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Medicare Open Enrollment: To Dis-enroll or Not? Searching For Answers with an AI Assist

by Gregg Anthony Masters, MPH

Some of you may have heard about the whining by UnitedHealthcare’s leadership on a recent earnings call which included the required ‘management’s discussion or operating results and market conditions’ analysis. A BIG WHAAAA!

Overfunded since inception and having perfected the art of ‘upcoding‘ (i.e,, severity of illness and intensity of medically necessary services) Medicare Advantage (MA) operators with often market-specific and generous redistribution of the Center for Medicare and Medicaid Services (CMS) funds thus enabling Zero premium plans with expanded benefits, I’m totally fed up with the relentless ‘ad copy’ of my current health plan (KP San Diego) where I’ve been a loyal member and advocate of their ‘best in class’ IDN status and outcomes performance. They are NOT, and my journey into ‘e-patient‘ hood affords me this opportunity to opine in public.

So, here’s the first installment:


Prompt

I am 72-year-old man in good health. Open enrollment for Medicare ends tomorrow (12/7/2023). I need to make a decision whether to dis-enroll from a Medicare advantage program and return to statutory Medicare, not a term based, private contract with a Medicare advantage operator. I was recently diagnosed with prostate cancer with a Gleason score of 7 (3+4) and am in active monitoring & surveillance (including periodic PSA, mpMRI & targeted biopsies) and am not under treatment, yet. What are the pro’s and con’s of staying with my current health plan (Kaiser Permanente, San Diego) vs. opting for Medicare plus a supplement? What are my best choices? Do you need additional context or prompting? Do you understand?

ChatGPT

I understand your situation and the importance of making an informed decision about your Medicare options, especially in light of your recent prostate cancer diagnosis. Here’s a general overview of the pros and cons of Medicare Advantage plans versus Original Medicare with a Supplement (Medigap) plan, particularly in the context of your condition and current health plan with Kaiser Permanente in San Diego.

Medicare Advantage (like Kaiser Permanente):

Pros:

  1. All-in-One Plan: Medicare Advantage plans often include Part D (prescription drug coverage) and may offer additional benefits like dental, vision, and wellness programs not covered by Original Medicare.
  2. Cost-Capping: These plans usually have an out-of-pocket maximum, which can help manage costs.
  3. Provider Networks: Plans like Kaiser Permanente often have a network of doctors and facilities, ensuring coordinated care and sometimes easier appointment scheduling.

Cons:

  1. Limited Provider Networks: You may be restricted to doctors and facilities within the Kaiser network, limiting your choices for specialists, especially if you need specialized cancer treatment.
  2. Referrals Required: Some plans require referrals for specialist visits, which might delay access to care.
  3. Plan Restrictions: Some treatments or medications might not be covered, or may require prior authorization.

Original Medicare with a Supplement Plan:

Pros:

  1. Wider Network: You have the flexibility to see any doctor or specialist that accepts Medicare, which can be beneficial for specialized cancer care.
  2. No Referrals: Generally, no referrals are needed to see specialists.
  3. Predictable Costs: Supplemental (Medigap) plans can help cover Medicare Part A and B deductibles, co-insurance, and other out-of-pocket costs, making expenses more predictable.

Cons:

  1. Additional Premiums: You’ll likely pay a premium for both Medicare Part B and the Medigap policy.
  2. Separate Drug Plan: You’ll need to enroll in a separate Medicare Part D plan for prescription drugs.
  3. Potential Gaps: Some Medigap plans don’t cover extras like dental, vision, or wellness programs.

Considering Prostate Cancer Treatment:

  • Access to Specialists: With Original Medicare and a Supplement, you might have more flexibility in choosing specialists for your prostate cancer treatment.
  • Coverage for Treatments: Check the specific coverage details for cancer treatments under both options to understand potential costs and restrictions.

Making Your Decision:

  1. Compare Costs: Consider premiums, deductibles, co-pays, and out-of-pocket maximums.
  2. Evaluate Provider Network: Ensure your preferred doctors and hospitals are covered and consider the ease of access to specialists.
  3. Review Drug Coverage: If you’re on medications, check how they’re covered under each option.
  4. Consider Future Health Needs: Think about potential changes in your health and how each plan would accommodate those needs.

Given your specific health situation, it’s crucial to consider how each option would cover your ongoing monitoring and any potential future treatments for prostate cancer. Additionally, it might be beneficial to consult with a healthcare advisor or a Medicare specialist who can provide more personalized advice based on your health status and needs.

Please remember that this is a general overview and not personalized medical or insurance advice. It’s important to review the specific details of your current plan and compare them with the benefits offered under Original Medicare plus a supplement.

You

continue. if i dis-enroll from current health plan and given the current prostate cancer diagnosis, will I qualify for a Medicare supplement via community rating? Or will I be medically underwritten and potentially denied coverage? And will the rate be adjusted to reflect pre-existing conditions? Do you understand or need further prompting?

ChatGPT

Yes, I understand your question regarding eligibility and rates for a Medicare Supplement (Medigap) plan after disenrolling from a Medicare Advantage plan, particularly in the context of your current prostate cancer diagnosis. Here are the key points to consider:

Medigap Eligibility and Underwriting:

  1. Guaranteed Issue Rights: Normally, when you first enroll in Medicare Part B at age 65 or older, you have a 6-month Medigap open enrollment period where you can buy any Medigap policy sold in your state without medical underwriting. During this period, you cannot be denied coverage or charged more due to pre-existing conditions.
  2. Switching from Medicare Advantage to Medigap: If you are in a Medicare Advantage Plan, you can switch to Original Medicare with a Medigap policy under certain conditions. These conditions generally include moving out of your plan’s service area or if the plan stops providing care in your area. However, these situations would grant you a Special Enrollment Period with guaranteed issue rights for a Medigap policy.
  3. Medical Underwriting Outside of Protected Periods: If you’re switching from Medicare Advantage to Medigap outside of these specific periods, insurance companies may use medical underwriting. This means they could charge higher premiums based on your health status, or potentially deny coverage due to pre-existing conditions.
  4. Community Rating in Some States: Some states, like New York and Massachusetts, use “community rating” for Medigap policies, where premiums are not based on age or health status. In these states, your prostate cancer diagnosis would not affect your premium rates.
  5. California Rules: Since you are in San Diego, California’s rules for Medigap plans apply. California uses a “birthday rule,” allowing Medicare beneficiaries to switch to a Medigap policy with the same or lesser benefits during the 30 days following their birthday each year, without medical underwriting. However, this is only applicable if you already have a Medigap policy.

Considering Your Situation:

  • Current Health Status: Given your prostate cancer diagnosis, if you are outside of a guaranteed issue period or special enrollment period, there is a risk of higher rates or denial of coverage due to medical underwriting.
  • Advice: It’s highly recommended to consult with a Medicare specialist or insurance advisor who can provide detailed information based on your specific situation, including your current health status and the rules in your state.

Remember, these are general guidelines and may not cover every nuance of your situation. It’s important to get personalized advice before making a decision, especially given the complexities surrounding health conditions like cancer and their impact on insurance eligibility and rates.

You

continue: create a blog post titled: “Medicare Open Enrollment: To Dis-enroll or Not? Searching For Answers with an AI Assist”. Use the above query and explanation. Create in witty yet professional tone. Do you understand or need further prompting?

ChatGPT

Absolutely, I understand your request. Here’s a blog post based on our previous discussion:

Medicare Open Enrollment: To Dis-enroll or Not? Searching For Answers with an AI Assist

Welcome to the rollercoaster ride of Medicare open enrollment! It’s that time of the year when we, the silver-haired brigade, scratch our heads, pore over pamphlets that might as well be written in Klingon, and try to make sense of our health insurance options. Fear not, dear reader, for today we have a secret weapon in our arsenal – an AI assistant (that’s me, by the way)!

The Great Debate: Medicare Advantage vs. Original Medicare with a Supplement

Imagine you’re at a health insurance buffet. On one table, we have Medicare Advantage plans, like the one from Kaiser Permanente in sunny San Diego. It’s like a combo meal – a bit of everything in one package. On the other table, there’s Original Medicare with a side dish of Medigap (Supplement) plans. More à la carte, you pick and choose what suits your palate.

The Medicare Advantage Plate: A Mixed Bag

Pros:

  1. Convenience: These plans roll your Medicare Parts A, B, and often D into one. It’s like getting a burger, fries, and a soda in one go.
  2. Cost Caps: There’s a limit on out-of-pocket expenses. It’s like knowing you won’t spend more than $20 on your meal, no matter how many extra fries you grab.
  3. Extra Goodies: They often throw in benefits like dental and vision – the cherry on top.

Cons:

  1. The Network Maze: You might be restricted to their network of doctors. It’s like only being able to eat at restaurants in one neighborhood.
  2. Referral Hoops: Need a specialist? Get ready to jump through some referral hoops.
  3. Coverage Caveats: Some treatments or drugs might not be on the menu.

The Original Medicare with Supplement Platter: Customize Your Meal

Pros:

  1. Freedom of Choice: See any doctor who accepts Medicare. It’s like having a pass to dine at any restaurant in the city.
  2. No Referrals Needed: Straight to the specialist you go, no pit stops.
  3. Predictable Costs: Supplement plans can cover those pesky out-of-pocket costs, making your expenses more like a fixed-price menu.

Cons:

  1. Extra Bills: You’re paying for two plans – think of it as buying a main dish and a side separately.
  2. Drug Plan Detour: You’ll need a separate plan for medications – yes, another dish to order.
  3. Extras Not Included: Want dental or vision? That’s another order you’ll need to place.

The Plot Twist: A Prostate Cancer Diagnosis

Here’s where the plot thickens. With a recent prostate cancer diagnosis and a Gleason score of 7, the decision gets more nuanced. You want a plan that covers your needs, like a chef who can cater to your specific dietary requirements.

Dis-enrolling and Medigap: Navigating the Maze

If you’re thinking of waving goodbye to your Medicare Advantage plan and waltzing over to Original Medicare with a Medigap policy, hold your horses. There are things to consider:

  • Guaranteed Issue Rights: This is your golden ticket to get a Medigap plan without being penalized for health issues. But it’s time-sensitive.
  • Medical Underwriting: Miss the golden period, and insurers might look at your health as closely as a chef inspects produce. This could mean higher rates or a polite “no thank you” to offering you a plan.
  • California’s Birthday Rule: In the Golden State, you get a chance to switch Medigap plans around your birthday without medical underwriting. It’s like getting a free dessert on your special day – but only if you already have a Medigap plan.

The Verdict?

It boils down to personal preference, health needs, and a bit of timing. Think of it like choosing between a set menu and a build-your-own meal. Each has its perks and drawbacks.

So, dear readers, as you navigate these choppy waters of Medicare decisions, remember: it’s about finding the right fit for your health and lifestyle. And while I, your AI assistant, can provide a map, it’s always wise to consult a human expert – think of them as your personal health insurance sommelier.

Happy enrolling! May your health insurance choices be as satisfying as your favorite meal.

ACO Digital Assets Available

by Gregg A. Masters, MPH

It’s been quite some time that I’ve updated this site though not for a lack of news. Yet some 434 posts later following the rollout of the Affordable Care Act, the signature, and against all odds accomplishment of then President Barack Obama, I thought I’d update both subscribers and followers of the blog including a number of generous guest contributors.

Since SARS-CoV-2 entered our collective consciousness in March 2020 as a global pandemic and has reconfigured any sense of ‘normal’ , like many of you, I have been reflecting on the nature and meaning of this uniquely challenging journey.

NOTE: See ‘We’re All Carriers‘.

Today, I celebrate 71 years of existence on this ‘pale blue dot‘. Yet, it doesn’t feel like a celebratory moment. With seemingly everything upside down from ‘truthiness’ and ‘alternative facts’ driving wedges of relentless tribalism between people and moments that matter, I am revaluing where are how I spend my time.

As Nick van Terheyden MD aka ‘Dr Nick’ once offered:

Gregg you may want to try the 5/25 approach. Where you concentrate on the 5 of the twenty five priorities on your to-do list.

As a public health graduate from the UCLA School of Public Health in the 70s (post HMO Act) and following serial up and down c-suite cycles (peppered by severe bouts of clinical depression) leading health system participation in managed care spanning, community and tertiary hospitals in the ‘non-profit’ and ‘proprietary’ sectors for nameplate health system parents and academic medical centers, I feel quite discouraged that the more things ‘change’ in healthcare delivery and finance, the more things remain the same. Or as otherwise put legacy momentum is likely to prevail as the status quo – or as our industry once characterized by Esther Dyson as a ‘calcified hairball’ – is likely to resist or assimilate all meaningful innovation (think population health or value based care).

In anticipation of the enshrinement of accountable care organizations or ‘ACOs’ in healthcare innovation lexicon for the foreseeable future, in addition to ACOwatch.com, I acquired a range of digital assets to potentially develop, co-develop, lease or sell.

So years ago, when twitter burst into the landscape of an emerging digital health economy (circa 2008/09), sitting in a Health 2.0 annual gathering and listening to the presentations two ideas came to mind as cute twitter handles that might host and gain conversational traction in health policy circles and the soon to be emerging tweetchats.

twitter ‘jail’!

They included @HealthcareBorg (a somewhat witty ‘resistance is futile’ play on the then very popular Healthcare Blog, courtesy of Matt Holt, et al). The other session generated name ID was @ReplaceMyMD (inexplicably suspended by content managers at twitter – including @ACOwatch, @DocTweets, @HospitalTweets, @TweetHealth, @PreferredPharma, @ACOalliance, @CancerCenterTV, @JustOncology, @BioMarkersToday and many others) which I thought was more than cute given the bifurcation of consumer friendly (from a retail POV, ie, app savvy and tech enabled) tools likely to flood the market to enable the essential literacy to navigate a progressively complex health policy environment that assumed the consumer with high deductible health plans would be interested in ways to shelter their out-of-pocket (cost shifting) spending from increasing co-pays, co-insurance and deductibles unfortunately enshrined in the ACA as an offset to the total cost of the Act.

Available ACO Assets Include:

ACOalliance.com

ACOroundtable.com

ACOregistry.com

ACOcor.com (anyone remember PhyCor??)

AccountableCare.Center

ACOchat.org

AccountableCare.Solutions

So with perhaps with more than a tinge of ‘battle fatigue’ and the increased participation of smart, motivated, and confident digital natives convinced value based healthcare is within sight, I am pivoting away from active work in this domain.

Instead I am concentrating on developing services for popupstudio.productions offering onsite ‘pop-up studios’ to simultaneously livestream conference, exhibition, tradeshow or event specific ‘user group’ streams across most major social channels including: YouTube, FaceBook Live, LinkedIn or enterprise/organization website(s).

My 2nd pivot is to concentrate on both B2B and B2C educational messaging in the emerging medical cannabis marketplace and the closely aligned and re-invigorated research activity into the therapeutic benefits of psychedelics.

If you have an interest in working with any of the ACO themed domains above, please follow then ping @GreggMastersMPH via DM on twitter.

As I note on the Health Innovation Media website,

“It is not necessary to change”

“Survival is not mandatory” W. Edwards Deming

Peace!

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CMS Announces 2019 Shared Savings Results

by Gregg A. Masters, MPH

Some eight plus years in, ACOs are still earning their ‘shared savings‘ industry ‘sea-legs’.

While they remain a central actor of transformation from volume to value birthed by the ACA for both the public (Medicare and Medicaid) and private (commercial health plans) sectors, the results are continuing to build.

The skeptics think they’re at best transitional vehicles toward more fully expressed and mature risk bearing entities with culture and risk infrastructure suitable to participate in an MA plan.

Below are are two recent articles that dive into the results:

2019 Medicare Shared Savings Program ACO Performance: Lower Costs And Promising Results Under ‘Pathways To Success’

Medicare Shared Savings ACOs Saved $2.6B in 2019

CMS posted the dataset on September 14, 2020 for program year 2019 for both financial and quality performance:

CMS released financial and quality performance results for Performance Year (PY) 2019 and PY 2019A. PY 2019 includes the performance periods beginning January 1, 2019 and ending June 30, 2019 as well as the performance period beginning January 1, 2019 and ending December 31, 2019. PY 2019A refers to the performance period beginning July 1, 2019 and ending December 31, 2019.

To view the complete performance results, refer to PY 2019 Performance Results and PY 2019A Performance Results.

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Need Another Acronym? Think ‘CHART’ Courtesy of ‘CMMI’

by Gregg A. Masters, MPH

In a sea of relentless ‘acronym soup’ that peppers the landscape and too often separates us from the constituency we ostensibly serve (patients) via added layers of dubious complexity to the dysfunctional U.S. healthcare delivery and financing ecosystem, the Centers for Medicare and Medicaid Innovation (CMMI) has added the ‘Community Health Access and Rural Transformation (CHART) Model‘ to our expanding nomenclature.

While we work through and perhaps finally remedy chronic and historically prevailing health in-equities across both urban and sub-urban settings vs. that typically found in rural markets driven by a ‘book of business’ (or financial class) series of incentives, the CHART model:

…aims to continue addressing disparities by providing a way for rural communities to transform their health care delivery systems by leveraging innovative financial arrangements as well as operational and regulatory flexibilities.

No doubt a noble cause and the ‘innovators’ at CMMI are to be recognized and commended for their efforts to make a meaningful difference in the lives of American’s who do not benefit from the typical healthcare asset concentrations in major markets – primarily urban and sub-urban.

While the range of ACO models – both commercial and public sector, i.e., Medicare and Medicaid – are seen by many as tepid responses to an uncharacteristically change or reform resistant healthcare economy fueled principally by still prevailing fee-for-service  production incentives, we’re still early on in the evolution of this managed competition model of healthcare innovation,  i.e., the ‘efficacy’ jury of ACOs to deliver on the ‘triple aim’ in aggregate is still out.

So read on and see what you think about the prospects of the CHART model to materially impact healthcare delivery while adding value to restraining the cost basis for accessing essential health services for largely under-served communities.

As always, your thoughts and comments are welcome.

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National Association of ACOs et al Weigh in on the ‘Value in Health Care Act of 2020’

by Gregg A. Masters, MPH

Article discovered via the National Association of ACOs (NAACOs) a ‘501 (c) 6 non-profit organization that allows Accountable Care Organizations (ACOs) to work together to increase quality of care, lower costs and improve the health of their communities’ . NAACOs et al weigh in on the Value in Health Care Act of 2020:

In association with the following health care industry advocacy groups including: the American Academy of Family Physicians, American College of Physicians, American Hospital Association, American Medical Association, America’s Essential Hospitals, America’s Physician Groups, the AMGA, Association of American Medical Colleges, the Federation of American Hospitals Health Care Transformation Task Force, Medical Group Management Association, National Association of ACOs and Premier have all endorsed the ‘Value In Health Care Act of 2020’.

The Act intends to:

‘further strengthen ACOs and APMs and ensure their continued success. We are pleased that the bill provides appropriate shared savings rates, modifies risk adjustment methodologies, removes barriers to participation, ensures fair and accurate benchmarks, and provides educational and technical support for ACOs. The bill also makes important steps to reinforce the transition to value through extending and modifying Advanced APM bonuses and addressing aspects of APM overlap. These reforms will ensure that value-based care models continue to be viable for physician and hospital participants’

Read a section by section summary here.

Also, the American Hospital Association (AHA) further reports via a ‘Coalition Voices Support for the Value in Health Care Act of 2020‘.

In a letter to Representatives. Peter Welch, Suzan DelBene, and Darin LaHood, thirteen organizations representing health care providers, including the AHA, voiced support for the Value in Health Care Act, legislation to strengthen Medicare’s value-based payment models and accountable care organizations.

You can read the full text of the letter here.

Clearly the systemic stressors associated with Covid-19’s impact on the usual and customary operations of U.S. healthcare financing and delivery may qualify as an unparalleled (perhaps ‘Black Swan’ scale) ‘may you live in interesting times’ challenge to healthcare leadership – perhaps of a lifetime?

So from a holistic perspective, it seems our leadership cohort across the continuum of an over-engineered, hierarchical, perhaps needlessly too complex but clearly stressed healthcare delivery and financing construct, we’re simultaneously presented with both clear and present ‘danger’ but also considerable ‘opportunity’ to re-engineer our change resistant healthcare borg?

If not now, when?

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Will Health Systems Recover from the COVID-19 Pandemic?

by Gregg A. Masters, MPH and Fred Goldstein, MS*

In the still unfolding operating ‘new normal‘ wrought by the COVID-19 pandemic the path forward presents perhaps the career challenge of a lifetime to both seasoned and emerging U.S. healthcare leadership. No doubt, in health system c-suites across the nation the strategic question is and will likely remain for some time, how to best position admittedly complex enterprises to re-tool, optimize and align their mission in service of the communities in which they operate.

There are many economic challenges we face as a nation, let alone the unique headwinds and potential ‘opportunities‘ health system leaders must assess. Yet, much is on the line. Vetting strategic signals from noise around the pandemic in order to identify the key actionable steps with the greatest potential to deliver the outcomes essential to maintain successful operational portfolios is the strategic imperative laid before our healthcare leadership.

Likely included in top of mind issues to be vetted is the need to examine the role of legacy momentum driven, fee-for-service-fueled health system (and related JV or affiliated entity) business models. Who can fault health system leadership for maximizing revenues to generate the bottom-lines typically required to support a broad range and mix of both ‘profitable’ and ‘un-profitable’ service lines? Yet, habituating (vs. innovating) to the inertia of an aging tapestry of payment incentives may have inadvertently played a role in incentivizing the ‘myopia‘ of short term performance vs. the re-tooling required by an aspiring value based enterprise focused on long term viability.

For instance, we’ve known for quite some time that an estimated 30% of the aggregate national healthcare spend is of the ‘waste, fraud and abuse (over-treatment)‘ variety. Yet whatever the percentage of an average health system’s base revenue can be so attributed, the historical contribution may have meant the difference between insolvency and viability for many health systems. In a production incentivized $3.7+ trillion annual spend healthcare economy, critical healthcare infrastructure (both professional and institutional) may have unwittingly put themselves ‘at risk’ by focusing solely on the short-term revenue optimization.

COVID-19: A Healthcare ‘Black Swan’ Event?

Wikipedia summarizes Nassim Taleb‘s theory of black swan events as follows:

The black swan theory or theory of black swan events is a metaphor that describes an event that comes as a surprise, has a major effect, and is often inappropriately rationalized after the fact with the benefit of hindsight. The term is based on an ancient saying that presumed black swans did not exist – a saying that became reinterpreted to teach a different lesson after black swans were discovered in the wild.

Does the disruption to U.S. healthcare operators presented by the COVID-19 pandemic qualify as a black swan event, or, was this ‘surprise‘ a wholly predictable event in the cross hairs of U.S. healthcare leadership for at least the last 20 years? For instance, might some of those ‘risk averse’ health system executives be re-assessing their choice to pass on percent of premium or global or partial PMPM capitated offers? Clearly those health systems that chose to work with their physicians and scalably enter into risk based contracts are in a better position than those who chose to stay with the familiarity of fee-for-servies incentives even of the ‘value based’ variety

Bottom-Line?

Without considerable transitional support if not operating subsidies to weather the storm and engineer the operating efficiencies of a ‘population centric’ health system with a holistic (vs. current payor class segmented book of business driven) mission to serve the communities in which they operate, our production driven health system chassis is at risk and on balance largely ill equipped to survive the demands of a post COVID-19 environment.

To address these critical issues and explore possible remedies, many national leaders will convene at the ‘Virtual Summit on Health System Recovery from the COVID-19 Pandemic‘ this June 22nd – 24th 2020. Loaded with top talent from major health systems, leading health plans and analysts this conference will explore the tremendous impact the COVID-19 Pandemic has had on the health care system and what the aftermath will look like.

Just thinking of the short and long term implications of the shutdown of elective procedures, the public health systems response, the management of the disease itself, the variable impact on communities around the country, the political response, lack of PPE, rapid move to telehealth, reopening facilites, employer responses and more, the effects have and will be profound.

Gaining an understanding of what the impact has been across the spectrum of healthcare delivery and finance and the likely road forward from key leaders who have and are managing through these issues will be critical to create a sustainable system able to deal with this new world.

This Virtual Conference will Bring together key leaders like:

  • Michael Dowling, CEO of Northwell Health, whose facilites have been dealing with the largest outbreak of COVID-19 in the World in New York City,
  • Humana’s CEO Bruce Broussard whose business has focused on the elderly on Medicare and innovative primary care models to
  • Donald Rebhun, MD Regional Medical Director, HealthCare Partners Medical Group and Affiliated Physicians,
  • Grace Emerson Terrell, MD, MMM, FACP, FACPE, General Internist, Wake Forest Health Network, chair of AMGA
  • Susan Dentzer, Senior Policy Fellow, Duke-Margolis Center for Health Policy.

And many others, this conference will provide a look into all sectors, players and issues. Here are just a few key highlights that caught our eye:

Primary Care has been uniquely impacted, from the financial threats associated with closing/scaling back practices to the rapid uptake of virtual visits. Presentations in this area will include:

  • The “New Normal”: How Primary Care can Reboot and Reopen
  • Advanced Primary Care/Medical Home COVID Impact Update
  • Health Care Without Walls: Telehealth and Virtual Care in the Public Health Emergency and Beyond

What about the move to value based care and alternative payment models? Are there opportunities in there, are some of these models a hindrance? Again some key presentations:

  • ACO COVID Impact Update
  • Bundled Payment COVID Impact Update
  • MACRA COVID Impact Update
  • Advanced Primary Care/Medical Home COVID Impact Update

And what of those areas that seem to receive less focus like The Post-Acute and Long-Term Care Systems in Covid-19 or Pandemic Palliative and Hospice Care. This conference will cover it all from an Update on Molecular and Serology Testing to Social Determinants of Health, Safety Net Hospitals and FQHCs to Big Data and AI. So join this two day conference to learn from others in your field and the broader healthcare system and help us all work to recover from this pandemic.

For a complete faculty listing and agenda, click here.

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*Post sponsored by GHC Health Care LLC.

 

 

 

 

 

 

 

 

 

 

Surprise Medical Bills In Context: Is Tech the Solution?

By Fred Goldstein, MS and Gregg Masters, MPH

It’s Q1 2020 and everyone is now rightfully preoccupied with the recent World Health Organization (WHO) declaration of the COVID-19 as a global pandemic.

Congress, the White House, National Institutes of Health (NIH), the Center for Disease Control (CDC) and local state and county health departments (collectively the public sector) and private or commercial healthcare ecosystem stakeholders are scrambling to ‘flatten the curve‘ on the spread of this novel coronavirus.

One of the many issues being debated includes who bears the cost burden, whether there should be co-pays or deductibles and whether the public health sector and private healthcare delivery and financing system can get on the same page to aggressively test the population at scale, and incidentally avoid the downstream drama of surprise medical billing. This will get interesting folks!

Meanwhile, some forty years have passed since ‘selective contracting’ or the managed care era launched in California and spread across the nation, driving the need for more accurate and complete databases to effectively drive ‘in-network’ utilization for health plan and managed care organization members, beneficiaries and patients. However, inaccurate provider directory information, both online and in print, is still common and often leads to (directly or indirectly) ‘surprise medical bills.’

Over the past few years the issue of in and out of network providers and ensuring patients can identify which providers are in network has received considerable attention. Almost everyone has a personal story ranging from annoyance to distress about the difficulty of finding the right in-network doctor or choosing a health plan — which is hard to reconcile in our otherwise digitally enabled information age.

Not only are accurate provider directories critical for health plan selection and referrals to appropriate care, it helps ensure that patients do not suffer the financial burden of having unintentionally gone to an out of network provider. In 2019, surprise medical bills associated with out of network providers has become a major political issue, with Congress this past year attempting to develop and pass legislation aimed at reducing the negative impact on patients.

In an article entitled ‘Surprise bills vary by diagnosis and type of admission’[1] the authors estimated that 18% of all emergency room visits and 16% of inpatient admissions resulted in at least one out of network bill.

While according to a 2018 survey[2] by the American Medical Association (AMA) and LexisNexis® Risk Solutions, more than half of U.S. physicians (52 percent) say they encounter patients every month with health insurance coverage issues due to inaccurate directories of in-network physicians.

This  issue not only impacts patients and their ability to access the care they need without experiencing a financial burden, but also the overall patient satisfaction for providers and facilities, who often times will hear from upset patients about unexpected out-of-network bills.

This is also a costly business issue for health plans and providers — It is estimated that health plans spend upwards of $2.1 billion per year maintaining their directories[3] including on provider outreach efforts. On the receiving end, providers may work with a dozen health plans, each with quarterly campaigns to keep their directories updated. In a climate of provider fatigue and strained plan-provider relations, this is both figuratively and literally adding more paper on our overflowing desks.

In 2015, California took a lead in seeking to solve this issue by passing SB-137 Health care coverage: provider directories. This bill recognized the importance of an accurate provider directory as the key piece to solving these issues.

This legislation requires:

a health care service plan, and a health insurer that contracts with providers for alternative rates of payment, to publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to the plan’s enrollees or the health insurer’s insureds, and would require the plan or health insurer to make an online provider directory or directories available on the plan or health insurer’s Internet Web site, as specified.

It also:

requires a plan to review and update their directory at least annually and to update its online provider directory or directories, at least weekly. 

That’s a tall order given the systems that health plans already had in place at the time. In an effort to meet compliance requirements, plans initiated even more outreach but the accuracy of provider directory data See CMS report: “Online Provider Directory Review Report”. Furthermore, many updates requested by providers did not end up reflected accurately in a plan’s member directories.

Shortly after SB 137 was passed, Blue Shield of California was tasked by the California Department of Managed Health Care (DMHC) to tackle the industry-wide provider directory inaccuracies in California as part of a large set of industry undertakings associated with their merger with Care1st (now Promise Health Plan).

Non-profit organization, Integrated Healthcare Association (IHA) was selected by Blue Shield, the California Department of Managed Care (DMHC) and a multi-stakeholder committee to lead the roll-out of a statewide solution for all plans and providers in California. This centralized platform, launched in 2019 as a the single place for healthcare providers and commercial, Medicare, and Medi-Cal health plans to update and reconcile the demographic and contractual information including primary phone number, address, specialty and accepting new patient status — information that patients ultimately depend on to make decisions about access and care.

[NOTE: On PopHealth Week we chat with IHA’s President and CEO Jeff Rideout. To listen, click on PopHealth Week logo.]

In a white paper summarizing results from the first year of Symphony’s roll-out in California, a baseline and early analysis shows that:

  • Nearly 30,000 records[4] contained at least 1 major provider identification issue that could cause significant consumer confusion
  • 317 records4 service locations listed are actually PO boxes
  • Nearly 4,000[5] unique providers were listed with a specialty inconsistent with their medical degree/training
  • 2765 unique providers still listed were actually deceased

While initial results are promising, a lot of work remains as more plans and providers onboard with Symphony. This data is a snapshot of how inaccurate current provider data can be. Understanding this baseline enables plans and providers to actionably correct these errors, leading to more accurate and up to date member directories and a more positive impact for patients, providers and payers.

The new white paper from the Symphony Provider Directory can be downloaded You can also learn more by watching this video or by going here.

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References:

[1] Pollitz, K., Rae, M., Cox, C., & Kurani, N. I. (2019, December 9). Surprise bills vary by diagnosis and type of admission. Retrieved from https://www.healthsystemtracker.org/brief/surprise-bills-vary-by-diagnosis-and-type-of-admission/

[2] Physicians, health plans must collaborate for network directory accuracy. (2018, February 27). Retrieved from https://www.ama-assn.org/press-center/press-releases/physicians-health-plans-must-collab-network-directory-accuracy.

[3] Issue Brief: Administrative Provider Data. CAQH [Analysis completed by Booz & Co., now Strategy&, Inc.]

[4] Based on 475,000 provider data records 

[5] Based on 160,000 unique providers

Population Health the 20th Anniversary Edition

By Fred Goldstein, MS, Alexandria Skoufalos, EdD and Gregg Masters, MPH

Can you believe it’s been 20 years since the first Population Health Colloquium? Back then, we were just a few months into a new century. Maybe some of you even remember the concern over whether Y2K (a programming shortcut that used two digits to represent a year) would cause a worldwide crash of IT systems.

We’ve come so far in 20 years…and it’s been an amazing ride! As we gear up for this year’s Colloquium, we thought it might be fun to take a look back so we can understand how far we’ve come in the field of population health.

Let’s step into the Wayback Machine to 2001…

Population Health’s BIG bang coincided with the publication of Crossing the Quality Chasm. This milestone report turned the industry on its head by pointing out many of the delivery system’s flaws and problems with quality. The recommendations in this report created a roadmap to redesigning America’s healthcare system.

Fast forward to 2007 (year 6 of the Colloquium), when the Triple Aim was the main topic of conversation…and we’ve been talking about it ever since! That trend will continue until we finally get it right!

The Triple Aim used a 3-legged stool as a concept model in 2007 with Population Health as one of the 3 original legs.

Clinicians have been working hard to make things better, so much so that the industry added an unofficial 4th aim in 2014.

  1. Improving the health of populations overall
  2. Reducing the per capita costs of health care
  3. Improving the patient experience, and voila
  4. Improving the work life experience for clinical providers

Whether it’s the Triple Aim or the Quadruple Aim, is there a stool (or chair) here we can sit on?

Let’s start with the first leg, Improving the health of populations. Life expectancy is a good measure of health.

According to the CDC’s National Center for Health Statistics, a child born in the US in 2000 had an average projected lifespan of 76.7 years (74.1 for men and 79.5 for women). There are stark disparities in the range, though, if you drill down into the details (we’ll come back to that later):

Although overall the North American continent enjoys the highest overall life expectancy, the US stats have not increased on par with other developed nations; in fact, they actually declined over some of the last few years.

United States – United Nations – World Population Prospects

During this 20 year period, the U.S. performed poorly, registering a modest increase of just 2.2 years overall. The rate of increase was affected by the fact that we actually experienced a reduction in Life Expectancy from 2014 through 2017 and a modest 0.1 increase in 2018 per a recent CDC report released January 30, 2020. During the same period, Japan showed a positive increase every year, and Portugal, which started slightly behind the US, showed a positive increase every year AND increased their Life Expectancy by almost 5 years,

https://population.un.org/wpp/Graphs/Probabilistic/EX/900

Infant Mortality is another good measure of population health. Let’s get a look at how we compare on that front with the same countries.

The US began the period with a higher infant mortality rate than either Japan or Portugal, and although we lowered our rates, so did they…and they outperformed us in terms of improvement, even though they began the period with lower mortality rates!

So as far as these measures and their association to improved health of populations, although we haven’t completely removed a leg, this stool is a little wobbly.

Let’s take a look at the next leg, reducing per capita costs.

“By 2000, health expenditures (in the U.S.) had reached about $1.4 trillion, and in 2018 the amount spent on health had more than doubled to $3.6 trillion. On a PMPM basis for the same time period the US increased 130% while Japan increased 55% and Portugal 86%.

(Source: KFF analysis of National Health Expenditure (NHE) data

This difference is well illustrated in the graph below on a Per Member Per Month Basis.

This leg of the stool has been practically sawn off!

One thing we in the US do better than anyone is spend money, and clearly this stool is in jeopardy of collapsing.

But, wait! We still have two more legs.

How about improving the experience of care?

Have you seen the headlines??

  • Bankruptcies due to healthcare costs (even among those with insurance),
  • Surprise bills
  • Spiraling costs for pharmaceuticals
  • Excessive wait times
  • Access to data

The list goes on…and Americans are not pleased.

And what of the fourth aim, improving the work life experience for healthcare providers?

The burnout rate for clinical professionals is at an all-time high, with suicides showing signs of increase.

At a number of recent healthcare conferences, many people quote Bill Gates when discussing our future:

“We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next ten. Don’t let yourself be lulled into inaction.”

Bill might be correct in terms of computers, software, IT and Silicon Valley, but another axiom is “Past Performance is Indicative of Future Behavior.” Might this doom healthcare forever? Or, is this the year we stand up at this Colloquium, and say

“NO!

We have planted many seeds over the past 20 years; some have sprouted and are growing, others may be close to harvest! We can drive change by focusing like a laser on the Quadruple Aim as one stool with 4 equally important legs…because if it won’t stand, neither will we.

Make 2020 the year of transformative change. Join us at the Population Health Colloquium. We can’t afford to waste a single second!

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Health Care ‘Texas Style’: A Model for the Nation?

By Gregg A. Masters, MPH

This a re-post of an article written in October 2009 following Atul Gawande‘s article in the New Yorker on the ‘cost conundrum‘ which launched his presence and eventual celebrity on the national stage. Gawande was calling attention to the regional variations (small area analysis) in the Medicare spend and associated health disparities that can be found in the United States while generally adjusting for comparable characteristics of each community. The comparison of Medicare costs in El Paso vs. McAllen caught and retained my attention as many years later the discrepancy remains largely unresolved.

One might ask why?

Having just returned from the Medical Group Management Association’s (MGMA) annual conference in New Orleans, I was struck by and tweeted out the following observation reported by the largest for-profit hospital operator in the U.S.:

Some 10 years later this 5% ‘share’ of risk business is evidence that the healthcare landscape (at least at the hospital or health system level and especially so for the for-profit sector) remains a risk averse, “heads in beds“, fee for services economy with pockets of innovation demonstrating value, while for the remainder of the cohort there’s little appetite for risk assumption beyond toe in the water shared savings or bundled payment commitments.

Unfortunately, ‘value based healthcare‘ often a proxy for capitation (full or partial), all in population based payments or downside risk assumption remains mostly ‘ad copy‘.

For more information on the dubious claims of health system horizontal and select vertical mergers, listen to ‘BS in Healthcare‘ interview with Layton R. Burns, PhD, Professor and Director, Wharton Center for Health Management and Economics, at the Wharton School.

Original post:

In the aftermath of Atul Gawande’s landmark piece ‘The Cost Conundrum‘ and the selective emergence of the ‘Mayo v. McAllen‘ mantra, I’ve been tweeting of late on the ‘irony’ of certain Texas health markets, particularly given the concentration of hospital assets in non profit health systems, and the timely question of whether such consolidations produce the ‘community benefits’ proffered by their leadership. The recently published Commonwealth Fund study ‘Aiming Higher: Results from a State Scorecard on Health System Performance, 2009‘ has supplied certain metrics to further contextualize the conversation.

First some background: I spent 13 years in the Lone Star state, initially advising a major national proprietary hospital management company’s implementation of its managed care strategy in the Houston market, followed by implementation physician networks for a 140,000 member global risk Medical Group, and finally managing payor and provider contracts for a joint venture ‘Super PHO’ affiliated with a dominant faith based hospital system in Dallas/Fort Worth.

Now mind you, everything in Texas is big – especially its delivery system players who have literally architected quite beautiful (and very expensive) ’cathedrals of medicine’. Examples include: the Texas Medical Center (an NIH like cluster of some 12+ competing institutions), Memorial Hermann Health System, Baylor Health Care System and Texas Health Resources to name a few of the trophy properties. Yet, years after the roll out of the strategic plans of these health systems, and the fulfillment of their market share objectives, certain of the state’s health care indicators look quite grim when contrasted to other parts of the country.

One might wonder why? Afterall, the typical pre-merger or alliance argument in favor of consolidation, acquisition or market expansion, was typically framed as follows, it will:

  • Improve quality
  • Improve access
  • Increase operating efficiencies; and
  • Lower costs

Yet according to the Commonwealth Fund study, and now years after these consolidations, here’s how Texas ranks on key metrics of health status compared to all 50 states, and the District of Columbia.

  • Overall: 46
  • Access to care: 51
  • Prevention & Treatment: 43
  • Avoidable Hospital Use & Costs: 42
  • Equality between rich and poor: 50
  • Equality between non-Hispanic white and minority: 48
  • Healthy lives: 21
  • Children with medical and dental check-ups in past year: 40
  • Adults with a regular doctor: 49
  • Medicare reimbursements: 46
  • Infant mortality: 19
  • Breast-cancer deaths: 18
  • Colorectal cancer deaths: 15
  • Adults who smoke: 17
  • Overweight or obese children: 32

Not exactly ‘best in class’. So why not ask, where is the ostensible and promised ‘community benefits’ and not just those codified in IRS code, to justify the tax exempt status for most of the entities above? How is this ‘return’ (to the community) being measured; (is it via Medicare or Medicaid ‘shortfalls‘, or charity and bad debt write-offs; or some tangible real world contribution); or is it even accurately measured? The IRS 990 filings are somewhat ‘fluid’ on the specific reporting of activities that count towards community benefit.

Most, if not all, of these institutions are primarily ‘non profit’ (with some affiliate JV exceptions) yet they are aggressively managed to generate a surplus of revenue over expenses; after all ‘no margin, no mission’. While they do not have stock holders or investors per se, they do have bonds that require adequate debt service coverage in order to maintain favorable credit ratings and competitive access to capital.

This is where the ’story’ for the consolidations and, for some, the unspoken truth of the matter emerge, IMO. While perhaps stated in the vision for some, most of the benefits of consolidation are to be found in the pricing leverage that comes from asset concentration. Hospitals want higher rates, and payors (health plans and insurance companies) can tell you how difficult it was, and likely remains today, to extract material discounts from these massive institutions given their scale and market dominance.

So the question remains open: have they delivered, or are they just plain ‘doin’ it wrong’? Is the promised value proposition a reality today for the Texas residents they purport to serve? Based on these, and other metrics, many would say no. Rather than more of these Texas sized giants, why not refocus the Lone Star state on their one home grown version of a ‘Mayo Clinic’ model domiciled in Temple, Texas aka ‘Scott and White‘.

In the next blog post, i’ll touch on the physician role in the Texas market, and the historical rise and fall of physician driven integrated delivery systems in particular.

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ACOs and Value Based Care: The Best of Times Or The Worst of Times? It Depends!

By Fred Goldstein, MS and Gregg Masters, MPH

This past year has seen major changes to the Medicare Shared Savings Program (MSSP) that launched the huge growth in Accountable Care Organizations (ACOs) a principal workhorse in the transformational copy of the Affordable Care Act (ACA).  It seems that the Center for Medicare and Medicaid Services (CMS) and the industry had a difference of opinion as to how successful ACO’s were under the original model, and of course CMS won.

The argument had to do with just how well the ACOs involved in the Medicare Shared Savings Program Track one participants were doing.  For those new to this, the Track 1 model were the least risky model, with most ACOs choosing this upside risk or shared savings only track which had a term of six years before they had to begin taking on two sided risk.

CMS looked at the 2016 data and was seeing limited savings particularly with the overwhelming majority of participating ACOs enrolled in this track. In May of 2018 Seema Verma (CMS Administrator) hinted at a new approach pointing to a study by Avalere that ACOs not only did not save money, but they have increased federal spending by $384 million, versus a projected $1.7 billion in net savings from 2013 to 2016. Couple this concern with the ongoing debate on whether Medicare Advantage Plans (MAs) are still costing the Treasury (via over funding or “up-coding”) vs. advancing the needle on the Triple Aim (better experience of care, better outcomes at lower per capita costs).

Of course, the industry, led by the National Association of ACOs (NAACOs), were completely against this decision and stated that the ACOs had indeed saved money when they reviewed the 2017 results, which indeed showed net savings of $314 million dollars. NAACOS also stated that if these changes were made many ACOs would quit , pointing to a survey they had conducted showing that 71% of the ACOs in track 1 would quit if they had to take on 2 sided risk.

But by then it was too late and in last December CMS announced their new Pathways to Success models with the following by Seema Verma:

…the presence of an “upside-only” track may be encouraging consolidation in the marketplace, reducing competition and choice for Medicare FFS beneficiaries. While we understand that systems need time to adjust, Medicare cannot afford to continue with models that are not producing desired results.

The key changes were as follows:

    • Only 2 years before ACO must accept down-side risk
    • Beneficiaries notification of ACO participation at 1st primary care visit
    • Payment for tele-health services
    • Incorporates regional spending into ACO targets
    • Authorizes termination of ACOs with multiple years of poor financial performance
    • Could potentially save $2.2 billion in Medicare costs during the next 10 years

The new tracks and their “glide path” are as follows:

 

So what does this mean for ACOs?

What better place to figure this out than the Florida Association of ACOs annual meeting. Florida has been leading the way in ACO participation and performance and while this conference is in beautiful Orlando Florida in the fall, the attendees and speakers are national so one can get a full view of the impact and what’s working.

For an update on market conditions including an overview of the annual conference from FLAACOS CEO Nicole Bradberry, listen here.

Florida Association of ACOs

Attending the 2019 FLAACOs annual conference you’ll hear from Aneesh Chopra, President, Care Journey and former CTO of the United States opening the conference, followed by, you guessed it, a panel on MSSP ACO and Pathways to Success with Sheila Fusé, Vice President, Policy and Payment Models Navvis Healthcare, Kelly Conroy, Executive Director Holy Cross Physician Partners ACO, Travis Broome, Vice President for Policy and ACO Administration, Aledade a technology enable physician practice management company who recently reported some rather impressive results for 2018 from their network of clients ACOs.

The conference will then dig deeper exploring such topics as the new CMS primary care contracting models, Social Determinants of Health (SDoH), Direct employer contracting 2.0 and mental/behavioral health from a rather packed agenda.

So, join us November 7th – 8th in Orlando Florida to network and learn from those getting it done in the ACO world.

For registration details, click here.

This post is sponsored by the Florida Association of Accountable Care Organizations (FLAACOs)

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