By Arvind Venkat, MD - As an emergency medicine resident in the early 2000s, I cared for a patient in her early 60s with back pain. Prior to the passage of the Affordable Care Act (ACA), approximately 16% of emergency department patients were uninsured. Often their issues were of low acuity, again because they had no other place to see a physician. Read Full Article…

VBA Article Summary

1. The Urgency of Addressing Medical Debt in Healthcare: The narration begins with a personal anecdote, emphasizing the pervasive issue of delayed or foregone medical treatment due to financial constraints in the United States. The article underscores the gravity of the situation, highlighting statistics about the extensive medical debt, its disproportionate impact on certain communities, and its role as a significant cause of bankruptcy. It sets the stage by painting a vivid picture of the current healthcare crisis, emphasizing the need for urgent reforms to alleviate medical debt and enhance accessibility to necessary healthcare services.

2. Proposed Solution - The Medical Debt Relief Act in Pennsylvania: The central portion of the article details a proposed legislative solution, the Medical Debt Relief Act, introduced by the author in the Pennsylvania General Assembly. This Act seeks to establish a Medical Debt Relief Program aimed at identifying and forgiving unpaid medical debts for individuals falling under specific income criteria. The program would operate through partnerships between the Pennsylvania Department of Health, hospitals, and other healthcare providers, working towards reducing the financial strain of medical debts and providing relief to hundreds of thousands of residents in Pennsylvania. It highlights the fiscal responsibility and efficiency of the proposed program, aiming to foster a win-win situation for all stakeholders involved.

3. A Call to Action - Advocacy for Broader Implementation: The conclusion of the article serves as a call to action, urging other cities and states to adopt similar measures to address the critical public health issue of medical debt. It articulates the potential of the Pennsylvania Medical Debt Relief Act to serve as a pioneering model for responsibly mitigating this crisis at a national level. The article also emphasizes the obligation of hospitals to publicize and assist patients with charity care programs, addressing one of the root causes of the accumulation of medical debt. It ends with a powerful plea, rooted in the author's personal experience as an emergency physician, urging for comprehensive action to prevent the continuation of tragedies caused by medical debt in the American healthcare system.

Save Billions Or Stick With Humira? Drug Brokers Steer Americans To The Costly Choice

By Arthur Allen - Tennessee last year spent $48 million on a single drug, Humira — about $62,000 for each of the 775 patients who were covered by its employee health insurance program and receiving the treatment. So when nine Humira knockoffs, known as biosimilars, hit the market for as little as $995 a month, the opportunity for savings appeared ample and immediate. Read Full Article…

VBA Article Summary

1. The Significant Economic Impact of Biosimilars: The advent of biosimilars, generic counterparts to biologic drugs, has the potential to bring a financial reprieve to the US healthcare system beleaguered by soaring drug prices. Notably, these biosimilars, like Yusimry, are priced significantly lower than their brand-name counterparts, offering an opportunity for tremendous savings. The potential economic windfall is seen in the projected annual savings of around $9 billion if a significant portion of the Humira patient base transitions to biosimilars. Despite this potential, PBMs, which play a substantial role in drug pricing and accessibility, have not aggressively positioned biosimilars in a manner that would foster extensive adoption, reflecting a systemic resistance to the financial logic presented by these alternatives.

2. Challenges in the Integration and Adoption of Biosimilars: Biosimilars face a rocky path to broad integration within the US healthcare system. While they promise significant cost savings and similar efficacy to drugs like Humira, their development is often hindered by high costs and long timelines, necessitating a significant market share to be viable. Moreover, key players like PBMs have exhibited a reluctance to incentivize the switch to biosimilars by offering them at similar prices as brand-name drugs like Humira, limiting doctors' and patients' motivations to make a switch. Furthermore, AbbVie, the manufacturer of Humira, has strategically guarded its market share by leveraging rebates and other tactics to discourage the adoption of biosimilars, highlighting the complex and often opaque business dynamics that perpetuate high drug prices.

3. The Crucial Role of Stakeholders in Facilitating the Transition to Biosimilars: The transition to a healthcare system more reliant on biosimilars is contingent upon the actions of various stakeholders, including PBMs, healthcare providers, and patients themselves. The existing practices of top PBMs are under increasing scrutiny, with some stakeholders pushing for more transparency and changes that could potentially facilitate the integration of biosimilars. Patients' access to more affordable medications is compromised by a tangled web of financial and contractual arrangements that incentivize higher drug prices and discourage switching to more cost-effective options. Doctors also exhibit inertia in prescribing new alternatives, often opting to stick with well-established medications to avoid potential disruptions in treatment. Nevertheless, there's an emerging awareness and push, even among healthcare providers, towards acknowledging the benefits of biosimilars, fostering hope for a gradual shift towards their broader acceptance and integration in the healthcare regimen.

Hospitals share differing medical prices online versus over the phone, secret shopper survey finds

By Rebecca Pifer - The study raises new questions about the dependability of hospital pricing, and builds on a mountain of past research finding wide varieties in facility costs. Hospitals are required to post a consumer-friendly display on their website of the prices of 300 shoppable services under a CMS rule finalized in 2019. The rule aimed to inject more transparency into medical prices by allowing consumers to choose more afforable sites of care. Read Full Article…

VBA Article Summary

1. Significant Discrepancies in Hospital Pricing Information: A new study published in the JAMA Internal Medicine has brought to light considerable inconsistencies in the pricing information hospitals share online versus over the phone. Despite the requirement for hospitals to post the prices of shoppable services online since 2021, the study uncovered that the prices mentioned online rarely match the prices shared with consumers telephonically. Wide variations were observed in cash prices for services like vaginal childbirth and brain MRIs, with some hospitals displaying a difference of more than 50% between online and telephone prices. These discrepancies highlight substantial barriers in achieving true price transparency in the healthcare sector, with the variations potentially emanating from a chaotic and disorganized pricing structure, among other factors.

2. Inadequate Compliance and Enforcement of Price Transparency Rule: The efforts to improve price transparency have encountered significant obstacles, including the absence of a standardized format for sharing prices, poor data quality, and lackluster compliance by hospitals. The CMS has the authority to impose fines up to $2 million for non-compliance with the price transparency rule. However, with only 14 hospitals being fined a cumulative amount of $4.6 million so far, critics argue that the current administration is not doing enough to enforce the reporting requirements on hospitals, thereby impeding the translation of newly available hospital price data into actionable information that can facilitate comparison shopping for consumers.

3. Implications for Hospital Pricing Reliability and Future Reforms: The findings of the study cast doubts on the reliability of hospital pricing, suggesting that many hospitals may not even be aware of their actual prices, evidenced by the vast differences between self-posted online prices and the prices communicated to potential patients over the phone. These discrepancies underscore a pressing need for reforms that can streamline and organize the pricing structures within hospitals, foster better communication of pricing data to patients, and create mechanisms that hold hospitals accountable for posting accurate and non-misleading cost information, thereby assisting consumers in making informed healthcare decisions and potentially fostering a more competitive and transparent healthcare market.

‘The rule has sticks as well’: Biden’s getting tough with health insurers

By Ben Leonard - The Biden administration is going after health insurers for flouting a federal law requiring them to provide mental health care on the same terms as other care. The administration has proposed new rules it says will make the insurers comply and it’s threatening big fines if they don’t. Insurers are pleading innocent and, backed by some of America’s biggest companies, claiming the Biden administration plan could make an intractable problem worse. Read Full Article…

VBA Article Summary

1. Escalating Mental Health Crisis and Policy Response: In light of the sharp rise in mental health issues exacerbated by the COVID-19 pandemic, the Biden administration is intensifying its efforts to enforce mental health care parity laws more rigorously. Under the proposed regulations, insurers would be required to analyze and adjust their coverage policies to ensure equal access to mental health services, based on outcomes. The administration plans to impose hefty fines on insurance companies that do not comply, charging them $100 per policyholder per day. This move has been met with resistance from insurance companies, who argue that the real issue lies in the shortage of qualified mental health care providers, and that the proposed rules might impose "unnecessary burdens" that could inadvertently hinder access to care.

2. Historical Perspective on Mental Health Care Parity: The fight for mental health care parity in the United States has spanned several decades, with administrations since John F. Kennedy taking steps to improve access to mental health care services. The journey has included legislations like the Mental Health Parity Act of 1996, and the Mental Health Parity and Addiction Equity Act of 2008, which aimed to make the coverage for mental health services equivalent to that for physical health care. Despite these efforts, the U.S. health care system has historically treated mental and physical health differently, with stigma and shame being significant barriers to seeking and obtaining necessary treatment.

3. Current State of Mental Health in the U.S. and Challenges Ahead: The current state of mental health in the U.S. presents a grim picture, with increasing rates of anxiety, depression, and suicide, coupled with inadequate access to appropriate treatment. Various data indicate a surge in mental health crises, including a significant rise in suicide rates and a large proportion of adults experiencing symptoms of anxiety or depression during the pandemic. Moreover, more than half of adults with mental illness do not receive treatment, a statistic that is even worse for conditions like opioid use disorder. The administration's new proposals aim to tackle these issues head-on, though there are concerns regarding the enforcement of these regulations and whether they will effectively address the root causes of the mental health crisis.

As executive compensation at big automakers soars, so does health care costs for the companies, workers

By Wendell Potter - GM CEO Mary Barra, who was paid $29 million last year — hundreds of times more than the average GM worker — used a talking point over the weekend that I used to trot out every time a pesky reporter asked me to justify the unjustifiable: the outrageously high amount of money Cigna paid its CEO, especially when so many of our customers were struggling to cover the deductibles we made them pay before their coverage kicked in. Read Full Article…

VBA Article Summary

1. Disproportionate Growth in CEO Compensation: The article discusses the increasing gap in the compensation received by CEOs and the average workers in large corporations, particularly focusing on the automotive industry. It cites staggering statistics including how Barra, the CEO of General Motors, earned 361 times more than the typical GM employee in the previous year, a significant increase from the 15-1 CEO-worker pay ratio in 1965. This alarming trend is not restricted to GM, but is evident across several big companies in the US, highlighting a broader issue of wage disparity that is fueling current labor disputes across various sectors in the country.

2. Manipulated Corporate Narratives and Shareholder Primacy: The article sheds light on the narrative techniques used by corporate communications to justify the exorbitant CEO pays, often terming a significant portion of it as "performance-based" or "at risk", which primarily involves stock grants and options. This mechanism not only serves to increase the net worth of executives annually but also provides tax advantages to the corporations. It criticizes the predominant corporate focus on satisfying shareholder expectations, often prioritized above meeting customer needs and expectations, despite what the public relations narratives might suggest.

3. The Impact on Workers and the Role of Healthcare Costs: The article points out the unfair treatment of workers who have witnessed only a modest increase in their wages over the years. It argues that one of the contributing factors to the paltry wage increments might be the escalating health insurance costs that companies have to bear. The role of health insurers is highlighted as they continue to raise premiums and fees, thereby compelling companies to transfer a larger share of healthcare costs to the employees, affecting their take-home pay. It concludes with a call to reconsider the allocation of company revenues, urging to curb the massive transfers to insurance companies and the bank accounts of top executives, emphasizing that such resources could potentially be utilized to better the wages and conditions of average workers.

Benchmarking medical prices with payer transparency files

By Scott Bennett, Esq. - When attempting to use transparency data to benchmark facility (hospital and ambulatory surgery center) pricing, Plato’s Allegory of the Cave draws a stark parallel to how the Payer Price Transparency files have deviated from their original intent. In Plato’s allegory, prisoners chained in a cave see only the shadows on the wall, mistaking them for reality. These distorted shadows are a far cry from the objects casting them. Read Full Article…

VBA Article Summary

1. Discrepancies in Real and Translated Rates: The transformation of payer-provider contracts into machine-readable files or TIC files often results in altered pricing structures that become increasingly abstract and intricate. This is characterized by a drift from the straightforward and foundational prices outlined in the initial contracts. By focusing on three key examples: "The Cascade", "Group Classification Rates", and "Per Case/Per Visit/Per Unit" methodologies, the article emphasizes the necessity to consider these original methodologies when benchmarking a fair price. These methodologies highlight the disparity between the simple rate-per-code translation in TIC files and the complex formulas contained in the actual contracts that consider various conditions and combinations of services.

2. Complication Over Simplification: The transformation process of payer-provider contracts into TIC files leads to an increase in complexity over clarity. This manifests as an explosion of the data size and structure, creating files that are sometimes nearly indecipherable. The effort to encompass every possible combination of provider and payer contract calculated rate results in files ballooning to terabyte sizes, obscuring the original simplicity of the contracts. The article advocates for the release of formula descriptions from the contracts, possibly alongside the TIC files, to avoid the unnecessary complexities and maintain the essence of the initial agreements.

3. Detachment from Original Intent and Templates: TIC files tend to bury the original contractual rate calculation formulas under millions of lines of extraneous data, leading to a loss of the original intent of the contracts. This conceals decades of uniform contract negotiation blueprints that could potentially reveal insights into high and low priced hospitals. The article suggests releasing the contract templates and the varying variables in individual datasets for each provider, which is likely how claims processing systems in payer's databases are maintained, thus providing a clearer, simplified, and more accurate representation of pricing structures.

Creating a well-being and wellness strategy should be your next HR priority

By Mikaela Cohen - Do you know the difference between well-being and wellness? While the definitions may vary depending on the organization, well-being is an employee’s overall health—financial, physical, mental, and social, as well as in their community and at work, according to Learning Dimensions Network, an Australia-based education consulting firm. Read Full Article…

VBA Article Summary

1. Centralized Resource and Community Engagement: According to Greg Hill, Chief People Officer at Exos, there is a need to centralize all the resources related to well-being and wellness in one place to avoid confusion among employees. Hill emphasizes the significant role employee resource groups play in discussing and coaching well-being practices regularly, even more than HR teams in many instances. By integrating this conversation into existing platforms where employees already feel comfortable, companies can foster a more cohesive and understanding environment around these topics.

2. Crafting Authentic Strategies: Hill accentuates the necessity of developing an authentic framework that aligns well with a company's various initiatives. This approach includes providing real-life examples of how well-being can manifest in employees' daily routines, making the concept of well-being and wellness tangible and integrated into the organization's culture. Authenticity in these practices is key, and at Exos, this is facilitated through offering access to performance coaches who assist employees in addressing their well-being and wellness needs comprehensively.

3. From Permission to Promotion: The final crucial step is the effective execution of the well-being and wellness framework, where many companies falter. Hill notes that companies often merely give permission for employees to access programs instead of actively promoting their benefits and expected impacts. To embed well-being and wellness deeply into the company culture, it's necessary to encourage both executives and employees to exemplify these principles in their daily work and life. By promoting an approach where well-being is integrated into the very fabric of work design and execution, as Melanie Langsett of Deloitte suggests, companies can help foster a work environment that promotes holistic health and productivity, rather than treating wellness as an afterthought or additional task.

Employee retention higher priority than revenue and sales growth, study finds

By Anson Jones – This year, retaining cornerstone workers through employee benefits and meaningful DEI is a top goal for many organizations, and may be focused upon more than revenue and sales stepping into 2024. These estimates were revealed in Gallagher’s 2023 U.S. Organizational Wellbeing Report, which pulled from about 4,000 firms across the U.S. The report noted a large emphasis on employees in particular. This year, nearly 3 in 4 employers forwarded their employees’ base salaries, while 40% of employers invested in expanded medical benefits. Read Full Article…

VBA Article Summary

1. Shifting Employee Retention Strategies: According to William F. Ziebell, CEO of Gallagher’s Benefits & HR Consulting Division, there is a pressing need for organizations to evolve their retention strategies. The contemporary workforce has different expectations and needs compared to the past, and meeting these through comprehensive benefits and compensation offerings can enhance the overall employee experience. The ultimate goal is to build a framework that is people-first and aligns with the diverse needs and interests of employees, thereby improving retention and impacting the bottom line positively.

2. Rising Healthcare Costs and Adaptative Measures: The report highlights a trend where 4 in 5 employers are expecting a moderate or significant surge in healthcare costs, potentially linked to an increase in cost-sharing methods implemented by over half of the firms surveyed. To mitigate this, employers are turning to various tools and strategies like telemedicine, healthcare decision support, and cost-transparency tools. Notably, there has been a growth in the adoption of telemedicine, escalating from 58% in 2022 to 63%, showcasing a trend in seeking innovative solutions to offset the growing expenses without compromising employee healthcare benefits.

3. Integrating DEI into Organizational Strategies: The emphasis on Diversity, Equity, and Inclusion (DEI) is notably growing within organizations, as seen in the report. Introducing and consistently communicating DEI initiatives can foster a positive work environment for all employees. It is integrated into several aspects of organizational management and total rewards, including succession planning, benefits, compensation, and performance management, with the respective percentages demonstrating the emphasis placed on these areas. Organizations are urged to align their benefits and broader vision with the employee interests to create an inclusive and supportive workplace environment, which, as Ziebell suggests, is essential in the current landscape.