The State of Telehealth as We Slide into 2022

By Clive Riddle, December 10, 2021

A HHS 34-page study released this week by ASPE (Office of the Secretary for Planning and Evaluation) entitled Medicare Beneficiaries’ Use of Telehealth in 2020: Trends by Beneficiary Characteristics and Location says the bottom line on telehealth in the first year of the pandemic was “Medicare telehealth flexibilities mitigated declines in in-person visits during the pandemic in 2020, but there is also evidence of disparities by race/ethnicity and for rural populations.”

The ASPE report found that “the share of Medicare visits conducted through telehealth in 2020 increased 63-fold, from approximately 840,000 in 2019 to 52.7 million. States with the highest use of telehealth in 2020 included Massachusetts, Vermont, Rhode Island, New Hampshire and Connecticut. States with the lowest use of telehealth in 2020 included Tennessee, Nebraska, Kansas, North Dakota and Wyoming.”

Other key findings included:

• Despite the increase in telehealth visits during the pandemic, total utilization of all Medicare FFS Part B clinician visits declined about 11% in 2020 compared to levels in 2019.
• Most beneficiaries (92%) received telehealth visits from their homes, which was not permissible in Medicare prior to the pandemic.
• Prior to the pandemic, telehealth made up less than 1% of visits across all visit specialties but increased substantially in 2020. Telehealth increased to 8% of primary care visits, while specialty care had smallest shift towards telehealth (3% of specialist visits).
• Visits to behavioral health specialists showed the largest increase in telehealth in 2020. Telehealth comprised a third of total visits to behavioral health specialists.
• While data limitations preclude clear identification of audio-only telehealth services, up to 70% of these telehealth visits during 2020 were potentially reimbursable for audio-only services.
• Black and rural beneficiaries had lower use of telehealth compared with White and urban beneficiaries, respectively. Telehealth use varied by state, with higher use in the Northeast and West, and lower in the Midwest and South.

At the same time, CMS released a Medicare Telemedicine Data Snapshot Overview, highlighting claims data between March 1, 2020 and February 28, 2021. In the CMS telemedicine world, they provide these definitions of services that they summarize in their snapshots:

• Telehealth Visits: Routine office visits provided via video (requires synchronous, real-time audio and/or video communication) with new or established patients. In this snapshot, we group audio-only telehealth in this service category.
• Virtual Check-ins: Short patient-initiated communications with a healthcare practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed.
• E-visits: Non-face-to-face patient-initiated communications with a healthcare practitioner through an online patient portal.

Here’s a peek at two of the seven sections they provide in the overview; they also provide a link to the entire data snapshot file:

Last week, RAND released a new study published in JAMA:   Assessment of Patient Preferences for Telehealth in Post–COVID-19 Pandemic Health Care, which ‘found that people who preferred video visits were more sensitive to out-of-pocket costs than those who preferred in-person visits, as a $20 increase in cost was associated with more people switching from video visits to in-person care.”

RAND reports that “when faced with a choice between an in-person visit or a video visit for a nonemergency health issue, survey participants generally preferred in-person care. Those who were younger, had higher incomes, and had more education were more likely to opt for video visits. Experience with telehealth was associated with a preference for future video visits. Just 2% of those who previously had a video visit were unwilling to do so again…. About 34% of participants did not see any role for video visits in their medical care. These people were generally older, had lower incomes, lived in more-rural areas, and had lower education levels.”

Last month, GoodRx, in collaboration with the American Telemedicine Association released a new report: The State of Telehealth, examining the role the COVID-19 pandemic has played in reshaping virtual care and patient-provider interactions. The report is based on a survey of over 1,000 patients and more than 600 healthcare providers. The key takeaways summarized in their report are:

1. The COVID-19 pandemic spurred telehealth use, and now both consumers and healthcare providers find value in virtual visits. Both report increased interaction and better outcomes.
2. Many consumers find value in a hybrid model of care, which combines both in-person visits and telehealth.
3. No-show rates for telehealth visits may be a pitfall for providers.

Other findings in their report included:

• About 40% of consumers reported they interacted more with providers because of telehealth appointments
• 40% of consumers noted that they spend more time with their providers
• Over 70% of providers said continuity of care was better or much better with telehealth
• More than 40% of providers reporting it was better than in-person care
• Before the pandemic, 17% of consumers had used telehealth
• Now, over 60% of consumers plan on using a hybrid model that combines in-person and telehealth visits
• More than 80% of providers plan to continue offering telemedicine to patients
• 60% of providers said telehealth has improved medication adherence and resulted in better conversations about healthcare costs with patients
• 45% of providers indicated that no-show rates for telehealth appointments were higher or much higher than that of in-person rates

A Trio of Value Based Care Surveys Indicate Technology Opportunities to Address Administrative Challenges

By Clive Riddle, November 10, 2021

The Guidehouse Center for Health Insights has just released analysis of an executive survey in conjunction with HFMA, the 2021 Risk-Based Healthcare Market Trends, that found health systems appear to be going big into risk sharing in 2022, with these percentages of respondents planning to advance into upside/downside risk sharing, professional capitation or global capitation for:

• Medicare Advantage: 59%
• Commercial Contracts: 52%
• CMS APMs: 49%
• Managed Medicaid: 36%
• Direct Employer Contracting 33%

Guidehouse's Richard Bajner tells us "We’re seeing increased interest from providers to own the premium dollar through risk-based arrangements. On the other hand, large payers have been more aggressive in building and even investing directly in primary care assets to gain control over the flow of care and better manage services delivered to members, compounding the need for payers and providers to align closely on market strategies. These moves have led health systems to gravitate toward programs more favorable for risk-based collaborations—or payvider models — such as Medicare Advantage, managed Medicaid, and self-insured models."

Guidehouse also share that “provider respondents to the survey cited data integrity, reporting, and the cost of technology (36%) as the No. 1 internal challenge in pursuing increased levels of risk. While half of respondents are building these capabilities in-house, 30% are partnering with payers to support risk-based capabilities and 21% are outsourcing services to a third-party organization.”

Avalere has just released their fifth annual outcomes based contract findings from a 50 question survey of  51 health plans and PBMs, indicating 56% have executed an outcomes based contract for prescription drugs. They also found 12% of payers reported having more than 10 OBCs currently in place, with another 6% of payers have 5–10 OBCs. This total 18% with 5+ OBCs decreased from 25% in 2020, although the portion with 10+ contracts increased from 2020.

Avalere’s Sarah Butler tells us “the significant increase in payers who have more than 10 OBCs in place is showing us that some payers are successfully executing these agreements. At the same time, however, the decline in payers that have tried 1 OBC indicates fewer new entrants in this space.”

Avalere reminds us that "OBCs typically include an agreement between health plans and drug or device manufacturers that ties product reimbursement to specific clinical, quality, or utilization outcomes. Although innovative contracting approaches, such as OBCs, aim to align cost with value, successful implementation and adjudication of an OBC or other type of value-based contract requires significant investment into infrastructure that can support outcomes tracking and coordination among entities involved. Therefore, while some payers may have successful experiences with OBCs, some payers may face significant administrative burden and have limited success in controlling costs."

Speaking of administrative burdens, the Medical Group Management Association (MGMA) recently released their 12-page Annual Regulatory Burden Report, finding that 91% felt the overall regulatory burden on their medical practice over the past 12 months has increased.

The Medicare Quality Payment Program (MIPS/APMs) ranked third (behind Prior Authorizations and COVID-19 workplace mandates) out of nine regulatory issues with regard to physician burden level, with 6% responding MIPS/APM were not burdensome; 6% slightly burdensome; 16% moderately burdensome; and 71% very or extremely burdensome. 79% said the move toward value-based payment (in Medicare/Medicaid) has increased the regulatory burden on their practice, and 70% said the program has not improved the quality of care for their patients, or been successful to date.

It should be noted survey responses were "from executives representing over 400 group practices. 70% of respondents are in practices with less than 20 physicians and 10% are in practices with over 100 physicians. Over 80% of respondents are in independent practices." Regulatory burdens might be anticipated to be greater with independent practices, and those with less than 20 doctors.

92% responded that CMS’ feedback was not actionable in assisting their practice in improving clinical outcomes or reducing healthcare cost related to the MIPS cost performance category, and 88% said the same for the MIPS quality performance category. 93% said positive payment adjustments do not cover the costs of time and resources spent preparing for and reporting under the program.

With respect to APMs, 80% said Medicare does not offer an Advanced APM that is clinically relevant to their practice, but 63% would be interested in participating in an Advanced APM if it was clinically relevant and aligned with their quality goals.

These findings would suggest an opportunity for value based care enabling applications that are designed to achieve program goals but also simplify participation and potentially reduce administrative burdens.

Dental and Vision Plan Satisfaction in 2021

By Clive Riddle, November 4, 2021

It’s time to see things eye-to-eye, and tell the tooth, about the state of vision and dental plan satisfaction. Setting Dad jokes aside, J.D. Power has just separately released their  2021 U.S. Dental Plan Satisfaction Report and their 2021 U.S. Vision Plan Satisfaction Report.

The J.D. Power Dental report tells us “overall customer satisfaction with dental plans increases slightly in 2021, driven by a combined 48-point increase in claims and reimbursement satisfaction (on a 1,000-point scale)  and customer service experience.” UnitedHealthcare Dental ranks highest with a score of 806. HumanaDental ranks second (793) and Aetna Dental ranks third (791).

Their vision report tells us “after a decrease in overall satisfaction in 2020, vision plan satisfaction is rebounding as doctor visits increase. Overall satisfaction is 769 (on a 1,000-point scale), an increase from 760 in 2020. Additionally, 5% more members visited their vision providers within the past six months compared with the same time in 2020.” UnitedHealthcare Vision ranks highest in customer satisfaction with vision plan insurers with a score of 825. Aetna Vision (816) ranks second and Davis Vision (775) ranks third.

The 2021 U.S. Dental Plan Satisfaction Report is based on responses from more than 1,203 dental plan members. The 2021 U.S. Vision Plan Satisfaction Report is based on responses from more than 1,110 vision plan members.

Both reports measure customer satisfaction applicable plans based on five factors (in order of importance): cost; coverage; communications; customer service; and reimbursement. coverage; cost; communications; customer service; and reimbursement.

Here are summaries that J.D. Power provided:

Telehealth Going Forward: More Measured, and Featuring Primary Care, Behavioral Health and Chronic Care

By Clive Riddle, September 10, 2021

The Center for Connected Medicine has just released a new report conducted in partnership with KLAS Research:  The Intersection of Value and Telehealth: Survey Findings on Adoption and Utilization, which tells us that “more than a year after many hospitals ended their COVID-19 shutdown of non-emergency care, the use of telehealth for patient visits is leveling off at 20% or less of all appointments.”

The study also found that “more than 80% of survey respondents said one-fifth or less of their organizations’ appointments were being conducted virtually….and of the small number of hospitals and health systems reporting 30% or more of patient volume as virtual, many said they expected that number to decline as the pandemic wanes.”

A previous CCM/KLAS report found 77% of organizations were measuring and analyzing use of telehealth by patients, while “the new survey found 92% reported measuring and analyzing at least one metric” and “about a quarter of respondents reported measuring health outcomes for patients using telehealth in the latest survey, up from 12% who said they were doing so in the 2020 report.”

Here are seven takeaways from their report’s key findings: 

• There are now fewer telehealth appointments as a percent of total appointments compared to earlier in the pandemic
• Primary care and behavioral/mental health are the service areas most likely to be using virtual care.
• Chronic care management is the service area most likely to be expanded in the future.
• The number of health systems measuring telehealth usage and patient satisfaction has increased
• The top two barriers to advancing telehealth are patient access to technology/broadband and uncertainty around future reimbursement levels.
• One-fourth of respondents reported gaps in telehealth integration with their electronic health record system
• Patient portals and digital front door solutions are the most commonly cited means by which patients access telehealth services.

The 2021 Medicare Trust Fund Report by The Numbers

By Clive Riddle, September 2, 2021

What is the state of the Medicare Trust Fund, by the numbers? $900 billion in income and $926 billion in  expenditures provided for the 62.6 million Medicare beneficiaries, with the Part A fund projected to be depleted in 2026, and current running at 4.0% of GDP that will increase to 6.5% before the end of this century.

Earlier this week, the 255-page 2021 Medicare Trust Fund report was released, which of course found that  in 2026  for Medicare Part A, “the fund's reserves will become depleted and continuing total program income will be sufficient to pay 91 percent of total scheduled benefits.”

The supplemental trust fund accounts - Part B and Part D, are "adequately financed into the indefinite future because current law provides financing from general revenues and beneficiary premiums each year to meet the next year's expected costs. Due to these funding provisions and the rapid growth of its costs, SMI will place steadily increasing demands on both taxpayers and beneficiaries."

The fund projections "have been significantly affected by the pandemic and the recession of 2020. Employment, earnings, interest rates, and GDP dropped substantially in the second calendar quarter of 2020 and are assumed to rise gradually thereafter toward full recovery by 2023, with the level of worker productivity and thus GDP assumed to be permanently lowered by 1 percent even as they are projected to resume their pre-pandemic trajectories. In addition, the Trustees also project elevated mortality rates related to the pandemic through 2023 (15 percent for those over age 15 in 2021, declining to 1 percent by 2023) as well as reductions in immigration and childbearing in 2021-22 from the levels projected in the 2020 reports, with compensating increases a few years later."

The report projects that for total Medicare expenditures as a percentage of GDP will increase from 4.0 percent in 2020 to 6.5 percent by 2095.” Here’s a graph of Medicare percent of GDP provided in the report, historical and projected, for this century:

Setting aside fund projections for now, perhaps the item of more immediate interest in the report is the Medicare fund snapshot for the year just completed, providing a view of the $900 billion total fund income, and $926 billion total fund expenditures for 2020, provided for the 62.6 million Medicare beneficiaries:

We compiled the fund benefits for 2020 and 2019, excluding Part C (Medicare Advantage, etc) to provide a comparison of percentage of benefit expenditures by category before (2019) and during (2020) the pandemic. The big change is in the “Other” category, which as the report footnotes “Includes the impact of the Accelerated and Advance Payments Program, which was significantly expanded during 2020 due to the COVID-19 pandemic. Total payments of $107.1 billion were made from the HI trust fund and the SMI Part B trust fund account.” Thus the $99.9 billion increase in “Other” from 2019 to 2020 is explained by these pandemic program payments.

Utilization Drop in 2020 May Have Not Been as Much as Feared, and 2021 May be Seeing a Spike

By Clive Riddle, August 19, 2021

Analysis of California Health Plan data indicates 2020 physician encounters and inpatient days didn’t plummet as far as some worried earlier in the pandemic, due to deferred care, although as all aspects of everyday like opened up more in 2021, a spike in utilization was evidenced.  These findings are a preview of the complimentary webinar presentation:  California Health Plans By the Numbers: Key California Health Plan Data and Trends, to be held this Wednesday, August 25^th at 10AM Pacific.

California health plan physician encounters per member per year dropped from 2019 to 2020 in all three segment populations: Commercial from 5.1 to 4.4, Medi-Cal from 4.4 to 3.7. and Medicare from 8.4 to 8.4. But all three segment have increased in 2021 through June (5.4, 4.2, and 10.7 encounters respectively), with Commercial and Medicare surpassing 2019 levels. The 2021 jump is even more pronounced compared to the first six months of 2020.

California inpatient days per 1,000 members experience was somewhat similar. Comparing 2020 to 2019, Commercial dropped to 162.0 from 173.0, and Medicare dropped to 676.9 from 708.4. However, Medi-Cal days per 1,000 increased in 2020, to 356.1 to, 327.5. This was likely somewhat due to effects from a marked increase in new Medi-Cal members in 2020 (927k net new members in 2020, almost a 10% increase.) 2021 days per 1,000 increased over 2020 levels for all three segments, and 2021 Medi-Cal and Medicare days were materially higher than 2019.

Come join us this Wednesday to find out more!

Life Expectancy at Birth in 2020: One Simple Number for COVID-Deniers

By Clive Riddle, July 23, 2021

Deniers of COVID-19's impact - sadly numbering in the millions - posted on social media in droves during the past year that COVID-19 deaths were vastly overstated because they were attributed to other actual causes of death. Countless reports on excess mortality due to COVID-19 have been dismissed by deniers as wonky number manipulation.

Perhaps the CDC’s NVSS Vital Statistics Rapid Release this month of Provisional Life Expectancy Estimates for 2020 will put things into simpler terms for such skeptics. The overall average life expectancy at birth for Americans has gone down. Life expectancy has been tracked as a statistic beyond our lifetimes, and the NVSS report has been released decades before anyone heard of COVID-19. And the report tells us that “in 2020, life expectancy at birth for the total U.S. population was 77.3 years, declining by 1.5 years from 78.8 in 2019.”

Robert Anderson, the Chief of Mortality Statistics at CDC's National Center for Health Statistics states "This is a huge decline. You have to go back to World War II, the 1940s, to find a decline like this." We downloaded the CDC historical data table for 1900-2018, and added in the new 2020 figure to produce this post-World War II chart:

Charts produced in the Rapid Release report also succinctly tell two main messages behind this drop in life expectancy: the cause of the drop (COVID-19) and the disparities of the drop (for minorities). With regard to the cause:

And with respect to changes in life expectancy by race:

Addressing Mental Health Requires Greater Focus on the Workplace

By Clive Riddle, June 25, 2021

Perhaps no aspect of healthcare is more intertwined with the workplace than mental health. In Health Affairs this week, Amanda Goorin, Richard G. Frank, and Sherry Glied in their post: Addressing Mental Illness Requires Workplace Policy As Well As Health Care Policy, frame a central workplace mental health issue as this:

“Nearly one in five adults, or 51.5 million people, in the United States meets diagnostic criteria for a mental illness, which can impair functioning across a spectrum of severity, ranging from mild to moderate to severe. Yet, despite advances in the diagnosis and treatment of these conditions, and considerable progress on including mental health care in health insurance, people with mental illness—including those with moderate illnesses such as depression or anxiety—continue to be tenuously connected to work and, hence, to full participation in society. Mental illnesses pose difficulties for workers because their symptoms can interfere with essential workplace skills, such as participating effectively in teams, interacting with customers and co-workers, and maintaining concentration.”

The Hartford this week released their 2021 Future of Benefits Study, stating that a “majority of employers recognize employee mental health as a significant workplace issue and report stigma associated with mental illness prevents treatment.” They found “70% of employers now recognize employee mental health is a significant workplace issue, and 72% said stigma associated with mental illness prevents U.S. workers from seeking help. Also, 52% of employers said they are experiencing significant or severe workplace issues due to substance misuse or addiction among their employees.”

Other key findings indicated that employers and workers are divided in key areas about mental health in the workplace::

• 80% of employers said their company culture has been more accepting of mental health challenges in the past year, but only 59% of workers agree;
• 79% of employers said they have an open and inclusive environment that encourages a dialogue about mental health, compared to 52% of workers who agree;
• 77% of employers said leadership at their company encourages conversations about mental health, compared to 56% of workers who agree; and
• 78% of employers said workers have flexibility in their schedule to get the mental health help they need, but just 58% of employees agree about this flexibility.

Patients Want Two “T”s From Providers: Telehealth and Texting

By Clive Riddle, May 20, 2021

Results from two surveys were released this week on what U.S. patients want in their provider communications: telehealth and texting.

Harris Poll, on behalf of NextGen Healthcare, found that 53 percent "say the pandemic changed how they want to communicate with their doctor. Notably, nearly half (48 percent) indicate they would switch to a different healthcare provider if their current provider did not offer telehealth appointments." A HIMSS survey sponsored by SR Health found that “patients want more regular and immediate interactions with providers and to be more engaged in their overall healthcare and wellbeing. Nothing is more effective for that kind of communication than text. Ideally, today, every healthcare interaction should begin with a text message.”

The Harris Poll found "an overwhelming majority of U.S. patients who received telehealth services since March 2020 (84 percent) plan to continue using telehealth appointments in the future, citing reasons such as convenience (43 percent) or to avoid being around people who are ill (39 percent)." 57% say they would be more likely to get follow-up medical care if telehealth appointments were an option.

But beyond telehealth, the Harris Poll also addressed overall online access to providers. 58% of patients stated they want online access to their healthcare provider. Age plays a role in this: Patients from 18-54 are significantly more likely than patients 55 and older to say they would like to have more online access to their healthcare provider (68% under age 55 and 43% age 55+.) The wish list includes:

• online appointment scheduling (49 percent)
• ability to check-in or complete health forms/appointment paperwork online before an appointment (49 percent)
• online prescription management (48 percent)
• online medical records access (47 percent)

The HIMSS survey report: “Patient Communication Preferences in 2021,” concludes that "since the pandemic began, more regular communication is expected from healthcare providers. During the pandemic, emailing and texting healthcare providers has increased with almost half of patients saying they prefer to communicate with healthcare providers via text.”

Their survey found that:

• Overall, 65 percent of people would like to receive healthcare text messages.
• Text communication rose by 14 percent during the pandemic.
• Eighty-seven percent of respondents said convenience was the reason they prefer messaging with providers.
• More than one-third of patients would be willing to switch providers to receive more modern communication like real-time text messaging.

Tracking COVID-19 Vaccination Enthusiasm and Hesitancy

By Clive Riddle, April 2, 2021

The monthly Kaiser Family Foundation COVID-19 Vaccine Monitor report released this week "finds enthusiasm for getting a COVID-19 vaccine continuing to grow, with roughly 6 in 10 adults (61%) now saying they have already gotten at least one dose (32%) or want to get vaccinated as soon as they can (30%)." KFF tells us "that’s up from a combined 55% in February and 47% in January, as more people report getting vaccinated and fewer say they want to “wait and see” how the vaccine works in others before getting it themselves (17% now, compared to 22% in February and 31% in January)."

The report finds that most people now know how to navigate the vaccine system: “For the first time, a majority of those who have not yet been vaccinated say they have enough information both about where (67%) and when (53%) they can get vaccinated, though the report also finds a sizeable minority that lacks key vaccine information.

For those still unsure how to navigate or if they are eligible, the report states “the share that is uncertain is highest among Hispanic adults (45%), those under age 30 (39%), with annual household incomes under $40,000 annually (37%), and those without a college degree (35%).”

KFF launched their Vaccine Monitor in December, tracking who has received the vaccine, would get one asap, or listed their degree of hesitancy. Previously, surveys were more hypothetical,  asking if they were somewhat or very likely to receive the vaccine We tracked selected surveys during the past year asking that question, indicating a trend of initial enthusiasm a year ago, waning acceptance as the year progressed until the rollout became more imminent, when acceptance picked back up again – just as in Kaiser’s more recent surveys now that actual vaccinations are taking place.

April 2020

• 74% JAMA Research Letter

May 2020

• 72% Pew Research Center

July 2020

• 66%  Gallup

August 2020

• 62%  Gallup

September 2020

• 50% Gallup
• 51% Pew Research Center

October 2020

• 47% SBB Research
• 58% Gallup

November 2020

• 60% Pew Research Center

December 2020

• 53% Invisibly
• 56% JAMA Research Letter
• 61% SBB Research
• 63% Gallup

January 2021

• 65% Gallup

February 2021

• 69%  Pew Research Center

What about those disinclined to be vaccinated? What is their state of mind? The Pew February 2021 study included this listing of reasons for those disinclined to take the vaccine:

• Concerned about side effects 89%
• Vaccines developed/tested to quickly 85%
• Want to know more about them 80%
• Too many vaccine mistakes in past 74%
• Don't think I need it 68%
•  Decline vaccines in general 57%

This compares to these reasons listed in the March 2021 KFF report:

• Might experience serious side effects 70%
• Effects of the vaccine will be worse than getting COVID-19 63%
• Might be required to get vaccine even if you don't want to 63%
• Might miss work if side effects make you feel sick 45%
• Might get COVID-19 from the vaccine 39%

Cigna COVID Global Impact Study: Physical Health Indicators Globally More Resilient, Stable Than Mental Health and Other Factors

By Clive Riddle, February 5, 2021

Cigna's International Markets business has just released its fourth COVID-19 Global Impact Study. Cigna states the series, based on Cigna's annual 360 Well-being Study, “provides further insight into the global impact of the COVID-19 pandemic on people's well-being in 11 markets around the globe.”

The new 17-page report, involved Cigna engaging “more than 23,000 people across Mainland China, Hong Kong, South Korea, New Zealand, Singapore, Spain, Taiwan, Thailand, United Arab Emirates, United Kingdom and the United States between January and October 2020, to show the changes in attitudes during the pandemic.”

Cigna reports that “the latest survey data shows that after months of pandemic-related restrictions, periodic stay-at-home orders, changing restrictions on travel and social gatherings, and multiple waves of infection, people worldwide have become even more concerned about the future. According to the study, almost half of global respondents said concern for the future is their greatest cause of stress. Another common area of stress is the balance between work life and family life. More than 40% of respondents reported low well-being scores and high stress levels in both of these areas, with 14% saying their level of stress is currently unmanageable.”

Cigna noted that while perceived well-being declined worldwide, from around a mean 62.5 on their index at the start of 2000 to 61.2 in June, and then rising slightly since – “in the U.S. it was a more positive picture, with the well-being index improving by a remarkable 2.6 points. Respondents reported significant improvements in their feelings of health and well-being.”

Cigna provides these two takeaways summarizing the report:

“What is striking about the study is that the pandemic is primarily a threat to health. And yet, the  physical indicators are the ones that remain most resilient and stable. It’s other factors, such as family, work, social and finance, that are showing the heavy toll of the virus and the global response to it. This is telling in itself of the nature of human health and well-being and the interconnected role of the factors that influence it.”

“We’re entering a new phase in response to the pandemic, one where it will be important for organizations to support their workforce by offering tailored healthcare programs that cater for a wide variety of perceptions and experiences across the globe. They need to be sensitive to the fact that emotions of employees could range across a broad spectrum and they need to provide solutions that truly address that.”

The Ever-Growing Body of Evidence of Racial Disparities in COVID-19 Prevalence

by Clive Riddle, September 18, 2020

Kaiser Family Foundation has released a new study: COVID-19 Racial Disparities in Testing, Infection, Hospitalization, and Death: Analysis of Epic Patient Data, which adds to the evidence of disparities in COVID prevalence.

KFF reports that "the racial disparities in illness and death are not fully explained by differences in underlying sociodemographic characteristics and health conditions, finds the study, which analyzed Epic electronic health record data for roughly 50 million patients from 53 health systems representing 399 hospitals across 21 states." They conclude that "people of color may face increased barriers to testing that contribute to delays in obtaining testing until they are in more serious condition compared to White patients. They also demonstrate that people of color are bearing a disproportionate burden of negative health outcomes related to the COVID-19 pandemic at every stage."

Although testing rates differed little by race and ethnicity, among those tested, Hispanic patients were over two-and-a-half times more likely to have a positive result comparted to White patients, while Black and Asian patients were nearly twice as likely. COVID-19 infection rates among Hispanic and Black patients were over three and two times higher, respectively, compared to the rate for White patients. Hospitalization rates for Hispanic and Black patients with COVID-19 were more than four times and over three times higher, respectively, compared to the rate for White patients. Death rates for both groups were over twice as high as the rate for White patients.

COVID19 Positive Test Results:

• Hispanic: 311 per 1,000 tests
• Black: 219 per 1,000 tests
• Asian: 220 per 1,000 tests
• White:113 per 1,000 test

COVID-19 Infection Rates

• Hispanic: 143 per 10,000 population
• Black: 107 per 10,000 population
• White: 46 per 10,000 population

COVID-19 Hospitalization rates

• Hispanic: 30.4 per 10,000 population
• Black: 24.6 per 10,000 population
• White: 7.4 per 10,000 population

COVID-19 Death Rates

• Hispanic: 5.6 per 10,000 population
• Black: 5.6 per 10,000 population
• White: 2.3 per 10,000 population

KFF reminds us that their analysis, a joint project of the Epic Health Research Network and KFF, builds upon the findings of numerous other studies. In fact, just during the past 30 days, some of these studies have included:

The Color of Coronavirus: Covid-19 Deaths By Race and Ethnicity in the U.S.

APM Research Lab, September 16, 2020

Beyond the Case Count: The Wide-Ranging Disparities of COVID-19 in the United States

The Commonwealth Fund, September 10, 2020

'Enough is enough': Gilead-Morehouse study racial, ethnic disparity in COVID-19

S&P Global Market Intelligence, September 8, 2020

Racial/Ethnic Disparities in Hospital Admissions from COVID-19 and Determining the Impact of Neighborhood Deprivation and Primary Language

medRxiv, September 2, 2020

Community-Level Factors Associated With Racial And Ethnic Disparities In COVID-19 Rates In Massachusetts

Health Affairs, August 27, 2020

Racial Disproportionality in Covid Clinical Trials

New England Journal of Medicine, August 27, 2020

Disparities in Incidence of COVID-19 Among Underrepresented Racial/Ethnic Groups in Counties Identified as Hotspots During June 5–18, 2020

CDC Morbidity and Mortality Weekly Report, August 21, 2020

Viscous Cycle: Pandemic Elevating Nation’s Blood Pressure, Which Increases COVID-19 Vulnerability

By Clive Riddle, September 3, 2020

The pandemic has increased our population’s stress levels, which has increased blood pressure levels, which creates a population more vulnerable to potential damaging effects of COVID-19. Livongo has released a paper: Tracking COVID-19’s Effect on the Nation’s High Blood Pressure, that examines their own national dataset in this regard.

Livongo refers to a August 14^th CDC Morbidity and Mortality Weekly Report article: Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic, which cites that “symptoms of anxiety disorder and depressive disorder increased considerably in the United States during April–June of 2020, compared with the same period in 2019”, and presents findings from their survey taken June 24–30, 2020 that include “40.9% of respondents reported at least one adverse mental or behavioral health condition, including symptoms of anxiety disorder or depressive disorder (30.9%), symptoms of a trauma- and stressor-related disorder (TSRD) related to the pandemic (26.3%), and having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%).

Livongo reminds us that “while anxiety and stress do not directly cause long-term hypertension, episodes of psycho-social stress and anxiety are well known to cause dramatic spikes in blood pressure (BP).” They note there was a 136% increase in utilization of their myStrength behavioral health solution in the period from January to May.

Livongo’s dataset in this case is driven by Livongo for Hypertension Members that “regularly measure their BP with a monitor and cuff that connect wirelessly with Livongo’s smartphone app. Readings are automatically transmitted to our Applied Health Signals platform where participants can view results.”

Their analysis did indicate a pandemic BP spike, and they report “until late January of this year the percentage of our Members nationally with high BP in any given week was on average 62%. At the end of January, however, we saw a rise in high BP roughly corresponding with the announcement of the first confirmed case of COVID-19 in the US (Jan 21) and the first mass quarantine of residents in the Chinese city of Wuhan (Jan 23). From that point forward, the proportion of our Members with high BP has mostly remained at a heightened level above 62%. An initial analysis of data at the state level shows that in 30 states the percentage of Members with high BP has increased between January and August. According to the data, high BP reached another significant peak in early to mid April when 68% of our Members nationally registered high BP.”

The implications? Livongo reminds us that “while no more susceptible to COVID-19, this population is more at risk of serious illness, hospitalization, and death from the virus. As our BP data reveals, the stress and anxiety and social isolation we have all experienced has had an outsized and measurable impact on this at-risk population.”

Livongo wasn’t the first to note this pandemic spike. Back in May, St. Luke’s Kansas City released an article in which their medical director discussed the trend: Doctors seeing more patients with high blood pressure amid coronavirus pandemic.

The American Heart Association has recently updated a guidance page: Keeping a lid on blood pressure during the coronavirus crisis, noting the need to manage stress, and cautioning that “high blood pressure might raise your risk of experiencing severe complications from the coronavirus. Nearly half of U.S. adults have high blood pressure, or hypertension, which is defined as consistent readings of 130/80 or above.”

Six Takeaways from a New White Paper for Payers on Pandemic Driven Medicaid and ACA Expansion

by Clive Riddle, August 21, 2020

Change Healthcare has just released a 13-page white paper: Pandemic-Driven Medicaid and ACA Expansion: Impacts and Considerations for Payers, that "details expected changes in the composition of national Medicaid and ACA member populations, and explores the potential financial consequences of the pandemic on payers."

Here are six takeaways from their report:

1. Five states with the biggest percentage jump in Medicaid enrollment from Feb 2020 to May 2020: Florida - 9.8%, Missouri - 8.8%, Wisconsin - 8.5%, Minnesota - 8.4%, Kentucky - 8.1%
2. Of those with employer-sponsored -care that are losing coverage, nearly half are eligible for Medicaid, and an additional 31% are eligible for marketplace subsidies.
3. Expect enrollment backlogs: “Typically, a new Medicaid member is assigned to a Managed Care Organization (MCO) within 45 days after enrolling. Current processing backlogs indicate that window will likely expand significantly and it might be 60 to 90 days before members can receive care through an MCO after enrollment—and that is dependent on the availability of healthcare services.”
4. Expect utilization backlogs: ”we expect the most dramatic impact of Medicaid member utilization to hit in 2021, when care services are likely to be more widely accessible.”
5. Coverage will shift back: “As the economy rebounds, coverage will likely shift back to commercial lines of business and payers should be prepared for continual changes in coverage for the foreseeable future.”
6. Five strategies are recommended payers mitigate challenges caused by the pandemic: 

• Prepare your infrastructure by expanding provider networks to increase capacity; expect and plan for payment delays from financially unstable states.
• Collaborate with providers to ensure that members who are most at-risk receive access to necessary healthcare services.
• Accurately identify primary healthcare insurance coverage to reduce exposure and avoid costly recoveries.
• Identify and capture missing risk-adjusting diagnostic codes for members by year’s end, using technology to close risk gaps and validate claims before submission.
• Aggressively manage risk scores by identifying members in need of documentation and proactively facilitating care visits by the end of the calendar year.

“Buts” to Navigate in the Pandemic Acceleration of the Digital and Healthcare Experience Intersection

By Clive Riddle, August 14, 2020

Accenture has just released a new 37-page report, the Accenture Digital Health Technology Vision 2020, based on a survey of 259 payer and provider healthcare executives, which found “that the vast majority (85%) of executives believe that technology has become an inextricable part of the human experience [and] furthermore, 45% of those polled said that rapid advancements in new technologies and scientific innovations are positioned to disrupt their industry.”

In a statement, Dr. Kaveh Safavi, a senior managing director in Accenture’s Health practice says that “COVID-19 has not slowed digital technology innovation; rather, it’s amplifying it to historic levels,” and surmised that “the intersection between digital technology and healthcare experiences has certainly accelerated with the COVID-19 pandemic, and leading the future of care will demand rethinking core assumptions about the intersection of people and technology. People’s perceptions of and relationships with technology are changing, and to adapt, healthcare payers and providers need to redesign digital experiences.”

The Accenture study found 78% of the healthcare provider and payer executives believe that the stakes for innovation have never been higher, but there are a number of “buts” in their findings that present obstacles to navigate in the middle of this digital and healthcare experience intersection, including:

• 69% of healthcare payers and providers are already piloting or adopting artificial intelligence; BUT 39% said they have inclusive design or human-centric design principles in place to support human-machine collaboration.
• 71% believe that robotics will enable the next generation of services in the physical world, BUT 54% believe that their employees will be challenged to figure out how to work with robots.
• 70% of healthcare consumers polled as part of the research said they are concerned about data privacy and commercial tracking associated with their online activities, behaviors, location and interests, BUT that same number (70%) of consumers also said they expect their relationship with technology to be more prominent in their lives over the next three years.

Ten Things to Know from HCCI's Health Care Cost and Utilization Report

by Clive Riddle, February 21, 2020

The Health Care Cost Institute has released its annual Health Care Cost and Utilization Report, now addressing 2018 data. The report "analyzes 2.5 billion medical claims to inform the public about trends affecting approximately 160 million U.S. individuals with employer-sponsored insurance." 

Here's ten takeaways from the 29-page report:

1. Health care spending grew 4.4% in 2018, slightly above growth in 2017 of 4.2%, and the third consecutive year of growth above 4.0%.
2. Total annual spending per person increased by 18.4%, from $4,978 to $5,892, between 2014 and 2018.
3. Between 2014 and 2018, average prices rose by 15%. Growth in average prices was 2.6% between 2017 and 2018, the slowest rate over the period.
4. Higher prices accounted for 74% of total spending increases above inflation over the 5-year period - an average of $453 per person.
5. Increased utilization of medical services accounted for 21% of spending growth after inflation - an average of $130 per person. Utilization of medical services rose by 3.1% between 2014 and 2018. Most of that increase, 1.8%, occurred between 2017 and 2018.
6. Professional Services averaged $1,985 per person, consuming 33.7% of spending. Outpatient Services averaged $1,662 per person, or 28.2% of spending. Inpatient Services averaged $1,128 per person, accounting for 19.1% of spending. Prescription Drugs averaged $1,118 per person, with 19.0% of spending.
7. Of the four major categories, outpatient visits and procedures saw the highest 2018 spending increase (5.5%), followed by prescription drugs (4.7%), professional services (4.5%) and inpatient services (2.2%)
8. Demographic shifts in the employer-insured population accounted for 4% of post-inflation spending growth over the 5-year period - an average of $27 per person.
9. People with job-based insurance saw their out-of-pocket costs rise by an average of 14.5%, or $114, between 2014 and 2018. The average out-of-pocket spending increased to $907 per person.
10. On average, Americans with employer-sponsored insurance spent $155 out-of-pocket on prescription drugs in 2018. Generic drugs accounted for 88% of all prescriptions. The average out-of-pocket price for generic drugs was less than 1/5 the average for brand-name drugs

The Visits, They Are A-Changing

By Clive Riddle, February 7, 2020

Many facets of daily American life woven into the fabric of the Greatest Generation and Boomers have been gradually unraveling -  Attending church regularly, Belonging to service clubs, and Golfing for example. Is having a primary care doctor another?

The February issue of the Annals of Internal Medicine features the research article: Declining Use of Primary Care Among Commercially Insured Adults in the United States, 2008–2016.  The authors pose the issue, that despite well documented value to primary care visits and relationships, "there is early evidence of a decline in per capita primary care visit rates, and little is understood about what is contributing to the decline." They conclude: "commercially insured adults have been visiting PCPs less often, and nearly one half had no PCP visits in a given year by 2016. Our results suggest that this decline may be explained by decreased real or perceived visit needs, financial deterrents, and use of alternative sources of care."

 

Their study of 142 million primary care visits among 94 million member-years found that PCP visits declined 24.2%, from 169.5 to 134.3 visits per 100 member-years, while the proportion of adults with no PCP visits in a given year rose from 38.1% to 46.4%. Yet visit rates to specialists remained stable and visits to urgent care, retail clinics, and telehealth increased by 46.9%. They also found that the decline was largest among the youngest adults (−27.6%), healthier patients - those without chronic conditions (−26.4%), and lowest-income area residents (−31.4%).

Prior studies prompted the authors to examine this trend. Some previous indicators include:

• The Kaiser Family Foundation Health Tracking Poll in July 2018 found that 26% of all adults don’t have a primary care doctor – and that rate grows much higher for younger age groups: 45% without a PCP for age 18029; 28% for age 30-49; 18% for age 50-64 and 12% for age 65+.

• A study published in the November/December 2019 issue of the Annals of Family Medicine: National Trends in Primary Care Visit Use and Practice Capabilities, 2008-2015, found that PCP visits per capita declined 20% during this time period, while visit duration increased 2.4 minutes per visit, and visits addresses 0.3 more diagnoses and 0.82 more medications per visit. The authors offered the hypothesis that “the decline in primary care visit rates may be explained in part by PCPs offering more comprehensive in-person visits and using more non–face-to-face care.”  But perhaps this could also be explained by an aging case mix (fewer younger people seeking visits) that require more visit intensity.

• A study published in the EBRI March 2018 Issue Brief Consumer Engagement in Health Care Among Millennials, Baby Boomers, and Generation X Findings from the 2017 Consumer Engagement in Health Care Survey, reported that "Eighty-five percent of Baby Boomers have a PCP, compared with 78 percent among Gen Xers and 67 percent among Millennials."

Further studies and time will tell how much of this generational shift away from PCP visits is due to alternative points of care,  vs. cost issues, vs. changes in perception of the value of primary care, or perhaps – just maybe – PCPs are doing too good a job with younger generations in communicating electronically via patient portals and other means, and participating in plans with nurse call line options and web based care information that renders the lowest level of primary care physician visits unnecessary.

The Yellow Brick Road to Savings $13B In Further Automated Healthcare Administrative Transactions

By Clive Riddle, January 24, 2020

CAQH has released their seventh annual report  - the 2019 CAQH Index - which measures "the progress made by the healthcare industry in reducing the costs and burden associated with administrative transactions through automation. Their 49-page report found that "of the $350 billion dollars widely cited as the cost of administrative complexity in the US healthcare system, $40.6 billion is spent on eight administrative transactions. Of that, the industry can save $13.3 billion, or 33 percent of existing annual spend, by transitioning to fully electronic processes." 

Regarding the $13.3 billion in potential savings through automation, the report tells us “$9.9 billion can be saved by the medical plans and providers, while $3.4 billion can be saved by the dental industry. In both industries, the greatest savings exist for providers as compared to plans.”

The Index report “analyzes levels of automation, spending and savings opportunities for eight administrative transactions related to verifying patient insurance coverage and cost sharing, obtaining authorization for care, submitting claims and supplemental information and sending and receiving payments.”

What are these eight transaction categories, and what were their corresponding rates of full electronic transaction processing in 2019 vs. 2015?

1. Eligibility and Benefit Verification:  84% 2019 | 71% 2015
2. Prior Authorization  13% 2019 | 10% 2015
3. Claim Submission  96% 2019 | 94% 2015
4. Attachments  20% 2019 | NA 2015
5. Coordination of Benefits  86% 2019 | 49% 2015
6. Claim Status Inquiry  70% 2019 | 57% 2015
7. Claim Payment  70% 2019 | 61% 2015
8. Remittance Advice  50% 2019 | 51% 2015

Of these eight transaction categories  - the term “Attachments” might be a little generic and require further definition. CAQH defines Attachments as "the exchange of patient-specific medical information or supplemental documentation needed to support administrative transactions and clinical decisions." They go on to say "serving as a bridge between clinical and administrative data, attachments are also critical to the success of value-based payment models" and that the majority of attachments are exchanges through mail and fax as opposed to electronically.

The largest remaining estimated savings opportunities from further automation are with:

• Eligibility and Benefit Verification:  $4.24 Billion
• Claim Status Inquiry: $2.16 Billion
• Remittance Advice: $1.85 Billion

CAQH’s call to action for the industry to achieve these savings centers around:

• Focusing efforts to reduce provider burden
• Accelerating standards and operating rule development to support harmonization of administrative and clinical data exchange
• Needing vendor adoption of all standards and operating rules; and
• Expanding research related to the administrative workflow

The CMS Innovation Center: Innovative Savings Projections?

Avalere has released a report: CMMI’s Financial Impact on Medicare Spending Challenging to Project, which concludes “CMMI’s impact on Medicare spending has not reached earlier projections by the Congressional Budget Office (CBO), demonstrating the difficulty in projecting savings from untested and future unknown alternative payment models.”

Before we delve into the details of Avalere’s findings, let’s take a step back and peek into what goes on these days at The Center for Medicare & Medicaid Innovation (CMMI), which they now like to refer to as the CMS Innovation Center.

The CMS Innovation Center tells us they develop new payment and service delivery models brought about by the Affordable Care Act and other legislation, overseeing a number of specific demonstrations to be conducted by CMS; and implement the Quality Payment Program brought about by MACRA. The demonstrations and QPP were developed with an underlying assumption of savings to be accrues, and Avalere is now finding the savings have missed their targets.

The CMMI site provides tables itemizing the Alternative Payment Models in the Quality Payment Program, which list 50 specific Alternative Payment Models (APMs), plus Other Payer Advanced APMs including 7 Medicaid Other Payer Advanced APMs; 59 Medicare Health Plan Payment Arrangements; and 2 CMS Multi-Payer Payment Arrangements.

The CMMI Site indicates 90 specific demonstration models, which fall under seven categories:

1. Accountable Care
2. Episode-based Payment Initiatives
3. Primary Care Transformation
4. Initiatives Focused on the Medicaid and CHIP Population
5. Initiatives Focused on the Medicare-Medicaid Enrollees (dual eligible)
6. Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models
7. Initiatives to Speed the Adoption of Best Practices

Given this scope, Avalere tells us that "CBO’s 2010 projection was $1.3 billion in net federal government savings from CMMI over the 2010-2019 budget window. In 2015, CBO began projecting more substantial savings from CMMI: $27 billion in net federal government savings over the 2016-2025 budget window; and then in 2016, $34 billion in net federal government savings over the 2017–2026 budget window."

Avalere however “estimates net Medicare savings of $18.0 billion from CMMI for the 2017-2026 budget window, lower than the $34 billion projected by the CBO in 2016. Net Medicare savings reflects expected reduced Medicare program expenditures net of CMMI outlays.” They break down their projection as follows:

1. The continuation and expansion of already-existing CMMI demonstrations generate $4.4 billion in gross Medicare savings between 2017 and 2026. 
2. Proposed demonstrations generate $21.4 billion in gross Medicare savings for 2017–2026. 
3. CMMI will launch new, not yet proposed demonstrations that generate $3.3 billion in gross Medicare savings for 2017–2026.

Of course, the aftermath of a Presidential election year could bring about any number of scenarios that could spin CBO or Avalere projections sideways.

The Facts of Managed Care

By Clive Riddle, January 10, 2020

The MCOL Managed Care Fact Sheets have just been updated, an ongoing online feature provided since the 1990s. Here’s some highlights:

Overall national managed care penetration is now 75.4%. Here’s a breakdown by payor segment, based on 2019 data: 

Sources: (see Note 1)

Here is the total national managed care enrollment by coverage type, based on 2018 data:

Health Maintenance Organization (HMO):  94.8 million

Preferred Provider Organization (PPO):    165.8 million

Point of Service (POS):                                 4.8 million

High Deductible Health Plan (HDHP):        15.6 million

Total*                                                          81.0 million

* The above total enrollment exceeds the total actual national managed care population due to double counting of A) spouses and dependents who have dual coverage; and B) HDHP plans that are also classified as PPO, HMO or POS

Sources: (see Note 2)

And here is major national health plans enrollment as of September 30, 2019:

United Health Group:  49.4 million

Anthem:                       41.0 million

CVS Health (Aetna):    22.8 million

Humana:                      16.6 million

CIGNA HealthCare:     17.1 million

HCSC:                         16.0 million

Centene*:                    15.3 million

Kaiser Permanente:    12.2 million

Wellcare*:                     6.4 million

Molina:                          3.3 million

*Centene/Wellcare Enrollment is reported separately, prior to public reporting of combined membership from merger

Source: Compiled by MCOL from company financial reports

The Managed Care Fact Sheets also include:

• National HMO Enrollment Graph
• Medical Cost Components
• Premium Rate Increase Trends Graph
• 2020 Premium Rate Increase Estimates

Notes

1: National Managed Care Penetration sources:

• MCMS Fast Facts: www.cms.gov/fastfacts/
• Kaiser Family Foundation State Health Facts Total Medicaid MCO Enrollment http://kff.org/other/state-indicator/total-medicaid-mco-enrollment/
• People Enrolled in Medicare and Medicaid, Fact Sheet March 2019, CMS Medicare-Medicaid Coordination Office  https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/MMCO_Factsheet.pdf    
• Tricare Prime Beneficiaries: https://www.tricare.mil/About/Facts
• Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey,  2018, Division of Health Interview Statistics, National Center for Health Statistics   https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201905.pdf   
• U.S. Census Bureau Quick Facts, United States  https://www.census.gov/quickfacts/fact/table/US/PST045216

2. National Managed Care Enrollment sources:

• 2018 PayerDigest Series, Sanofi Managed Care Digest Series www.managedcaredigest.com
• Health Coverage State-to-State, 2019  www.ahip.org/wp-content/uploads/StateDataBook_2019-FINAL.pdf