|High-deductible Health Plans are Moving Health Outcomes in the Wrong Direction|
By Jakob Emerson | February 22, 2023
As the number of Americans enrolled in high-deductible health plans continues to grow, recent studies conducted by researchers at some of the nation’s top hospitals and medical schools have linked HDHPs with worse health outcomes, less spending on preventive care, and higher utilization rates of emergency rooms.
High-deductible health plans are defined as plans that meet the minimum deductible amount required for health savings account eligibility — $1,400 for an individual and $2,800 for a family in 2021.
In 2021, more than 56 percent of private-sector Americans were enrolled in a HDHP — the highest state is Maine (76 percent) while the lowest is Hawaii (11.6 percent).
Conclusions of five HDHP studies recently reported by Becker’s:
1. A study published Jan. 20 in JAMA Network Open found that diabetic patients who were forced to enroll in a HDHP by their employer face a higher risk of acute diabetes complications compared to those enrolled in traditional health plans. HDHPs increased the risk of needing to visit the emergency room or hospital for severe hyperglycemia by 25 percent, and each year of enrollment increased the risk by 5 percent.
2. A study presented Nov. 29 by Boston Medical Center researchers to the Radiological Society of North America found that over 21 percent of women surveyed said they would not seek an additional screening after abnormal findings on a mammogram if they knew they had to pay a deductible.
3. A study published Oct. 5 in the American Journal of Managed Care found that individuals with HDHPs were 6.6 percent less likely to receive treatment for substance use disorders than those with traditional health plans.
4. An observational study presented in June by Harvard Medical School researchers at the American Society of Clinical Oncology’s annual meeting linked HDHPs with a 4.6 month delay in the detection of metastatic cancer compared to individuals enrolled in a low-deductible plan.
5. A study published May 9 in the American Journal of Managed Care found that when HDHPs are present, employees making less than $75,000 annually spend more on emergency care and have higher acute care utilization rates, and they have lower rates of primary care spending compared with high-salary employees.
To read more, go to Becker’s Payer Issues.
Medicare Advantage Plans Denying More Inpatient Claims
By Jeff Lagasse | February 21, 2023
Healthcare systems have found themselves in precarious financial standing due to a dramatic increase in the number of inpatient claims being denied by health insurers based on the lack of medical necessity, according to data collected by accounting and technology firm Crowe. These level-of-care reimbursement disputes are especially rising in frequency among Medicare Advantage plans.
One of the most straightforward payer categories when it comes to assigning the appropriate level of care is traditional Medicare, found Crowe. MA plans, on the other hand, have adopted more restrictive criteria commonly used by commercial health insurance carriers and, according to the report, deny more inpatient hospital claims than all other payer types.
Through November of 2022, the initial inpatient level-of-care claim denial rate for MA plans was 5.8%, compared with 3.7% for all other payer categories. When isolating just the payers within the MA plan population, providers wrote off 8.5% of their inpatient revenue as uncollectible in comparison to 4.7% in 2021.
WHAT’S THE IMPACT
In 2022 alone, clients in Crowe’s benchmarking database wrote off $535.4 million on account of Medicare Advantage plan denials based on lack of medical necessity.
Colleen Hall, managing principal of the healthcare group at Crowe, said that due to the immense popularity of MA plans, providers will have to adjust their clinical operations, “and should ensure their revenue cycle and care management teams are in alignment on which denied claims should be prioritized when managing appeals.”
The report also revealed that in 2021, providers wrote off 3.6% of their inpatient revenue as uncollectible. Through November 2022, that number jumped to 5.9% – a 64% increase.
Through November 2022, the dollar value of initial clinical denials by payers represented 4.2% of billed inpatient dollars. That percentage is 18.5% higher than in 2021.
To read more, go to Healthcare Finance News.
|AMGA Calls on Congress to Advance Value-Based Care, Support Providers|
By Victoria Bailey | February 21, 2023
Congress should focus on advancing value-based care by investing in proper infrastructure, incentivizing patient engagement, and supporting continuous telehealth coverage, according to the American Medical Group Association (AMGA).
The organization sent a letter to congressional leaders expressing appreciation for their efforts to support healthcare providers throughout the COVID-19 pandemic. However, the letter urged leaders to improve the Medicare program to help boost value-based care delivery.
Medicare reimbursement cuts, workforce shortages, and inflation have led to consistent burdens for providers and patients, AMGA said. These conditions make it difficult for providers to transition to value-based care. Thus, Congress should establish a more sustainable Medicare payment system.
Improving and incentivizing value-based models is a critical step to supporting the shift. AMGA asked Congress to create a more stable Advanced Alternative Payment Model (APM) program to inform providers that federal policymakers back the transition.
The Consolidated Appropriations Act of 2023 extended the Advanced APM incentive payment for an additional year but lowered the rate from 5 percent to 3.5 percent.
AMGA encouraged leaders to invest in essential infrastructure, including technology, care management, leadership, and analytics. In addition, Congress should support funding for programs that provide upfront financial support for value-based contracts.
Offering patients financial rewards, waived co-pays, and definite access to telehealth could help patients become active participants in their healthcare journey and improve their well-being. AMGA suggested that Congress develop and implement strategies to encourage patient engagement.
To read more, go to Revcycle Intelligence.
Senators Say Health Worker Shortages Ripe for Bipartisan Compromise
By Michael McAuliff | February 17, 2023
Senators are eying the growing shortage of health care workers in the United States as one of the few problems where there is room for bipartisan solutions, even in a deeply divided Congress gearing up for a presidential election cycle.
The shortage that’s only worsened since the pandemic is a prescription for skyrocketing costs, suffering, and unnecessary death, Sen. Bernie Sanders (I-Vt.), the new chairman of the Senate’s top health committee, warned in his committee’s first hearing Thursday.
“We are going to produce legislation, and I think people will be surprised about the level of bipartisan supporters,” Sanders said in a brief interview during a break from the hearing. He called for the committee to “produce something meaningful.”
The shortage of health care workers of all sorts is a widespread problem but is especially acute in rural areas and minority communities. Sanders pointed to the startling numbers of Americans living in medical care deserts to illustrate the point. There are nearly 100 million people who don’t have easy access to a primary care physician, almost 70 million with no dentist at hand, and some 158 million people who have few local mental health providers, Sanders said.
The covid-19 pandemic contributed to the nation’s existing worker shortage as many left the workforce as the crisis worsened. Some contracted the virus themselves, and large numbers of health care providers died. An investigation by KHN and The Guardian revealed more than 3,600 health workers in the United States died during the pandemic’s first year alone. Some got burned out or sought higher-paying jobs elsewhere.
“Despite all of our health care spending, we don’t have enough doctors, nurses, nurse practitioners, dentists, dental hygienists, pharmacists, mental health providers, and other medical professionals,” Sanders said, pointing to data that suggest the nation faces a shortfall of about 450,000 nurses and 120,000 doctors in the coming years, and 100,000 dentists now.
While Democrats and Republicans alike acknowledged the shortages hobbling care for hundreds of millions of Americans, any legislative solution must pass not only the Senate Health, Education, Labor, and Pensions Committee, but also the full Senate and House of Representatives. Far-right House Republicans have threatened to go so far as forcing the federal government to default on its debts as they demand spending cuts, and high government spending on health care could make new legislation a ripe target.
Sen. Bill Cassidy of Louisiana, the committee’s top Republican who is also a doctor, cited a few programs the committee is responsible for updating this year, such as an expiring program that trains many of the nation’s pediatricians. He said funding should reflect what works in the health care system and come “with the appropriate spending offsets.”
“We have to make sure that we’re not wasting the money we’re trying to productively spend,” he said.
To read more, go to Kaiser Health News.
Trends in the Adoption and Integration of AI into Radiology Workflows
By Dave Fornell | February 17, 2023
The integration of artificial intelligence into radiology PACS and enterprise imaging systems has become a big topic of discussion with IT vendors over the past couple years. This has become a bigger question from hospitals and radiology groups as there are now about 400 radiology related AI algorithms that have U.S. Food and Drug Administration clearance.
Amy Thompson, a senior analyst at Signify Research, is monitoring AI trends in radiology and said these algorithms are still relatively new to the market. Vendors are taking different approaches to how they integrate them into their radiology IT workflows.
“We know, to maximize that value of AI, it needs to be embossed into the workflow. It needs to have that seamless flow and you don’t want to open a pop-up window to have the AI results; you want it all within that single user interface,” Thompson explained.
However, since there are no standards set for how AI interfaces with various IT systems, she said it will take time. This is why many radiology IT PACS vendors are now partnering with a set number of AI companies that they feel offer a good product and work together to enable these types of seamless integrations.
“To do this for 200-plus vendors is not realistic for any vendor to do, so there are still a lot of unknowns for IT vendors. Like, which AI vendor should I partner with, because you have 200-plus, and most of them are limited to three or four applications in terms of mammography, lung, brain, and a few others. There is a lot of repetition currently in the market and there is not a lot of consolidation yet to have a top 10 or top 20 clear winners,” Thomson said.
Even asking radiology end users what vendors they prefer, there is no clear answer because 10 hospitals will give 10 different answers, she said.
To read more, go to Radiology Business.