Insurance Focused on Virtual Visits? The Pros and Cons of a New Twist in Health Plans

Insurance Focused on Virtual Visits? The Pros and Cons of a New Twist in Health  Plans | Kaiser Health NewsSource: Kaiser Health News, by Julie Appleby

At the height of the covid-19 pandemic, people often relied on telemedicine for doctor visits. Now, insurers are betting that some patients liked it enough to embrace new types of health coverage that encourages video visits — or outright insists on them.

Priority Health in Michigan, for example, offers coverage requiring online visits first for nonemergency primary care. Harvard Pilgrim Health Care, selling to employers in Connecticut, Maine and New Hampshire, has a similar plan.

“I would describe them as virtual first, a true telehealth primary care physician replacement product,” said Carrie Kincaid, vice president of individual markets at Priority Health, which launched its plans in January as an addition to more traditional Affordable Care Act offerings.

The often lower-premium offerings capitalize on the new familiarity and convenience of online routine care. But skeptics see a downside: the risk of overlooking something important.

“There’s a gestalt of seeing a patient and knowing something is not right, such as maybe picking up early on that they have Parkinson’s,” or listening to their heart and discovering a murmur, said Dr. David Anderson, a cardiologist affiliated with Stanford Health Care in Oakland, California. He said online medicine is a great tool for follow-up visits with established patients but is not optimal for an initial exam.

When enrolling in one of the new plans, patients are encouraged to select an online doctor, who then serves as the patient’s first point of contact for most primary care services and can make referrals for in-person care with an in-network physician, if needed. It’s possible patients never meet their online doctor in person.

Many insurers offering virtual-first plans hire outside firms to provide medical staff. The physicians may hold licenses in several states and not be located nearby. Insurers say participating online doctors can access patients’ medical information and test results through the insurers’ electronic medical records system or those of the third-party online staffing firm. What might prove tricky, experts warn, is transferring information from physicians, clinics or hospitals outside of an insurer’s network. Sharing patient information via EMRs is challenging even for doctors operating under traditional insurance plans with in-person visits — especially moving data between different health systems or specialty practices.

The virtual-first concept was so new that Priority Health called those enrolling this year to ensure they understood how it worked. “If people were more comfortable with brick-and-mortar, they should choose other options,” Kincaid said, adding that the plans have drawn 5,000 enrollees since January, a number she hopes will double next year.

Other versions of telehealth plans are available, offered by big names such as Humana, Kaiser Permanente, Oscar and UnitedHealthcare. Some emphasize but don’t require that primary care starts online. Some are aimed directly at consumers. Others are sold to employers.

Oscar Virtual Care health plans, sold in several states including Texas, Florida and New York, allow patients to choose between online or in-person services.

“These are not virtual-only plans,” said Marianna Spanos, an Oscar vice president and general manager of its virtual care division. “You can always opt to see a more traditional provider.”

Although Kaiser Permanente uses its own in-house medical staff, most insurers rely on contracted physicians, mental health therapists and other staff members, often provided by San Francisco-based Doctor on Demand.

Doctor on Demand launched in 2013, aimed at individual consumers. Starting with a Humana contract in 2019, it has since expanded to offer staffing for several other insurers. The company, which has its own electronic medical records system, hires a range of primary care, mental health and other medical providers. Physicians must be board-certified. Pay is partly based on how many patients they see, and there is no upper limit. Some want to work part time, for example, and many work from home.

In general, virtual-first health plans may carry lower premiums or provide such financial incentives as no copays for online visits. All boast that members can get appointments quickly, sometimes within minutes. Patients with serious problems are assisted in arranging emergency help. If online physicians determine patients need a blood test, immunization or a visit with a specialist, they refer them to a local practice, clinic or specialist within the insurer’s network.

As a strategy to contain costs, think HMO 2.0.

“There’s more control over the patient interaction and where they get referred,” said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

Still, patients should be aware that some of these plans may allow a brick-and-mortar visit only if their virtual doctor, who may have never examined them in person, deems it necessary.

Skeptics note that many circumstances demand in-person care. One recent study estimated about 66% of primary care visits required it. For example, it’s impossible to check reflexes and difficult to examine tonsils for infection virtually.

Patients in some programs, including Harvard Pilgrim’s, are sent kits that can include devices like blood pressure cuffs and thermometers — though at-home medical measuring devices are often not as accurate as those used in offices. Online physicians may also ask a patient to feel for swollen lymph nodes, shine a light into their throat while on camera or take other actions to help the physician diagnose a problem.

Kincaid, at Priority Health, noted that Doctor on Demand also sets protocols on children’s wellness visits, which it says must be done in person.

“It’s important for children’s wellness visits to get accurate height and weight measures and immunizations,” Kincaid said.

When considering virtual-first plans, advocates say, patients should look closely not just at premiums but also at deductibles and copayments, which may be set at levels that discourage in-person care. Rules are varied and dizzying.

The VirtualBronze plan offered through the federal ACA marketplace in parts of Texas by Community Choice Health, for example, requires hefty patient contributions for many types of in-person visits.

Patients incur no copay for using online Doctor on Demand physicians for primary care visits or for accessing in-person preventive services as defined by the ACA, such as immunizations or cancer screenings. But for other in-person services, Community Choice’s virtual plan will cost patients out-of-pocket because they pay the cost of the care until they meet an annual $8,530 deductible.

Kaiser Permanente’s Virtual Complete plan offered to large employers carries no copay for online care. Patients can opt to see an in-person doctor three times a year for primary care if they’re willing to pay a copay. After those three visits, any additional in-person visits are subject to a deductible.

Plans sold through federal or state marketplaces and those offered by employers must meet the ACA’s requirements. That includes a range of services, from doctor visits to hospital care.

Corlette, at Georgetown, said consumers should be wary of plans that are not ACA-compliant.

She fears the advent of plans that give patients “access to online providers, but nothing else.” And that, she said, “would not be considered major medical insurance.”

Mayo Clinic, Kaiser Permanente Recruit 11 Health System Partners For New Hospital-At-Home Advocacy Coalition

Mayo Clinic, Kaiser Permanente recruit 11 health system partners for new  hospital-at-home advocacy coalition | FierceHealthcareSource: Fierce Healthcare, by Dave Muoio

Following up on their big-ticket strategic investment into at-home acute care company Medically Home, Mayo Clinic and Kaiser Permanente are headlining a new advocacy movement backed by nearly a dozen other health systems from across the country.

Called the Advanced Care at Home Coalition, the partners are joining their voices to convince Capitol Hill to extend telehealth, remote and in-home care flexibilities implemented throughout the COVID-19 public health emergency.

The organizations said they will also be petitioning the Center for Medicare & Medicaid Innovation (CMMI) to test and establish a new delivery model for advanced care at home.

“Offering acute-level, hospital-quality care at home allows physicians and care teams to treat a whole person to meet their individualized care goals, while also helping address some of the social determinants of health,” Stephen Parodi, M.D., executive vice president of The Permanente Federation, part of Kaiser Permanente, said in a statement. “This coalition supports a policy foundation for this more equitable future of health care.”

Behind founding members Mayo, Kaiser and Medically Home, the new group is being backed by Adventist Health, ChristianaCare, Geisinger Health, Integris Health, Johns Hopkins Medicine, University of Michigan, Novant Health, ProMedica, Sharp Rees-Stealy Medical Group, UNC Health and UnityPoint Health, according to the announcement.

Participation in the Advanced Care at Home Coalition doesn’t include any formal commitments or requirements, a spokesperson told Fierce Healthcare. Rather, “the members will focus on advocacy by leveraging collective expertise and data, and by sharing learnings, best practices and information about state law barriers,” they said.

“By proving we can provide high-quality acute care outside of a hospital building, we have turned on its head the notion of where patients with serious or complex conditions can be cared for,” Michael Maniaci, M.D., physician leader for advanced care at home at Mayo Clinic, said in a statement. “By further developing a nurturing policy landscape, we can advance the well-being of patients by catalyzing innovative, collaborative, knowledge-driven models to redefine the standard of high-acuity care that meets each person’s unique needs.”

The Advanced Care at Home Coalition is currently accepting new members, according to its website. The group is being managed by McDermott+Consulting.

Mayo and Kaiser signaled their long-term ambitions for the hospital-at-home space in May with the announcement of a $100 million investment into Medically Home.

The systems said at the time that they would be massively scaling up their existing deployments of the company’s services—which include the installation and coordination of remote monitoring devices, emergency response systems and other medical equipment inside the patient’s home—across their service areas.

Both organizations said they were pleased with the early rollouts of Medically Home’s model, highlighting improved readmission rates, “extraordinarily low” complications and greater patient satisfaction scores.

“This model will finally allow underserved patients safe and cost-effective access to care that is long overdue,” Rami Karjian, CEO of Medically Home, said in a statement. “We look forward to working with Congress to expand access to this safe and effective model of care delivery.”

It’s not the first coalition aimed at advancing home-based care. Amazon Care, Intermountain Healthcare and Ascension are founding members of the Moving Health Home coalition, which aims to change the way policymakers think about the home as a site of clinical service.

Other providers have also ramped up or launched new programs to deliver high-acuity care inside of patients’ homes.

Also in May, AdventHealth inked a deal with startup DispatchHealth to expand a Tampa, Florida-based deployment across Daytona Beach, Ocala and Orlando, as well as into the Kansas City metro area.

Detroit-based Henry Ford Health System announced just a few weeks back that it had partnered with Contessa—a provider of home recovery care services and recent subsidiary of Amedisys—to build and launch hospital-at-home, skilled nursing facility (SNF)-at-home and palliative-care-at-home programs for its communities.

That deal came around the same time that UnityPoint Health, one of the Advanced Care at Home Coalition’s newly announced members, said that it would be collaborating with healthcare and community care coordination technology company WellSky to flesh out its SNF-at-home program.

Amazon Dominates Lobbying While Growing Telehealth Group

Amazon, Facebook spent record sums on lobbying in 2019 as tech industry  ramped up Washington presence - The Washington PostSource: Open Secrets, by Ariel Gans

Telehealth legislation is ramping up on the congressional floor, and Amazon is spending big on its telehealth investments and lobbying.

Telehealth became a necessity in the early days of the COVID-19 pandemic and spending on health services surged. Due to the historic amount of congressional legislation focused on health care services because of the pandemic, federal lobbying spending by health service groups reached a record $100.9 million in 2020. That was roughly five times what they spent 20 years ago — and the industry is on track to spend more in 2021.

Amazon, which is creating its own health care service, is the biggest corporate lobbying spender so far in 2021. The company has spent nearly $10.2 million on lobbying in the first six months of the year, and spent $18.7 million in 2020. Amazon has used some of its lobbying expenditure to spend on legislation focused on telehealth.

Amazon’s telehealth splurge comes during the second year of offering its own virtual health care service, Amazon Care. The app-based program connects customers with licensed clinicians, and allows them to message, audio call or video call each other. It also includes prescription delivery and in-home care.

As of now, Amazon Care’s in-person services are limited to a few areas in the U.S. — including Washington state, Washington, D.C., and Baltimore — but it is set to add 20 cities by the end of 2022. By the end of 2021, the service could reach Chicago, Philadelphia, Boston and Dallas, according to a report from Business Insider.

Amazon Care is currently funded by companies that pay it directly, including Amazon itself. The company has approached Aetna, an insurance provider owned by CVS Health, to work with the platform. CVS Health has spent $4.9 million on lobbying this year, and has lobbied telehealth bills. Other insurers such as Premera Blue Cross, an independent licensee of Blue Cross/Blue Shield, are also working with Amazon Care to make its services a covered benefit. Blue Cross/Blue Shield has spent $12 million on lobbying in 2021, according to an OpenSecrets analysis.

Amazon has lobbied in support of four specific telehealth bills this year. The most prominent is H.R. 1332 or the Telehealth Modernization Act of 2021, which codifies and expands telehealth services under Medicare. So far, 43 groups have lobbied the bill, and have spent a combined  $61.4 million on it and other issues, according to an analysis done by OpenSecrets.

The Hospital Corporation of America, one of the largest health systems in the country, is also rallying behind the Telehealth Modernization Act. The company has already spent nearly $1.1 million this year lobbying various issues. In 2020, the company’s lobbying expenditure jumped to $2.4 million, and it has already spent $2.1 million in 2021.

During the first half of 2021, 165 organizations collectively spent $175.8 million lobbying proposed legislation and telehealth bills, according to an OpenSecrets analysis. At least 13 bills focusing on telehealth have been introduced in Congress this year, and numerous companies, including Amazon, have lobbied them.

The U.S. Chamber of Commerce, which is the top lobbying spender so far in 2021, has lobbied on telehealth legislation as well. The group has spent $29.6 million on lobbying in the first six months of 2021.

The largest health care industry employer in the country, UnitedHealth Group, spent $1.8 million lobbying health services in the first half of 2021, and specifically lobbied two telehealth bills: S.150 and H.R. 2166. The bills would ensure Medicare Advantage and PACE beneficiaries can access audio-only telehealth services, and their providers can be reimbursed for them.

Some of the nation’s largest health care groups are also lobbying S.150 and H.R. 2166. In the first six months of 2021, Kaiser Permanente spent $2.3 million on lobbying, and Centene Corp spent $2.5 million.

Telehealth’s lobbying expansion coincided with an unprecedented increase in campaign spending by the health service groups. The industry donated over $160.7 million to campaigns during the 2020 election cycle — more than it spent on the 1990 to 2012 election cycles combined. A majority of that money ($109.1 million) came from Miriam Adelson, of the Adelson Clinic for Drug Abuse Treatment & Research. The 2020 total more than doubled the $68.4 million the industry spent in 2016. The majority of their 2020 contributions — $29.1 million — went to Democratic candidates.

Hygienists Brace for Pitched Battles With Dentists in Fights Over Practice Laws

Hygienists Brace for Pitched Battles With Dentists in Fights Over Practice  Laws | Kaiser Health News

Source: Kaiser Health News, by Giles Bruce

This year, the Illinois legislature was considering measures to expand oral health treatment in a state where millions of people live in dental care deserts.

But when the Illinois State Dental Society met with key lawmakers virtually for its annual lobbying day in the spring, the proposals to allow dental hygienists to clean the teeth of certain underprivileged patients without a dentist seemed doomed.

State Sen. Dave Syverson, a Republican legislative leader, warned against the bills even if they sounded minor. “It’s just getting the camel’s nose under the tent,” he said in an audio recording of the meeting obtained by KHN. “We’ll have, before long, hygienists doing the work that, if they wanted to do, they should have gone to dental school for.”

The senator added that he missed “the reception and the dinners that you guys host” and the “nice softball questions that I usually get” from the dental society’s past president, who happens to be his first cousin.

The bills never made it out of committee.

The situation in Illinois is indicative of the types of legislative dynamics that play out when lower-level health care providers such as dental hygienists, nurse practitioners and optometrists try to gain greater autonomy and access to patients. And the fate of those Illinois bills illustrates the power that lobbying groups such as the Illinois dental society have in shaping policies on where health professionals can practice and who keeps the profits.

“There’s always a struggle,” said Margaret Langelier, a researcher for the Center for Health Workforce Studies at the University of Albany in New York. “We have orthopedists fighting podiatrists over who can take care of the ankle. We have psychiatrists fighting with clinical psychologists about who can prescribe and what they can prescribe. We have nurses fighting pharmacists over injections and vaccinations. It’s the turf battles.”

In 2015, the Illinois Dental Practice Act was revised to let hygienists treat low-income patients on Medicaid or without insurance in “public health settings” — such as schools, safety-net clinics and programs for mothers and children — without a dentist examining them or being on-site. Besides doing cleanings, the hygienists can take X-rays, place sealants and apply fluoride.

This year, lawmakers proposed bills that would have expanded those settings to include nursing homesprisons and mobile dental vans.

The state dental society, in a memo to members, wrote that the fact it took years for hygienists to develop their public health training program shows “they have no real interest in providing access to care to needy patients.”

As it is, Illinois trails many other states in allowing dental hygienists unsupervised contact with patients. In Colorado, on the extreme end, hygienists can own practices.

“It’s just the nature of the beast politically in Illinois. The dental lobby isn’t as strong in those other states,” noted Margaret Vaughn, executive director of the Illinois Rural Health Association. “The Illinois State Dental Society is much more powerful, and they’re much more organized than the hygienists are politically.”

From 2015 to 2019, the dental society spent more than $55,000 on lobbying, for its annual gathering and meals for lawmakers, typically hosted at a swanky Italian spot near the state Capitol in Springfield, according to public disclosures. In the same period, the Illinois Dental Hygienists Association reported spending nothing in its lobbying reports. (Neither group has listed any expenditures since the beginning of 2020.)

The dental society has two exclusive lobbyists and four lobbying firms on contract, state records show. The hygienist group, meanwhile, employs no lobbyists and contracts with just one firm.

The dental society donates generously to both Republicans and Democrats. Its political action committee had nearly $742,000 in cash on hand as of June 30, according to Reform for Illinois’ Sunshine Database. While the PAC has given $4,050 since 2014 to support the campaigns of state Sen. Melinda Bush, a Democrat who sponsored the nursing home bill, the database shows it has contributed far more to help elect Syverson, the senator who spoke at the conference. It has given more than $123,000 to his campaigns since 1999, with bigger annual gifts than to Bush.

“I receive contributions from many groups on both sides of issues,” Syverson emailed KHN. “They are not contributing to influence my vote on a particular bill. In fact, if a PAC sent a check while we were negotiating or voting on an issue they are involved with, I would not accept it.”

The hygienists’ PAC gave $1,100 to the campaign committee of Bush, according to the database, but nothing to Syverson. Bush did not respond to requests for comment.

“The bottom line is, if you don’t have a healthy mouth, you don’t have a healthy body,” said Ann Lynch, director of advocacy and education for the American Dental Hygienists Association. “It only makes sense that we would remove any barriers that do not allow a licensed health care provider to practice at the top of their scope.”

But Dave Marsh, a lobbyist for the Illinois dental society, said it would be dangerous for hygienists to treat nursing home residents, who are often elderly and sick.

“I just don’t feel anybody with a two-year associate’s degree is medically qualified to correct your health,” Marsh added. “They’re trained to clean teeth. They take a sharp little instrument and scrape your teeth. That’s what they do. That’s all they do.”

He said the problem is not a shortage of dental professionals but, rather, a lack of dentists who can afford to accept Medicaid patients — and “nobody wants to raise taxes to actually be able to reimburse” dentists at higher rates.

He also pointed to the scarcity of research on the benefits of dental hygienists having more professional freedom.

Langelier acknowledged that little academic literature exists on this topic, in part because of inadequate data collection on oral health. But in 2016, a study she co-authored in Health Affairs found that, as dental hygienists gained more autonomy, fewer people had teeth removed because of decay or disease. And she said Medicaid data shows more children had dental visits as hygienists expanded their practice.

“I don’t want this to be acrimonious,” said Laura Scully, chair of the access-to-care committee of the state hygienists association. “I would like it to be more of a collaboration, because truly that’s what this is about: getting together so we can help more people.”

Karen Webster works as a dental hygienist for the Tri City Health Partnership, a free clinic in St. Charles, Illinois, about 40 miles west of Chicago. In the past, she could only briefly screen patients before scheduling them with one of the center’s volunteer dentists, often months out.

“Imagine if you had a toothache and the doctor couldn’t see you that day,” she said, noting that her patients have low incomes. “They can’t afford the services. They wait till something hurts.”

But since becoming a public health dental hygienist, Webster now does immediate cleanings, takes X-rays she sends to teledentists for exams, and applies a solution called silver diamine fluoride that can halt tooth decay.

“The whole thing, start to finish, it’s just a lot more efficient,” she said.

Walmart Selects Transcarent To Provide Go-to-Market Solution for Self-Insured Employers

Walmart Selects Transcarent To Provide Go-to-Market Solution for Self-Insured  Employers

Source: Business Wire

Walmart (NYSE: WMT) and Transcarent today announced they would be working together as go-to-market partners for self-insured employers across the country. The agreement allows Transcarent, which offers employees and their dependents a new, different and better health and care experience, to share Walmart’s everyday low cost on pharmaceuticals and other services with self-insured employers and their employees for the first time.

The collaboration makes it easier for millions of employees and the families of self-insured employers to access high-value care  no matter where they live  at affordable prices. This new offering will allow employers of all sizes to leverage Walmart’s health care size and scale to more easily provide their employees convenient care and cost-effective health and wellness options.

Today, half of all Americans are covered by employer-sponsored health insurance. According to the Kaiser Family Foundation, in 2020, the average annual premiums for employer-sponsored health insurance were $7,470 for single coverage and $21,342 for family coverage. What’s more, employers have seen costs escalate year after year without corresponding improvements in the quality of care. And while many employers have tackled this challenge head on by offering access to many new and innovative health care benefits, employees and their families are often left overwhelmed and confused by a growing list of options that have yet to demonstrate an impact on health outcomes or cost.

“We are committed to providing care to customers and the communities we serve through an integrated, omnichannel approach that improves engagement, health equity and outcomes,” said Dr. Cheryl Pegus, executive vice president of Health & Wellness at Walmart. “Most of America lives within 10 miles of a Walmart, which makes us uniquely positioned to deliver the right care at the right time in the right way. We are proud to bring our size and scale to make it simple to live healthier and leverage our collaboration with Transcarent to reach even more people where they live and work.”

Walmart’s omnichannel offerings include Pharmacy services – retail and specialty, Optical services, national telehealth services that include a focus on behavioral health, OTC, Walmart health centers and low-cost fresh food. Through this range of services, the company focuses on Social Determinants of Health, personal behaviors and clinical care seven days a week. Walmart provides prescriptions, over-the-counter medications, a variety of immunizations and COVID-19 drive-thru testing in select locations. For those who receive their COVID-19 vaccination at Walmart and Sam’s Club, a Digital Vaccine Record is available for easy access of their vaccination record that can be saved, downloaded or shared with third-party verification apps. Walmart customers with a Walmart+ membership can also get free shipping on store purchases and medicines offered as part of the membership.

The company’s recent launch of ReliOn™ NovoLog® vials and FlexPens®, which will save customers 58% to 75% off the cash price of branded insulin products, demonstrates Walmart’s commitment to improving affordability for chronic disease management. To learn more about wellness resources available at your neighborhood Walmart, visit

In addition to the high-value Walmart prescription benefits that will be available to employers, employees and their families, Transcarent’s health and care experience will serve as the on-ramp for self-insured employers and their employees to a 24/7 personalized health and care experience for virtually all of the most common and most challenging needs. Employees and their families will be able to easily engage Transcarent’s Health Guides and extended clinical team for unbiased information, trusted guidance to better understand care options and associated costs, and easy access to high-value virtual and in-person care — either through Transcarent digital offerings, Transcarent’s Centers of Excellence or Walmart’s in-community clinics. Employers have no up-front or per-employee-per-month (PEPM) fees, as Transcarent offers a fully at-risk model. Transcarent also pays health systems up front for surgeries, yet another difference in the model that health care providers love.

“Together, Walmart and Transcarent have the scale and innovation required to transform the way health and care are delivered and paid for across the nation, regardless of a person’s economic or geographic situation,” said Glen Tullman, chief executive officer of Transcarent. “Transcarent is putting employers and employees back in charge of their health and care. Employees can trust that Transcarent will focus on value and quality first, provide clear and unbiased information, offer a full range of choices and share the rewards with employees that their better health decisions generate.”

With Vaccine Mandates Looming, Companies Are Worried About Worker Shortages

Vaccine Mandate Leads Thousands of New York Health Workers to Get Vaccinated  - The New York TimesSource: San Francisco Chronicle, by Chase DiFeliciantonio

The coming federal vaccine mandate could result in a wave of firings of employees who are reluctant to get the life-saving shots. That has many companies nervous that those jobs will be difficult to fill in a labor market where willing hands are increasingly hard to come by.

Close to three quarters of respondents to a survey this month who haven’t implemented a mandate of their own said fears of worker shortages were behind that decision. The survey, run by labor law firm Fisher Phillips LLP, contacted more than 1,500 professionals from different companies including executives, general counsels, human resources staff and others.

The same survey also found that about three quarters of companies that have implemented vaccine mandates haven’t seen an impact on their staffing levels.

The industries that have seen the highest turnover because of vaccine mandates were health care and transportation, the survey found, with more than half of respondents saying they had already encountered worker shortages as a result of requiring vaccination as a condition of employment.

The coming requirements would force businesses with 100 or more employees to get vaccinated unless they have a religious or medical exemption, or face weekly testing. There is uncertainty about how to accommodate, or not, workers who continue to refuse, and immediate firing is an unlikely first step.

Companies have also been mulling whether to institute the requirements ahead of time, and some research suggests only the most reluctant would be willing to sacrifice their jobs to avoid getting the shots.

Resistance to vaccines is still widespread, according to one study by job search site ZipRecruiter, which found that about 14% of job seekers surveyed in September said they don’t want to get the vaccine while another 20% said they wanted to wait before deciding.

“About a third of job seekers are reluctant to take the vaccine and it’s probably about the same for the workforce generally,” said Julia Pollak, chief economist at ZipRecruiter. “That’s a lot when (companies) are hard-pressed to try and control vacancies” during nationwide labor shortages, she said.

By some measures, labor shortages are less pronounced in California than in other states because of a sluggish recovery and high unemployment rates, but local businesses including restaurants are still finding themselves scrambling to find willing hands.

Despite the difficulty in finding workers, job postings that mention vaccine mandates have been ticking up recently in California and elsewhere.

If the federal mandate passes legal muster, companies and unions will have to grapple with which vaccine-reluctant employees to fire and which are granted some kind of exemption or potentially subjected to frequent testing instead. It’s a question on the mind of officials like Marty Frates, secretary and treasurer of the Teamsters Local 70 union, which represents some UPS employees at the company’s Oakland depot.

Currently, UPS has not mandated vaccines for its employees, Frates said, adding that he didn’t know how many union members had gotten the shots, but a portion of them are still refusing to get vaccinated.

“I’m in an awkward position,” he said, adding he feels it should be mandatory but that he’s obligated to represent union members who are against vaccination.

He said he hopes no one will lose their job once the mandate takes effect, and that alternatives like frequent testing or unpaid leaves of absence might work instead.

“You go a few weeks without a check, sometimes things change a little bit,” Frates said.

UPS spokesman Matthew O’Connor said in an email that the company is encouraging employees to get the shots and requiring them for some remote office workers to return in person. He didn’t address questions about the company’s vaccination rate or how difficult it might be to staff up if employees quit over the requirements.

Some private and public sector employees and their unions have been vocal about their opposition to vaccine mandates. The expected federal rules would apply to private-sector employers.

Gov. Gavin Newsom has backed a legal challenge by the state’s prison guards’ union to resist a mandate. More recently BART officials voted to require the shots for the agency’s employees, of which more than 800 of its 4,000-plus workers haven’t gotten the shots. Enough employees of the San Francisco Municipal Transportation Agency also remained unvaccinated earlier this month to raise the specter of service cuts.

Some city first responders have continued to hold out as well, starting a process that could eventually lead to their firing.

California First to Let Kids Add Parents to Insurance Plans

California bill would let adults add parents to health plans - Los Angeles  Times

Source: U.S. News, by Associated Press

California is the first state to let some adult children add their parents as dependents on their insurance plans, a move advocates hope will cover the small population of people living in the country illegally who don’t qualify for other assistance programs.

The trend nationally has been to let children linger on their parents’ health insurance plans. Former President Barack Obama’s health care law let children stay on their parents’ plans until age 26. Some states have gone further and let kids stay on their parents’ plans until at least age 30, including FloridaIllinoisPennsylvania and New Jersey.

But California is now the first state to go the other direction by letting some adults join their kids’ health insurance plans. Gov. Gavin Newsom, a Democrat, signed the law this week, but it won’t take effect until 2023.

“The signing of the Parent Healthcare Act will help more families care for their parents the way they cared for us,” Insurance Commissioner Ricardo Lara said.

To be eligible, adults must rely on their child for at least 50% of their total support. The law applies only to people who buy their health insurance on the individual market. Those who get insurance through their jobs, which includes most people in the state, aren’t eligible.

That makes the law much cheaper. A previous version, which would have applied to more people, could have increased employer premiums between $200 million and $800 million per year, depending on how many people enrolled. That prompted business groups, including the California Chamber of Commerce, to oppose the bill — winning key concessions.

This narrower version of the law ensures far fewer people can enroll. The California Department of Insurance estimates just 15,000 adults will use this law, prompting an annual increase of between $12 million and $48 million per year for individual premiums, according to an analysis by the Senate Appropriations Committee. The change was enough for the Chamber of Commerce to remove its opposition.

The law’s author, Democratic Assemblyman Miguel Santiago of Los Angeles, said it targets people who can’t get subsidized health insurance because they are living in the country illegally.

Covered California, the state’s health insurance marketplace, offers discount insurance plans — but only to citizens. California’s Medicaid program offers government-funded insurance to people 50 and over and 25 and younger regardless of their immigration status. But some adults might be ineligible because they make just over the income limits.

The University of California Berkeley Labor Center predicts more than 3 million people won’t have health insurance in California next year, 65% of them people who are living in the country illegally.

The law is “a way to close that gap,” Santiago said, while also helping other adults who “fall through the cracks.”

“We all talk about increasing health care access, and here was a real easy way to do it,” he said.

Hospital Prices Vary Widely, Often Higher With Insurance Than Cash, The New York Times Finds

Why Hospitals and Health Insurers Didn't Want You to See Their Prices - The New  York Times

Source: Fierce Healthcare, by Anastassia Gliadkovskaya

Private insurers sometimes negotiate rates on hospital services that are higher than the cash price, a recent New York Times investigation found, and the same basic service can cost widely varying amounts even at the same hospital.

The Times surveyed 60 major hospitals that are complying with this year’s new Centers for Medicare & Medicaid Services (CMS) rule that requires hospitals to publish their negotiated, cash and chargemaster rates. Compliance has been spotty, and even with some published prices, the data has been difficult to draw meaning from.

Below is a graphic that, using data from the Times story published in August, shows the costs of a service at a hospital from each of the four regions of the U.S.

Fierce Healthcare reached out to all four hospitals included in our review of the Times’ data. In response, Erin Goff, Intermountain Medical Center’s media relations manager, noted a number of factors are considered when negotiating rates with payers that are “common across many industries.” These include “the number of patients the payer will direct to us, scope of facilities the payer includes in their network, and the payer’s demonstrated administrative efficiencies.”

In a statement, Beaumont Health presented similar influencing factors, adding that the severity of a visit also determines price. “Finally, it’s important to note that the published rates often do not reflect what is actually paid by the patient—negotiated rates include both the insurer’s payment to the provider plus patient’s payment,” the statement said.

Penn Medicine said in a statement it’s working to update price information on its sites to be compliant with the regulation and to be “as user-friendly as possible.” It suggested using its price estimator tool in the patient portal to estimate certain out-of-pocket costs. It noted that market position also contributes to the contracting process, and said “although we anticipate some continued variation in payment structures for the vast array of services we provide given the mix of commercial and governmental payors we contract with, we also hope that price transparency efforts will play a role in driving down overall variation across the healthcare industry.”

Wake Forest Baptist declined to comment for this story.

Given the price fluctuations, the Times argued that the data shed a light on how little power the consumer has to shop for insurance plans and for healthcare services.

But experts and hospital advocates caution that the data—payer-negotiated rates made public in the form of machine-readable files or hospital cost estimator tools—are not necessarily an accurate representation of the price a patient might pay.

“Numbers in the spreadsheets do not necessarily reflect the patient experience or their course of treatment,” said Ari Levin, senior associate director for policy at the American Hospitals Association. Since the final amount depends on several factors, including volume discounts, quality bonuses and whether multiple services are provided at once, “there is no way to capture all of those factors in a single ‘negotiated rate,’” Levin said.

Last year, the AHA along with other groups sued the U.S. Department of Health and Human Services (HHS) over the price transparency rule. They lost despite appealing the case.

America’s Health Insurance Plans published a statement saying the attempt to look at the data “spotlights a lot of numbers with little context” and “often compares apples and oranges.”

Because of these complexities, the CMS rule does not help patients “shop for services” as intended, said Delphine O’Rourke, a healthcare attorney and partner at Goodwin Procter. “I, as a consumer, don’t know at the end of the day what I’m going to be responsible for,” she said.

To O’Rourke, it’s not surprising that at times, a hospital’s cash price is lower for a service. Since people paying cash price are generally a small segment of patients, she explained, and tend to be uninsured or undocumented, hospitals structure cash pay anticipating that it will be “challenging to collect,” O’Rourke said. (Earlier this year, the Wall Street Journal found that many times, patients who pay with cash are actually charged the highest price across hospitals.)

Since healthcare is a market, those with hefty bargaining power—whether a hospital or a payer—can leverage better rates for themselves, O’Rourke said. That’s one reason driving provider consolidations, which can increase prices and premiums. “If you want to have a system where every MRI in the country is the same cost, that’s your national healthcare system,” she said.

Another possible reason some payer-negotiated rates are high is that they may be offsetting lower-priced services in a given contract, which can contain thousands of items, Levin added, making it difficult to draw conclusions about insurers and health plans based only on the cost of one service.

Cash pay can be complicated, too. Most hospitals don’t have a set self-pay rate—they negotiate one based on a patient’s financial circumstance, Levin noted.

The Times was not able to obtain some hospitals’ cash rates for this reason, the bottom of the story notes. When an insured patient pays cash, that payment does not count toward their deductible. “When you’re stepping outside of insurance, you’re removing the consumer protections that come with it,” Levin said.

Payers and hospitals can issue gag orders in their contracts, preventing them from disclosing their negotiated rates, even to public officials, the Times noted in its story. “Hospitals and plans negotiate prices for services and medical goods behind closed doors,” said Nisha Kurani, a senior policy analyst at Kaiser Family Foundation. “How price transparency will impact those negotiations remains to be seen.”

recent KFF poll found that most adults are not aware of the rule that requires hospitals to post their prices. The majority (85%) also reported not researching the price of a hospital treatment in the past six months.

“We have found that current implementation of the rule often makes it difficult to estimate the true cost of care,” Kurani said. In April, KFF tracked the negotiated rates for an MRI of the lower spine across 102 hospitals and found that “even when these prices were published, gaps or inconsistencies in data made it difficult to compare prices across hospitals,” according to Kurani.

Part of the rule requires hospitals to provide a patient cost estimator tool with prices for 300 common services; the AHA recommends patients use the tool as one way to get “the most accurate estimate” of their expected costs. But KFF found in its analysis that price estimates for the same service differed between the tool and the hospital’s machine-readable file.

Experts told Fierce Healthcare they would expect stronger compliance with the price transparency rule if providers were not in the middle of dealing with the COVID-19 pandemic. The AHA has urged for extensions to the rule, to allow providers more time to publish prices.

Donald Trump’s 2019 executive order, Levin said, led to the rushed price transparency policy that now burdens hospitals and does not serve patients. The No Surprises Act, which was passed in Congress and is meant to protect patients from surprise billing, has allowed for a more nuanced policy-making process that considers patients, she said. As before, the AHAalong with other groups, requested that HHS delay enforcement of some parts of the No Surprises Act.

Small Businesses Navigate Ever-Changing COVID-19 Reality

Business & Growth | Capital Region Albany New York | Spectrum News 1

Source: Associated Press, by Mae Anderson

For a brief moment this summer, it seemed like small businesses might be getting a break from the relentless onslaught of the pandemic. More Americans, many of them vaccinated, flocked to restaurants and stores without needing to mask up or socially distance.

But then came a surge in cases due to the delta variant, a push for vaccine mandates and a reluctant return to more COVID-19 precautions. Now, small business owners are left trying to strike a balance between staying safe and getting back to being fully open.

Navigating ever-changing coronavirus reality comes with a number of risks, from financial hardship to offending customers to straining workers. Those challenges could intensify as winter approaches and outdoor alternatives become limited. Still, small business owners say the whiplash is worth it to keep customers and employees as safe as possible.

“Just weeks ago, small business owners hoped that a return to normalcy would help jump start our recovery,” said Jessica Johnson-Cope, Chair of Goldman Sachs 10,000 Small Businesses Voices National Leadership Council and owner of a small business herself, Johnson Security Bureau in New York.

New York City ordered a vaccine mandate for customers in August. For Dan Rowe, CEO of Fransmart, which runs the Brooklyn Dumpling Shop, the mandate has been a financial burden, and a headache. Brooklyn Dumpling Shop first opened in May and has six staffers. It’s pandemic-friendly format is contactless and automated.

“It was engineered to be a restaurant with less employees,” Rowe said. Glass separates the kitchen and staff from customers, who order food from an app. When the kitchen is finished making the food, it’s placed an automat-style window, so workers don’t come into contact with customers.

“We’ve engineered this great low labor restaurant, and the government is making us go backward,” he said.

Rowe had to hire another staffer to check vaccine cards at the door, increasing his overhead. His complaint is that retail stores and groceries with prepared foods like Whole Foods don’t face the same restrictions.

“It’s not fair what’s going on and it’s not practical,” he said.

The changing rules can cause customer confusion – and even some resentment. Suzanne Lucey has owned Page 158 Books bookstore in Wake Forest, N.C., for six years. When the pandemic began, the store was closed for three months. Page 158 Books reopened last July, and gradually increased store capacity from 5 to 12, abiding by state guidelines. Capacity limits were lifted ahead of the holidays last year.

When case numbers started crawling up this summer, Lucey’s zip code became the third highest in the state for COVID-19 cases. They have a sign in the window that says a mask is required inside the store, but without state or city rules to back them up, they’re not enforcing it.

Lucey said only about one or two people a month disregard the rule.

“It’s hard. You don’t want to turn people away. But I want my staff to feel secure,” Lucey said, especially since two of her staff have medical conditions that make them more vulnerable. “I don’t want my staff to feel like they have to be combative. So that’s how we’re handling it. Most people are pretty respectful.”

Allison Glasgow, director of operations for McNally Jackson bookstores in New York, echoed Lucey’s sentiment.

Her stores follow state and city rules for restrictions. One store has a cafe, which must follow the New York City mandate for customers being vaccinated. The bookstores also require vaccination proof at events. Otherwise, masks are optional, though recommended, if customers and staff are vaccinated.

“You can seem antagonistic when you’re trying to monitor people’s vaccination status,” she said. “It’s not ‘Hey, welcome in!’ which is what you have always wanted to do — it’s a bit of a roadblock there.”

Although safety is the priority for everyone, the changes can be draining for owners and staff alike. Jennifer Williams, founder and CEO of closet organization company the Saint Louis Closet Co., said the company scrambled at first to implement a COVID-19 plan, including masking and increased sanitization.

“We don’t have the option to ‘work from home,’ our business happens in our manufacturing plant and in our client’s homes, so we had to adjust quickly at the onset of the pandemic with Covid precautions,” she said.

She nixed the mask requirement July 1, after her staff was fully vaccinated, COVID-19 cases were declining and the CDC recommendations changed. But that was short-lived.

In early August, Missouri was one of the top three states of coronavirus cases. Williams re-implemented the mask mandate.

Williams’ staffers can spend up to eight hours a day in a mask installing closet organizing systems in a customer’s home. “The mental drain on employees has been extreme,” Williams said.

Jessica Benhaim, owner of Lumos Yoga & Barre, an independent fitness studio in Philadelphia, gradually increased size limits of classes from late spring into the summer, but capped them at 12, short of pre-pandemic levels of 18 students for yoga and 14 for barre.

Even though the city has lifted capacity restrictions, she’s keeping it capped in case restrictions come back. She lifted mask requirements for vaccinated students on June 15 but reinstated them when Philadelphia implemented a mask mandate in mid-August. Vaccinated students can remove their masks when they reach their mats.

“The constant adjustments over the last 18 months have been draining,” Benhaim said. “More than anything, it’s been stressful balancing making adjustments with trying to keep a sense of normalcy for my staff and clients.”

Teladoc Takes Its Primary Care Service Nationwide With Aetna Slated To Roll Out In Early 2022

Teladoc takes its primary care service nationwide with Aetna slated to roll  out in early 2022 | FierceHealthcare

Source: Fierce Healthcare, by Heather Landi

Teladoc Health is taking its primary care pilot nationwide, expanding it to commercial health plans, employers and other payers.

The telehealth giant piloted its virtual primary care program, called Primary360, in 2019 with the aim of early detection of chronic disease. The service now offers 70 distinct diagnoses such as hypertension and diabetes, Teladoc CEO Jason Gorevic said during a J.P. Morgan virtual presentation in January.

Teladoc says it has signed several Fortune 1000 employers onto the new primary care service, with other large employers and health plans such as Aetna launching nationwide in early 2022.

The company is pitching Primary360 as a way to expand access to primary care in the U.S.

Teladoc’s pilot programs have shown that two-thirds of members previously lacked traditional primary care and are now benefitting from longitudinal relationships with physician-led care teams.

“Primary360 has the unique power to drive the unified health care experience that consumers are demanding by removing longstanding barriers like access, cost and convenience,” said Donna Boyer, chief product officer at Teladoc Health in a statement. “Primary360 gives people greater control over their healthcare experience without losing the personal connection they seek—all from a brand that they trust.”

Through the service, members have access to a Teladoc primary care physician and a care team offering a range of services including guidance for an individual’s care, and navigation to in-person, in-network providers. Users also get a personalized care plan that includes reminders and nudges for follow-ups.

The service provides members with access to prevention and screening, which has helped members to detect earlier and treat previously undiagnosed chronic diseases, according to the company. Early results with year one members show one in four chronic conditions identified for Primary360 members have been new diagnoses of common disorders such as diabetes and hypertension.

Preliminary findings from the first year of the pilot show that more than 50% of Primary360 members take advantage of at least one other Teladoc Health service and nearly 30% use two connected services, like mental health care, urgent care, dermatology and nutrition.

Teladoc says its physicians are currently available within a week for a new patient visit as compared to the average wait time of roughly a month for a new primary care physician.

An Annals of Family Medicine study estimated that if everyone in the United States had a primary care physician, the annual savings would top $62 billion dollars.

Primary care has become a red-hot sector as startups like Carbon Health and VillageMD try to disrupt the traditional primary care model. Tech-enabled providers like One Medical, Oak Street Health, Privia Health and Forward also are looking to shake up the $260 billion market.

Primary care was the second largest sector for venture dollars in healthcare in the first quarter of 2021, according to Rock Health. The companies listed below raised a total of $8.9 billion, including $2.6 billion in 2020, and $1.8 billion in the first half of 2021.

There are also high-profile deals in the market. Health benefits platform Accolade plans to acquire virtual primary care company PlushCare for $450 million.

And payers are jumping into the virtual primary care market as well. In January, UnitedHealthcare launched a new, virtual primary care option as part of an effort to expand access to local clinicians in its employer-sponsored plans.

Last Updated 10/20/2021

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