AHA: Biden admin's short-term plan crackdown a good start on addressing 'convoluted' coverage gaps

By Dave Muoio - Hospitals are on board with the Biden administration’s increased scrutiny of “inadequate” short-term health plans, and are hoping that the federal government will go further in its crackdown on payers’ “convoluted policies.” In early July, the White House said it was working to reverse a controversial Trump-era rule that expanded the duration of the controversial coverage option critics—patient advocates, medical groups and even some insurance industry organizations—often refer to as “junk plans.” Read Full Article…

VBA Article Summary

1. Biden Administration's Proposed Changes: The Biden administration suggests modifications to short-term health insurance plans, aiming to:

   • Limit their duration to three or four months instead of the existing three-year maximum.

   • Mandate the inclusion of a disclaimer for consumers to better understand the plans' coverage limitations.

2. Feedback from the American Hospital Association (AHA): The AHA, while commending the move to limit the scope of such short-term plans, emphasized the importance of not obstructing innovative, non-traditional insurance coverage options that might offer suitable coverage. The organization highlighted issues where patients enrolled in such plans often found themselves without coverage for essential services due to misleading marketing. They support the proposal to include straightforward notices for consumer education on these short-term plans. The AHA expressed grave concerns regarding the complexity and amount of patient cost sharing in ACA-compliant health plans. They cited instances of commercial health insurers implementing confusing policies, which leaves patients uncertain about their coverage. Additionally, they urged for a reevaluation of the rise and implications of high-deductible health plans, which may mislead many, resulting in unexpected medical bills.

3. Feedback from Other Stakeholders: The Association of American Medical Colleges (AAMC) supported the administration's efforts to regulate short-term plans. They stressed the negative impacts of such plans, highlighting how they might force patients to delay essential care, which in turn can lead to more severe health conditions and higher medical costs.

Streamlining Healthcare Insurers’ Processes: Unlocking Efficiency and Collaboration for Enhanced Outcomes

By Susan Taylor - The healthcare industry is constantly evolving, and recent news about insurers rolling back authorization requirements has been met with optimism. While this step forward is undoubtedly positive for healthcare providers and patients, it is essential to acknowledge that insurers still have a long way to go in streamlining processes and reducing administrative burdens. A comprehensive approach to process improvement and automation is required to enhance outcomes within the healthcare ecosystem. Read Full Article…

VBA Article Summary

1. Utilizing AI/ML for Efficient Data Management: Insurers grapple with vast amounts of unstructured healthcare data, which results in prolonged manual data entry and increased costs. AI/ML technologies automate and expedite data analysis, enabling insurers to focus more on refining patient care and making informed decisions.

2. Automating Workflows to Optimize Healthcare Processes: Administrative burdens consume excessive resources, which could otherwise be utilized for patient care. Implementing best practices in automation helps reduce errors, redundancy, and ensures that clinical staff have comprehensive insights into prior determinations. This results in a better patient experience. Leveraging guided workflows and real-time reviews can ensure seamless and efficient prior authorization processes. By doing so, unnecessary requests for additional documentation are curtailed, and healthcare services can be aligned better with medical best practices. Deploying pre-approval learning models allows for an enhanced focus on reviewing requests that might need subsequent investigations, helping in detecting potential misuse or fraudulent requests.

3. Emphasizing Collaboration for Innovative Solutions: To enhance healthcare delivery, it is paramount that insurers, providers, and technology solution providers collaborate to pinpoint areas ripe for automation and improvement. A collective, end-to-end approach spearheads innovation and paves the way for transformative solutions that not only cut costs but also improve patient experiences and outcomes. Despite recent advancements in reducing authorization requirements, further work is necessary to optimize processes and lessen administrative strains. This can be achieved by holistically improving processes, adopting AI/ML, and bolstering collaboration among industry stakeholders.

Popular Weight-Loss Drugs Could Be Harmful for Children: Researchers

By Mary Gillis - The potential lifelong consequences that weight-loss drugs could have on adolescents and children have a multidisciplinary team of clinicians, exercise and behavioral scientists, pharmacists, and ethics researchers at the University of California–Irvine (UCI) sounding alarms. Read Full Article…

VBA Article Summary

1. Concerns Over GLP-1RA Usage in Children: GLP-1RA medications like Wegovy and Ozempic, traditionally used for adults, have been proposed as a remedy for childhood obesity and Type 2 diabetes. However, the research paper suggests that their benefits in adults, such as hunger suppression, may have unintended physical and emotional ramifications when used in children. For instance, the suppression of appetite in growing kids can lead to nutritional deficiencies, impacting brain development, immunity, and overall growth. Dr. Dan M. Cooper emphasizes that unlike adults, children require sufficient calories not just for physical activity but also for their holistic growth and development.

2. Potential for Abuse and Misuse: With societal pressures from sports with body weight expectations, such as wrestling and ballet, and increasing exposure to unattainable body images via social media, there is a genuine concern about the potential abuse of these drugs among adolescents. This is further aggravated by the possibility of an influx of illegal, unregulated versions of these medications. Jan D. Hirsch highlights the damaging impact of social media on young people's perception of body image, which could amplify the risks associated with these drugs.

3. Lack of Research and Unintended Consequences: Very few studies focus on the effects of weight-loss drugs on children. This paucity of research leaves a gap in understanding their long-term impacts, especially concerning growth and development. Adverse effects could include a distorted balance of calorie intake, medication abuse for competitive advantages in sports, unwarranted use due to misconceptions about body weight, and the potential of pediatricians prescribing these drugs without fully grasping their long-term consequences.

Low-quality health care is costing employers big

By Tina Reed - U.S. companies are spending big on employees' health, often with little insight into whether they're paying for quality care. Why it matters: Whether patients are given and stick with the best documented course of care — such as statins for heart disease — can have everything to do with what doctor they go to. Read Full Article… 

VBA Article Summary

1. Wide Variation in Quality of Care: The new report from JPMorgan Chase's health care arm, Morgan Health, highlights a significant variation in the quality of care patients receive. Employers annually spend over a trillion dollars on health care for their employees, often with the expectation of receiving high-quality health care in return. However, data shows disparities in provider performance within employer-sponsored insurance. Two specific examples underscore this variation:

   • For statin therapy, a guideline-recommended treatment, only 37% of patients with coronary artery disease seeing the lowest-performing 10% of cardiologists adhered to the therapy. In contrast, 73% of patients consulting the top 10% of performing doctors followed the therapy.

   • While clinical guidelines advise against unnecessary cesarean sections due to increased risks, over 60% of women with uncomplicated pregnancies seeing the lowest-performing obstetricians underwent a C-section. Among women seeing obstetricians in the top 10% of performers, only 14% had a C-section.

2. Increased Costs without Improved Outcomes: The disparity in the quality of care doesn't only lead to potentially poorer health outcomes for patients. It also has financial implications, especially for employers. They face soaring health costs without necessarily seeing a proportionate improvement in the health outcomes of their employees. The expectation for most employers is that their significant investment in health care would yield a high-quality experience for their employees, but the data suggests otherwise.

3. Recommendations for Improvement: To address these challenges, the researchers have several recommendations:

   • Employers should make provider quality data accessible to plan members. This will empower them to make informed decisions and potentially choose higher-performing providers.

   • There should be an ecosystem where clinicians can access and review their performance data, allowing them to self-reflect and make necessary improvements.

   • Employers are encouraged to collaborate directly with insurers, leveraging provider-quality data to establish higher-quality networks. One practical application of this is exemplified by Walmart, which chose to cover a more significant portion of health costs for employees who consult clinicians identified as high quality.

Companies Are Getting Serious About Their Employees’ Mental Wellness

By Joseph Bednar - It’s easy to tell when someone is struggling with asthma, Krista Mazzuca said. “If I come to work with bad asthma, you see me breathing hard. My supervisor says, ‘hey, Krista, take a minute,’” said Mazzuca, first vice president of Human Resources at PeoplesBank. But mental distress, she noted, can be tougher to spot. Read Full Article…

VBA Article Summary

1. Growing Awareness of Workplace Mental Health: Due to the aftermath of COVID and the stresses of the current work environment, mental health has become a prominent topic in team-building sessions and managerial conversations. Shana Hendrikse, a senior advisor at Giombetti Associates, highlights that creating a safe and stigma-free space for employees to discuss their mental health is crucial for high-performance companies. The increased attention to burnout and the need for mental wellness can lead to happier employees, which in turn positively impacts business outcomes.

2. The Role of Empathetic Leadership in Retention: As companies face recruitment and retention challenges in a talent-crunch market, Pam Thornton emphasizes the importance of empathetic leadership. By having individualized conversations with employees to understand their work-life balance, workload, and overall happiness, leaders can foster trust and loyalty. Recognizing the need for mental health days or addressing overburdening workloads can make employees feel valued, ultimately benefiting both the employee and the business.

3. Providing Support Systems and Resources: Companies are increasingly offering resources to promote employee well-being. For example, PeoplesBank offers classes on burnout and resilience, mental-health coverage in their health plans, and free access to online mental health resources. Furthermore, Employee Assistance Programs (EAPs) are highlighted as valuable tools for supporting employees, offering them confidential professional assistance. Creating a culture where mental health discussions are normalized and encouraged can bridge the gap between employer offerings and employee needs, fostering a more inclusive and understanding workplace environment.

AstraZeneca sues US over Medicare drug price negotiation plans

By Bhanvi Satija, Dhanya Ann Thoppil and Shilpi Majumdar - AstraZeneca (AZN.L) said on Friday it has sued the U.S. government to block parts of a program that gives the Medicare health insurance plan the power to negotiate lower drug prices. The British drugmaker, which filed its complaint in a Delaware district court, joins other drugmakers and business groups claiming that the program would restrict the development of new medicines. Read Full Article…

VBA Article Summary

1. Legal Challenges and Concerns: The drug price negotiation program faces numerous court challenges. Leading pharmaceutical companies and industry groups, including PhRMA, Johnson & Johnson, Merck & Co, Bristol Myers Squibb, and Boehringer Ingelheim, have voiced their opposition. AstraZeneca, specifically, is concerned about the potential impact on medicines for orphan indications, as they believe the program could deter the development of vital treatments such as Lynparza and Soliris, which hold orphan drug status for several conditions.

2. Program Overview and Its Significance: The drug price negotiation program is a pivotal component of President Joe Biden's Inflation Reduction Act (IRA). Under the direction of the U.S. Department of Health and Human Services (HHS), the initiative is designed to negotiate prices for select high-priced drugs to potentially reduce healthcare costs for senior citizens and individuals with disabilities. These negotiated prices are set to be implemented in 2026.

3. Government's Stance and Future Steps: The U.S. government has a history of offering incentives for the development of treatments targeting orphan indications or rare conditions. With the impending negotiations slated to commence next month on 10 significant drugs, the HHS remains committed to defending the program. They assert that the negotiation law is crucial for lowering healthcare expenses for vulnerable populations.

How Much Is Long-Term Care Insurance?

By Les Masterson - Long-term care (LTC) insurance helps pay for long-term care like nursing homes, hospice care, adult day care and getting assistance with activities of daily living, such as bathing, dressing and eating. Long-term care insurance costs differ based on multiple factors. LTC rates aren’t set and can increase as you age. People with pre-existing conditions or health problems may have trouble finding long-term care insurance or face hefty long-term care insurance costs. Read Full Article…

VBA Article Summary

1. Overview of LTC Insurance Costs: For a 60-year-old man, the average annual cost is $1,200 for $165,000 coverage, while for a 60-year-old woman, it's $1,960. Married couples aged 60 can opt for a joint policy, which costs an average of $2,550 annually but combines the coverage limit. Long-term care insurance premiums might rise over time due to factors like inflation, which can be factored in by increasing benefits by 1% to 5% annually. However, this will also elevate the rates.

2. Factors Influencing LTC Insurance Cost:

   • Age: Premiums tend to be lower when coverage is bought at a younger age.

   • Health: Individuals with pre-existing conditions might face higher premiums or even denial of coverage.

   • Gender: Since women have a longer life expectancy, they typically pay more.

   • Coverage Details: Costs vary based on daily limits, maximum benefits, and elimination periods.

   • Riders: Provisions like inflation protection can increase costs.

   • Type of Coverage: Joint policies for couples are often more affordable than individual policies for each person.

   • Insurance Provider: Rates differ across companies, so it's recommended to obtain multiple quotes for comparison.

3. Handling LTC Insurance Rate Increases and Other Considerations: Policyholders can make adjustments like reducing daily benefits or increasing the elimination period to manage sudden cost hikes. While LTC insurance might seem costly, not having it can be even more expensive considering the high costs associated with services like nursing homes. Most claims (around 81%) are made after the age of 75, implying the importance of early coverage. It's essential to weigh the pros and cons: While LTC insurance provides security, peace of mind, and financial support during retirement, not everyone qualifies for it, and the costs can be prohibitive. Furthermore, only a limited number of insurance providers offer LTC insurance.

Healthcare executives' worries about talent retention, recession beginning to ease

By Jeff Lagasse - In assessing the biggest risks to their business, most healthcare executives say that the risk landscape is starting to ease, with recessionary fears not as prevalent as they once were and the overall picture improving for talent acquisition and retention – although cyberattacks and uneven economic growth remain top concerns. Read Full Article… 

VBA Article Summary

1. Evolving Business Landscape: Business executives are pivoting from traditional business models to a more technologically inclined and innovative approach. This includes investments in technology and even the establishment of their own training schools for clinical staff. The healthcare business environment is witnessing stabilization after facing numerous challenges like the COVID-19 pandemic, hybrid work shift, supply chain disturbances, and rising interest rates. This stability, accompanied by decreased fears of a recession and rising consumer confidence, offers opportunities for economic expansion.

2. Current Risks and Priorities: While the risk of recession has decreased, with only 17% of executives predicting one in the upcoming six months (down from 35% in October 2022), other risks like cyberattacks are more pronounced. A significant 74% view cyberattacks as a moderate to serious risk. Despite these challenges, executives are more inclined to invest in growth. There's a keen interest in integrating new technologies into their business model (27%), followed by exploring new revenue streams (24%). However, while executives are eager to implement new technology, they face challenges. Achieving tangible value from such technology stands out, with 88% citing it as a hurdle. Other notable challenges include updating their operational model (85%), managing the costs (85%), and training their staff (84%).

3. Strategic Recommendations and Focus Areas: PwC emphasizes the importance of prioritizing cybersecurity and privacy, especially during digital transformations. These aspects, often overlooked, should be integral from the beginning, as retroactive changes can be challenging. Data governance is pivotal. As data becomes an increasingly valuable asset, there's a need to treat it with utmost importance. While it's essential to provide project teams with data for product and service development, protective measures are crucial to prevent unintended leaks or vulnerabilities.