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By Jonathan Burroughs
HRAs, or health reimbursement arrangements, are defined as a type of account-based health plan that employers can use to reimburse employees for their medical care expenses. Employer-sponsored health plans cover more than 155 million employees in this country. Enthusiastic administration officials say the plan will give the private insurance market a shot in the arm, and help small businesses offer health coverage to all levels of employees. The healthcare community is calling this HRA expansion. As the National Law Review explains in extensive legal detail, the new law reverses long-standing ACA policy that prevented HRAs or premium payment plans from being used to reimburse premiums paid for individual market coverage. The new HRAs give employees the freedom to purchase insurance in the individual market, from an exchange or not. ‘Your Attention Please’ On June 13, three departments — Health and Human Services, Labor and the Treasury —teamed up to announce the new policy that becomes effective Jan. 1, 2020. Business owners can provide an individual coverage HRA or ICHRA (Yes, another acronym) or an excepted benefit HRA. The HRA experts at PeopleKeep, personalized benefits automation software providers, explain the nuances of these two options this way. The ICHRA allows employers to give employees a set amount of tax-free money each month, to spend on healthcare and/or individual health insurance, and then be reimbursed up to that amount. The excepted benefit HRA mandates that employers offering group health plans offer an HRA that reimburses for dental and vision coverage, along with short-term premiums. The federal government’s announcement says that more than 11 million American workers, which include 800,000 uninsured, will ultimately enroll in HRA plans. That 800,000 number is used again, referring to companies that will likely jump on the HRA bandwagon, with almost 90 percent employing fewer than 20 people. A Brief History of HRAs HRAs aren’t anything really new, hence the current “expansion” label. They were ticking along until 2013 when the IRS wrote guidance with IRS Notice 2013-54 around the Affordable Care Act that cut employers’ ability to offer HRAs. The agency said “OK” to HRAs paired with group health coverage but “no” to a combo of an HRA and individual coverage. In December 2016, enter the qualified small employer HRA or (You guessed it: another acronym) QSEHRA (Some people call it “Q-Sarah.”). It’s great for smaller employers, those with 50 or less on board. The employer can put away money every month for staff to buy their own individual health insurance or spend on necessary medical costs and again, it’s all tax-free. Fast forward to fall 2017, when President Trump’s executive order directed the above three departments to revisit that 2013 guidance so all employers could pair the HRA with individual coverage for their employees. A year later, the 2013 rule was gone in favor of that duo of HRAs we’ve just described — and here we are. Those in Favor Say “Aye” Supporters say that since employers need to provide health insurance as a highly desirable benefit in a tight employee market and that doing so can be expensive, the new HRA alternative is ideal. It doesn’t mandate that an employer choose just one health plan for its entire employee group, which can sometimes be an expensive proposition. Those same employers can also reap tax benefits that big corporations do but can do it a different way with the HRA, which, as noted, excludes premiums from federal income or payroll taxes. On June 14, Brian Blase, special assistant to the president at the National Economic Council focused on healthcare policy, wrote for CNN that “the Obama administration forbade workers in the individual insurance market to use HRAs to pay for coverage — significantly impeding employer flexibility and worker choice. Trump’s new rule undoes this misguided restriction.” He notes that 80 percent of employers that offer insurance only offer one type of plan. He also shares that between 2010 and 2018, the proportion of workers at firms with three to 49 workers covered by an employer plan fell by more than 25 percent. The often controversial yet undeniably influential Blase thinks that HRAs may bolster the individual market by more than 50 percent, yielding more competition that ultimately delivers better choices for consumers. Insiders credit him for getting the HRA rule done and note that, ironically, he’s leaving his job soon. In an opinion in The Washington Post, Avik Roy, president of the Foundation for Research on Equal Opportunity cheers the move, saying it could cause a revolution in the private insurance market. Roy even goes a step further, suggesting the administration require “all newly incorporated businesses seeking the tax break for employer coverage to do so through HRAs.” Those Opposed Say “No” True, under the HRA system, employees do have free rein to choose a plan that works with their budget, which receives rave reviews in some circles, and a thumbs-down in others. So an employee with champagne healthcare coverage taste could go for broke, while another might choose bottom-of-the- barrel coverage which provides the bare minimum and leaves them exposed to a sky-high deductible, as with some catastrophic plans. Short-term or limited benefits plans can expose consumers if the plans discriminate against pre-existing conditions, says the former editor of Modern Healthcare, Merrill Goozner. He sounds the alarm bell about HRAs, calling the move another way to undermine the ACA exchanges. And here’s something not mentioned in that announcement, says Goozner: “Moreover, if an employer no longer offers an employer-provided health plan, an employee that accepts HRA cash could be cut off from receiving premium tax credits on the ACA exchanges.” He says that many employers will get lost trying to understand the detailed parameters around eligibility — it will be Greek to them — which will in fact buff up employment “for insurance brokers and employee benefit consultants.” Joining the “not-so-fast-here” congregation, Larry Levitt, senior vice president of the Kaiser Family Foundation, tweeted about an irony he perceives with the entire situation. He believes HRAs can only fly “if the ACA individual insurance market is stable and attractive,” and as he noted, and we’ve written about here, the current administration has tried on numerous occasions to undermine that market. Finally, Speaker of the House Nancy Pelosi responded with a formal statement, which said, among other things, that “the Trump Administration has worked relentlessly to push families into disastrous junk plans, increase their health care costs and gut their health care protections.” Truthfully, the rules around this new rule are very complicated, experts agree. The Trump administration has adopted what’s been termed an aggressive timeline, and 2020 is just around the corner. Looking for your next healthcare speaker? Get in touch with us at the Capitol City Speakers Bureau today to make your healthcare event a success!
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By Jonathan Burroughs
With the midterms coming up, a new poll published October 18th by the non-partisan Kaiser Family Foundation got a lot of attention. Over seventy percent of voters say health care is a very important issue in deciding who to vote for. But exactly what happens to key healthcare initiatives, especially the Affordable Care Act including expansion of Medicaid in many states — which tends to be more popular among Democratic lawmakers than Republicans — depends on whether it’s the Democrats or Republicans who get control of the House, says Eric Feigl-Ding, MPH, Ph.D., a health economist and visiting scientist at the Harvard Chan School of Public Health in Cambridge, Mass. Based on multiple polls, the New York Times reported on October 23 that a likely outcome is that Democrats will gain the majority in the House of Representatives and the Republicans will keep the majority in the Senate. But the Times and many other news outlets continually point out that many factors including the news of each day make it difficult to predict the outcome. Feigl-Ding says having opposing parties in the House, Senate and White House could make it harder to pass national legislation. Changes can still happen to the ACA, however, because the President can continue to make certain executive level decision such as ending the penalty for not having health insurance which he did last year. That change takes effect in 2019. In terms of new legislation, Feigl-Ding says a split Congress and White House means that passing legislation will be difficult because what comes from the House side, if most members are Democrats in the next sessions, could be more liberal and the corresponding bills from the Senate, likely to remain Republican, could be more conservative. So, says Feigl-Ding, either a bill won’t pass at all, or there will have to be much more of a compromise. “And assuming they would get to compromise is a big assumption, that then requires the president to agree to sign that legislation,” adds Feigl-Ding. A report this week by strategy and policy group Manatt Health, based in Washington, DC lists the health care issues the firm thinks will dominate in states and the federal government after the elections:
Other important health care issues for 2019-20120 include: Pre-Existing Conditions Listening to ads for some Republicans candidates for Congress makes it appear protecting pre-existing conditions will be a top priority for some Republicans, even among some who voted against them previously. But Feigl-Ding says keeping coverage for preexisting conditions in health insurance plans also requires figuring out how to pay for it. Under the original ACA legislation, the hope was that a financial penalty for not having health coverage would keep more healthy people in the plans—along with the prohibition against letting insurers “cherry pick” only healthy consumers. But that penalty is now gone. “Take that away and you probably can’t sustain the preexisting conditions, says Feigl-Ding. Medicaid Work Requirements and Other Conditions of Eligibility. Legal challenges in several states could impact the implementation of work requirements. Some governors have said they’ll cut the number of state Medicaid beneficiaries to save money if work requirements are overturned. ACA Repeal. Twenty states are challenging the constitutionality of the ACA in Texas v. The U.S., a case that could make it to the Supreme Court. Association Health Plans and Short-Term Plans. Several Democratic state attorneys general have filed a lawsuit against the administration’s rule promoting association health plans that allow individuals and small businesses to join to purchase health care coverage and short-term plans. The suit argues that the new rules for both avoid protection for people with pre-existing conditions, according to Manatt. No one has a crystal ball for what will happen, but everyone has hindsight. According to the Manatt report, in 2010 Republicans replaced Democratic governors in eleven states, and all but one of those states ended plans to establish a state-based health insurance marketplace (SBM). In five states where Democrats replaced Republicans, all those states set up those marketplaces. And whatever the outcome of the 2018 elections, their impact on healthcare may only be short lived. At a foundation briefing on the midterm elections earlier this week Mollyann Brody, Executive Director, Public Opinion and Survey Research at the Kaiser Family Foundation reminded the crowd that “the day the 2018 elections are over the 2020 campaign starts.” Still the end of the week also brought a glimmer of hope. In response to President Trumps remarks on October 25th about his administration’s plan to test new drug pricing models in Medicare Part B help to lower drug prices Frederick Isasi, executive director of FamiliesUSA, a liberal-leaning health insurance advocacy group, released a statement that said, in part, “I hope this is a serious policy that will be formally proposed and finalized by the Trump administration. If so, it is an important step forward for our nation’s seniors and taxpayers.” Looking for your next healthcare speaker? Get in touch with us at the Capitol City Speakers Bureau today to make your healthcare event a success! By Jonathan Burroughs
The Centers for Medicare & Medicaid Services’ (CMS) bundled payment initiative for joint replacement surgery likely means it is just a matter of time before such forms of finance are normalized in healthcare delivery. Bundled payments can reap significant savings when well executed. Euclid Hospital, a member of the Cleveland Clinic healthcare system, was able to perform lower extremity joint replacements at 9.8 percent below the cost target set in a CMS demonstration project that began in 2013. The average length of hospital stay also dropped in some cases more than 20 percent, from 3.4 days to as low as 2.67 days. Cases of catheter-associated urinary tract infections were completely eliminated. As a result, Euclid Hospital saved $362,818 beyond the initial target, while CMS saved $159,571. Patient experience surveys also improved. But how does a medical group, hospital or healthcare system succeed in transitioning from fee-for-service to bundled payments? Teamwork is a big key, say several top physician executives. “With payment bundles, the providers are focused on well-defined segments of patients with similar needs. Whether or not the work they are performing is surgical or non-surgical, you need great teams where people are really working together, have to deliver value, have to be technically excellent and give patients a great experience as well,” said Thomas Lee, M.D., chairman of the Geisinger Health hospital system. Yet there is even more important pre-clinical teamwork that has not yet been performed in many healthcare organizations. That is creating a bridge between hospital/healthcare system management and the medical staff. Sachin Jain, M.D., chief executive officer of CareMore Health, a Medicare Advantage health plan and provider in Cerritos, Calif., observed that the financial, management and clinical teams of healthcare organizations often don’t trust each other. Moreover, he believes physicians “don’t ever learn a lick about financing healthcare” unless the opportunity is presented to them directly. “No one ever went to medical school to be a deliverer of value-based healthcare,” Jain said, “but to to treat COPD and other diseases.” Andrew Agwunobi, M.D., chief executive officer of the UConn Health system in Farmington, Conn., believes that succeeding in a bundled payment environment requires a nexus of high quality care, incremental but steady financial improvements, business growth and customer service. However, there is one significant problem: “Physicians are too disengaged,” Agwunobi said. He added that there are currently misalignments in the agendas between clinicians and management, and even a misalignment in the incentives available to cut costs and improve outcomes. That leads to the overarching question Agwunobi said many physicians ask: “Why should I do anything different?” Jain has a similar view: “Physicians have difficulties consuming change,” he said. Given their training and backgrounds, Agwunobi noted that data is critical in changing the hearts and minds of doctors. Any compelling vision toward a shift in bundled payments is going to have to be based on hard data that is “bulletproof.” But that shift should not pivot specifically on hard savings projections. “Don’t start by saying your initiative is going to save $10 million,” Agwunobi said. Such a firm commitment can lead to concerns among clinicians that the quality of care is going to suffer to reach that goal. Instead, he recommended communicating a more flexible target, say $5 million to as much as $20 million. “That will help everyone look for every way to implement cost savings while keeping quality intact. And you can probably get more out of that than you think,” he added. Education Can Help To try and better engage physicians with management, CareMore has created a special academy to provide educational opportunities to physicians on healthcare delivery and business, with a particular focus on recently on-boarded doctors. Although UConn Health has not gone that far, Agwunobi has recommended that management do its best to try and educate physicians on their terminology and jargon. “You have to explain all the business terms. They’re embarrassed if they don’t know, and they’re not going to ask what a FTE (full-time employee) or an RVU (relative value unit – a factor in determining employee productivity) is,” he said. At the same time, management also needs to bone up on the clinical operations within their organizations. According to Jain, nothing is more disastrous for trust building than having a manager mention to medical staff that he’s heard the cardiac catheterization lab is important to the ongoing operations of the hospital – what does it do, exactly? As silly as such a scenario sounds, Jain said it happens more than is expected. “Managers need to spend some time shadowing clinicians,” he said. Poring over patient data and preferences together can also help. This leads to what Jain calls “micro-insights” – which can help drive incremental changes in how care is delivered to CareMore enrollees. One example: Older patients are worried about preserving their teeth so they can continue to eat solid foods. They are significantly more likely to visit their dentists multiple times a year than their doctors. As a result, Jain said CareMore is experimenting in merging oral and medical care visits. That could lead to better control of chronic conditions and therefore improved performance in a bundled payment environment. Such work is difficult and complicated. But it must be performed in order for doctors, hospitals and other healthcare providers to be able to effectively accept a flat payment to perform specific clinical tasks at a consistently high level of quality. “I believe teamwork in almost every area of medicine is going to be a very important competitive differentiator for providers,” Geisinger’s Lee said. Looking for your next healthcare speaker? Get in touch with us at the Capitol City Speakers Bureau today to make your healthcare event a success! By Jonathan Burroughs
Medical staff services once was a mostly clerical/administrative task focused on the job of verifying the CVs and credentials of physicians for onboarding at hospitals and other providers. But it has become increasingly complicated in recent years, requiring wider bandwidths for the relevant staffs of many provider organizations. The growth of healthcare jobs that require close vetting, providers that coalesce and interact in new ways, and increasingly sophisticated vetting technologies are among the reasons medical staff services has become a far more complicated task. And the job is challenging to begin with: It can take weeks, if not a couple of months, just to locate enough peer references to obtain privileges for a single doctor. More Non-Physicians to Vet There are about 234,000 nurse practitioners (NPs) and 95,000 physician assistants (PAs) practicing in the U.S., with more than 50,000 new positions being created every year, according to trade association data and the Bureau of Labor Statistics. Although those combined figures still comprise less than half the number of physicians who practice nationwide, their growing numbers pose a challenge to medical staff services departments. Both professions require licenses that need to be verified and allow prescribing of medications. And federal regulations require hospitals grant privileges in order to practice onsite. “The same rules apply as for physicians,” said Karen Beem, who oversees standards interpretation for the Chicago-based Healthcare Facilities Accreditation Program. “Their education and licensing need to be confirmed, and there has to be a delineation of privileges, and they have to apply every two years.” Unlike most physicians, NPs and PAs are mostly employees of the hospital or healthcare system as well, meaning there is an overlap in responsibilities between staff services and human resources that needs to be reconciled between the two departments. Moving From Paper to Electronic Systems It wasn’t that long ago when the most striking thing when entering a hospital’s medical staff services were the rows of filing cabinets used to keep track of the hundreds of physicians practicing on-site. But the numbers of those filing cabinets have been shrinking in recent years as more sophisticated electronic credentialing systems have become available. According to Beem, such software can be integrated into a hospital or healthcare system’s electronic medical record systems. “You can scan in all the documents,” she said, and keep them for future reference. Such systems can also semi-automate some of the more complicated aspects of medical staff services. That includes primary source verification, which includes authenticating state licenses and specialty certifications, and periodical appraisals of those staffers who have already been on-boarded. But while some of those tasks have been made easier by computers, the complexity of what is being asked of medical staff services has multiplied geometrically. Among the issues have been mergers that have created multi-site healthcare systems, as well as the acquisition of medical practices by hospitals. That often means a staff services department is vetting a single provider to simultaneously obtain privileges at multiple hospitals. “The ability to have an integrated and unified medical staff has become a new demand,” Beem said. There are also some loopholes. An NP practicing at an outpatient clinic affiliated with a healthcare system may be able to write prescriptions without specific hospital privileges. It depends on system-specific policies and state and local laws and regulations – all of which medical staff services must track. There has also been a growing emphasis in recent years on what Beem calls “negative credentialing” – determining whether practitioners who have been granted privileges may have received them inappropriately. That has taken on greater urgency as recent court cases have found hospitals liable if a physician who loses a malpractice verdict was not meticulously vetted. Telemedicine The advent of treating patients remotely through a sophisticated medical hookup is also challenging medical services departments. Not only must the credentials of their organization’s medical staff be vetted, but the providers on the other end as well, requiring ongoing communications between departments at two different providers. “The distance site hospital must provide a current list of all the practitioners,” Beem said. Failure to keep such lists current could lead to a violation that could impact the future accreditation of both hospitals. Credentials Verification Organizations (CVOs) As healthcare organizations consolidate into healthcare delivery systems and larger multisystem organizations, many create a CVO headed by an experienced team of Medical Staff Services Professionals to handle the increasingly complex task of credentialing/privileging physicians and other practitioners not only for traditional inpatient facilities (e.g. hospitals) but for ambulatory facilities (e.g. patient-centered medical homes, accountable care organizations), health plans, insurance companies, and large employers. This activity requires executive skills, multiple accreditations (often from NCQA as well as The Joint Commission, DNV, or HFAP), and multiple payer contracts, each with their unique and often delegated credentialing requirements. More Extensive Certifications Partly as a result of the more complex work facing medical services staff, the demands for higher levels of training and education have grown. The National Association of Medical Staff Services (NAMSS) offers a certification known as the Certified Professional in Medical Services Management. Along with the required education in order to take the exam for certification, it requires continuous employment in the medical services field for the past year and employment in the profession for five of the last eight years. The exam itself “focuses on the management role in medical services to include functions such as staffing, budgets, medical staff information systems, continuing education, and practitioner/provider recruitment and relations,” according to NAMSS. Looking for your next healthcare speaker? Get in touch with us at the Capitol City Speakers Bureau today to make your healthcare event a success! By Jonathan Burroughs, MD
Patient Centered Medical Homes are one of the three top care delivery models supported by the Patient Protection and Affordable Care Act (PPACA). What are the essential components that make for a successful patient-centered medical home as determined by those working with these models in the field? “First, there must be access. That’s a key factor,” said Amy Gibson, chief operating officer for the Patient-Centered Primary Care Collaborative in Washington, D.C. “When a patient calls in, there should be flexibility for same-day appointments. If they have a concern and call at 8 o’clock at night, they can’t just get an answering service and suggestion to go to the emergency room.” George E. Lowe, M.D., the medical director for Maryland Family Care in Baltimore, noted that his organization’s practices offer early morning hours (with some sites opening as early as 6:30 a.m.); late evening hours (some sites closing as late as 8 p.m.); and Saturday hours. “Our goal is that any patient who wants to be seen that day will be seen,” he said. “We now have a system of healthcare on demand, where patients expect care when they want it and convenient to their place of employment. “We’re trying to get patients in before work or after work, and we don’t take any time off for lunch.” Although the medical homes at Maryland Family Care are fully staffed with primary care physicians and nurse practitioners, Lowe noted that each practice also contains a wide array of specialists, along with full imaging and laboratory services. “We call our sites ‘healthcare under one roof,’ and can provide comprehensive services with limited exceptions, such as major surgeries,” he said. “There must be team-based care for more comprehensive and coordinated care,” said Emma Mandell Gray, a senior manager with ECG Management Consultants in Boston. Another component of a successful medical home is an integrated electronic health records system. "It’s becoming more challenging for clinicians that don’t have integrated EHR systems to have an effective medical home,” Gibson said. She added that practices that have not made the EHR leap cannot adequately scrutinize patient records to decipher care delivery patterns and coordinate care more appropriately. Having an EHR system in place also makes it easier to share records with providers if a patient has a medical emergency out of state. However, there can be a downside in some instances to using EHRs. Mark W. Friedberg, M.D., a senior natural scientist and director with the RAND Corp. in Boston, co-authored a 2014 study in the Journal of the American Medical Association examining the effectiveness of patient-centered medical homes involved with the Pennsylvania Chronic Care Initiative. Those practices that installed and deployed EHRs during the study period tended to underperform because they were struggling with the cost of the undertaking and the transition to the new system. “That on its own is incredibly stressful for a practice, and may distract it from making an effective medical home transformation,” Friedberg said. Another major component of the medical home is being able to have access to patient-use data, particularly from participating payers, according to Friedberg. In his Pennsylvania study, there was a stark performance differential between medical homes that had access to payer data and those that did not. If one practice knows which of its patients are ‘frequent fliers’ to the hospital emergency room based on payer data and another does not, Friedberg said it’s the “difference between flying blind and having good eyesight.” But having access to such data is not just a means to an end. According to Mandell Gray, that data should be used as a springboard for continuing success. “Using claims and EHR data…providers and organizations must have robust systems to measure, track, and report clinical and business intelligence to support decision-making and ensure ongoing continuous improvement and development of best practices,” she said. Buy-in on both sides is crucial. Friedberg noted that some practices are a better cultural fit for being a medical home. They tend to be affiliated with a larger organization, and the staff tends to be open to the idea of making transformations. They are also more amenable to being coached on changing their care delivery style from consultants or ‘collaboratives’ such as the Institute for Healthcare Improvement (IHI). Gibson noted that a successful patient in the medical home would also have a personal champion. “That can be the hardest obstacle to tackle. Obviously, with a young child, it will be the parent or legal guardian. But (for an adult), it could also be a neighbor. It is someone who can help implement the care program for the patient and be part of the care-based team.” Building a successful patient-centered medical home is but another potential model to implement clinical integration at the community level; what make up the success factors for each organization will ultimately be as specific as the needs of the providers and community members themselves. Looking for your next healthcare speaker? Get in touch with us at the Capitol City Speakers Bureau today to make your healthcare event a success! |
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