Author: lesmastersonmedia

Originally published on Healthcare Dive.

The industry transition to value-based payments is leading to more population health management programs, but providers are finding it’s difficult when patients lack secure housing, access to food or a way to get to appointments.

So many are now going beyond one buzz word, population health, and taking into account the role that another, social determinants of health, play in a person’s health.

“Population health management efforts are most successful when they are tied to efforts to address social determinants of health issues, since the challenges that patients face around housing, food and transportation, for example, are completely tied to their ability to engage in the healthcare system, manage their chronic conditions and stay well,” said Dr. Amy Flaster, an assistant medical director for the Center for Population Health at Partners HealthCare in Boston, told HealthCare Dive.

Flaster, also a physician at Brigham & Women’s Hospital and vice president for health management and care management at Health Catalyst, said a population health management infrastructure, such as working with community-based nurses and organizations that help at-risk people, allows health systems to address medical issues before patients wind up in the emergency room.   

“The key to population health is truly about taking care of patients across the care continuum.”

Dr. Sarika Aggarwal, chief medical officer, Beth Israel Deaconess Care Organization

Leveraging an entire team within and beyond her office’s four walls, she gets help from social workers, community resource specialists, community health workers, pharmacists and nurses.

Across town at Beth Israel Deaconess Care Organization, Chief Medical Officer Dr. Sarika Aggarwal has seen PHM both from the provider and payer side. She’s led initiatives at both BIDCO and Fallon Community Health Plan.

“The key to population health is truly about taking care of patients across the care continuum,” she said. “I have not found a (population health management) program that hasn’t helped the patient.”

For these programs to work, they need invested partners on all sides —payers, providers and communities.

Still, ROI is difficult to prove. Potential cuts to Medicaid and an apparent lack of interest in population health at the federal government level could also stand in the way of organizations looking to go down that road.

Social determinants of health

Providers can’t ignore tackling social determinants of health in many communities.

Boston Medical Center, for example, treats a large at-risk patient population.

“They’re trying to look at patients more holistically,” said Rosemarie Day, who runs consulting firm Day Health Strategies, noting examples like physicians writing prescriptions for food and then sending the patient to the hospital’s own food pantry.

Another factor: Patients with mental health challenges may have a harder time caring for themselves, especially when they have co-morbidities, Day noted.

Some state Medicaid programs, health plans and providers are starting value-based payments for behavioral health services. Arizona, Maine, New York, Pennsylvania and Tennessee have all created Medicaid managed care organizations with value-based payments that target behavioral health.

“If you can manage mental health issues, you actually have a big opportunity to reduce medical cost spend,” said Day, who served as chief operating officer for Massachusetts’ Medicaid program and deputy director and chief operating officer at the state’s Health Connector.

Three legs of a stool

Population health programs can be considered as a three-legged stool, made up of a provider side, the payer side and community programs. Providers serve on the front line with patients, Payers use analytics to coordinate care and provide value-based payments and community programs help patients outside the physician’s office.

Payer involvement is crucial, offering claims data to match patients with the most appropriate interventions and providing contract incentives to providers.

Of course, physicians are tasked with treating patients the same regardless of the payment model, but alternative payment models can provide the extra funding to help compensate for that care coordination.

“The creation of ACOs and other alternative payment models are directly changing how health systems think about delivery care for their patients,” Flaster said.

Community programs provide services that patients can’t get during a physician visit. Community organizations help people find food and housing and resolve transportation issues for appointments.

Are they worth it?

So providers say the programs can help improve patient health and tackle social determinants.

But the big questions are: Can they save money in the long run? Are they worth it?

Aetna Chairman and CEO Mark Bertolini has touted the goals of the company’s foundation, which invests in population health projects that aim to reduce chronic diseases, provide walkable neighborhoods and improve quality of life.

An Aetna Foundation-financed study found that investments in certain areas did result in better health outcomes. For example, getting residents active is connected to decreased diabetes and cardiovascular disease; and cutting smoking rates reduced asthma and improved mental health. The study additionally found areas with the highest unemployment rates are also the unhealthiest, which goes back to social determinants of health.

With this in mind, Aetna’s Healthiest Cities and Counties Challenge provides $10,000 grants to 50 communities or organizations. Programs promote healthy foods, increase mental wellness and seek ways to decrease prison reentry. The programs that show an improvement are eligible for more funding — as much as $500,000.

A Health Affairs report recently highlighted a Colorado program called Bridges to Care, involving an emergency department and the community to promote primary care. The Center for Medicare and Medicaid Innovations funded the program through a grant.

The program offers medical, behavioral health and social care coordination services, such care coordinators, health coaches, behavioral health specialists and community health workers.

Six months after Bridges to Care intervention, there was a 28% reduction in ED visits and 114% more visits to primary care physicians compared to patients in the control group.

Digging further, the researchers found that patients with mental health co-morbidities had 30% fewer ED visits and 30% fewer hospitalizations — and 123% more primary care visits compared to the control group.

However, PHM programs aren’t always cost-effective, despite their success with patients. Aggarwal gave the example of a program that offered home visits to the more costly patients with comorbidities. She said the program was successful with patients and staff, but ultimately it was too expensive.

So instead, Beth Israel spun off the cost-effective parts of the program into one for pharmacists and disease management. Improving a patient’s medication management can result in improved outcomes quickly.

In that case, BIDCO initially connected patients with out-of-control diabetes to pharmacists, who provided recommendations to providers. Aggarwal said 40% of patients involved saw a significant decrease in their A1C levels.

Beth Israel then expanded the effort to health coaches and added similar chronic obstructive pulmonary disease and depression programs, with hopes to move into other chronic illnesses.

Potential barriers

Despite signs of success, the hurdles are many: Potential pushback from leadership, funding crunches and the difficulty in measuring what’s working are among the big ones.  

The first piece of PHM is creating a cross-disciplinary team. Each stakeholder needs to set aside territorial hangups. Respect is needed for each stakeholder no matter their background or whether they have a medical degree. “Getting a team to truly come together and flourish to reach that ideal of a patient-centered medical center is not easy to do,” Day said.

Leaders of these efforts must become “a champion of change,” she said.

“Generally, you can throw a lot of money (at population health), but if they’re not led well and they’re poorly executed, you don’t get the results you want,” she said.

They require planning, outreach to other stakeholders and physician buy-in. Health system leaders need to communicate with providers and fully explain the programs.

“You need to engage them and put in the right incentives. A lot of my work is spent with providers in our system. That is important to the core of the population health,” Aggarwal said.

Flaster said one way to get physician buy-in is through data. Physicians will buy into the program if they can see it will lead to better care.

Aggarwal said modifying patient behavior and achieving a positive ROI isn’t always easy. Programs may take 18 to 24 months to show a significant impact. And one can never be sure which part of the intervention was successful.

Plus, the care teams need to coordinate to eliminate duplications in post-acute care. Aggarwal gave the example of a discharged patient who may receive calls from multiple stakeholders. The patient becomes frustrated by the multiple calls and stops answering the phone. That doesn’t help the quality of care and is a waste of resources.

Instead, population health requires continual dialogue among the stakeholders to limit duplications.

Future of population health

Population health programs are expected to expand as payment incentives become more aligned with value rather than volume. Aggarwal said infrastructure, data, financial incentives and administrative pieces will all become better aligned, as well as the model to identify patients who would most likely benefit from the programs.

Day believes that states and the private sector will continue to innovate. Oregon and New York both have Medicaid ACOs and Massachusetts’ Medicaid program called MassHealth will soon start its own managed care ACO. Massachusetts was the first state in the nation in October 2016 to create a payment model that added SDH variables to medical diagnoses, age and sex.

Seventeen healthcare organizations are taking part in the Massachusetts ACOs, including Partners HealthCare, BIDCO and Lahey Health on the provider side and Tufts Health Public Plans, Fallon Community Health Plan and Neighborhood Health Plan on the payer side.

Starting March 1, the ACOs will be financially accountable for cost, quality and member experience for more than 850,000 MassHealth members. The program includes investments in primary care and community support services.

The federal government is providing $1.8 billion to restructure MassHealth via a five-year 1115 Medicaid waiver. ACOs will receive more than $100 million in new investments this year to support the change to value-based care.

Day said having states try these kinds of initiatives in Medicaid is a positive — as long as the federal government doesn’t cut Medicaid funding. Day doesn’t think the current administration will undermine population health, but also doesn’t think it will be a priority either.

“I don’t feel too optimistic at the moment about the national level,” she said.

Originally published on Healthcare Dive.

Medicare Advantage (MA) and the Affordable Care Act (ACA) exchanges are both federal programs, but they couldn’t be more different in payers’ eyes. Insurance companies are entering or expanding their footprints in the MA market, while simultaneously pulling back or out of the ACA exchanges. They’ve found success in MA. Not so much in the ACA exchanges.

Payers see MA as a stable market. That’s evident in the fact that MA premiums are expected to decrease by 6% next year. Insurance companies like stability. Insurers increase premiums by double digits when there isn’t stability, which is the case with the ACA exchanges.

A large part of the ACA exchanges’ problems is linked to actions and inaction in Washington, D.C. President Donald Trump’s administration stopped paying cost-sharing reduction payments to insurers, cut the exchanges’ open enrollment in half, reduced the exchanges’ advertising budget by 90%, offered proposed rules and executive orders that hurt the ACA and threatened not to enforce the individual mandate that requires almost all Americans to have health insurance.

Congress, meanwhile, has tried and failed to repeal the ACA this year. All of this created an unstable exchanges market, which resulted in payers leaving the exchanges or jacking up premiums by 20% or more for 2018.

Meanwhile, the MA market is a picture of stability and payer success.

• There is a steady stream of new people eligible for Medicare daily, and many choose MA.
• People usually don’t switch back from MA plans after leaving traditional Medicare.
• Payers can easily convert members from traditional Medicare to MA via marketing campaigns.
• The MA demographics are usually people who once had an employer-based plan, so they know insurance and how healthcare works. That also means they usually don’t have pent-up healthcare needs.
• The CMS pays MA plans upfront for covering people with high healthcare costs and payers have enjoyed stable MA payments from the CMS.

So, MA members are easier to get and keep, they usually have fewer health needs and payers like the MA payment structure better than the exchanges, which get compensated at the end of the year. All of that equals a stable market for payers.

One-third of Medicare beneficiaries are enrolled in an MA plan this year compared to 25% just six years ago. Enrollment grew by 8% between 2016 and 2017 and the CMS recently announced that MA membership will grow by 9% to 20.4 million members in 2018.

Gretchen Jacobson, associate director with the Kaiser Family Foundation’s (KFF) Program on Medicare Policy, told Healthcare Dive that more than half of those in Medicare will have MA plans in many counties next year.

That growth isn’t expected to slow — especially with Republicans controlling both houses of Congress and the White House, according to Steve Wiggins, founder and chairman of Remedy Partners.

“With Republican control of the federal government, it is conceivable that Medicare Advantage will become a centerpiece of CMS’ strategy to control spending growth,” Wiggins told Healthcare Dive.

What more MA members and payers means for hospitals and providers

With more MA members expected next year, the continual shift to MA will have mixed benefits for providers. Jacobson said it’s not entirely clear how more MA members will affect hospitals and providers. “One of our studies recently showed that the provider networks for Medicare Advantage plans greatly varies and these networks will become even more important as enrollment in Medicare Advantage plans grows,” she said.

Fred Bentley, vice president at Avalere Health, told Healthcare Dive that MA’s growth will present a whole new set of challenges for hospitals and health systems.

Bentley listed two issues:

• Narrow networks
• Tighter utilization management compared to Medicare’s fee-for-service model

A recent KFF report found that 35% of MA enrollees were in narrow-network plans in 2015. Payers have increasingly turned to narrow networks to control costs and improve quality of care. To take part in the narrower networks, physicians usually have to agree to payer demands concerning cost and quality.

Originally published on Healthcare Dive. 

Threats, actions and inactions from Washington, D.C., have left the Affordable Care Act (ACA) exchanges teetering and insurance companies fleeing the individual market for 2018. This state of affairs can be harmful for payers, who are sometimes unable to share population risk with other insurers. It’s also an issue for providers, who will see fewer people with coverage and will lose leverage in payer negotiations on reimbursement and provider networks.

The effects of an uncertain individual market are already showing in premium rate hikes, but 2019 will likely be even more troublesome — unless there are policy changes.

Congress has failed to pass major healthcare legislation this year, and critics charge the executive branch has been undermining the exchanges, including:

• President Donald Trump has ended cost-sharing reduction (CSR) payments to insurers. CSR payments help keep down out-of-pocket costs for lower-income Americans.
• The Trump administration may not enforce the individual mandate. This would lead to fewer members and cause younger, healthier people to leave the exchanges. The result would be an imbalanced risk pool with not enough healthy people to offset the sickest members.
• The administration cut the open enrollment period for ACA plans in half this year, slashed its advertising budget by 90% and moved healthcare.gov offline on Sundays, which is when many working people may try to sign up for an ACA plan. These moves could reduce ACA plan membership.

These actions and threats have resulted in some payers exiting the ACA exchanges or proposing more than 20% premium increases.

“Insurance markets work best when there’s stability and when everyone has a pretty good sense of how the market is going to operate. Sadly, we’re not there right now,” Ken Wood, senior vice president of health plan development at Evolent Health, told Healthcare Dive.

During her time at HHS, Chiquita Brooks-LaSure, a managing director at Manatt Health, saw firsthand how much insurers worry about uncertainty. As director of policy coverage at HHS during President Barack Obama’s administration, Brooks-LaSure was there at the start of the ACA exchanges. She recalled how insurers’ No. 1 concern was uncertainty.

Brooks-LaSure told Healthcare Dive insurers care less about specific rules and regulations than not knowing what to expect. They can price bad risk and design products when they know the market.

“Uncertainty has caused a lot of insurers to say (the exchanges are) too volatile,” said Brooks-LaSure.

Only one ACA payer in nearly half of counties in 2018

The ACA market uncertainty almost resulted in counties without any options in the exchanges. Major payers like UnitedHealth Group, Aetna, Humana and Anthem pulled back or completely out of the exchanges for 2018, which left state insurance commissioners scrambling to fill the gaps.

Nevada, Ohio, Missouri, Indiana, Virginia, Tennessee, Washington and Wisconsin all feared that they would have counties with no ACA payers in 2018. Ultimately, state officials and payers were able to get all counties covered. However, nearly half of counties will have only one ACA plan option in 2018, which is far from ideal for payers, providers and members.

Entire states like Kentucky, Oklahoma, Iowa, Nebraska, South Carolina, Mississippi and Wyoming will have only one payer for the entire state. Other states like North Carolina, Georgia, Tennessee, Alabama and Arizona will have most counties with only one payer.

Counties with only one payer option are mostly rural areas. Higher population areas mostly have multiple payers competing for business. For instance, Texas has four or more ACA payers in metro areas like Dallas-Fort Worth and Houston, while the more rural areas have only one or two ACA payers.

Having only one payer doesn’t provide members any choice, leads to higher health costs and gives insurers more leverage over physicians and hospitals. Chris Sloan, senior manager at Avalere, told Healthcare Dive that payers can pretty much say “we want to pay X or you’re not in the network.”

Brooks-LaSure said those insurers also can set prices, provider networks and cost-sharing structures without any competition.

“States don’t have a lot of leverage if there’s only one insurer,” she said. “(The payer) has no incentive to try to compete better because they’re not competing against anyone.”

What does having only one ACA payer mean for hospitals and providers?

Payer contracts are likely already signed for 2018, so reimbursements won’t be affected in the counties with only one ACA payer next year. That impact may come in 2019.

This lack of competition will mean higher premiums. Sloan said Avalere’s research found that premiums are higher with lower competition. Places with one insurer had about 10% lower premiums than those with two and 15% less than places with three or more carriers.

There are three major concerns for hospitals in areas with only one ACA payer:

• Out-of-pocket costs could increase. Higher out-of-pocket costs, especially in high-deductible health plans, may result in more bad debt for providers.
• Narrower networks may nudge members toward HMOs, which will affect doctors not in those networks.
• Decreased ACA plan enrollment will result in people using the emergency room for non-urgent healthcare. If this happens, hospitals will see more bad debt and uncompensated care because of fewer insured Americans.

To prepare for 2018, Sloan suggested hospitals in lone ACA insurer areas review their patient population. Find out the percentage of patients in ACA plans. Think about what would happen if say 10% of those patients drop out of the plans in 2018. Then, determine whether you need to set aside more money for charity care next year.

Wood said providers can also help patients who lose their insurer and need to choose a new plan. “I think the most important thing that hospitals and physicians can do is get the word out for people to get coverage,” Wood said.

Sloan suggested another way to help is for providers to advertise open enrollment in their waiting rooms. Having those patients insured is not only important for their health, but providers’ bottom lines.

What will this mean for payers?

Being the only game in town isn’t exactly great news for insurers either. Sure, they get all the business, but that’s not a positive. There’s a reason the other payers pulled out of the counties.

“There is clearly a reason why plans didn’t want to stay in those counties. There are clearly risk issues,” Sloan said.

Without any competition, the insurance companies don’t have another payer in which to share the risk. This means the remaining insurer will need to find ways to balance the risk and figure out how to reach profitability.

Given the increasing costs and reduced outreach and open enrollment period, insurers will likely see fewer members enrolled in ACA plans next year. Sicker members will remain in the plans. This will lead to higher premiums and out-of-pocket costs, which in turn may make more people leave the ACA plans.

Payers in rural areas especially will need to work on getting enough healthier members to offset those who need the most care, Wood said. Those insurers may also need more innovation, such as using telehealth, to help keep down costs.

“If you’re in a rural area and you’re the only health plan, you’re just hoping for an adequate mix of enrollment,” Wood said.

Sloan will closely watch how the only insurers in counties perform in 2018. He’s especially interested to see if they can manage risk and price plans correctly for the patient population.

“It’s going to be interesting how these health plans do,” Sloan said.

How will payers perform in 2018?

Sloan said one reason some of the larger payers pulled out the ACA exchanges is they’re publicly traded, and need to explain to shareholders why they’re losing money in the exchanges. The Blues, on the other hand, are nonprofit and have a mission to serve the individual market. Sloan said Blues plans cover about 90% of counties with only one payer in 2017.

“The Blues are holding up the market,” he said.

The Blues were in the individual market well before the ACA. So, while insurers with limited individual experience have pulled out of the ACA exchanges, the Blues continue to largely stay in the exchanges except for Anthem, a Blues plan that pulled out of nine of 13 exchanges for 2018.

“The Blues have been in this market and, in general, have been interested in making it work,” Brooks-LaSure said.

Beyond the Blues, another insurer to watch is Centene, which is expanding its ACA plan footprint. The St. Louis-based payer is growing ACA plan coverage in six states and entering three new ones (Kansas, Nevada and Missouri).

Centene has experience in Medicaid managed care plans. Those plans are closer to the ACA plan population than employer-based plans, so that could be a reason company officials spoke positively about their experience in the ACA market. Centene, which has 1.2 million ACA plan members, announced earlier this year it saw 69% growth in the first quarter of the year.

What about 2019?

Will more insurance companies drop out of the ACA exchanges for 2019? A lot can change over a year — or even over a week given the current political climate. Predicting the future is difficult when everything keeps changing.

However, health insurance experts agree that unless Congress passes legislation to provide CSRs — and take the decision out of the hands of the president — more payers will leave in 2019 and members’ costs will continue to skyrocket.

This scenario would lead to counties with no ACA plan options in 2019, more counties with only one payer, difficult negotiations with payers, higher costs for members and likely more bad debt for providers.

One possible solution may come from the states. States are seeking their own reinsurance programs, which helps insurers manage risk. Brooks-LaSure said states could create reinsurance programs to help balance the market.

Ultimately, however, she would prefer a federal solution. “A national reinsurance program would be great. I’m not sure if it’s feasible now,” she said.