Archives for September 2022

NAIC Takes Aim At Misleading Health Insurance Marketing

NAIC takes aim at misleading health insurance marketing – InsuranceNewsNet

Source: InsuranceNewsNet, by Susan Rupe

Consumers are bombarded with misleading advertising for Medicare Advantage and other health plans. Insurance regulators are taking action to identify and combat the improper marketing of these health plans.

Two state insurance regulators gave a rundown on efforts to crack down on misleading advertising during Wednesday’s session of the National Association of Insurance Commissioners 2022 Insurance Summit.

TV commercials featuring celebrity endorsers urging viewers to call a toll-free number to sign up for Medicare Advantage plans, and advertising selling short-term, or “skinny” health plans, that are not compliant with the Affordable Care Act are two of the best-known examples of improper health plan marketing, the speakers said.

“We are working to do cease-and-desist orders on these short-term plans, but it’s like a game of Whack-a-Mole,” said Franklin T. Pyle Jr., special deputy commissioner for the Delaware Insurance Department.

NAIC established the Improper Marketing of Health Insurance (D) Working Group in 2021. Its charges include:

  • * Coordinating with state and federal regulators to provide assistance and guidance monitoring the improper marketing of health plans, and coordinating the appropriate enforcement actions.
  • * Reviewing existing NAIC models and guidelines that address the use of lead generators for sales of health insurance products, and identify models and guidelines that need to be updated or developed to address current marketplace activities.
  • * Creating language within an existing model or creating a new model that would give states the ability to take action against lead generators.

The working group is reviewing the Unfair Trade Practices Act, particularly in regard to the act’s definition of “insurance lead generator,” said Martin Swanson, deputy director and general counsel for the Nebraska Department of Insurance.

Under Section 2 of the act, “insurance lead generator” means any marketing-related activity or entity that publicizes the availability of an insurance, or what purports to be, an insurance product or service.

What the group is trying to do, Swanson said, is define “lead generator.”

Section 3 of the Act states that it is an unfair trace practice for any insurer to make, publish, disseminate, circulate or place before the public in a publication, internet communication, mailing, or on radio or TV an advertisement, announcement or statement containing any assertion, representation or statement that is untrue, deceptive or misleading about insurance or about the insurer’s business.

 

Swanson said the working group wants to change the language of Section 3 to include insurance lead generator with insurer. “As it stands now, we have jurisdiction over the producer but not the lead generator,” he added.

“It’s broad language but it needs to be because of mode of these scams keeps changing,” he said. “Grandma is on Facebook looking at pictures of her grandkids when she starts getting inundated with Medicare Advantage ads.”

Swanson said his agency has heard from several Medicare beneficiaries who said they have received phone calls from someone wrongly claiming to be with the state Department of Aging and saying they need to change their Medicare plans. “It’s fraud,” he said.

Several insurers who offer short-term plans, or so-called “skinny” plans, have moved to the Medicare Advantage market and are offering seniors what Pyle called “junk plans.”

“They think they it’s easier to con a senior who thinks they are getting more benefits by moving to another plan,” he said. “I don’t want to see our seniors getting lied to and getting talked out of their plans to get into a junk plan.”

Health care sharing ministries

NAIC also is looking at health care sharing ministries, which are not required to comply with the ACA.

Pyle said NAIC does not have regulatory authority over health care sharing ministries, but added “that could change” as some plans become ACA compliant.

He pointed to Virginia’s Bureau of Insurance, which produced a list of FAQs for agents who offer these plans. The list noted that health care sharing ministries do not guarantee payment of claims, which could leave consumers with significant medical bills to pay. Agents who wish to offer these plans should ensure they understand their limitations and must be able to explain these limitations to consumers to avoid misleading them. Agents also must provide consumers with a legally required disclaimer.

“Good plans want to get rid of the bad actors. We want to get rid of the bad actors. That’s good for everyone, especially consumers,” he said.

Amazon, Walmart And Hundreds Of Providers Lobby Senate For Extension Of Telehealth Policies

Amazon, Cleveland Clinic join call for telehealth flexibilities

Source: Fierce Healthcare, by Heather Landi

Big tech and retail giants like Amazon and Walmart joined hundreds of provider groups, hospitals and virtual care companies pressing Congress to take action on telehealth legislation this fall.

 
 

More than 370 organizations sent a joint letter (PDF) to bipartisan leadership of the U.S. Senate to pass a two-year extension of important telehealth policies enacted at the start of the COVID-19 pandemic. Currently, those policies are set to expire 151 days after the end of the public health emergency.

 
 

Policy certainty beyond the COVID-19 public health emergency is essential to continuing access to telehealth for both Medicare and commercial market patients, the groups wrote in the letter.

The hundreds of employers, providers and health tech companies that signed the letter represent a spectrum of organizations with customers and patients that are impacted by telehealth policy. The signers include consumer groups representing mental health, chronic disease and primary care as well as providers including physicians, nurses and physical therapists along with employers representing millions of Americans who receive their coverage through their jobs.

The groups urge the Senate to pass legislation that would extend critical telehealth flexibilities, including provisions to waive provider and patient location limitations, remove in-person requirements for telemental health, ensure continued access to clinically appropriate controlled substances without in-person requirements and increase access to telehealth services in the commercial market, including for those with a high-deductible health plans coupled with a health savings account.

 

“More than 400 members of the House voted to extend telehealth flexibilities in July, and it’s time for the Senate to follow. Without more policy certainty around telehealth, beneficiary access could be compromised,” said Krista Drobac, executive director of the Alliance for Connected Care. “The House created the momentum, we hope the Senate will seize it and enact comprehensive telehealth legislation this fall.”

The joint letter was co-led by the Alliance for Connected Care, the American Telemedicine Association, the College of Healthcare Information Management Executives, the Connected Health Initiative, the Consumer Technology Association, Executives for Health Innovation, the Health Innovation Alliance, HIMSS and the Partnership to Advance Virtual Care.

With expanded flexibilities, telehealth has helped bridge gaps in care, especially in communities facing significant workforce shortages, the groups wrote. Almost 3 in 4 Americans “strongly agree” or “somewhat agree” that patients should have the option to receive telehealth, even after the pandemic, which increases to 84% among recent telehealth patients, according to a poll from the Alliance for Connected Care and Morning Consult.

Most recently, reports from the Department of Health and Human Services’ Office of Inspector General showed dually eligible beneficiaries were more likely than others to use telehealth to ensure access to care and that telehealth expanded access for minority populations.

 

Telehealth is helping address the crisis-level mental health and primary care shortages and has expanded access to care for underserved communities, according to the groups.

Patients who utilize telehealth as part of their care plan face the possibility of a forced return to in-person care. “This is particularly concerning for those utilizing telehealth to reach experts at longer distances, for access to mental and behavioral health practitioners, and those receiving ongoing remote care for chronic conditions,” the groups wrote.

Bringing Pharmacy Costs Into The Light: Transparency Is Key To Capping Costs

Bringing pharmacy costs into the light: Transparency is key to capping costs  | BenefitsPRO

Source: BenefitsPRO, by Will Young

America’s prescription-drug prices are out of control.

The problem is so large that it has begun attracting high-profile new market entrants, like the Mark Cuban Cost Plus Drug Company that launched earlier this year. Cuban seeks to fix the convoluted prescription-drug market by not taking insurance, and charging 15% over cost.

 

But another path exists for health plans to tame prescription drug costs within the confines of a health plan — a new model of pharmacy benefits managers. PBMs are companies that manage health insurers’ prescription-drug plans. Transparent PBMs, like San Francisco-based SmithRx, provide their clients 100% of payments they receive from drug manufacturers, be they rebates, incentives, administrative fees or data fees. Transparent PBMs also supply clients with any discounts they negotiate with pharmacies.

Other transparent PBMs include CapitalRx, Navitus Health Solutions and TransparentRx.

Passing through rebates and fees isn’t the only benefit of transparent PBMs. A 2019 report by the Commonwealth Fund, for example, found pharmacy benefit plan sponsors could also accrue savings “by reducing the use of high-cost, low-value drugs.” Removing PBM rebates frees them to choose the best value drugs for any given treatment. The Commonwealth Fund estimated that the sponsors it evaluated could save about $63 million annually.

 

Why affordable prescription coverage remains elusive

Americans spend more than twice the amount on prescription medications compared with our counterparts in the 37 other member nations of the Organisation for Economic Co-operation and Development. U.S. per-capita average spending in 2019 was $1,126 compared to OECD per-capita average spending of $552.

Cuban’s online pharmacy is one example of efforts underway to combat what everyday Americans spend on prescription medications. Customers save money by paying cash for prescriptions at prices Cuban says frequently will be lower than the “discounted rates” negotiated by many insurance plans.

Cuban’s venture addresses a core, systemic obstacle to reducing prescription drug costs: spread prices — the difference between what a PBM pays for a drug, and what it charges its customers.

 

The current PBM model that pervades the U.S. health care system is one with labyrinthine and opaque costs and pricing, making it almost impossible for patients and payers to make cost-conscious decisions. Worse, the model incentivizes PBMs to promote more expensive drugs.

PBMs historically have negotiated a list price, and typically receive a drug-manufacturer rebate. But PBMs share little or no information about the rebate amount — or how much of that rebate is passed on to the plan or the patient. That lack of transparency makes it difficult for the plan or patient to choose the most cost-effective solution.

Perverse PBM incentives are another consequence of the current model. For example, it makes financial sense for PBMs to include in their covered medications a $100 name-brand drug that provides a $50 rebate, all of which the PBM may keep, and exclude a $20 generic drug with a $5 rebate.

It would appear that employers are aware of these flaws in their current PBMs. A 2017 National Pharmaceutical Council report found that just 41% of employers rated their PBMs as “very good” in negotiating rebates from pharmaceutical manufacturers to secure cost savings. Only one-third described their PBMs as “very trustworthy.” And, 50% believe that PBMs are not transparent with covered medications.

Yet, just a handful of legacy PBMs — namely those owned by Blue Cross Blue Shield, United Healthcare, Cigna, Aetna, Humana, or their parent companies — dominate the market. According to a report released earlier this year by the Drug Channels Institute, the PBMs associated with those insurance giants managed 92% of prescription claims. Data released earlier this year by the independent, non-partisan market research firm Health Industries Research found comparable domination of the PBM market, with those same players handling 92% of claims.

It’s unlikely that big health insurers will seek more effective PBM partners any time soon. Their affiliated PBMs increasingly are driving revenue and profitability growth for those insurers and their parent companies.

The CVS PBM segment, for instance, fueled about $46 billion of the company’s  $324 billion in revenue last year. Cigna’s PBM, Express Scripts Holding Co., accounted for much of the doubling in revenue the company reported in 2019, to $38.2 billion from $14.3 billion. United Healthcare’s PBM collected more profit in the fourth quarter of 2019, $3 billion, than the company’s insurance arm, $2.1 billion.

This landscape has resulted in 18 million Americans, or 7% of U.S. adults, being unable to pay for prescriptions they need, according to a 2021 West Health and Gallup survey. That group could not pay for at least one prescribed medication during a three-month period, the survey found. Adults younger than 65 were twice as likely as seniors to report being unable to pay for prescriptions, and that group also was twice as likely to skip doses to save medicine and money.

Solutions to reducing prescription-drug costs

If we can’t depend on the big commercial health plans to drive the shift to transparency, what can we do? In the absence of federal government action, many state legislatures have proposed bills requiring various levels of transparency and limiting costs to patients.

But, businesses need not wait on legislative action. They may partner with transparent PBMs right now through one of two ways. They can negotiate a pharmacy carveout from their legacy-company health plans, which is commonly done for larger businesses. Or, they could find a health plan that utilizes a transparent PBM.

Companies that do so know that incentives will be aligned among the PBM, the payer and member. Many transparent PBMs will also improve employees’ drug choices by providing their respective costs and arming them with real-time information about which drugs are effective treatment options.

Regardless of the path to reducing prescription drug costs, a fundamental starting point is transparency — supplying all stakeholders with clear data on where the money is going and what it’s for. That will enable companies, payers and patients to make better decisions.

Health Care Spending For Mental Health Disorders Increases Between 2013 And 2020

Health care spending for mental health disorders increases between 2013 and  2020 | BenefitsPRO

Source: BenefitsPRO, by Michael Popke

Overall spending on mental health services increased from 6.8% to 8.2% between 2013 and 2020, according to a new study published by the Employee Benefit Research Institute (EBRI).

“Approximately 1 in 5 adults and 1 in 6 youth experience mental illness each year, and these rates have been rising,” Paul Fronstin, director of EBRI’s Health Benefits Research and co-author of the study, says in a statement. “Over 20 million Americans have a substance use disorder. The COVID-19 pandemic has exacerbated mental health issues nationally and in the workplace. With increases in both the number of individuals diagnosed with mental health disorders and use of health care services, higher spending is of great concern to plan sponsors of health benefit programs.”

Here are five key findings from EBRI’s research:

  1. 1. The percentage of the population under the age of 65 with employment-based health coverage diagnosed with a mental health disorder increased from 14.2% in 2013 to 18.5% in 2020.
  1. 2. Use of mental health care services increased between 2013 and 2020, and use of outpatient services increased the most. The percentage of enrollees using outpatient services increased from 12% to 16%, a 33% increase.
  1. 3. Among enrollees with a mental health diagnosis, average annual spending on mental health care services increased from $1,987 to $2,380 between 2013 and 2020 — an average of 3% per year.
  1. 4. Spending on outpatient mental health services increased 37%, while spending on prescription drugs for mental health disorders fell 15%.
  1. 5. Outpatient mental health care services accounted for two-thirds of total spending in 2020, up from just over one-half in 2013.

“Employers and workers spent nearly $77 billion on mental health disorders in 2020,” Fronstin adds. “Employers are looking for ways to address the mental health needs of workers given the current economic climate, and they are especially interested in addressing mental health needs because of the connection between depression and productivity losses. Taking responsibility for workers’ mental health may not only reduce spending on health care but may increase worker productivity.”

What’s Ahead For Telehealth Policy After The Pandemic

Opportunities and Barriers for Telemedicine in the U.S. During the COVID-19  Emergency and Beyond | KFFSource: Healthcare IT News, by Andrea Fox

The American Telehealth Association is working with Congress and several federal agencies to shape the fate of policies and payments for telehealth services that experienced a rapid uptake during the COVID-19 pandemic.

WHY IT MATTERS

Now that President Joe Biden has declared the COVID-19 pandemic over, the ATA’s Telehealth Awareness Week policy update webinar explored how federal and state telehealth policies may be affected as Congress decides whether or not to end the public health emergency (PHE).

Federal priorities for telehealth have evolved with the pandemic with restrictions lifted by a Congress deciding if the limiting of certain restrictions should be lifted permanently.

The PHE must be reviewed every 90 days, so Congress will have to revisit the renewal by mid-October, according to policy experts presenting during Wednesday’s online event.

“As we know, [President] Biden has said in recent days that the pandemic is over, so it’s possible that the technical public health emergency might expire sometime in the very near future,” said Megan Herber, director at Faegre Drinker who advises ATA and ATA Action on all things Federal policy.

Telehealth payments and provider practices are highly regulated on the Federal level, said Quinn Shean, strategic advisor at Tusk Ventures and the state policy advisor for ATA and ATA Action.

But even if providers do not serve Medicare populations, “Medicare policy trickles down,” added Herber.

For example, before the pandemic, patients had to be in a rural area in a hospital or clinical setting to receive reimbursement for telehealth.

“That is the current status quo right now – as long as the COVID-19 public health emergency is in place,” Herber explained. But in about five months, “all of those waivers go away automatically unless Congress does something.”

Approaches to policy can be different in different contexts, noted moderator Alexis Gilroy, co-leader of the healthcare and life sciences practice at Jones Day. “Where do you come at it based on the particular lane it sits in?”

In terms of state-level telehealth policy, there are multiple state priorities because states differ in their approaches to telehealth coverage requirements for public and private health plans, reimbursement for services provided via telehealth, and eligibility to deliver reimbursable services.

States also differ in how they regulate synchronous and asynchronous telehealth and remote patient monitoring. They vary on which types of providers can deliver telehealth, what establishes a valid patient/provider relationship and if out-of-state practitioners can treat patients in the state remotely without a license, explained Shean.

“We have a patchwork of 50 different state requirements here,” she said.

The ATA has been focused on developing a consistent regulatory framework so telehealth can be deployed across states and fully leveraged.

“The ATA is committed to modality-neutral policies,” instead of dictating which tools clinicians choose to use to deliver telehealth, she said. ATA is pushing for fair payment for telehealth and home health as well as licensure flexibility across state lines.

“It’s really aligning our state frameworks with the 21st Century care model,” and the states are moving quickly, she said. There have been hundreds of pieces of legislation to update state telehealth policies.

The organization is also working with the U.S. Drug Enforcement Agency and Congress to address the future of online prescribing of controlled substances.

Many of the barriers to telehealth policy have been based on perceptions that telehealth is somehow substandard and that romanticizes in-patient care, but telehealth has often delivered care where there was no prior access to healthcare, said Shean.

“We need to recognize the access gaps that telehealth can fill” and recognize the guardrails that are in place with telehealth as they are with other care settings, said Shean.

As more retail providers like CVSAmazon and others enter the space through mergers and acquisitions, they will also have an impact on the direction of telehealth policy, including how to protect the patient data these companies will have more access to.

But with more stakeholders pushing for telehealth on the state level, “having a broader tent now helps show the different patient populations that can be served here and brings more focus,” Shean pointed out.

THE LARGER TREND

Under the CARES Act, Congress granted the Centers for Medicare & Medicaid Services authority to waive certain restrictions for Medicare coverage of telehealth.

The agency was able to remove geographic restrictions, expand care at home, increase the amount of Medicare-covered services via telehealth and more.

Additional legislative proposals, including the Telehealth Benefit Expnasion for Workers Act, Telehealth Extension Act and others, suggest broadening access to telehealth.

“Throughout the pandemic, telehealth has proven to be a vital tool for Americans to receive timely and quality care from their own home,” said Tim Walberg, R-Mich, during the bill’s introduction at the Capitol in March.

“For rural communities in particular, telemedicine has helped remove barriers to care, expand access to specialists and improve health outcomes.”

ON THE RECORD

“There is urgency [for Congress] to act – don’t wait until four months and 20 days after the pandemic ends; we need some stability,” said Herber.

“We’d love to make it permanent, and a lot of these policies we have been asking for since before the pandemic, so it’s not really new,” she concluded.

Last Updated 10/05/2022

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