CMS tweaks ACO REACH to stabilize model

By Rebecca Pifer - ACO REACH, which began its first model year in January, is a redesign of CMS’ controversial direct contracting model that’s meant to tie traditional payments in Medicare to value and improve care coordination. Regulators shelved the direct contracting program last year, after some progressives slammed the model as a thinly veiled effort to privatize the Medicare fee-for-service program. Read Full Article…

VBA Article Summary

1. Major Changes Introduced: The CMS (Centers for Medicare & Medicaid Services) has unveiled several changes to the ACO REACH program. These changes aim to boost participation in the alternative payment model. Key alterations include a decrease in the enrollment minimums for accountable care organizations (ACOs) and modifications to the risk adjustment methodology, bringing it in line with Medicare Advantage's system. Additionally, the amount of money that ACOs must reserve to offset risks has been increased. This model offers physicians the option to accept full or partial capitation, and it poses higher levels of risk and reward than other ACO models while granting more flexibility.

2. Emphasis on Health Equity and Governance: The revamped ACO REACH program places a greater emphasis on health equity and provider governance. This distinguishes it from its direct contracting predecessor. Additionally, the CMS has incorporated new criteria to identify underserved beneficiaries for the health equity benchmark adjustment. Recognizing the need to support ACOs with the most vulnerable beneficiaries, CMS will offer an additional $30 per-person per-month for those ACOs with the highest-need beneficiaries.

3. Stakeholder Reception and Specific Adjustments: The changes introduced have garnered positive feedback from stakeholders, particularly the National Association of ACOs (NAACOs). NAACOs has remarked that the concerns of its members have been substantially addressed with these changes. The CEO of NAACOs, Clif Gaus, has expressed confidence that these changes will ease apprehensions and stabilize future participation in the program. Specific adjustments include reducing the minimum enrollment numbers from 5,000 to 4,000 for new ACOs starting the upcoming year. For ACOs catering to high-need, complex patients, the minimum has been decreased to 1,000 for 2025 and 1,250 for 2026. Moreover, the CMS has broadened the enrollment criteria for these high-need ACOs and introduced a buffer, permitting ACOs that fall short of the enrollment mark by up to 10% to stay in the program for an extra year.

Senators Warren, Grassley and others taking bi-partisan action to address business practices of non-profit hospitals

By Wendell Potter - American Hospitals: Healing a Broken System, a documentary I helped produce, premiered in Washington on March 29. One of the main points of the movie is that many nonprofit tax-exempt hospitals are sitting on piles of cash, but few are filling their legal obligation to spend appropriate amounts of money to improve the health and well-being of people in the communities they serve. Read Full Article…

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1. Nonprofit Hospitals and the Law: For over 50 years, federal law mandates that nonprofit hospitals allocate enough revenues towards "community benefit" initiatives to maintain their tax-exempt status. The Affordable Care Act of 2010 introduced further requirements for these hospitals, including the obligation to conduct a community needs assessment every three years, and prohibitions against discrimination and unfair billing practices. However, a study by the Lown Institute found that 77% of the 1,700 hospitals examined spent less on charity care and community investment than the estimated value of their tax exemptions.

2. Concerns and Calls for Accountability: A documentary spotlighting this issue caught the attention of influential lawmakers, leading to increased scrutiny of hospital practices and finances. Senators Charles Grassley, Elizabeth Warren, Bill Cassidy, and Raphael Warnock issued a joint letter to the IRS and Treasury Department. They expressed concerns that many nonprofit hospitals might be exploiting the broad definition of "community benefit", and that some were counting spending on administrative functions that shouldn't qualify. The letter highlighted how many tax-exempt hospitals have accumulated substantial reserves, directing funds towards opulent facilities in affluent neighborhoods while neglecting hospitals serving impoverished and rural communities. Additionally, some of these hospitals have been aggressively seeking payments from financially struggling patients who should be eligible for charity care.

3. Push for Change and Oversight: Senator Grassley, in particular, has advocated for reforms in nonprofit hospital practices based on his past investigation into their adherence to legal obligations. The aforementioned bipartisan letter from the senators urged the Treasury Inspector General for Tax Administration and the IRS to examine hospital compliance with federal requirements and to clarify the criteria for what can be considered a "community benefit." The article promises to keep readers updated on the response from the Treasury and IRS, as well as the availability of the documentary for private viewings.

KFF Tracking Poll July 2023: Substance Use Crisis And Accessing Treatment

By Grace Sparks, Alex Montero, Ashley Kirzinger, Isabelle Valdes, and Liz Hamel - Substance use disorder and addiction issues surged during the COVID-19 pandemic, coming after more than a decade of increased use of alcohol and an opioid crisis that has been labeled by public health officials as “an epidemic.” The latest KFF Health Tracking Poll explores the public’s concern and experiences with alcohol and drug addiction and its consequences, as well as access to treatment and ways to prevent opioid use disorder (OUD) and overdoses. Read Full Article…

VBA Article Summary

1. Magnitude and Reach of Substance Use Crisis: U.S. overdose deaths reached a record high in 2022. A significant 66% of adults have been directly affected by the substance use crisis, either personally or through a family member. This includes experiences such as addiction to alcohol or drugs, homelessness due to addiction, or having undergone a drug overdose leading to hospitalization or even death. Opioid addiction has been reported by 29% of U.S. adults, revealing its extensive reach. Demographic differences were observed in the impact, with a more significant number of White adults and those in rural areas indicating personal or familial experiences with opioid addiction.

2. Treatment Access and Efficacy: Less than half (46%) of those affected by addiction (whether prescription drugs, alcohol, or illegal drugs) have received treatment. Disparities in treatment access persist, with White adults being more likely to report receiving treatment compared to Black and Hispanic adults. Among those who reported opioid addiction, only a quarter mentioned treatment using specific medications like buprenorphine or methadone.

3. Impact on Relationships and Mental Health: A substantial 76% of those affected by addiction reported at least a minor impact on their family relationships. Additionally, significant shares reported impacts on their mental health and financial situation. Beyond the immediate impacts of addiction, many Americans express deep-seated concerns about the substance use crisis. For instance, 51% are worried about a family member developing a substance use disorder, and 32% are concerned about potential overdoses on opioids.

The findings underscore the extensive reach of the substance use crisis in the U.S., revealing how it has touched the lives of a majority of adults in various ways. The challenges in accessing treatment, particularly among certain demographic groups, highlight areas where more focused efforts might be required. Additionally, the profound impact on familial relationships and mental health emphasizes the broader repercussions of the crisis beyond the immediate health risks associated with substance use.

The latest trend in employee retention? Even more pet benefits

By Dawn Kawamoto - As HR leaders struggled with recruiting and retention in recent years, many set their sights on expanding benefits for employees. With the added challenge of getting talent to come back into the office today, experts say, HR needs to double down on innovation in benefits—and one way to do that is to broaden the focus to include pets. Read Full Article…

VBA Article Summary

1. Pandemic’s Role in Heightened Pet Adoption and Changing Work Culture: The COVID-19 pandemic led to a surge in pet adoption, with nearly one in five households in the U.S. welcoming a new cat or dog, equating to 23 million households. As many employees transitioned to work-from-home arrangements during this period, a bond developed between them and their pets. This emotional attachment has influenced some employees' decisions about returning to in-person work, with many now seeking jobs that are more accommodating to their pets. Nationwide's survey underscores this trend, revealing that about one-third of pet owners would have a stronger inclination to stay with an employer that provides pet benefits. This sentiment is even more pronounced among Gen Z (49%) and millennials (45%).

2. Emerging Pet-Related Employee Benefits:

   Pet Insurance: Once a niche offering, pet insurance has grown in popularity, with its adoption rate among employers jumping from 11% in 2020 to 16% recently. This insurance has also expanded in scope to cover a wider range of pet care services.

   Paid Time Off for Pet Care: Businesses are increasingly recognizing the deep bond between employees and their pets, leading to benefits like "paw-ternity" leave for new pet adoptions and paid time off for pet-related emergencies.

   Pet-Friendly Workplaces: Some businesses are transforming their empty office spaces into pet daycare centers to appeal to employees. Research suggests that dog-friendly offices can bolster company culture, improve employee morale, and elevate happiness at work.

3. Guidelines for Establishing a Pet-Friendly Workplace: While creating a pet-friendly work environment can yield significant benefits, it's crucial to approach the transition collaboratively and gradually. To ensure a smooth transition, businesses can start by hosting events like "Take Your Dog to Work Day" before formalizing more permanent pet-related policies. Design considerations, including décor selections, should prioritize pet safety. Employers must also account for potential challenges like allergies or apprehensions some employees might have around animals. Implementing a designated pet-friendly zone and ensuring compliance with local regulations can help navigate these challenges.

Demand for weight loss drugs soars to nearly half of Americans

By Alexandra Pecci - Drugs like the buzzy Ozempic are high on consumers’ radar — but lofty barriers to access remain. American consumers want to take weight loss drugs and are confident in pharma companies’ ability to develop them, according to a new KFF Health Tracking Poll. Read Full Article…

VBA Article Summary

1. Popularity and Consumer Interest in GLP-1 Receptor Agonists: Ozempic, an injectable form of semaglutide, has gained significant popularity in pop culture, especially for its off-label use for weight loss among celebrities. Other GLP-1 receptor agonists, such as Wegovy and Mounjaro, have also gained recognition with about 70% of adults indicating some level of familiarity. Despite the high level of interest and trust in pharmaceutical companies to develop these drugs (75% trust in development, 66% in safety information, and 64% in effectiveness information), pricing remains a significant concern.

2. Cost and Accessibility Concerns: Only 22% of consumers trust pharmaceutical companies to price their products fairly, and the cost becomes a determinant in whether consumers would use these products. Drugs like Ozempic and Wegovy often aren't covered by insurance, leading to high out-of-pocket expenses for patients. The average cost of Ozempic is around $804 per month. The high costs highlight a disparity: those who can afford Ozempic for weight loss versus those who need it for its approved indication (Type 2 diabetes) but can't afford it.

3. Emerging Studies and Controversies Surrounding GLP-1 Receptor Agonists: There are emerging studies and discussions around potential uses of Ozempic for conditions like Alzheimer’s, liver disease, kidney disease, and even COVID-19. A recent study by Novo Nordisk reported that semaglutide reduces the risk of major adverse cardiovascular events in overweight adults. However, controversies also exist. A woman in Louisiana is suing Novo Nordisk and Eli Lilly, alleging they did not sufficiently warn consumers about possible side effects like gastroparesis.

Radiation, a mainstay of cancer treatment, begins a fade-out

By Angus Chen - Every year, doctors get better tools to fight cancer. Engineered cancer-killing cells, immunotherapies, targeted drugs, and more are helping clinicians cure more patients. Increasingly, though, oncologists are trying to use less radiation, long one of the main pillars of cancer therapy. In some cases, they are even keeping certain patients with low-risk tumors off radiation entirely. Read Full Article…

VBA Article Summary

1. Evolution of Cancer Treatments: Historically, there's been a dilemma in cancer treatment about how much therapy a patient can withstand before it becomes too toxic. This has led to a continuous evaluation and adjustment of the intensity of treatments like surgery, radiation, and chemotherapy. Over decades, medical professionals have become more comfortable with less intensive interventions. For instance, procedures like the radical mastectomy have transitioned to breast-sparing surgeries due to evidence-based approaches and clinical trials. Radiation therapy, from its inception after the discovery of X-rays and radium in the late 1800s, has undergone significant advancements. Its application and intensity have changed in tandem with the aim of reducing off-target damage and improving patient outcomes.

2. Reducing Radiation in Favor of Precision: Ongoing research shows that there are now scenarios, especially for certain low-risk or early-stage cancers, where radiation might be safely omitted without compromising the treatment's efficacy. Modern treatments and tools, such as improved imaging and biomarkers, allow oncologists to better assess the risk profile of different cancers. With advancements in surgeries, chemotherapies, and molecular tests, there's a push towards reducing treatment toxicity. An example of this transition can be seen in rectal cancer treatment, where certain "higher" tumors might be treated effectively with just chemotherapy, omitting radiation. This reduces potential side effects without negatively affecting survival rates.

3. The Future of Radiation in Oncology: Despite the de-escalation in some scenarios, radiation remains crucial in cancer management. Its role might be shrinking in early-stage or low-risk cancers, but it's expanding in metastatic diseases and more aggressive cancers. Advancements in radiation therapy, like proton beam therapy and stereotactic body radiotherapy, allow for targeted, effective treatments without significant damage to surrounding tissues. The overarching goal in the evolution of cancer treatments, including radiation, is to decrease the associated morbidity without sacrificing cure rates. This ensures better long-term outcomes and quality of life for patients.

The ERISA Edit: Analysis of MHPAEA Proposed Rule

Analysis of MHPAEA Proposed Rulemaking and Report to Congress: Part I

By Miller & Chevalier - Over the next several weeks, we'll analyze key provisions of the proposed rulemaking to amend regulations under the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and implement the 2020 amendments to ERISA § 712 (ERISA's parity provision) mandating written comparative parity analyses. We'll also cover the July 2023 MHPAEA Comparative Analysis Report to Congress. The MHPAEA regulatory proposal was published in the Federal Register on August 3, 2023, making comments due on October 1, 2023. Read Full Article…

VBA Article Summary

1. MHPAEA's Purpose and Regulatory Proposals: The MHPAEA regulatory proposal focuses on enhancing access to mental health and substance use disorder benefits. The proposed regulations aim to ensure participants and beneficiaries in plans that offer such benefits aren't subjected to restrictive limits and requirements that are more stringent than those applied to medical/surgical benefits. The approach now emphasizes evaluating and adjusting outcomes when administering benefits and paying claims, making a shift from previous interpretations where disparate outcomes were considered potential red flags but not definite indications of MHPAEA violations.

2. Clarifications on Key Terms: The proposal provides a clearer definition of terms such as "medical/surgical benefits," "mental health benefits," and "substance use disorder benefits," eliminating the reference to state laws and guidelines. Instead, these terms will be defined based on recognized medical standards, referencing sources such as the WHO's International Classification of Diseases (ICD) or the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). There are also clarifications on the definition of non-quantitative treatment limitation (NQTL) terms such as "Processes," "Strategies," "Evidentiary standards," and "Factors," providing a more comprehensive understanding and setting expectations for plans and issuers.

3. Washington State's Abortion-Coverage Mandate: In 2018, Washington state passed SB 6219, requiring all health insurance plans offering maternity coverage to also provide equivalent abortion coverage. Cedar Park Assembly of God, a Christian church, challenged this law, alleging it violated the First Amendment's free exercise clause due to the church's religious beliefs against abortion. However, the U.S. District Court for the Western District of Washington upheld the law, ruling it doesn't burden religion and has multiple legitimate governmental purposes such as promoting gender equity and improving women's health. The church's next steps regarding an appeal remain uncertain.

Forcing people off short-term health plans is the real insurance scam

By Sally Pipes - The Biden administration recently proposed new regulations that would curb short-term health plans — or, as the White House likes to call them, "junk" or "scam" insurance. But the true scam is this attempt to deprive people of affordable coverage they like. Read Full Article… 

VBA Article Summary

1. Short-Term Plans vs Obamacare Plans: Short-term health insurance plans are notably more affordable than the plans available through Obamacare's exchanges. For instance, monthly premiums for short-term plans can be as low as $55, which is a fraction of the $453 that a 40-year-old would typically pay for the average benchmark plan on the exchange. This cost difference makes short-term plans especially appealing for certain demographics, such as healthy young adults and individuals temporarily out of work. However, Democrats have criticized these plans for potentially undermining Obamacare. They argue that these plans draw healthy individuals away from the exchanges, leading to a sicker pool of enrollees and consequently, higher premiums.

2. Proposed Changes to Short-Term Plans: President Joe Biden is proposing regulatory changes that would significantly limit the duration of short-term plans. These rules aim to reverse a policy from the Trump administration that permitted consumers to enroll in these plans for almost a year and allowed for a renewal period of up to three years. Under Biden's proposal, short-term plans would be restricted to a maximum of three months, with a possible one-month extension. This change is projected to redirect many of the 1.5 million individuals currently on short-term plans to the Obamacare exchanges. By the administration's estimates, this would mean an increase of about 60,000 exchange enrollees each year from 2026 to 2028. This move is perceived by some as a method to make more Americans reliant on government-provided insurance and a step towards a "Medicare for all" system.

3. Implications and Reactions: With these proposed changes, Biden expects a boost in Obamacare enrollment figures, building on the momentum of his "record-breaking" enrollment facilitated through offering generous subsidies. However, critics argue that these changes would strip many people of their preferred coverage, forcing them to opt for potentially pricier and not necessarily superior coverage available on the exchanges. Those who might lose their short-term coverage due to the proposed rule may feel deceived.