A survey of over 300 payer executives reveals what is keeping the industry leaders up at night.
The pace of change for payers has picked up significantly in the past year, causing executives in the industry to rethink their top challenges, according to a survey from HealthEdge.
Based on the answers of 312 respondents from a wide range of payer types, managing costs and operational efficiencies are now the priorities for health plans today. Those challenges ranked fourth and fifth, respectively, in the previous annual survey for 2021. The change, the survey states, can be attributed to an increase in claims volume after the COVID-19 pandemic, rising costs due to delays in care, and outdated administrative systems.
Conducted by brand intelligence platform PureSpectrum from April to May, the survey revealed common themes among payers, including "the move to modern systems to support digital transformations, the growing demand for real-time data access, and anticipated benefits of greater interoperability to help overcome the growing complexities and challenges of the health insurance industry."
Among the respondents, 46% cited managing costs as one of their top three challenges, while increasing interoperability (44%) and improving claims accuracy (40%) were the most popular answers for addressing the issue.
With executives relaying that claims are often not paid accurately the first time and that the cost per claim has increased, the survey notes that there is a heightened focus on advancing automation solutions that will cause health plans to revisit their payment integrity strategies.
Meanwhile, 41% of payer executives chose operational efficiencies as one of their top three challenges. The workforce shortage has forced payers to look for new ways to do more with fewer resources, the survey states, and that includes optimizing processes and increasing access to real-time data.
Member satisfaction and alignment of IT and business needs tied for third place for biggest challenges among the respondents, which was consistent with the previous year's survey.
Looking ahead, payer executives said they are aiming to increase quality, improve provider relationships, meet regulatory compliance requirements, and increase member satisfaction.
To tackle those goals, 53% of respondents plan to make significant investments in innovation, 53% plan to align the business and IT organizations towards common goals, 52% plan to improve engagement strategies, and 51% plan to modernize technology.
Though most of the organizational priorities remained similar to last year's survey, aligning the business and IT organizations towards common goals jumped from last to second place this year. The drastic shift is indicative of health plans' growing understanding of just how much technology plays a role in their business goals, the survey concluded.
Nearly 20 months after the mandate went into effect, hospitals continue to be noncompliant with providing clear pricing for patients.
Hospitals have made little progress on complying with the price transparency rule as compliance rates remain low, according to a report by PatientRightsAdvocate.org.
The latest Semi-Annual Hospital Price Transparency Compliance Reportreveals that just 16% of hospitals are adhering to the necessary requirements for providing pricing data for patients, nearly 20 months after the law went into effect on January 1, 2021.
The rule requires hospitals to post pricing information online through a comprehensive machine-readable file with all items and services they provide, as well as through a display of shoppable services in a consumer-friendly format.
Findings in the Compliance Report, which reviewed 2,000 hospitals, show there hasn't been much headway made on getting facilities to follow the mandate. Along with 16% of hospitals being noncompliant, the latest report uncovered that 5.1% did not post any standard charges at all. In the two previous reports released by PatientsRightsAdvocate.org, hospitals complied at a rate of 14.6% one year after the rule in February 2022, and at a rate of 5.6% six months after the rule in July 2021.
"It's alarming to see that progress on compliance with federal law on transparency has ground nearly to a stop," said Cynthia Fisher, founder and chairperson of PatientsRightsAdvocate.org.
The latest report also found that two of the largest health systems in the nation, HCA Healthcare and Ascension Health, are the worst perpetrators of the rule as none of their hospitals are compliant.
Meanwhile, another one of the biggest health systems, CommonSpirit Health, now features a compliance rate of 40.5%, which is up from just one of 88 hospitals being compliant in the February report.
Despite the low compliance rates, only two hospitals have been penalized to date—Northside Hospital Atlanta to the tune of a $883,180 fine, and Northside Hospital Cherokee, which received a $214,320 fine. The report highlights that after the two hospitals were issued the fines on June 7 of this year, they both updated their standard charges files and came into full compliance by July 1.
Fisher believes the quickest way to get hospitals on board with the rule is with stronger enforcement.
"With enforcement, fines, and transparent hospital accountability we will see the power shift to healthcare consumers and employers to lower costs," Fisher said. In this report we have outlined more than 100 hospitals that HHS could fine today based on criteria applied to the two hospitals they've previously fined. That is a great place to start."
Initially introduced as Bind in 2016, Surest eliminates deductibles and coinsurance while offering upfront pricing.
The payer giant revealed the plan will be available nationwide to employers with self-funded plans, as well as to fully insured employers with 51 or more employees in 11 states (Arizona, Florida, Georgia, Michigan, Minnesota, Missouri, Ohio, South Carolina, Tennessee, Utah, and Virginia). UnitedHealthcare stated it also intends to offer the plan in up to five more states by the end of the year.
More than 150 employers are currently using Surest, with more planning to add the program ahead of the 2023 open enrollment period.
"People and employers are looking for a simpler and more sustainable health care plan," said Alison Richards, CEO of Surest. "Our new brand name, Surest, helps convey the idea of clarity, confidence and control our members have with their plan."
The plan's primary benefit is its lack of deductibles or coinsurance, with transparent cost data available through the Surest app. According to UnitedHealthcare, Surest members utilized high-quality providers with the lowest price for procedures more than half the time and had 6% fewer emergency department visits. Virtual visit use, on the other hand, was 10 times higher.
Affordability is another benefit UnitedHealthcare is striving for with Surest. Employers that introduced the plan saw costs up to 15% less per member per month compared to high-deductible plans, while out-of-pocket costs for members were 44% less.
The New York surgeon's bid against the No Surprises Act for being unconstitutional was tossed as the federal law was upheld.
A federal judge denied a New York doctor's lawsuit against the No Surprises Act, dismissing the request for a preliminary injunction and ruling that the law is constitutional.
U.S. District Judge Ann Donnelly rejected surgeon Daniel Haller's injunction to blow the law, which was filed on December 31, 2021, the day before the No Surprises Act took effect.
The surprise billing ban was put in place to protect patients from receiving unforeseen bills for out-of-network and emergency services after receiving treatment.
Haller and his private practice, which performs procedures on patients who are admitted after an emergency department visit, alleged in the complaint that the law is unconstitutional and deprives providers the right to be paid a reasonable payment for their services due to the independent dispute resolution process (IDR). The arbitration is meant to keep patients out of negotiations between providers and insurers as the parties attempt to reach agreement on the payment for services.
Haller claims that 78% of his patients are covered by health plans with which the practice has no contractual relationship, making the majority of his patients out-of-network.
However, Donnelly ruled that Haller and his practice's due process claim was "unripe" and did not carry jurisdiction.
"The plaintiffs do not allege that they have participated in an arbitration, much less that the IDR process resulted in a payment amount below the reasonable value. At the time of oral argument—almost six months after the Act went into effect—the plaintiffs could not say whether they had participated in the IDR process," Donnelly wrote in the ruling. "They do not allege that the IDR process has caused any concrete harm, so their claims of constitutional injury are speculative."
HHS released a report showing 5.2 million people have gained health insurance since 2020 as a result of the Biden administration's efforts to expand coverage.
The national uninsured rate reached a record-low of 8% in the first quarter of the year, according to a report by HHS.
The report examines data from the National Health Interview Survey and the American Community Survey to analyze changes in health insurance coverage from January to March.
Besting the previous low of 9% in 2016, the new all-time mark comes after 5.2 million people gained insurance coverage since 2020, HHS announced. The progress aligns with the Biden administration's efforts to expand coverage and lower costs through the American Rescue Plan, along with the continuous enrolment provision and state expansions with Medicaid.
"As we move forward, the Department of Health and Human Services will continue to do everything we can to protect, expand, and strengthen the programs that provide the quality, affordable health care Americans rely on and deserve," HHS secretary Xavier Becerra said in a statement.
"And I'm hopeful that with Congressional action we can continue the work to lower costs for more Americans by both extending the enhanced Affordable Care Act tax credits that have helped drive the uninsured rate to an all-time low and increasing the affordability of prescription drugs for Medicare beneficiaries -- reducing their cost sharing and allowing Medicare to negotiate a better deal on prescription drug prices."
Other findings in the report include that the uninsured rate for adults aged 18-64 declined from 14.5% in late 2020 to 11.8% in the first quarter of 2022. For children aged 0-17, the uninsured rate dropped from 6.4% in 2020 to 3.7% this year after previously increasing during 2019 and 2020.
Meanwhile, changes in uninsured rates from 2020 to 2022 were largest among people with income below 100% of the federal poverty line (FPL) and income between 200% and 400% FPL.
A HealthCare.com analysis of federal data examines emergency department statistics related to diagnoses, payer types, costs, and income level.
Health insurance type plays a role in the reason for an emergency department visit, according to analysis by HealthCare.com.
The researchtakes a look at federal dataon emergency department visits in 2018 and finds the four payer types—private, Medicare, Medicaid, and self-pay—are differentiators for trips to the ER.
Among the top 15 treat-and-release diagnoses, the four payer types have in common just six conditions: nonspecific chest pain, abdominal pain/diarrhea, superficial injury, musculoskeletal pain, urinary tract infections, and sprains and strains.
Meanwhile, five conditions behind treat-and-release emergency department visits are among the top 15 for only one payer type. Headaches are among the top 15 for private insurance, whereas teeth and gum disorders are among the top 15 for self-payers, chronic obstructive pulmonary disease is among the top 15 for Medicare, and pregnancy nausea and ear infections are among the top 15 for Medicaid.
The most common treat-and-release ER visits for all payers were for abdominal pain, respiratory infection, and chest pain.
Hospitals in the U.S. saw 143.5 million emergency department visits in 2018, with 14% of visits resulting in hospital admission and 86% resulting in treatment and release. However, emergency department visits by privately insured and self-pay patients declined from 2009-2018, while visits by those insured by Medicare and Medicaid increased, according to HealthCare.com.
Part of the reason for the changes in number of ER visits could be due to the differing costs of a trip based on insurance type.
Additional analysis by HealthCare.com of 2017 federal datafinds Medicare patients have an average cost of $660 per visit, followed by private insurance at $560, self-pay at $460, and Medicaid at $420.
Income level is also a factor, with the research uncovering that patients in the lowest income quartile visit ERs at a rate of 641 per 1,000 people, compared to 281 per 1,000 people for the highest income quartile.
When it comes to outcomes, it's clear that having insurance allows individuals to be more willing to seek out necessary care and make a trip to the emergency department.
"We know that expanding health insurance leads to better health and financial security for families," Ben Sommers, HHS deputy assistant secretary Ben Sommers told HealthCare.com.
"The emergency department is one area where disparities can show up prominently. That's why the department's focus has been making sure that we have as good coverage and access as we can, and we've seen that in near historic lows in the uninsured rate in the past year, and the record high of people enrolled in Affordable Care Act coverage and Medicaid. If you don't have coverage you'll face big bills and risk not getting the care you need."
The company co-founder and president will step into the role vacated by founder Vivek Garipalli as part of a succession plan.
Changes are ahead for Clover Health, which announced president and co-founder Andrew Toy will be the new CEO from the start of next year.
Toy will transition into the role while current CEO and founder Vivek Garipalli continues his responsibilities as executive chairperson and works closely with Toy in what the company is calling an "inherently symbiotic" relationship.
Garipalli revealed the move is the culmination of a succession plan Clover has had in place since Toy joined as CTO and led the development of Clover Assistant.
"Andrew is a unique technologist and business strategist," Garipalli said in a statement. "He's a true founder in every sense of the word — having built companies from scratch, he has an abundance of grit needed to solve the hardest problems in healthcare. He has the fastest learning speed of anyone I've ever met, and I believe his transition to CEO will give Clover a strategic edge overnight that will only continue to pay dividends for our mission moving forward."
Toy stated Garipalli will continue at the company in a more strategic fashion.
"While Vivek would no doubt continue to be an incredibly successful CEO of Clover for years to come, I know that his true passion is big picture strategy and the rapid, scrappy uncertainty that exists in the building stages of a company," Toy said. "In this more strategic role, he can continue to lean into his strengths and bring outsized value to Clover and to me as CEO."
Clover announced the executive move on the same day it released its second quarter financial report, which showed a significant rise in year-over-year revenue dampened by skyrocketing operating expenses.
Second quarter revenue was $846.70 million, compared to $412.47 million over the same period in 2021, but total operating expenses also shot up from $594.33 million in Q2 of last year to $949.25 million for this year.
The result was a net loss of $104.18 million, which is down from the $317.61 million lost in the second quarter of 2021.
"Our focus on building a sustainable, intelligent growth engine has led to a reduction in MCRs and improvement in operational efficiencies which we believe is the foundation of our progress toward profitability." Toy said in a statement.
He added: "Our technology platform is moving from strength to strength as Clover Assistant penetration continues to show significant growth. We believe there is tremendous opportunity and potential to continue iterating and advancing Clover Assistant's clinical capabilities. We believe each improvement supports physicians in catching and treating conditions earlier to increase the health and well-being of their patients while simultaneously reducing costs for the healthcare system."
The group is asking CMS to provide an appropriate timeline for layering new surprise billing requirements, which have created administrative burden for providers.
The Medical Group Management Association (MGMA) is pushing HHS and CMS to give providers at least six months' notice before enforcing any additional requirements for the No Surprises Act.
Several aspects of the surprise billing mandate went into effect on January 1 of this year, including federal protections against balance billing, uninsured and self-pay good faith estimate (GFE) requirements, continuity of care protections, and provider directory requirements. While the policies have been beneficial for patients, MGMA says the requirements have created administrative burden for providers as the interim final rules were published with minimal time before implementation.
With HHS and CMS indicating additional rulemaking will be published related to the advanced explanation of benefits (AEOB) requirements, continuity of care protections, and provider directory requirements, MGMA recommends an appropriate timeline for implementation and enforcement.
"MGMA recognizes the statutory requirements and the urgency to prevent any further delays in patient access to this information, however, we believe that existing cost estimate information provided by both insurers and practices can adequately ensure patients are aware of cost estimate information prior to the implementation of the AEOB requirements," the group writes in a letter to HHS secretary Xavier Becerra and CMS administrator Chiquita Brooks-LaSure.
"Similarly, group practices have been complying with the continuity of care protections and provider directory requirements in a good faith, reasonable effort according to the statute since January 1, 2022."
MGMA cites a recent member educational webinar in which 58.2% of respondents said additional guidance on state vs. federal surprise billing requirements is necessary, while 54.2% wanted additional guidance on the uninsured and self-pay GFE requirements, and 41.2% wanted additional guidance on the prohibition on balance billing.
Additionally, MGMA is asking HHS and CMS to delay the implementation of the convening and co-provider requirements related to the uninsured and self-pay GFE requirements, set to take effect on January 1, 2023.
Over 60% of MGMA members need more guidance on the convening and co-provider requirements before they go into effect to properly implement the policy, the group states.
"These new mandates require significant time to understand and implement," MGMA writes. "Group practices are currently facing significant staffing shortages, record-breaking inflation, and significant reductions in Medicare payment."
The health solutions company reported net income of $2.95 billion, a significant increase from the $2.78 billion posted in the second quarter of 2021, while revenue rose to $80.64 billion, compared to $72.62 billion over the same period last year.
For the year, CVS Health has brought in $157.5 billion in total revenue, up 11% from 2021, illustrating that the company's strategy of adding more health services is delivering results.
"Despite a challenging economic environment, our differentiated business model helped drive strong results this quarter, with significant revenue growth across all of our business segments," CVS Health president and CEO Karen Lynch said in a statement. "The continued success of our foundational businesses accelerated our strategy to expand access to health services and help consumers navigate to the best site of care."
CVS Health also revealed its plans of expanding individual coverage under the Affordable Care Act to four new states in 2023.
The news was delivered in the company's earnings call, in which Lynch announced the company's Medicare Advantage membership hit the 2 million milestone in the second quarter, including dual eligibles.
"As we continue to build our individual exchange business, we're on track to expand coverage where we currently have individual exchange offerings and are obtaining final approval to add four new states to our portfolio, bringing our total to 12 states," Lynch said.
Both hospital groups stressed the importance of the waivers for providing care to patients during the COVID-19 pandemic, as well as allowing providers the necessary flexibility during a difficult climate rife with challenges such as the labor shortage.
In the letter to HHS secretary Xavier Becerra, FAH urged for the PHE to be renewed another 90 days when it expires in October, with another 90 day-day extension in the works if necessary. AHA, meanwhile, asked for the PHE to be continued without specifying a renewal length in their penned response.
Pointing to the waivers specifically, AHA outlined several benefits for patients and providers, including hospital-bed flexibilities and relief from administrative burdens.
"Additionally, the PHE declaration has allowed for several critical coverage and hospital payment policies, including a 20% DRG add-on payment for COVID-19 patients, new technology add-on payments for new COVID-19 therapeutics, an enhanced Federal Medical Assistance Percentage (FMAP) rate of 6.2% for states," AHA wrote. "Ending the PHE prematurely would place our hospitals in an extremely challenging position and would directly affect our ability to care for our patients and communities."
AHA cited responses from hospitals and health systems to their survey, which showed that 93% of respondents said their hospitals would be impacted if the waivers were rolled back, with 60% indicating it would be significant. Another 89% said they still depend on the flexibilities provided by the waivers to deliver needed care.
FAH argued that the waivers have transformed the healthcare system by encouraging new technologies to modernize delivery of care and accelerating adoption of alternative care models.
In the letter, FAH also listed key waivers and policies that it wants made permanent, spanning remote services, clinical services, lab services, discharge planning, behavioral health, physician self-referral, workforce, and increased capacity.
"Indeed, the PHE has already served as a bridge to CMS' efforts, which we strongly endorse, to transform certain temporary waivers into permanent Medicare policy, some of which may require Congressional action to avoid any disruptions," FAH stated.
