The payer giant has signed contracts with four health systems in a milestone initiative.
Blue Cross Blue Shield of Massachusetts (BCBSMA) announced value-based contracts with four health systems with the aim of reducing racial and ethnic inequities in care.
The health insurer said the agreements are the first in the state of Massachusetts, as well as among the first in the nation, to create a financial payment model that rewards providers for improving equity measures.
The four Massachusetts health systems to sign on are Steward Healthcare Network, Beth Israel Lahey health, Mass General Brigham, and Boston Accountable Care Organization. In total, the health systems provide care to more than 550,000 Blue Cross members.
"For more than a decade, we've collaborated with physicians and hospitals via our Alternative Quality Contract, which replaced the fee-for-service model and instead rewards clinicians' efforts to improve the quality and value of the care they deliver," Andrew Dreyfus, CEO of Blue Cross, said in a statement.
"We're now building on that model to help health systems in our value-based payment programs improve equity. As a health plan, this is the most important tool we have to work toward a health system that provides affordable, quality and equitable care to all our members."
At the start, the agreements will focus on measuring and rewarding equity in care in multiple clinical areas with inequities, such as colorectal cancer screenings, care for diabetes, and blood pressure control. As the payment model evolves, more categories will be included.
The Center for Healthcare Organization and Innovation Research at the UC Berkeley School of Public Health will conduct an independent external evaluation of the contracts and publish the effects of their effectiveness.
Whopping statistics show how quickly payers responded to the price transparency rule this year, compared to hospitals.
When it comes to price transparency rules, the hospital regulation has been in place four times longer than the payer version, yet the difference in the data available for the two is miles apart.
More specifically, enough miles that it would be the equivalent of traveling from Earth to Neptune and back 14 times, according to Turquoise Health. The price transparency data company put together numbers that illustrate how much payer pricing information is out there in its 2022 year in review.
Since the hospital price transparency rule went into effect on January 1, 2021, Turquoise Health has collected about three terabytes of hospital data. That figure pales in comparison to the 630 terabytes of payer data since the payer rule arrived on the scene July 1, 2022. If you're calculating at home, that's a gargantuan 20,090% increase in size from the hospital data.
Those 630 terabytes consist of 78 billion payer price records, with 163 total number of payers in Turquoise Health's database. If you decided to manually count the rows of data after payers refresh their data monthly, the company says it would take a mind-boggling 76,104 decades.
Despite the size of all that data, payers haven't yet figured out the best way to display it for consumers. Turquoise Health found payer machine-readable files that varied 50-100 times in size.
"The takeaway: payers can drastically reduce their file sizes by taking measures to ensure smart architecture," Turquoise Health said. "For example, using references to provider groups within rates, as opposed to duplicating the provider group data within each rate shrinks the overall file sizes."
A survey reveals what frustrates Americans about the financial experience after receiving care.
Medical bills are more likely to come across as confusing than straightforward to patients, according to a YouGov survey commissioned by revenue cycle firm AKASA.
Responses were fielded from 2,206 Americans between March 9 and March 14, 2022, to gauge patient burden with the billing experience. The results show that patients are confused by bills in general and have frustrations with specific parts of the billing process.
Nearly one in five respondents (19%) said bills were extremely confusing, while another 19% found bills somewhat confusing. On the other end of the spectrum, 11% answered that bills were not confusing at all and 14% leaned towards bills not being confusing. The most chosen answer, by 37% of respondents, was neutrality on the confusion of bills.
Amy Raymond, VP of revenue cycle operations at AKASA, said of the findings: "The rise of high-deductible health plans, the uncertainty of what's being billed, the complexities of in- and out-of-network charges, and how much patients are on the hook for makes understanding and managing medical bills challenging for many families."
Additionally, the survey asked respondents what parts of the financial experience after seeking medical care frustrates them the most.
Most of the respondents (29%) identified being able to understand what they're being billed for as the biggest source of frustration, while 27% chose uncertainty on if they can pay the bill. Not getting the bill until weeks after they received service (24%) and uncertainty if the final bill will be consistent with the estimate of responsibility (20%) rounded out the selections.
Finally, the survey asked respondents what would be most helpful in allowing them to understand how much they are expected to pay for care or services. More than a quarter (27%) chose a call before the procedure from the provider to walk through what's expected and payment plan options as the most helpful.
That option was followed by an online calculator to help determine cost ranges for care or procedures (12%), an email from the insurance company to walk through the bill after receiving care or services (11%), a call from the insurance company for the same assistance (9%), access to live online customer service through their insurer's website (9%), and a call from the provider to walk through the bill after receiving care or services. Nearly another quarter (24%) of respondents chose none of the above.
"These results show that medical billing is still a black box to patients," Raymond said. "The onus is on healthcare organizations—both providers and insurers—to make medical billing less painful for patients, who may fear going into debt and avoid seeking out care. One critical tool healthcare leaders can leverage to course correct on medical billing and make it more seamless for patients is automation."
The American Hospital Association (AHA) and Better Medicare Alliance (BMA) both support the agency's effort to improve Medicare Advantage (MA).
In an attempt to reform MA, CMS released a proposed rule that aims to streamline prior authorization, promote health equity, and curb deceptive marketing.
The Biden administration has shown a commitment to increasing oversight of MA plans and the proposed rule would better align MA with traditional Medicare with new provisions and policies.
Building on a separate proposal by CMS, the new rule strengthens prior authorization protections for patients and makes the administrative process more efficient. It would require that a granted prior authorization approval remain valid for an enrollee's entire course of treatment, require MA plans to annually review utilization management policies, and require coverage determinations be reviewed by professionals with relevant expertise.
The rule would also tackle misleading marketing by MA plans by prohibiting ads that don't mention a specific plan name, as well as ads that use words, imagery, language, or logos that can be confusing and deceptive. MA marketing has been scrutinized by lawmakers for using tactics that are harmful to beneficiaries.
Additionally, the proposed rule would put forward a health equity index for MA star ratings and implement a key provision of the Inflation Reduction Act to lower prescription drugs costs for low-income Medicare beneficiaries.
"From streamlining prior authorization to cracking down on misleading marketing, we are committed to ensuring that everyone can have peace of mind and get the health care they need," HHS Secretary Xavier Becerra said.
The AHA commended CMS for taking steps to increase oversight of MA plans.
"The AHA has previously raised concerns about the negative effects of certain Medicare Advantage practices and policies that have the potential to directly harm patients through unnecessary care delays or outright denial of covered services," the AHA stated. "CMS' proposed rule includes helpful provisions to ensure more consistency between Medicare Advantage and traditional Medicare by curtailing overly restrictive policies that can impede access to care and add cost and burden to the health care system."
Meanwhile, the BMA, an MA advocacy group, also showed their support for the proposed rule.
Mary Beth Donahue, president and CEO of BMA, said in a statement: "Better Medicare Alliance commends CMS's work on delivering a thoughtful, comprehensive proposed rule and appreciates the agency's engagement with stakeholders across the health care spectrum ahead of the rulemaking process."
New research finds that a significant rise in high-intensity billing since 2006 isn't solely due to coding practices.
High-intensity billing for treat-and-release emergency department (ED) visits has increased notably over the past 14 years, according to a study published in Health Affairs.
Researchers used the Nationwide Emergency Department Sample to examine treat-and-release ED visits and found that 19.2% of those visits exhibited high-intensity billing in 2019—a sharp rise from 4.8% in 2006.
However, the authors state that 47% of the growth in high-intensity billing was expected due to the changes in administrative measures for patient case mix and care services as data of later years showed higher proportions of older patients and those with more serious conditions.
While the researchers admit that the remainder of the growth may involve upcoding, the study highlights that coding practices alone aren't to blame. Providers have taken criticism from payers for their role in inflating high-intensity billing over recent years.
"Coding practices have become one element of an ongoing tug-of-war between payers and providers," the authors wrote.
The study also points to there being more clinical pathways and observation care for patients with more common but potentially serious issues, while more urgent care clinics are claiming low-acuity patients. With hospitals facing pressure to reduce spending, they have greater incentive to emphasize ED visits over low-value admissions.
The authors conclude that "future policy work must address controversies around high-intensity billing" given the context of shifting emergency care landscape, but payers must also recognize that patients are getting older and have more chronic conditions.
"In addressing potentially inappropriate billing practices, payers must acknowledge the increasing complexity of care for a treat-and-release ED patient population composed of older, more comorbid, and clinically undifferentiated patients, to avoid hospitalization, ensure safe discharge, and improve acute care outcomes," the study states.
Multiple payers are the target of concern in a letter to CMS urging for an investigation into program participants.
A group of House and Senate Democrats are asking CMS to boot organizations that have committed fraud out of the ACO REACH program before they "further encroach on the Medicare system."
In a letter to CMS administrator Chiquita Brooks-LaSure, the lawmakers, led by Senator Elizabeth Warren (D-Mass.) and Representative Pramila Jayapal (D-Wash.), express their concern that payers will continue "ripping off taxpayers" with their participation in the new payment model, which will start on January 1, 2023.
The ACO REACHprogram is replacing the Global and Professional Direct Contracting (GPDC) model, with participants of GDPC allowed to enroll as ACOs if they maintain a strong compliance record and agree to meet the requirement of the model. However, the lawmakers point out that participants have troubling records, including notable health insurers Centene, Humana, Cigna, Clover Health, and Bright Health.
A preliminary review of the direct contracting entities (DCEs) by Physicians for a National health Program (PNHP) found that at least 10 current GPDC participants had documented cases of fraud and abuse.
Centene, for example, paid $97 million in 2021 to settle allegations of "duplicated and inflated claims" to the Department of Veterans Affairs. The payer giant's pharmacy benefit managers also allegedly overcharged state Medicaid programs on prescription drugs last year, resulting in settlements that totaled more than $260 million.
"The ability of organizations with known histories of fraud and abuse to take part in the program increases the risks for Medicare beneficiaries, and raises concerns that CMS screening procedures for participants are inadequate, putting taxpayer dollars at risk" the lawmakers write.
The letter calls on CMS to address these issues and protect patients before the ACO REACH program begins by stopping the participation of the organizations with histories of fraud and removing DCEs that do not meet the new standards for the program.
In addition, the lawmakers want written answers to multiple questions by January 16, 2023, such as how organizations that have been accepted into GPDC been screened for acceptance into ACO REACH, and what methods CMS will use to screen ACO REACH participants.
Blue Cross Blue Shield of Massachusetts is expanding its mental health provider network to keep up with the rise in demand.
The use of in-person and virtual visits for mental health have doubled since 2019, according to new data by Blue Cross Blue Shield of Massachusetts (BCBSMA).
The payer's numbers are reflective of a nationwide trend that sees a greater demand for mental health treatment since the beginning of the COVID-19 pandemic.
In response to that demand, BCBSMA announced it will further expand its mental health provider network, which includes partnering with national mental health provider groups to have more clinicians available and a greater variety of services.
BCBSMA highlighted that its mental health provider network has expanded by 46% over the past five years and now features almost 18,000 clinicians.
"As the need for mental health services continues to grow, access to convenient and affordable care is critical," Andrew Dreyfus, Blue Cross president and CEO, said in a statement. "By expanding and diversifying our mental health network, we're ensuring that our members are able to find and receive the high-quality care they need, when they need it."
One of the partnerships is with Talkiatry, a telehealth psychiatric therapy provider, which joins the four other in-person and virtual mental health providers BCBSMA partnered with earlier this year.
The health insurer also said it is adding two specialty mental health providers: And Still We Rise, which offers culturally affirming practices, and DynamiCare, focused on substance abuse.
"It's not enough to simply expand our network with more clinicians," Greg Harris, a psychiatrist and senior medical director for mental health at Blue Cross, stated.
"We want to ensure we have the right clinicians to treat members' specific needs – and that includes specialized treatment and approaches. When it comes to mental health treatment, one size does not fit all. We're committed to building a network of practitioners to serve a diverse array of needs for children, adolescents and adults."
The rule aims to streamline the administrative process by requiring certain payers to implement electronic prior authorization.
Medical associations and payer groups are reacting approvingly to CMS' proposed rule which would require Medicare Advantage (MA) plans and other payers to implement electronic prior authorization.
The rule is part of the Biden administration's initiative to increase health data exchange and investing in interoperability, CMS announced. It would apply to MA organizations, state Medicaid and Children's Health Insurance Program (CHIP) agencies, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan Issuers on the Federally-facilitated Exchanges.
"The prior authorization and interoperability proposals we are announcing today would streamline the prior authorization process and promote health care data sharing to improve the care experience across providers, patients, and caregivers – helping us to address avoidable delays in patient care and achieve better health outcomes for all," said CMS administrator Chiquita Brooks-LaSure.
The proposed rule would require the implementation of a Health Level 7 Fast Healthcare Interoperability Resources standard Application Programming Interface to support electronic prior authorization, payers to give a reason when denying requests, publicly reporting certain prior authorization metrics, and sending decisions within 72 hours for expedited requests and seven calendar days for standard requests—twice as fast as the existing MA response time limit.
CMS stated that the rule would save providers more than $15 billion over a 10-year period.
The response to the rule from both provider and payer groups has been positive, ranging from the American Hospital Association (AHA) to MA advocacy group Better Medicare Alliance (BMA).
AHA: "The AHA commends CMS for taking important steps to remove inappropriate barriers to patient care by streamlining the prior authorization process for some health insurance plans. Hospitals and health systems especially appreciate that CMS included Medicare Advantage plans in these requirements, as the AHA has urged. Prior authorization is often used in a manner that results in dangerous delays in care for patients, burdens health care providers and adds unnecessary costs to the health care system."
Medical Group Management Association: "MGMA is encouraged to see that CMS heeded our call to include Medicare Advantage plans in the scope of this proposed rule. An alarming number of medical groups report completing prior authorization requests via paper forms, over the phone, or through varying proprietary online payer portals. The onerous methods of completing these requests, coupled with the increasing volume is unsustainable. An electronic prior authorization program, if implemented appropriately, has the potential to alleviate administrative burden and allow practices to reinvest resources in patient care. This is a positive step forward for both medical groups and the patients they treat."
America's Health Insurance Plans: "AHIP's Fast PATH demonstration showed that electronic processes for prior authorization are essential for ensuring that patients receive swift, evidence-based care that improves value and reduces administrative burdens for everyone. This proposed rule would require clinicians and hospitals to adopt electronic prior authorization to meet certain quality measures, ensuring that we are all incentivized to work together for a better patient and clinician experience that improves satisfaction, efficiency, and affordability for everyone."
BMA: "Better Medicare Alliance thanks CMS for their leadership in modernizing the prior authorization process for beneficiaries. While we continue to review the proposed rule in closer detail, we believe it complements our goals of protecting prior authorization's essential function in coordinating safe, effective, high-value care while also building on the Medicare Advantage community's work streamlining this clinical tool to better serve its 30 million diverse enrollees. We additionally welcome the proposed rule's data exchange provisions, which will further improve communication between health plans, providers, and beneficiaries."
A survey of providers highlights their experiences and satisfaction with patient payment solutions.
While most providers have seen an implementation of new patient payment solutions in the past five years, the platforms still have room for improvement for both providers and patients, according to a survey by Bank of America and The Strawhecker Group.
Over 650 providers in the U.S. were surveyed, sharing their experiences with patient payment solutions and what more they want out of the platforms.
Only 58% of respondents reported high satisfaction with their current patient payment systems, with 30% saying the implementations were not successful.
Providers know that patients expect payment methods that are both convenient and efficient, and if they can't get that with their current provider, they may find a new one.
That is why the surveyed providers pointed to improvements to patient payment solutions that would make it easier for patients to use, such as better integrations of software and patient collections workflow, better payment terminal functionality, and the addition of other digital payment forms like Apple Pay.
According to the respondents, 72% of patients used credit or debit cards for their last payment, with 54% interested in email or text payment notifications and 43% interested in automated digital payments.
Providers also want to make their own lives easier, which includes fully integrating patient payment solutions with their electronic health records or revenue cycle software—something only 33% of respondents reported having. More than half (58%) said the seamlessness of their current systems could be improved.
Other improvements on providers' wish list were patient privacy and HIPAA-compliance—the most frequently mentioned crucial platform feature—data safety, improved efficiencies and cost reductions, and confidence from a patient payment solutions partner they can trust.
The majority of providers (78%) said they would feel more confident in a solution provided by a bank, while 66% said they would feel more confident with a solution provided by a "sizeable financial brand."
Software investment and particularly cycle management is a priority for providers going forward, research from Bain & Company and KLAS found.
The report revealed that 45% of providers accelerated software investment over the past year, while more than 95% expect to make new software investments over the next year. Revenue cycle management was at the top of the list for where those investments will go.
The Senate Finance Committee is calling for MA plans to get their provider directories in order with the aim of improving mental health parity in Medicare and Medicaid.
Senators released a discussion draft with policiesto put access to mental health and substance use disorder services on the same level with physical healthcare — the fifth and final legislative draft the committee has released focusing on its bipartisan initiative of advancing mental health.
"Too often the notion of mental health parity falls short of reality," Senate Finance Committee chair Ron Wyden said in a statement. "These policies represent the first step towards addressing the mental health parity and ghost network challenges that I intend to build on in the coming months -- especially the challenges I hear about consistently from families at home who aren't able to find available mental health professionals covered in their insurance networks."
The policies include codifying existing requirements for MA plans to maintain updated provider contact information, whether a provider is accepting new patients, and in-network status changes within two days.
The discussion draft also calls for a Government Accountability Office study on the differences in enrollee cost-sharing and utilization management between behavioral and non-behavioral health services in MA and compared to free-for-service Medicare.
"These proposals will help us gather additional data and increase transparency to ensure Medicare beneficiaries have access to affordable mental health services, on par with their access to physical health services," committee ranking member Mike Crapo said.
