Daily Insurance Report - July, 25 2023

Your summary of the Voluntary and Healthcare Industry’s most relevant and breaking news; brought to you by the Voluntary Benefits Association®

N.C. Researchers to Study Telehealth Use for Children with Complex Conditions

By David Raths - With PCORI funding, researchers will test the benefits of a telehealth intervention called enhanced primary care (E-PRIME) at 36 primary care pediatric offices across North Carolina. A team at Wake Forest University School of Medicine plans to research the benefits of expanded use of telehealth by primary care physicians for children with complex chronic conditions and their caregivers. Read Full Article… 

VBA Article Summary

  1. Background and Funding: A collaborative project between Wake Forest University School of Medicine and Atrium Health received $4.4 million in funding from the Patient-Centered Outcomes Research Institute (PCORI). The initiative aims to explore the most effective and evidence-based ways to incorporate telehealth into routine care, particularly for chronic disease management, while addressing health disparities.

  2. The Need for Telehealth in Pediatric Care: The COVID-19 pandemic led to a rapid expansion of telehealth services. However, the article highlights that families with medically fragile children face numerous challenges with in-person appointments, such as missing work and financial strain. The complexity of medical care for these children, including feeding and medications, requires extensive planning.

  3. The E-PRIME Telehealth Intervention: The research team will conduct a multicenter randomized control trial involving 400 children at 36 primary care pediatric offices across North Carolina. The study will test the benefits of a telehealth intervention called Enhanced Primary Care (E-PRIME). Participants will be randomly assigned to either early implementation (first six months) or delayed implementation (later six months) of E-PRIME. The primary objective is to improve care delivery for these children, and the team aims to understand health disparities by including at least 180 children from minority groups. The effectiveness of E-PRIME will be evaluated based on hospitalizations, emergency room visits, and caregiver stress, with all participants followed for one year. The study was chosen for PCORI funding due to its potential to provide real-world evidence for integrating telehealth into primary care for individuals with multiple chronic conditions and to identify differences in care among populations at risk for health disparities.

VBA Poll Question of the Week - Please share your insights

Are you confident in your knowledge around the reporting and filing requirements now in effect from the Consolidated Appropriations Act (CAA)?

Login or Subscribe to participate in polls.

FTC, DOJ propose new changes to guidelines for reviewing anticompetitive mergers

By Dave Muoio - The Federal Trade Commission (FTC) and the Department of Justice (DOJ) released a draft update to merger guidelines, which they use to determine merger and acquisition deals’ compliance with antitrust laws, for public comment. The proposed update has been in the works since early 2022 when the agencies launched a joint public inquiry into ways that federal regulators could better monitor a surge in merger filings and multi-industry market concentration. Read Full Article… 

VBA Article Summary

  1. Informed by Extensive Public Input: The draft Merger Guidelines proposed by the FTC and DOJ have been shaped by over 5,000 public comments from various stakeholders, including healthcare workers, farmers, patient advocates, musicians, and entrepreneurs. This extensive input ensures that the guidelines reflect the realities of how firms do business in the modern economy.

  2. Updated Considerations for Platform Acquisitions: The proposed updates highlight the unique competitive differences that arise when platforms are involved in acquisitions, which differ significantly from traditional market structures of the 20th century's economy. These considerations aim to address the challenges posed by platform-driven businesses in the context of mergers and acquisitions.

  3. Strengthened Measures to Safeguard Competition: The draft guidelines tighten the market concentration threshold for challenging merger deals. The agencies propose reviewing deals that yield a post-merger Herfindahl-Hirschman Index (HHI) of 1,800 and those that demonstrate a significant increase in concentration. By doing so, the FTC and DOJ aim to prevent unchecked consolidation and protect free and fair markets, reflecting the complexities of the modern economy.

Note: The article discusses the updates to the Merger Guidelines, the principles used to determine anti-competitive mergers, and the broader context of the regulators' crackdown on economy-wide deal-making. The proposed changes come as a response to President Biden's executive order and address concerns about consolidation, particularly in the healthcare sector.

If you’re resisting wellness models, prepare to be left behind.

By Lisa Eramo - Laura Kaiser is on a mission to help people live healthy lives. As president and CEO of SSM Health, Kaiser is moving the St. Louis-based Catholic health system toward an approach that promotes health instead of healthcare, and prevention instead of treatment. For SSM Health, that goal entails such things as creating frequent touchpoints with patients who have one or more complex chronic conditions. Read Full Article… 

VBA Article Summary

  1. Shifting from treating acute care to a holistic health approach: SSM Health and other health systems are recognizing the need to move away from the traditional focus on acute care and revenue generation. Instead, they are adopting a more holistic view of health that involves managing chronic conditions and promoting wellness to improve the overall health of patients.

  2. Implementing patient-centric care management and virtual care: SSM Health is adopting a whole-patient strategy centered around care management and a virtual care center that operates seven days a week. By partnering with patients and providing continuous care support, they aim to ensure patients do not get lost in the healthcare system and effectively manage their health conditions.

  3. Embracing value-based care models and full-risk contracts: To achieve the goal of promoting health and wellness, health systems like Atrius Health and Allina Health are embracing value-based care models and full-risk contracts with payers. By taking on risk and incentivizing good health outcomes, they aim to shift the focus from simply treating diseases to preventing them and promoting overall well-being.

Join our LinkedIn Community!

FTC rescinds policy statements backing PBMs

By Axios Vitals - The Federal Trade Commission sent another shot across the bow of the pharmacy benefit managers on Thursday, warning the companies  against relying on "outdated" agency statements and studies that opposed more regulatory oversight and transparency of PBMs. The move signals the FTC's growing interest in challenging what commissioners characterized as "competitively troubling changes in the PBM market" and its efforts to remove hurdles to state efforts to address concerns with the drug chain middlemen. Read Full Article…

VBA Article Summary

  1. FTC's Examination of PBM Market Practices: In June 2022, the Federal Trade Commission (FTC) initiated a study to investigate the practices of Pharmacy Benefit Managers (PBMs). The study aimed to gain insights into how the PBM market has evolved since the issuance of 11 letters and reports by the FTC between 2004 and 2014, which expressed concerns about potential transparency measures affecting competitive processes. These letters were often cited by the industry to argue against increased oversight.

  2. State-Level Efforts and Opposition: Over the past two decades, several state-level attempts were made to address PBM practices, particularly by proposing greater disclosure requirements. However, some of these state efforts faced opposition, not only from PBMs but also from the FTC. FTC Chair Lina Khan noted the challenges faced by these state efforts during a recent meeting.

  3. Deep Consolidation and Legislative Actions: The PBM market has experienced significant consolidation, with three major PBMs (OptumRx, CVS Caremark, and Express Scripts) controlling around 80% of the market. Concerns have arisen about the effects of this consolidation, leading FTC Commissioner Alvaro Bedoya to question the supposed benefits of vertical integration. Meanwhile, Senators Tom Carper and Chuck Grassley introduced legislation to grant CMS oversight authority over PBMs and their drug formulary decisions. Additionally, the FTC and HHS' Office for Civil Rights issued warnings to 130 hospital systems and telehealth providers about the risks associated with using online tracking technologies like the Meta/Facebook pixel and Google Analytics.

What the Supreme Court's ruling on student loan forgiveness means for employees

By Alyssa Place - As anxious borrowers react to the Supreme Court's ruling to stop student loan forgiveness, employees are once again faced with the financial burden of college debt. But with widespread financial stress already taking its toll on the workforce, will employees be able to manage yet another expense?  Read Full Article… 

VBA Article Summary

  1. The Supreme Court's Ruling on Student Loan Forgiveness: The Supreme Court has ruled against the Biden administration's plan to forgive more than $400 billion in student loan debt. The plan, introduced last August, aimed to forgive up to $20,000 in loan payments for individuals earning less than $125,000 per year. However, the court's decision means that the loan forgiveness initiative is now blocked, leaving borrowers with their existing debt burden.

  2. End of COVID-Era Payment Pauses and Financial Strain: With the loan forgiveness plan halted, employees who have student loan debt are facing additional challenges. The COVID-era payment pauses on student loan repayments will come to an end on October 1 of this year, as the pandemic federal emergency concludes. For many borrowers, this marks the end of a period during which they did not have to worry about their student debt burden. As loan payments resume, borrowers are expected to experience financial strain, with one in five borrowers struggling to repay their loans.

  3. Growing Trend of Student Loan Repayment Benefits: Despite the Supreme Court's decision and the impending resumption of loan payments, there is some relief available to employees. A growing number of employers have started offering student loan repayment benefits as part of their employee benefits package. These programs have gained popularity due to their positive impact on workplace productivity and employees' financial well-being. Some companies, like Avangrid, have already implemented student loan repayment benefits and have seen positive outcomes, including increased employee loyalty and engagement.

By providing this benefit, employers aim to ease the financial burden on their workforce and attract and retain talented employees. For some borrowers like Alexis McDonald, who works for Avangrid, these benefits have been life-changing, providing much-needed financial stability and peace of mind. Employers are recognizing that student loan forgiveness is not only an essential need for many employees but also a crucial factor in building a strong employer-employee relationship.

Survey Finds Medicare Members Spend More on Healthcare Than Non-Medicare Members

By Briana Contreras - Medicare households spent an average of $6,557 on healthcare, accounting for 15% of their total household spending ($44,686), while non-Medicare households spent $4,598 on their healthcare, accounting for 7% of their total household spending ($67,769). The healthcare spending amount for Medicare households compared to non-Medicare households is about double, according to a recent KFF analysis. Read Full Article…

VBA Article Summary

  1. Healthcare Spending Disparity: Based on the 2021 Consumer Expenditure Survey data, Medicare households experienced double the healthcare spending burden compared to non-Medicare households. On average, Medicare households spent $6,557 on healthcare, which accounted for 15% of their total household spending ($44,686), while non-Medicare households spent $4,598 on healthcare, comprising 7% of their total household spending ($67,769).

  2. Growing Medicare Benefit Payments: Another analysis by KFF revealed that Medicare benefit payments rose significantly, reaching $829 billion in 2021 from $541 billion in 2011. Among these benefit payments, Medicare Part B services accounted for the largest share, making up 48% of Medicare benefit spending in the same year.

  3. Projected Future Medicare Spending: The analysis projected that Medicare spending is expected to rise substantially in the coming years due to several factors. It is estimated to increase from 10% of total federal spending in 2021 to 18% in 2032. Similarly, Medicare spending is projected to grow from 3.1% to 3.9% of the gross domestic product value in the same period. This rise is attributed to factors such as growing enrollment, increased utilization of services and intensity of care, and rising healthcare costs.

It's important to note that some limitations in the survey data were identified, as it did not include the cost burden for households with long-term care facility costs. Additionally, the impact of the COVID-19 pandemic was noted, which may have led to lower health spending data for both Medicare and non-Medicare households in 2021 than expected. However, various policy initiatives have been proposed, such as the Inflation Reduction Act of 2022, to address prescription drug costs and expanded eligibility for financial support programs, which could help combat the overall spending challenges faced by Medicare members.

How the Veterans Benefits Administration is coping with PACT Act claims

By Tom Temin - The PACT Act, which became law in 2022, aims to help veterans who were exposed to toxins. Since June 3, it has sparked more than 625,000 new claims. For how the agency is dealing with the caseload, Federal Drive with Tom Termin spoke with Josh Jacobs, the Department of Veterans Affairs Undersecretary for Benefits. Read Full Article… 

VBA Article Summary

  1. Increased Staffing and Workforce Expansion: The Department of Veterans Affairs (VA) has been actively increasing its staffing well before the enactment of the PACT Act in August 2022. They started a 2000-person hiring campaign and increased their total workforce in the Veterans Benefits Administration (VBA) by about 20% over the last 18 months. This has led to a historic high of over 30,000 employees working on processing claims. The claims processors, known as VSRs and RVSRs, are responsible for developing evidence and rating the cases.

  2. Coverage and Impact of the PACT Act: The PACT Act has expanded the VA's ability to deliver benefits and healthcare to veterans who were previously underserved for decades. For example, Vietnam veterans are now able to receive benefits for hypertension, which was not possible before. Since the enactment of the PACT Act, the VA has received close to 680,000 PACT claims, and they have processed more than 300,000 of those claims, with an approval rate of about 80% for claims with PACT contentions. However, the increasing number of PACT claims is also contributing to an increase in the total pending claims inventory, comprising approximately 45 to 50% of the total.

  3. Challenges and Solutions: The PACT Act and other laws governing VA benefits are complex, requiring extensive training for claims processors. The VA has implemented a robust training program for new employees that can take up to two years to ensure full proficiency in processing claims. Additionally, the VA has modernized its technology, moving from a paper-bound process to an electronic system called the Veterans Benefits Management System, which has significantly improved processing efficiency. Despite efforts to expedite claims, the average processing time is slightly longer than the target of 125 days, as the VA aims to strike a balance between timely decisions and accuracy. The VA has also prioritized certain claims based on individual circumstances to expedite benefits for veterans in dire need.