Our research team breaks down this week’s top healthcare news.
In an age of unprecedented change, staying current has never been more important. Our team at Chartis is curating news most relevant to the healthcare industry and tracking the topics that are trending on seven key issues: high reliability care, digital and advanced technology, financial sustainability, health disparities, the health ecosystem of the future, partnerships, and the provider enterprise. Each week, we break down what’s happening and why it matters.
In a recent poll conducted by Nature, nearly 90 percent of respondents (more than 100 scientists, immunologists, infectious-disease researchers, and virologists who are working on the coronavirus) think the COVID-19 virus is “likely” or “very likely” to become an endemic virus.
In contrast to COVID’s current status as a pandemic, an endemic virus or disease is defined as a constant presence in a specific location. Examples include malaria, which is endemic to many parts of Africa, and the seasonal flu (also a coronavirus, and one that mutates frequently), which is endemic to North America.
COVID-19 may become endemic to many parts of the world in part because we couldn’t (and still can’t) effectively contain it. This is due to several factors:
The COVID-19 virus is now mutating, as is apparent from the new strains originating from the United Kingdom, South Africa, and India. This will make containment even more difficult, as it is not known whether the vaccines currently approved and those in development will handle these and future new strains as effectively.
It seems likely that the COVID-19 virus and its variants will become endemic to many parts of the world, which, per Science, “reinforce[s] the importance of behavioral containment during pandemic vaccine rollout, while prompting us to evaluate scenarios for continuing vaccination in the endemic phase.” If precautionary behaviors like mask wearing and hand washing are followed as we continue with vaccine rollout and the development of related vaccines that may more effectively treat variants in the virus, we could arrive at a state of “mild disease endemicity” per Science. Like the seasonal flu, this would mean COVID would still contribute to deaths annually, but its impact would transition to more of an ongoing nuisance than a widespread, highly deadly pandemic. However, as a recent interview in The Atlantic points out, vaccine production must be significantly increased, and efforts to distribute the vaccine worldwide must be scaled up — even in poorer parts of the world, where the cost of the process may require support from external agencies — in order for there to be a possibility of “mild endemicity” or any slim chance of eradication.
While efforts to completely eradicate COVID-19 seem unlikely to succeed, lessons can be gleaned about our heroic but unprepared and uncoordinated efforts to respond to the virus, and help us better prepare for preventing new viruses from transitioning to pandemic or endemic viruses.
Healthcare software start-up Turquoise Health released an analysis late last week that found one-third of the more than 6,000 hospitals reviewed (all listed in the United States), publicly posted “highly transparent” payor-negotiated rates for common hospital-based procedures and services, as reported in Fierce Healthcare.
This follows a federal rule that took effect on January 1 of this year, which per the Centers for Medicare & Medicaid Services (CMS), indicates that hospitals must post on their websites:
1. A “single machine-readable digital file containing the following standard charges for all items and services provided by the hospital” — including gross charges, discounted cash prices, payor-specific negotiated charges, and de-identified minimum and maximum negotiated charges.
2. A “display of at least 300 ‘shoppable services’ (or as many as the hospital provides if less than 300) that a healthcare consumer can schedule in advance… in plain language” — including discounted cash prices, payor-specific negotiated charges, and de-identified minimum and maximum negotiated charges.
A second part of the rule, which goes into effect in 2023, requires that insurers must offer consumer-focused digital tools allowing consumers to look up prices and out-of-pocket costs for 500 medical services. All covered medical services and items must be included by 2024.
One-third of hospitals complying with “highly transparent” rate posting is far from all. As the Wall Street Journal noted, “many [hospitals] have begun offering at least a peek, while not always making the data easy to find, even though the rule says it is supposed to be displayed publicly and prominently.” Indeed, some health systems have posted negotiated rates for all services and items offered by their hospital(s), but the files are so large that their website warns “you may need special software/speed to open the files.” Other health systems have posted charges for services and items in easily readable files but don’t include all the categories listed in the CMS rule, just gross charges. Still others post easily readable files that cover all the data required under the rule.
The price transparency rule is a step forward in helping consumers understand what their insurance company will pay for a given service or item, and it theoretically allows consumers to “shop” across multiple hospitals. However, many hospitals and health systems — those complying with the CMS rule in full and those partly or not complying — rightly point out that this required pricing list does not represent what a consumer will actually pay. The prices do not include out-of-pocket costs, nor do they take into consideration other factors that can impact a patient’s bill, like the patient’s ability to pay, which can be used to negotiate a lower total price. For this reason, many hospital websites direct patients to contact customer service and billing by phone to receive a more accurate estimate of pricing and total costs, or offer an online estimator tool, usually with a disclaimer that the patient should still call customer service and billing to confirm any estimates. A website that provides information that is not a complete picture and requires follow-up by phone is not particularly easy or efficient from a consumer’s perspective. Some groups have begun aggregating the data for easier cross-hospital comparisons, but these are fairly rudimentary or still in development.
The new rule is a step in the right direction but doesn’t bring this country’s health system to full price transparency, provided in a way that enables consumers to predict the actual total cost of services or efficiently shop across multiple hospitals. Some hospitals and health systems may see the rule as a nuisance or even something that could negatively impact their negotiations with payors. However, by not complying, hospitals may be called out by their competitors, damaging consumer reputation.
Furthermore, on the positive side, the rule can be viewed as an opportunity for hospitals to build out a more comprehensive, easily navigable digital front door and to improve the consumer experience. Along with better online pricing transparency and cost calculators, clear definitions of the terms used in the pricing lists, as the AAMC suggests, could be posted. A link to online scheduling and an option to review physician profiles would allow a patient who has reviewed the costs and wishes to schedule an appointment to do so through the same online point of entry. Additionally, this provides patients an opportunity to communicate the need for financial counseling or assistance, which helps start the conversation much sooner and in a more timely manner. A simple online payment option for services already received or for those that are upcoming would provide a convenient payment option for patients and potentially improve bill collection rates.
While this new rule may seem time consuming and ineffective to hospitals, there are opportunities to use it as a starting point to improve the entire online experience for consumers, potentially keeping patients in that hospital or health system for future services because of the good experience, and improving revenue cycle activities and billing collections.
Since 2016 the population of uninsured in the United States has been rising. Uninsured levels in 2019 reached 30 million, and COVID-19 likely only exacerbated this as many faced job or benefit losses. In response, President Biden has reopened the insurance marketplace for three months, from February 15 to May 15. Any person from the 36 states utilizing the healthcare.gov platform who is uninsured or who is already insured through the marketplace will be eligible to change or purchase their plan during this time. Also eligible for the insurance exchange are those currently covered under COBRA, who may drop COBRA coverage for the likely less expensive marketplace coverage during this period. Under normal circumstances, a major life event, such as marriage, job loss, or birth, would be required to change or enroll in plans mid-year. Many states with their own marketplace are also offering special enrollment periods, though the exact dates and eligibility rules may vary.
While uninsured numbers have risen since 2016, enrollment through the federal marketplace has declined each year, which many attribute to cuts in outreach and education to the eligible population. There are encouraging signs that the downward exchange enrollment trend will not continue. The Biden Administration plans to spend $50 million to increase awareness about the special enrollment period this year. CVS’s Aetna insurance announced they will return to the federal insurance exchange for the 2022 plan year, citing better market conditions and the goal of making healthcare more accessible and affordable.
In addition to those who are uninsured, or who may want to change their plan, those who have had their income negatively impacted are encouraged to visit the exchange to update their pay in case they are eligible for larger subsidies or Medicaid. Should an individual be eligible for Medicaid, they will be pushed to sign up for the program and can enroll at any point in the year. In another move to ensure all those meeting financial thresholds are eligible to enroll in Medicaid, the Biden Administration started to rollback 13 states’ Medicaid policies that required enrollees to participate in work or other community activities to qualify for coverage. While the Trump Administration had previously approved these policies, only Arkansas had begun to implement through a demonstration project.
A Health Affairs study on Arkansas’ work requirements Medicaid demonstration project found nearly 25 percent of those previously eligible for Medicaid by the waiver lost their coverage due to the new work requirements, and employment in the same population did not increase. Those that lost insurance faced significant negative impacts, including medication adherence.
We are currently in the midst of a once-in-a-generation pandemic, in which people need access to care and coverage. Many are struggling financially and may have lost employer-sponsored healthcare or are newly eligible for increased subsidies or Medicaid enrollment. Now is the time to do all we can to ensure insurance eligibility. Allowing for special enrollment periods on the exchange, educating those without insurance on their options, and removing onerous and unnecessary requirements for Medicaid eligibility are steps toward decreasing uninsured rates at a vital time among communities inequitably impacted by COVID.
For many organizations, the tidal wave of change in a relatively short period of time has made it even more challenging to manage — let alone adapt and improve — the most fundamental attributes and indicators that drive performance.
Leaders need to think broadly about the capabilities of their clinicians and staff to respond to COVID-19 capacity issues. One group primed for elevation and expansion of role is advanced practice providers (APPs).
Non-traditional entities are capturing the value void through innovative models, partnering with funding entities to receive compensation for addressing needs. What activities and strategies should health systems consider?