospital. But the question still looms about the costs for her emergency care. Connolly had left her job as a corrections officer at the prison in September because coronavirus cases began to spike inside. Without her employer-sponsored health insurance, Connolly now relies on Medicaid and Medicare Part A, which means she is responsible for more out-of-pocket costs for things like pharmaceuticals and ambulance services.
Connolly worries so much about her finances that she’s been too scared to look at her recent ambulance bills. Being a single parent, living with kidney failure and undergoing dialysis during a pandemic are her primary concerns.
As with many underlying conditions, covid-19 appears to pose an extra risk for people with kidney failure and patients undergoing dialysis, said Dr. Alan Kliger, a nephrologist at Yale University and co-chair of the American Society of Nephrology’s COVID-19 Response Team.
Data from New York and Europe early in the pandemic showed that about 1 in 5 dialysis patients who acquired covid died, he said. However, the complication and mortality rates have fallen in recent months, according to unpublished survey data from members of the nephrology society, Kliger said.
“It’s still a high risk,” he said.
For Connolly, the pandemic has also complicated her three-times-a-week 3½-hour dialysis schedule. For example, when her daughter’s kindergarten class was told to quarantine for 14 days after an in-class exposure to the virus, she had to scramble to find babysitters so she could attend dialysis.
“I don’t want too many people to watch her because of covid,” Connolly said of her daughter, adding that she is lucky the girl’s father is supportive. But he can’t always step in, which means if Connolly can’t find a sitter, she may have to skip or reschedule dialysis.
Connolly wants to get another job. But living in a county where so many refuse to wear masks and some elected leaders accuse the health department of providing false information about covid testing rates and statistics makes her afraid to be in public more than necessary.
“I want to work,” she said. “I had a good job. I served my community. The reality of knowing how bad it is at the hospital — I have seen it firsthand. And now I am out and seeing people without masks and I am thinking, ‘If I get this and I have to go back, I may not leave the hospital next time.’”
The reality, said Kliger, Welch and others, is that while the virus runs rampant, hospitals will struggle to keep up, which potentially endangers medical staffers and anyone needing hospital care — and the virus will continue to spread as long as people refuse to wear masks and disregard scientifically sound guidelines.
Connolly said she would love to see more empathy for people who have underlying health concerns like her from those resisting safety measures such as masks.
“Even if they think that it doesn’t work, what if it does? What if it could? I don’t really understand how wearing a mask is going to take so much out of your day, compared to someone who is immunocompromised and gets sick,” said Connolly. “Or you lose your grandma, or your parent. That’s going to affect your life a lot longer than wearing a mask for a little while.”
Como jefa de enfermería en uno de los hospitales más concurridos de la red de seguridad de atención médica de Chicago, Raquel Prendkowski ha sido testigo del devastador número de víctimas que COVID-19 ha causado entre los residentes más vulnerables de la ciudad, incluyendo a personas que no tienen seguro médico por su estatus migratorio.
Algunos llegan tan enfermos que van directo a cuidados intensivos. Muchos no sobreviven.
“Vivimos una pesadilla constante”, dijo Prendkowski mientras trataba a pacientes con coronavirus en el Hospital Mount Sinai, fundado a principios del siglo XX para atender a los inmigrantes más pobres. “Ojalá salgamos pronto de esto”.
La enfermera cree que algunas muertes, y mucho sufrimiento, podrían haberse evitado si estas personas hubieran tenido un tratamiento regular para todo tipo de condiciones crónicas —asma, diabetes, enfermedades del corazón— que pueden empeorar COVID-19.
Defensores de los inmigrantes esperan que inspire a otros estados a hacer lo mismo. De hecho, legisladores demócratas de California están presionando para expandir su Medicaid a todos los inmigrantes indocumentados del estado.
“Hacer esto durante la pandemia muestra nuestro compromiso con la expansión y ampliación del acceso a la atención de salud. Es un gran primer paso”, señaló Graciela Guzmán, directora de campaña de Healthy Illinois, que promueve la cobertura universal en el estado.
Muchos inmigrantes indocumentados sin cobertura de salud no van al médico. Ese fue el caso de Victoria Hernández, una limpiadora de casas de 68 años que vive en West Chicago, Illinois. La mujer, nativa de la Ciudad de México dijo que, cuando no tenía seguro, simplemente no iba al médico.
Soportaba cualquier dolencia hasta que encontró un programa de caridad que la ayudó a tratar su prediabetes. Dijo que tiene la intención de inscribirse en el nuevo plan estatal una vez que tenga más información.
“Estoy muy agradecida por el nuevo programa”, explicó a través de un traductor que trabaja para DuPage Health Coalition, una organización sin fines de lucro que coordina la atención de caridad para personas sin seguro médico como Hernández en el condado de DuPage, el segundo más poblado del estado. “Sé que ayudará a mucha gente como yo. Sé que tendrá buenos resultados, muy, muy buenos resultados”.
Primero, Healthy Illinois intentó ampliar los beneficios de Medicaid a todos los inmigrantes de bajos ingresos, pero los legisladores decidieron empezar con un programa más pequeño, que cubre a adultos mayores de 65 años o más que son indocumentados, o que han sido residentes permanentes, tienen tarjeta verde, por menos de cinco años (este grupo no califica para seguro de salud auspiciado por el gobierno).
Los participantes deben tener ingresos que estén en o por debajo del nivel de pobreza federal, que es de $12,670 para un individuo o $17,240 para una pareja. Cubre servicios como visitas al hospital y al médico, medicamentos recetados, y atención dental y oftalmológica (aunque no estancias en centros de enfermería), sin costo para el paciente.
La nueva norma continúa la tendencia de expandir la cobertura de salud del gobierno a los inmigrantes sin papeles.
El año pasado, California fue el primero en ofrecer cobertura pública a los adultos indocumentados, cuando amplió la elegibilidad para su programa Medi-Cal a todos los residentes de bajos ingresos menores de 26 años.
Según la ley federal, las personas indocumentadas generalmente no son elegibles para Medicare, Medicaid que no es de emergencia y el mercado de seguros de salud de la Ley de Cuidado de Salud a Bajo Precio (ACA). Los estados que ofrecen cobertura a esta población lo hacen usando sólo fondos estatales.
Se estima que en Illinois viven 3,986 adultos mayores indocumentados, según un estudio del Centro Médico de la Universidad de Rush y el grupo de demógrafos de Chicago Rob Paral & Associates; y se espera que el número aumente a 55,144 para 2030. El informe también encontró que el 16% de los inmigrantes de Illinois de 55 años o más viven en la situación de pobreza, en comparación con el 11% de la población nacida en el país.
Dado que la administración saliente de Trump ha promovido duras medidas migratorias, sectores del activismo pro inmigrante temen que haya miedo a inscribirse en el nuevo programa porque podría afectar la capacidad de obtener la residencia o la ciudadanía en el fututo, y trabajan para asegurarles que no lo hará.
“Illinois cuenta con un legado de ser un estado que acepta al recién llegado y de proteger la privacidad de los inmigrantes”, señaló Andrea Kovach, abogada que trabaja en equidad en la salud en el Shriver Center for Poverty Law en Chicago.
Algunos representantes estatales republicanos criticaron la expansión de la cobertura, diciendo que era imprudente hacerlo en un momento en que las finanzas de Illinois sufren por la pandemia. En una declaración condenando el presupuesto estatal de este año, el Partido Republicano de Illinois lo denominó “atención de la salud gratuito para los inmigrantes ilegales”.
Pero los defensores de la nueva política sostienen que muchos inmigrantes sin papeles pagan impuestos sin ser elegibles para programas como Medicare y Medicaid, y que gastar por adelantado en cuidados preventivos ahorra dinero, a largo plazo, al reducir el número de personas que esperan para buscar tratamiento hasta que es una emergencia.
Para Delia Ramírez, representante estatal de Illinois, ampliar la cobertura de salud a todos los adultos mayores de bajos ingresos es personal. A la demócrata de Chicago la inspira su tío, un inmigrante de 64 años que no tiene seguro.
Dijo que intentó que la legislación cubriera a las personas de 55 años o más, ya que la gran mayoría de los indocumentados no son personas mayores (señaló que muchos de los inmigrantes mayores —2,7 millones, según estimaciones del gobierno— obtuvieron el estatus legal con la ley de amnistía federal de 1986).
Un mayor número de inmigrantes más jóvenes también pueden estar sin seguro. En los Centros de Salud Esperanza, uno de los mayores proveedores de atención médica para inmigrantes de Chicago, el 31% de los pacientes de 65 años o más carece de cobertura, en comparación con el 47% de los de 60 a 64 años, según Jeffey McInnes, que supervisa el acceso de los pacientes a las clínicas.
Ramírez dijo que su tío la llamó después de ver las noticias sobre la nueva legislación en la televisión en español. Contó que su tío ha vivido en el país por cuatro décadas y ha trabajado para que sus cuatro hijos fueran a la universidad. También padece asma, diabetes e hipertensión, lo que lo hace de alto riesgo para COVID-19.
“Yo le dije: ‘Tío, todavía no. Pero cuando cumplas 65 años, finalmente tendrás atención médica, si es que aún no hemos conseguido legalizarte”, recordó Ramírez, emocionada, durante una reciente entrevista telefónica.
“Así que es un recordatorio para mí de que, en primer lugar, fue una gran victoria para nosotros y ha significado la vida o una segunda oportunidad de vida para muchas personas”, dijo. “Pero también significa que todavía tenemos un largo camino por recorrer para hacer de la atención de salud un verdadero derecho humano en el estado, y en la nación”.
As a nurse manager for one of Chicago’s busiest safety-net hospitals, Raquel Prendkowski has witnessed covid-19’s devastating toll on many of the city’s most vulnerable residents — including people who lack health insurance because of their immigration status. Some come in so sick they go right to intensive care. Some don’t survive.
“We’re in a bad dream all the time,” she said during a recent day treating coronavirus patients at Mount Sinai Hospital, which was founded in the early 20th century to care for the city’s poorest immigrants. “I can’t wait to wake up from this.”
Prendkowski believes some of the death and suffering could have been avoided if more of these people had regular treatment for the types of chronic conditions — asthma, diabetes, heart disease — that can worsen covid. She now sees a new reason for hope.
Amid a deadly virus outbreak that has disproportionately stricken Latino communities, Illinois recently became the first state to provide public health insurance to all low-income noncitizen seniors, even if they’re in the country illegally. Advocates for immigrants expect it will inspire other states to do the same, building on efforts to cover undocumented children and young adults. Currently, Democratic legislators in California are pushing to expand coverage to all low-income undocumented immigrants there.
“The fact that we’re going to do this during the pandemic really shows our commitment to expansion and broadening health care access. It’s an amazing first step in the door,” said Graciela Guzmán, campaign director for Healthy Illinois, a group that advocates for universal coverage.
Undocumented immigrants without health insurance often skip care. That was the case for Victoria Hernandez, 68, a house cleaner who lives in West Chicago, a suburb. The Mexico City native said she had avoided going to the doctor because she didn’t have coverage. Eventually, she found a charity program to help her get treatment, including for her prediabetes. She said she intends to enroll in the new state plan.
“I’m very thankful for the new program,” she said through a translator who works for the DuPage Health Coalition, a nonprofit that coordinates charity care for the uninsured in DuPage County, the state’s second-most populous. “I know it will help a lot of people like me.”
Healthy Illinois pushed state lawmakers to offer health benefits to all low-income immigrants. But the legislature opted instead for a smaller program that covers people 65 and older who are undocumented or have been legal permanent residents, also known as green card holders, for less than five years. (These groups don’t typically qualify for government health insurance.) Participants must have an income at or below the federal poverty level, which is $12,670 for an individual or $17,240 for a couple. It covers services like hospital and doctor visits, prescription drugs, and dental and vision care (though not stays in nursing facilities), at no cost to the patient.
The new policy continues a trend of expanding government health coverage to undocumented immigrants.
Illinois was the first state to cover children’s care — a handful of states and the District of Columbia have since followed suit — and organ transplants for unauthorized immigrants. In 2019, California became the first to offer public coverage to adults in the country illegally when it opened eligibility for its Medi-Cal program to all low-income residents under age 26.
Under federal law, undocumented people are generally not eligible for Medicare, nonemergency Medicaid and the Affordable Care Act’s health insurance marketplace. The states that do cover this population get around that by using only state funds.
An estimated 3,986 undocumented seniors live in Illinois, according to a study by Rush University Medical Center and the Chicago demographer group Rob Paral & Associates — but that number is expected to grow to 55,144 by 2030. The report also found that 16% of Illinois immigrants 55 or older live in poverty, compared with 11% of the native-born population.
Given the outgoing Trump administration’s crackdown on immigration, some advocates worry that people will be afraid to enroll in the insurance because it could affect their ability to obtain residency or citizenship. Andrea Kovach, senior attorney for health care justice at the Shriver Center on Poverty Law in Chicago, said she and others are working to assure immigrants they don’t need to worry. Because the new program is state-funded, federal guidance suggests it is not subject to the “public charge” rule designed to keep out immigrants who might end up on public assistance.
“Illinois has a legacy of being a very welcoming state and protecting immigrants’ privacy,” Kovach said.
The Illinois policy is initially expected to cover 4,200 to 4,600 immigrant seniors, at an approximate cost of $46 million to $50 million a year, according to John Hoffman, a spokesperson for the Illinois Department of Healthcare and Family Services. Most of them would likely be undocumented.
Some Republicans criticized the coverage expansion, saying it was reckless at a time when Illinois’ finances are being shredded by the pandemic. The Illinois Republican Party deemed it “free healthcare for illegal immigrants.”
But proponents contend that many unauthorized immigrants pay taxes without being eligible for programs like Medicare and Medicaid, and that spending on preventive care saves money in the long run by cutting down on more expensive treatment for emergencies.
State Rep. Delia Ramirez, a Chicago Democrat who helped shepherd the legislation, advocated for a more expansive plan. She was inspired by her uncle, a 64-year-old immigrant who has asthma, diabetes and high blood pressure but no insurance. He has been working in the country for four decades.
She wanted the policy to apply to people 55 and older, since the vast majority of those who are undocumented are not seniors (she noted that a lot of older immigrants — 2.7 million, according to government estimates — obtained legal status under the 1986 federal amnesty law).
The real impact of this plan will likely be felt in years to come. At Esperanza Health Centers, one of Chicago’s largest providers of health care to immigrants, 31% of patients 65 and older lack coverage, compared with 47% of those 60 to 64, according to Jeffrey McInnes, who oversees patient access there.
Ramirez said her uncle called her after seeing news of the legislation on Spanish-language TV.
“And I said to him, ‘Tío, not yet. But when you turn 65, you’ll finally have health care, if we still can’t help you legalize,’” Ramirez recalled, choking up during a recent phone interview.
“So it is a reminder to me that, one, it was a major victory for us and it has meant life or a second chance at life for many people,” she said. “But it is also a reminder to me that we still have a long way to go in making health care truly a human right in the state and, furthermore, the nation.”
With the pandemic taking a heavy toll among older Americans, the Centers for Disease Control and Prevention and most states have placed a high priority on vaccinating residents and staff of long-term care facilities. People in nursing homes and other long-term care settings account for 8 percent of cases but 40 percent of deaths from…More
Ted Howard started taking Truvada a few years ago because he wanted to protect himself against HIV, the virus that causes AIDS. But the daily pill was so pricey he was seriously thinking about giving it up.
Under his insurance plan, the former flight attendant and customer service instructor owed $500 in copayments every month for the drug and an additional $250 every three months for lab work and clinic visits.
Luckily for Howard, his doctor at Las Vegas’ Huntridge Family Clinic, which specializes in LGBTQ care, enrolled him in a clinical trial that covered his medication and other costs in full.
“If I hadn’t been able to get into the trial, I wouldn’t have kept taking PrEP,” said Howard, 68, using the shorthand term for “preexposure prophylaxis.” Taken daily, these drugs — like Truvada — are more than 90% effective at preventing infection with HIV.
Starting this month, most people with private insurance will no longer have to decide whether they can afford to protect themselves against HIV. Most health plans must begin to cover the drugs then without charging consumers anything out-of-pocket (some plans already began doing so last year).
Drugs in this category — Truvada, Descovy and, newly available, a generic version of Truvada — received an “A” recommendation by the U.S. Preventive Services Task Force. Under the Affordable Care Act, preventive services that receive an “A” or “B” rating by the task force, a group of medical experts in prevention and primary care, must be covered by most private health plans without making members share the cost, usually through copayments or deductibles. Only plans that are grandfathered under the health law are exempt.
The task force recommended PrEP for people at high risk of HIV infection, including men who have sex with men and injection drug users.
In the United States, more than 1 million people live with HIV, and nearly 40,000 new HIV cases are diagnosed every year. Yet fewer than 10% of people who could benefit from PrEP are taking it. One key reason is that out-of-pocket costs can exceed $1,000 annually, according to a study published in the American Journal of Public Health last year. Required periodic blood tests and doctor visits can add hundreds of dollars to the cost of the drug, and it’s not clear if insurers are required to pick up all those costs.
“Cost sharing has been a problem,” said Michael Crews, policy director at One Colorado, an advocacy group for the LGBTQ community. “It’s not just getting on PrEP and taking a pill. It’s the lab and clinical services. That’s a huge barrier for folks.”
Whether you’re shopping for a new plan during open enrollment or want to check out what your current plan covers, here are answers to questions you may have about the new preventive coverage requirement.
Q: How can people find out whether their health plan covers PrEP medications without charge?
The plan’s list of covered drugs, called a formulary, should spell out which drugs are covered, along with details about which drug tier they fall into. Drugs placed in higher tiers generally have higher cost sharing. That list should be online with the plan documents that give coverage details.
Sorting out coverage and cost sharing can be tricky. Both Truvada and Descovy can also be used to treat HIV, and if they are taken for that purpose, a plan may require members to pay some of the cost. But if the drugs are taken to prevent HIV infection, patients shouldn’t owe anything out-of-pocket, no matter which tier they are on.
In a recent analysis of online formularies for plans sold on the ACA marketplaces, Carl Schmid, executive director of the HIV + Hepatitis Policy Institute, found that many plans seemed out of compliance with the requirement to cover PrEP without cost sharing this year.
But representatives for Oscar and Kaiser Permanente, two insurers that were called out in the analysis for lack of compliance, said the drugs are covered without cost sharing in plans nationwide if they are taken to prevent HIV. Schmid later revised his analysis to reflect Oscar’s coverage.
Coverage and cost-sharing information needs to be transparent and easy to find, Schmid said.
“I acted like a shopper of insurance, just like any person would do,” he said. “Even when the information is correct, [it’s so] difficult to find [and there’s] no uniformity.”
It may be necessary to call the insurer directly to confirm coverage details if information on the website is unclear.
Q: Are all three drugs covered without cost sharing?
Health plans have to cover at least one of the drugs in this category — Descovy and the brand and generic versions of Truvada — without cost sharing. People may have to jump through some hoops to get approval for a specific drug, however. For example, Oscar plans sold in 18 states cover the three PrEP options without cost sharing. The generic version of Truvada doesn’t require prior authorization by the insurer. But if someone wants to take the name-brand drug, they have to go through an approval process. Descovy, a newer drug, is available without cost sharing only if people are unable to use Truvada or its generic version because of clinical intolerance or other issues.
Q: What about the lab work and clinical visits that are necessary while taking PrEP? Are those services also covered without cost sharing?
That is the thousand-dollar question. People who are taking drugs to prevent HIV infection need to meet with a clinician and have bloodwork every three months to test for HIV, hepatitis B and sexually transmitted infections, and to check their kidney function.
The task force recommendation doesn’t specify whether these services must also be covered without cost sharing, and advocates say federal guidance is necessary to ensure they are free.
“If you’ve got a high-deductible plan and you’ve got to meet it before those services are covered, that’s going to add up,” said Amy Killelea, senior director of health systems and policy at the National Alliance of State & Territorial AIDS Directors. “We’re trying to emphasize that it’s integral to the intervention itself.”
A handful of states have programs that help people cover their out-of-pocket costs for lab and clinical visits, generally based on income.
There is precedent for including free ancillary care as part of a recommended preventive service. After consumers and advocates complained, the Centers for Medicare & Medicaid Services (CMS) clarified that under the ACA removing a polyp during a screening colonoscopy is considered an integral part of the procedure and patients shouldn’t be charged for it.
CMS officials declined to clarify whether PrEP services such as lab work and clinical visits are to be covered without cost sharing as part of the preventive service and noted that states generally enforce such insurance requirements. “CMS intends to contact state regulators, as appropriate, to discuss issuer’s compliance with the federal requirements and whether issuers need further guidance on which services associated with PrEP must be covered without cost sharing,” the agency said in a statement.
Q: What if someone runs into roadblocks getting a plan to cover PrEP or related services without cost sharing?
If an insurer charges for the medication or a follow-up visit, people may have to go through an appeals process to fight it.
“They’d have to appeal to the insurance company and then to the state if they don’t succeed,” said Nadeen Israel, vice president of policy and advocacy at the AIDS Foundation of Chicago. “Most people don’t know to do that.”
Q: Are uninsured people also protected by this new cost-sharing change for PrEP?
Unfortunately, no. The ACA requirement to cover recommended preventive services without charging patients applies only to private insurance plans. People without insurance don’t benefit. Gilead, which makes both Truvada and Descovy, has a patient assistance program for the uninsured.
Prior to the pandemic, telehealth was a limited ad-hoc service with geographic and provider restrictions. However, with both the pandemic restrictions on face to face interactions and a relaxation of governmental regulations, telehealth utilization has significantly increased from thousands of visits in a week to well over a million in the Medicare population. What we’ve learned is that telehealth allows patients, especially high-risk populations like seniors, to connect with their doctors in a safe and efficient way. Telehealth is valuable for many types of visits, mostly clearly ones that involve mental health or physical health issues that do not require a physical exam or procedure. It’s an efficient modality for both the member and provider.
With the growing popularity of telehealth services, we may see permanent changes in regulatory standards. Flexible regulatory standards, such as being able to use platforms like FaceTime or Skype, would lower the barrier to entry for providers to offer telehealth and also encourage adoption, especially among seniors. Second, it’s likely we’ll see an emergence of providers with aligned incentives around value, such as in many Medicare Advantage plans, trying very hard to encourage utilization with their members so that they get the right care at the right time. In theory, the shift towards value-based care will allow better care and lower costs than the traditional fee for service model. If we are able to evolve regulatory and payment environments, providers have an opportunity to grow these types of services into 2021 to improve patient wellness and health outcomes.
Dr. Salvatore Viscomi, Chief Medical Officer, GoodCell
2021 will be the year of patient controlled-health
The COVID-19 pandemic brought the realities of a global-scale health event – and our general lack of preparedness to address it – to the forefront. People are now laser-focused on how they can protect themselves and their families against the next inevitable threat. On top of this, social distancing and isolation accelerated the development and use of digital health tools, from wellness trackers to telehealth and virtual care, most of which can be accessed from the comfort of our homes. The convergence of these two forces is poised to make 2021 the year for patient-controlled health, whereby health decisions are not dictated by – but rather made in consultation with – a healthcare provider, leveraging insights and data pulled from a variety of health technology tools at people’s fingertips.
Anish Sebastian, CEO of Babyscripts
Telemedicine was the finger in the dyke at the beginning of pandemic panic, with healthcare providers grabbing whatever came to hand — encouraged by relaxed HIPAA regulations — to keep the dam from breaking. But as the dust settles, telemedicine is emerging as the commodity that it is, and value-add services are going to be the differentiating factors in an increasingly competitive marketplace. Offerings like remote patient monitoring and asynchronous communication, initially considered as “nice-to-haves,” are becoming standard offerings as healthcare providers see their value for continuous care beyond Covid.
Daniel Kivatinos, COO and Co-Founder of DrChrono
Telehealth visits are going to supersede in-person visits as time goes on.
Because of COVID-19, the world changed and Medicare and Medicaid, as well as other insurers, started paying out for telehealth visits. Telemedicine will continue to grow at a very quick rate, and verticals like mental health (psychology and psychiatry) and primary care fit perfectly into the telemedicine model, for tasks like administering prescription refills (ePrescribing) and ordering labs. Hyperlocal medical care will also move towards more of a telemedicine care team experience. Patients that are homebound families with young children or people that just recently had surgery can now get instant care when they need it. Location is less relevant because patients can see a provider from anywhere.
Dennis McLaughlin VP of Omni Operations + Product at ibi
Virtual Healthcare is Here to Stay (House Calls are Back)
This new normal however is going to put significant pressure on the data support and servicing requirements to do it effectively. As more services are offered to patients outside of established clinical locations, it also means there will be more opportunity to collect data and a higher degree of dependence on interoperability. Providers are going to have to up their game from just providing and recording facts to passing on critical insight back into these interactions to maximize the benefits to the patient.
Sarahjane Sacchetti, CEO at Cleo
Virtual care (of all types) will become a lasting form of care: The vastly accelerated and broadened use of virtual care spurred by the pandemic will become permanent. Although it started with one-off check-ins or virtual mental health coaching, 2021 will see the continued rise in the use and efficacy of virtual care services once thought to be in-person only such as maternity, postpartum, pediatric, and even tutoring. Employers are taking notice of this shift with 32% indicating that expanded virtual health services are a top priority, and this number will quickly rise as employers look to offer flexible and convenient benefits in support of employees and to drive productivity.
Omri Shor, CEO of Medisafe
Digital expansion: The pandemic has accelerated patient technology adoption, and innovation remains front-and-center for healthcare in 2021. Expect to see areas of telemedicine and digital health monitoring expand in new and novel ways, with increased uses in remote monitoring and behavioral health. CMS has approved telehealth for a number of new specialties and digital health tools continue to gain adoption among healthcare companies, drug makers, providers, and patients.
Digital health companions will continue to become an important tool to monitor patients, provide support, and track behaviors – while remaining socially distant due to the pandemic. Look for crossover between medical care, drug monitoring, and health and wellness – Apple
Watch has already previewed this potential with heart rate and blood oxygen monitoring. Data output from devices will enable support to become more personalized and triggered by user behavior.
Kelli Bravo, Vice President, Healthcare and Life Sciences, Pegasystems
The COVID-19 pandemic has not only changed and disrupted our lives, it has wreaked havoc on the entire healthcare industry at a scale we’ve never seen before. And it continues to alter almost every part of life across the globe. The way we access and receive healthcare has also changed as a result of social distancing requirements, patient concerns, provider availability, mobile capabilities, and newly implemented procedures at hospitals and healthcare facilities.
For example, hospitals and providers are postponing elective procedures again to help health systems prepare and reserve ICU beds amid the latest COVID-19 resurgence. While level of care is always important, in some areas, the inability to access a healthcare provider is equally concerning. And these challenges may become even more commonplace in the post-COVID-19 era. One significant transformation to help with the hurdle is telehealth, which went from a very small part of the care offering before the health crisis to one that is now a much more accepted way to access care. As the rise in virtual health continues to serve consumers and provide a personalized and responsive care experience, healthcare consumers expect support services and care that are also fast and personalized – with digital apps, instant claims settlements, transparency, and advocacy. And to better help serve healthcare consumers, the industry has an opportunity to align with digital transformation that offers a personalized and responsive experience.
Brooke LeVasseur, CEO of AristaMD
Issues pertaining to the COVID-19 pandemic will continue to be front-and-center in 2021. Every available digital tool in the box will have to be employed to ensure patients with non-COVID related issues are not forgotten as we try to free up in-person space and resources for those who cannot get care in any other setting. Virtual front doors, patient/physician video and eConsults, which connect providers to collaborate electronically, will be part of a broadening continuum of care – ultimately aimed at optimizing every valuable resource we have.
Bret Larsen, CEO and Co-Founder, eVisit
By the end of 2021, virtual care paths will be fairly ubiquitous across the continuum of care, from urgent care and EDs to specialty care, all to serve patients where they are – at home and on mobile devices. This will be made possible through virtualized end-to-end processes that integrate every step in patient care from scheduling, waiting rooms, intake and patient queuing, to interpretation services, referral management, e-prescribe, billing and analytics, and more.
Laura Kreofsky, Vice President for Advisory & Telehealth for Pivot Point Consulting
2020 has been the year of rapid telehealth adoption and advancement due to the COVID pandemic. According to CDC reports, telehealth utilization spiked as much as 154% in late March compared to the same period in 2019. While usage has moderated, it’s clear telehealth is now an instrumental part of healthcare delivery. As provider organizations plan for telehealth in 2021 and beyond, we are going to have to expect and deliver a secure, scalable infrastructure, a streamlined patient experience and an approach that maximizes provider efficiency, all while seeing much-needed vendor consolidation.
Jeff Lew, SVP of Product Management, Nextech
Earlier this year, CMS enacted new rules to provide practices with the flexibility they need to use telehealth solutions in response to COVID-19, during which patients also needed an alternative to simply visiting the office. This was the impetus to the accelerated acceptance of telehealth as a means to both give and receive care. Specialty practices, in particular, are seeing successful and positive patient experiences due to telehealth visits. Dermatology practices specifically standout and I expect the strong adoption will continue to grow and certainly be the “new normal.” In addition, innovative practices that have embraced this omni-channel approach to delivering care are also establishing this as a “new normal” by selectively using telehealth visits for certain types of encounters, such as post-op visits or triaging patients. This gives patients a choice and the added convenience that comes with it and, in some cases, increases patient volume for the practice.
Sharon Clark is able to get her life-sustaining cancer drug, Pomalyst — priced at more than $18,000 for a 28-day supply — only because of the generosity of patient assistance foundations.
Clark, 57, a former insurance agent who lives in Bixby, Oklahoma, had to stop working in 2015 and go on Social Security disability and Medicare after being diagnosed with multiple myeloma, a blood cancer. Without the foundation grants, mostly financed by the drugmakers, she couldn’t afford the nearly $1,000 a month it would cost her for the drug, since her Medicare Part D drug plan requires her to pay 5% of the list price.
Every year, however, Clark has to find new grants to cover her expensive cancer drug.
“It’s shameful that people should have to scramble to find funding for medical care,” she said. “I count my blessings, because other patients have stories that are a lot worse than mine.”
Many Americans with cancer or other serious medical conditions face similar prescription drug ordeals. It’s often worse, however, for Medicare patients. Unlike private health insurance, Part D drug plans have no cap on patients’ 5% coinsurance costs once they hit $6,550 in drug spending this year (rising from $6,350 in 2020), except for very low-income beneficiaries.
President-elect Joe Biden favors a cap, and Democrats and Republicans in Congress have proposed annual limits ranging from $2,000 to $3,100. But there’s disagreement about how to pay for that cost cap. Drug companies and insurers, which support the concept, want someone else to bear the financial burden.
That forces patients to rely on the financial assistance programs. These arrangements, however, do nothing to reduce prices. In fact, they help drive up America’s uniquely high drug spending by encouraging doctors and patients to use the priciest medications when cheaper alternatives may be available.
Growing Expense of Specialty, Cancer Medicines
Nearly 70% of seniors want Congress to pass an annual limit on out-of-pocket drug spending for Medicare beneficiaries, according to a KFF survey in 2019. (KHN is an editorially independent program of KFF.)
The affordability problem is worsened by soaring list prices for many specialty drugs used to treat cancer and other serious diseases. The out-of-pocket cost for Medicare and private insurance patients is often set as a percentage of the list price, as opposed to the lower rate negotiated by insurers.
For instance, prices for 54 orally administered cancer drugs shot up 40% from 2010 to 2018, averaging $167,904 for one year of treatment, according to a 2019 JAMA study. Bristol Myers Squibb, the manufacturer of Clark’s drug, Pomalyst, has raised the price 75% since it was approved in 2013, to about $237,000 a year. The company believes “pricing should be put in the context of the value, or benefit, the medicine delivers to patients, health care systems and society overall,” a spokesperson for Bristol Myers Squibb said via email.
As a result of rising prices, 1 million of the 46.5 million Part D drug plan enrollees spend above the program’s catastrophic coverage threshold and face $3,200 in average annual out-of-pocket costs, according to KFF. The hit is particularly heavy on cancer patients. In 2019, Part D enrollees’ average out-of-pocket cost for 11 orally administered cancer drugs was $10,470, according to the JAMA study.
The median annual income for Medicare beneficiaries is $26,000.
Medicare patients face modest out-of-pocket costs if their drugs are administered in the hospital or a doctor’s office and they have a Medigap or Medicare Advantage plan, which caps those expenses.
But during the past several years, dozens of effective drugs for cancer and other serious conditions have become available in oral form at the pharmacy. That means Medicare patients increasingly pay the Part D out-of-pocket costs with no set maximum.
“With the high cost of drugs today, that 5% can be a third or more of a patient’s Social Security check,” said Brian Connell, federal affairs director for the Leukemia & Lymphoma Society.
This has forced some older Americans to keep working, rather than retiring and going on Medicare, because their employer plan covers more of their drug costs. That way, they also can keep receiving financial help directly from drugmakers to pay for the costs not covered by their private plan, which isn’t allowed by Medicare.
‘This Is a Little Nuts’
All this has caused financial and emotional turmoil for people who face a life-threatening disease.
Marilyn Rose, who was diagnosed with chronic myeloid leukemia three years ago, until recently was paying nothing out-of-pocket for her cancer drug, Sprycel, which has a list price of $176,500 a year. That’s because Bristol Myers Squibb, the manufacturer, paid her insurance deductible and copays for the drug.
But the self-employed artist and designer, who lives in West Caldwell, New Jersey, recently turned 65 and went on Medicare. The Part D plan offering the best deal on Sprycel charges more than $10,000 a year in coinsurance for the drug.
Rose asked her oncologist if she could switch to an alternative medication, Gleevec, for which she’d pay just $445 a year. But she ultimately decided to stick with Sprycel, which her doctor said is a longer-lasting treatment. She hopes to qualify for financial aid from a foundation to cover the coinsurance but won’t know until sometime this month.
“It’s just strange you have to make a decision about your treatment based on your finances rather than what’s the right drug for you,” she said. “I always thought that when I get to Medicare age I’ll be able to breathe a sigh of relief. This is a little nuts.”
Given the sticker shock, many other patients choose not to fill a needed prescription, or delay filling it. Nearly half of patients who face a price of $2,000 or more for a cancer drug walk away from the pharmacy without it, according to a 2017 study. Fewer than half of Medicare patients with blood cancer received treatment within 90 days of their diagnosis, according to a 2019 study commissioned by the Leukemia & Lymphoma Society.
“If I didn’t do really well at scrounging free drugs and getting copay foundations to work with us, my patients wouldn’t get the drug, which is awful,” said Dr. Barbara McAneny, an oncologist in Albuquerque, New Mexico, and past president of the American Medical Association. “Patients would just say, ‘I can’t afford it. I’ll just die.’”
The high drug prices and coverage gaps have forced many patients to rely on complicated financial assistance programs offered by drug companies and foundations. Under federal rules, the foundations can help Medicare patients as long as they pay for drugs made by all manufacturers, not just by the company funding the foundation.
But Daniel Klein, CEO of the PAN Foundation, which provides drug copay assistance to more than 100,000 people a year, said there are more patients in need than his foundation and others like it can help.
“If you are a normal consumer, you don’t know much about any of this until you get sick and all of a sudden you find out you can’t afford your medication,” he said. Patients are lucky, he added, if their doctor knows how to navigate the charitable assistance maze.
Yet many don’t. Daniel Sherman, who trains hospital staff members to navigate financial issues for patients, estimates that fewer than 5% of U.S. cancer centers have experts on staff to help patients with problems paying for their care.
Sharon Clark, who struggles to cover her cancer drugs, works with the Leukemia & Lymphoma Society counseling other patients on how to access helping resources. “People tell me they haven’t started treatment because they don’t have money to pay,” she said. “No one in this country should have to choose between housing, food or medicine. It should never be that way, never.”
Under the Trump administration, federal health care policymakers have long been vocal about the ability of Medicare Advantage (MA) to lower costs and improve outcomes among vulnerable populations.
A recent report from the Washington, D.C.-based Better Medicare Alliance (BMA) and consulting firm Avalere Health is now putting hard numbers on that claim, particularly around home health services and post-acute care.
“The hallmark features of Medicare Advantage — risk-adjusted capitated payment, strong value-based performance incentives and flexibility in benefit design — enable health plans to offer care management interventions that meet complex care needs of vulnerable beneficiaries in ways that produce robust positive outcomes and greater value for high need, high cost beneficiaries,” the report states.
To study cost and outcomes differences between MA and traditional fee-for-service (FFS) Medicare, Avalere and BMA analyzed data tied to more than 1.4 million MA enrollees and 7.9 million FSS beneficiaries. Researchers pulled data from 2015 to 2017.
Broadly, the findings show that MA enrollees spend far fewer days on home health services compared to their FSS peers. For every 1,000 individuals, home health days on service were nearly 20% lower in MA than in traditional Medicare, with an even greater difference among certain subpopulations.
For every 1,000 individuals under the age of 65 living with a disability, for example, home health days on service were about 27% lower in MA than FFS. For every 1,000 individuals living with a major complex and chronic condition, home health days on service were again 27% lower.
The smallest gap in home health agency days came in the frail elderly subpopulation, according to the report. For every 1,000 frail and elderly individuals, home health days on service were about 10% lower in MA than in traditional Medicare.
“The data … show that home health utilization is lower for all three populations in Medicare Advantage compared to traditional FFS Medicare,” the report notes. “One possible explanation is that inappropriate use of these services is minimized in Medicare Advantage relative to traditional FFS Medicare, but further research is needed to evaluate differences in use of home health services.”
High-need, high-cost MA beneficiaries had lower rates of post-acute utilization across all settings compared with those in traditional Medicare. Skilled nursing facility (SNF) days were 16% to 41% lower in MA, for instance.
In general, differences in post-acute care costs were similarly aligned with differences in utilization of post-acute care.
Across all populations, home health agency costs were about 38% lower in Medicare Advantage compared to FSS Medicare.
The Congressional Budget Office (CBO) forecasts that 47% of all Medicare enrollees will be Medicare Advantage beneficiaries by 2029.
“This study finds that overall Medicare Advantage delivered robust positive outcomes for high-need, high-cost beneficiaries compared to similar populations in traditional FFS Medicare,” the report continues. “Higher utilization of preventive screenings, preventive therapy and post-acute care follow-up in Medicare Advantage suggests that care management results in higher quality of care for this vulnerable population.”
The combination of Teladoc Health and Livongo creates a
global leader in consumer-centered virtual care. The combined company is
positioned to execute quantified opportunities to drive revenue synergies of
$100 million by the end of the second year following the close, reaching $500
million on a run-rate basis by 2025.
Price: $18.5B in value based on each share of Livongo
will be exchanged for 0.5920x shares of Teladoc Health plus cash consideration
of $11.33 for each Livongo share.
Siemens Healthineers Acquires Varian Medical
On August 2nd, Siemens Healthineers acquired
Varian Medical for $16.4B, with the deal expected to close in 2021. Varian is a
global specialist in the field of cancer care, providing solutions especially
in radiation oncology and related software, including technologies such as
artificial intelligence, machine learning and data analysis. In fiscal year 2019,
the company generated $3.2 billion in revenues with an adjusted operating
margin of about 17%. The company currently has about 10,000 employees
Price: $16.4 billion in an all-cash transaction.
Gainwell to Acquire HMS for $3.4B in Cash
Veritas Capital (“Veritas”)-backed Gainwell Technologies (“Gainwell”),
a leading provider of solutions that are vital to the administration and
operations of health and human services programs, today announced that they
have entered into a definitive agreement whereby Gainwell will acquire HMS, a technology, analytics and engagement
solutions provider helping organizations reduce costs and improve health
Price: $3.4 billion in cash.
Philips Acquires Remote Cardiac Monitoring BioTelemetry for $2.8B
Philips acquires BioTelemetry, a U.S. provider of remote
cardiac diagnostics and monitoring for $72.00 per share for an implied
enterprise value of $2.8 billion (approx. EUR 2.3 billion). With $439M in
revenue in 2019, BioTelemetry annually monitors over 1 million cardiac patients
remotely; its portfolio includes wearable heart monitors, AI-based data
analytics, and services.
Price: $2.8B ($72 per share), to be paid in cash upon
Hims & Hers Merges with Oaktree Acquisition Corp to Go Public on NYSE
Telehealth company Hims & Hers and Oaktree Acquisition Corp., a special purpose acquisition company (SPAC) merge to go public on the New York Stock Exchange (NYSE) under the symbol “HIMS.” The merger will enable further investment in growth and new product categories that will accelerate Hims & Hers’ plan to become the digital front door to the healthcare system
Price: The business combination values the combined
company at an enterprise value of approximately $1.6 billion and is expected to
deliver up to $280 million of cash to the combined company through the
contribution of up to $205 million of cash.
SPAC Merges with 2 Telehealth Companies to Form Public
Digital Health Company in $1.35B Deal
Blank check acquisition company GigCapital2 agreed to merge with Cloudbreak Health, LLC, a unified telemedicine and video medical interpretation solutions provider, and UpHealth Holdings, Inc., one of the largest national and international digital healthcare providers to form a combined digital health company.
Price: The merger deal is worth $1.35 billion, including
WellSky Acquires CarePort Health from Allscripts for
Price: $1.35 billion represents a multiple of greater
than 13 times CarePort’s revenue over the trailing 12 months, and approximately
21 times CarePort’s non-GAAP Adjusted EBITDA over the trailing 12 months.
Waystar Acquires Medicare RCM Company eSolutions
On September 13th, revenue cycle management
provider Waystar acquires eSolutions, a provider of Medicare and Multi-Payer revenue
cycle management, workflow automation, and data analytics tools. The
acquisition creates the first unified healthcare payments platform with both
commercial and government payer connectivity, resulting in greater value for
Radiology Partners (RP), a radiology practice in the U.S., announced a definitive agreement to acquire MEDNAX Radiology Solutions, a division of MEDNAX, Inc. for an enterprise value of approximately $885 million. The acquisition is expected to add more than 800 radiologists to RP’s existing practice of 1,600 radiologists. MEDNAX Radiology Solutions consists of more than 300 onsite radiologists, who primarily serve patients in Connecticut, Florida, Nevada, Tennessee, and Texas, and more than 500 teleradiologists, who serve patients in all 50 states.
PointClickCare Acquires Collective Medical
PointClickCare Technologies, a leader in senior care technology with a network of more than 21,000 skilled nursing facilities, senior living communities, and home health agencies, today announced its intent to acquireCollective Medical, a Salt Lake City, a UT-based leading network-enabled platform for real-time cross-continuum care coordination for $650M. Together, PointClickCare and Collective Medical will provide diverse care teams across the continuum of acute, ambulatory, and post-acute care with point-of-care access to deep, real-time patient insights at any stage of a patient’s healthcare journey, enabling better decision making and improved clinical outcomes at a lower cost.
Teladoc Health Acquires Virtual Care Platform InTouch
Teladoc Health acquires InTouch Health, the leading provider of enterprise telehealth solutions for hospitals and health systems for $600M. The acquisition establishes Teladoc Health as the only virtual care provider covering the full range of acuity – from critical to chronic to everyday care – through a single solution across all sites of care including home, pharmacy, retail, physician office, ambulance, and more.
Price: $600M consisting of approximately $150 million
in cash and $450 million of Teladoc Health common stock.
AMN Healthcare Acquires VRI Provider Stratus Video
AMN Healthcare Services, Inc. acquires Stratus Video, a leading provider of video remote language interpretation services for the healthcare industry. The acquisition will help AMN Healthcare expand in the virtual workforce, patient care arena, and quality medical interpretation services delivered through a secure communications platform.
CarepathRx Acquires Pharmacy Operations of Chartwell from
CarepathRx, a leader in pharmacy and medication management
solutions for vulnerable and chronically ill patients, announced today a
partnership with UPMC’s Chartwell subsidiary that will expand patient access to
innovative specialty pharmacy and home infusion services. Under the $400M
landmark agreement, CarepathRx will acquire the
management services organization responsible for the operational and strategic
management of Chartwell while UPMC becomes a strategic investor in CarepathRx.
Cerner to Acquire Health Division of Kantar for $375M in
Cerner announces it will acquire Kantar Health, a leading
data, analytics, and real-world evidence and commercial research consultancy
serving the life science and health care industry.
This acquisition is expected to allow Cerner’s Learning
Health Network client consortium and health systems with more opportunities to
directly engage with life sciences for funded research studies. The acquisition
is expected to close during the first half of 2021.
Cerner Sells Off Parts of Healthcare IT Business in
Germany and Spain
Cerner sells off parts of healthcare IT business in Germany and Spain to Germany company CompuGroup Medical, reflecting the company-wide transformation focused on improved operating efficiencies, enhanced client focus, a refined growth strategy, and a sharpened approach to portfolio management.
Price: EUR 225 million ($247.5M USD)
CompuGroup Medical Acquires eMDs for $240M
CompuGroup Medical (CGM) acquires eMDs, Inc. (eMDs), a
leading provider of healthcare IT with a focus on doctors’ practices in the US,
reaching an attractive size in the biggest healthcare market worldwide. With
this acquisition, the US subsidiary of CGM significantly broadens its position
and will become the top 4 providers in the market for Ambulatory Information
Systems in the US.
Price: $240M (equal to approx. EUR 203 million)
Change Healthcare Buys Back Pharmacy Network
back pharmacy unit eRx Network
(“eRx”), a leading provider of comprehensive, innovative, and secure
data-driven solutions for pharmacies. eRx generated approximately $67M in
annual revenue for the twelve-month period ended February 29, 2020. The
transaction supports Change Healthcare’s commitment to focus on and invest in
core aspects of the business to fuel long-term growth and advance innovation.
Walmart acquires CareZone, a San Francisco, CA-based smartphone
service for managing chronic health conditions for reportedly $200M. By
working with a network of pharmacy partners, CareZone’s concierge services
assist consumers in getting their prescription medications organized and
delivered to their doorstep, making pharmacies more accessible to individuals
and families who may be homebound or reside in rural locations.
Verisk, a data
analytics provider, announced today that it has acquiredFranco Signor, a Medicare Secondary Payer
(MSP) service provider to America’s largest insurance carriers and employers.
As part of the acquisition, Franco Signor will become part of Verisk’s Claims
Partners business, a leading provider of MSP compliance and other analytic
claim services. Claims Partners and Franco Signor will be combining forces to
provide the single best resource for Medicare compliance.
Rubicon Technology Partners Acquires Central Logic
Private equity firm Rubicon Technology Partners acquires
Central Logic, a provider of patient orchestration and tools to accelerate
access to care for healthcare organizations. Rubicon will be aggressively driving Central Logic’s
growth with additional cash investments into the business, with a focus
on product innovation, sales expansion, delivery and customer support, and
the pursuit of acquisition opportunities.
As we close out the year, we asked several healthcare executives to share their predictions and trends for 2021.
Kimberly Powell, Vice President & General Manager, NVIDIA Healthcare
Federated Learning: The clinical community will increase their use of federated learning approaches to build robust AI models across various institutions, geographies, patient demographics, and medical scanners. The sensitivity and selectivity of these models are outperforming AI models built at a single institution, even when there is copious data to train with. As an added bonus, researchers can collaborate on AI model creation without sharing confidential patient information. Federated learning is also beneficial for building AI models for areas where data is scarce, such as for pediatrics and rare diseases.
AI-Driven Drug Discovery: The COVID-19 pandemic has put a spotlight on drug discovery, which encompasses microscopic viewing of molecules and proteins, sorting through millions of chemical structures, in-silico methods for screening, protein-ligand interactions, genomic analysis, and assimilating data from structured and unstructured sources. Drug development typically takes over 10 years, however, in the wake of COVID, pharmaceutical companies, biotechs, and researchers realize that acceleration of traditional methods is paramount. Newly created AI-powered discovery labs with GPU-accelerated instruments and AI models will expedite time to insight — creating a computing time machine.
Smart Hospitals: The need for smart hospitals has never been more urgent. Similar to the experience at home, smart speakers and smart cameras help automate and inform activities. The technology, when used in hospitals, will help scale the work of nurses on the front lines, increase operational efficiency, and provide virtual patient monitoring to predict and prevent adverse patient events.
Omri Shor, CEO of Medisafe
Healthcare policy: Expect to see more moves on prescription drug prices, either through a collaborative effort among pharma groups or through importation efforts. Pre-existing conditions will still be covered for the 135 million Americans with pre-existing conditions.
The Biden administration has made this a central element of this platform, so coverage will remain for those covered under ACA. Look for expansion or revisions of the current ACA to be proposed, but stalled in Congress, so existing law will remain largely unchanged. Early feedback indicates the Supreme Court is unlikely to strike down the law entirely, providing relief to many during a pandemic.
Brent D. Lang, Chairman & Chief Executive Officer, Vocera Communications
The safety and well-being of healthcare workers will be a top priority in 2021. While there are promising headlines about coronavirus vaccines, we can be sure that nurses, doctors, and other care team members will still be on the frontlines fighting COVID-19 for many more months. We must focus on protecting and connecting these essential workers now and beyond the pandemic.
Modernized PPE Standards Clinicians should not risk contamination to communicate with colleagues. Yet, this simple act can be risky without the right tools. To minimize exposure to infectious diseases, more hospitals will rethink personal protective equipment (PPE) and modernize standards to include hands-free communication technology. In addition to protecting people, hands-free communication can save valuable time and resources. Every time a nurse must leave an isolation room to answer a call, ask a question, or get supplies, he or she must remove PPE and don a fresh set to re-enter. With voice-controlled devices worn under PPE, the nurse can communicate without disrupting care or leaving the patient’s bedside.
Voice-controlled solutions can also help new or reassigned care team members who are unfamiliar with personnel, processes, or the location of supplies. Instead of worrying about knowing names or numbers, they can use simple voice commands to connect to the right person, group, or information quickly and safely. In addition to simplifying clinical workflows, an intelligent communication system can streamline operational efficiencies, improve triage and throughput, and increase capacity, which is all essential to hospitals seeking ways to recover from 2020 losses and accelerate growth.
Michael Byczkowski, Global Vice President, Head of Healthcare Industry at SAP,
New, targeted healthcare networks will collaborate and innovate to improve patient outcomes.
We will see many more touchpoints between different entities ranging from healthcare providers and life sciences companies to technology providers and other suppliers, fostering a sense of community within the healthcare industry. More organizations will collaborate based on existing data assets, perform analysis jointly, and begin adding innovative, data-driven software enhancements. With these networks positively influencing the efficacy of treatments while automatically managing adherence to local laws and regulations regarding data use and privacy, they are paving the way for software-defined healthcare.
Smart hospitals will create actionable insights for the entire organization out of existing data and information.
Medical records as well as operational data within a hospital will continue to be digitized and will be combined with experience data, third-party information, and data from non-traditional sources such as wearables and other Internet of Things devices. Hospitals that have embraced digital are leveraging their data to automate tasks and processes as well as enable decision support for their medical and administrative staff. In the near future, hospitals could add intelligence into their enterprise environments so they can use data to improve internal operations and reduce overhead.
Curt Medeiros, President and Chief Operating Officer of Ontrak
As health care costs continue to rise dramatically given the pandemic and its projected aftermath, I see a growing and critical sophistication in healthcare analytics taking root more broadly than ever before. Effective value-based care and network management depend on the ability of health plans and providers to understand what works, why, and where best to allocate resources to improve outcomes and lower costs. Tied to the need for better analytics, I see a tipping point approaching for finally achieving better data security and interoperability. Without the ability to securely share data, our industry is trying to solve the world’s health challenges with one hand tied behind our backs.
G. Cameron Deemer, President, DrFirst
Like many business issues, the question of whether to use single-vendor solutions or a best-of-breed approach swings back and forth in the healthcare space over time. Looking forward, the pace of technology change is likely to swing the pendulum to a new model: systems that are supplemental to the existing core platform. As healthcare IT matures, it’s often not a question of ‘can my vendor provide this?’ but ‘can my vendor provide this in the way I need it to maximize my business processes and revenues?
This will be more clear with an example: An EHR may provide a medication history function, for instance, but does it include every source of medication history available? Does it provide a medication history that is easily understood and acted upon by the provider? Does it provide a medication history that works properly with all downstream functions in the EHR? When a provider first experiences medication history during a patient encounter, it seems like magic.
After a short time, the magic fades to irritation as the incompleteness of the solution becomes more obvious. Much of the newer healthcare technologies suffer this same incompleteness. Supplementing the underlying system’s capabilities with a strongly integrated third-party system is increasingly going to be the strategy of choice for providers.
Angie Franks, CEO of Central Logic
In 2021, we will see more health systems moving towards the goal of truly operating as one system of care. The pandemic has demonstrated in the starkest terms how crucial it is for health systems to have real-time visibility into available beds, providers, transport, and scarce resources such as ventilators and drugs, so patients with COVID-19 can receive the critical care they need without delay. The importance of fully aligning as a single integrated system that seamlessly shares data and resources with a centralized, real-time view of operations is a lesson that will resonate with many health systems.
Expect in 2021 for health systems to enhance their ability to orchestrate and navigate patient transitions across their facilities and through the continuum of care, including post-acute care. Ultimately, this efficient care access across all phases of care will help healthcare organizations regain revenue lost during the historic drop in elective care in 2020 due to COVID-19.
In addition to elevating revenue capture, improving system-wide orchestration and navigation will increase health systems’ bed availability and access for incoming patients, create more time for clinicians to operate at the top of their license, and reduce system leakage. This focus on creating an ‘operating as one’ mindset will not only help health systems recover from 2020 losses, it will foster sustainable and long-term growth in 2021 and well into the future.
John Danaher, MD, President, Global Clinical Solutions, Elsevier
COVID-19 has brought renewed attention to healthcare inequities in the U.S., with the disproportionate impact on people of color and minority populations. It’s no secret that there are indicative factors, such as socioeconomic level, education and literacy levels, and physical environments, that influence a patient’s health status. Understanding these social determinants of health (SDOH) better and unlocking this data on a wider scale is critical to the future of medicine as it allows us to connect vulnerable populations with interventions and services that can help improve treatment decisions and health outcomes. In 2021, I expect the health informatics industry to take a larger interest in developing technologies that provide these kinds of in-depth population health insights.
Jay Desai, CEO and co-founder of PatientPing
2021 will see an acceleration of care coordination across the continuum fueled by the Centers for Medicare and Medicaid Services (CMS) Interoperability and Patient Access rule’s e-notifications Condition of Participation (CoP), which goes into effect on May 1, 2021. The CoP requires all hospitals, psych hospitals, and critical access hospitals that have a certified electronic medical record system to provide notification of admit, discharge, and transfer, at both the emergency room and the inpatient setting, to the patient’s care team. Due to silos, both inside and outside of a provider’s organization, providers miss opportunities to best treat their patients simply due to lack of information on patients and their care events.
This especially impacts the most vulnerable patients, those that suffer from chronic conditions, comorbidities or mental illness, or patients with health disparities due to economic disadvantage or racial inequity. COVID-19 exacerbated the impact on these vulnerable populations. To solve for this, healthcare providers and organizations will continue to assess their care coordination strategies and expand their patient data interoperability initiatives in 2021, including becoming compliant with the e-notifications Condition of Participation.
Kuldeep Singh Rajput, CEO and founder of Biofourmis
Driven by CMS’ Acute Hospital at Home program announced in November 2020, we will begin to see more health systems delivering hospital-level care in the comfort of the patient’s home–supported by technologies such as clinical-grade wearables, remote patient monitoring, and artificial intelligence-based predictive analytics and machine learning.
A randomized controlled trial by Brigham Health published in Annals of Internal Medicine earlier this year demonstrated that when compared with usual hospital care, Home Hospital programs can reduce rehospitalizations by 70% while decreasing costs by nearly 40%. Other advantages of home hospital programs include a reduction in hospital-based staffing needs, increased capacity for those patients who do need inpatient care, decreased exposure to COVID-19 and other viruses such as influenza for patients and healthcare professionals, and improved patient and family member experience.
Jake Pyles, CEO, CipherHealth
The disappearance of the hospital monopoly will give rise to a new loyalty push
Healthcare consumerism was on the rise ahead of the pandemic, but the explosion of telehealth in 2020 has effectively eliminated the geographical constraints that moored patient populations to their local hospitals and providers. The fallout has come in the form of widespread network leakage and lost revenue. By October, in fact, revenue for hospitals in the U.S. was down 9.2% year-over-year. Able to select providers from the comfort of home and with an ever-increasing amount of personal health data at their convenience through the growing use of consumer-grade wearable devices, patients are more incentivized in 2021 to choose the provider that works for them.
After the pandemic fades, we’ll see some retrenchment from telehealth, but it will remain a mainstream care delivery model for large swaths of the population. In fact, post-pandemic, we believe telehealth will standardize and constitute a full 30% to 40% of interactions.
That means that to compete, as well as to begin to recover lost revenue, hospitals need to go beyond offering the same virtual health convenience as their competitors – Livango and Teladoc should have been a shot across the bow for every health system in 2020. Moreover, hospitals need to become marketing organizations. Like any for-profit brand, hospitals need to devote significant resources to building loyalty but have traditionally eschewed many of the cutting-edge marketing techniques used in other industries. Engagement and personalization at every step of the patient journey will be core to those efforts.
Marc Probst, former Intermountain Health System CIO, Advisor for SR Health by Solutionreach
Healthcare will fix what it’s lacking most–communication.
Because every patient and their health is unique, when it comes to patient care, decisions need to be customized to their specific situation and environment, yet done in a timely fashion. In my two decades at one of the most innovative health systems in the U.S., communication, both across teams and with patients continuously has been less than optimal. I believe we will finally address both the interpersonal and interface communication issues that organizations have faced since the digitization of healthcare.”
Rich Miller, Chief Strategy Officer, Qgenda
2021 – The year of reforming healthcare: We’ve been looking at ways to ease healthcare burdens for patients for so long that we haven’t realized the onus we’ve put on providers in doing so. Adding to that burden, in 2020 we had to throw out all of our playbooks and become masters of being reactive. Now, it’s time to think through the lessons learned and think through how to be proactive. I believe provider-based data will allow us to reformulate our priorities and processes. By analyzing providers’ biggest pain points in real-time, we can evaporate the workflow and financial troubles that have been bothering organizations while also relieving providers of their biggest problems.”
Robert Hanscom, JD, Vice President of Risk Management and Analytics at Coverys
Data Becomes the Fix, Not the Headache for Healthcare
The past 10 years have been challenging for an already overextended healthcare workforce. Rising litigation costs, higher severity claims, and more stringent reimbursement mandates put pressure on the bottom line. Continued crises in combination with less-than-optimal interoperability and design of health information systems, physician burnout, and loss of patient trust, have put front-line clinicians and staff under tremendous pressure.
Looking to the future, it is critical to engage beyond the day to day to rise above the persistent risks that challenge safe, high-quality care on the frontline. The good news is healthcare leaders can take advantage of tools that are available to generate, package, and learn from data – and use them to motivate action.
Steve Betts, Chief of Operations and Products at Gray Matter Analytics
Analytics Divide Intensifies: Just like the digital divide is widening in society, the analytics divide will continue to intensify in healthcare. The role of data in healthcare has shifted rapidly, as the industry has wrestled with an unsustainable rate of increasing healthcare costs. The transition to value-based care means that it is now table stakes to effectively manage clinical quality measures, patient/member experience measures, provider performance measures, and much more. In 2021, as the volume of data increases and the intelligence of the models improves, the gap between the haves and have nots will significantly widen at an ever-increasing rate.
Substantial Investment in Predictive Solutions: The large health systems and payors will continue to invest tens of millions of dollars in 2021. This will go toward building predictive models to infuse intelligent “next best actions” into their workflows that will help them grow and manage the health of their patient/member populations more effectively than the small and mid-market players.
Jennifer Price, Executive Director of Data & Analytics at THREAD
The Rise of Home-based and Decentralized Clinical Trial Participation
In 2020, we saw a significant rise in home-based activities such as online shopping, virtual school classes and working from home. Out of necessity to continue important clinical research, home health services and decentralized technologies also moved into the home. In 2021, we expect to see this trend continue to accelerate, with participants receiving clinical trial treatments at home, home health care providers administering procedures and tests from the participant’s home, and telehealth virtual visits as a key approach for sites and participants to communicate. Hybrid decentralized studies that include a mix of on-site visits, home health appointments and telehealth virtual visits will become a standard option for a range of clinical trials across therapeutic areas. Technological advances and increased regulatory support will continue to enable the industry to move out of the clinic and into the home.
Doug Duskin, President of the Technology Division at Equality Health
Value-based care has been a watchword of the healthcare industry for many years now, but advancement into more sophisticated VBC models has been slower than anticipated. As we enter 2021, providers – particularly those in fee-for-service models who have struggled financially due to COVID-19 – and payers will accelerate this shift away from fee-for-service medicine and turn to technology that can facilitate and ease the transition to more risk-bearing contracts. Value-based care, which has proven to be a more stable and sustainable model throughout the pandemic, will seem much more appealing to providers that were once reluctant to enter into risk-bearing contracts. They will no longer be wondering if they should consider value-based contracting, but how best to engage.
Brian Robertson, CEO of VisiQuate
Continued digitization and integration of information assets: In 2021, this will lead to better performance outcomes and clearer, more measurable examples of “return on data, analytics, and automation.
Digitizing healthcare’s complex clinical, financial, and operational information assets: I believe that providers who are further in the digital transformation journey will make better use of their interconnected assets, and put the healthcare consumer in the center of that highly integrated universe. Healthcare consumer data will be studied, better analyzed, and better predicted to drive improved performance outcomes that benefit the patient both clinically and financially.
Some providers will have leapfrog moments: These transformations will be so significant that consumers will easily recognize that they are receiving higher value. Lower acuity telemedicine and other virtual care settings are great examples that lead to improved patient engagement, experience and satisfaction. Device connectedness and IoT will continue to mature, and better enable chronic disease management, wellness, and other healthy lifestyle habits for consumers.
Kermit S. Randa, CEO of Syntellis Performance Solutions
Healthcare CEOs and CFOs will partner closely with their CIOs on data governance and data distribution planning. With the massive impact of COVID-19 still very much in play in 2021, healthcare executives will need to make frequent data-driven – and often ad-hoc — decisions from more enterprise data streams than ever before. Syntellis research shows that healthcare executives are already laser-focused on cost reduction and optimization, with decreased attention to capital planning and strategic growth. In 2021, there will be a strong trend in healthcare organizations toward new initiatives, including clinical and quality analytics, operational budgeting, and reporting and analysis for decision support.
Dr. Calum Yacoubian, Associate Director of Healthcare Product & Strategy at Linguamatics
As payers and providers look to recover from the damage done by the pandemic, the ability to deliver value from data assets they already own will be key. The pandemic has displayed the siloed nature of healthcare data, and the difficulty in extracting vital information, particularly from unstructured data, that exists. Therefore, technologies and solutions that can normalize these data to deliver deeper and faster insights will be key to driving economic recovery. Adopting technologies such as natural language processing (NLP) will not only offer better population health management, ensuring the patients most in need are identified and triaged but will open new avenues to advance innovations in treatments and improve operational efficiencies.
Prior to the pandemic, there was already an increasing level of focus on the use of real-world data (RWD) to advance the discovery and development of new therapies and understand the efficacy of existing therapies. The disruption caused by COVID-19 has sharpened the focus on RWD as pharma looks to mitigate the effect of the virus on conventional trial recruitment and data collection. One such example of this is the use of secondary data collection from providers to build real-world cohorts which can serve as external comparator arms.
This convergence on seeking value from existing RWD potentially affords healthcare providers a powerful opportunity to engage in more clinical research and accelerate the work to develop life-saving therapies. By mobilizing the vast amount of data, they will offer pharmaceutical companies a mechanism to positively address some of the disruption caused by COVID-19. This movement is one strategy that is key to driving provider recovery in 2021.
Rose Higgins, Chief Executive Officer of HealthMyne
Precision imaging analytics technology, called radiomics, will increasingly be adopted and incorporated into drug development strategies and clinical trials management. These AI-powered analytics will enable drug developers to gain deeper insights from medical images than previously capable, driving accelerated therapy development, greater personalization of treatment, and the discovery of new biomarkers that will enhance clinical decision-making and treatment.
Dharmesh Godha, President and CTO of Advaiya
Greater adoption and creative implementation of remote healthcare will be the biggest trend for the year 2021, along with the continuous adoption of cloud-enabled digital technologies for increased workloads. Remote healthcare is a very open field. The possibilities to innovate in this area are huge. This is the time where we can see the beginning of the convergence of personal health aware IoT devices (smartwatches/ temp sensors/ BP monitors/etc.) with the advanced capabilities of the healthcare technologies available with the monitoring and intervention capabilities for the providers.
Simon Wu, Investment Director, Cathay Innovation
Healthcare Data Proves its Weight in Gold in 2021
Real-world evidence or routinely stored data from hospitals and claims, being leveraged by healthcare providers and biopharma companies along with those that can improve access to data will grow exponentially in the coming year. There are many trying to build in-house, but similar to autonomous technology, there will be a separate set of companies emerge in 2021 to provide regulated infrastructure and have their “AWS” moment.
Kyle Raffaniello, CEO of Sapphire Digital
2021 is a clear year for healthcare price transparency
Over the past year, healthcare price transparency has been a key topic for the Trump administration in an effort to lower healthcare costs for Americans. In recent months, COVID-19 has made the topic more important to patients than ever before. Starting in January, we can expect the incoming Biden administration to not only support the existing federal transparency regulations but also continue to push for more transparency and innovation within Medicare. I anticipate that healthcare price transparency will continue its momentum in 2021 as one of two Price Transparency rules takes effect and the Biden administration supports this movement.
Dennis McLaughlin VP of Omni Operations + Product at ibi
Social Determinants of Health Goes Mainstream: Understanding more about the patient and their personal environment has a hot topic the past two years. Providers and payers’ ability to inject this knowledge and insight into the clinical process has been limited. 2021 is the year it gets real. It’s not just about calling an uber anymore. The organizations that broadly factor SDOH into the servicing model especially with virtualized medicine expanding broadly will be able to more effectively reach vulnerable patients and maximize the effectiveness of care.
Joe Partlow, CTO at ReliaQuest
The biggest threat to personal privacy will be healthcare information: Researchers are rushing to pool resources and data sets to tackle the pandemic, but this new era of openness comes with concerns around privacy, ownership, and ethics. Now, you will be asked to share your medical status and contact information, not just with your doctors, but everywhere you go, from workplaces to gyms to restaurants. Your personal health information is being put in the hands of businesses that may not know how to safeguard it. In 2021, cybercriminals will capitalize on rapid U.S. telehealth adoption. Sharing this information will have major privacy implications that span beyond keeping medical data safe from cybercriminals to wider ethics issues and insurance implications.
Jimmy Nguyen, Founding President at Bitcoin Association
Blockchain solutions in the healthcare space will bring about massive improvements in two primary ways in 2021.
Firstly, blockchain applications will for the first time facilitate patients owning, managing, and even monetizing their personal health data. Today’s healthcare information systems are incredibly fragmented, with patient data from different sources – be they physicians, pharmacies, labs, or otherwise – kept in different silos, eliminating the ability to generate a holistic view of patient information and restricting healthcare providers from producing the best health outcomes.
Healthcare organizations are growing increasingly aware of the ways in which blockchain technology can be used to eliminate data silos, enable real-time access to patient information, and return control to patients for the use of their personal data – all in a highly-secure digital environment. 2021 will be the year that patient data goes blockchain.
Secondly, blockchain solutions can ensure more honesty and transparency in the development of pharmaceutical products. Clinical research data is often subject to questions of integrity or ‘hygiene’ if data is not properly recorded, or worse, is deliberately fabricated. Blockchain technology enables easy, auditable tracking of datasets generated by clinical researchers, benefitting government agencies tasked with approving drugs while producing better health outcomes for healthcare providers and patients. In 2021, I expect to see a rise in the use and uptake of applications that use public blockchain systems to incentivize greater honesty in clinical research.
Alex Lazarow, Investment Director, Cathay Innovation
The Future of US Healthcare is Transparent, Fair, Open and Consumer-Driven
In the last year, the pandemic put a spotlight on the major gaps in healthcare in the US, highlighting a broken system that is one of the most expensive and least distributed in the world. While we’ve already seen many boutique healthcare companies emerge to address issues around personalization, quality and convenience, the next few years will be focused on giving the power back to consumers, specifically with the rise of insurtechs, in fixing the transparency, affordability, and incentive issues that have plagued the private-based US healthcare system until now.
Lisa Romano, RN, Chief Nursing Officer, CipherHealth
Hospitals will need to counter the staff wellness fallout
The pandemic has placed unthinkable stress on frontline healthcare workers. Since it began, they’ve been working under conditions that are fundamentally more dangerous, with fewer resources, and in many cases under the heavy emotional burden of seeing several patients lose their battle with COVID-19. The fallout from that is already beginning – doctors and nurses are leaving the profession, or getting sick, or battling mental health struggles. Nursing programs are struggling to fill classes. As a new wave of the pandemic rolls across the country, that fallout will only increase. If they haven’t already, hospitals in 2021 will place new premiums upon staff wellness and staff health, tapping into the same type of outreach and purposeful rounding solutions they use to round on patients.
Kris Fitzgerald, CTO, NTT DATA Services
Quality metrics for health plans – like data that measures performance – was turned on its head in 2020 due to delayed procedures. In the coming year, we will see a lot of plans interpret these delayed procedures flexibly so they honor their plans without impacting providers. However, for so long, the payer’s use of data and the provider’s use of data has been disconnected. Moving forward the need for providers to have a more specific understanding of what drives the value and if the cost is reasonable for care from the payer perspective is paramount. Data will ensure that this collaboration will be enhanced and the concept of bundle payments and aligning incentives will be improved. As the data captured becomes even richer, it will help people plan and manage their care better. The addition of artificial intelligence (AI) to this data will also play a huge role in both dialog and negotiation when it comes to cost structure. This movement will lead to a spike in value-based care adoption
COVID-19 was the dominant — but not the only — health policy story of 2020. In this special year-in-review episode of KHN’s “What the Health?” podcast, panelists look back at some of the biggest non-coronavirus stories. Those included Supreme Court cases on the Affordable Care Act, Medicaid work requirements and abortion, as well as a year-end surprise ending to the “surprise bill” saga.
This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico, Anna Edney of Bloomberg News and Sarah Karlin-Smith of Pink Sheet.
Among the takeaways from this week’s podcast:
The coronavirus pandemic strengthened the hand of ACA supporters, even as the Trump administration sought to get the Supreme Court to overturn the federal health law. Many people felt it was an inopportune time to get rid of that safety valve while so many Americans were losing their jobs — and their health insurance — due to the economic chaos from the virus.
Preliminary enrollment numbers released by federal officials last week suggest that more people were taking advantage of the option to buy coverage for 2021 through the ACA marketplaces than for 2020, even in the absence of enrollment encouragement from the federal government.
The ACA’s Medicaid expansion had a bit of a roller-coaster ride this year. Voters in two more states — Oklahoma and Missouri — approved the expansion in ballot measures, but the Trump administration continued its support of state plans that require many adults to prove they are working in order to continue their coverage. The Supreme Court has agreed to hear a challenge to that policy. Although lower courts have ruled that the Medicaid law does not allow such restrictions, it’s not clear how the new conservative majority on the court will view this issue.
Concerns are beginning to grow in Washington about the near-term prospect of the Medicare trust fund going insolvent. That can likely be fixed only with a remedy adopted by Congress, and that may not happen unless lawmakers feel a crisis is very near.
The Trump administration has sought to bring down drug out-of-pocket expenses for Medicare beneficiaries. Among those initiatives is a demonstration project to lower the cost of insulin. About a third of Medicare beneficiaries will be enrolled in plans that offer reduced prices in 2021. But the effort could have a hidden consequence: higher insurance premiums.
Many members of Congress began this session two years ago with grand promises of working to lower drug prices — but they never reached an agreement on how to do it.
President Donald Trump, however, was strongly motivated by the issue and late this year issued an order to set many Medicare drug prices based on what is paid in other industrialized nations. Drugmakers detest the idea and have vowed to fight it in court. Although some Democrats endorse the concept, it seems unlikely that President-elect Joe Biden would want to spend much capital in a legal battle for a plan that hasn’t been carefully vetted.
The gigantic spending and COVID relief bill that Congress finally approved Monday includes a provision to protect consumers from surprise medical bills when they are unknowingly treated by doctors or hospitals outside their insurance network. The law sets up a mediation process to resolve the charges, but the process favors the doctors. Insurers are likely to pass along any extra costs to consumers through higher premiums.
A recent Advisory Board briefing examined the annual Centers for Medicare & Medicaid Services (CMS) Readmission penalties. Of the 3,080 hospitals CMS evaluated, 83% received a penalty for payments to be made in 2021, based on expected outcomes for a wide variety of treated conditions. While CMS indicated that some of these penalties might be waived or delayed due to the impacts of the Covid pandemic on hospital procedure volumes and revenue, they are indicative of a much larger issue.
For too long, patients discharged from the hospital have been handed a stack of papers to fill prescriptions, seek follow-up care, or take other steps in their journey from treatment to recovery. More recently, the patient is given access to an Electronic Health Record (EHR) portal to view their records, and a care coordinator may call in a few days to check-in. These are positive steps, but is it enough? Although some readmissions cannot be avoided due to unforeseen complications, many are due to missed follow-up visits, poor medication adherence, or inadequate post-discharge care.
Probably because communication with outside providers has never worked reliably, almost all hospitals have interpreted ‘care coordination’ to mean staffing a local team to help patients with a call center-style approach. Wouldn’t it be much better if the hospital could directly engage and enable the Primary Care Physician (PCP) to know the current issues and follow-up directly with their patient?
We believe there is still a real opportunity to hold the patient’s hand and do far more to guide them through to recovery while reducing the friction for the entire patient care team.
Strengthening Care Coordination for a Better Tomorrow
Coordinating and collaborating with primary care, outpatient clinics, mental health professionals, public health, or social services plays a crucial role in mitigating readmissions and other bumps along the road to recovery. Real care coordination requires three related communication capabilities:
1. Notification of the PCP or other physicians and caregivers when events such as ED visits or Hospitalization occur.
2. Easy, searchable, medical record sharing allows the PCP to learn important issues without wading through hundreds of administrative paperwork.
3. Secure Messaging allows both clinicians and office staff to ask the other providers questions, clarify issues, and simplify working together.
There are some significant hurdles to improve the flow of patient data, and industry efforts have long been underway to plug the gaps. EHR vendors, Health Information Exchanges (HIEs), and a myriad of vendors and collaboratives have attempted to tackle these issues. In the past few decades, government compliance efforts have helped drive medical record sharing through the Direct Messaging protocol and CCDAs through Meaningful Use/Promoting Interoperability requirements for “electronic referral loops.” Kudos to the CMS for recognizing that notifications need to improve from hospitals to primary care—this is the key driver behind the latest CMS Final Rule (CMS-9115-F) mandating Admission, Discharge, and Transfer (ADT) Event Notifications. (By March 2021, CMS Conditions of Participation (CoPs) will require most hospitals to make a “reasonable effort” to send electronic event notifications to “all” Primary Care Providers (PCPs) or their practice.)
However, to date, the real world falls far short of these ideals: for a host of technical and implementation reasons, the majority of PCPs still don’t receive digital medical records sent by hospitals, and the required notifications are either far too simple, provide no context or relevant encounter data, rarely include patient demographic and contact information, and almost never include a method for bi-directional communications or messaging.
Delivering What the Recipient Needs
PCPs want what doctors call the “bullet” about their patient’s recent hospitalization. They don’t want pages of minutia, much of it repetitively cut and pasted. They don’t want to scan through dozens or hundreds of pages looking for the important things. They don’t want “CYA” legalistic nonsense. Not to mention, they learn very little from information focused on patient education.
An outside practitioner typically doesn’t have access to the hospital EHR, and when they do, it can be too cumbersome or time-consuming to chase down the important details of a recent visit. But for many patients—especially those with serious health issues—the doctor needs the bullet: key items such as the current medication list, what changed, and why.
Let’s look at an example of a patient with Congestive Heart Failure (CHF), which is a condition assessed in the above-mentioned CMS Readmission penalties. For CHF, the “bullet” might include timely and relevant details such as:
– What triggered the decompensation? Was it a simple thing, such as a salty meal? Or missed medication?
– What was the cardiac Ejection Fraction?
– What were the last few BUN and Creatinine levels and the most recent weight?
– Was this left- or right-sided heart failure?
– What medications and doses were prescribed for the patient?
– Is she tending toward too dry or too wet?
– Has she been postural, dizzy, hypotensive?
Ideally, the PCP would receive a quick, readable page that includes the name of the treating physician at the hospital, as well as 3-4 sentences about key concerns and findings. Having the whole hospital record is not important for 90 percent of patients, but receiving the “bullet” and being able to quickly search or request the records for more details, would be ideal.
Similar issues hold true for administrative staff and care coordinators. No one should play “telephone tag” to get chart information, clarify which patients should be seen quickly, or find demographic information about a discharged patient so they can proactively contact them to schedule follow-up.
Building a Sustainable, Long-Term Solution
Having struggled mightily to build effective communications in the past is no excuse for the often simplistic and manual processes we consider care coordination today.
Let’s use innovative capabilities to get high-quality notifications and transitions of care to all PCPs, not continue with multi-step processes that yield empty, cryptic data. The clinician needs clinically dense, salient summaries of hospital care, with the ability to quickly get answers—as easy as a Google search—for the two or three most important questions, without waiting for a scheduled phone call with the hospitalist. X-Rays, Lab results, EKGs, and other tests should also be available for easy review, not just the report. After all, if the PCP needs to order a new chest x-ray or EKG how can they compare it with the last one if they don’t have access to it?
Clerical staff needs demographic information at their fingertips to “take the baton” and ensure quick and appropriate appointment scheduling. They need to be able to retrieve more information from the sender, ask questions, and never use a telephone. Additionally, both the doctor and the office staff should be able to fire off a short note and get an answer to anyone in the extended care team.
That is proper care coordination. And that is where we hope the industry is collectively headed in 2021.
About Peter Tippett MD, PhD: Founder and CEO, careMESH
Dr. Peter S. Tippett is a physician, scientist, business leader and technology entrepreneur with extensive risk management and health information technology expertise. One of his early startups created the first commercial antivirus product, Certus (which sold to Symantec and became Norton Antivirus). As a leader in the global information security industry (ICSA Labs, TruSecure, CyberTrust, Information Security Magazine), Tippett developed a range of foundational and widely accepted risk equations and models.
About Catherine Thomas: Co-Founder and VP, Customer Engagement, careMESH
Catherine Thomas is Co-Founder & VP of Customer Engagement for careMESH, and a seasoned marketing executive with extensive experience in healthcare, telecommunications and the Federal Government sectors. As co-founder of careMESH, she brings 20+ years in Strategic Marketing and Planning; Communications & Change Management; Analyst & Media Relations; Channel Strategy & Development; and Staff & Project Leadership.
Happy Holidays, Part D readers, and thank you for following along this year as we explored the impact of Medicare Part D and the important role the program plays for seniors and those with disabilities.
At the beginning of the month, the Centers for Medicare & Medicaid Services (CMS) released the final rule for the 2021 Medicare Physician Fee Schedule.
Since then, the rule has drawn criticism for the payment cuts CMS made to home-based primary care visits, a move that experts believe will jeopardize access to care for seniors and chronically ill patients. That’s especially true considering the ongoing public health emergency, when in-home care has never been more important.
Similar to the home health payment rule, CMS’s Medicare Physician Fee Schedule mandates how much Medicare physicians get paid for providing care in 2021.
Under the rule, home-based primary care saw an 8% to 10% payment cut to visits. One of the many organizations that has been critical of the cut is the American Academy of Home Care Medicine (AAHCM).
About 2 million seniors are permanently homebound, according to AAHCM. For seniors who fall under this category and certain others, receiving care outside of the home can be difficult — or impossible.
“One concern if this doesn’t get reversed or reconsidered by policymakers is that with the effective rate cuts to home-based medical care providers, the exact patients who we are trying to protect by not having to go to a clinic, hospital or urgent care facility will be impacted,” Theresa Soriano, president of AAHCM, told Home Health Care News. “If you are reducing rates by 10%, you’re going to threaten the ability of these largely small practices to be able to provide care quickly and on a large scale.”
Soriano also noted that home-based primary care providers are often delivering care to those who are most at risk for adverse health complications if they were to contract COVID-19.
Chicago-based AAHCM is a professional and advocacy organization that represents physicians, nurses, physician assistants, social workers and other health care professionals dedicated to working in the field of home-based medical care.
CMS’s payment cut to home-based primary care visits could also spell trouble for smaller providers and have long-term implications for the industry as a whole.
“Many of my colleagues are extremely worried that smaller practices — those that are not affiliated with large health systems or [similar] entities — will really struggle, and may either have to downsize or even close,” Soriano said. “This is not urban or rural — all parts of our country are being served by home-based medical care.”
Soriano pointed out that the recent rate cut was accompanied by a rate increase for primary care providers that don’t work in the home setting, which may speak to an oversight on CMS’s part.
“Office-based primary care is effectively seeing an increase in their reimbursement, which is appropriate and right,” she said. “We want people to be getting the care they need, but considering that the care we are providing is in an arguably safer setting, we just believe that there was a … lack of recognition that home-based medical care is primary care and should not be seeing a rate cut but the same increase,” she said.
In order to combat CMS’s decision, AAHCM has thrown its support behind legislation under consideration which would delay the cuts. The organization considers this a temporary solution.
Moving forward, Soriano believes that it’s important for providers to reach out to Congressional representatives, as well as CMS.
“Something that we are doing is reaching out to our state representation, both on the Senate and House side,” she said. “And to CMS, to make them aware that primary care and home-based medical care are related. Home-based medical care is a subset of primary care and needs to be recognized in the same way.”
In this brief, we analyze third quarter data from 2018 to 2020 to examine how insurance markets performed financially through the end of September. Average margins remained relatively high compared to the same point in recent years, suggesting many insurers remained profitable even as non-COVID-related care returned in the summer and fall.
As the U.S. prepares for nationwide distribution of vaccines to combat COVID-19, some are asking whether people who get the first of two doses will return to complete the series in order to be fully immunized. This analysis draws on Medicare Part D prescription drug claims data for the herpes zoster vaccine Shingrix, which also requires two doses, to shed light on this potential challenge of the leading COVID-19 vaccine candidates.
A global health crisis has thrust us into a scenario in which lives quite literally depend on the ability to virtually connect. Telehealth has rapidly emerged as a vital tool, enabling continuity of care, allowing vulnerable individuals to access their physician from home, and freeing up resources for providers to treat the most critical patients. The acceptance of telehealth and expansion of covered services for the senior population demonstrate that this technology will endure long after COVID-19 subsides.
Prior to the pandemic, just 11% of Americans utilized telehealth compared to 46% so far this year, and virtual healthcare interactions are expected to top 1 billion by year’s end. While the technology has been a life-saver for many, usage depends heavily on the availability of audio-video capabilities, internet access, and technological prowess – potentially leaving vulnerable patients behind.
Seniors Face Physical, Technical and Socioeconomic Barriers to Telehealth
Despite telehealth’s surge, there is growing concern that the rapid shift to digitally delivered care is leaving seniors behind. Telehealth is not inherently accessible for all and with many practices transitioning appointments online, it threatens to cut older adults off from receiving crucial medical care. This is a significant concern, considering older adults account for one-quarter of physician office visits in the United States and often manage multiple conditions and medications, and have a higher rate of disability. This puts an already vulnerable population at a higher risk of severe complications from COVID-19.
Research published recently in JAMA Internal Medicine found that more than a third of adults over age 65 face potential difficulties accessing their doctor through telehealth. Obstacles include familiarity using mobile devices, troubleshooting technical issues that arise, managing hearing or vision impairments, and dealing with cognitive issues like dementia. Many of these difficulties stem from the natural aging process; it is imperative for provider organizations employing telehealth and telehealth vendors to improve offerings that consider vision, hearing, and speaking loss for this population.
While barriers associated with aging are a key factor within the senior population, perhaps the greatest challenges in accessing telehealth are socioeconomic. The rapid shift to digital delivery of care may have left marginalized populations without access to the technological tools needed to access care digitally, such as high-speed internet, a smartphone or a computer.
According to the JAMA study, low-income individuals living in remote or rural locations faced the greatest challenges in accessing telehealth. A second JAMA study, also released this summer indicated that “the proportion of Medicare beneficiaries with digital access was lower among those who were 85 or older, were widowed, had a high school education or less, were Black or Hispanic, received Medicaid, or had a disability.”
These socioeconomic factors are systemic issues that existed prior to the pandemic, and the crisis-driven acceleration of telehealth has magnified these pre-existing challenges and widened racial and class-based disparities. Recent initiatives at the federal level, such as the FCC’s rural telehealth expansion task force, are a step in the right direction, though more sustained action is needed to address additional socioeconomic challenges that are deeply rooted within the healthcare system.
Fortunately, Telehealth Hurdles Can Be Overcome
Recognizing that telehealth isn’t a “one-size fits all” solution is the first step towards addressing the barriers that disproportionately impact seniors and work is needed on multiple levels. Telemedicine consults are impossible without access to the internet, so the first step is to provide and expand access to broadband and internet-connected devices. With more than 15% of the country’s population living in rural areas, expanding broadband access for these individuals is especially crucial. In addition, older adults in community-based living environments need greater access to public wi-fi networks.
Access to mobile and other internet-connected devices is also essential. Products designed with large fonts and icons, closed captioning, and easy set-up procedures may be easier for older adults to use. For example, GrandPad is a tablet designed specifically for seniors and has an intuitive interface that includes basic video calling, enabling seniors to virtually connect with their caregivers.
To address affordability, the Centers for Medicaid and Medicare Services (CMS) allowed for mid-year benefit changes in 2020 to allow for payment or provision of mobile devices for telehealth. Many Medicare Advantage organizations are enhancing plans’ provisions of telehealth coverage and devices for 2021.
In addition to increasing access to broadband and internet-connected devices, providing seniors with proper educational resources is another crucial step. Even if older adults are open to using technology for telehealth visits, many will need additional training. Healthcare organizations may want to connect older patients with community-based technology training programs. Some programs take a multi-generational approach, pairing younger instructors with older students.
For example, Papa is an on-demand service that pairs older adults with younger ‘Papa Pals’ who provide companionship and assistance with tasks such as setting up a new smartphone or tablet.
From a socioeconomic perspective, careful consideration is needed to address the concerns that telehealth may reinforce systemic biases and widen health disparities. Providers may be less conscious of systemic bias toward patients based on race, ethnicity, or educational status.
In turn, providers must address implicit bias head-on, such as offering workplace training and incorporating evidence-based tools to adequately measure and address health disparities. This includes pushing for policies that enable widespread broadband access funding to better connect communities in need.
Health plans can support expanded access to care through benefit design, reducing costs for plan members. To match members and patients with the right resources and assistance, health plans and providers should launch outreach campaigns that are segmented by demographic group. Outreach initiatives could include assessments to determine each person’s ability and comfort level with telehealth.
The Path Forward
Without question, telehealth is playing a central role in delivering care during the current pandemic, and many of its long-touted benefits have been accentuated by the current demand. Telehealth, along with other digital monitoring technologies, have the potential to address several barriers to care for seniors and other vulnerable populations for whom access to in-person care may not be viable, such as those based in remote locations or with mobility issues.
In the post-pandemic era, telehealth can provide greater access and convenience, but if not implemented carefully, the permanent expansion of telehealth may worsen health disparities. Careful consideration and collaboration will be essential in embracing the value of telehealth while mitigating its inherent risks.
If implemented correctly, telehealth can provide continued access to care for our vulnerable aging population and can significantly improve care as well. Enhancing the ability to connect with healthcare providers anytime, anywhere can give seniors the freedom to gracefully age in place.
About Anne Davis
Anne Davis is the Director of Quality Programs & Medicare Strategy at HMS, a healthcare technology, analytics, and engagement solutions company, where she’s focused on the company’s Population Health Management product portfolio.
When 2020 began, no one anticipated that complying with the Merit-based Incentive Payment System (MIPS)—the flagship payment model of the Centers for Medicare & Medicaid Services (CMS) Quality Payment Program (QPP)—would look so different halfway through the year. Like many other things, the COVID-19 crisis has delayed, diverted, or derailed many organizations’ reporting efforts and capabilities. Lower procedure volumes, new remote work scenarios, and shifting priorities have taken attention away from MIPS work.
Despite the disruptions and uncertainties associated with the pandemic, healthcare organizations should not lose track of MIPS compliance and the program’s intent to improve care quality, reduce costs, and facilitate interoperability. Here are a few strategies for keeping a MIPS program top of mind.
Understand the immediate effects of the pandemic on MIPS reporting
Due to COVID-19, CMS granted several 2019 data reporting exceptions and extensions to clinicians and providers participating in Medicare quality reporting programs. These concessions were enacted to let providers focus 100% of their resources on caring for and ensuring the health and safety of patients and staff during the early weeks of the crisis. For the 2020 MIPS performance period, CMS has also chosen to use the Extreme and Uncontrollable Circumstances policy to allow requests to reweight any or all of the MIPS performance categories to 0%.
Clinicians and groups can complete the application any time before the end of this performance year. If practices are granted reweighting one or more categories but submit data during the attestation period, the reweighting will be void and the practice will receive the score earned in the categories for which they submit data
Seize the opportunity to improve interoperability
Interoperability is a key area that organizations were focused on before the crisis, and this work still warrants attention. If an organization is not on the front lines of the COVID-19 response, it should use this time to shore up communications with other entities so, once things return to “normal,” it will be well prepared to seamlessly exchange information with peer organizations.
Establishing processes for sending and receiving care summaries via direct messaging is important for practices to earn a high score in the Promoting Interoperability category. Direct messaging is a HIPAA-compliant method for securely exchanging health information between providers, which functions as an email but is much more secure due to encryption. A regular pain point organizations face is being unable to obtain direct messaging addresses from peer organizations, including referral partners.
To assist providers in this area, the Office of the National Coordinator for Health Information Technology (ONC) and CMS has created a mandatory centralized directory of provider electronic data exchange addresses published by the National Plan & Provider Enumeration System (NPPES). The NPPES directory is searchable through a public API and allows providers to look up the direct messaging addresses for other providers. To meet current interoperability requirements, providers must have entered their direct messaging address into the system by June 30, 2020. If they haven’t done so, the provider could be publicly reported for failure to comply with the requirement, which could constitute information blocking.
Take time now to ensure direct messaging addresses have been entered correctly for all members of your practice. This is also a good time to begin reaching out to top referral sources to make sure they are also prepared to send and receive information.
Look for ways to streamline quality reporting
Over the next few months, the focus will return to quality measure reporting. As such, it’s wise to take advantage of this time to ensure solid documentation and reporting methods. Electronic medical records (EMRs) can be helpful in streamlining these efforts.
For example, dropdown menus with frequently used descriptions and automated coding can enable greater accuracy and specificity while easing the documentation process for providers. Customizable screens that can be configured to include specialty-specific choices based on patient history and problem list can also smooth documentation and coding, especially if screen layouts mirror favored workflow.
Regarding MIPS compliance in particular, it can be helpful to use tools that offer predictive charting. This feature determines whether a patient qualifies for preselected MIPS measures in real-time and presents the provider with data fields related to those items during the patient encounter—allowing the physician to collect the appropriate information without adding additional charting time later on.
With respect to reporting, providers may benefit from using their certified EMR in addition to reporting through a registry. At the beginning of the MIPS program, providers could report through both a registry and EMR directly and would be scored separately for their quality category through each method. They would then be awarded the higher score of the two. This method had the potential to leave some high-scoring measures on the table.
Beginning in 2019, providers reporting through both registry and EMR direct are scored across the two methods. CMS uses the six highest scoring measures between the two reporting sets to calculate the provider’s or group’s quality score, potentially resulting in a higher score than the provider would earn by reporting through either method alone.
A knowledgeable partner can pave the way to better performance
COVID-19 has impacted healthcare like no other event in recent history, and it’s not surprising that MIPS compliance has taken a back seat to more pressing concerns. However, providers still have the opportunity to make meaningful progress in this area. By working with a technology partner that keeps up with the current requirements and offers strategies and solutions for optimizing data collection and reporting, a provider can realize solid MIPS performance during and beyond this unprecedented time.
About Courtney Tesvich, VP of Regulatory at Nextech
Courtney is a Registered Nurse with more than 20 years in the healthcare field, 15 of which have been focused on quality improvements and regulatory compliance. As VP of Regulatory at Nextech, Courtney is responsible for ensuring that Nextech’s products meet government certification requirements and client needs related to the regulatory environment.
In the United States, seniors and people with disabilities enjoy broad coverage of physician-administered medicines under Medicare Part B because the program relies on market competition to balance access, innovation and cost control. But the same cannot be said for patients in other countries. In fact, a new analysis from Avalere underscores the dangers of the Most Favored Nation (MFN) rule and other foreign reference pricing proposals.
– Cityblock Health, a transformative, value-based healthcare provider focused on improving healthcare outcomes for marginalized communities, today announced a $160M Series C round, bringing its total raised to $300M.
– Cityblock is a care delivery trailblazer working to right the injustices of a healthcare system that cycles vulnerable communities through frequent ER visits and hospital stays. Its tech-enabled model delivers primary care, behavioral care, and social services, virtually and in-person, to the Medicaid and lower-income Medicare beneficiary communities.
– Cityblock provides social services that address core
aspects of poverty in order to improve health outcomes, including access to
nutritious food and support to safely care for oneself.
Health, a Brooklyn, NY-based healthcare provider for lower-income
communities, announced today the completion of a $160 million Series C funding
round and a valuation of over $1 billion. New Cityblock investor General Catalyst
led the round, with participation from crossover investor Wellington Management
and support from major existing investors, including Kinnevik AB, Maverick
Ventures, Thrive Capital, Redpoint Ventures, and more. The investment round
brings Cityblock’s total equity funding to $300 million, as they look to grow
their footprint to democratize access to community-based integrated care in a
more than $1.3 trillion market.
Care That Meets You Where You Are
Spun out of Sidewalk Labs, an Alphabet Company in 2017 and anchored in a first partnership with EmblemHealth, Cityblock is a transformative, value-based healthcare provider focused on improving outcomes for Medicaid and lower-income Medicare beneficiaries. The company provides medical care (both primary care and complex specialty services), behavioral health, and social services to its members virtually, in their homes, in the community, and in its neighborhood hubs. Their model reflects an underlying philosophy that improving health outcomes and minimizing systemic healthcare inequities requires fundamentals that address the root effects of poverty, like having access to nutritious food or the ability to safely care for yourself and others.
Value-Based Care Model
Cityblock leverages a value-based model, instead of a
fee-for-service basis, like most healthcare providers. Cityblock splits the
cost savings that come from better outcomes with the healthcare payer. Cityblock’s
financial structure squarely aligns the health needs of its members to continuously
deliver patient-centric care.
Cityblock is powered by Commons a groundbreaking care delivery platform that brings together distributed community-based care teams, care delivery workflows, data feeds, and multimodal member interactions. It allows social workers, pharmacists, doctors, paramedics, and our virtual care teams to all come together on the same page in real-time. With each new market we enter, our technology reinforces our care model, allowing us to serve more members while ensuring consistently high quality, empathetic, and effective care.
Integrated Care Team
Cityblock’s integrated care teams include doctors, nurses,
advanced practice clinicians, behavioral health specialists, licensed clinical
social workers, and community health partners, and leverage close partnerships
with existing healthcare providers and community-based social services
Today, Cityblock provides care to 70,000 members in Connecticut,
New York, Massachusetts, and Washington D.C., with high member engagement and
NPS scores of high 80s to 90s across its markets. Over the past year, Cityblock
members have seen reductions in in-patient hospital admission rates and
improvements in quality outcomes, keeping people healthier and driving down
costs across the board, while more than doubling membership and revenue,
The Impact of COVID Has Magnified Health Disparities
According to Cityblock, the COVID-19 pandemic has
significantly magnified health disparities highlighting three fundamental
– Inequity of
America’s social infrastructure, including the legacy of systemic racism, has
created unacceptably disparate health outcomes
– Healthcare’s volume-based, fee-for-service payment model contributes
poor outcomes, especially for marginalized communities
– The models that
have to-date addressed key components of these challenges have not successfully
Story of Cityblock Member Sonia
The story of Sonia, a Cityblock member, is featured in the blog post announcing the raise. Counted out and considered
a ‘nuisance’ by the healthcare system, Sonia was visiting the emergency room
several times a week for care and services, resulting in poor outcomes for the
health system and for herself. Cityblock enrolled Sonia in their high-risk
short-term housing program, placing her into a hotel during the peak of her
community’s Covid-19’s outbreak. As her trust in Cityblock grew, Sonia worked
with Cityblock and its community partners to secure permanent housing. Over the
course of two years, Sonia saw a 21% reduction in hospital use and a 24%
reduction in monthly costs, and has had zero ER visits since April 2020.
“The devastating impact of COVID-19 has been a painful
reminder of the vulnerability of lower-income communities and communities of
color,” said Iyah Romm, Cityblock Health co-founder and CEO. “We cannot turn a
blind eye to a healthcare system that cycles vulnerable communities through
frequent ER visits and hospital stays. We believe that new models of care
delivery, rooted in preventative care and augmented with social services, are
one major path forward to righting the injustices of our healthcare system.
This starts with listening to our members, extends through changing payment
models to create sustainability for primary care providers and building
technology to democratize access to the care models that we are building.”
– Elation Health, which provides an easy-to-use and
affordable clinical technology platform for more than 7 million independent primary
care clinicians serving 14M+ patients – including an EHR raises $40M in Series
C funding from Al Gore’s sustainable investment firm, Generation Investment
– Elation’s API-enabled platform also allows
organizations to transform the patient and provider experience and implement
their own models of data-driven, value-based care.
– Company will surpass a milestone this year of
delivering more than 20 million in-office and virtual visits through their
Health, a clinical-first technology company powering the future of
independent primary care, today announced a Series C financing round of $40
million led by Al Gore’s Generation Investment
Management, a firm that invests in sustainable businesses accelerating the
transition to a more healthy, fair, safe, and low-carbon society. The round
also included participation from existing investors, including Threshold Ventures and Kapor Capital.
Clinical-First Commitment to Independent Primary Care
Independent primary care is one of the few areas in healthcare where upfront investment leads to significant savings in the long term. For every dollar spent on primary care, studies suggest that as much as $13 in downstream healthcare costs are avoided. Increased spending on primary care is also associated with fewer emergency department visits and reduced total hospitalizations and specialty interventions for chronic conditions such as diabetes, high blood pressure, and congestive heart failure
Elation Health was founded in 2010 after siblings Kyna and
Conan Fong struggled to help their father transition his solo primary care
practice from paper charts to a digital system. Born from that experience,
today Elation Health powers the largest network for independent primary care,
with 14,000 independent clinicians caring for seven million patients. The
company offers an EHR
solution, enterprise APIs, revenue cycle services, patient engagement app, and
access to interoperability partners.
The company surpassed a milestone this year of delivering more than 20 million in-office and virtual visits through its provider network. In addition to serving small practices, Elation has partnered with primary care innovators such as Crossover Health and Cityblock Health to provide the underlying clinical platform for technology-enabled, team-based care.
Helping Intendent Practices Shift to Virtual Care Amid The
In 2020, Elation Health’s customer base of independent
practices has faced significant business challenges as primary care shifts to
virtual settings and the pace of insurance and government policy change has
accelerated. The company has responded by expanding its role as a critical
technology partner — including adding HIPAA-compliant telehealth to its core
offering, deepening support for Medicare and Medicaid quality programs, and
delivering new patient engagement capabilities for patients to schedule
appointments and interact with practices. Elation’s API-enabled platform also
allows organizations to transform the patient and provider experience and
implement their own models of data-driven, value-based care.
In the year ahead, Elation Health will continue to invest in
its core platform, while adding new capabilities to support business operations
for independent primary care. The company has plans to develop solutions in
billing and payment collection, patient population management, interoperability,
and quality reporting — ensuring practices have the tools to drive high-quality
patient outcomes and business success.
The new Geographic Direct Contracting Model aims to improve quality of care and slash costs for Medicare beneficiaries across an entire region. It involves setting up risk-sharing arrangements where participants will be responsible for the total cost of care for beneficiaries in the region.
– San Francisco-based digital health startup Pair Team
emerges out of stealth with $2.7M in seed funding backed by Kleiner Perkins,
Craft Ventures, & YC.
– Pair Team provides both a remote team and AI that automates workflows, provides infrastructure & improves medical practices — efficiencies and billing as you’d expect, but all driving toward value-based, quality patient care.
– Pair’s wrap-around technology tripled the rate of annual wellness visits and increased revenue by 15% for clinics in 2020.
Pair Team (“Pair”) announced today it has
emerged out of stealth and has raised $2.7 million in seed funding backed by Kleiner Perkins, Craft Ventures, and YCombinator, along with other prominent
funds. Pair is an end-to-end operations platform for value-based primary care,
backed by Pair’s own care team. For patients, Pair provides a digital front door
and helps them navigate healthcare.
Automate Primary Care Operations Infrastructure
Founded in 2019 by Neil Batlivala and Cassie Choi, RN after experiencing how critical a high functioning administrative team is to provide high-quality primary care by building out operations together at leading tech-enabled practices of Forward and Circle Medical. The majority of healthcare is local and fragmented, and no solutions were built to enable existing clinics. Pair came out of that need and provides a simple yet comprehensive solution that covers the front, mid, and back-office. Their automation, along with a human-in-the-loop approach provides end-to-end operations of patient outreach, scheduling, e-forms, care gap reports, record requests, referrals, lab coordination, etc., to offload the traditional job functions of the front desk and medical assistants.
“Primary care is systematically and chronically under-resourced. Pair ensures patients receive the very best practices in health care — from annual checkups, follow-ups after hospital discharge, and preventative care screenings,” commented Neil Batlivala, CEO and co-founder of Pair Team. “We not only monitor patient data, but we go further to operationalize it with automation and our care team.”
Pair provides a revenue-sharing model to the share cost of operations with primary care providers. The platform monitors health plan and system data to trigger automated workflows that engage patients to schedule clinically impactful visits, surface care recommendations to clinicians, and manage follow-up care coordination. Their bolt-on model allows them to work as an extension of your care team within existing processes and accelerate quality programs in days, not months. For practices, this drastically improves care quality and visit efficiency. For plans, this aligns day-to-day operations with a total cost of care.
Helping Medicaid Populations Navigate Their Healthcare
Pair helps Medicaid populations navigate their healthcare with follow-ups, preventive cancer screening, and those recommendations on current (and ever-changing) Medicaid requirements. The company starts with existing processes and accelerates quality programs in days, not months.
Despite COVID and patient’s avoidance of medical offices and care, Pair’s wrap-around operations technology and care team tripled the rate of preventative care visits and are on track to increase clinical revenue by 15% by end of the year through quality incentives alone. To date, Pair manages care for thousands of Medicaid patients in southern California and has closed hundreds of care gaps with their remote care team.
Telehealth and virtual care are not brand-new phenomena suddenly cobbled together as a rapid response to the onset of the COVID-19 pandemic, but the average US patient could be forgiven for thinking that it is. Indeed, virtual visits to care providers and remote patient monitoring have been available for quite some time, delivering two key benefits:
– Providing a platform to address cost-efficiencies and accessibility to quality healthcare for the populace at large
– Playing a key role in managing a growing population of chronically ill seniors.
Prior to 2020, however, the rules of reimbursement and implementation for associated telehealth services were difficult to navigate, wildly differing at the state and federal level with a host of regulations further complicating matters. Federal reimbursement policies are centered on Medicare, via the Centers for Medicare and Medicaid Services (CMS) – the single largest payer for seniors and chronically ill patients. Additionally, compliance with the Health Insurance Portability and Accountability Act (HIPAA) dictated rigorous standards for direct and monitoring communications between care providers and patients. Complicating matters further, US states offered a patchwork of individual telehealth laws dictating separate Medicaid policies.
The result was a lack of clarity of how healthcare providers could overcome regulatory and financial reimbursement barriers to implement effective telehealth programs as well as a lack of parity in coverage services and payments for patients. To address this at the federal level, CMS released new guidance in 2020 to relax reimbursement restrictions for providers. Now, we’re at the cusp of a new era of telemedicine where providers could widely offer:
– Virtual office visits that address traditionally in-person services such as primary care, behavioral health, and specialty care (e.g. pulmonary or cardiac health rehabilitation)
– On-demand virtual urgent care to address pressing concerns and urgently needed consultations
– Virtual broader home health services such as remote patient monitoring, outpatient disease management, and various forms of therapy (e.g. physical, speech)
– Tech-enabled home medication administration helping patients receive injectable or consumable medication via monitored self-administration
This is all, of course, dependent upon the mobile technology (e.g. tablets, wearables, etc.) and associated services that telehealth providers will rely upon to make these services happen at parity and scale for their patients. Even more importantly, virtual care programs being scaled up to cover a larger percentage of patients will fall apart if providers don’t have the resources to offer robust support and maintenance options for these devices and services. Quality of virtual care is highly dependent on persistent device and service availability and dependability.
Whether providers have already begun purchasing the mobile devices needed or are still struggling with the choice of what devices and services they need and/or can afford, however, they now face a different quandary: How to stand up these virtual care services at scale in a sustainable way that works within current budget resources and doesn’t pass on ballooning costs to your patients?
One way to make complex mobile technology deployments financially manageable is opting for a mobile device as a service (mDaaS) model which allows you to shift from a CapEx-based spending model to an OpEx spending model for purchasing hardware and allows telehealth providers to bundle or roll up a range of devices, accessories, services, maintenance and support into a single, predictable monthly per-device price. With mobile device technology rapidly evolving, telemedicine providers will need the operational agility to pivot to different solutions and quick technology refreshes as the need arises.
When done with the right third-party partner, it offers the additional advantages of outsourcing end-to-end support and lifecycle management to highly trained agents, who can free up precious IT resources. Most importantly, it creates a level of control over technology and spend that makes standing up virtual care programs convenient and stress-free.
There are many options to consider when expanding telemedicine services rapidly to larger patient bases, whether during disruptive events such as the COVID-19 pandemic or in the years to come. The key to making these services sustainable is finding a financing model that will free up internal resources, offer greater spending flexibility, and offer end-to-end support for your healthcare mobile technology ecosystem.
About Don Godbee Senior Mobile Solutions Architect at Stratix
Don brings a unique perspective to mobility in the Healthcare Vertical with over 25 years of consulting and delivery of critical solutions. Don has delivered various solutions from OEM integration of sensors in medical devices to mobile point of care solutions and services with major EHR software solution providers such as Epic, Cerner, GE Healthcare, Allscripts, and McKesson.
Medicare provides significant health and financial protections to more than 60 million Americans, but there are gaps in coverage and high cost-sharing requirements that can make health care difficult to afford. This report analyzes several policy options that could help make health care more affordable for people covered by Medicare: adding an out-of-pocket limit to traditional Medicare, adding a hard out-of-pocket cap to Part D, expanding financial assistance through the Medicare Savings Programs, and expanding financial assistance through the Part D low-income subsidy program.
This brief outlines the potential health policy actions that President Biden could take using executive authority, based on campaign pledges, and actions that would reverse or modify regulations or guidance issued by the Trump Administration.
U.S. Representatives Brad Schneider (D-Ill.) and David McKinley (R-W.Va.) introduced the Medicare Sequester COVID Moratorium Act last week.
If passed, the bill would extend the temporary suspension of Medicare sequestration payment reductions, giving home health agencies and other providers more financial flexibility headed into an uncertain 2021.
Since 2014, the U.S. Centers for Medicare & Medicaid Services (CMS) has been cutting Medicare reimbursements to home health providers by 2%, as directly by Congress. Under the law, payments that exceed Medicare’s cap must be returned to CMS.
As part of a larger COVID-19 relief effort, home health providers received a reprieve from sequestration when the CARES Act passed in March. CMS suspended the 2% Medicare sequestration, effectively boosting reimbursement rates during a period some health care experts referred to as a “holiday.”
The provision is soon set to expire at the end of December, but the newly introduced legislation would extend the temporary suspension of Medicare sequestration to an undetermined date.
The aim of the bill is to help providers focus on responding to the COVID-19 emergency instead of financial challenges that may arise during this time.
“At a time when health care workers are on the front lines battling the COVID-19 pandemic, Congress should be doing everything within their power to ease their burden,” Rep. McKinley said in a statement. “America’s health care providers continue to be stretched thin and face serious financial challenges as a result of the economic and public health crisis.”
For many home health agencies, CMS pressing pause on Medicare sequestration payment reductions has ensured that they have the resources to provide care during the public health emergency while staying afloat financially.
If the legislation doesn’t pass, this could mean trouble for providers, Matt Wolfe, a partner at law firm Parker Poe, told Home Health Care News.
“The CARES Act’s temporary suspension of Medicare sequestration payment reductions has allowed home health providers to purchase PPE, train staff, and otherwise invest in keeping patients and staff safe during the pandemic,” Wolfe said. “If this bill does not become law and the sequestration is reinstated, it will be a devastating blow for home health providers at a terrible time.”
With this in mind, the bill has also drawn support from organizations such as the Partnership for Quality Home Healthcare (PQHH).
“The Partnership, alongside the broader home health community and every other provider sector, is supportive of extending the suspension of the 2% sequestration cut for Medicare providers,” Joanne Cunningham, executive director of PQHH, told HHCN. “With COVID cases on the rise, the entire health care system continues to be challenged.”
Suspending the 2% reduction beyond 2020 is “a prudent step” that will provide much-needed support to the entire Medicare provider community and patients, she added.
PQHH is a home health care advocacy organization based in Washington, D.C.
Additionally, the bill has garnered support from organizations including the American Association for Homecare, LeadingAge, the Visiting Nurse Associations of America and the National Association for Home Care & Hospice (NAHC).
“We see an extension of the sequestration moratorium as a high priority for all Medicare providers in order to preserve our very fragile health care system,” NAHC President William A. Dombi told HHCN. “Reducing payments to health care providers, already stressed to a breaking point during the height of the pandemic, will add unnecessary risks to care.”
As if 2020 couldn’t be
any more challenging for healthcare providers, new federal rules on
interoperability and patient access, granting patients direct access to their healthcare
data, begin taking effect this November and continue into 2022. These rules,
while ultimately beneficial to patients, bring an additional level of
operational complexity to many revenue-stressed healthcare organizations.
If anything, the 2020 pandemic has illustrated the vast potential of interoperability. For example, consider the huge increase in 2020 in virtual care visits, projected to be more than 1 billion by year’s end, and with an estimated 90% related to Covid-19. Many of these new virtual health patients will move through different care networks, using different health plans, and seeking remote access to their health records. These are precisely the type of patients’ interoperability is meant to help.
What should healthcare providers be doing now to ensure they’re not only compliant with new interoperability rules, but also applying them as optimally as possible to benefit their patients and organizations? In this article, we review the upcoming rules and suggest five key steps providers can take to ensure their interoperability implementations proceed as smoothly as possible.
What’s Ahead with
After several years of discussion on interoperability standards, the Office of the National Coordinator (ONC) for Healthcare IT and the Centers for Medicare & Medicaid Services (CMS) issued their final rules on interoperability in the spring of 2020. The new rules, covering both health systems and health plans, are intended to ensure that patients can electronically access their healthcare information regardless of health system or type of electronic health records (EHR) and covering all CMS-regulated plan types, including Medicare Advantage, CHIP, and the Federally Facilitated Exchanges.
Starting Nov. 2, 2020, healthcare systems must begin complying with interoperability rules preventing information blocking, which means not interfering with patients’ access to or use of their electronic health information. Providers must also attest they are acting “in good faith” regarding preventing information blocking, with any non-compliance flagged on the National Plan and Provider Enumeration System. By May 1, 2021, hospitals, psychiatric hospitals, and critical access hospitals with an EHR must send notification of their patients’ admission, discharge, and transfer (ADT) events to providers.
Interoperability will replace the current fragmented and error-prone ways of exchanging vital healthcare information. Near-term benefits of interoperability include improved care coordination and patient experience, greater patient safety, and stronger patient privacy and security. Longer-term benefits include higher provider productivity, reduced healthcare costs, and more accurate public health data.
For providers, the good
news about interoperability is that they’ve had years to think about and
implement many of its fundamental tenets, based on their work meeting
meaningful use requirements. That’s borne out in a 2019 HIMSS survey of
healthcare organizations which found nearly 75% of respondents past the
“foundational” level of interoperability – “foundational” defined as allowing
data exchange from one IT
system to another, but without data interpretation.
Five Steps for
While healthcare systems
will achieve significant interoperability gains through technology investments,
they should not consider technology as the ultimate sole key to
interoperability success. If anything, financial and political considerations
may be far more important to your organization’s interoperability success. Here
are five critical non-technology factors to consider:
1. Determine your “master”
All pertinent stakeholders in your organization should be on the same page about your interoperability strategy, resources, and timing. Know up-front that those implementing interoperability may not have previously worked with patient-centric analytics, partners, or departments in your organization. Plan your resources and timing accordingly. Your strategy should focus on the value-add of interoperability internally, such as access to additional data points on your patients, and externally, such as how you describe the upcoming benefits of interoperability to your patients.
2. Convey your vision, expectations
and expected return
An interoperability implementation is
a massive change management initiative, which requires continuous, top-down
leadership and championship, and proper expectation-setting. Communicate where
your organization currently stands regarding its interoperability capabilities,
and where you wish to have it go. Convey how the organization plans to get to
its future desired state. And perhaps most importantly, share the likely return
on investment in this effort. Be as specific as possible. For example, if you
believe interoperability gains will ultimately enable a 5% decrease in your
hospital readmissions, state that.
3. Examine workflows and identify
specific use cases
Every type of ADT event in your
organization, and its corresponding workflows and system interactions, should
be under review. Consider all types of clinical use cases, the types of data to
be exchanged, and those involved in providing patient care. This will help
determine your optimal approach to data-sharing and how your organization can
strategically use the additional data you receive from other health
4. Rigorously prep your data
Standardized data collection and reporting
which produces quality data is the heart and soul of successful
interoperability. Be sure your organization’s data is clean and meaningful, and
will ultimately be understandable and useful to your patients.
5. Think big-picture differentiation
There’s nothing in the ONC and CMS
interoperability rules that says you need to stop at mere rules compliance.
Consider your pursuit of interoperability as a singular opportunity to be a
patient-centric leader in your market. Let everyone relevant know of the
success you’ve achieved.
offers a chance for healthcare systems to achieve multiple operational gains,
when handled well, it is ultimately a patient-centric endeavor. Always keep the
needs and interests of your patients at the core when facilitating access to
their personal health data. It’s the ultimate smart long-term interoperability
The home health industry is in a “dynamic state” and evolving into “multiple types of care,” according to the Medicare Payment Advisory Commission (MedPAC).
As a result, health care policymakers should start thinking about how to redesign the traditional home health benefit to make it more nimble, perhaps by breaking it up into pre-acute and post-acute categories.
“Like all the other sectors, [home health agencies] are not only in a dynamic state given COVID-19, but also given consolidation and a change in the role of home health in the orbit of the care continuum,” commissioner Karen DeSalvo, the chief health officer at Google Health, said Friday. “It’s going to be an interesting few years, as we continue to understand whether home health is one sector, or if it’s evolving into one … where there’s multiple pieces.”
DeSalvo’s comments came during MedPAC’s December 2020 public meeting, held virtually this year due to the COVID-19 pandemic. In addition to the changing nature of home health care, MedPAC’s 17 commissioners also discussed the Patient-Driven Groupings Model (PDGM), agency margins, future payment recommendations and more.
MedPAC was established by the Balanced Budget Act of 1997 with the purpose of advising Congress on Medicare issues. The commission publicly meets numerous times each year to discuss Medicare issues and policy questions.
The idea that home health care has turned into something more than a post-acute service is not new. Industry leaders have been pointing that out for years.
“We don’t like to use the word post-acute anymore,” LHC Group Inc. (Nasdaq: LHCG) Chairman and CEO Keith Myers told Home Health Care News in 2016. “We say regularly now that we’re not post-acute. We’re ‘non-acute.’”
MedPAC’s own data supports that claim. In 2018, about two-thirds of home health episodes were not preceded by a hospitalization or post-acute care stay, according to its latest data book, released in July.
Yet it’s not just the pre- or post-acute dichotomy that is catching MedPAC’s attention in regard to a benefit redesign.
During Friday’s meeting, the commission also discussed how home health agencies are playing vital roles in hospital-at-home models and in efforts to divert patients away from skilled nursing facilities (SNFs).
“I think one of the interesting challenges of home health is that it seems to be evolving into multiple types of care,” commissioner Amol Navathe, co-director of the Healthcare Transformation Institute at the University of Pennsylvania’s School of Medicine, said at the meeting. “We’ve heard already that there are developments in hospital-at-home, how many of the [alternative payment models] models like bundled payments are starting to shift patients from SNF to home health, which perhaps means that the acuity of patients in the home health care setting is also evolving, to some extent.”
Moving forward, MedPAC should take a deep dive into home health nuances to see if it makes sense to revisit the benefit.
‘A lifesaver for our system’
Commissioner Susan Thompson — interim president and CEO of UnityPoint Health, an integrated delivery system serving Iowa and parts of IIllinois — has witnessed the evolution of home health care firsthand.
The ability to deliver hospital-level care in the home has been a game changer over the past few months, Thompson noted.
“Hospital-at-home has been literally a lifesaver in our system, as we have used this program to decant patients who have low-intensity, chronic illness with exacerbation of symptoms, moving them to the home with monitoring equipment to make beds for patients that are in our emergency room,” she said. “It’s not surprising, folks like to be at home.”
Mount Sinai Health System, Massachusetts General, Mercy Hospital and the Huntsman Cancer Institute are among some of the other organizations to have received a hospital-at-home waiver.
Many health care leaders expect that list to grow in days to come.
“I anticipate we’re going to have a demand for this kind of a service going forward,” Thompson said.
Home health Medicare margins
Apart from home health care’s larger transformation, MedPAC also highlighted several key statistics about the industry.
In 2019, home health fee-for-service Medicare expenditures totaled $17.8 billion, distributed across over 11,300 agencies. As the landscape stands, beneficiaries currently maintain strong access to home health services, with 86% living in a ZIP code served by five or more agencies, according to MedPAC.
As has been the case in the past, MedPAC also pointed to the seemingly high margins in home health care.
In 2019, the Medicare marginal profit for all home health agencies was 18%, according to the commission. The all-payer margin for agencies, however, was just 5.9%.
“This type of the trend by type of provider is similar to what we have found in previous years,” MedPAC analyst Evan Christman said. “The for-profit agencies have higher margins than nonprofits, and urban agencies having higher profits than rurals.”
Meanwhile, the median Medicare margin for “efficient providers” — or those that meet certain cost and quality criteria — was 23.4% in 2019. There was a total of 532 efficient home health agencies last year — about 14% of the industry overall.
– CommonHealth has connected to 230
health systems in the United States, allowing patients to gather, manage and
share their health and test data, including COVID test and vaccination status. By
the end of this month, CommonHealth will connect to more than 340 health
– CommonHealth extends the health data
portability and interoperability model pioneered by Apple Health to the 55
percent of Americans with Android devices (85 percent globally)
The Commons Project, a nonprofit public trust established to build digital platforms and services for the public good, today announced that the CommonHealth app has now connected to 230 health systems in the United States, allowing patients using those health systems to gather, manage and share personal health information – including COVID test and vaccine status – on Android devices for free. CommonHealth enables broader and more equitable participation in remote consultations with doctors, telemedicine, innovative care models, next-generation health services, and research.
CommonHealth App Development Background
Developed in collaboration with UCSF, Cornell Tech, and Sage Bionetworks with a team of clinicians, public health experts, technologists, scientists and privacy advocates, CommonHealth is operated by The Commons Project. CommonHealth was first deployed at UCSF Health and underwent substantial testing and user experience research in multiple diverse populations in San Francisco. CommonHealth is the first and only platform designed to allow users of the Android operating system to collect and manage their health data on their mobile devices in a similar way that Apple Health Record operates on iOS.
Already integrated with LabCorp, which
operates one of the largest clinical laboratory networks in the world,
CommonHealth allows individuals to store their COVID test results and vaccination
status, in addition to any health record. CommonHealth plans to integrate with
an additional 110 health systems in December, connecting to more than 340
health systems before the year ends.
Earlier this year, the Center for Medicare and Medicaid (CMS) rolled out new patient health record sharing rules that will require hospitals and physician offices to send standardized medical information, such as lab test results, vaccination records, and imaging tests, directly to third-party apps, like CommonHealth, by July 2021.
Why It Matters
“The COVID pandemic has accelerated the need for the safe sharing of health data as medical consultations go online and individuals are required to demonstrate COVID test and vaccination status in order to travel, work, study and undertake other social activities,” said JP Pollak, co-founder and chief architect at The Commons Project. “CommonHealth extends the privacy-centered data portability and interoperability model pioneered by Apple Health to the 55 percent of Americans who have Android devices.”
When doctors know their patients have been to the hospital, they can act fast to provide needed support. Widespread use of hospital event notifications is associated with all kinds of health benefits, including a 10 percent decrease in readmissions for Medicare beneficiaries. These event notifications are one of the simplest, easiest (most-bipartisan!), and most impactful changes we can make to improve patient outcomes in U.S. healthcare.
To this goal, the Centers for Medicare and Medicaid Services (CMS) released new regulations in March that will require hospitals to share event notifications with community providers when a patient is admitted, discharged, or transferred (ADT). Hospitals have to comply by May 2021 if they want to keep getting paid by Medicare and Medicaid.
This policy will improve care, reduce costs, and save lives. It’s also simple and straightforward. CMS explains, “Lack of seamless data exchange in healthcare has historically detracted from patient care, leading to poor health outcomes, and higher costs.” ADT notifications close these gaps and many healthcare organizations have been using them for years, vastly improving care for patients.
Take the Utah Health Information Network (UHIN) which has utilized ADT notifications to reduce costs and readmissions for over a decade. According to the former UHIN President and CEO, Teresa Rivera,
“This level of care coordination quite literally saves both lives and money.” She continues, “This secure and cost-effective method provides the patient’s entire medical team, regardless of where they work, with the important information they need to coordinate care. That coordination is important to reducing readmission rates, and helps health care professionals provide a better experience to patients.”
ADT notifications are a standard set of messages that most electronic health record (EHR) systems can generate with minimal set-up. In fact, in a 2019 letter from the National Association of ACOs in support of CMS’ proposal to require hospitals participating in Medicare and Medicaid to send event notifications, they expressed that new standards efforts are not needed for the successful implementation.
The authors wrote, “In numerous conversations with HIEs, other intermediaries and providers, we were unable to find a single example where a hospital was unable to send an ADT notification today due to lack of standards.”
But you wouldn’t know it if you listened to the misconceptions that are currently being spread to hospitals about this requirement. Here are five myths that I’ve encountered just this month:
Myth 1: The ADT notification policies are strict and difficult to comply with. Not true. CMS listened to feedback that Meaningful Use requirements were too regimented and promoted a “check the box” not “get it done” mentality. CMS purposely worked to keep these ADT requirements broad and non-prescriptive. Hospitals don’t need to comply with any specific technical standard. The CMS regulations released in March are final.
Myth 2: You have to connect to a nationwide network. Wrong. Hospitals can choose from a wide variety of regional and statewide health information exchange (HIE) partners. The policy requires “reasonable effort” to send notifications to providers in your community. An intermediary can be used to comply with the rule as long as it “connects to a wide range of recipients.” Unlike what some nationwide companies are saying, the regulations do not mandate out-of-state alerts.
Myth 3: The policy creates a big technical burden for hospitals. More than 99 percent of hospitals have EHR systems in place today, and most of those can produce standard ADT transactions with relatively minimal effort. While the time to activate ADT notifications varies, it can usually be done in as little as a day by a hospital IT team.
Myth 4: The timing isn’t right. It’s happening too fast. A global pandemic is exactly the moment when we need this kind of data sharing in our communities. With COVID-19, it is even more crucial that care teams are alerted promptly when a patient is seen in the emergency department or discharged from the hospital so that they can reach out and provide support. Regardless, CMS has given an additional six months of enforcement discretion for hospitals, pushing back the deadline to May 2021.
Myth 5: There’s no funding available for this work. Wrong again. In California and several other states, hospitals can take advantage of public funding to connect to regional HIEs that provide ADT notification services. There’s $50 million in funding available just in California.
This new policy is an exciting step forward for patients and providers. It gives primary care and post-acute providers crucial, needed information to improve patient care. Hospitals can meet the requirements with minimal burden using existing technologies. Patients will have a more seamless experience when they are at their most vulnerable.
In healthcare, it’s easy to assume that great impact requires great complexity. But time and again the opposite is true. So let’s bust the myths, get it done, and keep it simple.
About Claudia Williams
Claudia Williams is the CEO of Manifest MedEx. Previously the senior advisor for health technology and innovation at the White House, Claudia helped lead President Obama’s Precision Medicine Initiative. Before joining the White House, Claudia was director of health information exchange at HHS and was director of health policy and public affairs at the Markle Foundation.
As mission-driven organizations, SCAN Group and SCAN Health Plan have leaned into trying to solve some of health care’s biggest problems. In particular, keeping seniors independent and healthy at home has been a major area of focus.
SCAN Group is a nonprofit organization focused on helping older adults age in place. Founded in 1977, Long Beach, California-based SCAN Health Plan is one of the nation’s largest not-for-profit Medicare Advantage plans, serving more than 200,000 members.
In June, Dr. Sachin Jain took the helm as CEO and president of SCAN Group. When coming on board, Jain — who previously served as CEO of Aspire Health and CareMore Health — saw an opportunity to take on problems that other organizations in its position may not attempt to tackle.
“I had a tremendous experience leading Aspire and CareMore but felt like I could do more for the U.S. health care system writ large from a platform like SCAN, which is very ambitious in its bones,” Jain told Home Health Care News.
As of late, SCAN Group has zeroed in on addressing the “digital divide” through its HEALHtech benefit.
In light of the COVID-19 emergency, telehealth has emerged as a critical means of delivering care services. Home health providers, for example, have embraced virtual care more than ever before.
Despite telehealth’s role in providing safe care delivery during the pandemic, SCAN Group noticed that, for some seniors, a lack of comfort with digital technologies became a barrier to receiving these services.
“We recognize the need,” Josh Goode, CIO of SCAN Health Plan, told HHCN. “Our seniors were being forced into this digital world, and there is a digital literacy gap. We see a lot of older adults who are, what I would consider, tech-savvy, but there is still a pretty sizable population that is struggling in a digital world.”
SCAN Group’s HEALHtech benefit offers its members free tech support. This can include things like setting up email accounts or installing video conference technologies.
As part of the benefit, the organization also helps older adults learn to navigate their providers’ online health systems.
The benefit has its origins in a technology support line SCAN Group set up for its members after the onset of the COVID-19 emergency.
“We did a pilot where we would triage the calls of those members that were needing support, accessing a telehealth visit or anything else — from a digital standpoint — to help enable them getting care in the home,” Goode said. “We would support them, and it’s been wildly successful.”
The benefit is still in the pilot phase but will officially be available in 2021.
The current embrace of telehealth during the COVID-19 emergency will be the new normal moving forward. That’s because 2020 has allowed providers to become more comfortable with this form of care delivery, according to Jain.
“I think it’s a little bit of an unknown, in terms of what form or fashion, or how widely adopted it will be, but I think [telehealth] is here to stay,” he said. “Obviously, reimbursement plays into this. We’ll see what happens in the long run, but … everybody recognizes the need to deliver care in the home and break down those barriers to access. People are recognizing how effective telehealth can be.”
Looking ahead, SCAN Group will continue to make home-based care a priority.
“We believe that the home is where most people want to stay,” Jain said. “We believe that bad things happen to seniors when they actually step out of their homes to access care. They are exposed to hospital-acquired infections. The orientation of SCAN has always been around [keeping] people in the home.”
To this end, the organization is in the process of launching a home-based geriatric primary care medical group that will include hospital-at-home and primary care services.
“We believe that geriatrics is a medical specialty whose time has really come,” Jain said. “Historically, geriatrics has been something that has been made available to seniors after they’ve had a primary care relationship with someone for a while And as a result, very few patients actually transition in their older age from primary care to geriatric care.”
SCAN Group also has plans to enter the palliative care space. Additionally, the organization is focused on building innovative solutions to address homeless seniors.
As Washington policymakers look to make changes to Medicare and our health care system overall, there are right ways and wrong ways to address the challenges that seniors and patients face. Indeed, as part of the 2020 election, voters made it clear what they want Washington policymakers to focus on: Addressing COVID-19 and concerns around pre-existing conditions and out-of-pocket costs.
Last month, the administration released the “Most Favored Nation” (MFN) rule, which allows foreign governments to decide the value of Part B medicines, while also likely limiting seniors’ access to existing medicines and discouraging investments in future treatments and cures. No matter how you look at it, the MFN rule is bad policy.
The US government has introduced a scheme to allow hospitals to reduce the number of inpatients they see through a telehealth platform that would helps deliver acute care at home.
The move comes as the number of new cases of COVID-19 have been climbing to around 180,000 a day, with deaths since the start of the pandemic now rising above 260,000, and concerns that some hospitals could become overwhelmed over the winter months.
The Centres for Medicare & Medicaid Services (CMS) announced the plans as part of broad plan to free up hospital capacity amid the COVID-19 surge, although it stressed patients won’t have to use the service unless they want to, and the first assessment by a physician must take place in person.
It said that treatment for more than 60 different acute conditions, including asthma, heart failure, pneumonia and chronic obstructive pulmonary disease (COPD), can be carried out “appropriately and safely in home settings with proper monitoring and treatment protocols.”
The new telehealth scheme applies to patients with conditions that require at least daily visits by a physician and ongoing medical team monitoring.
Six health systems across the country have already been approved to participate in the programme, getting the necessary Medicare waivers to allow them to treat patients at home.
They are Brigham and Women’s Hospital in Massachusetts, Massachusetts General Hospital, Huntsman Cancer Institute in Utah, Mount Sinai Health System in New York City, Presbyterian Healthcare Services in New Mexico, and Iowa’s UnityPoint Health.
Participating hospitals must have screening protocols in place before care at home begins, to assess that patients have access to working utilities, ensure there are no other physical barriers to care, and rule out welfare concerns such as a risk of domestic violence.
The US healthcare system has rapidly adopted telehealth and remote patient monitoring during the response to the coronavirus pandemic, with some suggesting it will transform the future of health care delivery, although there are dissenting voices.
In March 13, President Trump made an emergency declaration that empowered the CMS to issue waivers to Medicare programme requirements to support healthcare providers and patients during the crisis.
Since then, the CMS has added dozens of services to the list of telehealth services it will reimburse during the public health emergency, including emergency department visits, initial nursing facility and discharge consultations, home visits, and physical, occupational and speech therapy services.
Some of the changes have found their way into the proposed 2021 Physician Fee Schedule, which will make reimbursement for some telehealth and digital services permanent.
“We’re at a new level of crisis response with COVID-19 and CMS is leveraging the latest innovations and technology to help healthcare systems that are facing significant challenges to increase their capacity to make sure patients get the care they need,” said CMS Administrator Seema Verma.
“With new areas across the country experiencing significant challenges to the capacity of their health care systems, our job is to make sure that CMS regulations are not standing in the way of patient care for COVID-19 and beyond,” she added.
Healthcare can achieve optimum efficiency when patients are at the center of care. When patients have the necessary information to navigate their care journey, they will choose the path to high-quality care at the lowest costs. Cost-sharing and insurance premiums are rising consistently since the last decade for employer plans, which covers nearly half of the country’s population. Plan members are shouldering a part of the healthcare cost burden, so they want to keep it as low as possible. At the same time, they want maximum value for their money with access to quality care.
CMS identified this as an opportunity and issued the Final Interoperability and Patient Access rule. The rule allows patients to access electronic health data through any third-party application of their choice. The rule intends to allow patients to take control of their data and determine who can see which data. It will also make transferring data from provider to provider easier. So that patients can be ensured that their provider is fully aware of their medical history.
The Challenge of Providing Members Access to Healthcare Data
The biggest challenge that health plans will face is to extract data from multiple sources in-house, clean and scrub it, and ensure it is in the appropriate format as required by the Centers for Medicare and Medicaid Services (CMS). Some health plans have been in business for a really long time. Patient data has been accumulating through these years in legacy systems. Providing access to that data through certified third-party applications will require a lot of effort on the part of health plans. The health plans also have to ensure tight authentication standards so that only the people requested by the members have access to their healthcare data.
In addition, there are multiple problems associated with provider data. Incorrect data in the provider database costs close to $3 billion annually. CMS has also issued warnings for inaccurate provider directories, high claim-reprocessing volumes, and substantial encounter-data rejection rates. Payers have been addressing the data issues with short term solutions. But now they have to resolve the provider data problems for good and make health data readily available to the members.
The COVID Crisis Upended The Payer Compliance Initiatives
Payers are in solidarity with providers and patients in this time of crisis. While providers work tirelessly to help an increased number of patients access the required care, payers are providing support through fast track reimbursements and reduced utilization management.
Many health plans are focused on ensuring that their members have access to resources to fight COVID, which is why CMS extended the deadline for the Final Interoperability rule. Utilization patterns are witnessing a significant change. Many members are not receiving scheduled care as some elective surgeries are rescheduled and some provider offices are shut down. There has been a drop in certain kinds of utilization. Conversely, there has been a dramatic surge in telehealth office visits and behavioral health services.
The Road Ahead for Health Plans
Healthcare payers have endured significant claims-based, economic, and operational challenges during the pandemic. While they battle those bottlenecks, they also have to ascertain and prepare for the future and devise ways to ensure that their members have access to quality care.
Health plans will have to try to anticipate what utilization patterns will look like in the future, especially in the next year. Telehealth utilization will not be the same as it was pre-COVID. They will also have to ensure that members have access to care. They will have to reach out to members, especially those who are the most vulnerable. They will have to make sure members are not suffering from social isolation, they are taking their medication and they have access to transportation to get to the doctor.
Provider Alliance for CMS Compliance
CMS is handing over the reins of the care journey to the patients to improve care delivery through the Interoperability rule. Providers will play a key role in enabling access to healthcare data to patients by streamlining data and closing coding gaps. Payers must assist providers with their data needs to ensure compliance with the CMS rules.
As the pandemic ends and CMS comes out with more definitive long term rules and coverages, it is going to be important to ensure that providers are on the same page with payers. Health plans can partner with providers to educate them about the acceptable telehealth codes and what type of services are to be performed using those codes. Providers want to take care of their patients and they want to do it well. They want to leverage technology to ensure patient access to care and ensure their safety, especially for patients who suffer from multiple comorbidities.
About Elizabeth Bierbower
Elizabeth Bierbower is a strategic leader with more than thirty years of executive experience in the health insurance industry. She has experience scaling cost-effective and profitable growth strategies through internal innovation, and a reputation as being one of the industry’s most fiscally responsible and progressive leaders. Bierbower currently serves on the Boards of Iora Health, the American Telemedicine Association, and is on Innovaccer’s Strategic Advisory.
Previously Beth was a member of Humana’s Executive Management Team and held various roles including Segment President, Group and Specialty Benefits, and was an Enterprise Vice President leading Humana’s Product Development and Innovation teams.
Senior isolation is a health risk that affects at least a quarter of seniors over 65. It has become recognized over the past decade as a risk factor for poor aging outcomes including cognitive decline, depression, anxiety, Alzheimer’s disease, obesity, hypertension, heart disease, impaired immune function, and even death.
Physical limitations, lack of transportation, and inadequate health literacy, among other social determinants of health (SDOH), further impair access to medical and mental health treatment and preventive care for older adults. These factors combine to increase the impact of chronic comorbidities and acute issues in our nation’s senior population.
COVID-19 exacerbates the negative impacts of social isolation. The consequent need for social distancing and reduced use of the healthcare system due to the risk of potential SARS-CoV-2 exposure are both important factors for seniors. Without timely medical attention, a minor illness or injury quickly deteriorates into a life-threatening situation. And without case management, chronic medical conditions worsen.
Among Medicare beneficiaries alone, social isolation is the source of $6.7 billion in additional healthcare costs annually. Preventing and addressing loneliness and social isolation are critically important goals for healthcare systems, communities, and national policy.
Organizations across the healthcare spectrum are taking a more holistic view of patients and the approaches used to connect the most vulnerable populations to the healthcare and community resources they need. To support that effort, technology is now available to facilitate analysis of the socioeconomic and environmental circumstances that adversely affect patient health and mitigate the negative impacts of social isolation.
Addressing Chronic Health Issues and SDOH
When we think about addressing chronic health issues and SDOH in older adults, it is usually after the fact, not focused on prevention. By the time a person has reached 65 years of age, they may already be suffering from the long-term effects of chronic diseases such as diabetes, hypertension or heart disease. Access points to healthcare for older adults are often in the setting of post-acute care with limited attention to SDOH. The focus is almost wholly limited to the treatment and management of complications versus preventive measures.
Preventive outreach for older adults begins by focusing on health disparities and targeting patients at the highest risk. Attention must shift to care quality, utilization, and health outcomes through better care coordination and stronger data analytics. Population health management technology is the vehicle to drive this change.
Bimodal Outreach: Prevention and Follow-Up Interventions
Preventive care includes the identification of high-risk individuals. Once identified, essential steps of contact, outreach, assessment, determination, referral, and follow-up must occur. Actions are performed seamlessly within an organization’s workflows, with automated interventions and triggered alerts. And to establish a true community health record, available healthcare and community resources must be integrated to support these actions.
Social Support and Outreach through Technology
Though older adults are moving toward more digitally connected lives, many still face unique barriers to using and adopting new technologies. So how can we use technology to address the issues?
Provide education and trainingto improve health literacy and access, knowledge of care resources, and access points. Many hospitals and health systems offer day programs that teach seniors how to use a smartphone or tablet to access information and engage in preventive services. For example, connecting home monitoring devices such as digital blood pressure reading helps to keep people out of the ED.
Use population health and data analyticsto identify high-risk patients. Determining which patients are at higher risk requires stratification at specific levels. According to the Centers for Disease Control and Prevention, COVID-19 hospitalizations rise with age, from approximately 12 per 100,000 people among those 65 to 74 years old, to 17 per 100,000 for those over 85. And those who recover often have difficulty returning to the same level of physical and mental ability. Predictive analytics tools can target various risk factors including:
– Recent ED visits or hospitalizations
– Presence of multiple chronic conditions
– Food insecurity, housing instability, lack of transportation, and other SDOH
– Frailty indices such as fall risk
With the capability to identify the top 10% or the top 1% of patients at highest risk, care management becomes more efficient and effective using integrated care coordination platforms to assist staff in conducting outreach and assessments. Efforts to support care coordination workflows are essential, especially with staffing cutbacks, COVID restrictions, and related factors.
Optimal Use of Care Coordination Tools
Training and education of the healthcare workforce is necessary to maximize the utility of care coordination tools. Users must understand all the capabilities and how to make the most of them. Care coordination technology simplifies workflows, allowing care managers to:
– Risk-stratify patient populations, identify gaps in care, and develop customized care coordination strategies by taking a holistic view of patient care.
– Target high-cost, high-risk patients for intervention and ensure that each patient receives the right level of care, at the right time and in the right setting.
– Emphasize prevention, patient self-management, continuity of care and communication between primary care providers, specialists and patients.
This approach helps to identify the resources needed to create community connections that older adults require. Data alone is insufficient. The most effective solution requires a combination of data analytics to identify patients at highest risk, business intelligence to generate interventions and alerts, and care management workflows to support outreach and interventions.
About Dr. Jenifer Leaf Jaeger
Dr. Jenifer Leaf Jaeger serves as the Senior Medical Director for HealthEC, a Best in KLAS population health and data analytics company. Jenifer provides clinical oversight to HealthEC’s population health management programs, now with a major focus on COVID-19. She functions at the intersection of healthcare policy, clinical care, and data analytics, translating knowledge into actionable insights for healthcare organizations to improve patient care and health outcomes at a reduced cost.
Prior to HealthEC, Jenifer served as Director, Infectious Disease Bureau and Population Health for the Boston Public Health Commission. She has previously held executive-level and advisory positions at the Massachusetts Department of Public Health, New York City Department of Health and Mental Hygiene, Centers for Disease Control and Prevention, as well as academic positions at Harvard Medical School, Boston University School of Medicine, and the Warren Alpert Medical School of Brown University.
If you’ve been watching TV lately, you may have seen actor Danny Glover or Joe Namath, the 77-year-old NFL legend, urging you to call an 800 number to get fabulous extra benefits from Medicare.
There are plenty of other Medicare ads, too, many set against a red-white-and-blue background meant to suggest officialdom — though if you stand about a foot from the television screen, you might see the fine print saying they are not endorsed by any government agency.
Rather, they are health insurance agents aggressively vying for a piece of a lucrative market.
This is what Medicare’s annual enrollment period has come to. Beneficiaries — people who are 65 or older, or with long-term disabilities — have until Dec. 7 to join, switch or drop health or drug plans, which take effect Jan. 1. By switching plans, they can potentially save money or get benefits not ordinarily provided by the federal insurance program.
For all its complexity and nearly endless options, Medicare fundamentally boils down to two choices: traditional fee-for-service or the managed care approach of Medicare Advantage.
The right choice for you depends on your financial wherewithal and current health status, and on future health scenarios that are often difficult to foresee and unpleasant to contemplate.
“I’ve been doing it for 33 years and my head still spins,” says Jill Selby, corporate vice president of strategic initiatives and product development at SCAN, a Long Beach nonprofit that is one of California’s largest purveyors of Medicare managed care, known as Medicare Advantage. “It’s definitely a college course.”
Which explains why airwaves and mailboxes are jammed with all that promotional material from people offering to help you pass the course.
Many are touting Medicare Advantage, which is administered by private health insurers. It might save you money, but not necessarily, and research suggests that, in some cases, it costs the government more than administering traditional Medicare.
But the hard marketing is not necessarily a sign of bad faith. Licensed insurance agents want the nice commission they get when they sign somebody up, but they can also provide valuable information on the bewildering nuances of Medicare.
Industry insiders and outside experts agree most people should not navigate Medicare alone. “It’s just too complicated for the average individual,” says Mark Diel, chief executive officer of California Coverage and Health Initiatives, a statewide association of local outreach and health care enrollment organizations.
However, if you decide to consult with an insurance agent, keep your antenna up. Ask people you trust to recommend agents, or try eHealth or another established online brokerage. Vet any agent you choose by asking questions on the phone.
“Be careful if you feel like the insurance agent is pushing you to make a decision,” says Andrew Shea, senior vice president of marketing at eHealth. And if in doubt, don’t hesitate to get a second opinion, Shea counsels.
You can also talk to a Medicare counselor through one of the State Health Insurance Assistance Programs, which are present in every state. Find your state’s SHIP at www.shiptacenter.org.
The website offers a deep dive into all aspects of Medicare. If you type in your ZIP code, you can see and compare all the Medicare Advantage plans, supplemental insurance plans, known as Medigap, and stand-alone drug (Part D) plans.
The site also shows you quality ratings of the plans, on a five-star scale. And it will display your drug costs under each plan if you type in all your prescriptions. Explore the website before you talk to an insurance agent.
California Coverage and Health Initiatives can refer you to licensed insurance agents who will provide local advice and enrollment assistance. Call 833-720-2244. Its members specialize in helping people who are eligible for both Medicare and Medicaid, the health insurance program for low-income people.
These so-called dual eligibles — nearly 1.5 million in California and about 12 million nationwide — get additional benefits, and in some cases they don’t have to pay Medicare’s monthly medical (Part B) premium, which will be $148.50 in 2021 for most beneficiaries, but higher for people above certain income thresholds.
If you choose traditional Medicare, consider a Medigap supplement if you can afford it. Without it, you’re liable for 20% of your physician and outpatient costs and a hefty hospital deductible, with no cap on how much you pay out of your own pocket. If you need prescription drugs, you’ll probably want a Part D plan.
Medicare Advantage, by contrast, is a one-stop shop. It usually includes a drug benefit in addition to other Medicare benefits, with cost sharing for services and prescriptions that varies from plan to plan. Medicare Advantage plans typically have low to no premiums — aside from the Part B premium that most people pay in either version of Medicare. And they increasingly offer additional benefits, including vision, dental, transportation, meal deliveries and even coverage while traveling abroad.
Beware of the risks, however.
Yes, the traditional Medicare route is generally more expensive upfront if you want to be fully covered. That’s because you pay a monthly premium for a Medigap policy, which can cost $200 or more. Add to that the premium for Part D, estimated to average $41 a month in 2021, according to KFF. (KHN is an editorially independent program of KFF.)
However, Medigap policies will often protect you against large medical bills if you need lots of care.
In some cases, Medicare Advantage could end up being more expensive if you get seriously ill or injured, because copays can quickly add up. They are typically capped each year, but can still cost you thousands of dollars. Advantage plans also typically have more limited provider networks, and the extra benefits they offer can be subject to restrictions.
The main appeal of traditional Medicare is that it doesn’t have the rules and restrictions of managed care.
Dr. Mark Kalish, a retired psychiatrist in San Diego, says he opted for traditional fee-for-service with Medigap and Part D because he didn’t want a “mother may I” plan.
“I’m 69 years old, so heart attacks happen; cancer happens. I want to be able to pick my own doctor and go where I want,” Kalish says. “I’ve done well, so the money isn’t an issue for me.”
Be aware that if you don’t join a Medigap plan during a six-month open enrollment period that begins when you enroll in Medicare Part B, you could be denied coverage for a preexisting condition if you try to buy one later.
There are a few exceptions to that in federal law, and four states — New York, Massachusetts, Maine, Connecticut — require continuous or yearly access to Medigap coverage regardless of health status.
Make sure you understand the rules and exceptions that apply to you.
Indeed, that is an excellent rule of thumb for all Medicare beneficiaries. Read up and talk to insurance agents and Medicare counselors. Talk to friends, family members, your doctor, your health plan — and other health plans.
When it comes to Medicare, says Erin Trish, associate director of the University of Southern California’s Schaeffer Center for Health Policy and Economics, “it takes a village.”
Razor-thin operational margins coupled with substantial and ongoing losses related to COVID-19 are culminating in a perfect storm of bottom-line issues for U.S. hospitals and health systems. A study commissioned by the American Hospital Association (AHA) found that the median hospital margin overall was just 3.5% pre-pandemic, and projected margins will stay in the red for at least half of the nation’s hospitals for the remainder of 2020.
The reality is that an increase in COVID-19 cases will not overcome the pandemic’s devasting financial impact. An internal analysis found that, in the first half of 2020, client organizations documented more than 1.2 million COVID-19 related cases. At least one study suggests that $2,500 will be lost per case–despite a 20% Medicare payment increase. And notably, a positive test result is now required for the increased inpatient payment.
The healthcare industry must face its own “new normal” as the current path is unsustainable, and the future stability of hospitals in communities across the nations is uncertain. If financial leaders do not act now to implement systems and embrace sound revenue integrity practices, they will face unavoidable revenue cycle bottlenecks and limit their ability to capitalize on all appropriate reimbursement opportunities.
The COVID-19 Effect: A Bird’s Eye View
The financial impact of COVID-19 is far-reaching, impacting multiple angles of operations from supply chain costs to lost billing opportunities and compliance issues. Findings from a Physician’s Foundation report released in August suggest that U.S. healthcare spending dropped by 18% during the first quarter of 2020, the steepest decline since 1959.
Already vulnerable 2020 Q1 budgets were met with substantial losses when elective procedures—a sizeable part of income for most health systems—were halted for more than a month in many cases. Many hospitals continue to lose notable revenue associated with emergency care and ancillary testing as patients choose to avoid public settings amid ongoing public safety efforts.
Outpatient visits also dropped a whopping 60% in the wake of the pandemic. While a recent Harvard report suggests that numbers are back on track, the reality is that a resurgence of cases could make consumers wary of both doctor visits and elective procedures again.
In addition, the supply chain quickly became a cost risk for health systems by Q2 2020 as the ability to acquire drugs and medical supplies came at a premium. Meeting cost-containment goals flew out the window as did the ability to create value in purchasing power.
Further exacerbating the situation is an expected increase in denials as healthcare organizations navigate a fluid regulatory environment and learn how to interpret new guidance around coding and billing for COVID-19 related care. For example, while telehealth has proved a game-changer for care continuity across the U.S., reimbursement for these visits remains largely untested. History confirms that in times of rapid change, billing errors increase—and so do claims denials.
While there is little that can be done to minimize the impact of revenue losses and supply chain challenges, healthcare organizations can take proactive steps to identify all revenue opportunities and minimize compliance issues that will undoubtedly surface when auditors come knocking to ensure the appropriate use of COVID-19 stimulus dollars.
Holistically Addressing Revenue
Getting ahead of the current and evolving revenue storm will require healthcare organizations to elevate revenue integrity strategies. Hospitals and health systems should take four steps to get their billing and compliance house in order by addressing:
1. People: Build a cross-functional steering committee that will drive revenue integrity goals through better collaboration between billing and compliance teams.
2. Processes: Strategies that combine the strengths of both retrospective and prospective auditing will identify the root cause of errors and educate stakeholders to ensure clean, timely filed claims from the start.
3. Metrics: Best practice key performance indexes are available and should be used. Clean claim submission, denial rate, bad debt reduction and days in AR are a few to consider.
4. Technology: The role of emerging technologies that use artificial intelligence cannot be understated. Their ability to speed identification of risks, perform targeted audits, identify and address root causes and most importantly, monitor the impact of process improvements is changing current dynamics. For one large pediatric health system in the Southwest, technology-enabled coding and compliance processes resulted in $230 million in reduced COVID-related denials and a financial impact of $2.3 million.
Current manual processes used by many healthcare organizations to assess denials and manage revenue cycle will not provide the transparency needed to both get ahead of problems and identify areas for process improvement and corrective action in today’s complex environment.
About Vasilios Nassiopoulos
Vasilios Nassiopoulosis the Vice President of Platform Strategy and Innovation at Hayes, a healthcare technology provider that partners with the nation’s premier healthcare organizations to improve revenue, mitigate risk and streamline operations to succeed in an evolving healthcare landscape. Vasilios has over 25 years of healthcare experience with extensive knowledge of EHR systems and PMS software from Epic, Cerner, GE Centricity and Meditech. Prior to joining Hayes, Vasilios served Associate Principal at The Chartis Group.
– Central Logic has acquired Omaha-based Ensocare, which
automates the referral process for patients from hospital to post-acute care
(PAC) when they are being discharged.
– This acquisition means that Central Logic’s technology
solution will now expand its reach across the care continuum, from acute to
post-acute care—into, through and out of the health system. This combined
capability is key to increasing patient satisfaction while also increasing
patient census by ensuring beds are available when they are needed by new
the leading healthcare access and orchestration company, announced today that
it has acquired
Omaha-based Ensocare, which automates
the inpatient referral process to post-acute care (PAC). Central Logic’s health
system technology solution currently focuses on referrals and transfers into a
health system by uniting all available provider, facility and transportation
resources. Financial details of the acquisition were not disclosed.
Making Care Transition More Efficient
About 40% of Medicare beneficiaries are discharged from the hospital to post-acute facilities. With a
large aging population, U.S. health systems face growing pressures to improve
care access and streamline transitions of care to optimize patient outcomes,
increase operating margins, and control costs.
Founded in 1999, Ensocare provides hospitals and post-acute care
providers software and proactive support to manage patient transitions of care,
improve efficiency in the referral management process and streamline
communication between healthcare organizations. Backed by live, 24/7 customer
support and tapping into the nation’s largest no-cost post-acute care network,
we’ll help you lower costs, enhance patient satisfaction and increase
profitability by automating workflows and eliminating inefficient systems.
Acquisition Expands Central Logic’s Solutions to Post-Acute
The acquisition of Ensocare expands Central Logic’s solution
to include successful transitions out of hospitals to post-acute care
settings—including skilled nursing and rehabilitation facilities, long-term
acute care centers, and even the home—by tapping into Ensocare’s active,
curated network of more than 50,000 PAC providers nationwide. Placement
confirmations are secured on average within 30 minutes.
In light of the Ensocare
acquisition, Central Logic becomes the only solution in the market that
provides region-wide acute care transfer, transport and post-acute care
transfer capabilities in one platform, enabling health systems to more
cohesively operate as one.
Private Equity firm Rubicon Technology partners, a leading
private equity firm based in Boulder, Colo., made a strategic majority investment in Central Logic in June,
with a commitment to accelerating growth. Two weeks before Rubicon’s majority
investment in Central Logic, the PE firm announced a new $1.25 billion fund that exceeded the fund target
of $850 million in less than 6 months. The Ensocare acquisition marks the first
major milestone in Central Logic’s growth trajectory that Rubicon committed to
when making its strategic majority investment in the company earlier this year.
Central Logic’s technology will now span 800 hospitals and
health systems, covering 150,000 providers and more than 5 million
patients—representing 14% of U.S. annual inpatient visits. he company now
employs 125 team members and will continue to operate Ensocare’s Omaha, Neb.,
location, as well as existing Central Logic offices in St. Paul, Minn., and
“This strategic acquisition means that our solutions will now span the care continuum from acute to post-acute care, which will improve transitions into, through and out of the health system, creating true ‘systemness’ for our clients,” said Angie Franks, CEO of Central Logic. “By operating as one, health systems can offer a more seamless experience for their patients across all acuity levels while enabling providers to stay connected and strengthening the relationships with PAC providers in their communities.”
Our fully integrated solution will provide visibility and access to data that ensures hospital beds are freed in a timely manner when inpatient care is no longer necessary. This decreases length of stay and increases throughput,” Franks said. “Further, this kind of efficient orchestration and navigation creates bed availability and access for incoming patients, creates more time for clinicians to operate at the top of their license and elevates revenue capture and reduction of system leakage.”
Central Logic’s existing solutions already deliver 10x ROI to health system clients in the first year, and Franks says that clients that expand their engagement to include the acute to post-acute orchestration and access solution will see even greater results. “This is more important now than ever as health systems across the country implement the necessary controls and programs to rebuild operating margin deficits due to COVID-19,” Franks added.
NEW YORK — Mike Angevine lives in constant pain. For a decade the 37-year-old has relied on opioids to manage his chronic pancreatitis, a disease with no known cure.
But in January, Angevine’s pharmacy on Long Island ran out of oxymorphone and he couldn’t find it at other drugstores. He fell into withdrawal and had to be hospitalized.
“You just keep thinking: Am I going to get sick? Am I going to get sick?” Angevine said in a phone interview. “Am I going to be able to live off the pills I have? Am I going to be able to get them on time?”
His pharmacy did not tell him the reason for the shortage. But Angevine isn’t the only pain patient in New York to lose access to vital medicine since July 2019, when the state implemented an excise tax on many opioids.
The tax was touted as a way to punish major drugmakers for their role in the opioid epidemic and generate funding for treatment programs. But to avoid paying, scores of manufacturers and wholesalers stopped selling opioids in New York. Instead of the anticipated $100 million, the tax brought in less than $30 million in revenue, two lawmakers said in interviews. None of it was earmarked for substance abuse programs, they said.
The state’s Department of Health, which has twice this year delayed an expected report on the impact of the tax, did not respond to questions for this story.
The tax follows strong efforts by federal and New York officials to tamp down the use of prescription opioids, which had already cut back some supply. Now, with some medications scarce or no longer available, pain patients have been left reeling. And the law appears to have missed its target: Instead of taking a toll on manufacturers, the greater burden appears to have fallen on pharmacies that can no longer afford or access the painkillers.
Among them is Epic Pharma. Independent Pharmacy Cooperative, a wholesaler, confirmed it no longer sells medications subject to the tax, but still sells those that are exempt, which are treatments for opioid addiction methadone and buprenorphine and also morphine. AvKARE and Lupin Pharmaceuticals said they do not ship opioids to New York anymore. Amneal Pharmaceuticals, which manufactures Angevine’s oxymorphone, declined to comment, as did Mallinckrodt.
Since the tax went into effect, Cardinal Health, which provides health services and products, published an extensive 10-page list of opioids it does not expect to carry. Cardinal Health declined to comment.
The New York tax is slowly gaining attention in other states. Delaware passed a similar tax last year. Minnesota is assessing a special licensing fee between $55,000 and $250,000 on opioid manufacturers. New Jersey Gov. Phil Murphy proposed such a tax this year but was turned down by the legislature.
The company that makes the first point of sale within New York pays the tax. That isn’t always the drugmaker. It can mean wholesalers selling to pharmacies here are assessed, explained Steve Moore, president of the Pharmacists Society of the State of New York.
Independent Pharmacy Cooperative said about half its revenue from opioid sales in New York would have gone to taxes.
Mark Kinney, the company’s senior vice president of government relations, said the law is putting companies in a very difficult position.
When wholesalers like IPC left the opioid market, competitive prices went with them.
Without these smaller wholesalers, it’s hard for pharmacies to go back to other wholesalers “and say, ‘Hey, your prices aren’t in line with the rest of the market,’” Moore said.
Indeed, nine independent pharmacies told KHN that when they can get opioids they are more expensive now. They have little choice but to eat the cost, drop certain prescriptions or pass the expense along.
“We can trickle that cost down to the patient,” said a pharmacist at New London Pharmacy in Manhattan, “but from a moral and ethics point of view, as a health care provider, it just doesn’t seem right to do that. It’s not the right thing to ask your patient to pay more.”
In addition, Medicare drug plans and Medicaid often limit reimbursements, meaning pharmacies can’t charge them more than the programs allow.
Stone’s Pharmacy in Lake Luzerne was losing money “hand over fist,” owner Leigh McConchie said. His distributor was adding the tax directly to his pharmacy’s cost for the drugs. That helped drive down his profit margins from opioid sales between 60% and 70%. Stone’s stopped carrying drugs like fentanyl patches and oxycodone, and though that distributor now pays the tax itself, the pharmacy is still feeling the effects.
“When you lose their fentanyl, you generally lose all their other prescriptions,” he said, noting that few customers go to multiple pharmacies when they can get everything at one.
If pharmacies have few opioid customers, those price hikes have less impact on their business. But being able to manage the costs is not the only problem, explained Zarina Jalal, a manager at Lincoln Pharmacy in Albany. Jalal can no longer get generic oxycodone from her supplier Kinray, though she can still access brand-name OxyContin. New York’s Medicaid Mandatory Generic Drug Program requires insurers to provide advance authorization for the use of brand-name prescriptions, delaying the approval process. Sometimes patients wait several days to get their prescription, Jalal explained.
“When I see them suffer, it hurts more than it hurts my wallet,” she said.
One of Jalal’s customers, Janis Murphy, needs oxycodone to walk without pain. Now she is forced to buy a brand-name drug and pays up to three times what she did for generic oxycodone before the tax went into effect. She said her bill since the start of this year for oxycodone alone is $850. Lincoln Pharmacy works with Murphy on a payment plan, without which she would not be able to afford the medication at all. But the bill keeps growing.
“I’m almost in tears because I cannot get this bill down,” she said in a phone interview.
Several pharmacists raised concerns that patients who lose access to prescription opioids may turn to street drugs. High prescription prices can drive patients to highly addictive and inexpensive heroin. McConchie of Stone’s Pharmacy said he now dispenses twice as many heroin treatment drugs as he did a year ago. Former opioid customers now come in for prescriptions for substance use disorder.
Trade groups and some physicians and state legislators opposed the tax before it went into effect, voicing concerns about a slew of potential consequences, including supply problems for pharmacists and higher consumer prices.
New London Pharmacy said one of its regular distributors stopped shipping Percocet, a combination of oxycodone and acetaminophen. Instead, the pharmacy orders from a more expensive company. The pharmacist estimated that a bottle of Percocet for which it used to pay $43 now costs up to $92.
“Even if we absorb the tax, we’re not getting a break from reimbursements either,” a pharmacist who spoke on the condition of anonymity explained, adding that insurance reimbursements have not increased in proportion to rising drug costs. “We’re losing.”
Latchmin Raghunauth Mondol, owner of Viva Pharmacy & Wellness in Queens, has also seen that problem. The pharmacy used to be able to purchase 100 15-milligram tablets of oxycodone for $15, but that’s now $70, she said, and the pharmacy is reimbursed only about $21 by insurers.
Other opioids are just not available.
Mondol said she has been unable to obtain certain doses of two of the most commonly prescribed opioids, oxycodone and oxymorphone — the drug Angevine was on.
After Angevine lost access to oxymorphone, his doctor put him on morphine, but it does not give him the same relief. He’s been in so much pain that he stopped going to physical therapy appointments.
Over the past few months, primarily as a result of the COVID-19 pandemic, telehealth has gone from a “nice-to-have” to a “must-have” for healthcare providers. The surge of COVID-19 patients in the spring, coupled with “stay-at-home” orders in many states, meant that many patients in need of care for chronic conditions and other non-emergent health issues were unable to visit their providers face-to-face.
Telehealth became the emergency solution, aided by relaxation of government regulations and improved reimbursement from health payers, led by the U.S. Centers for Medicare and Medicaid Services (CMS). But then a funny thing happened.
As COVID-19 restrictions eased, many patients and providers found they liked telehealth and wanted to keep it around. Patients liked it because they didn’t have to take hours out of their day to travel to an appointment, go through COVID-19 protocols, wait to be called, wait to see their provider, then travel home again.
Providers liked it because they could work more efficiently and, if they were incorporating remote patient monitoring, obtain a more complete view of their patients’ day-to-day health. Both sides also liked telehealth because, quite frankly, it helped them reduce their risk of contracting a highly contagious virus.
While we are not out of the woods yet – many experts are predicting a fall and winter surge that will make the spring surge look like a warm-up act – there are already discussions about whether telehealth was simply a stopgap measure in a crisis or should be viewed as a standard option for care going forward. In order to make telehealth permanent, however, healthcare organizations will want to know exactly what it can contribute once it’s safe to venture to the office once again.
Advanced analytics can help. They can show what worked, and what didn’t, so providers can make data-driven decisions about where, how, and whether to continue using telehealth. The following are eight ways analytics can contribute to present and future telehealth success.
1. Find the patients for whom telehealth visits offer the greatest benefits. Normally, these will be patients who can be diagnosed or assessed without direct laying-on of hands. They may have a condition such as a rash that can be inspected visually or may be able to use consumer-grade devices to take and report biometric readings. Advanced analytics can help discover them, enabling providers to close care gaps while improving Star ratings and HEDIS scores.
2. Prioritize patients by need. Analytics can help identify patients who are most at-risk of deterioration if they do not follow-up after preventive or elective procedures or are not closely monitored. They can also help providers make the appropriate adjustments to those priorities as patient health changes.
3. Get ready for additional surges. The next surge has already begun, and there are likely to be others before the pandemic is fully behind us. Providers need to have measures in place to keep staff safe and avoid the risk of more lockdowns or other changes that will disrupt their operations. Analytics can help them determine how much to invest in additional telehealth equipment and training to ensure uninterrupted service to their patients.
4. Measure telehealth’s impact on patient outcomes and reimbursement. Telehealth is so new, and the pandemic has caused so many shifts in reimbursement, that it can be difficult to determine exactly what effect it has had on outcomes and revenue. Analytics can uncover which changes have been positive and should be continued, and which should either be discontinued or adjusted to produce better health and/or financial result.
5. Uncover and rectify possible coding errors. As the pandemic took hold in March, CMS launched its “patients over paperwork” initiative. The goal was to ensure providers focused on care rather than worrying about coding accuracy, especially as the path to telehealth opened up. At some point, however, accurate coding will again be required. Analytics can help providers uncover and rectify any coding issues to ensure claims are paid fairly and completely.
6. Enable more effective remote patient monitoring. The presence of a global pandemic doesn’t halt chronic or other conditions affecting patient health. These conditions must continue to be managed to prevent them from deteriorating, which will place more of a health burden on patients while increasing long-term costs. Remote patient monitoring delivers the day-to-day data on these conditions. Analytics use that data to spot trends and update providers on the condition of all those patients, making it easier to ensure successful treatment for all of them.
7. Manage timed events more effectively. Risk-adjustment capture of previously documented conditions, which comes through CMS sweeps, retrospective reviews, and other means, can be disruptive to provider operations. Analytics can take the burden off an already exhausted staff by automating and simplifying the process.
8. Use trend and outcome data to inform the future. There is still much we don’t know about the effectiveness – and cost-effectiveness – of telehealth. This type of forward-looking analysis can be used to deliver policy and regulatory guidance for permanent reimbursement and best practices for telehealth-related visits.
As we continue to battle the global pandemic, telehealth does more each day to demonstrate its value. But what happens when the battle is finally won? Should it go back to the background or become fully integrated into a healthcare organization’s standard offerings?
Advanced analytics can be used to answer these questions and many others, helping providers make the decision that best fits their organization.
About Prasad Dindigal Prasad Dindigal serves as Vice President, Healthcare & Life Sciences, with EXL, a leading operations management and analytics company that helps our clients build and grow sustainable businesses.
– The American Medical Association (AMA) published an
update to the Current Procedural Terminology (CPT®) code set that includes new
vaccine-specific codes to report immunizations for the novel coronavirus
– The new Category I CPT codes and long descriptors for the vaccine products 91300 and 91301 for better tracking, reporting, and analysis that supports data-driven planning and allocation.
The American Medical Association (AMA) today published an update to the Current Procedural Terminology (CPT®) code set that includes new
vaccine-specific codes to
report immunizations for the novel coronavirus (SARS-CoV-2).
New Category CPT Codes
The new Category I CPT codes and long descriptors
for the vaccine products are:
91300: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative-free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use
91301: Severe acute respiratory syndrome coronavirus
2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike
protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use
In accordance with the new vaccine-specific product CPT codes, the CPT Editorial Panel has worked with the Centers for Medicare & Medicaid Services to create new vaccine administration codes that are both distinct to each coronavirus vaccine and the specific dose in the required schedule. This level of specificity is a first for vaccine CPT codes, but offers the ability to track each vaccine dose, even when the vaccine product is not reported (e.g. when the vaccine may be given to the patient for free). These CPT codes report the actual work of administering the vaccine, in addition to all necessary counseling provided to patients or caregivers and updating the electronic record.
Admin CPT Codes & Long Descriptors
For quick reference, the new vaccine administration CPT codes and
long descriptors are:
0001A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative-free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose
0002A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative-free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose
0011A: Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative-free, 100 mcg/0.5mL dosage; first dose
0012A: Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative-free, 100 mcg/0.5mL dosage; second dose
All the new vaccine-specific CPT codes published in today’s update will be available for use and effective upon each new coronavirus vaccine receiving Emergency Use Authorization or approval from the Food and Drug Administration. In addition to the long descriptors, short and medium descriptors for the new vaccine-specific CPT codes can be accessed on the AMA website, along with several other recent modifications to the CPT code set that have helped streamline the public health response to the SAR-CoV-2 virus and the COVID-19 disease.
Of his many plans to expand insurance coverage, President-elect Joe Biden’s simplest strategy is lowering the eligibility age for Medicare from 65 to 60.
But the plan is sure to face long odds, even if the Democrats can snag control of the Senate in January by winning two runoff elections in Georgia.
Republicans, who fought the creation of Medicare in the 1960s and typically oppose expanding government entitlement programs, are not the biggest obstacle. Instead, the nation’s hospitals, a powerful political force, are poised to derail any effort. Hospitals fear adding millions of people to Medicare will cost them billions of dollars in revenue.
“Hospitals certainly are not going to be happy with it,” said Jonathan Oberlander, professor of health policy and management at the University of North Carolina-Chapel Hill.
Medicare reimbursement rates for patients admitted to hospitals average half what commercial or employer-sponsored insurance plans pay.
“It will be a huge lift [in Congress] as the realities of lower Medicare reimbursement rates will activate some powerful interests against this,” said Josh Archambault, a senior fellow with the conservative Foundation for Government Accountability.
Biden, who turns 78 this month, said his plan will help Americans who retire early and those who are unemployed or can’t find jobs with health benefits.
“It reflects the reality that, even after the current crisis ends, older Americans are likely to find it difficult to secure jobs,” Biden wrote in April.
Lowering the Medicare eligibility age is popular. About 85% of Democrats and 69% of Republicans favor allowing those as young as 50 to buy into Medicare, according to a KFF tracking poll from January 2019. (KHN is an editorially independent program of KFF.)
Although opposition from the hospital industry is expected to be fierce, that is not the only obstacle to Biden’s plan.
Critics, especially Republicans on Capitol Hill, will point to the nation’s $3 trillion budget deficit as well as the dim outlook for the Medicare Hospital Insurance Trust Fund. That fund is on track to reach insolvency in 2024. That means there won’t be enough money to fully pay hospitals and nursing homes for inpatient care for Medicare beneficiaries.
Moreover, it’s unclear whether expanding Medicare will fit on the Democrats’ crowded health agenda, which also includes dealing with the COVID-19 pandemic, possibly rescuing the Affordable Care Act if the Supreme Court strikes down part or all of the law in a current case, expanding Obamacare subsidies and lowering drug costs.
Biden’s proposal is a nod to the liberal wing of the Democratic Party, which has advocated for Sen. Bernie Sanders’ (I-Vt.) government-run “Medicare for All” health system that would provide universal coverage. Biden opposed that effort, saying the nation could not afford it. He wanted to retain the private health insurance system, which covers 180 million people.
To expand coverage, Biden has proposed two major initiatives. In addition to the Medicare eligibility change, he wants Congress to approve a government-run health plan that people could buy into instead of purchasing coverage from insurance companies on their own or through the Obamacare marketplaces. Insurers helped beat back this “public option” initiative in 2009 during the congressional debate over the ACA.
The appeal of lowering Medicare eligibility to help those without insurance lies with leveraging a popular government program that has low administrative costs.
“It is hard to find a reform idea that is more popular than opening up Medicare” to people as young as 60, Oberlander said. He said early retirees would like the concept, as would employers, who could save on their health costs as workers gravitate to Medicare.
The eligibility age has been set at 65 since Medicare was created in 1965 as part of President Lyndon Johnson’s Great Society reform package. It was designed to coincide with the age when people at that time qualified for Social Security. Today, people generally qualify for early, reduced Social Security benefits at age 62, though they have to wait until age 66 for full benefits.
While people can qualify on the basis of other criteria, such as having a disability or end-stage renal disease, 85% of the 57 million Medicare enrollees are in the program simply because they’re old enough.
Lowering the age to 60 could add as many as 23 million people to Medicare, according to an analysis by the consulting firm Avalere Health. It’s unclear, however, if everyone who would be eligible would sign up or if Biden would limit the expansion to the 1.7 million people in that age range who are uninsured and the 3.2 million who buy coverage on their own.
Avalere says 3.2 million people in that age group buy coverage on the individual market.
While the 60-to-65 group has the lowest uninsured rate (8%) among adults, it has the highest health costs and pays the highest rates for individual coverage, said Cristina Boccuti, director of health policy at West Health, a nonpartisan research group.
About 13 million of those between 60 and 65 have coverage through their employer, according to Avalere. While they would not have to drop coverage to join Medicare, they could possibly opt to also pay to join the federal program and use it as a wraparound for their existing coverage. Medicare might then pick up costs for some services that the consumers would have to shoulder out-of-pocket.
Some 4 million people between 60 and 65 are enrolled in Medicaid, the state-federal health insurance program for low-income people. Shifting them to Medicare would make that their primary health insurer, a move that would save states money since they split Medicaid costs with the federal government.
Chris Pope, a senior fellow with the conservative Manhattan Institute, said getting health industry support, particularly from hospitals, will be vital for any health coverage expansion. “Hospitals are very aware about generous commercial rates being replaced by lower Medicare rates,” he said.
“Members of Congress, a lot of them are close to their hospitals and do not want to see them with a revenue hole,” he said.
President Barack Obama made a deal with the industry on the way to passing the ACA. In exchange for gaining millions of paying customers and lowering their uncompensated care by billions of dollars, the hospital industry agreed to give up future Medicare funds designed to help them cope with the uninsured. Showing the industry’s prowess on Capitol Hill, Congress has delayed those funding cuts for more than six years.
Jacob Hacker, a Yale University political scientist, noted that expanding Medicare would reduce the number of Americans who rely on employer-sponsored coverage. The pitfalls of the employer system were highlighted in 2020 as millions lost their jobs and workplace health coverage.
Even if they can win the two Georgia seats and take control of the Senate with the vice president breaking any ties, Democrats would be unlikely to pass major legislation without GOP support — unless they are willing to jettison the long-standing filibuster rule so they can pass most legislation with a simple 51-vote majority instead of 60 votes.
Hacker said that slim margin would make it difficult for Democrats to deal with many health issues all at once.
“Congress is not good at parallel processing,” Hacker said, referring to handling multiple priorities at the same time. “And the window is relatively short.”
Sacramento.- Cuando la Corte Suprema de los Estados Unidos esté escuchando el martes 10 un caso que podría decidir el destino de la Ley de Cuidado de Salud a Bajo Precio (ACA), California liderará la defensa de la ley federal que impacta en casi todos los aspectos del sistema de salud del país.
Por lo general, es tarea del gobierno federal defender una ley federal, pero la Administración Trump quiere que ACA, también conocida como Obamacare, se revoque.
Por eso, el fiscal general de California, Xavier Becerra, respaldado por más de 20 estados, defiende la ley contra el desafío presentado hace dos años por una coalición de funcionarios estatales republicanos.
Becerra ha sido uno de los adversarios más formidables de Trump: ha llevado a la administración a los tribunales decenas de veces por sus políticas, que van desde la inmigración y el control de la natalidad hasta el cambio climático. Se le considera uno de los principales contendientes para llenar la vacante del Senado que se abrirá ahora que la senadora por California Kamala Harris ha sido elegida vicepresidenta.
“Tan enérgicamente como un presidente y su administración están luchando para destruir la Ley de Cuidado de Salud a Bajo Precio, nosotros estamos luchando para salvarla para todos los estadounidenses”, dijo Becerra a los periodistas en una conferencia de prensa el lunes 9.
Si el tribunal anula toda la ley, el impacto se sentiría ampliamente. La ley proporciona seguro médico a más de 23 millones de estadounidenses. Permite a las personas que califican comprar seguros a través de los mercados estatales y el federal, y recibir subsidios.
También ha recomendado a los estados expandir sus programas de Medicaid a más personas; previene que las compañías de seguros nieguen cobertura a personas con afecciones médicas preexistentes; prohíbe los límites de por vida en la cobertura; agrega beneficios a Medicare; y permite que los hijos permanezcan en los planes de sus padres hasta los 26 años.
El tema central en California vs. Texas es la multa fiscal federal por no tener seguro médico, como exige la ley. En 2017, el Congreso liderado por los republicanos redujo esta multa a cero, pero mantuvo intacta al resto de la ley, una medida que, según Becerra y otros expertos en leyes, muestra la intención del Congreso de apoyarla.
Sin embargo, funcionarios estatales republicanos dicen que la pérdida de la penalidad invalida el mandato de tener un seguro, así como toda la ley.
Becerra dijo que es posible que el tribunal determine que los impugnadores no tienen legitimidad para demandar al gobierno porque nadie ha sido perjudicado por una multa que cuesta cero.
Aunque la corte ha ratificado dos veces esta ley, la composición de la corte ha cambiado desde su último fallo sobre ACA en 2015. Desde entonces, Trump ha nombrado a tres jueces conservadores. Dos reemplazaron a otros conservadores, pero Amy Coney Barrett, quien fue confirmada a fines de octubre, ocupa el asiento de un ícono liberal, la jueza Ruth Bader Ginsburg.
Abbe Gluck, directora del Centro Salomón de Derecho y Políticas de Salud de la Escuela de Derecho de Yale, dijo que si el tribunal cree que el requisito del seguro médico es inconstitucional sin la penalidad, debería simplemente declarar inválida esa sección de la ley, pero no anularla por completo.
Pero “he aprendido que nunca se puede predecir lo que sucede en la corte cuando se trata de la Ley de Cuidado de Salud a Bajo Precio”, dijo Gluck. “Por eso hay más preocupación, porque el estatuto se ha vuelto tan fundamentalmente importante para una quinta parte de nuestra economía y para la atención médica de prácticamente todos los estadounidenses”.
Becerra habló con Samantha Young de California Healthline sobre su defensa del Obamacare y el enorme alcance de la influencia de la ley. La entrevista ha sido editada por extension, y para mayor claridad.
¿Cuáles son las posibilidades de que la Corte Suprema derogue la Ley de Cuidado de Salud a Bajo Precio?
Confiamos en que no solo verán la lógica legal detrás de esto, sino también la sabiduría y el éxito práctico de la Ley de Cuidado de Salud a Bajo Precio, lo cual pesa mucho a favor de que los jueces reconozcan no solo que es legal, sino indispensable. Cuando los jueces examinen los fundamentos de la Ley de Cuidado de Salud a Bajo Precio, encontrarán que es constitucional.
La composición de la Corte Suprema de los Estados Unidos ha cambiado desde la última vez que se pronunció sobre ACA. ¿Por qué cree que estos jueces decidirán de la misma manera?
Eso no debería cambiar el hecho de que los fundamentos de la ley siguen siendo los mismos. Los fundamentos de ACA son sólidos y funcionan. Espero que nueve jueces que revisan la misma ley observen ese precedente.
¿A qué debe prestar atención el público durante los argumentos orales?
Algo interesante de observar es cómo la corte interpreta las acciones tomadas por el Congreso en 2017, cuando aprobaron el proyecto de ley de exención de impuestos y redujeron a cero la tarifa o multa por el mandato individual. Ahora, estamos ante un presidente y al menos una cámara en el Congreso que está preparada para defender la Ley de Cuidado de Salud a Bajo Precio. ¿Cómo podría considerar el tribunal el hecho de que otro Congreso podría restablecer parte de ese mandato?
¿Cómo se relaciona esto con el argumento legal de que haber reducido a cero el mandato de alguna manera provocó la inconstitucionalidad de toda la ley? Creo que es una cuestión que el tribunal tendrá que examinar.
¿Qué pasará si la Corte Suprema de los Estados Unidos declara inconstitucional la Ley de Cuidado de Salud a Bajo Precio?
Volverán las preocupaciones. La atención preventiva de Medicare desaparecería. Los días en que los estadounidenses no tenían que preocuparse por la bancarrota por haber pisado un hospital prácticamente se esfumarían.
Tengo tres hijas. Hubo un tiempo que, como adultas, las tres estaban en nuestra cobertura de atención médica. Eso desaparecería porque la disposición que permite que los hijos adultos menores de 26 años permanezcan en la cobertura de los padres desaparecería. Y podría seguir y seguir.
¿Podrían los estados, incluido California, darse el lujo de intervenir por su cuenta?
No sé si hay algún estado que tenga la capacidad de reemplazar lo que hace la Ley de Cuidado de Salud a Bajo Precio. Es casi imposible. Parte de eso se debe a que no podemos replicar algunas de las cosas que puede hacer el gobierno federal. No tenemos esa jurisdicción federal, no tenemos esa amplitud y profundidad de alcance.
Si el tribunal anula ACA, ¿el Congreso no puede aprobar protecciones parciales que cuenten con el apoyo de los republicanos, como la cobertura de afecciones preexistentes?
Hemos escuchado a los republicanos decir “revocar y reemplazar” durante más de 10 años, y ha sido una retórica vacía desde el principio. Para los padres que tienen hijos con afecciones médicas preexistentes, no es reconfortante que alguien les prometa que reemplazarán un derecho que saben que ahora tienen para que sus hijo vayan al hospital. Y, ¿por qué desecharías eso por una promesa vacía que ya lleva 10 años?
La mayoría de los estadounidenses dirían: sigue construyendo sobre la base de la Ley de Cuidado de Salud a Bajo Precio. Mejorémosla, pero no descartemos lo que ha funcionado.
¿Cómo sabe que la Ley de Cuidado de Salud a Bajo Precio está funcionando?
Mi antiguo distrito congresional en Los Ángeles se encontraba entre los distritos congresionales con más cantidad de personas sin seguro de salud de la nación. En cuestión de años, una vez que entró en vigor la Ley de Cuidado de Salud a Bajo Precio, la tasa de personas sin seguro en ese distrito se redujo en un 50%. Fue simplemente astronómico.
La Ley de Cuidado de Salud a Bajo Precio hizo posible que las familias trabajadoras pudieran obtener cobertura y eso es enorme. Ese es el tipo de carga que se quita del alma.
¿Cree que tener a Joe Biden como presidente y a Kamala Harris como vicepresidenta en la Casa Blanca llevará a una mejora en la Ley de Cuidado de Salud a Bajo Precio?
Como candidato a presidente, Joe Biden dijo que se basaría en el éxito de la presidencia de Obama-Biden y se aseguraría que sigamos aumentando el número de estadounidenses con acceso a una atención médica asequible. Lo bueno es que finalmente tienes a alguien en la parte superior del tótem que dice que lo vamos a mejorar. Por eso esta elección fue tan importante.
After one of the closest and most hotly contested campaigns in modern history, President-Elect Joe Biden addressed the nation on Saturday from an outdoor platform in Wilmington, Delaware.
While it’s far too early to say what the first 100 days of a Biden administration will look like from a detailed policy perspective, the president-elect has made one point abundantly clear. It’s time to get to work — and that work starts with the COVID-19 pandemic.
“Our work begins with getting COVID under control,” Biden said during his victory speech. “We cannot repair the economy, restore our vitality or relish life’s most precious moments — hugging a grandchild, birthdays, weddings, graduations, all the moments that matter most to us — until we get this virus under control.”
As the United States inches closer toward the macabre milestone of 10 million total coronavirus cases, the Biden administration’s response to the ongoing pandemic will need to be wide-ranging and thorough, touching on everything from vaccine development and distribution, to additional rounds of relief for health care providers. Long-term care and protecting America’s senior population will also need to be at the very center of its response.
“I will spare no effort — or commitment — to turn this pandemic around,” Biden continued.
In the weeks and months leading up to his victory this past weekend, Biden — a soon-to-be 78-year-old man himself — suggested a deep appreciation of home-based care.
In July, for example, the former vice president outlined a $775 billion plan to overhaul the nation’s caregiving infrastructure, which is mostly made up of women and people of color. As part of that plan, Biden said he hoped to create upwards of 3 million new caregiving and education jobs over the next decade, while likewise creating pathways for former caregivers to re-enter the workforce.
The plan additionally called for a $450 million boost for senior care, with some of those funds dedicated to improving wages and labor conditions for in-home care workers.
“Home health workers do God’s work, but aren’t paid much,” the then presidential candidate said on social media. “They have few benefits, and 40% are still on SNAP or Medicaid. It’s unacceptable. I’ll give caregivers and early childhood educators a much-needed raise.”
Biden hasn’t just highlighted his appreciation of home-based care in broad strokes and policy promises. In addition to his $775 billion plan, the president-elect has repeatedly brought attention to very specific, innovative programs that typically only industry insiders know about.
That includes making nuts-and-bolts references to CAPABLE, the increasingly popular program out of the Johns Hopkins School of Nursing designed to support aging in place by coordinating nursing, therapy and handyman services in the home.
“To hear him really describe [CAPABLE] was thrilling,” Sarah Szanton, the Johns Hopkins professor who helped create the program, recently told Home Health Care News.
Protecting America’s seniors
Moving forward, Biden and his staff will likely try to secure additional resources for home-based care providers and other long-term care operators. In its official policy plan for nursing home regulations, for instance, the Biden team stated it would invoke the Defense Production Act to increase the overall supply of PPE.
The campaign was highly critical of the Trump administration for failing to coordinate sufficient distribution of testing supplies and personal protective equipment (PPE) early on, so a lack of action on that front would only be viewed as hypocritical.
Currently, “protecting older Americans” is one of the main priorities featured on the Biden-Harris Transition website. That fact that hasn’t gone overlooked by those in the aging services space.
“We appreciate the Biden-Harris Transition team’s announcement regarding its COVID-19 response,” Argentum CEO James Balda said in a statement. “The specific emphasis on protecting at-risk populations, which includes older adults and those who serve them, as well as a focus on the efficacy of vaccine distribution, is critical to controlling the spread of this virus.”
Argentum is the country’s largest senior living association.
“Dealing with the coronavirus pandemic is one of the most important battles our administration will face, and I will be informed by science and by experts,” President-Elect Biden said Monday.
Notably, the advisory board also includes Dr. Atul Gawande, the surgeon and writer who founded Ariadne Labs, a joint center between Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health.
Gawande — former CEO of Haven, the health care venture founded by Amazon, Berkshire Hathaway and JPMorgan Chase — has been a staunch supporter of palliative medicine and end-of-life care. His participation on the board could signal a focus on those areas during the duration of the public health emergency.
The Coalition to Transform Advanced Care (C-TAC) said it has been encouraged by a number of Biden campaign proposals that have the potential to improve the lives of the seriously ill, particularly in home- and community-based settings.
“C-TAC looks forward to forging new relationships with those in the incoming Biden administration and Congress,” C-TAC Executive Director Jon Broyles said in a statement. “As we work toward building a health care system that works for everyone, it is essential that we come together to find innovative solutions that meet the needs of the sickest and most vulnerable among us, with particular attention to low-income, traditionally underserved individuals.”
Beyond home care
The advisory board may include others in days to come.
Given the pandemic’s outsized impact on people age 65 and older, additional expertise in aging — whether via gerontologists, industry leaders or researchers — would bring much value, according to Ruth Katz, LeadingAge’s senior vice president of policy. LeadingAge is a diverse association of nonprofit providers of aging services.
“We expect to see a focus on in-home and community-based services through programs in their platform on caregiving, education and workforce,” Katz said in a statement. “That’s a positive.”
Beyond directly supporting home-based care, a Democratic president in the White House and a split Congress may also mean a heightened willingness to reach across the aisle to get things done, at least compared to the past four years.
Initially, there’s bound to be friction between both governing parties, a concept reflected in the largely unsubstantiated voter-fraud concerns voiced by Republican leadership. Over time, though, lawmakers will hopefully find common ground on no-brainer, common-sense issues.
That could mean newfound momentum behind legislation with bipartisan support, such as the Home Health Emergency Access to Telehealth (HEAT) Act, a bill to provide Medicare reimbursement for audio and video telehealth services delivered by home health agencies during a public emergency. Among the bill’s backers is Sen. Susan Collins of Maine, one of the few Republicans to officially congratulate Biden on his victory.
It could also mean continued support for Medicare Advantage (MA), which, in turn, means continued support for home care. Often cited as the future of health care by Republicans, MA was actually first enacted under the Clinton administration as “Medicare Plus Choice.”
Better Medicare Alliance President and CEO Allyson Y. Schwartz reminded people of that on Monday.
“The story of Medicare Advantage is one this new administration can be proud to continue,” Schwartz, a former member of the U.S. House of Representatives, said in a statement. “We stand ready to work with President-elect Biden, Vice President-elect Harris and their team to build on this bipartisan success.”
Out of a total Medicare-eligible population of more than 62.4 million individuals as of October 2020, nearly 25.4 million had signed up for MA, federal statistics show.
Biden, of course, has also voiced support for “Medicare at 60,” a plan to allow Americans between the ages of 60 and 64 the option of buying into Medicare slightly earlier. If ever enacted, that plan would dramatically expand the population of Medicare beneficiaries able to receive Medicare-certified home health services.
SACRAMENTO — When the U.S. Supreme Court hears a case Tuesday that could decide the fate of the Affordable Care Act, California will be leading the defense to uphold the federal law that touches nearly every aspect of the country’s health care system.
It’s usually the federal government’s job to defend a federal law, but President Donald Trump’s administration wants this law, also known as Obamacare, to be overturned.
So California Attorney General Xavier Becerra, backed by more than 20 other states, is defending the law against the challenge brought by a coalition of Republican state officials two years ago.
Becerra has been one of Trump’s most formidable adversaries, taking the administration to court scores of times over its policies, ranging from immigration and birth control to climate change. He is considered one of the leading contenders to fill the Senate vacancy that will open now that Sen. Kamala Harris of California has been elected vice president.
“Just as vigorously as a president and his administration are fighting to destroy the Affordable Care Act, we are fighting to save it for every American,” Becerra told reporters in a press conference Monday.
Should the court overturn the entire law, the impact would be felt widely. The law provides health insurance to more than 23 million Americans. It allows qualified people to buy subsidized insurance through federal or state insurance exchanges; permits states to expand their Medicaid programs to more people; prevents insurance companies from denying coverage to people with preexisting medical conditions; bans lifetime limits on coverage; adds benefits to Medicare; and allows children to stay on their parents’ plans up to age 26.
At issue in California v. Texas is the federal tax penalty for not having health insurance, as the law requires. The Republican-led Congress in 2017 zeroed out the penalty but kept the rest of the health law intact, a move Becerra and some other legal experts say shows congressional intent to support the law. The Republican state officials, however, say the loss of the tax invalidates the mandate to have insurance — as well as the entire law.
Becerra said it’s possible the court may determine that the challengers don’t have standing to sue the government because no one has been harmed by a zero-tax penalty.
Although the court has twice upheld the federal health care law, the composition of the court has changed since its last ACA ruling in 2015. Trump has appointed three conservative judges since then. Two replaced other conservatives, but Amy Coney Barrett, who was confirmed in late October, took the seat of a liberal icon, Justice Ruth Bader Ginsburg.
Abbe Gluck, faculty director of the Solomon Center for Health Law and Policy at Yale Law School, said that if the court believes the health insurance requirement is unconstitutional without the penalty, it should just hold that section of the law invalid but not overturn the entire law.
But “I have learned that you can never predict what happens in court when it comes to the Affordable Care Act,” Gluck said. “And that is why there is this heightened sense of concern, because the statute has become so fundamentally important to one-fifth of our economy and the health care of virtually all Americans.”
Becerra talked to California Healthline’s Samantha Young about his defense of Obamacare and the far-reaching influence of the law. The interview has been edited for length and clarity.
Q: What are the chances the Supreme Court could overturn the Affordable Care Act?
We’re confident they will see not just the legal logic behind it, but the wisdom and the practical success of the Affordable Care Act — all of which weigh heavily in favor of the justices recognizing that it’s not only legal but indispensable. When the justices look to the fundamentals of the Affordable Care Act, they’re going to find that it is constitutional.
Q: The makeup of the U.S. Supreme Court has changed since it last ruled on the ACA. Why do you think these justices will rule the same way?
That shouldn’t change the fact that the fundamentals of the law have remained the same. The fundamentals of the ACA are grounded, they’re solid, and they work. I would hope that nine justices reviewing the same law would look at that precedent.
Q: What should the public pay attention to during the oral arguments?
One thing interesting to watch is how the court interprets the actions taken by Congress in 2017 when they passed the tax break bill and zeroed out the individual mandate fee or penalty. Now, we’re looking at a president and at least one house in Congress that’s prepared to defend the Affordable Care Act. How might the court look at the fact that another Congress could reinstitute part of that mandate?
What does that do to the legal argument that having zeroed out the mandate somehow triggered the unconstitutionality of the entire law? I think that’s a question the court will have to examine.
Q: What happens if the U.S. Supreme Court declares the Affordable Care Act unconstitutional?
The worries return. Preventative care under Medicare would be gone. The days when Americans don’t have to worry about going personally bankrupt for having visited a hospital would pretty much be gone.
I’ve got three daughters. There was a time when all three of them as adults were on our health care coverage. That would be gone because the provision that allows adult children under the age of 26 to remain on a parent’s coverage would disappear. I could go on and on.
Q: Could states, including California, afford to step in on their own?
I don’t know if there’s any state who has the capacity to replace what the Affordable Care Act does. It’d be almost insurmountable. Part of that is because we can’t replicate some of the things that the federal government can do. We don’t have that federal jurisdiction, we don’t have that breadth and depth of reach.
Q: If the court overturns the ACA, can’t Congress pass piecemeal protections that have Republican support, such as coverage for preexisting conditions?
We have heard Republicans say “repeal and replace” for more than 10 years, and it’s been empty rhetoric from the beginning. I’ve gotta tell you that for parents who have children with preexisting medical conditions, it is no comfort to have someone promise you that they will replace a right that you know you now have for your child to visit a hospital. And, why would you throw that away for an empty promise that’s 10 years old?
Most Americans would say, Keep building on the Affordable Care Act. Let’s make it better, but don’t scrap what’s worked.
Q: How do you know the Affordable Care Act is working?
My former congressional district in Los Angeles ranked among the most uninsured congressional districts in the nation. In a matter of years, once the Affordable Care Act took place, the uninsured rate in that congressional district had gone down by 50%. It was just astronomical.
The Affordable Care Act made it possible for working families to secure coverage and that’s huge. That’s the kind of burden that’s lifted off your soul.
Q: Do you think having a President Joe Biden and a Vice President Kamala Harris in the White House will lead to an improved Affordable Care Act?
As a candidate for president, Joe Biden said that he would build on the success of the Obama-Biden presidency and make sure that we continue to increase the number of Americans who have access to affordable health care. The good thing is you finally have someone at the top of the totem pole who says we’re going to make it better. And that’s why this election was so important.
Former Vice President Joe Biden secured the 270 electoral votes needed to capture the White House on Saturday, major news organizations projected, after election officials in a handful of swing states spent days in round-the-clock counting of millions of mail-in ballots and early votes.
The Democrat’s victory came after the latest tallies showed him taking an insurmountable lead in Pennsylvania, a state both Biden and President Donald Trump had long identified as vital to their election efforts. Trump has signaled he will fight the election results in several states, filing a number of lawsuits and seeking recounts.
“America, I’m honored that you have chosen me to lead our great country,” Biden tweeted shortly after the news organizations called the race. “The work ahead of us will be hard, but I promise you this: I will be a President for all Americans — whether you voted for me or not.”
The Democratic celebration was tempered because it appeared the party would have a hard time taking back the Senate majority it lost in 2014. If that bears out, it will likely keep Biden and Democratic lawmakers from enacting many of the plans they campaigned on, including major changes in health care.
Party control of the Senate may not be determined until January — thanks to what preliminary returns suggest will be runoffs for both Senate seats in Georgia. No candidate for either seat reached the required 50% threshold.
Without a Democratic majority in the Senate, Biden will likely face strong Republican opposition to many of his top health agenda items — including lowering the eligibility age for Medicare to 60, expanding financial assistance for health insurance under the Affordable Care Act, and creating a “public option” government health plan.
However, his administration would be a bulwark to defend the ACA against Republican attacks, although the Supreme Court case challenging the health law — which will be heard next week — presents a major wild card for its future.
Health care was a key element of Biden’s campaign, especially improving the federal response to the coronavirus pandemic. He championed the use of face masks and blasted the Trump administration for shifting to states much of the responsibility for fighting the virus and helping hospitals. He was regularly mocked by the president for wearing a mask, working and campaigning from home, and not having an in-person Democratic convention.
Even before the latest vote tallies were released late Saturday morning, Biden had begun moving toward setting up his administration. On Thursday his transition team unveiled a website, BuildBackBetter.com, although it was only one page. And the former vice president held a meeting Thursday with health and economic advisers on the pandemic.
In a brief television statement Friday night, Biden reiterated his commitment to fight the pandemic, which he said “is getting more worrisome across the country.”
“We want everyone to know on day one we are going to put our plan to control this virus into action. We can’t save any of the lives that have been lost, but we can save a lot of lives in the months ahead,” Biden said.
The electoral outcome is not the one Democrats were hoping for — or, to some extent, expecting, based on preelection polling. Andy Slavitt, who ran the Centers for Medicare & Medicaid Services during the Obama administration, noted that frustration in a tweet Wednesday. “A large disappointment is that many hoped for a significant repudiation of Trump & his indifference to human life, human suffering, his corruption, and goal of getting rid of the ACA. No matter the final total it will be hard to make that claim,” Slavitt said.
Still up in the air is how willing a Republican-led Senate will be to provide further relief to individuals, businesses and states hit hard by the pandemic, and whether they will participate in previously bipartisan efforts to curtail “surprise” out-of-network medical bills and get a handle on prescription drug prices.
California’s annual health insurance enrollment season for individuals and families kicks off this week against a dramatic backdrop: the hotly contested presidential election; a pandemic raging out of control in much of the U.S.; and, on Nov. 10, a Supreme Court hearing of a case that could end the Affordable Care Act and strand millions without coverage.
The massive unemployment caused by the pandemic has already stripped employer-based health insurance from millions nationwide and induced severe financial anxiety as families struggle to pay rent and buy food.
One question hovering over enrollment for 2021 health plans is whether the large-scale loss of medical coverage will generate a surge of sign-ups, or if more pressing financial worries for many people will push insurance lower down their priority list.
“People have so many things to deal with: They’ve lost jobs, they’ve lost a lot of income, and in California they’re also facing fires. I don’t think health insurance has been top of mind for people,” says Cheryl Fish-Parcham, director of access initiatives at Families USA, a consumer health care advocacy organization.
But Peter Lee, executive director of Covered California, the state’s ACA marketplace, is confident it will match the 40% increase in new sign-ups it had for 2020 coverage.
“It is clear that COVID is on Californians’ minds,” he says. “You cannot have COVID on your mind without also having coverage on your mind.”
A Supreme Court decision on the future of the ACA probably won’t come until well into next year, and it is unlikely to affect your 2021 coverage. “So people should feel confident in looking for a health plan,” says Sara Collins, vice president for health care coverage and access at the Commonwealth Fund.
If you are 65 or older, you probably qualify for Medicare, the federal program for seniors, which is entirely separate from the ACA exchanges and broader individual market. Open enrollment for the private Medicare Advantage plans and Part D drug plans is also underway and ends Dec. 7. Insurance agents can usually help you with Medicare, and you can get advice by calling 1-800-434-0222.
If you are under 65, live in the Golden State and want to buy insurance for you and your family, start with Covered California. It’s the only place you can get federal and state assistance to cover some or all of your premiums.
The enrollment period for Covered California, and for the individual market outside the exchange, started Nov. 1 and runs through Jan. 31. In states whose exchanges are operated by the federal government, the enrollment window shuts Dec. 15.
If you lost coverage and need it for the month of December this year, you can still get it through Covered California if you sign up by Nov. 30. For regular annual coverage that starts Jan. 1, you must sign up by Dec. 15. If you miss that deadline, you can still get coverage starting Feb. 1 if you enroll by the final Jan. 31 deadline.
Many people leave money on the table because they aren’t aware of the financial assistance or think they earn too much to qualify. But you don’t need to be poor to get aid.
The federal subsidies, which are tax credits typically provided in the form of reduced monthly premiums, are available to individuals with annual income up to about $51,000 and a family of four with income up to nearly $105,000.
California has supplemented the federal aid with state-funded assistance that extends further into the middle class: up to around $76,500 for an individual and $157,000 for a family of four.
If you log on to Covered California’s website, www.coveredca.com, you can check how much financial help you qualify for and compare health plans. Or, an insurance agent or certified enroller can do the legwork work for you — at no charge. You can find one on the website. You can also call Covered California directly at 800-300-1506.
If your income is below 138% of the federal poverty level, you will probably qualify for Medi-Cal, the government insurance program for people of limited means. The Covered California website — or an enroller — will let you know if you do and walk you through signing up. You can also contact your county’s Medi-Cal office. If you don’t qualify for Medi-Cal, your children might, because the income threshold is higher for them.
If you are looking for exchange-sponsored coverage, click the “shop and compare” tab on the Covered California website, which takes you to a screen that asks your age, income, ZIP code and family size and shows the health plans available, their premiums and your aid amount.
The website also provides quality ratings of the participating health plans. And you can check for plans that have your doctors in their networks — though, as the website warns, that information is not always up to date.
Comparison shopping on the website is straightforward, because at each of the four levels of coverage — bronze, silver, gold and platinum — benefits are uniform from insurer to insurer. So once you’ve decided which metal tier is best for you, you only need to think about the price and whether your providers are in the network.
If you have a Covered California health plan already, shop around rather than automatically renew the one you’re in. “The best deal last year is not necessarily the best deal this year,” says Anthony Wright, executive director of Health Access California.
Anthem Blue Cross, for example, will hike rates by a statewide average of 6%, and the Oscar Health Plan of California by 7.6%, while Blue Shield of California will cut rates by an average of 2.4% and the L.A. Care Health Plan by 4.6%.
If you switch to the lowest-cost plan in your current metal tier, you could reduce your premium by as much as 7.4%, according to Covered California.
Keep in mind that the lowest premium, a bronze plan, is not necessarily the wisest — or cheapest — choice.
Tom Freker, a Huntington Beach insurance agent, counsels people not to buy bronze, because its higher deductibles and coinsurance rates could cost more than a higher-premium plan if you fall ill or have a serious accident.
Freker recommends you enroll in Covered California rather than the off-exchange market, even if you don’t initially qualify for aid. That’s because if your income drops and you report it to the exchange, you might then qualify and get a break on premiums for the rest of the year or a tax credit the following April, he says.
If your income rises during the year you also should report it, so your monthly premium subsidy is reduced, helping you avoid a potentially hefty tax bill come April.
Your initial aid amount, if you qualify, will be based on your projected 2021 income. In this period of pandemic-driven furloughs, slashed hours and job loss, that might be difficult to predict.
Maria Weston, a massage therapist in Long Beach, said her income has fluctuated week to week since the pandemic started and is down about 50% overall.
Her priority for 2021 was to find a less expensive option, so she switched to a cheaper silver plan last month (current enrollees were allowed to make their health plan choices starting Oct. 1).
Weston’s new health plan will save her nearly $1,700 a year on premiums. “I could put that in my retirement account — or eat,” she says. “One of the two.”
Poor, elderly individuals who may qualify for both Medicaid (for being poor) and Medicare (for being elderly, blind, disabled or have ESRD). In these cases, Medicaid serves as a supplemental insurer, covering Medicare coinsurance and deductibles. The generosity of this supplemental coverage for so-called ‘dual-eligibles’ varies across states.
These differences in Medicaid payments arise from two sources of policy variation. First, states differ in their adoption of so-called “lesser-of” policies, which are provisions for Medicaid to pay the lower of (a) Medicare’s cost sharing, or (b) the difference between the Medicaid fee schedule and Medicare’s payment for a service (net of cost sharing).1 Second, Medicaid fee schedules, which vary across states and over time, affect the amount of cost sharing that Medicaid will pay providers in lesser-of states.
In lesser-of states with low Medicaid fee schedules, providers can be paid substantially less when rendering services to duals vs other Medicare beneficiaries, who either pay Medicare’s cost sharing out of pocket or have private supplemental (ie, Medigap) insurance to cover these expenses.
To measure variation in state Medicaid policies regarding dual eligibles, a paper by Roberts et al. (2020) describes the process of creating a database of these policies. The sources of the database were (i) state Medicaid plans and amendments filed with CMS; (ii) state laws from LexisNexis; (iii) and Medicaid provider manuals, program bulletins, and related online policy documents. Then the authors created a payment index using a nationally representative sample of claims data for evaluation and management services HCPCS codes. The database is publicly available here.
Based on these data, the share of states with <80% coverage of Medicare coinsurance and deductibles has grown over time, from 24 states in 2004 to 29 states in 2018. Further, the number of states that provide full reimbursement fell from 11 in 2004 to 7 in 2018.
One limitation of the data used for this evaluation is that it ignores managed care. Medicaid managed care organizations (MCOs) and MCOs are have grown–relative to Medicaid fee-for-service–over time.
Lesser-of policies function similarly under Medicaid managed care, except that Medicaid MCOs pay the lesser-of (a) the difference between their negotiated provider rates and Medicare’s payment amount, and (b) Medicare’s cost sharing. However, to the extent payment rates negotiated by Medicaid MCOs differ from those in fee-for-service Medicaid, our payment index will not accurately reflect provider payments for duals enrolled in Medicaid MCOs.
Further, the analysis also does not include Medicare Advantage beneficiaries. In 2018, Medicare Advantage plans covered 33% of dual-eligibles with full Medicaid.
Nevertheless, the creation of this dataset to track changes in Medicaid dual-eligible generosity is certainly a useful contribution to the literature.
Nearly half the nation’s hospitals, many of which are still wrestling with the financial fallout of the unexpected coronavirus, will get lower payments for all Medicare patients because of their history of readmitting patients, federal records show.
The penalties are the ninth annual round of the Hospital Readmissions Reduction Program created as part of the Affordable Care Act’s broader effort to improve quality and lower costs. The latest penalties are calculated using each hospital case history between July 2016 and June 2019, so the flood of coronavirus patients that have swamped hospitals this year were not included.
The Centers for Medicare & Medicaid Services announced in September it may suspend the penalty program in the future if the chaos surrounding the pandemic, including the spring’s moratorium on elective surgeries, makes it too difficult to assess hospital performance.
For this year, the penalties remain in effect. Retroactive to the federal fiscal year that began Oct. 1, Medicare will lower a year’s worth of payments to 2,545 hospitals, the data show. The average reduction is 0.69%, with 613 hospitals receiving a penalty of 1% or more.
Out of 5,267 hospitals in the country, Congress has exempted 2,176 from the threat of penalties, either because they are critical access hospitals — defined as the only inpatient facility in an area — or hospitals that specialize in psychiatric patients, children, veterans, rehabilitation or long-term care. Of the 3,080 hospitals CMS evaluated, 83% received a penalty.
The number and severity of penalties were comparable to those of recent years, although the number of hospitals receiving the maximum penalty of 3% dropped from 56 to 39. Because the penalties are applied to new admission payments, the total dollar amount each hospital will lose will not be known until after the fiscal year ends on July 30.
“It’s unfortunate that hospitals will face readmission penalties in fiscal year 2021,” said Akin Demehin, director of policy at the American Hospital Association. “Given the financial strain that hospitals are under, every dollar counts, and the impact of any penalty is significant.”
The penalties are based on readmissions of Medicare patients who initially came to the hospital with diagnoses of congestive heart failure, heart attack, pneumonia, chronic obstructive pulmonary disease, hip or knee replacement or coronary artery bypass graft surgery. Medicare counts as a readmission any of those patients who ended up back in any hospital within 30 days of discharge, except for planned returns like a second phase of surgery.
A hospital will be penalized if its readmission rate is higher than expected given the national trends in any one of those categories.
The industry has disapproved of the program since its inception, complaining the measures aren’t precise and it unfairly punishes hospitals that treat low-income patients, who often don’t have the resources to ensure their recoveries are successful.
Michael Millenson, a health quality consultant who focuses on patient safety, said the penalties are a useful but imperfect mechanism to push hospitals to improve their care. The designers of the penalty system envisioned it as a way to neutralize the economic benefit hospitals get from readmitted patients under Medicare’s fee-for-service payment model, as they are otherwise paid for two stays instead of just one.
“Every industry complains the penalties are too harsh,” he said. “if you’re going to tell me we don’t need any economic incentives to do the right thing because we’re always doing the right thing — that’s not true.”
The U.S. Centers for Medicare & Medicaid Services (CMS) released its final home health payment rule for CY 2021 on Thursday, with essentially no changes to the Patient-Driven Groupings Model (PDGM) or its controversial behavioral adjustment.
In addition to doubling down on PDGM, boosting the home health base payment rate by 1.9% and making minor adjustments to the Home Health Value-Based Purchasing Model, CMS also clarified its new policy on Requests for Anticipated Payment (RAPs) for next year and beyond.
Home health agencies likely won’t be happy with the fine print.
In its 2020 rulemaking, CMS announced it was moving forward with a plan to fully eliminate RAPs — or home health-prepayments that provide a chunk of an episode’s anticipated payment at the beginning of care — by 2021. In place of RAPs, the agency explained it will instead require agencies to submit a one-time Notice of Admission (NOA) starting in 2022.
Although NOAs kick in for 2022, 2021 would be a transition year, with agencies still required to submit a watered-down RAP for billing purposes.
“With the removal of the upfront-RAP payment for CY 2021, we relaxed the required information for submitting the RAP for CY 2021 and stated that the information required for submitting an NOA for CYs 2022 and subsequent years would mirror that of the RAP in CY 2021,” CMS wrote in Thursday’s final rule. “Starting in CY 2022, [agencies] will submit a one-time NOA that establishes the home health period of care and covers all contiguous 30-day periods of care until the individual is discharged from Medicare home health services.”
While the elimination of pre-payments is already incredibly impactful, especially for smaller, cash-strapped home health agencies, CMS’s new policies also come with a built-in penalty for late submissions.
The RAP in 2021 and the one-time NOA starting in 2022 must both be submitted within five calendar days from the start of care. If agencies fail to do so, they’re subject to a one-thirtieth reduction to the wage and case-mix adjusted 30-day period payment amount for each day from the start of care date until the date agencies submit their RAP or NOA.
In other words, home health agencies will be hit with a 3% fine for each day they’re late filing their paperwork.
The fine print
A 3% fine for each late day to file a RAP or NOA doesn’t seem too bad at first glance. But that 3% fine turns into a 20% penalty very quickly.
After issuing its proposed rule in June, CMS received multiple comments from industry stakeholders asking when the non-timely payment reduction actually begins.
“A commenter requested clarification on the methodology used to calculate the non-timely submission payment reduction,” CMS stated in its 2021 final rule. “This commenter asked whether the reduction begins on Day 1 or Day 6.”
For purposes of determining if a “no-pay” RAP is timely-filed, the no-pay RAP must be submitted within five calendar days after the start of each 30-day period of care. For example, if the start of care for the first 30-day period is Jan. 1, then the no-pay RAP would be considered timely-filed if it is submitted on or before Jan. 6, the agency clarified.
What’s that mean? Well, in the event that the no-pay RAP is not timely-filed, CMS will calculate the one-thirtieth penalty from the first day of that 30-day period. So in the previous example, the penalty calculation would begin on Jan. 1 — and not on Jan. 7, the first day after an agency misses its deadline.
Translation: If an agency submits its no-pay RAP one day late, the result would be a 20% reduction to its 30-day payment amount.
“That will take these small agencies out,” McBee Associates President Mike Dordick told HHCN in July 2019.
A possible 20% penalty on top of that just adds insult to injury.
Cheating on your taxes
The RAPs penalty is an important detail from CMS’s final payment rule for next year, but the main takeaway is still the agency’s decision to stick to PDGM’s behavioral adjustment — effectively a 4.36% cut if left unmitigated.
Industry stakeholders were hoping CMS would reconsider the adjustment after emerging data suggested it’s inherently flawed but exacerbated due to the COVID-19 pandemic. The adjustment has proven difficult for many agencies, particularly when paired with astronomical personal protective equipment (PPE) costs and other factors.
“Our members have been working hard throughout this health care crisis to serve older adults in need of home health care, while at the same time shouldering significant pandemic-related expenses for PPE, staffing and other needs,” Katie Smith Sloan, president and CEO of LeadingAge, told HHCN in an email. “They’ve cared for older adults both in person and via telehealth, despite shortcomings in Medicare reimbursement policies that keep providers from being paid for delivering telehealth services.”
Those facts, coupled with CMS’s decision to not address faulty behavior assumption adjustments in its rule for CY 2021, put home health agencies in “an untenable position,” she added.
In addition to her role at the Washington, D.C.-based aging services industry association LeadingAge, Smith Sloan also serves as acting president and CEO of ElevatingHOME and the Visiting Nurse Associations of America.
In part, PDGM’s behavioral adjustment was based on CMS assuming home health agencies would do everything possible to lower Low Utilization Payment Adjustment (LUPA) rates while always “upcoding” to the highest-paying primary diagnoses.
Intrepid USA CEO John Kunysz told HHCN that line of thinking was wrong from the start.
“Maintaining the behavioral adjustment is akin to the government saying, ‘We believe you are going to cheat on your taxes, so we are disallowing a percentage of your deductions,’” Kunysz said in an email. “We operate in a highly regulated environment. The incentives to provide appropriate care far outweigh any temptation to try and game the system.”
Dallas-based Intrepid USA is a home health, hospice and home care provider with operations in more than a dozen states. In 2019, the company cared for more than 22,000 patients under its home health service line.
The ongoing expansion of Medicare Advantage (MA), a federal minimum-wage hike and additional support for front-line health care workers during the COVID-19 public health emergency.
These are just a few of the industry-shaping topics that home health insiders are following going into Election Day this Tuesday. While each presidential election is important, 2020 will help set the trajectory of U.S. health care policy for years to come.
No matter who wins between President Donald Trump and former Vice President Joe Biden, one thing is clear: In-home care gained a larger role in the overall continuum of care this year — and that momentum isn’t going away.
To get a deeper understanding of the 2020 election and what it means for home-based care operators, Home Health Care News reached out to several stakeholders for their perspective. Their responses are provided below, edited for length and clarity.
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Regardless of who wins, the fundamentals for home health care remain the same. There is a growing need for more care and higher levels of care in the home. The pandemic has only accelerated this trend as family members eschew institutional care settings. Meanwhile, telemedicine and virtual care will play the dual role of supporting quality care in the home — particularly for patients who need fewer services — and blurring the lines of what is considered traditional home care.
As state Medicaid budgets tighten, care for dually eligible individuals who have chronic and long-term care needs will need to be addressed. These individuals account for 20% of Medicare and 15% of Medicaid enrollment, yet account for about a third of spending for each. In-home care and care management can play a critical role in improving outcomes while reducing the overall cost of care. However, the U.S. Centers for Medicare & Medicaid Services (CMS), Congress and state Medicaid programs will need to figure out the right models to integrate this care while figuring out who pays for what and who gets the savings.
Ensuring that home health agencies can fully participate in virtual care initiatives — including reimbursement for such services — and ensuring that dual eligible integrated care efforts fully value the impact of care in the home are two of our top priorities.
— Marki Flannery, president & CEO of the Visiting Nurse Service of New York (VNSNY)
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The health care industry experienced unprecedented strains this year, but we also made strides in many areas. At the highest level, we saw bipartisan cooperation in the time of crisis that led to solutions for those acutely impacted by the pandemic, from telehealth coverage to Paycheck Protection Program (PPP) loans.
Regardless of the 2020 election outcome, in 2021, we’re turning our focus to a few key areas based on lessons learned from the public health emergency. Further elevating home health care as a viable care alternative is crucial. Whether it was helping to divert the surge on hospitals or sending patients home to recuperate from the effects of the virus in order to free up ICU beds, home care really rose to the occasion.
While there has been an increased appreciation and awareness of the power of home health care, there is still an opportunity to elevate understanding around the need for better home care reimbursement rates, fueled by an authentic understanding of the tireless value skilled and direct care workers provide. We are also working towards ways to secure and drive more competitive pay so that the home health care industry can more effectively fill the labor demand needed to support Americans who want to heal and thrive safely at home. We are continuing to see how cost-effective and truly preferred the home setting is for seniors who desire to age in place safely and securely. We want to do everything in our power to make this option more accessible.
— Jennifer Sheets, president & CEO, Interim HealthCare
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Regardless of the outcome of the election, the prospects for positive legislation impacting the home health sector in 2021 are promising. The new Congress will be interested in making policy changes to strengthen the Medicare program, examining the needs of the Medicare population and building off of lessons learned because of COVID-19. One of these lessons is that access to home health care for vulnerable populations can and should be optimized, particularly at times when the Medicare patient population is uniquely vulnerable. The home health community has developed policy solutions that offer Medicare beneficiaries a wider array of post-acute care options, including those that expand the availability of care at home.
Being able to “choose home” for more Medicare patients who need care, as an alternative to other institutional care, can not only ensure that high-quality clinical care is available to a wider Medicare population, but can also ensure safety and increased patient choice.
We have also seen that care in the home should be optimized through increased use of technology. The availability of telehealth should be expanded upon for Medicare home health patients, particularly in times when infection risk is high, as was the case during COVID-19. The Partnership believes that telehealth opportunities should be optimized to ensure continuity of care for our nation’s most vulnerable patients.
— Joanne Cunningham, executive director, Partnership for Quality Home Healthcare (PQHH)
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I’m hopeful that the current election will have a very positive impact on the home health industry going forward. That is because our industry has done a wonderful job over the years of advocating for our interests with a paramount emphasis on bipartisanship that is clearly evidenced in the recently introduced federal legislation calling for home health telehealth reimbursement during national emergencies.
In both the House and the Senate, these bills are being sponsored and supported by both Democrats and Republicans. That is extraordinarily significant. And coupled with the magnificent work our industry has done treating those in need during the current pandemic, the message has been communicated far and wide that our industry’s support spans the partisan political divide and is here to simply treat patients, clients and families with the health care services they need, when they need them, in the comfort, safety, security and familiarity of their homes.
— Dean Chalios, president & CEO, California Association for Health Services at Home (CAHSAH)
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Home care and hospice have the advantage of being supported by both parties. As such, whatever the outcome of the election, we expect any health care reforms to embrace health care at home as the awareness of its value has grown significantly during the pandemic. Once the dust settles after the election, we are prepared to work with the incoming Congress and administration to further advance home care and hospice.
— William A. Dombi, president of the National Association for Home Care & Hospice (NAHC)
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The outcome of the 2020 presidential election could greatly impact legislation, support, attention and funding for home health care workers and agencies. Additionally, if the non-chronic illness Medicare-eligibility age is reduced to age 60 vs. 65, that will be a tremendous game-changer for payers, providers, patients and the entire health care ecosystem.
— Cleamon Moorer, Jr., president & CEO, American Advantage Home Care Inc.
Democrats are favored to win both chambers of Congress after years of campaign-trail promises about health care. But with a pandemic, a more conservative Supreme Court and lingering disagreements between progressives and moderates, it could be difficult for Democrats to turn those promises into law.
In the final days of the campaign, COVID-19 and the threat posed to the Affordable Care Act and Roe v. Wade by the court’s bolstered conservative majority are consuming congressional Democrats — right down to keeping them in Washington well after they would usually go home to campaign.
Even if they capture the Senate in this election, Democrats are not expected to win a decisive enough majority to pass bills without some support from the GOP. The Senate’s filibuster rules could force Democrats to stick to legislation that can attract 60 votes — if they do not move to eliminate that requirement, as some are advocating.
Frederick Isasi, executive director of Families USA, a health consumer-focused organization that supported passage of the ACA more than a decade ago, said a slim margin could make it “exponentially more difficult” to pass major health care legislation.
Although progressives are pushing for more dramatic changes, Isasi said Democrats would have to consider, in particular, which measures their senators who won close races in more conservative states could support.
“There’s going to be a lot of focus on making sure that they can support this because the vote will be so tight,” he said.
Democrats argue that consumers’ concerns about health care, which led them to secure a House majority two years ago, will drive them to White House and Senate victories this fall. It has been 10 years since Democrats controlled both chambers of Congress and the White House. One week before the election, the political modeling website FiveThirtyEight gave former Vice President Joe Biden and Democrats an 87-in-100 chance of winning the presidency; a 73-in-100 chance of winning the Senate; and a 96-in-100 chance of holding the House.
A recent poll from KFF shows voters preferred Biden’s approach to health care over President Donald Trump’s on every key issue, including handling the pandemic. (KHN is an editorially independent program of KFF.)
Democrats set high expectations early in the presidential campaign, with progressive candidates during the primaries arguing over sweeping proposals for government-funded insurance before Biden won the nomination. He championed a more incremental approach of giving consumers an option to purchase a public insurance plan, which would also be free for some based on need. That plan is now part of the party platform.
But the pandemic, and the Trump administration’s decision to largely leave states to manage the health and economic repercussions, has changed the subject. On many popular issues like insuring more Americans and ending the practice of surprise medical billing, Democrats look no closer to agreement than they were months ago — even as the pandemic has made problems worse, with nearly 27 million people losing their employer-sponsored insurance in its first two months.
Sen. Patty Murray of Washington, expected to take over the Senate’s health committee if Democrats win, called health care affordability “a top priority for Democrats.”
“The bottom line for me is that everyone in this country should be able to get the health care they need without worrying about the cost — and I think this pandemic and economic crisis have underscored how important that is,” Murray said in a statement.
But the disagreements that pitted Biden against progressives like Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.) during the primaries remain, with the party’s more liberal voices pushing for dramatic reforms to drive corporations out of the health care system. And in the halls of Congress, Democrats from traditionally “red” states may find fixing the ACA an easier sell than a government-funded public insurance option.
There is a lot of “ideological diversity” among Democrats, said Rodney Whitlock, a health care consultant who spent years working as a Republican Senate aide. Although Democrats like to refer to themselves as an inclusive, “big tent party,” he said in a recent podcast that such diversity can make it harder to agree and get much done, even if the party is in the majority.
Observers warn the party’s calculations could change if Democrats move to eliminate the Senate filibuster, removing one of the minority party’s most effective means of opposition.
If Democrats win control of Congress and the White House, there would be “incredible support among Democrats” to eliminate the filibuster to achieve their goals, especially on health care, said Robert Blendon, a professor of health policy and public opinion at Harvard University who has a new article on the election in the New England Journal of Medicine.
Democrats will effectively have a year to advance their agenda before the next election, he said, and liberal voters, who make up about 50% of Democratic voters, are angry about how Republicans have managed power and eager to embrace universal health coverage.
Their argument boils down to this: “This is our chance in history, and we’re not going to do it because we can’t get three votes” in the Senate, Blendon said.
“Policies that currently would have no chance in the Senate could come into play in 2021 if the legislative filibuster is removed,” Whitlock recently wrote. If that happens, he added, the health care industry would need to reevaluate proposals “that would have once seemed highly theoretical and unlikely.”
Without the power to set the agenda or the numbers to pass their proposals, congressional Democrats have spent the Trump presidency telling Americans — in heartbreaking public testimony, impassioned floor speeches and reams of stalled legislation — that they are the party to trust with health care.
These days, Democrats are quick to mention the need to shore up the Affordable Care Act, which Republican attorneys general and the Trump administration are seeking to overturn through a case the Supreme Court will hear Nov. 10.
Though even conservative scholars say Republican arguments in the case are weak, Democrats worry the death of Justice Ruth Bader Ginsburg and the confirmation of Justice Amy Coney Barrett could endanger the law.
If the ACA is overturned, other legislative priorities likely would fall by the wayside as lawmakers address the potential elimination of coverage and consumer protections affecting millions of Americans.
While in the minority, Democrats have proposed numerous ideas to strengthen the ACA, leaving some measures on the table for Democratic leaders to revisit when in power.
In June, the Democratic-controlled House passed legislation aimed at increasing coverage and affordability, including by capping insurance costs at no more than 8.5% of income. The bill would grant Medicare the authority to negotiate drug prices — drawing from a proposal crafted by House Speaker Nancy Pelosi and House Democratic leaders in 2019 and included in Biden’s platform.
That proposal initially ran afoul of progressives, though, who argued they had been cut out of writing the bill and that it was not aggressive enough.
Democrats also have failed to reach a consensus on banning surprise medical billing, which generally occurs when patients receive care unknowingly from a doctor or provider who is not in their insurance network. House Democrats disagreed earlier this year on proposals to solve the problem. A bipartisan proposal in the Senate also stalled, and efforts to ban surprise billing during COVID-19 proved ineffective.
In the meantime, as Democratic candidates talk up ideas like the public option to energize voters as voting draws to a close, Democratic leaders are making less specific promises.
“For the last four years, Donald Trump and Republicans have sabotaged the Affordable Care Act in the hopes of causing our health care system to collapse,” Sen. Chuck Schumer of New York, the Democratic minority leader, said in a statement. “If we Democrats win back the White House and the majority in the Senate, we will strengthen and improve our health care system to make it cheaper and easier for everyday Americans to get the care and coverage they need.”
If they’ve been listening to President Donald Trump, seniors may be expecting a $200 debit card in the mail any day now to help them pay for prescription drugs.
He promised as much this month, saying his administration soon will mail the drug cards to more than 35 million Medicare beneficiaries.
But the cards — if they are ever sent — would be of little help. Policy experts say that what Medicare beneficiaries really need, as well as younger Americans, are sweeping federal changes to close the gap between what their health insurance pays and what drugs cost them.
The nation’s 46.5 million enrollees in Medicare’s Part D prescription drug program — except for those who qualify for low-income subsidies — face unlimited out-of-pocket exposure to drug costs even though the Affordable Care Act finally closed the infamous “doughnut hole.” After Part D enrollees have spent $6,550 and reached the catastrophic threshold in a given year, they still must pay 5% coinsurance on the list price of their drugs.
Congress was considering legislation to lower drug prices and cap out-of-pocket costs until early this year, when the COVID-19 pandemic took center stage. But partisan disagreement, federal budget concerns and opposition from drug manufacturers and other health care industry groups hampered the efforts.
Many observers question the value, timing and legality of Trump’s drug card plan, with the promise coming just ahead of an election in which the president wants to shore up the support of older voters.
“A $200 card is better than a sharp stick in the eye, but it won’t be that meaningful,” said Tom Scully, the Medicare chief under President George W. Bush who in 2004 implemented a two-year, $1,200 drug card program passed by Congress as part of the law creating the Part D prescription drug benefit.
Two hundred dollars won’t go very far. One million Part D plan enrollees have out-of-pocket drug spending way above the program’s catastrophic coverage threshold, with average annual costs exceeding $3,200, according to KFF. (KHN is an editorially independent program of KFF.) Last year, Part D enrollees’ average out-of-pocket cost for 11 orally administered cancer drugs was $10,470, according to a 2019 JAMA study.
“A lot of people don’t have $2,000 or $3,000 to pay out-of-pocket when they go to the pharmacy,” said Stacie Dusetzina, a drug policy expert at Vanderbilt University.
Steven Hadfield, 68, of Charlotte, North Carolina, has a rare blood cancer requiring treatment with Imbruvica, with a list price of $132,000 a year. He also needs two different medications for Type 2 diabetes, including insulin at $300 a bottle, a blood pressure drug and a muscle relaxer to relieve leg cramps.
He continues to work at Walmart and holds three part-time jobs. He pays more than $4,000 a year for his drugs, out of his $12-an-hour wages and monthly $1,100 Social Security check. The only way he can afford Imbruvica is through the manufacturer’s copay cards.
If he left his Walmart health plan and signed up for Medicare Part D drug coverage, he would have to pay thousands of dollars more because, under Medicare rules, he would no longer be able to use copay cards. “My whole Social Security check would go to drugs, and I’d have nothing left for my car or anything,” he said
Asked about Trump’s $200 drug card, Hadfield said, “I’d be happy to get anything, but they need to do more. Our representatives need to create some kind of program to lower prices.”
The Republican-controlled Senate refused to consider a sweeping drug cost bill passed by House Democrats a year ago that would have capped Part D out-of-pocket costs at $2,000 a year, penalized drugmakers for raising prices above inflation rates and let Medicare negotiate drug prices. Trump threatened to veto it.
In addition, Senate Republican leaders wouldn’t take up a bipartisan bill backed by the White House capping Part D out-of-pocket costs at $3,100 and also imposing penalties for price hikes above inflation.
The lack of action hasn’t stopped Trump from claiming, mostly inaccurately, that he has implemented policies that have reduced drug prices and saved seniors lots of money.
“Day after day I’m fighting to defend seniors from Big Pharma,” Trump said Oct. 16 in a Florida speech promising drug price cuts of 50% to 80%. “We have this terrible system that’s taken years and years to rig.”
The president’s centerpiece proposal is to index the drug prices paid by Medicare to lower prices paid by foreign countries. But his administration has not yet issued a rule to carry that out, and any such rule would face a strong legal challenge from drugmakers.
Joe Biden’s drug cost platform includes allowing Medicare to negotiate prices with drug manufacturers, limiting launch prices for new drugs, capping price increases at the inflation rate and letting consumers buy cheaper medicines from other countries. His plan would also likely spark opposition from drug companies.
Trump’s $200 drug card appears to be in trouble within his own administration. White House chief of staff Mark Meadows said last week that details will be finalized shortly and that the cards will be mailed to seniors in November or December.
But the general counsel of the Department of Health and Human Services warned in an internal memo the plan could violate election law. Congressional Democrats have called for an investigation, saying Trump is “attempting to buy votes.”
In a draft document obtained by Politico, the White House set the cost of the drug card plan at nearly $8 billion. To avoid having to seek congressional approval for the expenditure, Trump’s advisers want to call it a demonstration project, testing whether lowering Medicare patients’ out-of-pocket drug costs boosts their compliance in taking medications.
“It will be difficult to learn anything from this demonstration project that we do not already know from other studies,” Dusetzina said.
“It’s a whole lot of money that would be more effectively focused on people with cancer and serious chronic illnesses who are struggling with high out-of-pockets,” said Daniel Klein, CEO of the Patient Access Network Foundation, which provides grants to help patients with drug costs.
Maureen Allen, 80, a retired marketing specialist who lives in Talking Rock, Georgia, said she could apply the $200 card to her annual cost of more than $2,000 for the anti-blood clot drug Eliquis and other medicines.
“It would help me with one month of Eliquis,” she said. “We’ll take the card because we need the money. But don’t think for a moment it will have the slightest impact on my vote.”
The Oncology Care Model is slated to end soon. Specifically, the last set of six-month episodes would initiate no later than December 31, 2020 and thus all episodes will be completed in June 30, 2021. Nevertheless, CMS is proposing a successor to the Oncology Care Model called the Oncology Care First (OCF) Model. CMS describes the revised approach as follows:
…the payment mechanisms for the potential OCF Model would include: (1) A prospective, monthly population payment (MPP) for an OCF participant’s assigned population of Medicare FFS beneficiaries with cancer or a cancer-related diagnosis that would include payment for Evaluation and Management (E&M) services, “Enhanced Services” required under the terms of the model participation agreement, and drug administration services; and, (2) Total cost of care accountability for Medicare costs, including drug costs, incurred during a six-month episode of care triggered by a Medicare beneficiary’s receipt of a Part B or D chemotherapy drug, 6 with the opportunity to achieve a performance-based payment (PBP) or owe a repayment to CMS (PBP recoupment), depending on quality performance and costs relative to benchmark and target amounts
What are the differences between OCM and OCF? AJMC reports some key differences:
* CMS wants to shift some of the FFS payment to capitation, which “will pose challenges for OCF participants.” Evaluation and management (E/M) services and drug administration fees, which were previously outside the monthly practice transformation fee, would be folded inside it. * Improved performance-based-payment formulas would do a better job of accommodating rapidly rising drug costs and protect oncologists from being held responsible for events that are beyond their control. * New requirements may be added to require practices to gather patient-reported outcomes (PROs).
…today’s OCM are completely unpredictable because the actual expenses may vary from baseline depending on the specific nature of each cancer treated. Moreover, in OCF as in OCM, the treating physician is at risk for total costs of care, including services having nothing to do with cancer, like care after a car accident or for brittle diabetes. Adequately risk adjusting for each cancer type and stage across all possible cancers, including underlying patient-specific characteristics, seems all but impossible.
Research by my colleagues Jim Baumgardner and colleagues (Baumgardner et al. 2018) quantifies some of the variation in cost types across OCM episodes.
But during COVID-19, it’s really a bad time to do new models and experimenting or pushing the envelope too quick, too hard, because we are under a tremendous amount of stress, and none of us wants to fail and not deliver and have consequences in terms of 2-sided risk for our practices that could impact access to care to our patients. For Oncology Care First, I’m happy that they pushed back 12 months for 2022. We may need more time, but we’ll see how this plays out.
For 2021, the average Medicare beneficiary has access to 33 Medicare Advantage plans, the largest number of options available in the last decade, and can choose from plans offered by eight firms. Among the majority of Medicare Advantage plans that cover prescription drugs, 54 percent will charge no premium in addition to the monthly Medicare Part B premium. As in previous years, the vast majority of Medicare Advantage plans will offer supplemental fitness, dental, vision, and hearing benefits. In addition, virtually all will also offer telehealth benefits in 2021.
This issue brief provides an overview of the Medicare Part D prescription drug benefit plan landscape for 2021, with a focus on stand-alone drug plans. It includes national and state-level data on plan availability, premiums, benefit design, cost sharing, information about premium-free plans for low-income beneficiaries, and information about the national Part D drug plans available in 2021.
CMS’ interim rule states that Medicare will cover Covid-19 vaccines approved by the FDA, including those receiving emergency use authorization, in a reversal from its usual policy. The vaccine will be made available at no cost to Medicare beneficiaries.
The Centers for Medicare and Medicaid Innovation (CMMI) created the Direct Contracting Model to expand opportunities for more diverse providers and healthcare organizations to participate in value-based care arrangements for Medicare fee-for-service (FFS) beneficiaries.
The goal of the new model is to create the next generation of risk-sharing arrangements to improve outcomes for patients, lower costs, and ensure high-quality care. In developing the Direct Contracting model and associated payment options, CMMI decided to build on lessons learned from accountable care initiatives, in particular, the Next-Generation ACO (NGACO) Model, as well as Medicare Advantage and other innovative private payers. The new model specifically aims to attract providers new to Medicare FFS and Innovation Center models: “the payment model options appeal to a broad range of physician practices and other organizations because they are expected to reduce burden, support a focus on beneficiaries with complex, chronic conditions, and encourage participation from organizations that have not typically participated in Medicare FFS or CMS Innovation Center models.”
High risk equals high reward for the new Direct Contracting Entities (DCE). The payment model options that participants can choose from aim to (1) increase risk-sharing arrangements through capitated and partially capitated population-based payments, (2) include providers and organization new to Medicare FFS, (3) increase access and empower beneficiaries in their care, and (4) decrease provider burden by emphasizing only core quality metrics and making certain care delivery waivers available. Importantly, the model offers options for new entrant DCEs, meaning DCEs that have no or limited experience with Medicare FFS beneficiaries and associated Medicare risk-based contracts, as well as high needs DCEs that will focus specifically on high cost, high acuity beneficiaries.
The Direct Contracting model begins with an optional six-month implementation period on October 1, 2020, which is intended to support organizations that need additional time to align beneficiaries and optimize their care coordination and management functions. In light of COVID-19’s overwhelming impact on healthcare this year, CMMI announced the first Direct Contracting Model performance year will start April 1, 2021—a three-month delay from the original start date, with five performance years to follow. The second cohort of Direct Contracting participants will begin in January 2022.
The Innovation Center will initially test two risk-sharing options:
Professional – includes a 50% shared savings/shared losses provisions and Primary Care Capitation, a capitated, risk-adjusted monthly payment for enhanced primary care services that’s equal to seven percent of the total cost of care benchmark for enhanced primary care services
Global – is 100% full risk option with either Primary Care Capitation or Total Care Capitation, which is a capitated, risk-adjusted monthly payment for all services provided by Direct Contracting Participants and preferred providers.
CMS may test a third option, the Geographic Option, in the future, which would also be a 100% risk arrangement offering an opportunity for participants to assume the total cost of care risk for Medicare FFS beneficiaries in a defined region.
Achieving Success in the Direct Contracting Model:
Similar to existing accountable care models, critical elements to achieve success in the Direct Contracting model include a focus on workflows, systems, and partnerships that support care coordination activities, including connections to needed healthcare and wrap-around services, as well as supporting providers in attaining quality benchmarks while managing overall utilization. Underlying these capabilities is access to real-time actionable information to drive timely interventions and coordination activities.
Real-time information through admission, discharge, and transfer (ADT) event notifications for Emergency Department, hospital, or post-acute encounters enable care coordination teams to deploy workflows and resources to more easily and quickly support patients. Knowing when and where patients are receiving care and understanding the clinical context for their care allows providers and care teams to more seamlessly work together to provide the right care at the right time without unnecessary or duplicative interventions. It also allows care teams to identify patients at high risk for complications, including readmissions and can prompt time-sensitive outreach and connection to additional resources.
Having access to real-time information can not only improve patient outcomes and quality but will also help to maximize payment incentives for Direct Contracting participants. Coordinated care consistently leads to shorter lengths of stay, which not only has positive quality implications for patients but also financial benefits for Direct Contracting Entities.
In addition, healthcare organizations can use real-time information to continuously strengthen and refine care network partnerships and collaborations.
To effectively manage Medicare FFS patients within the Direct Contracting Model, participants will need to coordinate with other providers across care settings and deploy timely interventions that support patients’ health and well-being. Real-time information, through ADT data, will provide participants with a new level of clinical intelligence to successfully prioritize and deploy care coordination services and ensure seamless transitions of care for patients while also creating optimal opportunities to achieve shared savings.
About Vanessa Kuhn, Ph.D
Vanessa Kuhn, Ph.D., is the Director of Policy at PatientPing, a care collaboration platform that provides real-time visibility into patient care events across the continuum. PatinetPing works with hospitals, post-acutes, health plans, ACO’s and beyond, the platform connects providers across the nation to improve patient and organizational outcomes.
This analysis shows that more than half of Medicare beneficiaries do not compare coverage options annually during the open enrollment period, despite the fact that Medicare Advantage and Part D plans often change from one year to the next, which could lead to unexpected and avoidable costs for beneficiaries who do not review their options annually. It also highlights that many beneficiaries have difficulty understanding the Medicare program and comparing coverage options. Further, it shows that most beneficiaries do not use Medicare’s official information resources.
It’s no surprise, then, that in an ad released this month, former Vice President Joe Biden’s campaign played the Medicare card.
“Donald Trump is lying about Medicare and Social Security,” an ominous, mature, male voice warns viewers in the ad. He goes on to say that “Trump’s pushing to slash Medicare benefits.”
Clearly, we’ve heard this dire message before — from candidates of both parties through the years.
We issued a skeptical rating of a claim that Trump promised to gut Social Security and Medicare if re-elected, noting that his deferral of payroll taxes did not mention Medicare at all. But Trump has not mentioned cuts to Medicare benefits on the trail, and he’s promised to make cuts to the program in the future. So what is Biden’s claim talking about?
As a rationale for the statement, a Biden campaign spokesperson pointed us to the Trump administration’s support of Republicans’ efforts in a court case, California v. Texas, which seeks to overturn the Affordable Care Act. But the ad does not include any reference or explanation of how the case would affect Medicare benefits.
The legal challenge, brought by a group of Republican attorneys general, is pegged to the 2017 tax bill, which zeroed out the tax that functioned as a penalty for not having health coverage — known as the individual mandate. Without this linchpin tax, the Republicans argue, the entire law should be struck down. They based that on the Supreme Court decision in 2012 that the law was constitutional because the penalty was a valid use of Congress’ ability to levy taxes.
In the current case, lower courts have found the law unconstitutional, and a group of Democratic attorneys general appealed to the Supreme Court.
Oral arguments are scheduled for Nov. 10. The Trump administration filed a brief in support of invalidating the entire law unconstitutional.
Though best known for its vast expansion of health coverage through marketplace plans and Medicaid, the ACA also included a range of consumer protections — such as the ban on discrimination against people with preexisting conditions — and an estimated 165 Medicare-related provisions.
The Biden spokesperson pointed to one, which ended Medicare’s so-called doughnut hole.
We asked experts for their take. Immediately, we found differences in opinion.
That’s a “perfectly fair claim,” said Nicholas Bagley, a professor at the University of Michigan Law School. Closing the doughnut hole matters to many people, he said.
Case Western Reserve University law professor Jonathan Adler took a different view. The argument that Medicare would be affected “is a very aggressive reading of the filing in this case,” he said, referring to the Trump administration’s brief in support of nullifying the ACA.
The next step seemed to be getting a better grasp of what’s at stake.
A Quick Review of the Doughnut Hole, Other Medicare Provisions
The Medicare doughnut hole refers to the gap in Part D prescription drug coverage that begins after a beneficiary spends a set amount — usually a few thousand dollars. Before the ACA, beneficiaries who reached that threshold were responsible for 100% of their medication costs until they spent enough for catastrophic coverage to kick in, which could be more than $1,000 in additional spending. Even with this coverage, beneficiaries were responsible for 5% of their drug expenditures. (If beneficiaries were responsible for 100% of costs today, people with high drug costs would obviously pay a lot more without the ACA provision.)
The ACA would have gradually ended that coverage gap. But, in 2018, Congress adopted changes to expedite the process. As of 2019, the doughnut hole was closed. Adler pointed to that congressional intervention as a step that could keep the doughnut hole closed if the ACA were overturned. Based on this legislative history, the argument could be made that closing the coverage gap was something Congress had an interest in apart from the ACA. Since the doughnut hole is officially closed, some analysts said this provision may not be vulnerable to the upcoming Supreme Court decision on the ACA.
“You can make a lot of claims,” said Gail Wilensky, a former head of the Centers for Medicare & Medicaid Services. “That one is really a stretch.”
Other ACA provisions tied to Medicare benefits seem more at risk, such as the one that mandated annual wellness visits and certain preventive services, such as mammograms, bone mass measurement for those with osteoporosis, and depression and diabetes screening, with no patient cost sharing.
“It’s not clear that the administration actively supports any change to the Medicare benefits with the case before SCOTUS,” said Tricia Neuman, KFF senior vice president and executive director of the KFF’s program on Medicare policy. “But if they didn’t explicitly seek to wall off certain provisions, it is at least conceivable — though maybe not likely — that Medicare benefits in the ACA could be collateral damage.” (KHN is an editorially independent program of KFF.)
According to an amicus brief filed by the AARP, the Center for Medicare Advocacy and Justice in Aging in 2016, an estimated 40.1 million Medicare beneficiaries received at least one preventive service and 10.3 million had an annual wellness visit with no copay or deductible.
Other experts pointed to a troubling implication for Medicare: the nullification of the ACA provisions related to costs and slowing the growth of the program’s spending. Those efforts had been credited with extending the solvency of the Health Insurance Trust Fund and slowing the growth in Medicare premiums.
It “would impair the financial fitness” of the trust fund, said Paul Van de Water, a senior fellow at the Center on Budget and Policy Priorities.
Trump “may not say it is his intent to slash Medicare benefits,” agreed David Lipschutz, associate director of the Center for Medicare Advocacy, but overturning the ACA entirely would “cause chaos writ large.” And, because of the program’s size, that chaos “would upend the financial markets and the entire health care system,” according to the brief filed by Medicare advocates.
What Comes Next Is Complicated
Enter the concept of severability. Many court watchers are quick to say the high court’s decision could go beyond upholding the entire law or declaring it unconstitutional. Instead, the justices could separate or sever parts of it not directly related to the zeroed-out tax penalty, the so-called individual mandate.
Of course, the Trump administration argued in its brief that the interwoven nature of the ACA’s provisions demanded that the entire law be invalidated.
“If you just go on that basis, they are not arguing for severability,” said Van de Water.
But others point out another layer that warrants consideration.
“Everyone who comments on this focuses on the administration’s argument for inseverability,” Adler said. But he said it was more complicated than that.
The Trump administration’s position is “simultaneously that the entire ACA should be invalidated” and also that relief should be provided only where injury to the plaintiffs is shown. (The administration defines the plaintiffs as the two individuals who signed on to the original challenge.)
Another view is that this point in the administration’s argument is not clear-cut, mostly because it gives no hint as to which programs or provisions would fit into the category of harming the plaintiffs.
Ultimately, the fate of the sweeping health law is in the hands of the Supreme Court.
“Legal analysts didn’t anticipate the case getting as far as it has,” said Lipschutz.
But “the White House threw its weight behind the lawsuit,” said Bagley, at the University of Michigan. “So, they own the consequences. Especially in the context of this presidential campaign.”
An attack ad by the Biden campaign states that Trump is “pushing to slash Medicare benefits” and ties this charge to the administration’s position on the pending legal challenge to the ACA.
The Biden campaign pointed to an ACA provision that sought to close the Medicare doughnut hole to support this claim. It may not be the best example, though, because some experts suggest it may not be as vulnerable as other parts of the law.
Experts outlined a range of other Medicare provisions that either provided new benefits or shored up the program’s financial fitness. If the whole law were to be nullified, as the administration has advocated, these changes could also be erased — a step that would affect benefits and potentially cause premiums to rise.
Overall, the Biden ad seems plausible, even though the link between Trump’s position on the legal challenge and its impact on Medicare benefits is less straightforward than in similar claims we have checked regarding preexisting conditions.
– Doctor On Demand and CareLinx, one of the largest professional networks for in-home care, have announced a collaboration to bring in-home virtual care services to CareLinx clients.
– At a time when seniors have been encouraged to stay home to avoid exposure to COVID, Doctor On Demand’s partnership with CareLinx will vastly improve their opportunity to receive comprehensive healthcare while remaining safe.
After being the first and only telemedicine provider to roll out medical care for Medicare Part B beneficiaries, Doctor On Demand is doubling down on their efforts to support seniors in their homes. Doctor On Demand, the nation’s leading virtual care provider, and CareLinx, a nationwide, professional network for in-home care, today announced a partnership to bring in-home virtual care services to CareLinx clients.
Supporting High-Risk Patients at Home
The partnership aims to expand CareLinx’s in-home care offerings and improve health outcomes for their clients, geriatric and high-risk patients who need support at home. Today, CareLinx tech-enabled caregivers have digital care plans on their smartphones — enabling quality delivery of everyday care services such as bathing and meal prep, as well as direct communication to a patient’s family.
Doctor On Demand will augment these existing services by connecting CareLinx clients with virtual care providers in real-time. CareLinx caregivers will support the Doctor On Demand registration process and assist with in-home follow-ups and care coordination recommended by Doctor On Demand’s board-certified physicians as well.
CareLinx Clients Receive Access to Virtual Visits, Powered by Doctor on Demand
Eligible CareLinx clients will receive initial visits with board-certified physicians through Doctor On Demand at no cost. These virtual visits can be used to treat a spectrum of health issues, including diagnosis and testing of COVID-19, typical ailments like infections, rashes, cold and flu, and ongoing chronic diseases like asthma, diabetes, high blood pressure, and thyroid issues. Doctor On Demand physicians can also fill prescriptions and order lab work, and patients can see the same physician time and time again, building a trusted, personal relationship via video.
Why It Matters
“Now more than ever, finding high-quality, in-home care is pivotal during a time when seniors and high-risk patients are being encouraged to stay at home to minimize risk and exposure to COVID-19. Our partnership with Doctor On Demand enables CareLinx to continue equipping caregivers with digital tools and technologies to make caregiving easier, more transparent, and higher quality,” said Sherwin Sheik, CEO, CareLinx. “Additionally, this partnership is helping to supplement in-home activities of daily living with a telehealth option for our clients, who may not otherwise realize they have the option to see a provider virtually for medical ailments. Combined with the in-home care they are receiving, these services can help provide an expanded continuum of care to help them stay healthy and safe where they want to be — at home.”
This analysis examines the extent to which non-pediatric physicians have opted out of the Medicare program. The analysis finds that few physicians have opted out of Medicare, with the share of opt-out physicians varying by specialty.
If Joe Biden wins the presidency in November, health is likely to play a high-profile role in his agenda. Just probably not in the way he or anyone else might have predicted.
Barring something truly unforeseen, it’s fairly certain that on Jan. 20 the U.S. will still be in the grip of the coronavirus pandemic — and the economic dislocation it has caused. Coincidentally, that would put a new President Biden in much the same place as President Barack Obama at his inauguration in 2009: a Democratic administration replacing a Republican one in the midst of a national crisis.
Obama had only a financial crisis to deal with. Still, Biden would have a couple of advantages his Democratic predecessor lacked, including the fact that, as vice president, he helped guide the country through that financial meltdown. He’s also had time to plan how to address the crisis, which was not the case in 2009, when the economy was in freefall just as the new administration was taking office.
But like Obama before him, Biden will face a long must-do list on taking office. He will have to tackle the pandemic and economic crisis before he can turn to some of the big health changes he’s promised, such as expanding the reach of the Affordable Care Act, creating a “public option” that would allow every American to enroll in a government-sponsored plan and lowering the eligibility age for Medicare from 65 to 60.
And even if Democrats do retake the Senate majority and keep control of the House, it is unlikely the majority in either chamber will be as large as in 2009, when Obama had 60 Senate votes.
Still, no matter what the partisan makeup of Congress, “priority one is to get the COVID response going,” said Len Nichols, a professor of health policy at George Mason University.
Biden’s COVID plan includes taking major responsibility for the pandemic back from the states. His federal response would include more money for, and coordination of, testing and contact tracing; ensuring adequate protective equipment for health professionals; and assuring the public that new treatments and vaccines will be based on science, not politics.
In an updated version of his plan, Biden has also promised that one of his first calls if he is elected will be to Dr. Anthony Fauci, the government’s top infectious disease expert, who has been derided by President Donald Trump. “Dr. Fauci will have full access to the Oval Office and an uncensored platform to speak directly to the American people — whether delivering good news or bad,” says Biden’s website.
Biden’s COVID plan also addresses the economy — including calls for emergency paid leave for workers dislocated by the pandemic and more financial aid for workers, families and small businesses.
“If we’ve learned anything, it is that the health sector and the economy are not two separate spheres. They are connected,” said Nichols. “I think health care and the economy are complementary and will be for the foreseeable future.”
Biden took heat throughout the primaries for his “moderate” approach to improving health insurance access and costs, compared with the “Medicare for All” plans for a government-run system supported by his top rivals, Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.). But that doesn’t mean his far less sweeping approach would be easy to get through Congress.
“There’s a really big difference when you’re running the government than when you’re running for office,” said Dan Mendelson, a former Clinton administration health official and founder of the health consulting firm Avalere Health.
Many of Biden’s proposals, including a public option and larger subsidies to help low- and middle-income people pay for insurance, are the very things that an overwhelmingly Democratic Congress could not pass as part of the original Affordable Care Act in 2010. Conservative Democratic senators objected to the plan.
“We pushed,” Obama said in a recent interview on the podcast “Pod Save America,” talking about the public option. “I needed 60 votes to get it through the Senate. Joe Lieberman, Ben Nelson and a couple others said, ‘I’m not voting for a public option.’”
Mendelson said another big obstacle is that for all the detail Biden has in his health plan, concepts like the public option “are not well-defined, and there are many different theories of what it should be and where it should be fielded. There’s no common vision about what it really means.”
The same thing is true, he added, for something that seems as simple as reducing the Medicare eligibility age. “More than half these people have commercial insurance,” he said. “What will happen to them?”
Grace-Marie Turner, of the conservative Galen Institute, suggested Biden — or Trump, if he’s reelected — might be better served by pursuing one of the more bipartisan health issues that already have broad support from the public, like prescription drug prices or “surprise” medical bills patients receive after getting care from a doctor outside their insurance network while being treated at an in-network facility. “It would be a big statement,” she said. “Whoever wins would then have the wind at their back.”
But even those issues have a way of getting complicated. Both Democrats and Republicans say they want to bring down drug prices, but Republicans are vehemently against one of the Democrats’ preferred ways of doing that: by allowing Medicare to negotiate with drugmakers. And surprise medical billing has so far defied efforts to fix it, as Congress seems unable to choose between health insurers and health providers, who each want the other to bear the additional costs.
As always, even when health is at the top of the agenda, it proves difficult to address.
As the 2020 Election Day approaches, many candidates continue to focus on health care issues, including on the public health and economic response to COVID-19, the future of the Affordable Care Act, health care costs and abortion. To help reporters understand and cover these issues, KFF offers independent, non-partisan policy analysis, polling and other research and…More
As home health and home care operators move toward the ninth month of the COVID-19 pandemic, it’s important to take stock of what has been accomplished from a policy perspective. Many of 2020’s regulatory changes will be fleeting, but others will shape the future of post-acute care for years to come.
That was the message delivered Monday by National Association for Home Care & Hospice (NAHC) President William A. Dombi during the nonprofit advocacy organization’s annual conference. In addition to providing a regulatory recap, Dombi hinted at new Medicare benefits on the horizon and explained how the value of home-based care is at an all-time high.
“There has been an increased awareness of the breadth and depth of care at home, and this will have a long-standing impact on policy and politics as well,” he said. “There has been an absolute, exponential increase in respect for what you do in the home care setting. We took the stresses of the pandemic head-on and proved that care in the home is not only essential but [the best option].”
During Monday’s Washington update, Dombi revealed that 67% of in-home care providers are serving COVID-19-positive patients.
To support them in delivering that care, providers have been able to lean on a variety of lifelines, including funds from the CARES Act Provider Relief Fund and the Paycheck Protection Program (PPP). Providers have also received essential-worker classification and greater telehealth flexibilities.
Additionally, the U.S. Centers for Medicare & Medicaid Services (CMS) has recognized that virtually the entire Medicare population meets homebound status requirements.
“When you’re Medicare eligible, over the age of 65 or on disability, and you need health care services, you have a compromised condition to put you at even greater risk of fatality,” Dombi said. “CMS agreed with our position on this and issued interpretive guidance indicating that individuals who need to leave the home for services, it is medically contraindicated, thereby meeting the homebound standard.”
During the public health emergency, CMS also paused claims audits and the Review Choice Demonstration (RCD), a regulatory initiative designed to reduce improper billing in home health care. That has since been restarted, with temporary administrative flexibilities.
COVID-19 testing, non-physician certification
At the end of September, the U.S. Department of Health & Human Services (HHS) announced that home health and hospice agencies would receive 10 million rapid COVID-19 tests from a federal inventory of about 150 million. Dombi likewise touted that as a win.
In the first week of distribution alone, he noted, about 160,000 tests were distributed to home health and hospice agencies.
“The fact that HHS recognized that home care was an essential part of health care services and made us part of that allocation in itself is a notable success,” Dombi said. “Just being recognized, not being considered some stepchild in health care.”
Among the other topics he touched on during his Washington update, NAHC’s president highlighted excitement around non-physician certification, something the home health industry had been working toward for years.
Senator Susan Collins (R-Maine) first introduced legislation that pushed for this change in 2007.
“We found ourselves in the middle of discussions, negotiations and advocacy with the CARES Act, and Senator Collins said, ‘I think this is our chance to get it done.’ [She] was able to convince the Senate that now is the time to allow non-physician practitioners to have equal status with physicians, to the extent that the state law allows it within the Medicare home health benefit,” Dombi said.
New Medicare benefits
Despite making major inroads across various fronts, there are still a number of measures that need to be taken.
For one, providers are still on the lookout for the next coronavirus-related stimulus package, which was originally expected before the July 4th Congressional recess, then again before the August recess.
“This is a back and forth that’s happening between the House and the Senate, between Republicans and Democrats,” Dombi said. “We’re still looking to see if we can have something before they go on recess in October, but we’re planning also for a lame-duck session on it.”
As far as what providers hoped to see in the next package, the list includes continued funding for the Provider Relief Fund, plus expanded funding for Medicaid home- and community-based services. The list also includes premium pay for front-line workers and litigation immunity.
Another area of focus for NAHC is palliative care. The organization is moving to get revisions in the Medicare coverage manual under home health care to fully recognize palliative care as one of the services provided as part of the existing benefit.
“We don’t think we need Congressional action to get there,” Dombi said. “Some of you — maybe many of you — are already doing things that would qualify as skilled palliative care under the benefit and getting Medicare to pay for it.”
Home health providers can also expect to see the 2021 payment rule finalized before the end of October or during the first few days of November. NAHC is calling on CMS to roll back the 4.36% behavioral adjustment in the Patient Driven Groupings Model (PDGM) ahead of the announcement of the final rule.
“It’s not just because we are in this unprecedented year of COVID-19,” Dombi said. “CMS projected a decrease in [Low Utilization Payment Adjustments], as they thought home health agencies would try to maximize 30-day episodic reimbursement. We have seen just the opposite of that, partially influenced, of course, by COVID-19.”
Additionally, NAHC is pushing for the creation of a new benefit that will allow for a skilled nursing facility (SNF) level of care at home.
“We have designed a [SNF-at-home] benefit to give individuals on the Medicare program the option of going home with expanded services,” Dombi said. “We think the design will work to be a win for the Medicare program as well. It’s been proven that you can provide less costly and high-quality care at home.”
Medicare’s annual open enrollment period is right around the corner. In fact, beginning October 15 and running through December 7, newly qualified patients and current Medicare beneficiaries may review their coverage options and select their health plans for 2021.
Finding a health insurance plan that provides the coverage you need is critical and we’ve previously discussed the importance of considering available options during open enrollment and this year is no exception. There’s a lot to consider when it comes to choosing your health insurance benefits, and here is a checklist you can use as you assess your coverage options in the coming weeks:
Medicare doesn’t currently cover drugs approved under emergency use designations. But CMS Administrator Seema Verma said the agency was coming up with a plan to make sure Medicare beneficiaries were covered once a coronavirus vaccine is developed.
When it announced plans to go public through a blank-check company, Clover Health shared ambitious projections for its future membership. Much of that growth is pinned on plans to launch a direct contracting business.
Healthcare providers won’t have to start paying back Medicare advance loans until a year after they were issued. Under the original timeline, hospitals were supposed to start paying back the loans in August.
This brief provides an overview and status update of the Medicare accelerated and advance payment program, which provided $100 billion in loans to Medicare providers in the spring of 2020 to compensate for revenue shortfalls due to the coronavirus pandemic. The brief describes who got the funds, and how these loans are distinct from other funds that providers received, which do not have to be repaid.
Now that the dust has settled on the Patient-Driven Groupings Model (PDGM), some have returned their attention toward the idea of another major reimbursement overhaul: a unified post-acute payment system.
There had been mounting momentum behind a unified payment model for post-acute care providers headed into 2020. The ongoing COVID-19 emergency has derailed a lot of that momentum, but conversations are starting to pick up again.
Generally, the post-acute care landscape includes skilled nursing facilities (SNFs), in-patient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs) and, of course, home health providers.
Currently, these providers operate under setting-specific Medicare reimbursement mechanisms, such as PDGM in the home health care and the Patient-Driven Payment Model (PDPM) in the SNF space. A unified model would eliminate this separation, creating one payment system for all post-acute providers.
It’s an idea that was originally born out of the IMPACT Act, which was passed in 2014.
“The idea was to flatten payment across the four post-acute care settings,” David Grabowski, a health care policy professor at Harvard Medical School, told Home Health Care News. “Rather than paying different payment rates for four different sets of services, it was an idea that the Medicare program could level the playing field and pay a common rate for patients who might be discharged to any of those four settings.”
A key benefit of having one post-acute reimbursement system would be having payment tied to a patient’s condition rather than setting, according to Grabowski.
“Currently, we have these distortions where we have individuals that probably could be cared for in lower-intensity settings, [but they’re] unfortunately being discharged to institutional settings or going to an LTCH when they could be at a SNF, or getting discharged to a SNF when they could be at a home health agency,” he said.
As envisioned by the IMPACT Act, there is also a greater emphasis on outcomes as a driver of reimbursement under a unified post-acute payment system, Lisa Grabert, a research professor at Marquette and Georgetown universities, told HHCN.
“It required that all of the data that’s reported to CMS across the four different settings be done in a consistent manner,” Grabert said. “You could potentially make comparisons across the settings.”
Making sense of an ‘anomaly of a year’
Despite perceived benefits, there are a number of potential difficulties in creating a unified post-acute payment model.
“Unifying payment also means unifying regulation,” Grabowski said. “It also means unifying quality measurement across the four settings, and it’s not clear to me that some of the rules that we’ve had in place work very well.”
For example, in the SNF world, the three-day rule requires an individual to have been admitted to the hospital on an in-patient basis no fewer than three consecutive days in order to qualify for fee-for-service reimbursement in a SNF.
Grabowski questioned how a rule such as this one would persist under a new model, especially in relation to home health care, where a number of individuals are receiving services without prior hospitalization. He pointed out that exceptions will have to be made in order to proceed.
There is also the COVID-19 emergency to consider.
In some ways, the public health emergency shifts post-acute care toward a universal payment model, according to Grabowski and Grabert. In other ways, it pushes the segment further away from it.
It’s important to remember that 2020 is an anomaly of a year in terms of the services that the Medicare program has delivered in the four settings of post-acute care. It would be difficult to use information gleaned from this year as the baseline to form the new model, according to Grabert.
Additionally, the comprehensive payment reforms in both the home health and SNF settings may further contribute to these difficulties.
“Those two factors coupled on top of each other mean that it’s really difficult to figure out what were new changes and phenomenons of the new payment system, versus just changes and phenomena associated with the pandemic,” Grabert said. “Those two stacked on top of each other may mean that it will be several years before CMS can figure out if they have accurate enough data to move to that unified payment system.”
Support for a unified model
On the other hand, the spotlight that has been placed on nursing homes throughout the public health emergency may play a role in pushing a unified post-acute payment model.
At the beginning of the month, the Medicare Payment Advisory Commission (MedPAC) had its first meeting of the year and released new data that revealed 80% of COVID-19 deaths are in the Medicare population, and over 40% of deaths are among residents of nursing homes and assisted living facilities.
Many policymakers, in addition to the media, have zeroed in the nursing home space because of this. The public perception of the nursing home industry, as a result of the public health emergency, may be strong enough to give CMS the political cover it needs to use its unified payment authority to implement a big policy change for nursing homes without any legislative barriers, according to Grabert.
“Given that skilled nursing facilities make up nearly half of the overall annual spend in the Medicare post-acute baseline, policymakers may be tempted to take advantage of the unified [post-acute care] model as a policy tool to address SNF, and possibly broader, reform,” she said. “Though actually implementing unified payment may need additional Congressional action, the mechanics to actually develop payment reform and release a detailed plan need no further Congressional action — a tremendous amount of authority already exists within the executive branch.”
If the Trump administration is reelected, it’s likely officials will be looking at looming fiscal pressures. The concept of a unified payment system has been on its radar in the past as a cost-savings tool
In February, the Trump administration released its proposed budget for the fiscal year 2021, which projected that a unified post-acute care payment model would save $101.5 billion from 2021 to 2030.
Even if a new administration is elected, this could still remain a factor.
“If the Biden administration comes into power, they may be looking again at this post-acute care space and the idea of unified payments as a [way] to get some savings out of the Medicare program,” Grabert said.
As of now, CMS has only affirmed its intentions of following the Congressional mandate, according to Grabert.
“There’s nothing really significant, I would say, coming out of CMS on this topic, aside from the fact that they take the current Congressional mandate of coming up with this unified prototype seriously, and they plan on issuing a report to Congress on time, as is required under current law of the IMPACT Act,” she said.
Congress has also begun to posture that it would like the agency to do some oversight and report to them on how the implementation has been going and possibly slow things down on the timeline.
“The evidence of that is a recent letter that came out from [Senators Pat Toomey (R-Pa.) and Michael Bennet (D-Colo.)] to CMS on the IMPACT Act timeline,” Grabert said. “There’s this Senate letter requesting some oversight of how CMS has implemented the underlying law, and certainly suggest that a delay should be considered at this time due to the pandemic and comprehensive home health and SNF payment reform.”
– Humana Inc. and Fresenius Medical Care North America
(FMCNA) today announced an agreement to broaden their collaboration toward
improving the health of eligible Humana Medicare Advantage members
agreement between Humana and Fresenius Medical Care North America goes into
effect Jan. 1, 2021.
Humana Inc. and leading renal care company Fresenius Medical Care North America (FMCNA) announced an agreement to broaden their collaboration toward improving the health of eligible Humana Medicare Advantage and commercial members with chronic kidney disease (CKD) and end-stage renal disease (ESRD) through more coordinated, holistic care.
The expanded partnership is in keeping with the goals
outlined in the 21st Century Cures Act, which enables people with ESRD to
enroll in Medicare Advantage Plans, and with federal initiatives that call for earlier diagnosis and
treatment of kidney disease; a reduction in the number of Americans developing
ESRD; and support for patient treatment options such as home dialysis or kidney
transplant as applicable.
The agreement between
Humana and Fresenius Medical Care North America goes into effect Jan. 1, 2021,
and encompasses the following:
Expanded Availability of Care Coordination Services:
FMCNA currently provides specialized care coordination services for Humana
members with CKD in three states: Iowa, Kentucky, and North Carolina. The
agreement expands the availability of these services to eligible Humana members
in an additional 39 states, with the goals of improving quality of life and
health outcomes, increasing access to care and minimizing care gaps, slowing
disease progression and lowering hospitalization rates, and reducing the cost
FMCNA’s care coordination services include early detection of CKD to slow
disease progression; medication reviews and regimen adherence guidance;
behavioral health screenings; nutritional counseling; strategies for managing
multiple comorbidities; education about – and support for – home dialysis
treatment when applicable and beneficial to the patient; transplant education;
and palliative care.
FMCNA partners with InterWell Health, a physician-led population health
management company working to improve clinical outcomes and lower medical costs
through its network of over 1,100 nephrologists across the country.
Transitional Care Units: These units are
designed to help people recently diagnosed with kidney failure learn about
treatment options available to them – including transplant and home dialysis –
and be more empowered in managing their own care. Transitional Care Units may be either a space within a
dialysis center or a standalone facility, offering comprehensive, hands-on
education from dedicated staff that is individualized for each patient. This
includes the importance of renal nutrition, medication adherence, and vascular
access care; assisting patients transitioning between modalities (e.g., from
in-center dialysis to home dialysis); and supporting individuals returning to
dialysis from transplant. The agreement is intended to locate Transitional Care
Units in select areas where Humana has significant Medicare Advantage
Value-Based Agreement: The expanded
collaboration also improves upon the parties’ existing clinic network contract,
which provides eligible Humana Medicare Advantage and commercial members with
ESRD access to dialysis at more than 2,600 centers of Fresenius Kidney Care, the dialysis services division of
Fresenius Medical Care North America. By implementing a value-based payment
model for in-center and home dialysis services and at Transitional Care Units,
as well as for CKD care coordination services, compensation will be based on
meeting agreed-upon quality improvement and patient outcome goals, and reducing
overall costs to the system.
Individuals with CKD have kidneys that do not filter blood
properly, which causes waste and fluid levels that can be dangerously high. CKD
and ESRD affect a wide spectrum of the population but the degree of impact is
not uniform. For example, kidney failure rates among Black Americans are about
three times that of white Americans. In total, approximately 15% of American
adults, or about 37 million people, have CKD, but many are unaware of their
condition. CKD management is complex, and failure to appropriately manage the
condition may cause considerable symptoms and worsening health outcomes,
This agreement represents an evolution of our work with
Humana and leverages our over 10 years of industry leadership in value-based
care,” said Bill Valle, Fresenius Medical Care North America’s Chief Executive
Officer. “Our scale, integrated nephrology network, and standardized clinical
interventions and protocols uniquely position us to predictably and
consistently improve health outcomes and reduce overall costs. We welcome this
opportunity to offer more coordinated, holistic care to Humana’s members, with
a keen focus on education, comorbidity management, early detection, and
treatment options, including home dialysis. This approach also helps eliminate
barriers to keep renal disease treatment uninterrupted for at-risk
– Innovaccer unveils new risk adjustment solution to help providers better segment their population to refine the risk scoring process and improve coding accuracy and efficiency, thereby improving performance on risk-based contracts.
– The solution utilizes Artificial Intelligence (AI) and
Natural Language Processing (NLP) to make risk predictions.
Innovaccer, Inc., a
technology company, has launched its Risk Adjustment
Solution. Leveraging Innovaccer’s industry-leading, FHIR-enabled Data
Activation Platform, providers can better segment their population to refine
the risk scoring process and improve coding accuracy and efficiency, thereby
improving performance on risk-based contracts. The solution utilizes Artificial Intelligence
(AI) and Natural Language Processing (NLP) to make risk predictions. By
improving care management workflows, Innovaccer works to help all members of
the health team care as one.
Addressing End-to-End Risk Adjustment
Innovaccer’s solution is designed to address end-to-end risk
adjustment needs by allowing providers to use actionable insights on dropped
codes and suspected codes across various risk models. The solution works with
the Centers of Medicare & Medicaid hierarchical condition categories
(CMS-HCC), Department of Health and Human Services hierarchical condition
categories (HHS-HCC), and the Chronic Illness and Disability Payment System
(CDPS), helping providers improve coding accuracy.
Segment Patient Population Based on Risk Scores
Providers can identify codes that can be integrated into the EHR using simple
steps through advanced risk adjustment analytics. Innovaccer’s platform can
also segment the patient population based on risk scores available through
historical data and provide dashboards to identify details related to Risk
Adjustment Factor (RAF) and risk capture trends. Providing curated insights to
risk coders prevents them from having to switch between multiple screens,
reducing the time spent on coding processes.
“Innovaccer’s Risk Adjustment Solution caters to all risk management needs through one seamless platform. It is AI and NLP ready, and by leveraging the platform’s smarter workflows and actionable insights, providers can decrease time spent on risk-related coding by up to 40%. The solution helps providers to refine the risk scoring process and improve coding accuracy and efficiency for improved performance on risk-based contracts,” says Abhinav Shashank, CEO at Innovaccer.
Home health is often utilized as a recovery tool when patients transition out of the hospital because of its ability to improve outcomes. But many of the Medicare beneficiaries who receive referrals after being discharged aren’t actually receiving these services.
Overall, the past several decades have seen an increase in the use of post-acute services, with more than 40% of Medicare beneficiaries receiving such care after being released from a hospital, according to a recently published study in JAMA Network Open.
When it comes to home health care, in particular, roughly 2.3 million Medicare patients were discharged from hospitals with home health referrals in 2016. Despite that large amount of referrals, only 54% of those individuals utilized home health services after their hospitalization within two weeks.
Additionally, 37.7% never received care; 8.3% were either institutionalized or died within 14 days, without receiving a home health visit. This data underscores the role these services can often play in helping patients return to prior levels of functioning.
“After 14 days, patients get home, think they’re fine, then they have a decrease in their mobility or whatever their status is from the hospital,” Mike Gregory, chief patient advocacy officer at Intrepid USA Healthcare, told Home Health Care News.
Dallas, Texas-based Intrepid USA Healthcare Services is one of the largest home health, hospice and home care companies in the country.
Although the study’s findings were gleaned from 2016 Medicare data, it’s likely that the results haven’t seen much improvement, Jun Li, one of the study’s authors and an assistant professor at Syracuse University, told HHCN.
“Certainly from speaking with discharge planners, for example, it seems like not much has changed in terms of their ability to track which patients are actually getting home health care,” Li said.
Falling through the cracks
From a home health perspective, there are a number of factors that contribute to this breakdown of whether hospital-referred patients receive care.
One factor: Providers aren’t always getting useful and accurate patient information from hospitals, Cleamon Moorer, Jr., president of American Advantage Home Care Inc., told HHCN.
“[That includes] contact information of patients, as well as emergency contacts and family members,” Moorer said. “There’s an opportunity to close the gap on clarifying correct contact information. I think from time to time, if a patient is highly sedated, or if there’s been a change to their contact information prior to leaving the hospital, discharge planners, case managers, social workers and the like may not be made aware of the latest contact information.”
Dearborn, Michigan-based American Advantage Home Care provides skilled nursing, rehab and specialty care services across nearly a dozen counties.
In order to avoid inaccurate information, it’s important to validate it on the front-end. For American Advantage Home Care, this means reaching out to emergency contacts in a timely manner.
“We take the patient referral, and we begin to validate as soon as we possibly can,” Moorer said. “To some, it may seem intrusive, if you call the emergency contact number while the patient is still in the hospital. We start by saying who we are and that it’s not an emergency, but we’re calling on behalf of the patient, because we received a referral from either a hospital or a clinic or a primary care physician.”
Providers that aren’t creating multiple points of contact with patients may find themselves having a difficult time keeping track of patients, he added.
“You almost need to be a patient navigator or tracker as a home health care provider,” Moorer said. “If you simply pass along the patient’s information to your start-of-care nurse or clinician … it may not be of the utmost urgency to start a new patient if they already have a full caseload.”
Once a patient has been discharged and an initial visit has been set, American Advantage Home Care’s call center team reaches out to patients to inform them about their assigned clinician and to nail down specifics as well as personal preferences.
“Within the first week of receiving a referral, we try to make at least four points of contact with a patient and/or an emergency contact within their profile,” Moorer said. “Some of that conversation is about educating on what to expect from a skilled care provider.”
Improving patient education
Another factor that pops up is patients leaving the hospital aren’t always educated on the difference between non-medical personal care and home health care. This results in patients turning down services because they believe a family member or friend can fill in as their caregiver.
“In the event that a patient is being discharged and they don’t know the difference between the two, they may lean on a loved one,” Moorer said. “They may say, ‘My son or daughter lives with me. I’ve got a niece or nephew that helps me get in and out of the bed. They bathe me. I don’t need anyone coming in and out.’”
Additionally, some patients may turn down services due to reservations about having someone they are unfamiliar with in their home.
“They’re quite often embarrassed about having strangers in their home,” Intrepid’s Gregory said. “For whatever reason, they’re just not comfortable having someone they don’t know. When you’re able to build that relationship up front, … they’re much more likely to allow a stranger in.”
For home health providers, working closely with referrals partners can go a long way in making sure patients don’t fall through the cracks. This means following up with discharge planners after a patient has been released.
This can also mean working with referral sources in cases where a provider is unable to accommodate a patient, Scott MacInnis, chief revenue officer at Elara Caring, told HHCN.
“If for some reason, if we are unable to see the patient, we would contact the referral source and help to coordinate the sourcing of another provider, making sure that there are alternative resources for the patient, especially in instances where the needs of the patient are beyond the scope of home health,” MacInnis said.
Addison, Texas-based Elara Caring is a home health, hospice and personal care provider that operates across several states, caring for thousands of patients each year.
Looking forward, making sure that patients actually receive quality home health care will be especially important as the U.S. prepares for a possible second wave of the COVID-19 emergency.
“Home health is still underutilized,” Gregory said. “It is one of the most cost-effective forms of taking care of the patients, especially now with COVID-19. Patients do not want to go to the nursing home, they don’t want to be in the hospital.”
– Walmart announced it will begin selling Medicare
insurance plans during this year’s annual enrollment period, Oct. 15 through
announced the launch of Walmart
Insurance Services, LLC, a licensed insurance brokerage, which will assist
people with enrolling in insurance plans—and simplify what’s historically been
a cumbersome, confusing process. Walmart Insurance Services will begin selling
Medicare insurance plans during this year’s Annual Enrollment Period (AEP),
Oct. 15 through Dec. 7.
Walmart Insurance Service Offerings
Starting today, Walmart Insurance Services will provide Medicare plans (Part D, Medicare Advantage, and Medicare Supplement plans) offered by Humana, UnitedHealthcare, Anthem Blue Cross Blue Shield, Amerigroup, Simply Health, Wellcare (Centene), Clover Health, and Arkansas Blue Cross and Blue Shield. More carriers may be added in the future. The brokerage is licensed in all 50 states, plus Washington D.C. Walmart has built a team of licensed insurance agents who can help people find the right insurance plan for them.
“We want customers to feel confident in selecting a Medicare plan that best fits their needs, budget and lifestyle,” said David Sullivan, general manager of Walmart Insurance Services. “And we want to be a trusted partner on their health care journey. Helping customers select the right Medicare insurance plan to meet their needs aligns with Walmart’s mission of helping people save money and live better.”
People 65 and older, who have been hardest hit by COVID-19 in terms of hospitalizations and deaths, are also at high risk of severe flu illness and are more likely to die of the flu than younger people. This analysis explores variation in the rate of flu vaccination among adults ages 65 and older covered by Medicare, and reasons cited for not getting vaccinated, based on data from the 2018 Medicare Current Beneficiary Survey.
This side-by-side comparison examines President Trump’s record and former Vice President Biden’s positions across a wide range of key health issues, including the response to the pandemic, the Affordable Care Act marketplace, Medicaid, Medicare, drug prices, reproductive health, mental health and opioids, immigration and health coverage, and health care costs.
The coronavirus pandemic accelerated telemedicine exponentially as patients and doctors switched from in-person visits to remote consultations. Health providers rapidly scaled virtual offerings in March and April and traffic volumes soared to unprecedented levels, with practices “seeing 50 to 175 times the number of patients by telehealth than before the outbreak,” according to McKinsey. By early August, the U.S. Department of Health and Human Services expanded the list of allowable telehealth services in Medicare and there was an executive order supporting permanent telehealth provisions for rural areas.
But the surge in telemedicine adoption comes with a host of cybersecurity risks and regulatory compliance requirements unique to the healthcare sector.
As telemedicine traffic increases, so does the volume of hacking attempts. Recent cybersecurity news indicates healthcare organizations are top targets for cyberattacks and “providers remain the most compromised segment of the healthcare sector, accounting for nearly 75 percent of reported breaches.” The consequences are chilling: “The average cost of a healthcare data breach is $7.13 million globally and $8.6 million in the United States.
Further, whenever patient information is involved, HIPAA compliance is required. While HHS temporarily suspended pursuing HIPAA penalties on providers for “good faith provision of telehealth during the COVID-19 nationwide public health emergency,” such permissiveness will not last.
Luckily, most telemedicine providers can utilize managed services and cloud infrastructure to keep pace. Here are some best practices to meet IT compliance and cybersecurity demands for telemedicine.
Telemedicine Compliance Best Practices
Compliance should be viewed as a real-time process that drives security. Telemedicine tools and technology should therefore reflect significant expertise with all healthcare regulations (HIPAA, HITRUST, HITECH), with compliance functions permeating processes. Recommended compliance best practices include:
1. Automate Remediation
Healthcare applications cannot offer high reliability if every potential compliance problem is remediated manually; there’s just too much that can go wrong and never enough staff to address it when needed. The solution is to automate everything that can be automated, and rely on people to handle exceptions or potential violations that don’t impact reliability. Cloud-based services can integrate AI and operational intelligence to automatically remediate anomalies when possible, present recommendations to operations staff for cases that cannot be resolved automatically, and present clear choices such as:
· Do Nothing: Take no action, delete ticket after [x number of days]
· Fix Now: Implement the recommended actions immediately
· Schedule: Perform the recommended actions during the next maintenance window
This approach speeds resolution and decreases service disruptions, and improves the reliability of telemedicine delivery. The automated response also plays a critical role in security (which will be discussed shortly).
2. Perform Formal Risk Assessments
Understanding the risk level and specific risk issues are critical components for an effective compliance plan. Many providers of healthcare services underestimate their level of risk, in part because it is difficult to quantify. The HHS has published guidance in its Quantitative Risk Management for Healthcare Cybersecurity, which offers insight. There are also cloud solutions that can aid the process. Cloud services providers such as Amazon Web Services (AWS), Microsoft Azure, and Google Cloud offer automated security assessment services that help improve the security and compliance of applications deployed on their cloud hosting platforms. They can generally assess applications for exposure, vulnerabilities, and deviations from best practices. A good inspection service should highlight network configurations that allow for potentially malicious access, and produces a detailed list of findings prioritized by level of severity.
3. Reduce Attack Surface
To provide secure access to sensitive information, hybrid architectures supporting telemedicine applications need a virtual private network (VPN) gateway between on-premises and cloud resources. However, developers, test engineers, remote employees, and others who need access to cloud-based protected health information (PHI) may bypass a VPN gateway by either cracking open the cloud firewall to allow direct unencrypted internet traffic or using peering connections. To prevent such potential exposures, secure desktop-as-a-service (DaaS) solutions provide an elegant way to allow cloud-based access to PHI without exposing connections or records. A DaaS is generally deployed within a VPC providing each user with access to persistent, encrypted cloud storage volumes using an encryption key management service. No user data is stored on the local device, which reduces overall risk surface area without impeding development capability.
Telemedicine Security Best Practices
While the full scope of cybersecurity strategies is beyond the scope of this article, here are three best practices that telemedicine providers can use bolster their security profile:
1. Deploy Proactive Network Security
Modern cyber threats have become steadily more sophisticated in evading traditional security measures and more devastating once they penetrate network perimeters. For that reason, telemedicine providers need a highly proactive, multilayered approach to prevent malware-based outages, theft of intellectual property, and exfiltration of protected health information (PHI).
A combination of network anti-malware, application control, and intrusion prevention systems (IPS) is recommended. Such proactive solutions are generally bundled in managed cloud services that should automatically detect suspicious system changes in real-time, isolate and quarantine affected resources, and prevent the spread of exploits by locking down any server whose configuration differs from the installed settings.
2. Encrypt Data Storage
Data encryption is the last line of cyber-defense for PHI and other critical information. Even if an attacker can penetrate the perimeter and proactive network security and exfiltrate data from the provider, those data are useless to the hacker if encrypted. It’s good practice to encrypt all web and application servers running on cloud instances using a unique master key from a key management service when creating volumes.
Encryption operations generally occur on the servers that host cloud database (DB) instances, ensuring the security of both data-at-rest and data-in-transit between an instance and its block storage. For additional protection, you can also opt to encrypt DB instances at rest, underlying storage for DB instances, its automated backups, and read replicas.
3. Harden Operating Systems
Both Microsoft Windows Server and Linux are ubiquitous operating systems in telemedicine. They are also both attractive targets for cybercriminals because they provide complex capabilities, frequently remediate vulnerabilities, and are so common (increasing attackers’ chances of finding an unpatched system). Hackers use OS-based techniques such as remote code execution and elevation of privilege to take advantage of unpatched operating system vulnerabilities. Hardened images of Windows Server and Linux virtual machines (VMs) should be used, employing default configurations recommended by the Center for Internet Security (CIS). Such hardened images make gaining OS administrative extremely difficult, and coordinate well with proactive security bundles described earlier.
While these best practices are targeted primarily at telemedicine companies, they can also be applied to a wide range of healthcare providers and organizations delivering vital services in the face of 2020’s dramatic swings in demand.
About Gerry Miller
Gerry Miller is the founder and chief executive officer at Cloudticity. He is a successful serial entrepreneur and healthcare fanatic. From starting his first company in elementary school to selling his successful technology consulting firm in 1998, Gerry has always marched to his own drummer, producing a series of successes. Gerry’s first major company was The Clarity Group, a Boston-based Internet technology firm he founded in 1992. Gerry presided over seven years of 100% aggregate annual growth and sold the company in 1998 when it had reached $10MM in revenue.
He was recruited by Microsoft to become their Central US Chief Technology Officer, eventually taking over a global business unit and growing its revenue from $20MM to over $100MM in less than three years. Gerry then joined ePrize as Chief Operating Officer, where he grew sales 38% to nearly $70MM while improving operating efficiency, quality, and both client and employee satisfaction. Gerry founded Cloudticity in 2011 with a passion for helping healthcare organizations radically reshape the industry by unlocking the full potential of the cloud.
– NovuHealth and Revel merge to bring together NovuHealth’s
personalized healthcare loyalty programs with Revel’s applied behavioral
research and health action technologies.
– Together, Revel and NovuHealth work with more than 50
healthcare organizations, including seven of the top 10 largest health insurers
in the United States representing more than 65 percent of all members in
government programs such as Medicare and Medicaid.
Revel and NovuHealth, two of the nation’s leading
healthcare consumer engagement, communications and technology companies, today
announced a merger
of the companies effective immediately. The merger establishes Revel and
NovuHealth as the largest technology company focused on member engagement for
healthcare’s most trusted organizations.
Merger Establishes Largest Healthcare Member Engagement Platform
The merger establishes Revel and NovuHealth as the largest
technology company focused on member engagement for healthcare’s most trusted
organizations and delivers a next-generation SaaS platform that creates
omnichannel personalization at scale for healthcare. Together, Revel and
NovuHealth work with more than 50 healthcare organizations, including seven of
the top 10 largest health insurers in the United States representing more than
65 percent of all members in government programs such as Medicare and Medicaid.
Over the course of the next few months, the Revel and
NovuHealth teams will be working to merge their sales and marketing operations,
customer experience, operations and product teams. The new company will
continue to operate in growth mode and expects to add professional talent
through the balance of the year. The company will reveal a new brand for the
combined enterprise in the new year.
As part of the merger, NovuHealth CEO Steve Wigginton will
serve as CEO, while Revel CEO Jeff Fritz will transition to an advisor to the
CEO and the board of directors of the merged company.
“This merger creates a dream team of experts in consumer marketing, behavioral science, healthcare regulatory expertise, data science and technology,” said Jeff Fritz, CEO of Revel. “This is a rare opportunity to connect the complementary nature of the Revel and NovuHealth platforms to create personalization at scale for the most trusted healthcare organizations. The result is a platform designed to reach the full spectrum of members including the hardest to reach, noncompliant consumers who are the toughest to motivate to take healthy actions,” Fritz said.
For more than a decade, Medicare Part D has provided seniors affordable and comprehensive prescription drug coverage. Its unique, market-based structure has kept overall Part D program costs far below initial projections, coming in at nearly $350 billion less than the Congressional Budget Office’s initial 10-year estimate.
The COVID-19 pandemic is not just a medical crisis. Since the highly contagious disease hit American shores in early 2020, the virus has dramatically changed all sectors of society, negatively impacting everything from food supply chains and sporting events to the nation’s mental and behavioral health.
For some people, work-from-home plans and limited access to entertainment are manageable obstacles. For others, the shuttered schools, lost wages, and social isolation spell disaster – especially for individuals already living with socioeconomic challenges.
The social determinants of health have always been important for understanding why some populations are more susceptible to increased rates of chronic conditions, reduced healthcare access, and shorter lifespans. COVID-19 is throwing the issue into high relief.
Now more than ever, healthcare providers need to gain full visibility into their populations and the non-clinical challenges they face in order to help individuals maintain their health and keep their communities as safe as possible during the ongoing pandemic.
Exploring correlations between socioeconomic circumstances and COVID-19 vulnerability
Clinicians and researchers have worked quickly to identify patterns in the spread of COVID-19. Early results have emphasized the danger posed by advanced age and preexisting chronic conditions such as obesity, diabetes, and heart disease.
Further, data from the Johns Hopkins University and American Community Survey indicates that the infection rate in predominantly black counties is three times higher than in mostly white counties. The death rate is six-fold higher.
Data from the Centers for Medicare and Medicaid Services (CMS) confirms the trend: black Medicare beneficiaries are hospitalized at a rate of 465 per 100,000 compared to just 123 per 100,000 white beneficiaries. Hispanic Medicare beneficiaries had 258 hospitalizations per 100,000, more than double the white population’s hospitalization rate.
Researchers suggest that the social determinants of health may be largely responsible for these disconnects in infection and mortality rates. Racial, ethnic, and economic factors are strongly correlated with increased health concerns, including longstanding disparities in access to care, higher rates of underlying chronic conditions, and differences in health literacy and patient education.
Leveraging data-driven tools to identify vulnerable patients
Healthcare providers will need to take a proactive role in identifying which of their patients may be at enhanced risk of contracting the virus and experiencing worse outcomes from the disease.
They will also need to ensure that person gets adequate treatment and participate in contact tracing efforts after a positive test. Lastly, providers will have to ensure their public health reporting data is accurate to inform local and regional efforts to contain the disease.
The process begins by developing confidence in the identity of each individual under the provider’s care. Healthcare organizations often struggle with unifying multiple electronic health record (EHR) systems and other health IT infrastructure, resulting in medical records that are incomplete, inaccurately duplicated, or incorrectly merged.
Access to current and complete medical histories is key for highlighting at-risk patients. An enterprise master patient index (EMPI) can provide the underlying technical foundation for initiating this type of population health management.
EMPIs help organizations create and manage reliable unique patient identifiers to ensure that records are always associated with the correct individual as they move throughout the healthcare system.
When paired with claims data feeds, health information exchange (HIE) results, and interoperability connections with other healthcare partners, EMPIs can bring a patient’s complete healthcare status into focus.
This approach ensures that providers stay informed about past and present clinical issues and service utilization rates. It can also support a deeper dive into the social determinants of health.
Combining EHR data with standardized data about socioeconomic needs can help providers develop more comprehensive and detailed portraits about their patients’ holistic health status.
By including this information in EHRs and population health management tools, providers can develop condition-specific registries to guide outreach activities. Providers can deploy improved care management strategies, close gaps in care, and connect individuals with the resources they need to stay healthy.
Healthcare organizations can acquire socio-economic data about their communities in a variety of ways, including integrating public data sources into their population health management tools and collecting individualized data using standardized questionnaires.
Once providers start to understand their patients’ non-clinical challenges, including the ability to avoid situations that may expose them to COVID-19, they can begin to prioritize patients for outreach and develop personalized care plans.
Conducting effective outreach and interventions for high-needs patients
COVID-19 has taken a staggering economic toll on many families, including those who may have been financially secure before the pandemic. Routine healthcare, prescription medications, and even some urgent healthcare needs are often the first to fall by the wayside when finances get tight.
Healthcare providers have gotten creative about staying connected to patients through telehealth, drive-in consults, and other contactless strategies. But they must also ensure that their vulnerable patients are aware of these options – and that they are taking advantage of them.
Contacting a large number of patients can be challenging since phone numbers, emails, and home addresses change frequently and are prone to data entry errors during intake. Organizations with EMPIs can leverage their tools to ensure contact information is up to date, accurate, and associated with the correct individual.
Care managers should prioritize outreach to patients with complex medical histories and known clinical risks for vulnerability to COVID-19. These conversations are a prime opportunity to collect social determinants of health information or refresh existing data profiles.
Looking to the future of healthcare in a COVID-19 world
Combining technology-driven strategies with targeted outreach will be essential for healthcare organizations aiming to provide holistic support for their populations during – and after – the COVID-19 pandemic.
By developing certainty about patient identities and synthesizing that information with data about the social determinants of health, providers can efficiently and effectively connect with their patients to offer much-needed resources.
Taking a proactive approach to addressing the social determinants of health during the outbreak will help providers maintain relationships with high-needs patients while building new connections with those facing unanticipated challenges.
With a combination of population health management strategies and innovative technology tools, healthcare providers and public health officials can begin to view the social determinants of health as a fundamental component of the fight against COVID-19.
Andy Aroditis, is CEO of NextGate, the global leader in healthcare enterprise identification.
– Independence Blue Cross and Signify Health launches
social determinants of health network, CommunityLink to connect data from multiple
CBOs to integrate social directly into medical care in the Philadelphia area.
– CommunityLink represents one of the first examples
nationwide of combining in-home health with social care.
Independence Registered Nurse Health Coaches, Signify Health
social care coordinators, and local community-based organizations are now all
connected via the CommunityLink network and are able to coordinate on behalf of
Independence Medicare Advantage members and other people throughout the region
for non-medical services. Starting in 2021, clinicians and other healthcare
providers will be able to use CommunityLink to refer patients as well.
Independence and Signify Health are now among the first in
the nation to have designed a community-based network that combines management
of social determinants of health with in-home health visits. The new
community-based network expands Independence’s existing relationship with
Signify Health, which sends clinicians into the homes of Independence Medicare
Advantage members to assess overall health, facilitate the management of
chronic conditions, and provide diagnostic and other clinical services.
By using Signify Health’s privacy-enabled collaboration platform, organizations can leverage CommunityLink to safely and securely collaborate, share, and track an individual’s whole-health needs longitudinally across different care settings to address their social determinants of health. This gives Independence – as well as other community-based organizations that may be referring to CommunityLink – the ability to track and measure an individual’s whole-health needs over time as they interact with multiple social and clinical providers and community organizations.
“Creating a more equitable health care system includes acknowledging that health not only happens in the doctor’s office, but in our members’ homes and communities. That is why we are so pleased to work with Signify Health on developing CommunityLink,” said Daniel J. Hilferty, Independence Blue Cross President and CEO. “We will be able to identify obstacles our members may be facing and offer solutions that are available to them right where they live through this new network.”
When food production technology made it possible, wheat flour processors started to eliminate the tough exterior (bran) and nutrient-rich core (germ) of the kernel to get at the large, starchy part (the endosperm) only. The bread produced from this process is white and fluffy, and it makes great PB&Js and takes forever to grow mold, but it is almost totally lacking nutritional value.
Nutrition experts eventually pointed this out, of course, after which commercial bakers tried fortifying their bread by adding back essential nutrients stripped out by processing. It didn’t work. While white bread from refined flour is still available, nutrition experts strongly recommend whole grain products as the healthier alternative.
Opposition to this reductionist approach to nutrition is perhaps best captured by the idea of the sum being the whole of its parts: If inputs are lacking, the end result will fall short also.
Each human being is also a sum of parts, and the reductionist approach to healthcare is essential when it comes to advancing many aspects of medicine and healthcare.
“Historically, the invention of the microscope, the defining of Koch’s four infectious disease postulates, the unraveling of the human genome, and even intelligent computers are salient examples of the dramatic benefits of biomedical reductionism,” explained Dr. George Lundberg.
These successes, however, may have convinced many in both the medical community and society at large that reductionism is a necessary, if not sufficient, approach. The numbers say otherwise.
“Classical medical care interventions contribute only about 10 percent to reducing premature deaths compared to other elements such as genetic predisposition, social factors, and individual health behaviors,” Lundberg goes on to say. “Most contemporary medical researchers have concluded that the chronic degenerative diseases of modern Western humans have multiple contributory causes, thus not lending themselves to the single agent-single outcome model.”
Paging Dr. House. It turns out your particular form of genius just isn’t frequently that useful.
And nowhere is the single agent-single outcome model arguably less effective than in behavioral health and chronic disease management. What many in medicine and healthcare now realize is that a vicious cycle of alternating physical and mental ailments are the norm with both chronic illness and long-term mental health challenges.
“Depression and chronic physical illness are in a reciprocal relationship with one another: not only do many chronic illnesses cause higher rates of depression, but depression has been shown to antedate some chronic physical illnesses,” says Professor David Goldberg of the Institute of Psychiatry in London.
It’s an unsurprisingly intuitive conclusion to reach. A man with depression lacks the desire to eat well, exercise, often practice necessary daily hygiene. As his untreated depression deepens, his physical health declines as well. A woman with chronic, untreated pain feels like it will never end and her life is over. Faced with a seemingly unmanageable challenge, she falls into a funk that eventually metastasizes into full-blown depression.
A reductionist approach to these scenarios might be to encourage more exercise or prescribe antidepressants. While both are necessary, neither will likely be sufficient.
So why hasn’t a more holistic approach to patient care become the norm? In a nutshell, because it’s expensive. Chronic illnesses, generally, are the most expensive component of healthcare.
According to a New England Journal of Medicine study, patients “with three or more chronic conditions (43 percent of Medicare beneficiaries) account for more than 80 percent of Medicare health care costs.”
For this expensive, highly at-risk group, holistic care is what actually works.
The NEJM articles conclude that “an intervention involving proactive follow-up by nurse care managers working closely with physicians, integrating the management of medical and psychological illnesses, and using individualized treatment regimens guided by treat-to-target principles improved both medical outcomes and depression in depressed patients with diabetes, coronary heart disease, or both.”
Of course, the regimen included in the NEJM study is expensive—perhaps more so than what qualifies as holistic care now.
But it requires a certain type of twisted logic to argue for holding down costs by rationing care inputs—by reductively treating only just the most obvious health concerns—when this approach invariably leads to readmissions, more office visits, more disability payments, more days of work missed.
Indeed, a reductive approach to accounting—silos of financial impact across the continuity of a life lived—hides the fact that specific healthcare costs are not alone the measure of how chronic illness detracts from both individual life satisfaction and broader societal efficiencies.
The key, then, is to make holistic health both the norm and affordable. How can that be done? By creating initiatives designed to achieve a core set of goals:
Incentivize primary care: In the last two decades, the number of primary care providers (PCPs) available to patients in the United States has decreased by about 2 percent. This may not sound like a lot, but the decline comes as the population has increased, naturally, which means fewer patients have a PCP. As healthcare shifts to pay for performance, not services, the PCP is the natural quarterback of patient care. The country needs many more PCPs, not fewer, and the federal government has an opportunity to use loan forgiveness incentives and other tools to nudge medical school students in that direction.
Embrace technology: Arguably, holistic care only became possible with the digital age. Chronic disease management requires frequent measurement of patient vitals, which is very expensive without wearables and similar digital age technologies. Now, patients can regularly provide data with no clinical intervention, that data can automatically upload to an electronic health record, and that EHR can alert the clinician when results are alarming.
Make poor choices expensive: Perhaps only because smoking has become so socially unacceptable can the cost of cigarettes be so high ($7.16 per pack in Chicago with all taxes) without creating significant protests. But the data is clear that higher costs equal fewer smokers. The same types of behavioral economics programs can also apply to fast food, soda, etc. Yes, people will get upset and complain about the nanny state, but absent some attempt to change behavior, we may want to consider changing the name to the United States of Diabetes.
Reward smart choices: Healthy people use healthcare and insurance less often, which drives down costs. Duh. Combining technology and incentives (avoiding diabetes), Utah’s Intermountain Healthcare engaged almost 1,500 pre-diabetic employees in a program through Omada Health that collectively yielded 9,162 pounds lost. Omada billed Intermountain based on the level of success, and without speaking to specific numbers, Intermountain felt the cost of the program was a wise investment when compared with the costs of diabetes treatment.
These four bullets are probably just the most obvious suggestions, of course. They don’t account for the complexities of the American healthcare system focused on payment models, the profit motive, or what to do with the uninsured, homeless, and devastatingly mentally ill.
But the benefits of holistic thinking when reductionism is inadequate applies to both individual care and the healthcare system as a whole. Public health, for example, takes a holistic approach to communities by looking at how housing, transportation, and education impact general overall health. Where this approach is done well, the benefits are obvious.
Reductionist isolation will always be necessary when identifying specific genes or determining which natural elements are effective in treating disease. But it’s wise to always bring the right tools for the job.
Finding previously unidentified insurance coverage can feel a little like a game of hide and seek. Patients may not always be aware of their insurance or eligibility for Medicare and Medicaid, and, in an effort to both improve the patient financial experience and simultaneously improve collections, providers are often tasked with finding this information on the spot. Historically, providers have used demographic information like Social Security Numbers (SSN) as a means to verify patient identities and locate this information, but that tactic is increasingly unreliable as it is possible for more than one person to use the same SSN and SSNs are a lucrative route to stealing someone’s identity.
With this in mind, many health plans are no longer using SSNs as an identifying number for insurance coverage. In fact, the Centers for Medicare & Medicaid Services recently removed SSN-based Health Insurance Claim Numbers (HICNs) from Medicare cards and are now using Medicare Beneficiary Identifiers (MBIs) for Medicare transactions like billing, eligibility status, and claim status.
The latest health plans to remove this piece of demographic information is Health Net Medi-Cal and Health Net National. Effective September 25, 2020, the search options for eligibility for this plan have changed. Providers will ONLY be able to find and verify coverage with a subscriber ID.
“Providers are often tasked with finding this information on the spot.”
While Health Net Medi-Cal and Health Net National are the latest health plans to do away with demographic searches, it’s certainly not a surprising trend and more will likely follow suit.
Bridging the gap with historical data
Uncovering previously unidentified coverage is critical for providers as it helps to eliminate costly self-pay situations, bad debt write-offs and unwarranted charity designations. And, without the proper insurance information, patients also risk delayed access to care and other financial hardships.
With demographic searches on the decline, providers will need a more efficient and reliable way to search for coverage. As a data-driven company with a historical repository of claims data, Experian Health is uniquely positioned to help providers search for coverage.
Combining search best practices, multiple proprietary databases and historical information, Experian Health’s Coverage Discovery locates patients’ billable commercial insurances that were unknown or forgotten, and combs through Medicare and Medicaid coverage. This flags accounts that may have been destined as a write-off or charity and maximizes reimbursement revenue by identifying primary, secondary and tertiary coverage. Not only do fewer accounts go to bad-debt collections, but providers can automate the self-pay scrubbing process.
A tool like Coverage Discovery is even more beneficial for providers during COVID-19, where limitations of face-to-face contact make it more difficult to complete the usual coverage checks. Coverage Discovery empowers providers to facilitate coverage checks remotely, avoiding delayed reimbursements during a time when revenue streams are already feeling pressure.
“As a data-driven company with a historical repository of claims data, Experian Health is uniquely positioned to help providers search for coverage.”
Want to learn more? Contact us to see how Coverage Discovery can help find previously unidentified coverage and reduce bad debt.
CBO projects a federal budget deficit of $3.3 trillion in 2020, more than triple the shortfall recorded in 2019. That increase is mostly the result of the economic disruption caused by the 2020 coronavirus pandemic and the enactment of legislation in response. At 16.0 percent of gross domestic product (GDP), the deficit in 2020 would be the largest since 1945.
The deficit in 2021 is projected to be 8.6 percent of GDP. Between 1946 and 2019, the deficit as a share of GDP has been larger than that only twice
As we know, the federal government spent a lot of emergency funds to help stabilize the health care system in the wake of the COVID-19 pandemic. Where did the $225 billion lawmakers appropriated for the HHS Pulic Health and Soical Services Emergency Fund go?
CBO projects that the funding will result in $135 billion in outlays in 2020 and $89 billion in outlays over the 2021–2025 period. Most of the funding, $175 billion, was dedicated to reimbursing health care providers (such as hospitals) for expenses related to health care or lost revenues as a result of the coronavirus pandemic. The remaining amount, including $16 billion for the Strategic National Stockpile, can be used to support the development and purchase of vaccines, therapeutic treatments and drugs, and medical supplies.
As the economy declined, a larger share of individuals switched to government-funded health insurance. See how CBO projects federal health insurance spending to be impacted by the pandemic.
Medicare. Outlays for Medicare (net of offsetting receipts) will rise by 12 percent in 2020, from $644 billion in 2019 to $721 billion, CBO projects. That increase results in part from payments made to providers in 2020 in advance of expected health care claims. CBO expects that those payments will be recouped from providers in 2020 and 2021…
Medicaid: Outlays for the program will total $466 billion this year …an increase of $57 billion (or 14 percent) relative to spending in 2019. The deterioration in the economy has caused enrollment in the program to rise. In addition, legislation has raised the portion of costs the federal government must cover and required that states maintain coverage for all Medicaid enrollees during the public health emergency regardless of any changes in their income or circumstances that would otherwise have caused them to become ineligible for the program.
Over the next decade, expect Medicare finding to rise dramatically as the baby boomers retire whereas Medicaid spending–assuming know change in legislation–will be fairly stable as a share of the economy.
Outlays for Medicare, which equal 3.2 percent of GDP in 2021, rise to 4.3 percent of GDP in 2030.
Federal outlays for Medicaid remain relatively stable as a percentage of GDP over the coming decade, averaging about 2 percent each year.
Outlays for subsidies for health insurance purchased through the [ACA] marketplaces and related spending are projected to average 0.2 percent of GDP per year through 2030.
This policy watch examines the likely impact of an executive order signed by President Trump in July 2020 related to prescription drugs, which would use lower international drug prices to set prices for a limited set of drugs in the U.S.
The Trump administration’s latest effort to use COVID-19 rapid tests — touted by one senior official as a “turning point” in arresting the coronavirus’s spread within nursing homes — is running into roadblocks likely to limit how widely they’ll be used.
Federal officials are distributing point-of-care antigen tests — which are cheaper and faster than tests that must be run by a lab — to 14,000 nursing homes to increase routine screening of residents and staff. The initial distribution targets nursing homes in hot spots and those with at least three COVID-19 cases, senior Trump administration officials said in July, hailing it as a tool that could root out asymptomatic carriers who might still infect others.
But there’s a hitch: Two manufacturers that have received Food and Drug Administration authorization and whose instruments are being delivered — Becton, Dickinson and Co., known as BD, and Quidel — say their antigen tests are intended for patients with symptoms, calling into question how valuable the tests would be for broad screening purposes. The Centers for Disease Control and Prevention estimates 40% of infected people may be asymptomatic.
“It’s important always to use a diagnostic in the way that it has been designed to be used,” said Elizabeth Talbot, New Hampshire’s deputy state epidemiologist. “We simply don’t know how [the tests] will perform in persons who are asymptomatic.”
Perhaps the highest-profile example of the problem occurred in Ohio this month, when Gov. Mike DeWine had no symptoms and tested positive for COVID-19 with Quidel’s antigen test. Within hours, the Republican governor’s diagnosis was reversed after he got a PCR test.
“People should not take away from my experience that testing is not reliable or doesn’t work,” DeWine said on CNN after his false-positive diagnosis. “The antigen tests are fairly new,” he said. “We’re going to be very careful in how we use it.”
The bigger problem is false-negative results, which show someone isn’t infected when they actually are. BD’s false-negative rate — how often a test incorrectly says someone isn’t infected — is about 15%; Quidel’s is 3%.
Quidel and BD say their tests are intended to be used for people within the first five days of showing symptoms. A spokesperson for BD said its test should not be used on asymptomatic individuals. Quidel through a spokesperson deferred to FDA guidelines, which allow asymptomatic testing in certain scenarios.
“For routine surveillance, this is a great tool and these are our best tools that we have available,” said Adm. Brett Giroir, assistant secretary for health at the Department of Health and Human Services, on a July call with nursing home officials, according to a recording obtained by KHN. Seema Verma, the administrator of the federal Centers for Medicare & Medicaid Services, on the call referred to the effort as a “turning point” in the fight against the virus.
A month after the initial announcement, the Trump administration invoked the Defense Production Act to bump its contracts with the two companies to the front of the line and expedite shipments. BD will send roughly 11,000 devices and 3.75 million tests to nursing homes; Quidel and HHS declined to answer questions about its volume.
As states and the federal government move to mandate COVID testing inside nursing homes, whose patients are deemed highly vulnerable to infection and severe complications, several industry officials have said they hoped to use the tests on asymptomatic people. But many states restrict the use of antigen tests or still require lab-based testing because of accuracy concerns.
If a person with a negative test result has to default to getting a more accurate PCR test, “then we simply have just added time and cost,” Talbot said. “That’s a problem.”
Officials said the antigen test announcement caught them by surprise, underscoring the administration’s chaotic testing strategy. Separate from the federal effort, 10 states have banded together through the Rockefeller Foundation to secure 5 million tests from the two companies in hopes of curbing the virus’s spread this fall.
After nursing homes receive an initial batch of tests — each facility gets between 150 and 900 — they would have to buy future supplies. Medicare will cover the costs of diagnostic tests but not expenses for routine surveillance.
“I just have a lot of skepticism,” said Brendan Williams, president of the New Hampshire Health Care Association, which represents nursing homes and assisted living facilities in the state. “Basically you’re giving some lousy tests for nursing homes and you’re making them pay for them. I don’t see that as a win; I see that as a risk.”
Public health experts have become increasingly vocal that frequent rapid testing is the best tool for stopping the virus — which has killed more than 174,000 Americans including tens of thousands in nursing care — rather than relying on more accurate lab-based tests that have been plagued by delays and shortages. In a call this month with the industry, Verma estimated that half of the country’s nursing homes have experienced cases.
“I don’t see an avenue where these will not help to stop transmission chains, and I don’t see another option on the table for us,” said Dr. Michael Mina, an assistant professor of epidemiology at the Harvard T.H. Chan School of Public Health and a proponent of rapid tests. “It is what we need to be doing right now.”
“This is better for the folks in our buildings, without a doubt,” added Jason Belden, director of emergency preparedness and physical plant services for the California Association of Health Facilities.
In theory, antigen tests can serve dual purposes — diagnosing a person with a suspected infection or screening a group of people to more quickly identify sick individuals. The tests by Quidel and BD, under their FDA authorizations, can be used on certain asymptomatic individuals, including those suspected of having COVID-19 after exposure to an infected person. The companies would need additional FDA authorization to screen any asymptomatic person regardless of whether they’re suspected of being sick, according to agency guidelines.
The CDC has suggested antigen tests could be useful in high-risk settings if performed repeatedly. It said there was limited data to guide using them to screen asymptomatic people.
Nonetheless, HHS recommends universal screening of nursing home residents at least once and regular screening of staff regardless of symptoms, said agency spokesperson Mia Heck, citing the fact that COVID-19 viral loads are similar between patients with and without symptoms. “Only one test in the U.S. is authorized for asymptomatic individuals,” she said, referring to a PCR test from LabCorp, “yet the overwhelming majority of testing is being done on asymptomatic individuals.”
“If the world were ideal we’d say, ‘Oh, we want the more accurate test.’ But the more accurate test takes forever to get the results back,” said Peter Van Runkle, executive director of the Ohio Health Care Association, which represents the state’s nursing homes.
All targeted nursing homes will receive tests by the end of September, according to federal officials, who recently announced that facilities in states with a positivity rate of at least 5% must test staff each week.
“I don’t see this as a federal strategy so much as a stopgap method to bring a little relief to nursing homes,” said Katie Smith Sloan, president of LeadingAge, which represents nonprofit nursing homes. “It’s really tragic that we are where we are right now.”
Boosted by $71 million in federal funds for Quidel and $24.3 million for BD, Quidel plans to produce 1.8 million tests weekly by September; BD will produce similar volumes by October.
“The situation is much too urgent to wait a few months so we can put bows and lipstick on the program. So we’re going to build this plane a little bit while we’re flying it,” Giroir told nursing homes in July. “Just work with us. We want to get you what you need. And then in September, October you can get what you want.”
States take different approaches in deploying antigen tests in nursing homes; in at least seven — including California, Illinois and Maryland — officials say PCR tests should still be used to confirm results or to screen patients without symptoms. In Massachusetts, nursing homes must use PCR tests to meet surveillance requirements.
In Maryland, “our goal is to screen out staff who are positive as quickly as possible, particularly asymptomatic folks,” said Dennis Schrader, chief operating officer of the health department.
Maryland nursing homes can use antigen tests for weekly staff testing if there isn’t an outbreak. But if at least one person tests positive for the coronavirus, all staff and residents must be tested with PCR tests.
Democrats have shown a remarkably united front, including on health care, in their socially distant, made-for-TV convention this week. That’s likely due, at least in part, to the physical separation of party members who disagree on issues — this year they cannot chatter on live television — and to the party truly being united in its desire to defeat President Donald Trump in November.
Meanwhile, the coronavirus pandemic continues to complicate efforts around the country to get students back to school, from preschool to college. And the Trump administration’s effort to eliminate anti-discrimination protections in health care for transgender people is put on hold by a federal judge.
This week’s panelists are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Paige Winfield Cunningham of The Washington Post and Shefali Luthra of The 19th.
Among the takeaways from this week’s podcast:
Democrats’ online convention has helped make the party seem unified. But on health policy, divisions remain even though Vice President Joe Biden has agreed to broaden some of his plans, such as lowering the eligibility age for Medicare and agreeing to have federal regulators run a public option plan he is advocating. Progressives in the party still hope to move the debate next year back to establishing a “Medicare for All” system.
The heated Democratic primary campaign put a good deal of focus on health policy, including whether to support a Medicare for All system and efforts to make health care more affordable. But the convention rhetoric on health hasn’t focused much attention on that and instead has played up issues surrounding the Trump administration’s response to the coronavirus pandemic.
The emphasis on COVID-19 in recent months has also pushed out much of the debate on the issues of high drug prices and surprise bills.
As the question of a mail slowdown has enveloped the country, concerns are being raised about mail delivery of prescription drugs, especially for seniors and veterans. Despite anecdotal reports of missed deliveries, most drug industry experts say problems haven’t been widespread.
The controversies about reopening schools — both K through 12 and colleges — point to difficulties with the country’s COVID testing program. It is too hard and too expensive for schools to be able to test enough students to guarantee that the virus isn’t spreading.
Schools may want to reconsider which age groups they target for returning to the classroom. Since there is little evidence that younger kids spread the virus widely and since they may need the in-classroom experience more, it could make sense to bring them back to school sooner than older students. Plus, older students generally can better handle online classes.
Federal health officials have recently warned that the pandemic is having an impact on mental health for many people, raising levels of depression and anxiety. The physical isolation and the economic stresses are fueling much of that.
The Trump administration’s rule overturning an Obama administration rule on transgender protections in the Affordable Care Act has been put on hold by a federal judge. But the Obama-era rule had also been put on hold by another judge. So the question is in limbo until higher courts — perhaps the Supreme Court — take up the case.
Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:
Earlier this month, my husband picked up the phone and learned his 92-year-old father had been taken to the hospital that morning, feeling sick and short of breath.
We were nearly 2,000 miles away, on a vacation in the mountains of southern Colorado.
No, it wasn’t COVID-19. My father-in-law, Mel, who has diabetes, high blood pressure and kidney disease, was suffering from fluid buildup in his legs and around his lungs and excruciating knee pain. Intravenous medications and steroid injections were administered, and he responded well.
Doctors monitored Mel carefully, adjusted his medications and recommended a few weeks of home health care after eight days in the hospital.
In other words, this was not a life-threatening emergency. Yet we realized how poorly prepared we were for a real crisis, should one arise. We needed a plan.
Why didn’t we have one already? The usual reasons: denial, avoidance and wishful thinking. It was easier to imagine that Mel would be all right until it became clear that we couldn’t take that for granted.
Although I routinely advise readers about preparing for changes in their health, I didn’t want to be a know-it-all with my husband’s family. Their assumption seemed to be “We’ll deal with whatever comes up when that happens.”
Now, eyes wide open, we got organized.
Some background: Mel lives in a well-run continuing care retirement community in upstate New York, in the independent living section. His three sons all live at a distance: one out West, one overseas and one a few hours away.
Hiring a care manager. Last year, as Mel’s kidney function declined, I suggested we hire a geriatric care manager who could look in on him regularly. After a few visits, Mel let her go. Her services were too expensive, he complained. In truth, we understood, he didn’t want someone interfering in his affairs.
My husband respects his father’s autonomy and didn’t press the point.
So, when Mel went to the hospital a few weeks ago, he was alone, with no one to turn to for assistance.
This was especially problematic because Mel has hearing loss and it is almost impossible to talk with him by phone. “How are you, Dad?” my husband yelled on twice-a-day calls to check on his father in the hospital. “What?” Mel replied querulously. This was repeated a few times, with mounting frustration and no useful information exchanged.
Now a care manager who could serve as our eyes and ears on the ground was necessary, not optional, and we hired back the professional we’d already found.
Finding companion care. What kind of assistance was Mel going to need when he left the hospital, deconditioned and weaker than when he went in?
When we spoke with the physician overseeing Mel’s care in the hospital, he suggested that “companion care” for at least a few weeks would be a good idea. Mel needed someone to help him up out of the chair, stay at his side while he walked to the bathroom and bring him a glass of water, among other tasks. (Also, we realized, we needed to arrange for meals to be delivered to Mel and for someone from his senior community to buy groceries for him — a service they’d started during the pandemic.)
An excellent organization that works with older adults in Mel’s area supplied me with a list of 21 agencies that provide these kinds of services — a dizzying array of choices.
Fortunately, the senior community where Mel lives recommended an agency that often works with its residents. We hired 24/7 care for several days after Mel left the hospital with the understanding that we’d continue services if necessary. Now, this agency is on our list of essential resources.
Understanding the options. Mel’s senior community incorporates assisted living and a nursing home for residents who need short-term rehabilitation services or longer-term round-the-clock care.
But it was clear Mel wanted to go home after being in the hospital instead of going to that rehab. Medicare would pay for a few weeks of visits from nurses and physical and occupational therapists. Would that be enough to set him on the road to recovery? We had no idea.
If Mel couldn’t return to his previous level of functioning after returning home, he might need to transition to assisted living, where he could receive more medical oversight and assistance. How would this work? We didn’t know and asked the geriatric care manager to find out.
Getting paperwork in order. Years ago, Mel assigned power of attorney for his health care decisions and financial and legal affairs to my husband. So long as Mel can manage on his own, he makes his own decisions: The legal papers were a backup arrangement.
But Mel hadn’t prepared a document naming all three sons as his “personal representatives” under the Health Insurance Portability and Accountability Act of 1996. This waives privacy concerns and gives them access to his medical information. It went on our “to-do” list.
The brothers also didn’t have a complete list of Mel’s doctors, the medications he was on and why he was taking them. Another item for our list, especially important since Mel left the hospital with prescriptions for 14 medications, several of them new. While he’d always managed on his own before, in his post-hospital fog it was clear he was nervous about managing this complicated regimen.
Understanding the prognosis. Before Mel’s hospitalization, we knew his kidney function was worsening. But what lay ahead? Was dialysis even an option for a 92-year-old in this time of COVID-19?
Who was best prepared to help us understand Mel’s prognosis and the big picture?
I’ve written for years about geriatricians’ comprehensive approach to the health of older adults. It turns out, there’s a top-notch group of geriatricians affiliated with the hospital where Mel was being treated.
After several calls, I reached one who agreed to see Mel after he was released from the hospital. Now, we have another new team member who can help us understand Mel’s health trajectory and issues that might arise going forward.
Having the conversation. What has yet to happen is the conversation that my husband hasn’t wanted to have. “Dad, if your health takes a turn for the worse again, what do you want? What’s most important to you? What does quality of life mean to you? And what can we do to help?”
With Mel’s hearing problems, doing this over the phone won’t do.
My husband would have to fly cross-country and, ideally, meet his New York brother at Mel’s place for a conversation of this kind. Before that happens, the brothers should talk among themselves. What’s their understanding of what Mel wants? Are they on the same page?
Also, no one has discussed financial arrangements.
Each time we explain to Mel one of the new services we’ve arranged, his first question is “What’s the cost?” His impulse is to guard his cherished savings and not to spend. My husband tells him he shouldn’t worry, but this, too, is a conversation that has to happen.
Being prepared. Professionally, I know a lot about the kinds of problems families encounter when an older relative becomes ill. Personally, I’ve learned that families don’t really understand what’s involved until they go through it on their own.
Now, Mel has a new set of supports in place that should help him weather the period ahead. And my husband is keenly aware that planning doesn’t stop here. He’ll be attending to his father far more carefully going forward.
An attack ad, which was released in mid-July, states that Montana Gov. Steve Bullock, a Democratic candidate for the Senate, supports a government-run health care program that would wreak havoc on the state’s health care infrastructure.
“Bullock’s health care plan will force rural hospitals to close. Medicare as we know it will change, replaced by a government-run program with fewer doctors and longer wait times,” says the narrator in the dark and grainy advertisement paid for by the National Republican Senatorial Committee (NRSC).
Bullock is running against first-term incumbent Republican Sen. Steve Daines in a race viewed as a toss-up. Given the COVID-19 pandemic, both candidates have been focusing on health issues.
Because this race is critical to determining whether Democrats or Republicans control the Senate, and considering that its themes are likely to be repeated in many congressional campaigns, we thought it was important to check the ad’s validity.
We first asked the NRSC for the evidence on which the ad was based. A spokesperson pointed to Bullock’s support for a “public option” health plan and provided us with a report predicting this proposal’s negative impact on rural hospitals, as well as quotes from both Republicans and Democrats about how the public option could lead to the eventual implementation of a “Medicare for All” program. (Medicare for All refers to the single-payer health system, advocated by Vermont Sen. Bernie Sanders, which would eliminate private insurance and replace it with a government-run health care system.)
We also reached out to the Bullock campaign for its response.
In a statement, Sean Manning, spokesperson for Montanans for Bullock said, “The claims in this ad are false. Montana hasn’t lost one rural hospital under Governor Bullock, and he will continue to support policies that protect rural hospitals while making affordable healthcare available to all Montanans in the Senate.” (According to the University of North Carolina Sheps Center for Health Services Research, no rural hospitals have closed in Montana since 2005.)
Hold Up ― Which Health Care Plan Is the NRSC Ad Talking About?
The ad vaguely refers to Bullock’s “health care plan” but doesn’t say outright what the candidate supports.
According to Bullock’s campaign website, he supports the creation of a public option.
A public option is generally defined as a health plan administered by the federal government that exists alongside and competes with private health insurance plans on the Affordable Care Act exchanges. Public option proposals differ by political candidate, and can take various forms, including Medicare or Medicaid buy-ins as well as a new government-run entity.
Opponents of such plans say that a public option, which would have the scale and regulatory power of the federal government to set lower reimbursement rates to providers, would have a competitive advantage and could put private insurance companies out of business. This would leave Americans with only one choice ― government-backed insurance. But that conclusion is debatable. Some health care scholars argue a public option would increase competition, leading to expanded access to health coverage, lower health care costs and lower premiums for consumers.
In the end, the outcomes from implementing this approach are difficult to predict unless a specific plan is released, said Benedic Ippolito, a health care research scholar at the American Enterprise Institute.
“Things can be radically different based on what the public option looks like,” said Ippolito. “The two big variables are, who is covered? And how does that insurer actually pay health care providers? You can imagine two public options looking totally different.”
The Payment Rate Is Key
Now to tackle the first part of the ad, which says that “Bullock’s health care plan will force rural hospitals to close.”
This argument stems from the idea that a public option would lead to lower reimbursement rates, based on the model provided by Medicare, which pays less than private insurance. And, because many rural hospitals are already severely financially strapped, lowered payments would do them in, the argument goes.
When we asked the NRSC for the evidence to support this position, a spokesperson provided an August 2019 study conducted by Navigant, a consulting firm. The study was commissioned by the Partnership for America’s Healthcare Future, a health industry coalition including drugmakers, insurance companies and private hospitals. The organization opposes Medicare for All and a public option.
The study modeled what would happen to rural hospitals if three separate public option approaches were implemented.
While it found that a public option could, depending on the scenario, cause a revenue reduction for rural hospitals of between 2.3% and 14%, the study reached these findings by assuming that the hospitals would be paid at Medicare rates.
Bullock’s campaign website, though, under his rural health care policy proposals, specifically states: “We need a public option that includes higher reimbursements for rural hospitals.”
We asked the Bullock campaign if it could provide us with details about what the “higher reimbursement” rate would be based on. It declined. A campaign staffer told us Bullock would support a public option that pays rural hospitals above Medicare rates. Since the reimbursement rates would be higher than Medicare’s, the assumptions in the Navigant study cannot be applied here.
“If the public option is a reasonably generous payer, that won’t be the end of rural health care,” said Ippolito. “But, you can easily imagine due to budgetary concerns, a public payer could have a lower reimbursement, which would have consequences.”
Some health policy experts argue that a public option would help rural hospitals by increasing the number of people in rural areas who have health insurance.
This would “benefit rural hospitals, since getting virtually nothing from uninsured patients is worse than getting a reasonably good rate from the public option,” said Gerard Anderson, a professor of health policy and management at Johns Hopkins University in Baltimore.
That’s a Big Jump
Next, we’re on to the NRSC ad’s second claim: “Medicare as we know it will change, replaced by a government-run program with fewer doctors and longer wait times.”
As several experts pointed out, this sentence doesn’t make a lot of sense. Medicare is already a government-run program.
Also, the design of most public option proposals thus far keeps Medicare and the public option as two separate government programs, said Linda Blumberg, a health policy analyst at the Urban Institute, a think tank.
The NRSC clarified its position and told us it was referring to the idea that a public option would stifle competition in the insurance market, eventually leading to only government-run insurance or Medicare for All. The evidence the NRSC provided to support this claim were quotes from a selection of Republicans, Democrats, professors, and experts from conservative think tanks saying that the public option is a stepping stone to this single-payer approach.
But others suggest that’s a big leap in logic.
“I think that analysis is almost surely wrong,” said Matthew Fiedler, a fellow with the Brookings Institution. “In a world where there is a public option, the negotiating dynamics between insurers and providers would change substantially.”
This would likely create an environment in which private insurers could negotiate lower rates and providers would have to respond to that change in revenue with more efficiencies, he added. However, depending on how a public option plan is structured — specifically if providers can opt out of participating — some in-demand providers may choose to stay in private-plan networks where they could negotiate higher payments. This would keep private plans competitive.
“I don’t think it’s reasonable to argue that a public option would drive all other plans out of the market,” Fiedler said.
Again, Ippolito said it all depends on how the public option program is designed, and he allowed that if providers and hospitals were paid at Medicare rates, the public option would have a huge competitive advantage over commercial insurers because it would be paying out less for services and then could charge lower premiums, and “there’s no question in the short run, that it would be disruptive.”
As we noted earlier, the prediction of any outcome is difficult without specifics. Without details of Bullock’s public option plan, it’s misleading to characterize the outcome of the public option as surely leading to Medicare for All.
Why It Matters
The race between Bullock and Daines is indicative of a trend occurring in campaigns across the country. Republicans often paint Democrats as left of the general public and health care has often been one of the issues the GOP highlights in that effort.
In this case, the NRSC ad links Bullock to Medicare for All, despite his expressed support for a public option. Sean Manning, Bullock’s campaign spokesperson, said the governor does not support Medicare for All.
Jeremy Johnson, an associate professor of political science at Carroll College in Helena, Montana, said that even before COVID-19 became a major campaign issue, Daines, echoing a Trump theme, had pushed the idea that he stood for freedom versus socialism.