HEALTH CARE un-covered's New Beat: Disintermediation

By Wendell Potter - As I’ve written previously, before I left my job as VP of corporate communications at big health insurer Cigna, I was in a leadership meeting with the company’s CEO at the time, Ed Hanway. Read Full Article… 

VBA Article Summary

1. Ed's Insightful Concern: In 2007, during a casual meeting, Ed, a respected leader, voiced his concern about "disintermediation," highlighting a fundamental fear within the health insurance industry. This term referred to the potential erosion of the industry's role as intermediaries between employers and health care providers, prompting a deep-seated worry about the future viability of their business model.

2. Rising Trends of Disintermediation: Recent developments indicate Ed's apprehension was well-founded. Increasingly, employers and unions are exploring alternatives to traditional health insurance models, driven by dissatisfaction with rising costs and opaque practices. This awakening among key stakeholders signifies a significant shift in the landscape of employee health benefits, away from reliance on major insurance companies.

3. Introducing the Disintermediation Beat: In response to these emerging trends, HEALTH CARE un-covered is launching a new focus area termed "DISINTERMEDIATION." This initiative aims to shed light on the efforts of individuals and organizations actively disentangling themselves from the grip of major insurers. Through in-depth reporting and analysis, the publication seeks to champion a fairer, more transparent approach to employee health benefits, showcasing success stories and advocating for systemic reforms.

Hospitals largely keep quiet on maternal care since Dobbs, STAT survey finds

By Olivia Goldhill - The Supreme Court decision to overturn Roe v. Wade has transformed not just abortion access but maternal health care across the United States, causing physicians in states with restrictive laws to shift treatment of conditions including ectopic pregnancy and miscarriage. Read Full Article…

VBA Article Summary

1. Silencing of Physicians: In the aftermath of the Dobbs ruling, a STAT survey conducted across 100 hospitals revealed a pervasive silence among physicians regarding changes in maternal healthcare. Fear of political scrutiny and financial repercussions has created a climate where physicians feel unable to openly discuss their experiences, leading to a stark lack of transparency within the medical community.

2. Impact on Patient Care: The implications of Dobbs extend far beyond abortion, affecting various aspects of maternal healthcare across different states. Instances of denying care for conditions like preterm premature rupture of membranes (PPROM), miscarriage, and ectopic pregnancy highlight the restrictive environment faced by physicians, ultimately compromising patient well-being and access to essential healthcare services.

3. Consequences of Silence: The reluctance of physicians and hospitals to openly discuss the impact of Dobbs not only perpetuates fear and uncertainty within the medical community but also hampers efforts to advocate for patients, particularly marginalized populations. This lack of discourse limits public awareness and understanding of critical healthcare issues, hindering efforts to ensure equitable access to comprehensive maternal healthcare services.

Feds open another PBM probe

By Paige Twenter - CMS is auditing vertically integrated Medicare Part D sponsors, including pharmacy benefit managers and payers, according to HHS' Office of Inspector General. Read Full Article…

VBA Article Summary

1. CMS Investigates Part D Medication Prices: CMS is launching an investigation into unspecified insurers and PBMs regarding their pricing practices for Part D medications. This move comes as a response to the growing trend of vertical integration between PBMs, health insurers, and pharmacies, with concerns about inflated drug prices.

2. Federal Agencies Unveil Reporting Portal: On April 18, the Federal Trade Commission, Justice Department, and HHS introduced an online portal for the public to report anticompetitive healthcare practices. This initiative aims to gather information and address concerns about potential antitrust violations within the healthcare industry.

3. Ongoing Federal Probes Targeting PBMs: Multiple federal investigations into PBMs are already underway. The FTC's scrutiny focuses on the six largest PBMs, including CVS Caremark, Express Scripts, OptumRx, Humana Pharmacy Solutions, Prime Therapeutics, and MedImpact Healthcare Systems, which accounted for 94% of all prescription claims in 2023. Despite ongoing investigations, none of these PBMs have fully complied with requests, according to FTC Chair Lina Khan's communication in a Feb. 13 letter.

HHS streamlines 340B dispute process to hospitals' applause, pharma's disappointment

By Dave Muoio - The Biden administration has put the finishing touches on the steps entities covered under the 340B Drug Discount Program must take to resolve disputes with drug manufacturers. Read Full Article…

VBA Article Summary

1. Streamlined Access for 340B Entities: The final rule issued by the Department of Health and Human Services (HHS) and the Health Resources and Services Administration (HRSA) aims to address "policy and operational challenges" in the existing 340B Administrative Dispute Resolution (ADR) process, making it more streamlined and accessible for 340B entities of all sizes. This move is welcomed by hospital groups but draws frustration from the pharmaceutical industry.

2. Enhanced Accessibility and Fairness: HHS acknowledges the need for accessibility in the ADR process, especially for small, community-based organizations with limited resources. By moving away from federal evidence and procedural rules that made disputes "trial-like" and establishing a panel of subject matter experts, the final rule seeks to ensure a fair and accessible resolution process.

3. Stakeholder Reactions and Calls for Further Consideration: While associations like 340B Health and the American Hospital Association (AHA) commend the updates, pharmaceutical trade groups like PhRMA express dissatisfaction, claiming the revised process favors 340B hospitals. Calls for further reconsideration include excluding Medicaid managed care claims from ADR review and shortening the decision timeline, highlighting ongoing tensions between stakeholders in the 340B program.

Burnish your value proposition: 5 ways to combat rampant medical overbilling

By William R. Mattecheck - Overbilling of medical services is running rampant across a benefit broker's book of business, hidden in plain sight. It's a national epidemic. Read Full Article…

VBA Article Summary

1. The Hidden Toll of Overbilling: Most group health clients are unknowingly overbilled millions annually, leading to staggering costs for employers and members alike. This systemic issue erodes trust between clients and brokerage firms, highlighted by alarming annual renewals and escalating out-of-pocket expenses.

2. Escalating Legal and Financial Risks: Recent lawsuits, like the one against Johnson & Johnson, signal a troubling trend in ERISA fiduciary duty breaches over mismanaged health plan funds. Moreover, routine hospital practices, such as adding billions in facility fees, exacerbate the problem, fueling dissatisfaction and mounting financial hardships for individuals and businesses.

3. Navigating Towards Solutions: Despite the daunting landscape, there's a clear path forward. Advanced payment-integrity technology coupled with expert medical and legal oversight offers a beacon of hope. Engaging experienced physicians and surgeons in bill review and repricing not only shields patients from predatory practices but also saves clients millions yearly. These measures not only ensure fair payment for medical services but also safeguard against litigation, ultimately elevating the value proposition of brokerage and advisory firms across multiple fronts.

Optum enacts layoffs, workers say 

By Jakob Emerson - Former employees with UnitedHealth Group's Optum and its subsidiaries took to social media beginning April 18 regarding a reduction in force they say occurred across the company. Read Full Article…

VBA Article Summary

1. Optum's Silence and Uncertainty: Despite inquiries, Optum declined to offer additional details on April 19 regarding recent layoffs. Becker's Hospital Review hasn't confirmed specific numbers or timelines for the termination of employees, leaving a cloud of uncertainty over affected individuals and communities.

2. Widespread Impact Across Roles: Former employees across LinkedIn have shared accounts of layoffs affecting various roles within Optum and its affiliated providers. From RN case managers to senior directors, the layoffs seem to have had a broad impact, underscoring the depth of the restructuring within the organization.

3. Context of Industry Trends: The layoffs at Optum come amidst a broader trend in the insurance sector. In 2023, many major insurers undertook significant workforce reductions due to financial challenges and restructuring initiatives. Optum itself had previously executed layoffs in August, affecting multiple facilities across different regions, further highlighting the ongoing turbulence within the organization and the industry as a whole.

UnitedHealth CEO to testify before US House panel on cyberattack at tech unit

By Reuters - UnitedHealth (UNH.N), CEO Andrew Witty will testify before a U.S. House subcommittee on May 1 about a recent cyberattack at the company's technology unit and its impact on patients and providers, the Energy and Commerce Committee said on Friday. Read Full Article…

VBA Article Summary

1. Disruption of Healthcare Payments Nationwide: The hack at Change Healthcare on Feb. 21 resulted in a significant disruption of payments to doctors and healthcare facilities across the United States for a month, highlighting vulnerabilities in healthcare billing and data systems.

2. Financial Strain on Providers and Patients: Individuals and smaller healthcare providers have faced financial challenges in the aftermath of the cyberattack. This financial strain not only threatens the viability of these providers but also jeopardizes critical access to healthcare services for patients who rely on them.

3. Congressional Inquiry and Industry Impact: Congressional leaders, including Cathy Rodgers and Morgan Griffith, have expressed concern over the incident and have called for a hearing to investigate the attack and its consequences. With UnitedHealth estimating the cost of the hack to be up to $1.6 billion this year, the incident underscores the need for robust cybersecurity measures in the healthcare sector to safeguard the well-being of all Americans.

Connecting the voluntary dots … and data

By Nick Rockwell - Application programming interface technology — software that allows different computer systems to "talk" to each other and share data — may be one of the hottest trends in the voluntary benefits industry. Less than two-thirds of carriers surveyed for Eastbridge's new "Application Programming Interface & Artificial Intelligence Carrier Practices" Frontline™" report are using APIs now, but nearly all respondents expect to in the near future. Read Full Article…

VBA Article Summary

1. Adoption Trends: The majority of carriers leveraging APIs focus on enrollment facilitation and insurability verification. While fewer integrate APIs for billing and policy setup presently, ongoing advancements suggest broader adoption in the future. Most carriers have recently added new APIs, indicating a growing comfort with and recognition of their potential.

2. Operational Efficiency: APIs significantly enhance carrier operational efficiency, reducing data errors, expediting enrollments, and accelerating account setup. Carriers report quicker underwriting, proposal generation, and billing processes. Clients benefit from streamlined interactions, finding it easier to engage with carriers utilizing APIs.

3. Barriers to Adoption: Despite evident benefits, over a third of carriers have yet to embrace API data exchange. Common obstacles include financial constraints, lack of technical resources, and competing priorities. Nevertheless, many of these carriers are in the process of building or updating systems to accommodate API functionality, indicating a shift towards integration.

Medical Providers Still Grappling With UnitedHealth Cyberattack: ‘More Devastating Than Covid’

By Samantha Liss - Two months after a cyberattack on a UnitedHealth Group subsidiary halted payments to some doctors, medical providers say they’re still grappling with the fallout, even though UnitedHealth told shareholders [last] Tuesday that business is largely back to normal. Read Full Article…

VBA Article Summary

1. Severe Disruption in Healthcare Operations: The cyberattack on Change Healthcare, a key player in processing U.S. patient records, has caused significant disruption in the healthcare sector. Therapists like Emily Benson in Edina, Minnesota, and medical practitioners such as urologist Alex Shteynshlyuger in New York City are struggling to maintain their practices and pay their bills due to the inability to process claims and receive payments from insurers.

2. Financial Hardship for Providers: The fallout from the cyberattack has led to financial strain for healthcare providers across the country. Benson had to take out a loan of nearly $40,000 just to cover her practice's bills. Shteynshlyuger resorted to transferring personal funds to keep his office running. This financial burden not only affects the providers themselves but also jeopardizes their ability to provide care and maintain their businesses.

3. Delayed Resolution and Congressional Scrutiny: Despite efforts by UnitedHealth Group to restore services and provide assistance to affected providers, the full restoration of operations is not expected until next year. The cyberattack has already cost the company $870 million, with expectations of exceeding $1 billion in losses for the year. Congressional hearings, such as the one held by the House Energy and Commerce Health Subcommittee, highlight the severity of the situation and the frustration among lawmakers regarding the impact on patient care and provider stability.

Clear Communication and Management of Expectations at Admission and Discharge Emerge as Key Drivers of Hospital Patient Satisfaction

By J.D. Power - In the post-pandemic world, hospital staffing has become a moving target. Costs have soared for many facilities, forcing them to stretch their resources to match fluctuating demand. Add in frequent provider turnover and employee burnout, and these conditions have left many hospitals across the United States struggling to meet demand. Hospital patients are noticing. Read Full Article…

VBA Article Summary

1. Admission and Discharge Efficiency: Almost half of hospital patients in the United States report waiting more than two hours to reach their room after arriving, significantly impacting their satisfaction. Streamlining admission and discharge processes and providing comprehensive post-discharge care information can enhance patient experience and reduce readmissions.

2. Nursing Care Excellence: While access to doctors remains a challenge, patients express high satisfaction with nursing care. Effective communication of care plans, timely tests and procedures, and regular check-ins from nurse managers contribute significantly to patient satisfaction scores.

3. Quality of Amenities and Environment: Patient dissatisfaction persists with hospital food quality, menu choices, and noise levels during nighttime hours. Improvements in food services and creating a quieter, more conducive environment for rest can elevate overall patient satisfaction, alongside maintaining cleanliness standards and minimizing disruptions.