What HR needs to know about the EEOC’s new enforcement plan

By Stephen Paskoff - The EEOC’s newly adopted strategic enforcement plan aims to increase the public’s access to the EEOC and increase investigation training and resources. The plan describes the EEOC’s vision of fair and inclusive workplaces and details expanded efforts to reduce systemic barriers to equal opportunity, including an enhanced focus on identifying offenses and additional staff and resources for enforcement. Read Full Article…

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1. Balancing Act Amidst Regulatory Developments: The Supreme Court’s June 2023 decision on affirmative action in college admissions has set a precedent that may influence the legality and acceptance of affirmative action in the workplace. With different states' attorneys general offering varying interpretations and levels of support for workplace Diversity, Equity, and Inclusion (DE&I) initiatives, organizations face the challenge of navigating through a patchwork of potentially contradictory legal stances. Lawsuits targeting elements of firms' DE&I programs have increased, further stirring uncertainty and anxiety among HR professionals. This legal landscape requires HR leaders to delicately balance their anti-discrimination efforts, ensuring compliance with both the Supreme Court’s decision and the new enforcement guidance from the Equal Employment Opportunity Commission (EEOC).

2. Mitigating Discrimination and Legal Risks in DE&I Initiatives: Organizations should prioritize attracting top talent from various protected classes while fostering an environment where they can excel individually and collaboratively. The EEOC's new plan brings increased attention to different forms of discrimination (direct discrimination, disparate treatment, and disparate impact) and calls for stricter enforcement against these practices. HR departments should be vigilant in eliminating behaviors and practices that may inadvertently favor one group over another, unless these practices are based on legitimate, nondiscriminatory criteria and conduct. The risk of legal repercussions exists, both from potentially discriminatory practices and from failing to establish fair employment processes. Employers should systematically review and adjust their recruitment, selection, hiring, promotion, and compensation practices to ensure fairness and non-discrimination, thereby avoiding legal claims and fostering a diverse and inclusive workplace.

3. Proactive Culture Building for Legal DE&I Support: To legally uphold DE&I principles and avoid the risks associated with non-compliance, organizations must actively promote a culture that values diversity and inclusion. This involves setting clear DE&I goals and expectations, effectively communicating organizational values related to fairness, collaboration, and inclusion, and fostering an environment where open communication is encouraged and valued. Leaders should model desired behaviors and establish policies and procedures that support diversity and inclusion, with enforced consequences for non-compliance. Implementing and bringing organizational values to life requires continuous effort and commitment from both HR and leadership teams, ensuring the creation of an inclusive workplace that aligns with the organization’s operational and strategic objectives while navigating through the complex legal environment.

CMS urged to change GLP-1 drug coverage determination

By Noah Tong - Healthcare organizations are continuing to push the Centers for Medicare & Medicaid Services (CMS) to rethink its coverage policy for anti-obesity medications. Read Full Article…

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1. Statutory Exclusion for Weight-related Drugs: Medicare Part D currently does not cover certain medications, including GLP-1s, due to a statutory exclusion for drugs used for anorexia, weight loss, or weight gain. However, advocates from Manatt, Phelps & Phillips and the Obesity Action Coalition argue that this exclusion is outdated. They emphasize that obesity, which GLP-1s can target, is a complex disease, not merely a weight-related condition. Michael Kolber from Manatt Health highlights the inconsistency in CMS’ policy, as it covers some obesity treatments (like bariatric surgery) but not others.

2. Call for Updated Policies to Reflect Current Understanding of Obesity: Kolber stresses that the understanding of obesity as a disease has evolved since Congress's decision over 30 years ago. Other federal agencies and departments, including the Social Security Administration, the NIH, the IRS, the Department of Defense, and the Department of Veterans Affairs, recognize obesity as a disease and provide coverage for anti-obesity medications. The advocates insist that Medicare Part D's coverage policies should be updated to reflect the current knowledge and treatment landscape for obesity.

3. Advocates Argue for Inclusive Coverage to Promote Health Equity: Expanding Medicare Part D to cover anti-obesity medications aligns with recent FDA approvals and health equity initiatives, including President Biden’s Cancer Moonshot. The advocates argue that improving access to these treatments can not only help in managing obesity but also in addressing related health conditions and reducing the stigma associated with the disease. Tracy Zvenyach of the Obesity Action Coalition points out that currently, only 1-3% of individuals have access to evidence-based obesity treatments, underscoring the need for broader coverage and access to care for older Americans.

Senate HELP committee advances community health center bill

By Paige Minemyer - Despite concerns about pay-fors and some negative feedback from the industry, a key Senate panel has advanced a bill that aims to provide a financial boost to community health centers. Read Full Article…

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1. Bipartisan Support and Opposition: The Health, Education, Labor and Pensions Committee approved a bipartisan bill with a 14-7 vote, aimed at strengthening primary care in the U.S. The bill, co-sponsored by Committee Chair Bernie Sanders, I-Vermont, and Sen. Roger Marshall, R-Kansas, faces opposition from some lawmakers and hospital groups who express concerns over funding cuts and potential jeopardization of access to various essential healthcare services, particularly in rural and underserved areas.

2. Investment in Primary Care and Workforce: The proposed legislation plans to allocate over $26 billion to primary care programs and initiatives designed to expand the healthcare workforce. Significant investments include $5.8 billion for community health centers, $3 billion for expanding dental and mental health services, and substantial funding for scholarships, debt forgiveness for clinicians, and educational programs for doctors, nurses, and dentists serving in vulnerable communities. The bill also supports the extension of health center hours, school-based health programs, and newly mandated nutrition services.

3. Controversies and Funding Sources: Critics, including the Federation of American Hospitals CEO Chip Kahn, argue that the bill doesn’t offer practical solutions to current healthcare issues, claiming that the proposed funding cuts might hinder access to telehealth, primary care, and other crucial services. In contrast, Sanders and Marshall contend that the bill, crafted through over a month of negotiations, addresses critical shortages and inadequacies in primary care and the healthcare workforce. The bill’s costs will be covered by addressing waste, fraud, and abuse within the existing healthcare system.

About 18 million US adults have had long COVID: CDC

By Mary Kekatos - Millions of Americans say they've had long COVID, and some say they're still battling it, according to new federal data. Two new reports, published early Tuesday by the Centers for Disease Control and Prevention's National Center for Health Statistics, looked at data from the 2022 National Health Interview Survey. Read Full Article…

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1. Prevalence and Demographics: In 2022, around 6.9% of adults, equating to approximately 18 million Americans, reported having experienced long COVID, with 3.4% (or about 8.8 million) currently dealing with the condition. Furthermore, the data shows a discernible demographic variance, with women, adults aged 35-49, and Hispanic individuals more prone to the ailment. For children, approximately 1 million have had long COVID, with 0.5% still showing symptoms. The highest prevalence in the pediatric population is seen among Hispanic children and those aged between 12 and 17.

2. Symptoms and Definition of Long COVID: Long COVID refers to the persistence of COVID-19 symptoms lasting at least four weeks after the initial infection has cleared, with some individuals experiencing these issues for months or even years. The array of symptoms is diverse, including but not limited to fatigue, difficulty breathing, headaches, brain fog, joint and muscle pain, and a continued loss of taste and smell. The exact cause of long COVID remains unidentified, but research is ongoing to understand the mechanisms and potential treatments.

3. Government Response and Support Initiatives: Recognizing the increasing prevalence and prolonged impact of long COVID, the Biden administration has initiated efforts to address this public health issue. A dedicated Office of Long COVID Research and Practice has been established under the Department of Health and Human Services, tasked with coordinating government-wide responses and supporting continued research and practice related to long COVID. This initiative underscores the commitment to understanding, mitigating, and providing necessary support for individuals suffering from the long-term effects of COVID-19.

CMS to get ‘tougher’ on Medicare Advantage, official promises

By Rebecca Pifer - The CMS is poised to crack down further on health insurers in the Medicare Advantage program, according to new comments from a top agency official. MA plans — which now cover more than half of Medicare beneficiaries — have faced rising criticism over care denials and access, along with improper coding practices that inflate the program’s cost. Read Full Article…

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1. Tightening Regulation and Oversight: The CMS (Centers for Medicare & Medicaid Services) Deputy Administrator, Jon Blum, announced at the National Association of ACOs' fall conference that the agency will be a tougher payer and regulator to guarantee value and service for beneficiaries and taxpayers. The future actions will address the concerns raised by watchdogs and patient advocates regarding access in the increasingly popular Medicare Advantage (MA) plans. These concerns include the frequent delay or denial of care that is typically covered under traditional Medicare. With rising costs and the fast growth of MA plans, CMS is considering stringent oversight to ensure that the additional payments made to these plans are justified and valuable.

2. Addressing Overpayments and Compliance: MA plans have come under scrutiny for alleged profiteering, with overpayments estimated to reach more than $75 billion this year, according to the USC Schaeffer Center for Health Policy and Economics. Overpayments have been linked to favorable beneficiary selection, aggressive coding, and quality bonus engineering. The CMS has initiated measures to rectify this, including clawing back billions in overpayments and reinforcing compliance with coverage rules applicable to traditional Medicare. However, there have been calls from health policy experts for CMS to adopt even stricter oversight and regulation of MA plans to prevent overpayments and ensure compliance.

3. Legal and Policy Challenges: Despite CMS's efforts to tighten regulations, healthcare companies offering MA plans, including industry giants like Humana, have legally challenged these regulations. Humana argues that some of the new rules are illegal, reflecting the tension and disputes between healthcare providers and regulators over the future framework and oversight of MA plans. Amid this legal and policy landscape, the CMS continues to evaluate the balance between providing flexibility to MA payers to offer additional benefits and ensuring that these plans provide value and access to essential services for beneficiaries. The agency is deliberating tough questions regarding the cost and value of MA programs as they navigate through these challenges and criticisms.

5 reasons ICHRAs could be a an alternative to self-funding

By Tom Muffle - As employers’ health care premiums rise to the tune of 8.5% for 2024, HR professionals and benefits consultants are exploring alternatives to group coverage. The first stop for many companies feeling the full weight of that increase – which is nearly double what it was from 2022 to 2023 – is to consider moving from fully insured plans to a self-funded strategy. Read Full Article…

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1. Stable and Predictable Pricing: One of the significant advantages of Individual Coverage Health Reimbursement Arrangements (ICHRAs) over self-funded plans is their predictable pricing structure. Self-funded plans inherently involve a yearly financial gamble for employers as they bear the claims risk, leading to potential cost uncertainties. In contrast, ICHRAs disperse risk across the broader individual market, providing stable and predictable pricing. This stability is particularly beneficial for companies with high claims due to high utilizers, offering an average savings of 20% on annual premiums. Unlike the initial cost savings shown by self-funded plans, ICHRAs ensure long-term financial predictability, making them a more reliable option for employers seeking to manage their healthcare expenditure effectively.

2. Administrative Simplicity and Ease: The transition to a self-funded model often imposes an administrative burden on employers. These companies not only assume financial risk but also face the responsibility of managing various administrative tasks, even when working with third-party administrators (TPAs). These tasks include constant monitoring of claims and managing stop-loss policies, which can be complex and time-consuming. ICHRAs offer a solution by simplifying the entire administrative process. Employers adopting ICHRA models do not have to deal with claims, and with the right administrative partner, they won’t need to navigate through the processes of paying individual carriers or reimbursing employees for premiums. This streamlined administrative process allows for more efficient and hassle-free management of health benefits.

3. Enhanced Plan Portability and Choice: ICHRAs are revolutionary in providing both employers and employees with unprecedented choice and flexibility regarding health plans. For employees, ICHRAs grant the ability to select health plans that best suit their individual needs, as opposed to being restricted to limited options provided by employers. This level of choice is crucial for employees seeking plans that align with their healthcare requirements and financial capacities. Furthermore, ICHRAs provide the added advantage of plan portability. Unlike self-funded models where employees “rent” coverage from employers and risk losing it upon termination, ICHRAs allow employees to own and retain their plans even after leaving their current employment. This feature not only ensures continuity of coverage for employees but also facilitates smoother transitions during employment changes, underscoring the flexibility and employee-centric design of ICHRAs.

3 undervalued benefits of disruption every HR leader should know

By RxBenefits - The fear of disruption keeps HR leaders from meeting their benefits goals every year. A plan change that would ultimately benefit members may never see the light of day because lowering plan costs and improving the benefits package for the entire team gets less consideration than the calls that may come in the weeks after implementation. Read Full Article…

VBA Article Summary

1. Protection Against Rising Drug Prices:

   Budget Safeguard: Introducing minor disruptions in pharmacy benefits can shield all plan members from escalating drug prices and premiums. With finite resources, the company can effectively manage expenditures, providing a safety net against inflated costs in pharmaceuticals.

   Selective Utilization Management: Implementing precise utilization management rules allows the company to exert control over disruption. By focusing on high-priced medications, which are seldom used but significantly impact costs, the company can address 90% of the plan expenses without affecting 95% of members. This selective approach fosters an environment where both the company and its members can enjoy beneficial financial outcomes with minimized disruptions.

2. Fostering Trust through Minimized Disruption:

   Smooth Transition: The process of altering benefits packages inevitably brings changes that might be met with resistance from the team. However, this transition phase can serve as a trust-building period. Ensuring a smooth shift with transparent communication about modifications to the plan, coupled with adequate support during implementation, can enhance the team's trust in the company.
   Risk Limitation through Focused UM Programs: With utilization management programs zeroing in on a small percentage of prescriptions that incur the highest costs, the company can effectively minimize risks. This focused approach not only facilitates trust-building but also ensures that the transition to the new plan is straightforward for all members, even those affected by the changes.

3. Preventing the Negative Impact of Trending Medications:

   Informed Medication Choices: Many factors influence the prescriptions doctors write, but not all physicians are up-to-date with the latest research and pricing models for medications. Implementing step therapy rules can prevent the negative impact of trending, often overprescribed medications that may not necessarily be the best fit for members. This approach protects members from potential side effects and the company from increased costs due to overprescription.

   Beneficial Step Therapy Implementation: Introducing step therapy rules helps in identifying and intervening in cases of off-label prescribing. Even though some members may experience temporary inconvenience, the overall impact of these rules proves positive for both the plan and the members. These measures ensure that members only receive medications that benefit them, safeguarding their health while protecting the company’s financial resources.

As Younger Children Increasingly Die by Suicide, Better Tracking and Prevention Is Sought

By Cheryl Platzman Weinstock - He had dropped off his 9-year-old son, Montana, at Stewart’s Creek Elementary School in The Colony, Texas, that morning. “There were no problems at home. He was smart. He wore his heart on his sleeve and he talked and talked and talked,” said Lance. It was “the same old, same old normal day. There were kisses and goodbyes and he said, ‘I love you, Daddy.’” Read Full Article…

VBA Article Summary

1. Increasing Awareness & Vigilance: Suicide among children, especially between ages 5 to 11, has been a growing concern, with its rate notably increasing in the past decade. It is essential for parents, teachers, and caregivers to remain vigilant and attentive to the mental health of children as they return to their school routines. The signs of mental distress in younger children can be subtle and may manifest differently than in teens and adults, often requiring keen observation and intuition from adults to identify and address.

2. Early Detection & Prevention Strategies: Experts advocate for lowering the screening age for suicide ideation in children. Developing effective early suicide risk detection mechanisms and targeted prevention strategies is crucial. This approach should be broad and collaborative, involving pediatricians, teachers, and parents working together to build resilience in children from a young age, helping them manage stress, and providing support mechanisms. Various factors, including isolation, lack of school structure, neurodivergence, psychiatric disorders, and bullying, can make children more vulnerable, necessitating a multifaceted approach to prevention and support.

3. Improving Reporting & Intervention Systems: Accurate reporting and investigation of pediatric suicides are vital for developing effective prevention programs. Current reporting might underestimate the actual numbers due to incomplete counts and pending investigations. Efforts are underway nationally to enhance the quality and consistency of pediatric death investigations, ensuring a better understanding of the issue. Technology and intervention programs, like specific software strategies and the Good Behavior Game, are being implemented in schools to identify at-risk children and offer timely intervention, despite some challenges in adoption due to privacy concerns.

Cigna hit with second class action suit over claims automation software

By Rebecca Pifer - Cigna has been in the hot seat over its use of automatic claims processing software since earlier this year, after a ProPublica investigation found Cigna physicians used PxDx to automatically reject claims without opening a patient’s file. Read Full Article…

VBA Article Summary

1. New Class Action Lawsuit Against Cigna: Cigna, a health insurer, faces a second class action lawsuit filed in Connecticut over the alleged misuse of its PxDx software in processing and denying customer claims without professional medical review. This suit closely mirrors a previous one filed in California earlier in the summer, with both highlighting the mass denial of claims through automated processes.

2. Alleged Unlawful Denials & Regulatory Investigations: The lawsuits accuse Cigna of employing the PxDx software to systematically deny claims by flagging discrepancies between diagnoses and acceptable tests and procedures, thus potentially affecting hundreds or thousands of patients at a time. Additionally, the House Energy and Commerce Committee, along with state regulators, is scrutinizing Cigna's use of the contentious software, following lawsuits from two California members who claim illegal payment denials due to PxDx.

3. Cigna’s Defense and Potential Class Action Scope: Cigna maintains that the legal challenges are unfounded, arguing that their PxDx review process is a standard practice in line with industry norms, and that specific complaints were not subject to this automated review. The Connecticut lawsuit aims for class-action status, potentially encompassing every individual nationwide whose claims were processed using PxDx. Given Cigna’s substantial customer base of 19.5 million in the U.S., the number of affected individuals could be significant.