Congress has had its hands full on various pieces of legislation this week, including a response to the Zika Virus, cost-saving programs for Medicare, and the expansion of health savings accounts, to name a few.
H.R. 4396, Frank Pallone, to support a comprehensive public health response to the heroin and prescription drug abuse crisis
H.R. 4400, G.K. Butterfield-Susan Brooks, to expand the tropical disease product priority review voucher program to encourage treatments for Zika virus
H.R. 4428, Diane Black, to amend title XVIII of the Social Security Act to ensure fairness in Medicare hospital payments by establishing a floor for the area wage index applied with respect to certain hospitals
H.R. 4435, Gene Green, to improve access to mental health and substance use disorder prevention, treatment, crisis, and recovery services
H.R. 4442, Diane Black-Peter Welch, to amend titles XVIII and XI of the Social Security Act to promote cost savings and quality care under the Medicare program through the use of telehealth and remote patient monitoring services, and for other purposes
H.R. 4446, Chris Stewart, to authorize the use of Ebola funds for Zika response and preparedness
H.R. 4447, Joe Courtney, to make appropriations to address the heroin and opioid drug abuse epidemic for the fiscal year ending September 30, 2016, and for other purposes
H.R. 4469, Erik Paulsen, to amend the Internal Revenue Code of 1986 to improve access to health care through expanded health savings accounts, and for other purposes
S. 2467, Sheldon Whitehouse, to reduce health care-associated infections and improve antibiotic stewardship through enhanced data collection and reporting, the implementation of state-based quality improvement efforts, and improvements in provider education in patient safety, and for other purposes
S. 2479, Richard Blumenthal, to amend Public Health Service Act to expand access to prescription drug monitoring programs
S. 2484, Brian Schatz, to amend titles XVIII and XI of the Social Security Act to promote cost savings and quality care under the Medicare program through the use of telehealth and remote patient monitoring services, and for other purposes
S. 2495, Mike Crapo, to amend the Social Security Act relating to the use of determinations made by the Commissioner
S. 2498, Michael Bennet, to amend title XVIII of the Social Security Act to establish a pilot program to improve care for the most costly Medicare fee-for-service beneficiaries through the use of comprehensive and effective care management while reducing costs to the Federal Government for these beneficiaries, and for other purposes
S. 2499, Orrin Hatch, to amend the Internal Revenue Code of 1986 to improve access to health care through expanded health savings accounts, and for other purposes
S. 2500, Michael Bennet, to provide for the establishment of a health insurance premium reduction program to ensure that health insurance premiums remain low for American families
S. 2503, Patty Murray, to establish requirements for reusable medical devices relating to cleaning instructions and validation data, and for other purposes]]>
A recent blog post in Health Affairs shows the health care system needs collaboration among all players to deliver high-value, patient-centered care. We are seeing this collaboration in action with two health care organizations that are working together to foster a value-based approach to medical innovation – Anthem and Lilly.
“As a health benefits company and a biopharmaceutical company, we approach this problem from different perspectives but with common ground,” write Samuel Nussbaum, former Executive Vice President and Chief Medical Officer of Anthem, and Lilly Bio-Medicines President David Ricks. “We cherish the value of medical innovation — both in discovery and delivery. We believe that innovative medicines can be an incredibly powerful and cost-effective way to improve people’s lives.”
All of us across the health care system want patients to have access to innovative medicines. So what will it take to get us there? Anthem and Lilly suggest better communication between health plans and drug companies prior to drug approval and regulatory pathways for value-based arrangements that clearly benefit the health care system and patients.
As drug prices continue to escalate, partnerships like Anthem and Lilly are essential to finding a solution that ensures affordability, innovation, and access for patients. You can’t have innovation without collaboration, and that’s why stakeholders across the health care system should continue to come together to drive value for patients and ensure access to life-saving treatments.]]>
The latest Drug of the Week installment calls attention to a growing problem that’s putting pharmaceutical profits ahead of patient access: abuse of the Orphan Drug Act.
Instead of encouraging the development of treatments that will help patients with rare diseases, pharmaceutical companies are seeking “orphan” status to develop blockbuster drugs used to treat other common medical conditions. They reap the lucrative benefits of orphan status – subsidies, tax credits, and waivers – while generating billions of dollars in profits.
This exploitation is what enables Rituxan to be considered an orphan drug while also being the 12th best-selling medication in the United States.
Originally approved as an orphan drug for follicular B-cell non-Hodgkin’s lymphoma, Rituxan is now used to treat several hematologic cancers including chronic lymphocytic leukemia, several autoimmune diseases including rheumatoid arthritis, and organ rejection following kidney transplantation. More approved indications mean more sales – which is how orphan drug Rituxan has become one of the top-selling drugs of all time.
If you haven’t yet, check out our previous drug spotlights.]]>
These stats come from a new AHIP report that looks at the demographic make-up of Medicare Advantage beneficiaries. The report shows low-income and diverse populations of Medicare beneficiaries continue to rely on the high-quality health care coverage provided by Medicare Advantage plans.
The report also reinforces why funding stability for the Medicare Advantage program is so important. Protecting seniors from any further cuts in 2017 will ensure MA plans can continue to meet the health needs of diverse, low-income communities.]]>
“Everyone, regardless of economic, cultural, racial, or geographic differences, must have their choices and values heard and respected,” BCBSMA CEO Andrew Dreyfus wrote in a Boston Globe op-ed. “Everyone deserves the chance to live the best life possible, to the very end.”
Dreyfus saw how important end-of-life care was to his brother and parents, and knew BCBSMA must do whatever it can to honor the choices, preferences, and values of its members with advanced illnesses. That’s why the Massachusetts health plan is expanding member benefits to allow the earlier use of hospice care, developing a new program to help individuals with advanced illnesses receive more care at home, and adding advance care planning to its employee wellness program.
A Boston Globe article highlighted the comprehensive end-of-life benefits offered by BCBSMA and noted that health plans play a key role in getting more patients to discuss end-of-life care with their doctors. For example, BSBCMA is changing payments for advance care planning to include visits with psychologists, social workers, and other mental health workers, with whom patients can have important conversations about where and how they want to live out their last days.
Every family is impacted at some point by the need for advanced illness care. As efforts to improve end-of-life care gain momentum, health care organizations can look to what health plans like BCBSMA are doing to meet the health care needs of patients with advanced illness.]]>
People often think of health insurance as a safety net and financial product that helps pay medical bills. And it is but it’s also much more than that. Health plans help people lead healthy lives, make informed health care decisions, and manage chronic conditions.
This week in Health Care in Focus, we share how health plans are providing more than just insurance by offering new tools and services, like mobile apps and cost and quality comparison tools.]]>
Provider networks are a key tool for delivering the right balance of quality, affordability, and choice for consumers. They tend to feature smaller provider networks comprised of selected, high-value providers who have a track record of providing high-quality, efficient care to patients. Health plans use high-value provider networks to reduce premiums and promote more affordable coverage for consumers. We asked two of AHIP’s policy leads, Vice Presidents Greg Gierer and Crystal Kuntz, to explain why health plans are turning to high-value provider networks designed to reward quality and effectiveness.
What are provider networks and why are they important to patients?
Greg Gierer: Provider networks have been a mainstay of private health insurance coverage for more than 35 years – providing consumers with access to a broad range of hospitals, physicians and other providers along with financial incentives for members to obtain medical care within the plan’s provider network.
By including hospitals, physicians, and other providers that meet standards set by established accrediting organizations in their networks, health plans work to ensure that consumers have access to high-quality, effective care. Provider networks also enable health plans to make care more affordable for consumers by negotiating better prices with physicians and hospitals and protecting consumers from “balance billing” by network providers.
How do plans develop their networks?
Crystal Kuntz: Health plans evaluate doctors and hospitals for quality and safety before including them in a network. This involves ensuring that facilities and providers meet patient safety goals and credentialing standards. In fact, performance on quality measures is the key part of criteria used for provider selection and inclusion in a plan’s network – including high-value network plans.
Provider performance is measured and evaluated based on consensus quality, patient satisfaction, and health outcomes measures developed by organizations such as the National Committee on Quality Assurance (NCQA) and the Agency for Healthcare Research and Quality (AHRQ). The strong emphasis on provider quality and effectiveness enables health plans to improve value for consumers.
With many patients frustrated by exorbitant out-of-networks charges, how do networks protect patients against surprise medical bills?
Gierer: Consumers benefit when receiving care in-network because they have peace of mind that the provider meets standards for the quality of care they deliver as well as lower cost sharing and out-of-pocket costs. Moreover, using network providers protects patients and consumers from excessive costs due to “balance billing.” That is, consumers benefit from health plans’ negotiated payment rates to contracted providers and, likewise, participating providers are barred from charging any additional costs to subscribers.
When choosing coverage, what should patients know about their health plan’s provider network?
Kuntz: When making a decision about health plan coverage, patients should know if their current provider – primary care provider, specialist, or health care facility – is included in the plan’s provider network. Health plans are required under state and federal law to have up-to-date provider directories and health plans provide interactive search tools (such as online provider finders) to help patients locate providers and know whether they are participating in the plan or coverage.
In the new exchange marketplaces, new consumer oriented tools – such as the provider search tool – allow patients to shop for plans based on their preferred provider or facility. Providing consumers with easy-to-use information on participating providers and other key elements of plan design is one way health plans are helping consumers select the plan or coverage that best meets their medical and financial needs.
How do patients feel about high-value networks?
Gierer: In the price sensitive exchange marketplace, consumers strongly value the affordable premiums that high-value network plans deliver. Those who are uninsured or purchase their own insurance strongly favor a less costly “narrow” network plan (54 percent) over more expensive plans with broader networks. Moreover, small employers also valued the cost savings associated with high-value networks – with a majority of small employers (57 percent) indicating they would choose a smaller provider network if it resulted in a 5 percent lower premium.
A majority of consumers surveyed (58 percent) prefer “less expensive plans with a limited network of doctors and hospitals” as compared with “more expensive plans with a broader network of doctors and physicians.”
It’s important to note that consumers have a wide array of high-quality choices in the new marketplaces: 90 percent of consumers have access to both high-value and broad network plans. And, consumer satisfaction with exchange plans remains high overall and across a broad array of plan design elements, including choice of doctors, affordability of premiums and cost-sharing amounts.]]>
Changes to the Medicare Advantage risk adjustment model undermine health plans’ efforts to care for beneficiaries managing multiple chronic conditions, concludes a new report from Avalere Health. This will have real consequences for the millions of seniors and individuals with disabilities who rely on the Medicare Advantage program.
The Avalere report found that the model under-predicts costs for individuals with osteoarthritis, rheumatoid arthritis, Alzheimer’s disease, and chronic kidney disease, and the under-prediction can significantly limit health plans’ early intervention efforts – which are critical to managing these conditions and mitigating complicated health issues that may arise in the future.
A previous Oliver Wyman analysis demonstrated the serious trade-offs that come with changes to the Medicare Advantage program. That analysis showed that under CMS’ proposal the majority of beneficiaries with chronic kidney disease would not be identified as having the disease and would risk losing access to the disease management services that help them get the right care at the right time before their health conditions worsen or become more serious.
Medicare Advantage beneficiary Paula Ercolini depends on her Medicare Advantage coverage for innovative care coordination benefits and disease management services to keep on top of her chronic kidney disease. When CMS releases proposed changes to Medicare Advantage payments for next year, it should protect the stability of the program and help seniors like Paula take control of their health and their lives.]]>
Health plans use provider networks to make sure consumers have access to affordable, high-quality coverage. You may be wondering, what is a provider network?
Provider networks consist of the group of doctors and hospitals that health plans have contracted with to provide member care. Health plans negotiate prices with these providers to help lower health care costs.
In this week’s Health Care in Focus, you’ll learn why consumers see big savings when they visit contracted providers.]]>
Seniors and other beneficiaries with Medigap insurance are overwhelmingly happy with this supplemental coverage. A recent survey found 94 percent of Medigap enrollees are satisfied with their coverage and 91 percent would recommend Medigap to a friend or relative.
One of the benefits enrollees like most about their Medigap coverage is the financial protection that comes with having limits on out-of-pocket costs and the ability to budget for unexpected medical costs. The freedom to see the doctor of their choice and relief from dealing with complex medical bills and paperwork also make Medigap beneficiaries very pleased with their policies.
For the more than 11 million seniors and people with disabilities across the nation choosing Medigap coverage, the peace of mind about their financial security and the reliability of their health care benefits are invaluable.