MCO collaboration and value creation were a focus of the second annual Inspire Recovery conference.
"When you are addicted to fentanyl, you want it seven times more than you want water when you're hydrated." This hard reality is but one story of substance use disorder (SUD), spotlighted at the 2024 Inspire Recovery conference on Apr. 3 in Nashville.
Addiction amplifies everything that is already hard about being human: knowing our worth, respecting it in others, and relating to one another from a place of similarity versus difference.
What role does managed care have to play in the SUD epidemic? Especially for Medicaid members in particular, for whom low income, social needs, and addiction are nothing less than a perfect storm?
"Medicaid MCOs are faced with trying to balance the continued push for greater treatment access and fast-rising behavioral health costs that can negatively affect Medical Loss Ratios, notes Carter Paine, CEO of Wayspring, presenter of the Inspire Recovery conference.
"This type of environment makes it increasingly ripe for value-based providers to work with health plans."
Or as one conference panelist put it: "Have you called your managed care company today? Anytime there is a barrier or obstacle to remove, please tap into managed care. Please use the resources available."
When a provider or patient does call their managed care company, what are they likely to hear?
Money and stigma
There was a common refrain at Inspire Recovery: The only way is reimbursement.
Carpenter helmed a session on the role of criminal justice partnerships to support SUD needs.
"Giving providers the flexibility to help drive recovery is important. Different reimbursement structures with payers are what can help that happen," said Collen Nicewicz, CEO of Groups.
This linked to another important conference theme: the need for payer "co-opetition," the cooperation and competition that payers must demonstrate to meet the industry's biggest challenges.
Conference panelists identified three factors that strengthen both payer co-opetition and proprietary considerations: the importance of the public health lens, a market's maturity, and — again — the role of reimbursement.
"When there are quality withholds, you have to have MCO collaboration," noted Dr. Madelyn Meyn, Executive Director and Regional CMO for Aetna, a CVS Health Company. "If there are repercussions, then everyone stands to benefit."
So when is it not about the money in SUD? When people don't take it.
"Medicaid expansion has been a godsend to people who need access to benefits and treatment," said Wayspring CEO Paine. He marveled at the states that do not take advantage of this "90% funded insurance pool from the federal government."
There are risks to making progress and innovation dependent on reimbursement. Similar dependencies impact the stigma around SUD patients and treatment.
"In this day and age, saying we can't do something because of stigma just isn't good enough."
This from Dr. Tom McLellan, founder of the Treatment Research Institute.
McLellan's statement is especially true where stigma is not only perpetuated but codified.
"The industry tends to create policies that actually create stigma," noted Aetna's Meyn, who cited practices around Medication Assisted Treatment (MAT) for substance use.
MCO collaboration and value creation in SUD
The challenge with SUD progress is that everything is the key.
"When we're not managing SUD well, it spills back into physical health. Utilization creeps up because we don't have all the levers we need to manage the continuum of care."
Corey Ewing, CEO-WellCare of Kentucky, added: "If you're not addressing a member's immediate needs, you can't engage in a discussion about SUD treatment."
Dr. Meyn with Aetna noted another important first.
"Patient identification is the most important thing, with provider assessment and support."
Providers are the next "first."
"Providers are the key to engagement, innovation, and reimbursement," Meyn added, acknowledging that SUD progress is "multifactorial, also involving payers and SDOH."
The last "firsts" combine all of the others: the importance of integrated care — medical, behavioral, SUD, and social — and of incentives to drive stakeholder engagement.
"The goal is to reward providers for creating better access, outcomes and value," noted Wayspring's Paine.
'There's a lot of meat on this bone'
What is true for SUD progress is true for value-based care (VBC): everything is key.
But how do you deliver value when you don't know how to define it or measure it, how to declare success or identify needed improvements? These questions — and the lack of evidence-based medicine (EBM) and common metrics — led to a common refrain on VBC in the SUD field: "There's a lot of meat on this bone."
"It is possible to weed out the bad actors in a fee-for-service system." This from Beth Mason, Chief Customer Officer at Wayspring. "But it's also difficult to define an SUD episode, to define success from the data, and to define SUD VBC measures and outcomes."
"You really have to measure success one member at a time," added WellCare's Patel, noting that flexibility, variability, and support are also important.
So is the role of utilization management, provided it helps not hinders.
"Without prior authorization, there is no forced conversation between the provider and the payer," said Mason.
Patel added: "We want to see utilization can come down, but not all utilization is the same. A patient has to settle down neurologically before peer support can work."
The CMO termed this the "sequencing of treatment": see the person, stabilize the person, support the person. "That's what we look for in a value-based model."
Defining traditional VBC in terms of episodic, primary care-based metrics, Patel stressed: "That can't work for SUD. We're trying to enable teams to think more broadly. It's not just about length of stay. Are patients maintaining their care or relapsing?"
"You have to look at the big picture. Success doesn't come in the first year of a VBC agreement."
Perhaps the best summary of stakeholder roles in SUD treatment came from Dr. Jim Casey, Statewide Director of Behavioral Health Services, Tennessee Department of Correction.
"We're going to get there, just not as fast as we'd like."
Meet the organizations that helped bring substance use disorder privacy and consent into the 21st century.
Until February 2024, the Code of Federal Regulations Section 42 Part 2 required patients receiving SUD care to provide written consent for the use and disclosure of their treatment, payment, and health care operations information (TPO) for every service, every time — an added burden for those already in pain.
HealthLeaders interviewed Maeghan Gilmore, Vice President of Government Affairs-ABHW and Chairperson for The Partnership. In the two months since the Part 2 rules were finalized, ABHW and The Partnership have assessed the impact on healthcare stakeholders and the road ahead.
What is new about Part 2?
The final Part 2 rule allows patients to provide a single consent for TPO related to their SUD while also protecting their privacy.
“ABHW had this as a policy priority for a number of years,” says Gilmore. “About six or eight years ago, there was a small group of stakeholders that represented health systems, providers, EHR vendors, and others that came together and formed this partnership.”
Why now?
The CARES (Coronavirus Aid, Relief, and Economic Security) Act required the HHS Office for Civil Rights (OCR) and the Substance Abuse and Mental Health Services Administration (SAMHSA) to align components of Part 2, HIPAA, and the Health Information Technology for Economic and Clinical Health Act (HITECH).
“The question was, How could we align Part 2 with HIPAA so that the appropriate use and sharing of SUD treatment and prevention records can be a part of the comprehensive treatment plan,” notes Gilmore.
The original regulations, designed to protect patients from stigma and discrimination, have inadvertently increased both, making it harder for patients to access treatment and providers and health plans to deliver it.
CARES recognized that Part 2 had not kept pace with other privacy updates and that multi-consent requirements were a challenge for not only patients but also providers, health plans, and other stakeholders. HHS and SAMSHA issued proposed Part 2 rule updates in December 2022 and finalized them in February 2024.
“This is a step toward modernizing privacy regulations for persons with substance use disorders and ensuring patients receive improved, coordinated whole-person care,” said Gilmore in The Partnership press release.
Speaking with HealthLeaders, she added: “SUD got left behind. Part 2 protected maybe too much for effective information sharing and the best treatment and collaboration.”
The Part 2 regulations add data breach protections.
The final regulations also strengthen privacy protections in the form of notification, enforcement, and penalties for data breach and inappropriate use. HHS has published a summary of rule updates in a new Fact Sheet.
They leave other things on the table.
CARES also required regulatory updates on SUD anti-discrimination. HHS and SAMHSA will issue these separately, with more patient protection rules also coming.
Separately, there is state law.
“We're working with partners and others as they try to really digest, understand, and implement with state law in mind,” says Gilmore, adding: “They are going to perhaps be more stringent. And what will that mean for providers and plans that work in different states?”
The update affects all healthcare stakeholders, with challenges and opportunities.
Gilmore notes that the Part 2 update will allow for an “easier flow of information on the use, disclosure, and redisclosure” of TPO when stakeholders receive SUD consent.
“There will need to be work on how you operationalize that. How do you conduct training and promote understanding? Are there updated policies and procedures that need to ensure you’re now aligning with Part 2? There is also the option for patients to revoke their consent and what that would mean going forward.”
“These are some of the opportunities and challenges for plans, providers, and others,” the executive adds.
Gilmore adds: “There may still be some challenges around data segmentation. While the final rule explicitly states that data segmentation in the medical record is not required, there may be a time when you need to have that, especially when someone later limits or revokes consent.”
What roles did the ABHW and The Partnership play in updating 42 CFR Part II?
The ABHW represents health payers who provide — and work to advance — high-quality mental health and SUD access, benefits, and care.
ABHW is the chair of The Partnership to Amend 42 CFR Part 2. The Partnership is a coalition of 50 provider, payer, pharmacy, and other healthcare organizations. Payer-specific organizations include the Alliance of Community Health Plans, AHIP, ABHW, Association for Community Affiliated Plans, Blue Cross Blue Shield Association, and Medicaid Health Plans of America.
What’s next?
ABHW and Partnership members plan to continue collaborating during stakeholder implementation on Part 2 education and training opportunities, state-specific legislation, and other issues.
And that’s just the beginning.
“There is a lot of other activity in the privacy area of healthcare,” says Gilmore. “We’ll be watching how information blocking [in the medical record] and other regulations that apply to privacy interconnect with Part 2 and what will happen moving forward.”
The Digital Therapeutics Alliance is helping outline integrated digital product workflows that identify gaps for payers, clinicians, and patients.
Digital therapeutics (DTx) have a long way to go to become standardized treatment. Even after a DTx manufacturer demonstrates product cost-benefit, there are the larger pain points: how to pay for and integrate therapies delivered via hardware and software innovation into the U.S. healthcare delivery system.
But progress is happening — from defining more specifically what the pain points are to how they differ based on the payer. A new DTx Integration & Workflow Report this month from the Digital Therapeutics Alliance (DTA) provides more answers as one company — RelieVRx — makes strides in coverage classifications, pathways, and reimbursement.
A new category of medicine
As DTA notes about digital therapeutics: “As a new category of medicine, one of the first barriers is the challenge of integration into the traditional healthcare system so patients can receive access in a way that is convenient and consistent for them.” The organization’s March 2024 report adds that reimbursement “has significant influence on the workflows of the full ecosystem.”
Reimbursement varies based on whether a payer classifies a digital therapy as a pharmacy benefit, medical benefit, or wellness category — a classification that often varies over time and by payer.
Pharmacy and Medical Benefit Workflows both begin with negotiations between the DTx manufacturer and the payer and PBM, who make decisions about:
overall coverage based on the therapy’s cost versus its benefit to the health plan;
formulary placement, including tier and Preferred Drug List (PDL) status;
utilization management, such as prior authorization or step therapy requirements;
product pricing; and
contract details.
The workflow that gets a DTx from coverage determination to patient treatment is much simpler if the payer covers the treatment as a Medical versus a Pharmacy benefit.
Following formulary integration, health plan member communication, and vendor integration, a provider can prescribe the DTx — if required — and either a pharmacy or the manufacturer fulfills the prescription. Continued coverage and formulary decisions are based on ongoing cost-benefit analysis.
Three reasons why DTx pathways are important
These pathways — Medical versus Pharmacy, prescription versus non-prescription — are important for multiple reasons.
First, the U.S. healthcare system must be able to pivot for innovation. The right care in the right place at the right time is shifting — from remote facilities to the home and from traditional treatments and prescription drugs to software and wearables.
Second, every DTx company faces the same challenge: the best way to take their product to market, direct-to-consumer (DTC) or direct to payer. Big Health was one of the first companies to realize that the customer is the payer. It has partnered with national PBMs covering 150 million+ lives to expand access and scale faster. Because it has taken other companies longer to learn these lessons, the DTA has also published a playbook.
Third, things are looking up for reimbursement. One year ago this month, another company — AppliedVR — was the first to:
have an immersive virtual reality (VR) product approved under an existing Medicare benefit category; and
be approved with an entirely new reimbursement code.
The result? AppliedVR is the first company to create an immersive therapeutic now covered by Medicare.
CMS clears the way for virtual reality DTx reimbursement
In 2022, CMS approved RelieVRx, a treatment for chronic lower back pain, as a Durable Medical Equipment (DME) and under new HCPCS Level II code: E1905 - “Virtual reality cognitive behavioral therapy device (CBT), including pre-programmed therapy software.”
HCPCS stands for Healthcare Common procedure Coding System, “a collection of standardized codes that represent medical procedures, supplies, products and services” that allow Medicare and other insurers reimburse health insurance claims (NLM). A Level II code applies to products, supplies, and services including those that involve DME.
CMS approved RelieVRx as a DME with its own code because:
The product met all five CMS DME requirements related to use, effectiveness, and purpose.
It had already been FDA authorized as “Software in a Medical Device” versus “Software as a Medical Device” (emphasis added).
CMS noted that — with RelieVRx— “the medical software and the device on which it is housed are so integral to each other that we consider them to be one whole device, not software and a separate device.”
RelieVRx had received “FDA breakthrough status for the first de novo FDA-authorized immersive virtual reality (VR) medical device for home-based treatment” of chronic low back pain.
FDA breakthrough devices and de novo pathways allow innovative medical devices that are more effective than existing options to receive expedited review and approval for faster patient access.
The FDA and CMS approvals pave the way for Medicare reimbursement and make it more likely that other payers (commercial, Medicaid) will follow suit.
DTx pain points and open questions
While AppliedVR awaits specific Medicare payment and MAC fee schedule decisions, it has expanded its RelieVRx contract with the Veterans Health Administration, part of the Department of Veterans Affairs (VA).
The VA partnership is helping AppliedVR work through multiple coverage, reimbursement, and clinical workflow pain points. For RelieVRx, these include the pain points associated with DTx as a Medical Benefit that requires a prescription:
Coverage is lacking and/or inconsistent. This remains true for DTx across all payers. Medicare now covers AppliedVR’s RelieVRx, but the product will need commercial, Medicaid, and employer reimbursement to grow and scale.
Provider scope of practice is unclear. This includes who can prescribe, fulfill, and monitor the treatment. AppliedVR’s government contract allows VA physicians to prescribe AppliedVR.
Delivery is not standardized. How DTx is delivered and by whom (pharmacy, specialty pharmacy, manufacturer). RelieVRx can be administered in VA facilities or in veterans’ homes.
In past interviews, AppliedVR founder and CEO Matthew Stoudt has noted that the VA partnership will help establish national guidelines for home-based prescription because RelieVRx is now on the VA formulary (the VA Federal Supply Schedule, or FSS).
These pain points must now be answered for other payers.
The Digital Therapeutics alliance plans to advance this work through future research, Task Groups, and DTx Integration & Workflow Reports “to make healthcare more accessible and of higher quality for patients and their families . . . [and to address issues] that prevent a positive experience for patients, payors, and providers.”
The payer’s partnership with Carallel addresses multiple industry pressures.
Too many epidemics are invisible or forgotten.
The pandemic reminded us of healthcare disparities that had existed for decades. The U.S. Surgeon General sounded the alarm on something Americans were already feeling: lonely. And now: the critical role that family caregivers play in a healthcare system that hasn’t really helped them.
To address the latter, Independence Blue Cross and Carallel have expanded a partnership that supports the caregivers of Independence Medicare Advantage members. The program gives loved ones access to expert advice, practical assistance, planning resources, support groups, and connections with Carallel's Care Advocates.
HealthLeaders spoke with Dr. Heidi Syropoulos, Medical Director of Government Markets with Independence, and Shara Cohen, CEO of Carallel, who described:
how their program launched with hospital discharges and how it expanded;
how a multi-week, high-touch program design earned a 90+ Net Promotor Score (NPS); and
how program satisfaction intersects with payment incentives to expand payer caregiver investment.
“Caring for a loved one can be very rewarding, but it also takes a huge, huge toll on the person who's providing the care,” says Syropoulos. At Independence, we really wanted to ease that burden, even just a little bit, by offering extra help and helping connect caregivers to the right resources.”
Cohen adds: “The fact that healthcare organizations have had limited involvement with caregivers is a real gap. Independence has asked very proactively, ‘How do you fill that gap? How do you create that connection and create a relationship with a key person in the whole-person circle of care?’”
Today’s caregivers face significant challenges
Cohen notes that 80% of home care is provided by a family caregiver. That care runs the gamut from paying bills from 2,000 miles away to helping a loved one get dressed on a daily basis.
The Carallel CEO and Independence executive paint a stark picture of caregiving today.
“Caregivers do every job from the janitor to the CEO and everything in between. But they are often hidden and left out of the healthcare system,” says Cohen.
Syropoulos adds: “Being a caregiver is like being diagnosed with a disease — you’ve been given a job that you didn't want, that you didn't even know existed, that you didn't apply for, that you often are not qualified for, and that you can't quit.”
“Also, you’re not going to be paid. This is essentially what chronic disease management is in the 21st century. There's just not enough money to go around. There should be. At Independence, we really wanted to ease that burden, even just a little bit, by offering extra help and helping connect caregivers to the right resources.”
Insight #1: The most dissatisfied health plan members
How did Independence and Carallel decide which members to target first?
“The members who rated the plan worst all have one thing in common: they had all been admitted to the hospital or a nursing home recently,” says the Independence exec.
This insight led Independence and Carallel to create the Post-Acute Care Initiative, which has now expanded.
“Going into the hospital is just a painful, complicated thing to do,” says Syropoulos. “That transition of care between leaving a facility and coming back is significant. So we thought, ‘Here’s a place where we need to do something better.”
Cohen adds: “If you think about that moment in time when somebody is discharged, it's not that they're healthy. It's just that they're not sick enough to stay in the hospital.”
“Hospitalizations are a high friction point for family members trying to interact with health plans . . . That was one of the first program measures.”
It was exciting, Cohen adds, that the Independence team recognized these collective factors and wanted to create caregiver relationships that would impact both CAHPS and cost outcomes.
The Post-Acute Care Initiative and the Age-Friendly Model
Introduced in January 2023, the Independence-Carallel program features:
Early contact: Independence Case Managers (CMs) contact all members admitted to a hospital or nursing home as soon as possible after admission. CMs identify if there is a caregiver and explain the program benefits.
Early enrollment: Carallel enrolls interested caregivers post-discharge and designs structured touchpoints between caregivers and care advocates, including 24/7 resources that support caregiver resilience.
A manageable, well-executed plan: Caregiver assistance includes help with complex tasks like advanced-care planning, finding and vetting at-home or residential support.
Case manager collaboration: Independence CMs stay involved to help ensure the member’s experience is a good one.
The program incorporates the Age-Friendly Health Systems model, which supports adults and their family caregivers with “four evidence-based elements of high-quality care, known as the ‘4Ms’: What Matters, Medication, Mentation, and Mobility.”
When Syropoulos learned of the health system model, she thought: “Hmm, why aren’t Medicare Advantage companies Age Friendly? We should be.” She and her Government Markets team pursued a health plan recognition program but shifted their focus to implementing 4M principles to improve the care for older Independence members.
Program results: Satisfaction, expansion, and cost targets
“We feel strongly that caregiver support helps improve health outcomes for the members that they care for — that members feel heard and satisfied,” notes Syropoulos.
That would appear to be true. The Post-Acute-Care Initiative has a Net Promotor Score (NPS) of 90+. The NPS measures customer loyalty and satisfaction with a single question: "On a scale of 0 to 10, how likely are you to recommend our product/service to a friend or colleague?" An NPS above 70 is rare.
“90 plus shows that caregivers are overwhelmingly satisfied with the program.”
The Post-Acute-Care Initiative was designed to include eight weeks of touchpoints but around 50% of caregivers request support beyond that period with 12 program/caregiver interactions on average.
“We had full recognition that we would go at the caregiver’s pace,” says Cohen. “We were going to design the program with flexibility to their preferences.”
The post-acute program expanded in January 2024 to include the Dementia/Alzheimer’s Carallel Plus Program and additional support for all members in case management.
“The more we can help caregivers navigate benefits, access to services, and avenues to be more involved, I think we’ll see results in the cost, experience and quality of care,” the Carallel CEO adds.
“CAHPS is your friend”
Why focus on caregiver support now? Medicare reimbursement cuts and annual CMS Medicare Advantage program regulations.
“I can tell you one overarching reason: the Medicare Advantage plans in this space,” says Syropoulos. “That has completely to do with the CMS Star Ratings program. Stars is about quality and customer satisfaction. There are a lot of clinical outcome measures, but CAHPS is completely about customer service.”
CAHPS is the Consumer Assessment of Healthcare Providers and Systems and includes questions about member satisfaction with their health plan and providers.
“Those questions in CAHPS are highly weighted in the Star Ratings so you have to do well in that survey,” says Syropoulos, stressing its importance.
“CAHPS is your friend. You need to really pay attention to member pain points. We're all consumers of healthcare and can list tons of pain points. So now think about a frail, elderly, 85-year-old who lives alone.”
“If you do well with Stars and you’re a four-star plan or above, you get a significant bonus. That is part of the P&L of that division of the company. So, it does come down to finances. That's just a reality.”
Cohen adds: “We didn’t get into this just to cut costs. We got into it because we think this is really going to help members and create satisfaction with the plan. Decreasing cost of care is an added bonus.”
“It's not that people haven't wanted to do this. You just have to figure out how to pay for it.”
From the top post, Wang leads a plan that serves the world.
For 113 years, International Women’s Day has celebrated the social, economic, cultural, and political achievements of women and is designed to accelerate equality. IWD’s 2024 theme is the campaign theme for International Women's Day 2024 (March 8) is Inspire Inclusion.
One way to inspire inclusion is to represent it with excellence. In honor of IWD, HealthLeaders followed up our July 2023 interview with Pat Wang — the Healthfirst president and CEO who is also in her second year of serving as a director with the New York Fed.
Gaps in the C-suite
A designated day to recognize women shows both how far we’ve come and how far we have to go. In 2023, women held just 8.2% of CEO positions at S&P 500 companies (Catalyst, cited by Harvard Law). The numbers are much higher in healthcare and outside of the S&P but still need work: 15.3% of health system CEOs and 15.8% of health plan CEOs were women as of 2021 (JAMA).
Wang is one of them. She is also Chinese-American. Those factors are important, but it’s equally important to ask about them in the right way.
"I really appreciate your sensitivity towards that,” says Wang. “I don't have a strong reaction because I think it's legit. When I first took this job, the Chinese and Chinese-American community just couldn't believe it.”
“There are a lot of people in these communities who run businesses and have leadership titles,” Wang notes, adding: “But my role was a kind of Main Street, American company, so it was all the more notable from their perspective. I thought that was really interesting."
Leading by example
Wang reflected further.
“Which focus is more important: woman? Asian woman? I don't know, but 70% of Healthfirst employees are women. Those with children are by definition working moms who are setting important examples for their families. This is a community we celebrate and honor!”
Healthfirst and Wang understand how much this matters, on International Women’s Day but every day. Last year a female executive administrative assistant brought her daughter to the Healthfirst office and asked if she could meet Wang.
"She said to me, ‘I want her to see that somebody like you exists.’ There is a pride and an obligation to signal and set an example: You can do this too. It's really important to be aware of that."
A hyperlocal approach that delivers for women
Healthfirst’s hyperlocal approach is a recognition of its multi-cultural membership. Healthfirst is New York state's largest not-for-profit health insurance company, serving New York City's five boroughs, Long Island and the mid-Hudson Valley. Its 1.8 million members span multiple lines of business and speak 76 languages and dialects.
Nearly 1.5 million of those members are in Medicaid. More broadly, 19% of total U.S. Medicaid members are women (KFF, 2022). Female Medicaid members face unique health challenges, access to preventive care and screenings.
“Women with Medicaid are less likely than women with private health insurance to receive a mammogram,” notes Wang. “To help address this, Healthfirst performs culturally informed outreach to members and connects them with our provider partners who are committed to clinical quality and who we can recognize through incentives that are designed to improve health equity.”
“We are energized by the results of a controlled pilot in our Healthfirst Cares Maternity program which showed that model was able to identify high-risk members more than seven weeks earlier than traditional clinical decision tree methods, allowing earlier intervention by care managers working with our trusted provider network.”
The CEO adds: “Evidence-based approaches like this are helping us evolve and improve what we do for women.”
Street smart and book smart
"As one of my VPs for external sales says, we have to be street smart and book smart."
"To be truly hyperlocal — in any aspect of the way that people access their healthcare — getting member trust is a cornerstone. We have a lot of offices in the community,” adds Wang. “We hire people from the community who speak the language, who look like our members, who understand the culture, and can really communicate in a way that people feel like they can trust that person.
Another example? “Many of the local residents we serve — especially the Chinese-, Spanish- and Russian-speaking communities — have a unique relationship with their local pharmacists. They trust their community pharmacy and often consult them for any clarifications on the medications they may be taking.”
Noses in, fingers out
Wang may be one of the few Chinese-American women in the C-suite but her experience lends insight that all leaders can apply: understand your role, be willing to stretch, and never be afraid to ask questions.
"There's an expression: noses in, fingers out. As CEO, you've got to keep track of what's going on but it’s the lead manager's job to pay a lot of attention to what's going on a daily basis."
Wang has applied these principles to one of her newest posts: Class C director on the Federal Reserve Bank of New York’s Board of Directors.
"The New York Fed has been really interesting for me. It's a tremendous opportunity to meet people from completely different backgrounds and to start learning. In situations like that, the most important thing is to feel secure in knowing who you are and not be embarrassed about what you don't know."
Not just one day
So how is Healthfirst celebrating International Women’s Day on Mar. 8? With an entire month of initiatives to honor women’s contributions.
“Our WISE Employee Resource Group [Women in Search of Excellence] is spearheading a variety of events in March aiming to encourage, inspire, inform, and empower our female employees. I look forward to participating in these events, as do all of our female executives.”
Wang understands how novel it is to be one of those executives. She also understands what it's like to be a working mother and a single mother.
"Working mothers are a very special group of people. It's important to let them know, 'I am here for you. And I understand because that was me.'”
A new Medecision market report highlights payer UM, CM and population health challenges in 2024.
Healthcare’s key Whats remain dependent on its Hows. Three of those Whats are utilization management, case management, and population health management (UM, CM and PHM). The How is personalization that can improve the care experience while reducing cost and improving outcomes and efficiencies. But personalization in a digital world requires automation and data. Today’s tools and platforms aren’t cutting it, and hope is not a plan.
Large gaps exist between “executives' recognizing the importance of personalization and the current state of implementation.” So notes the press release for a new report from Medecision: The State of Utilization Management, Care Management, and Population Health in 2024. Medecision, a clinical data and analytics platform company, partnered with health consultancy Sage Growth Partners on an independent survey of 53 healthcare leaders from 24 unique organizations.
Health plan CEOs, CIOs, CMOs, and other leaders reported their top barriers to the Triple Aim. Their own systems are part of the problem—preventing cost cutting, better outcomes, and efficiencies. And while plan executives are optimistic, they can’t reach advanced patient personalization from here. Today’s UM, CM, and PHM needs tomorrow’s technology.
“What health plans need now is a way to transform their utilization management, care management, and member engagement capabilities to drive impact at the health inflection point,” Medecision CEO Kenneth Young tells HealthLeaders.
“Leveraging new technologies that enable strategic use of data to speed decision making, deliver a level of personalization that encourages trust from members, and reaches more members in need of services, will enable health plans to drive down administrative, operational, and medical costs, improve efficiencies, and decrease staff burden.”
The need for personalization, automation and data
Health plan leaders and Medecision see AI-driven automation and diversified data as part of the solution. But first, a key problem.
Among survey respondents, 68% rate inefficient workflows as a top health plan frustration. Limited member engagement tools and the ability to respond to patient needs and in real-time are top barriers.
Three other insights from the Sage survey-Medecision report reveal significant gap —between what health plan executives see as necessary for healthcare transformation and what their current systems and strategies deliver:
Personalization: 95% view personalized care management as “moderately important” or “very important”—but only 34% rate their health plan as “very personalized.”
Data: 77% of health plan execs believe that it is “very important” to see all touch points for high-risk enrollees—but more than a third say that their plan doesn’t accommodate many of these members (less than 40%).
Automation: 51% respond that AI and ML would be “very impactful” on member engagement and health outcomes workflows—but 38% report that their health plan’s current AI/ML tools are insufficient to optimize workflows and increase engagement.
The prognosis? “today’s tools are long overdue for an upgrade.”
Fundamental struggles in UM, CM, PHM
“[H]ealth plan leaders are at a turning point, grappling with outdated tech and fragmented data,” notes Medecision’s Young in the report press release. These are the effects:
UM lacks data integration and automation, making it hard to use and yielding poor results.
CM wrestles with even the most basic technology (e.g., self-scheduling, text messages, digital assessments). This is despite investment an up to 10% administrative spend on CM.
Health plan PHM still utilizes traditional data sets (claims, prescriptions). Outdated technologies like faxes are still in high use, representing 47% of leveraged data.
What’s a health plan executive to do?
Medecision recommends:
Customizing CM and PHM to personalize the member experience across the health journey.
Simplifying processes, minimizing manual tasks, and expediting decision-making through “intelligent automation.
Employing strategic data utilization to obtain contextual insights and make more informed UM and CM decisions.
Personalization is the What. Automation and data are the How. Health plan executives believe personalization can have a high impact on desired UM outcomes, including lower unnecessary utilization and costs, and higher program quality.
High-touch personalization must also be compliant across the care continuum. In the Medecision-Sage survey, 63% of health plan leaders rate CM and care coordination tools highly for regulatory compliance.
“The Room Where It Happens” recounts Aaron Burr’s decision to run for office after being excluded from key decisions by American architects Alexander Hamilton, Thomas Jefferson, and James Madison.
As for Tarbet, there isn’t a room at PHP she’s been excluded from. Why? The unique intersection of her executive roles, the unique benefits that affords, and Tarbet’s unique ability to deliver ROI.
A unique approach to equity and experience
No one really knows how the parties get to "Yes"
The pieces that are sacrificed in every game of chess
We just assume that it happens
But no else is in the room where it happens — Hamilton
Tarbet’s roles as Chief Equity Officer and Chief Experience Officer are embedded in health plan senior leadership functions.
“That is one of the reasons why I was so excited to come to Providence,” says Tarbet. “In my role, I am part of the Executive Leadership Team. I am in the room where it's happening. As we're setting the strategy, my voice is at that table all the time. It's not that I get invited to present and then leave. That’s what happens with a lot with diversity roles.”
Another difference? “Most times you see either Chief Health Equity Officer or internal DEI officer. But you can't do those things in silos. I'm able to blend the two, to find ways to empower the voices of our internal caregivers and our members and ensure all of those voices are coming through.”
The centrality of her role and its application to internal and external stakeholders isn’t the only thing that’s unique. Tarbet’s hire in June 2023 marked the creation of the equity officer role at PHP. Less than six months later, there was another first: the expansion of Tarbet’s role to include Chief Healthcare Experience Officer.
How claims can benefit from equity-experience intersections
This unique intersection of C-suite roles is delivering unique benefits that other health plans can learn from, particularly those in payvider organizations. Providence Health Plan includes members in Oregon and Washington and is integrated with Providence Health System, which serves patients in those states and five more.
About these intersections, Tarbet notes: “It provides an environment where you start to get a different level of engagement, where you hear and come up with ideas that you never might have thought about otherwise.”
One of those ideas is how bias can make its way into patient claims coding.
"A trainer for our claims teams came to me with some new ways to address health equity and implicit bias—not just in how we're training our internal caregivers but how we're processing our members' claims. This includes things I never would have thought about.”
This is another benefit of her equity-experience roles and how they intersect at PHP.
“If I was only doing internal DEI work and not customer experience, I might not have guessed at the claims portion in addressing health equity, maternal and mental health, getting your flu shot and colonoscopy. The intersection allows for different types of conversations.”
Sub: “I watched him code me”
No one really knows how the game is played
The art of the trade
How the sausage gets made
We just assume that it happens
But no one else is in the room where it happens — Hamilton
Tarbet has a personal story of implicit bias in claims coding.
“I'll use me as an example, as a Black woman and as a veteran with PTSD. I've also had five knee surgeries, which can involve associated codes for potential issues like mental health disorders. Using a mental health code for one individual versus another is really going to change how you look at the claim.”
The executive adds: “When I got my hip replaced, I also worked with a cardiologist who asked me: ‘Are you just trying to get pain meds?’ I said no, but I watched him code me as being at risk for dependence on opioids. I can’t even take them; they make me physically ill. The only reason I can think that he did that is because I was a Black woman. I asked him why he did that and he responded, ‘It's just something I need to do.’"
Tarbet’s example illustrates how the healthcare sausage has historically been made. That changed with an emerging pandemic and a long-standing reality: that people of color experience poorer healthcare outcomes and that 80% of all outcomes are based on non-clinical factors (social drivers of health). Claims coding is just one area that needs improvement for the industry to achieve health equity.
“Are we taking a step back and asking if we’re making an assumption in what we enter? If we're not, are we able to see the trends that could continue to perpetuate implicit bias that we didn't even realize?” Tarbet asks.
Referring again to her own experience, she adds: “I think it's important to tell these stories, to realize that this happens.”
The equity-experience intersection: Two added benefits
Tarbet notes two other areas that benefit from equity-experience integration at PHP: provider credentialing and patient data.
“If you start to peel back the onion, you have to ask: What are the outcomes for, say, a trans woman compared to a cisgender woman? How do we start to work with our providers on this?”
Tarbet adds: “I think all of this is incredibly important when we think about equity and my expanded role now in member experience. How are we able to advocate for patients, to look at care holistically with the equity overlay and ensure we're driving quality underneath?”
Another overlay area is data, including how to:
capture as much as possible
look for outliers
track trends at the population level
stratify by diversity factors
analyze with potential bias in mind
“This is the only way we’ll see impactful, meaningful change,” says Tarbet.
Providence Health Plan’s equity-experience strategy
I’ve got to be in the room (the room where it happens)
I gotta be, I gotta be, gotta be (the room where it happens)
In the room (I wanna be in the room where it happens)
The rooms where Tarbet operates include PHP strategy and her equity and experience objectives for 2024 and beyond. These include:
strengthening the stakeholder value chain
advancing maternal health and HbA1c outcomes
improving Medicare Star ratings, especially consumer-reported metrics
Tarbet is looking for ROI on these and other clinical areas through Providence’s payvider integration and its partnerships — with PHP’s brokers, workforce, and the community at large.
“We need to be willing to work with our partners in ways we might not have in the past — to find unique and innovative ways, driven by data, that solve for root cause and not just the symptoms.”
For Tarbet, all roads connect to the member journey.
“When I first started [at Providence], I would ask questions like, ‘How many members does this affect? What is the membership breakdown?’” says Tarbet. “Now I'll go into the meeting, and they start the conversation that way. I want to drive people to think about these things because I'm not always going to be in the room.”
Even when Tarbet isn’t in the room, her influence is.
Is short-term limited duration insurance a viable option in a broken system?
As mentioned in Part 1, short-term limited duration insurance (STLDI) is “health coverage provided pursuant to a contract with an issuer that has an expiration date specified in the contract … taking into account renewals or extensions.” STLDI provides gap protection during health insurance coverage transitions (e.g., job loss or change).
Since 2016, federal regulations have updated STLDI coverage terms from 12 months to three months to three years. Proposed Biden regulations would again reduce the term (four months), but not eliminate the questions: Is STLDI a viable longer-term alternative to ACA coverage and should consumers be allowed to decide?
Even oversight agencies are uncertain. In May 2022, the General Accounting Office (GAO) reported these three conclusions:
Data limitations hinder understanding of the role short-term plans played [including] during the COVID-19 pandemic.
Views varied widely about the value of short-term plans to consumers and as compared to individual health insurance coverage.
Additional data would enhance understanding of the role of short-term plans and help states oversee insurer market conduct.
The National Association of Insurance Commissioners (NAIC) is also at a loss, noting: “State insurance regulators know little about the size of the market for STDLI because the plans are generally not required to report data on enrollment.”
There are also conflicting pictures of the three industry pain points highlighted in Part 1:
Affordability. STLDI premiums can be 54-91% lower than ACA-compliant Marketplace plans (GAO).
Access. Affordability supports access to STLDI benefits, which do include mental health, substance abuse, and prescription drugs in most states (GAO).
The GAO notes a contrast to each. Lower STLDI premiums may “not reflect the full cost to the consumer,” with one study showing a $24,000 cost difference for heart attack treatment under an STLDI versus ACA plan. In addition, the same data that showed most states offer STLDI plans with more comprehensive benefits showed that only a small percentage of plans overall do so. And while claim approvals may be comparable, STLDI coverage requires underwriting while ACA plans cover all pre-existing conditions.
Insurance and its core functions
The core function of health insurance is to protect consumers from unexpected, high medical costs. Conversely, the core function of public, for-profit insurers — like UnitedHealthcare, CVS Health/Aetna, and Cigna — is to maximize value and generate profit for shareholders and owners. The two functions are often in conflict, and U.S. healthcare policy and coverage design — before and after the Affordable Care Act — are part of the problem.
In 2008, The Innovator's Prescription emphasized the combination of Health Savings Accounts (HSAs) with high-deductible health plans (HDHP) as "one of the most important reforms to be made in health care.” This construct “unbundles” comprehensive healthcare coverage into two parts — a defined contribution (pot of money) to pay for pre-deductible care and defined benefits to pay for addition costs and care.
The theory was that upfront personal spending would curb unnecessary medical utilization and encourage prevention. While HSA-HDHP uptake has grown, it has failed to curb rising healthcare costs. In addition, consumer cost-shares have increased, leading to deferred care or medical debt.
"If cost sharing is large enough to have a meaningful impact on medical spending, it interferes with the primary function of health insurance, which is to protect people against the risk of having to pay large medical expenses."
So note the authors of the latest proposal for healthcare reform, We've Got You Covered: Rebooting American Health Care. Citing the "deep-seated rot in US health insurance coverage," Liran Einav and Amy Finkelstein propose auto-enrolled free basic coverage for all Americans paired with separate optional insurance customized and paid for by consumers — a twist on the defined contribution-defined benefit model.
Which is closer to these models: STLDI or Marketplace plans? Short-term plans don’t include free basic services, but they do combine defined benefits with defined contributions when paired with an indemnity (cash) plan. Likely consumers are healthy individuals without pre-existing conditions who don’t need most EHBs — until they do. Marketplace plans don’t offer free basic coverage either but their required EHBs and free preventive services come closer, offering more affordable and comprehensive defined benefits than pre-ACA healthcare.
An interesting gap remains for both coverage types: STLDI plans are not HSA eligible, nor are many Marketplace HDHPs that don’t also meet MOOP requirements.
Options continue to be important. As the GAO notes, “if relatively healthy individuals choose short-term plans instead of PPACA-compliant plans, this could result in higher premiums for PPACA-compliant plans and higher federal subsidies.”
A three-year versus three-month STLDI term will not make or break the Marketplace at current enrollment levels. But two other factors could: the end of expanded subsidies and mandated no-cost preventive care for Marketplace plans. Congress must renew those subsidies for them to continue past 2025 and the Fifth Circuit Court of Appeals must overturn a currently stayed District Court Opinion to preserve select no-cost preventive care mandates. Oral arguments begin in less than a month (March 4).
Beyond federal regulations, states continue to do their part to close gaps and make coverage more affordable. Idaho, for example, offers an STLDI option with enhanced coverage that meets the benchmark for essential health benefits. Post-enactment, overall STLDI enrollment increased nearly 20% (GAO).
The larger issue is that the golden age of medicine still needs a golden age of coverage — one that protects both consumer and market health.
The regulatory tug of war over short-term limited duration insurance.
Short-term limited duration insurance (STLDI) is "health coverage provided pursuant to a contract with an issuer that has an expiration date specified in the contract … taking into account renewals or extensions" (federal regulatory definition). Introduced in 1997, STLDI provides gap protection during health insurance coverage transitions (e.g., job loss or change). It still does but the rules keep changing.
Proponents argue that STLDI provides valuable protective coverage. Opponents agree, unless consumers choose STLDI as a longer-term coverage option — at which point, it becomes "junk insurance." Labeled as such throughout the new Biden regulation footnotes, STLDI lacks the federal coverage mandates of Marketplace plans: 10 Essential Health Benefits (EHB) and their out-of-pocket maximums (MOOP), free preventive services, and guaranteed issue.
Conversely, STLDI is often much cheaper and the benefits it may exclude aren't benefits that every consumer needs. This includes healthy, younger and/or childless individuals with no pre-existing conditions who may not require most preventive services, many of which apply only to older and/or specific high-risk populations.
This is not to make a case for or against STLDI as a longer-term coverage option. But rather, poses a question: Should consumers have less choice when healthcare still struggles to deliver on its core functions:
Access. As of early 2023, 7.7% of Americans remain uninsured (HHS).
Affordability. Rising costs have delayed health care, worsened outcomes, and increased medical debt — including for the insured (Commonwealth Fund).
Reliability. As of 2022, wait times for new patient appointments averaged 26 days across 15 metropolitan areas (Washington Post).
These are the products of patchwork U.S. healthcare policy — forged from crisis response and coverage gap plugs versus a unified approach that serves human health above political interests. STLDI sits at the nexus. With new rules yet again pending, it deserves a closer look.
The federal tug of war
STLDI plans are largely state regulated, including whether they can be sold at all. The only aspects of STLDI governed by federal regulations are its core definition and policy term durations. The latter is where the battle is raging:
The Biden rule, proposed in July 2023, has received nearly 16,000 public comments with final publication scheduled for April 2024.
A risk to the risk pool
Before 2016, a policy term of up to 12 months had been in place for STLDI for nearly two decades. Since 2016, federal regulations governing STLDI have been updated three times.
Why this tug of war? Easy: The Marketplace.
Authorized by the Affordable Care Act (ACA), Marketplace plans offer coverage with no medical underwriting, required access to 10 EHBs, free designated preventive services, and premium tax credits (PTC, or subsidies) that reduce costs for those who qualify.
The 2016 STLDI regulations noted: "Because short-term, limited-duration insurance is exempt from certain consumer protections, the Departments [Treasury, Labor, and HHS] are concerned that these policies may have significant limitations, such as lifetime and annual dollar limits on essential health benefits (EHB) and pre-existing condition exclusions, and therefore may not provide meaningful health coverage."
The proposed 2023 regulations make a similar argument. But the Democratic Administration regs said something else: "[B]ecause these policies can be medically underwritten based on health status, healthier individuals may be targeted for this type of coverage, thus adversely impacting the risk pool for Affordable Care Act-compliant coverage."
The 2018 Trump regulations acknowledged that longer terms for STLDI coverage — which costs less than many Marketplace plans, then and now — could "siphon off healthier individuals" and "have an impact on the risk pools for individual health insurance coverage, thereby raising premiums for such coverage."
The Trump rules, however, also cited the then-failures of the Marketplace, the lack of evidence "that short-term, limited-duration insurance policies have not historically or are unlikely to cover hospitalization and emergency services" and "the critical need for coverage options that are more affordable."
In 2018, enrollment was less than 12 million with one-quarter of enrollees having just one insurer to choose from (KFF). Large insurers like Aetna had left and only recently returned. Six years, one pandemic, and one administration later, the 2024 Marketplace has attracted a record-breaking 20+ million enrollees.
In contrast, less than 2.9 million Americans were enrolled in STLDI plans as of 2020 (2023 Commonwealth Fund report). After STLDI term lengths were extended, STLDI enrollment did grow and largely from Marketplace defection but by only one-fifth of the 1.5 million figure projected by the Congressional Budget Office.
Does long-term STLDI pose a real risk to the Marketplace? Not even the oversight agencies know entirely. Part 2 of this feature will explore those statistics and what's next for STLDI.
Health plan efforts featured among the 5 key trends, insights, and predictions that will mark the year.
U.S. maternal mortality doubled between 1999-2019, with the Centers for Disease Control and Prevention estimating that up to 80% of these deaths are preventable. These devastating statistics are from the 2024 report A Troubling Reality, a Hopeful Future from ProgenyHealth, LLC, a tech-enabled women's healthcare company focused on Maternity and NICU Care Management.
Payers are one group targeting better outcomes. The report features maternal health interventions from four health plans: Aetna Better Health of Florida, Community Health Choice, Western Sky Community Care of New Mexico Health Care Service Corporation (HCSC).
Susan Torroella, ProgenyHealth CEO, provided exclusive quotes on payer roles and on all five multi-stakeholder trends from the report, including:
Stronger Health Plan Interventions
A Promising Shift in Healthcare Research
Bettering Maternal and Infant Care through AI and Machine Learning
The Rise of Virtual Prenatal and Postpartum Healthcare
New Definitions of Risk
Trend: Maternal health outcomes are benefitting from stronger health plan interventions
As noted in the ProgenyHealth report: “While progress toward equitable, accessible maternal and infant healthcare has been slow, it continues to be steady — and these innovative new avenues for improvement show that plans are committed to reversing these alarming trends.”
ProgenyHealth’s CEO agrees: “In our experience, payers want to make a difference. They understand that they are uniquely positioned to drive collaboration among partners who can positively impact maternal and infant health.”
Focus areas include:
Stay-at-home-but-stay-in-touch prenatal care
Postpartum care
Associated mental health care for women who develop anxiety and depression after delivery (10% and 20%, respectively)
Home care links to the ProgenyHealth report Trend #4: The Rise of Virtual Prenatal and Postpartum Healthcare. CEO Torroella says: “Technology and digital tools are changing the playing field for women who live in maternity deserts. Remote patient monitoring devices, virtual healthcare, and mobile apps can help close gaps during the prenatal and postpartum stages.”
All focus areas will require increased payer reimbursement including from Medicaid programs. Many have extended postpartum coverage for up to a full year after birth. The ProgenyHealth report notes that “commercial plans are taking notice—and devising their own solutions to the maternal and infant health emergency.”
What four health plans are doing
The ProgenyHealth report features these examples:
Aetna Better Health of Florida — An initiative to reduce the rising c-section births associated with higher infant mortality. Aetna has partnered with ProgenyHealth to deliver an integrated Maternity & NICU Care Management program for health plan members.
Community Health Choice (Houston) — A multi-pronged approach to address the Black infant death crisis. In addition, CHC members have access to a ProgenyHealth app for self-enrollment in Maternity Care Management programs in early pregnancy. Nearly 15% of MCM enrollments have come through this “digital front door.”
Western Sky Community Care of New Mexico — A doula network, with services available via 24/7 digital appointments for births, postpartum mental health resources, and many others.
Health Care Service Corporation (HCSC) — The Blues plan has created the Centering Pregnancy program to improve access and expand coverage through mobile health programs in multiple states.
Payer intersections that improve maternal and infant health
Speaking on maternal and infant health, ProgenyHealth CEO Torroella tells HealthLeaders: “No one entity can solve this issue – it will take a team of contributors.”
As an example, Torroella identifies a clear payer-provider intersection point: maternal health co-occurring conditions.
“More women are beginning their pregnancy with pre-existing conditions such as diabetes or high blood pressure, which puts them at higher risk for maternal mortality or morbidity,” says Torroella. “What we’ve seen is that it isn’t just one condition leading them to our program, it’s often multiple conditions that require complex care management. The sooner we can identify those issues and begin working with those women, the better the outcomes.”
10-15% reduction in Length of Stay and up to 50% in readmissions and reduced ER visits
A 90%+ member satisfaction rate
Artificial intelligence and machine learning have played a role.
“As a tech-enabled women’s health company,” says Torroella “our own platform has predictive and prescriptive analytics to aid our clinical teams in decision-making. Still, our most important asset is our people, who use technology to help them make meaningful connections with those we support.”
She adds: “We have made so many advances in healthcare, and yet pregnant women are at greater risk today than their mothers were,” says Torroella. “We simply must do better when it comes to maternal and infant health.”