The HHS points to expanded overage and lower healthcare costs in the first year of the Biden Administration.
On the 12th anniversary of the Affordable Care Act (ACA), a new report by the U.S. Department of Health and Human Services (HHS) details record-setting enrollment under the Biden administration.
Overall, 14.5 million people signed up nationwide for healthcare coverage—a 21% increase from the previous year—while nearly six million new customers joined as part of the special enrollment period and the open enrollment period during the first full year of the Biden administration, according to the report.
Additionally, the HHS highlighted that 2.8 million more consumers are receiving tax credits to assist with coverage premium costs in 2022 compared to 2021, as a result of President Biden's American Rescue Plan (ARP).
"On the 12th Anniversary of the ACA, it is clear that the Affordable Care Act and the American Rescue Plan are working to expand access to healthcare coverage and have been critical to advancing health equity," CMS administrator Chiquita Brooks-LaSure said ina statement.
"The Biden-Harris administration's ARP subsidies were successful and ensured that more marketplace consumers than ever had access to quality, affordable healthcare, and the peace of mind that comes with having healthcare coverage that best fits their needs."
The ARP has helped lower healthcare costs for many, according to the HHS report, with four in five people able to find a plan for $10 or less per month. After the ACA subsidies during the open enrollment period, 28% of enrollees can select coverage for $10 or less. Absent the ARP, the average monthly premium after tax credits would have been $59 per month higher.
Following the implementation of the ARP and the 2021 special enrollment period, the uninsured rate reportedly fell to 8.9% for the third quarter, down from 10.3% for the last quarter of 2020.
Meanwhile, 18.7 million adults are now covered across 39 states through Medicaid expansion, according to the report.
"President Biden promised to build on the success of the Affordable Care Act, and just one year into his administration, we have already broken records with all-time high enrollment numbers and all-time low prices," said HHS secretary Xavier Becerra. "We will continue working to deliver on that promise until we make healthcare a right for all."
In a letter to the Office of the National Coordinator for Health Information Technology (ONC), the American Hospital Association (AHA) commented on prior authorization rulemaking.
The AHA is stating its support for streamlined prior authorization to the ONC but wants the division to test any potential changes in standards before applying regulations in the administrative process.
While acknowledging the negative effects prior authorization can have on providers and patients, the AHA urged in a letter to Micky Tripathi, national coordinator for health information technology, that the ONC be cautious as it attempts to create solutions.
In January, the ONC released a request for information to seek comment on electronic prior authorization standards, implementation specifications, and certification criteria to help potential future rulemaking.
"The AHA strongly supports the creation of a useable, scalable, and efficient solution to help reduce prior authorization impacts on patients and providers," the AHA wrote. "However, we urge ONC—in collaboration with CMS—to pilot the technologies and workflows described in the rule prior to taking any regulatory steps, including certification or codification of standards to minimize unintended negative consequences, such as an inadvertent increase in costs or burden in the health care system."
Arguably the most significant deterrent of prior authorization is the potential for delay in care. The AHA cited a recent physician survey conducted by the American Medical Association (AMA) in which 93% of respondents said prior authorization led to delayed patient access to necessary care.
Losing time to the approvals process is not an option for many patients who could be at risk of worsening conditions or serious adverse events like hospitalization, disability, or even death.
Though standardizing prior authorizations could combat those concerns, the AHA also offered additional reform: an increase in oversight over health plans, applying prior authorization to services with high costs, and the requirement that plans process prior authorizations around the clock.
Providers, meanwhile, face their own set of challenges when it comes to the administrative process. The AHA once again pointed to the AMA physician survey, highlighting that 88% of respondents described the burden associated with prior authorization as high or extremely high.
To both improve patient care and curb provider burnout, the AHA stated their support for the adoption of electronic prior authorization. From strictly a resources perspective, the 2021 CAQH Index found that automation of prior authorizations had a cost savings opportunity of $437 million annually.
Incorporating new technology, however, can be a resource-intensive process for hospitals and providers, the AHA argued. Premature implementation of new solutions that have yet to completed and tested is also a concern.
As such, the AHA recommended that prior authorization solutions be fully developed and tested prior to the creation of any regulations. Pilot testing and real-world analysis would be essential to not only ensure the changes in the process are working as intended but create data that proves to providers that those changes are worthwhile.
Ultimately, improving prior authorization has the potential for widespread benefits, but the method and application require thoughtfulness.
"In order to effectively update and create standard transactions without unduly burdening healthcare payment processes, regulators should approach potential changes judiciously," the AHA concluded. "Any substantial change in the technology and/or standards used in healthcare information exchange should be sufficiently tested to ensure functionality, analyzed to establish projected return on investment, and incorporated according to an appropriate glide path to minimize systematic disruption."
The American Hospital Association (AHA) is asking to mandate waiving the administrative process during public health emergencies (PHE) as patients suffer from delays in care.
The AHA is urging CMS to require Medicare Advantage (MA) plans to waive prior authorizations during PHEs so care can be streamlined when it is most necessary.
While CMS encouraged MA plans to waive the administrative process during the COVID-19 pandemic, the AHA detailed in a letter to CMS administrator Chiquita Brooks-LaSure the importance of working with Congress on a mandate to avoid similar pitfalls as experienced in the past two years.
"The continued use of prior authorization and other health plan utilization management policies by some plans throughout the pandemic exacerbated capacity issues, caused delays affecting patient care, and resulted in high rates of inappropriate denials," the AHA stated.
Concerns over prior authorization and its potential negative effects on patient care and costs to health systems are longstanding. During PHEs, however, the impact can be far more damaging as timeliness becomes a priority.
During the pandemic, the AHA noted that hospitals have faced challenges in quickly turning over hospital beds for higher-need COVID-19 patients, while transferring patients who require post-acute care (PAC) to the appropriate clinical pathways, such as long-term care hospitals (LTCH) or inpatient rehabilitation facilities.
When prior authorization was not waived in these instances, it often resulted in patients forcibly staying in acute care settings as they awaited discharge and beds not being given to higher-need patients.
The AHA also cited inconsistent use of prior authorization during the pandemic, as some plans waived the process during the initial stages before expiration, while other waivers excluded certain provider services.
According to the AHA, MA plans offered less flexibility with waivers compared to Medicaid plans, even when certain insurers operated both a MA and Medicaid plan. MA plans that did not waive prior authorizations during the pandemic took approximately three days to respond to a request for PAC, based on AHA's members estimate, with the total turnaround time potentially increasing by several days for denials and appeals processes.
Speaking to a larger trend, the AHA pointed to one multi-state member reporting that MA prior authorization denial rates for their LTCHs were significantly higher in 2021 and 2022, compared to before pandemic. Though CMS encouraged MA plans to relax prior authorization requirements, some plans have seemingly gone the opposite direction with an increase in denials.
"Prior authorization processes have exacerbated workforce challenges and contributed to physician and other staff burnout during the PHE," the AHA wrote. "Hospitals often have multiple full-time employees whose sole role is to manage health plan prior authorization requests. These staff often are physicians and nurses who have been diverted from patient care."
While the AHA recognizes the utility of prior authorizations, it concluded in the letter that MA plans would substantially improve pandemic responses through prior authorization waivers.
"Urgent and continued action is needed to ensure that health plans' administrative processes do not impede patients' ability to receive timely, quality, medically necessary care in clinically appropriate downstream settings," the AHA said. "This is more important than ever as we continue into our third year of a global pandemic, fighting new variants and surges, administering additional vaccine doses, addressing workforce shortages, and maintaining critical testing and treatment capacity."
The large insurer claims GS Labs charged more than five times the market rate for COVID-19 tests and administered additional tests to drive up the amount owed.
Blue Cross and Blue Shield of Minnesota has filed a lawsuit against COVID-19 testing laboratory GS Labs to recoup more than $10 million in alleged overpayments stemming from price inflation since the beginning of the pandemic.
The health insurer filed the complaint in the U.S. District Court of Minnesota last week, claiming the Omaha-based lab fraudulently charged more than five times the median market value for its most common COVID-19 test. Blue Cross also alleges that GS Labs administered additional tests just to increase the total amount it could charge the payer.
The price transparency requirement under the Coronavirus Aid, Relief, and Economic Security (CARES) Act, says each COVID-19 testing provider is required to disclose specific cash prices on their website in the absence of a contractual payment agreement. According to Blue Cross, GS Labs intentionally posted inflated prices on their website with the intention of charging the payer larger amounts than what it was willing to accept from individual customers.
"It is our claim that GS Labs intentionally disregarded and misinterpreted federal guidelines for the sole purpose of maximizing profits during a public health emergency," Scott Lynch, senior vice president of pharmacy and chief legal officer at Blue Cross and Blue Shield of Minnesota, stated in a press release.
"After months of attempts at good-faith negotiations, we were unable to reach an agreement with GS Labs that would put in place appropriate COVID-19 testing practices at a fair price. It's egregious price-gouging like this that ultimately drives up the cost of health care for everyone," Lynch said.
In response, GS Labs spokesperson David Leibowitz told the Twin Cities Pioneer Press that the lawsuit amounts to “strong-arm gamesmanship” by the insurer and that Blue Cross owes the lab more than $1 million for thousands of tests.
"GS Labs has followed federal law to the letter," Leibowitz said. "Our posted cash price for COVID tests is in line with the marketplace across the U.S. and we have been paid that price or a negotiated rate by numerous insurers around the country."
GS Labs, which has eight facilities in Minnesota alone, said that its advertised cash price for a rapid COVID-19 antigen test was $179 in January, according to the report.
Blue Cross, meanwhile, stated its continued commitment to providing COVID-19 testing, treatment, and vaccines to all its members. "Since the start of the pandemic, Blue Cross has paid and processed claims for more than 3.5 million COVID-19 tests administered by thousands of different providers in Minnesota and across the country," the insurer said.
The insurer is opting for a name change to better reflect its purpose in the healthcare business.
Anthem is changing its name to Elevance Health to emphasize its commitment to "elevating whole health," the company announced today.
The rebrand by the insurer, which serves 118 million people through its affiliated companies, will be subject to shareholder approval but will not affect Anthem Blue Cross Blue Shield health plans' name.
"Improving health means more than just treating what ails us. We must address whole health and the physical, behavioral, and social drivers that impact it," said Anthem president and CEO Gail Boudreaux.
"This need has driven our transformation from a health benefits organization to a lifetime, trusted health partner. Our commitment to always expect more from ourselves has led us to reimagine the way we operate and take a more holistic approach to health. As Elevance Health, we will continue to work toward a healthcare system that better serves the needs of our consumers, care providers, communities, partners, and associates," Boudreaux said.
Anthem's portfolio has expanded over the years to offer more than just health insurance. Between pharmacy, behavioral, clinical, and complex care assets, along with its digital capabilities, the payer offers consumers a wide range of services. With the name change, Anthem believes Elevance Health better encompasses their mission as they seek continued growth.
"Elevance Health represents who we are today," said Boudreaux. "Powered by industry-leading capabilities and a digital platform for health, Elevance Health's companies will serve people across the entire care journey, connecting them to the care, support, and resources they need to lead healthy lives. By simplifying every step and making health more equitable and accessible, Elevance Health will remain committed to helping everyone reach their full potential."
There was no observed correlation between higher-priced hospitals and higher quality of care in certain markets, a study by the National Bureau of Economic Research found.
The assumption that higher prices translate to better quality of care was challenged by the study, which found that the relationship between the two is largely dependent on location and market size of the hospital. Mortality rates decreased in hospitals with higher prices in only unconcentrated markets, while no correlation was observed with hospitals in concentrated markets.
The cost of care at hospitals has steadily climbed over the years as mergers of health systems have impacted the bottom line for patients. The Department of Justice has even blocked acquisitions in an effort to curb monopolies and the undermining of competition.
To quantify any perceived connection between hospital prices and patient outcomes, researchers from the NBER gathered data from June 2007 to June 2014 from the Health Care Cost Institute for individuals aged 18 through 64 with employer-sponsored insurance provided by Aetna, Humana, or UnitedHealthcare. To overcome selection challenges, the study used data of patients who were transported to the hospital by ambulance, as ambulances are effectively randomly assigned to emergency calls.
The final sample consists of 202,408 admissions among 171,432 patients that occurred at 1,814 hospitals, with the mean hospital price of $14,652 and the standard deviation at $4,634. The researchers also used the Herfindahl-Hirschman Index (HHI) to measure the market concentration of the hospitals, with the mean hospital HHI in the study being 4,327 and the HHI at the 25th and 75th percentile being 2,344 and 5,422, respectively.
Ultimately, the study found that in markets with an HHI of less than 4,000, receiving care from hospitals with two standard deviations higher prices resulted in a 35% reduction in in-hospital mortality. For each life saved in this instance, the cost was an additional $1.09 million in health spending, "suggesting that higher priced hospitals are likely saving lives cost effectively," according to the researchers.
In concentrated markets, however, the study concluded that higher prices are more indicative of patients' lack of options and not quality of care. But with approximately 69% of hospitals in the U.S. located in markets with an HHI of greater than 4,000, competition isn't geographically feasible, according to the researchers.
That raises the topic of price regulation and whether patients would benefit from policymakers stepping in. While the strategy has cost-saving potential for hospitals and patients, it could also adversely affect quality of care.
"Our findings suggest policymakers should use caution in regulating hospital prices in less concentrated markets. Regulating prices in these markets has the scope to lower clinical quality," the researchers wrote. "Finally, while we cannot rule out a positive or negative relationship between price and quality in concentrated markets, our results suggest policymakers should consider regulating providers' prices where competition is geographically infeasible."
The health system said it will officially disband the process of turning Conifer into a standalone business following a turnaround in financial prospects.
Tenet Healthcare announced it will reverse course on its plans to spin off its revenue cycle management subsidiary Conifer Health Solutions citing the division's renewed financial profile and growth potential.
"We have achieved significant operational and financial progress within Conifer in the last few years and dramatically improved Tenet's profile across key financial metrics like adjusted EBITDA, free cash flow, and net debt leverage," Ron Rittenmeyer, executive chairperson of Tenet Healthcare, stated in a press release. "We believe that continuing to build on our progress with Conifer will provide greater returns for Tenet's shareholders."
The resolution of Conifer's fate closes the book on plans Tenet first put in motion more than four years ago to either sell the unit or spin it off into a standalone business. With cost-cutting in mind, Tenet announced in December 2017 it would begin exploring a potential sale of Conifer. Then, in July 2019, the company said it would officially pivot to a tax-free spinoff of the subsidiary to maximize Conifer's value.
Now, the health system, which operates 60 hospitals and approximately 550 outpatient centers, will keep Conifer in-house after an improvement in outlook. In their announcement, Tenet said Conifer's adjusted EBITDA margin has increased by more than 1,000 basis points since 2017 with expectations that the subsidiary will deliver revenue growth in the mid to high-single digits in the fiscal year 2022.
In addition to a strong margin and cash flow profile, Conifer should see benefits from revamped commercialization, new sales talent and technology, and new clients, according to Tenet.
"Conifer is primed with a robust pipeline and recent client wins with value that is not yet fully realized," said Saum Sutaria, MD, chief executive officer of Tenet Healthcare. "When coupled with ongoing efficiency opportunities from offshoring and automation, we have a compelling runway for the business."
Last month, Tenet reported a quarterly profit of $250 million—a drop-off from the $414 million in the fourth quarter of the previous year but an increase from $89 million to $153 million when removing COVID-19-related stimulus grant income. For the fiscal year 2021, net income was reportedly $915 million compared to $399 million for 2020.
Proposed legislation follows the lead of the No Surprises Act to take aim at surprise bills and price gouging from COVID-19 testing.
U.S. Representatives introduced the No Surprises for COVID-19 Tests Act last week to extend free COVID-19 testing while combating associated price gouging and surprise bills.
While Congress passed the Coronavirus Aid, Relief, and Economic Security (CARES) Act in 2020 to provide free COVID-19 testing for the public regardless of insurance coverage, some providers are using loopholes to slap patients with surprise bills for tests at unreasonable prices, according to the legislators.
The No Surprises for COVID-19 Tests Act would extend coverage of free testing beyond the public health emergency until December 31, 2023, with insurance companies required to continue providing coverage for related items and services without any cost-sharing such as health provider office visits, urgent care visits, and emergency room visits resulting in a COVID-19 test. The bill would also strike a provision of the CARES Act that allows providers to bill at whatever cash price they choose, causing price gouging of tests.
"Congress passed the Families First Coronavirus Response Act to ensure that everyone would have access to free and widely available COVID-19 testing," Frank Pallone, chairperson of the Energy and Commerce Committee, said in a statement.
"Unfortunately, some test providers are exploiting unintended loopholes in the system to unfairly price gouge and wrongfully bill patients for tests that should be free. The No Surprises for COVID-19 Tests Act will close these loopholes and ensure that Americans do not receive surprise medical bills for doing their part to stop the spread of COVID-19. Congress must act on this commonsense legislation soon," he added.
The legislation follows the No Surprises Act, which was signed in 2020 and took effect on January 1 to protect patients from surprise bills after receiving care. As support grows against unfair billing practices, the No Surprises for COVID-19 Tests Act appears to be a natural next step for Congress to take while the pandemic continues.
"One of the most critical steps Congress took at the onset of the pandemic was providing Americans with free COVID-19 testing and vaccinations. We must provide consumers with the certainty that this protection will remain in effect in the months ahead," said Robert Scott, chairperson of the Education and Labor Committee. "The last thing families need during this ongoing public health emergency is an unexpected medical bill for a COVID-19 test. This legislation will help ensure that all Americans can continue to access no-cost COVID-19 testing and slow the spread of COVID-19."
"I decided to join Clover because of where they sit in the healthcare ecosystem," Wai told HealthLeaders. "Leading a team building its own proprietary tech stack within an insurer allows us to prioritize developing functionality that makes the product more useful to physicians. At the end of the day, helping doctors practice more effectively and efficiently, by definition, means healthier patients.
"Additionally, Clover's unique position as a technology company and insurer has allowed it to build a data feedback loop to fuel consistent product iteration in close collaboration with its users – healthcare providers. I believe this gives Clover a significant advantage over so many others in the market and is part of why I'm so excited about the opportunity,” added Wai.
“With this new chapter of my career, I welcome the challenge to develop truly transformational technology that positively impacts the lives of hundreds of thousands of Americans today, and what I believe could be millions more in the future."
Before making the move to Clover, a company focused on healthcare plans for seniors, Wai oversaw functions such as product management, design, data analytics, and growth as senior vice president of product for Hinge Health. He has also held leadership positions at Yahoo and Google and began his career in venture capital, consulting, and engineering after earning a bachelor’s and master’s degree in computer science from Stanford University.
"Conrad is a world-class technologist and will take the lead on day-to-day Clover Assistant product development, engineering, and deployment," said Toy. "His background in driving success through constant product iteration at large technology organizations, combined with his healthcare background, makes him a perfect fit for realizing the full potential of the Clover Assistant."
Vidant Health is being accused of unfair billing and debt collection schemes after charging a patient 11 times the Medicare rate for a CT scan in 2018.
One of North Carolina's largest hospital systems is the target of a lawsuit alleging deceptive billing and debt collection methods.
George Cansler is accusing the 1,477-bed system Vidant Health of not informing him of how much his care would cost, as well as deploying FirstPoint Collection Resources for aggressive debt collection practices on the unpaid bills.
According to the lawsuit, Cansler visited the Vidant Chowan Hospital emergency room in Edenton, North Carolina in 2018 for extreme pain from a likely kidney stone. More than a year later, he received a bill from Vidant asking him to pay $3,119 for a CT scan, 11 times the Medicare rate for the procedure at the time.
Cansler also alleges he was not told of the price beforehand and that Vidant later falsely told him it was a violation of federal law for them to disclose prices to patients before care.
While Vidant's alleged actions predate the No Surprises Act, this is in direct opposition to the federal law which took effect January 1 and prevents healthcare organizations from springing surprise medical bills on patients. For people covered under group and individual health plans, the new protections deal with most emergency and non-emergency services from out-of-network providers at in-network facilities, while those who are uninsured or opt for self-pay will receive a good faith estimate that provides the cost of care up front.
Even so, Vidant’s practices were manipulative and highly unreasonable, according to Cansler and his attorneys.
"Surprise billing is a widely criticized, predatory practice and it is especially harmful when one hospital system is the monopoly provider in a region because patients have no alternatives for care," Jamie Crooks of the law firm Fairmark Partners, LLP, said in a statement. "This complaint alleges that Vidant has abused its monopoly by sending surprise bills demanding unreasonable prices for common procedures."
Cansler's lawsuit is asking the court to require Vidant to reimburse residents who were overbilled and put an end to their alleged surprise billing and debt collection practices.
