High Deductibles, Primary Care Practices, and more....

If You Created an Expensive Health Plan, You Can Help Pay for It

Here’s a well-known, unfortunate fact: a greater portion of the out-of-pocket healthcare costs consumers face are the result of insurance plans with high deductibles, co-payments, and co-insurance. Here’s something that is not as well known: when patients with these unaffordable co-payments, co-insurance, and high-deductibles receive care, they often can’t pay their expenses and the hospital treating them is left with unpaid debt.
Once that happens, the current system is set up so that healthcare providers are responsible for trying to collect the relevant co-insurance, deductibles, and co-payments that patients owe after claims have been adjudicated and paid by insurance companies. But what happens after a hospital makes a good-faith, but unsuccessful, effort to get payment for its services from the patient? If the unfortunate patient just can’t pay because he or she is stuck with a financially debilitating policy that a health insurer has created and sold, should that be the end of the story? Or does the insurance company bear any responsibility for the expensive, impractical policies they are selling?
Proposed legislation before the Joint Committee on Financial Services addresses those questions. HB976, An Act Relative to Uncollected Co-pays, Co-insurance and Deductibles, requires providers to continue making the effort to collect what they are owed. But if the collection efforts are unsuccessful, the provider may submit a request to the patient’s insurer for reimbursement of 65% of the uncollected amount. This percentage is the same amount that the Medicare program reimburses hospitals for patients’ uncollected out-of-pocket expenses.
“Health insurance companies determine which products are created and sold and they establish the rules for those products,” said MHA’s Senior Vice President of Government Advocacy Mike Sroczynski. “However, healthcare providers alone must deal with patient confusion and anxiety about their financial responsibilities, bear the brunt of patient anger, expend considerable time and money attempting to collect patient liability after insurance, and write-off millions of dollars in bad debt annually when patients cannot, or choose not, to pay the amounts owed.”
The Center for Health Information and Analysis (CHIA) has documented the insurer-to-consumer shift in healthcare expenses. According to CHIA’s September 2019 annual report, membership in high-deductible plans grew from 24.5% in 2016, to 31.5%, representing 1.2 million Massachusetts members. According to CHIA, the majority of high-deductible plan members were enrolled through larger employers. However, 80% of unsubsidized individual purchasers and more than half of members covered through small and mid-size employers also enrolled in high-deductible plans in 2018. This is a significant increase from 2012, when only 14% of insurance company members were in high-deductible plans.
“As health insurers promote products that require ever-increasing and unaffordable co-payments, co-insurance, and deductibles, those insurers must take greater responsibility for the resulting bad debt that falls on those that provide care,” Sroczynski said. “HB976 levels the playing field, giving providers additional financial security for uncollectable debt without unduly burdening insurers.”

CMS is Looking for a Few Good Advanced Primary Care Practices

CMS is pushing ahead with “Primary Care First” – a voluntary, five-year alternative payment model to reduce Medicare spending by preventing avoidable inpatient hospital admissions, and improve quality and access to care, particularly for those with complex chronic conditions and serious illness. Last week the Primary Care First Request for Applications went live.
Primary Care First is similar to the existing CMS model, Comprehensive Primary Care Plus (CPC+). But while CPC+ is designed for primary care practices at different stages of readiness to assume accountability for patient outcomes, Primary Care First is geared toward advanced primary care practices that are ready to accept financial risk in exchange for greater flexibility, increased transparency, and performance-based payments that reward participants for outcomes. In Primary Care First, CMS will provide payments that are higher than historical Medicare fee-for-service payments, in the aggregate, for participating practices that care for complex, chronically ill patients. It will be tested over six performance years, with two staggered cohorts of participating practices, each participating for five performance years; one cohort will participate in the model from 2021 through 2025 and a second will participate from 2022 through 2026. Visit the Primary Care First website for more information.

Nurse Workforce Efforts in D.C. and on Beacon Hill

The U.S. House of Representatives has passed H.R. 728, The Title VIII Nursing Workforce Reauthorization Act, which would reauthorize federal programs to develop the nursing workforce for five years. Last Thursday, the Senate Health, Education, Labor & Pensions Committee passed its version of the bill (S. 1399). Massachusetts Senator Elizabeth Warren (D) is a member of the committee.
MHA is a strong supporter of the federal bill and has been involved in related workforce advancement efforts in the state. For example, MHA is advocating for H1944, An Act Relative to Nurse Licensure Compact in Massachusetts, which would allow R.N.s to have one multistate license from the state in which they reside, with the privilege to practice in their home state and all others that are members of the Compact. MHA has also testified in support of HB1737/SB1147, An Act Establishing a Behavioral Health Workforce, which would create a behavioral health workforce commission to identify reasons for behavioral health workforce shortages in inpatient and community-based settings and make recommendations to address such shortages. The commission would be composed of state officials, as well as provider and consumer groups.

Enter Your Zip Code and Find SUD Treatment Options

FindTreatment.gov is up and running, helping individuals locate substance use disorder treatment facilities across the U.S. More than 13,000 sites across the U.S. are included.
The website is operated by SAMHSA, the Substance Abuse and Mental Health Services Administration, which is part of U.S. Health and Human Services.
The site is easy to use but fairly sophisticated in that its users can pick the type of treatment they’re looking for (outpatient, inpatient, residential, etc.), the type of payment the facility accepts (private insurance, Medicaid, free care, and more), any special program required (for Veterans, LGBT, or those hard of hearing), and medication for opioid use disorder (MOUD) treatment options offered. In announcing the site, SAMHSA noted that in 2019, estimates suggest 1.27 million Americans are receiving MOUD treatment (which SAMHSA refers to as medication-assisted treatment) – a 38% increase from an estimated 921,000 Americans in 2016.

D.C. Bill Addresses Telemedicine in Medicare Program

Members of the House and Senate Telehealth Caucus have introduced the CONNECT for Health Act, AHA-supported legislation that would expand access to telehealth for Medicare patients.
“Currently, 76% of U.S. hospitals connect with patients and consulting practitioners at a distance through the use of live voice and video and other supporting technologies. Yet, systemic barriers to widespread adoption of telehealth in the Medicare program remain,” AHA wrote in a letter of support.
The federal legislation would permit the expansion of telehealth for mental health services and emergency medical care in the Medicare program, along with the ability to waive restrictions on the use of telehealth during national and public health emergencies. The legislation also would appropriately expand the ability of rural health clinics and federally qualified health centers to provide telehealth services for their patients. These sites are important partners to hospitals, particularly in rural and underserved areas.
In Massachusetts, MHA convenes tMED, the Massachusetts Telemedicine Coalition, which supports HB991/SB612, sponsored by Rep. Thomas Golden (D-Lowell) and Sen. Jason Lewis (D-Winchester). The proposal would create a comprehensive definition of telemedicine that includes all technological formats; require coverage parity across all insurance types, including MassHealth and the Group Insurance Commission that are on-par with in-person visits; and allow for proxy credentialing for providers to reduce administrative burdens. Governor Baker’s recent healthcare reform legislation includes some elements of the pending bills; specifically, the governor’s proposal promotes telemedicine by establishing a regulatory framework for it that ensures coverage parity by prohibiting insurers from denying coverage based on the sole fact that the service is provided via telemedicine. It additionally includes an expansive definition of telemedicine that includes both interactive and asynchronous (that is, store and forward) technologies.

CHIA: Co-Morbid Behavioral Health Issues Complicate Readmissions

On Halloween, the Centers for Health Information and Analysis (CHIA) released its second report on behavioral health and readmissions in Massachusetts acute care hospitals. The report examines both the prevalence and readmission rates of adult patients with co-morbid behavioral health conditions hospitalized between July 1, 2016, and June 30, 2017.
CHIA found that 45% of adults hospitalized in Massachusetts acute care hospitals had at least one co-morbid behavioral health condition in FY2017, and that co-morbid behavioral health conditions among hospitalized Medicaid adults was 63%.
The co-morbid mental health conditions with the highest prevalence were mood disorders and anxiety disorders, at 26% each. The co-morbid substance use disorders with the highest prevalence were alcohol- and opioid-related disorders, at 9% and 6%, respectively. Readmission rates for patients with any behavioral health co-morbidity were nearly double the readmission rates for patients without a co-morbid behavioral health condition (21.1% vs. 10.8%).
“While hospitals cannot control many of the factors that lead to patients returning to their facilities, it is still absolutely imperative for hospitals to play a leading role in reducing unnecessary readmissions,” MHA said in a statement. “Today’s CHIA report provides helpful data to inform these ongoing efforts.”

WEBINAR: Essentials of Facility Reimbursement for ED and Observation Services

Thursday, December 5; 1 - 2 p.m. (EST)

Successful Emergency Department financial performance requires identifying key opportunities and avoiding common pitfalls. Join us and position your ED for optimized performance by taking a focused look at the critical areas of ED documentation, revenue capture, and compliance. Learn about the most important and hot-off-the-presses 2020 Outpatient Prospective Payment System changes affecting ED facility reimbursement and the evolving comprehensive APC. Topics covered will include correct E/M level assignment, procedure charge capture, and observation services. Learn more, including speakers and registration fees, by clicking here.

John LoDico, Editor