Health Care Trends

Paying to Address Social Determinants of Health: Medicare Advantage to Offer “Supplemental Benefits”

By M2|2018-05-07T14:32:50+00:00May 4th, 2018|Health care spending, Health Care Trends, Medicare, Social Determinants of Health, Uncategorized, What do we pay for and why|

Paying to Address Social Determinants of Health: Medicare Advantage to Offer “Supplemental Benefits”

CMS recently announced it will change its policy regarding Medicare Advantage plans and the scope of “supplemental benefits” these plans may offer. As of the 2019 plan year, CMS says it is reinterpreting existing law and expanding the options that Medicare Advantage plans may offer to enrollees.

In the past, CMS has not allowed an item or service to be eligible as a supplemental benefit – an additional benefit beyond the standard benefits under traditional Medicare – “if the primary purpose includes daily maintenance,” the agency says.

However, in the 2019 final Call Letter for Medicare Advantage, CMS says the policy change will “expand the scope of the primarily health-related supplemental benefit standard” to allow benefits used to “diagnose, prevent, or treat an illness or injury, compensate for physical impairments, act to ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization.”

Items and services under this expanded scope could include things like “air conditioners for people with asthma, healthy groceries, rides to medical appointments and home-delivered meals,” a recent article in Kaiser Health News notes.

Transportation, different food options, and items such as grab bars in bathrooms might be covered options now. While a physician’s order or prescription is not necessary, the new benefits must still be “medically appropriate” and recommended by a licensed health care provider.

While public health types (me included) often focus on explaining what a social determinant of health is and how it could be addressed in order to improve health equity, this policy change is significant in that it attaches payment to interventions – even if they are not clinical – that could lead to improved health.

Separately, the most recent federal budget agreement lifts the annual caps on the amount Medicare pays for physical, occupational, or speech therapy, and streamlines the medical review process. This policy change will apply to both traditional Medicare and Medicare Advantage enrollees.

As of Jan. 1, Medicare beneficiaries will be eligible for therapy indefinitely as long as their provider confirms their need for therapy and they continue to meet other requirements. Also, under a 2013 court settlement, enrollees will not lose coverage “simply because they have a chronic disease that doesn’t get better,” KHN says.

In an interview with KHN, Judith Stein, executive director, Center for Medicare Advocacy, said, “Put those two things together and it means that if the care is ordered by a doctor and it is medically necessary to have a skilled person provide the services to maintain the patient’s condition, prevent or slow decline, there is not an arbitrary limit on how long or how much Medicare will pay for that.”

These are innovative moves on CMS’s part; they show the agency recognizes the need for a more holistic approach to health care for Medicare enrollees and that it’s willing to address the social determinants of health, such as the impact of the home environment on a patient’s health.

CMS is now moving beyond purely “medical” treatments for Medicare Advantage enrollees and addressing broader aspects of health. We get what we pay for, and by covering different types of care, CMS is encouraging actions that may lead to improved health outcomes and avoidance of some preventable health events for patients.

Nearly Every State Engaged in Value-Based Payment Models

By M2|2018-03-14T17:37:20+00:00March 14th, 2018|Health Care Trends, Health Reform, Innovation, Medicaid, State Health Initiatives, Uncategorized|

Nearly Every State Engaged in Value-Based Payment Models

Value-based payment is not just for Medicare and private payers, states are also engaged in a multitude of value-based payment initiatives. While variation exists in the scope, leadership commitment, and resources devoted to these efforts, “more than 40 states have a state-initiated plan or strategy” to move toward value-based payment instead of fee-for-service (FFS) payment, and “almost half of those initiatives are multi-payer in scope,” according to the report by Change Healthcare, based on a national study of publicly available information compiled from May through October 2017.

Of note:

Of the states engaged in VBP, nearly all are using patient-centered medical homes (PCMH) or health homes (HH).
For the most part, these tests are being tried in Medicaid; 31 states are testing one of these value-based approaches in Medicaid alone. In three states, they are testing at least one of the two in Medicaid and with their state employees: Oklahoma, Tennessee, and Washington. Thirteen states have multi-payer efforts: Arkansas, Colorado, Connecticut, Delaware, Idaho, Iowa, Maryland, Michigan, New York, Ohio, Pennsylvania, Rhode Island, and Vermont.
Fourteen states have chosen the ACO model: seven in Medicaid (Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New Jersey, Oregon), two in Medicaid and with state employees (Oklahoma, Washington), and five in multi-payer arrangements (Colorado, Iowa, New York, Rhode Island, Vermont).
Episodes of care (EOC) is another approach being used; currently in 12 states though some are considering it and some only use EOC in a single service area: Colorado, Maine, and South Carolina are considering EOC; New York is using it only in maternity and chronic care; Washington is using it only for total joint episodes of care.
Pay for performance is also being tried in the following 12 states: California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Iowa, Maryland, Missouri, New Hampshire, Texas, and Wisconsin.
Seven states have “little to no activity around value-based payment” (Georgia, Indiana, Louisiana, Mississippi, North Dakota, South Dakota, Wyoming).

The following map (created by M2 based on data in the Change Healthcare report) shows the details of each state’s initiatives in this area:

For a few states, testing alternative payment models is not new. Some states have been engaged in these efforts for nearly a decade. Minnesota was the first state to engage in a value-based payment approach of some sort, in 2008. Colorado and Maryland began their efforts in 2011; Oregon in 2012, Arkansas and Vermont in 2013.

States are often the leaders in testing new ideas. Alternative payment models for health care are no different. As health care costs continue to rise, and most states need to balance their budgets every year, it makes sense that finding different ways to pay for Medicaid and state employees’ health care is something nearly every state is focused on.

VBP is not dead, as evidenced by nearly all states are taking action to transition from a FFS approach to one that is focused on value. To slow health care costs, we have to stop paying for what doesn’t work. The more we can reward outcomes in health care, the more likely it is that providers and patients will make decisions based improvements in care, rather than adverse financial incentives for low-value care.

Interoperability – all that’s old is new again

By M2|2018-03-08T16:02:41+00:00March 7th, 2018|EHRs, Health Care Trends, Health Information Technology, Hospitals, Uncategorized, What do we pay for and why|

Interoperability – all that’s old is new again

For some of us in health care policy, 2018 so far is the year of testing just how good our filing systems are. All that is old is new again and ideas to “fix the U.S. health care system” from years ago are popping back up. This week “interoperability” is the hot topic, in part because Seema Verma, Administrator of the Centers for Medicare & Medicaid Services (CMS), made a big announcement at the Healthcare Information and Management Systems Society (HIMSS) annual conference, saying interoperability would again be a focus of the federal government. She made three big announcements really, but today we are focused on Verma’s announcement that CMS will be overhauling the “Electronic Health Record (EHR) Incentive Programs to refocus the programs on interoperability and to reduce the time and cost required of providers to comply with the programs’ requirements.” Not surprisingly, when she mentioned the burdens on health providers of meeting meaningful use requirements and that CMS would be changing those requirements, the full ballroom broke into applause.

Patients Should Control Their Data. Yes, but…

The CMS administrator also announced a new initiative, “MyHealthEData – to empower patients by giving them control of their healthcare data, and allowing it to follow them through their healthcare journey.” It may seem obvious that patients should have electronic access to, and full control of, their health records, but the government does seem to need to intervene in order to get this information released from government agencies and payers, as well as from private health insurers and providers. Susan Morse (@SusanJMorse), who covered the HIMSS Conference for Healthcare IT News, explains that part of the issue is hospitals involved in data blocking. Verma told conference goers CMS would be strengthening requirements for providers to stop the practice: “It’s not acceptable to limit patient records or prevent them from seeing their complete history outside of (that) health system,” she said.

Data blocking may not be the primary barrier to patient control of their health care data, however. The March 2018 American Hospital Association Trendwatch: Sharing Health Information for Treatment shows hospitals and health systems have rapidly improved electronic sharing of clinical/summary care records over the past several years as the AHA Trendwatch chart below shows.

Can (Will?) Health Providers Use Patient Data?

Interoperability at its core means information can move back and forth between the various entities that have it. That could be from provider to provider, from plan to provider, provider to patient, etc. The fact sheet explaining the Trump Administration MyHealthEData Initiative Putting Patients at the Center of the U.S. Healthcare System mentions one of the goals of the effort is:

“Reducing Duplicative Testing – Provider systems typically do not share patients’ data, which can lead to duplicative tests when a patient goes to see a different provider. This increases costs and can lead to patient inconvenience or even harm. CMS is studying the extent and impact of duplicate testing, and will identify ways to reduce the incidence of unnecessary duplicate testing.”

In a study published in 2010, (all that’s old is new again…) in the Journal of the American Medical Informatics Association titled, “A Preliminary Look at Duplicate Testing Associated With Lack of Electronic Health Record Interoperability For Transferred Patients,” found approximately 20% of patients had non-clinically indicated duplicate testing resulting in added costs to the system. The study authors continued, “The most common setting for duplicate testing identified in the current study happened on admission from an outpatient clinic site. Patients from outpatient clinic transfer to hospital admission via several paths, including entrance via hospital admitting services or directly to the inpatient ward, either escorted or unescorted by hospital clinical staff.”

However, while hospitals and health systems have improved their sharing of clinical summaries with outside entities, the same AHA Trendwatch shows much slower progress in integrating information from outside sources. As the chart (from AHA Trendwatch) below shows, 65% of hospitals and health systems are either not able or not routinely able to integrate external information electronically.

Giving patients access to all of their health care data electronically is no doubt important. However, it is not sufficient to improve care or reduce costs, even for something as simple as avoiding non-clinically indicated duplicate testing. Achieving interoperability will also require payment incentives to change. As this blog has pointed out in other instances, money matters and you avoid what you have to pay for. Electronic health data vendors can still charge providers for building interfaces that help disparate systems “talk” and can charge providers to move data. Keith Aldinger, MD, an internist who practices in Houston, Texas wrote for Medical Economics in late 2017, physicians have “been assessed financial penalties for not attesting to meaningful use and yet the IT industry gets a pass.” His idea for improving interoperability is to put health IT vendors on the hook: “They should not be allowed to charge one cent for transferring information and any attempt to do so should elicit a financial penalty.”

All that’s old is new again. We still have to figure out how to get health care data moving in ways that improve health care for patients. Interoperability, you’re hot again. Let’s hope you do better this time around.

Rising obesity rates indicate the need for improved insurance coverage of proven effective treatment options, both medical and surgical

By M2|2018-02-21T15:54:35+00:00February 21st, 2018|Health Care Trends, Health Plans, Insurance, Reimbursement, Uncategorized, What do we pay for and why|

Rising obesity rates indicate the need for improved insurance coverage of proven effective treatment options, both medical and surgical

Mortality improvements in the U.S. have declined relative to other wealthy countries, and a new study points to obesity as the culprit.

“Rising levels of body mass index [BMI] have prevented the United States from enjoying the full benefits of factors working to improve mortality,” according to study author Samuel Preston, professor of sociology at the University of Pennsylvania, et al. The study is published in the Proceedings of the National Academy of Sciences, as noted in a recent article in HealthDay.

In addition, according to the article, rising BMI has “reduced the annual rate of improvement in U.S. death rates between 1988 and 2011 by more than half a percentage point—equivalent to a 23% relative reduction in the rate of mortality decline—a large amount by international standards.”

“Heart disease deaths had declined consistently for nearly 40 years,” the article notes. “These declines have slowed or stopped altogether” and “rates of decline in cancer deaths have also slowed,” the article says. “At the same time, rates of obesity have been rising in the United States. From 1976 to 1980, 15 percent of Americans were obese. By 2014, 38 percent of Americans were classified as obese.”

The study’s researchers evaluated how much of the change in the death rate trend could be explained by rising BMI, and found that the increase in BMI reduced life expectancy by 0.9 years, almost 11 months, at age 40, and accounted for 186,000 excess deaths in 2011.

Despite rising obesity rates, another new study finds that many obese patients are not receiving antiobesity medications – and patients who are being prescribed medicines may be getting them because of provider bias. 80 percent are women, although obesity rates are similar for men and women in the U.S.

Fewer than 1 in 50 people in the U.S. eligible for antiobesity medications are receiving them, according to an evaluation of electronic records conducted by University of Colorado endocrinologist David Saxon, MD. Patients above a specific BMI threshold are eligible for weight-loss medication, but only 1.3% had received any prescription from 2009 to 2015, a recent Medscape article notes.

In addition, among patients who had received a prescription, 85% of the prescriptions were for phentermine, as opposed to newer agents. Primary care providers were most likely to prescribe these drugs.

Patients want “more information from their physicians about these medication options but there’s rarely the conversation,” Saxon says in the article. “Patients are probably more interested in them than the 1.3% who are receiving them.”

My friend and colleague, Scott Kahan, MD, is the director of the National Center for Weight and Wellness, and the medical director of Strategies To Overcome and Prevent (STOP) Obesity Alliance at George Washington University. Kahan explains that physicians historically have received little training in obesity management, and may hold misperceptions about obesity medications, including that they are unsafe, ineffective, or not well-studied.

“These misconceptions are likely a legacy of older medications that had lesser requirements for approval and were likely misused,” Kahan says. Another issue is lack of insurance coverage.

Yet another successful obesity treatment option is surgery. Two recent studies published in the Journal of the American Medical Association (JAMA) compared Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy in morbidly obese patients.

First, researchers at St. Claraspital in Basel, Switzerland, conducted a randomized trial of morbidly obese patients to determine whether there are differences between the two surgical options, in terms of weight loss, changes in comorbidities, increase in quality of life, and adverse events, as noted in an article in The Clinical Advisor. Excess BMI loss was not significantly different at 5 years: 61.1%, with sleeve gastrectomy vs 68.3% with RYGB.

In the second study, researchers in Finland also studied morbidly obese patients to examine the clinical equivalence of the two surgeries. The trial found the estimated mean percentage excess weight loss at 5 years was 49% with sleeve gastrectomy and 57% with RYGB, with no statistically significant difference in quality of life between groups and no treatment-related mortality. At 5 years, the overall morbidity rate was 19% and 26%.

In an accompanying editorial, David Arterburn, MD, MPH, and Anirban Gupta, MD, state that “these and other studies suggest that sleeve gastrectomy and bypass are overall quite similar in terms of their effects on weight and comorbid conditions through 5 years.” They also note that “these procedures may be associated with improved long-term survival compared with usual medical care. Overall, it seems that both procedures are excellent options for surgeons and patients to consider in the treatment of obesity.”

With the slowing gains in life expectancy in the US linked to obesity, patients need their insurance plans to cover effective treatment options. If these options are going to be accessible for patients, insurers will need to have reasonable coverage and reimbursement policies in place; today, with FDA-approved drugs available to treat obesity and promising research showing that the sleeve and bypass surgeries are two excellent options, we need policies that encourage use of both drug and surgical approaches.

Health Care Expenditures and You. Know Your Numbers.

By M2|2018-02-16T16:58:12+00:00February 15th, 2018|Health care spending, Health Care Trends, Medicaid, Uncategorized|

Health Care Expenditures and You.

Know Your Numbers.

As a Valentine’s Day gift to health policy types, the economists in the Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS) published the National Health Expenditure Projections for 2017–26 and Health Affairs published an insightful analysis, as well. The storyline has been pretty consistent for the past few years and looking forward to 2026, several trends are intact:

The U.S. population is aging, which is pushing health cost trends higher.
Medicare spending is growing faster than private spending as Baby Boomers age out of private insurance plans through their employers and into Medicare.
A “higher share of aged and disabled enrollees” continues to contribute to faster growth in Medicaid spending.

The topline is that health spending growth, provided there are no significant policy changes, is expected to increase around 5 to 6 percent per year from 2017-2026. If this is estimate is correct, by 2026 health care will account for nearly 20 percent of the U.S. economy, compared to 17.9 percent in 2016. Digging deeper into the estimates reveals some items that may not have crossed your radar yet:

The rate of 5.5 percent per year from 2017-2016 is much less than the 7.3 percent average increase per year the U.S. experienced from 1990-2007.
Prices for medical goods and services saw historically low growth rates of just 1.1 percent per year between 2014 and 2016, and will average 2.5 percent per year in 2017–26.
The projected price increases for medical goods and services at 2.5 percent is much lower than the 3.3 percent average annual growth rate in 1990–2007.

These low price increases might seem surprising if you rely on general news reports, but it is really just a matter of thinking about which numbers are being reported, by whom, and about which group of people. For example, earlier this month, Express Scripts, a pharmaceutical benefits manager with more than 34 million members, published their annual Drug Trend Cost Report announcing a Record-Low Increase in Rx Spending in 2017. “Commercial plans saw the lowest increase in drug spending in 24 years – just 1.5%, compared with 3.8% in 2016,” explained the report. In Medicare, “total per-person spending increased 2.3%, with diabetes leading all classes.” In Medicaid, “total per-person spending increased 3.7%, with HIV leading all classes.” For the health insurance exchanges, “total per-person spending decreased 3.3%.” These numbers are just about drug spending.

If you look at yet another set of data, you get yet another picture. The Health Care Cost Institute (HCCI) 2016 Health Care Cost and Utilization Report explained, “Total spending per person is now growing at faster rates than prior years, with 4.6% growth in 2016.” The HCCI report is based on claims in employer-sponsored insurance sponsored by Aetna, Humana, Kaiser Permanente, and United Healthcare for 39 million members. The report produces a “per-person health care spending estimate” that only includes the amount the insurance companies paid and the cost-sharing amount the patients paid for those services. It does not include the premiums that consumers or employers paid, however.

The HCCI report agrees with the Express Scripts report, however, by noting, “In 2016, increased spending on outpatient services was the biggest contributor to the annual growth in total spending. This is a change from prior years. In 2014 and 2015, prescription drug spending was the biggest contributor to total spending growth.”

You can see that different reports, written for different audiences and looking at different cuts of the data, reflect different truths – and all are based in fact.

One Thing is For Sure, Patients Aren’t the Problem

The State Of Health Care Today: How Physicians, Consumers, and Employers View Health Care Costs, Outcomes, and Reform Efforts, a survey of more than 600 physicians, 500 employers, and 5,000 consumers published in January 2018 by Leavitt Partners, explains these dueling data sets fairly well, though my guess is that was not their intention. The report explains, “In general, physicians, employers, and consumers agree that the health care system requires change; however, they disagree on what changes are needed, who is responsible for making changes, and which reform efforts hold the most promise.” This makes sense because most people’s experience and understanding of health care is personal. It’s about my health care provider, my insurance coverage, my health care costs.

As this chart from the Leavitt report shows, when asked who or what is responsible for the problems with the U.S. health care system, patients mostly blame the government, physicians primarily blame insurance companies, and employers blame both government and insurance companies nearly equally. Patients seem to have escaped blame, however, at least for the more than 7,000 people in the Leavitt survey. Keep that in mind the next time you see a news report about health care expenditures and a recommended policy change. Know your numbers. It might change your policy life!

Payers and Providers Focused on Engagement, But Consumers’ Interest in Price Information Still Not Addressed

By M2|2018-02-07T21:24:42+00:00February 7th, 2018|Health Care Trends, Health Plans, Out-of-pocket spending, Physician-patient communication, Uncategorized|

Payers and Providers Focused on Engagement, But Consumers’ Interest in Price Information Still Not Addressed

With the rise in consumer engagement, health plans and providers are making investments in technology and services in order to provide patients with more useful and timely information. The ultimate goal is to help facilitate patient decision making, in an era of increased financial responsibility on the part of consumers. What are the results so far?

A recent white paper provided the results from a survey of nearly 90 payers, 250 providers (hospitals), and 800 consumers. The paper reveals “concerning gaps between what payers and providers think they’re achieving and what consumers are actually experiencing.”

80% of payers and 72% of providers said “investment in consumer engagement was a top priority” for them. Drivers of change included the transition to value-based care, competitive pressures, and “consumer demand for a more retail-like experience.”

However, while payers and providers are spending as much as a third of their health care information technology dollars on consumer engagement, nearly three-quarters of consumers polled told interviewers, “their experience with providers and health plans hasn’t improved—or has worsened—over the last two years.” Only 21% of consumers indicated their care experience had improved in the previous year.

Cost Information a Top Priority for Patients

Providers are focusing their investments in departments and functions that have a “high degree of personal interaction with patients,” such as ambulatory/outpatient services and inpatient services. Providers said the majority of their consumer-centric investments went toward software solutions (28%), followed by in-person and website investments (both 18%).

Payers, similarly, are focusing on customer service, member education, and marketing departments, with primary investments made in websites, call centers, software, and mobile apps.

Notably, cost information is a “top priority for patients, because they’re increasingly responsible for the cost of their medical care.” However, less than 20% of providers have developed cost-of-care education programs or post prices publicly. And among payers, 80% do not yet provide cost transparency tools.

This paper shines a spotlight on the continuing inability of patients to access the information they want most – pricing and cost data. Consumers are telling their providers and payers what they want; technology alone will not solve the problem. What will it take for the system to respond? Providers and payers are increasing their consumer engagement related to care management, especially with websites, apps and other technology. But as consumers have increased financial responsibility for their care, they will need better information on what their care will cost, ideally before they incur the care.

In general, there is an “alarming engagement gap between consumers, providers, and payers.” But the gap “can be closed if providers and payers would tailor experiences to what consumers want, promote adoption of services and technologies, and solicit feedback.”

While Most Consumers Want to Discuss Costs Before Receiving Treatment, Most Providers Do Not Bring Up Financing Options with Patients

By M2|2018-01-24T21:41:19+00:00January 24th, 2018|Health care spending, Health Care Trends, Insurance, Out-of-pocket spending, Physician-patient communication, Uncategorized|

While Most Consumers Want to Discuss Costs Before Receiving Treatment, Most Providers Do Not Bring Up Financing Options with Patients

Seventy-seven percent of health care consumers say it’s “important” or “very important” to know their costs before treatment; however, most providers are not satisfying these demands, according to a recent article in Healthcare Finance.

Only 18% of health care consumers said that “any of their providers had spoken to them, at any time, about patient financing options in the past two years.” The article summarizes the results of a survey conducted by ORC International and commissioned by patient financing company HealthFirst Financial.

The survey highlights consumers’ interest in financing options for health care services: 53% of the 1,011 U.S. adults surveyed would like to discuss financing options before they receive care, and 57% consider it important or very important that their provider offer ways to extend payments over time with no interest.

However, only 8% received zero- or low-interest financing from a provider. “These findings highlight a huge gap in what patients want and what hospitals, medical groups and other healthcare providers are delivering,” KaLynn Gates, HealthFirst Financial president and corporate counsel, says in the article. “Providers that care for the financial as well as clinical needs of their communities are much more likely to thrive in this era of rising out-of-pockets costs and growing competition for patients among traditional and non-traditional providers.”

Furthermore, “a full 40% of millennials 18 to 36 years old said they’d be very likely or likely to switch providers if a competitor offered low- or zero- interest financing for medical bills.” And among survey participants overall, 29% “said they’d move to different providers that offer attractive payment programs.”

Concerns about covering the cost of care exist in all income brackets; 42% are very concerned or concerned about their ability to pay out-of-pocket medical bills in the next two years, and the number increases to 54% for those with incomes of less than $35,000 a year. Among those with incomes of $100,000 or more annually, the number drops, but still, 24% in this bracket are very concerned or concerned.

Consumers are worried about their ability to pay for unexpected medical expenses; 53% of those surveyed expressed concern about the ability to pay a medical bill of less than $1,000; 35% worry about the ability to pay a bill of less than $500, and 16% are concerned about the ability to pay a bill of less than $250.

The survey was commissioned in order to “learn more about how consumers are coping with their medical expenses,” Gates says in the article. “Without providing and communicating these viable financing options, they are likely to delay care or switch providers to find financial help. In either case, providers will be hurt by those choices, and they need to develop a strategy to meet these consumers’ needs.”

Despite these findings, however, another survey, published recently in Health Affairs, finds that while most U.S. consumers support price shopping for health care services, most do not actually seek out information on pricing.

The findings also come at a time when states are taking various measures to improve price transparency for consumers. For example, Ohio has enacted a law aimed at informing patients what health care procedures will cost prior to receiving care. However, the law is currently in limbo, after criticism from hospital and physician groups, who claim the law would slow down access to care.

This HealthFirst survey reinforces what we’ve said in the past and what other studies have shown; for example, we blogged earlier this year about a study published in Health Affairs showing that physicians are missing opportunities for communication to help reduce patient costs. We’ve also written about employers sending patients to high-quality, bargain-priced providers; sometimes these providers are out of town, or out of state, yet employers are still able to save money with this approach, which points to inefficiencies in the health care system.

Clearly consumers need price options, and talking with physicians beforehand about costs would help inform patient decision-making. However, it’s noteworthy that this new survey emphasizes consumers’ desire for financing options; thus, consumers appear to be seeking to base their costs decisions not on actual total costs of services, but on monthly payment options. They are therefore not necessarily taking a savvy approach to overall costs.

One area of cost concern that the survey did not cover, but which is coming up soon for most patients, is the annual deductible that most health plan enrollees must meet. Each year, consumers must consider the re-setting of the deductible on January 1, and factor that into health care choices. This is a particular concern for patients with chronic illness, and it points all the more to the need for consumers to know their costs upfront, before services are provided.

Innovation Series, Part 2: App for Substance Abuse Disorders

By M2|2018-01-10T22:28:15+00:00January 10th, 2018|Health Care Trends, Innovation, Uncategorized, What do we pay for and why|

Scientific Breakthroughs: From Gene Therapy to Creative New Approaches to Cancer Surgery, Patients Stand to Benefit Dramatically, But How Will We Pay For This Innovation?

Innovation Series, Part 2: App for Substance Abuse Disorders

From gene therapy to a “pen” that can detect cancerous tissue in 10 seconds, we live in a time of amazing scientific breakthroughs. Advances in technology and our understanding of the genetic basis of disease are resulting in a range of innovations that hold the promise of improving our approaches to treatment – including things like new treatment options for rare diseases and innovations that are more consumer friendly.

Last year, for example, the U.S. Food and Drug Administration (FDA) approved for marketing the first mobile application to help treat substance use disorders. Yes, there’s an app for that! Cognitive behavioral therapy (CBT) is a kind of talk therapy that is a proven treatment for a number of mental health and substance abuse disorders. The newly approved app, developed by Pear Therapeutics, essentially makes CBT digital. The app, called reSET®, is designed to be used in conjunction with counseling and would be prescribed as appropriate by a health care provider.

Digital therapeutics are a hot space for health care start-ups and Pear Technologies is leading the way. Founder and CEO of the company, Corey McCann told CNBC, “This is the moment for digital therapeutics.” While not yet available for sale in the U.S., the clinical data that led to FDA approval is promising. The trial included more than 500 patients with substance use disorder (SUD) over a 12-week period. The randomized trial compared intensive face-to-face counseling – a standard treatment for SUD – to reSET® combined with a reduced amount of face-to-face counseling. Of the patients using reSET® who were dependent on stimulants, marijuana, cocaine, or alcohol, nearly 60% were abstinent at the end of the study period, while just 30% of patients who received only the face-to-face counseling were abstinent.

Of note, data from the clinical studies indicated no side effects from the device. If a prescription digital therapy improves patient outcomes and has few or no side effects, should it be reimbursed at a higher rate than a competing intervention that is safe but has more side effects for the patient? Meeting the patient where she or he is seems obvious, and prescription digital therapeutics are another great example of innovation that is consumer-focused.

What do all of these new and potentially lifesaving innovations mean for the health care system? As with any innovation that offers new hope for patients, there will likely be high demand, but that will have to be considered in the context of limited resources. We are witnessing significant new innovations and scientific advancement; the usual questions of access and how to pay for it will be dramatically amplified in this modern era, given the unprecedented price tags.

Health Care and the Tax Bill: ICYMI

By M2|2017-12-21T10:45:42+00:00December 20th, 2017|Health Care Trends, Uncategorized|

Health Care and the Tax Bill: ICYMI

The Tax Cuts and Jobs Act signed by President Trump December 20, 2017, The Wall Street Journal called “the most sweeping changes to the tax code in more than 30 years.” Tax policy is not my expertise, but we do love policy in general at M2, so this blog highlights some of the best pieces we have read so far on what the tax bill may mean for various parts of the health care system.

For a quick, but thoughtful primer, read Paige Winfield Cunningham’s The Health 202: It’s a happy holiday for medical tax breaks, but not Obamacare’s individual mandate. Cunningham gives a snapshot of health care interests including patients, hospitals, health systems, insurers, pharma companies, and academic medical centers.

Over at HealthcareDIVE, Shannon Muchmore provides a bit deeper dive on the bill’s effects across the health care industry. Steven Porter at HealthLeadersMedia also covers some technical provisions important to various industries that you might not have read about.

Brian Bowden blogged for The National Association of Counties before the final bill, but his take is still useful in thinking about how various provisions of the tax bill affect health care delivery at the county level.

As always, an excellent, deep analysis is provided by Health Affairs. Timothy Jost posted The Tax Bill and The Individual Mandate: What Happened, And What Does It Mean? and included this under-reported tidbit: “…the repeal of the individual mandate penalty will not by any means bring an end to the ACA. The numbers who lose coverage will likely be much smaller than the CBO estimates. S&P Global estimates that it is more likely that three to five million will lose coverage by 2027. The Medicaid expansions, which have accounted for a majority of the ACA’s coverage of the uninsured, will continue.”

(The short S&P piece is worth a read too. Click through!)

To close out, if you are dying to know about S Corps and “pass-through” entities, and what that has to do with the health care world, read through this well-rounded piece by Harris Meyer at Modern Healthcare. He covers how hospital systems might restructure employment agreements with providers and whether the new tax cut for small business might address access in rural areas.

We hope you learn something new from reading these pieces – we certainly did. Of course, feel free to let us know about any articles you think shed new light on health care and the tax bill.

ICYMI: The CVS-Aetna Proposed Merger Could be Public Health Rocket Fuel

By M2|2017-12-07T01:22:04+00:00December 6th, 2017|Health Care Trends, Health Disparities, Insurance, Public Health, Retail Health, Social Determinants of Health, Uncategorized|

ICYMI: The CVS-Aetna Proposed Merger Could be Public Health Rocket Fuel

Sunday, December 3, CVS Health announced it will acquire health insurer Aetna for $69 billion. Lowering the cost of care by enabling a broader range of treatment in retail clinic settings, of which CVS Health has more than 1,100 in 33 states, is one of the obvious rationales of the combination. But what struck me in the comments of the merging companies’ CEOs was how much they sound like public health professors. Social determinants of health? Health as a path to fulfillment? What have they done with the business people? In case you missed it…

Mark Bertolini Really Cares About the Whole Person

Aetna Chairman and CEO Mark T. Bertolini has been talking publicly for quite some time about the importance of thinking about people not as patients, but more holistically. In September, in an interview with Dennis Berman, the Wall Street Journal financial editor, he said, “We believe the only way to truly disrupt the cost of health care … is to go into the homes and meet the social determinants that are now driving as much as 60 percent of life expectancy of Americans.”

What Bertolini has had to say now that the merger is official is straight-up public health speak. On CNBC Monday morning, when explaining the vision of the merger, Bertolini sounded like a philosopher: “Most people,” he explained, “find their health is a barrier to the life they want to live.” Indeed.

Larry Merlo is Fixated on Unmet Need

Larry J. Merlo, President and CEO of CVS Health, reminded anyone who was paying attention something that we in public health have known for a long time, but surprised the CNBC reporters, “You look at chronic disease in this country today, about half of all Americans have at least one of those chronic diseases. It’s accounting for 80% of the health care costs.”

Merlo further explains, “there’s billions of dollars every year on unnecessary and avoidable spending because people are not following…care plans.” Merlo’s solution, to be executed in part with the announced merger, is to address the unmet need the traditional health care system is creating, but CVS Health knows first-hand because patients come through its doors with health care needs that aren’t being met.

We “lack the element of convenience and coordination…that is the unmet need we are talking about,” says Merlo.

We Are All Public Health

As a public health student, educator and professional, I am public health. This merger discussion shows we are all public health. Georges C. Benjamin, M.D. Executive Director, American Public Health Association wrote in 2015, “Today, the biggest threats to the health and longevity of Americans are preventable diseases. These are the diseases that are burying us in preventable suffering, as well as crippling our communities with mountains of avoidable medical bills. The root causes of many of these health threats are inextricably linked to the social determinants of health and the conditions that shape a person’s opportunity to attain good health and adopt healthy behaviors. These social determinants include access to safe housing, good jobs with living wages, quality education, affordable health care, nutritious foods, and safe places to be physically active. They also include racism, discrimination, and bias.”

To see such similar language from Mark Bertolini and Larry Merlo in the CVS-Aetna merger discussion to date shows that the leaders of what could become the largest health care company in the U.S. are thinking differently about the broken U.S. health care system. Near the end of the investor call about the merger, an analyst asked whether the combined entity planned to be a person’s primary care physician. Bertolini answered: “The real important part here is that you have to understand that almost 60% of Americans don’t have a regular doctor.”

When you connect these dots, you can really see the big picture come together. The CVS-AET vision is bigger than managing the pharmacy benefit.

Will it work? Hard to say at this early stage. Should consumers want it to work? Absolutely. A health care company with a public health lens that focuses on health well before a person shows up at the doctor and prioritizes convenience, coordination, and social determinants of health would be a welcome change for individuals, families, and employers. Score one for public health.

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