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.”

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.

Ban On ‘Surprise’ Medical Bills On Track For Jan. 1 Rollout

Ban on 'Surprise' Medical Bills on Track for Jan. 1 Rollout | Health News |  US News

Source: Associated Press, by Ricardo Alonso-Zaldivar

The Biden administration on Thursday put final touches on consumer protections against so-called “surprise” medical bills. The ban on charges that hit insured patients at some of life’s most vulnerable moments is on track to take effect Jan. 1, officials said.

Patients will no longer have to worry about getting a huge bill following a medical crisis if the closest hospital emergency room happened to have been outside their insurance plan’s provider network. They’ll also be protected from unexpected charges if an out-of-network clinician takes part in a surgery or procedure conducted at an in-network hospital. In such situations, patients will be liable only for their in-network cost sharing amount.

The rules released Thursday spelled out for the first time a key part of the new system: a behind-the-scenes dispute resolution process that hospitals, doctors and insurers will use to haggle over fees, without dragging patients into it.

When an insurer and a service provider disagree over fair payment, either side can initiate a 30-day negotiation process. If they still can’t come to an agreement, they can take the matter to an independent arbitrator.

The arbitrator will use as a guide a set amount intended to balance the value of the medical services provided with goal of keeping costs from ballooning out of control. Clear justification will be required for the final payment to end up higher or lower.

There will also be a new way for uninsured people and patients who pay their own way to get an estimate of charges for medical procedures, as well as a process for them to resolve billing disputes.

“We’re hoping to give folks a sigh of relief, who have been blindsided by billing,” said Health and Human Services Secretary Xavier Becerra.

Surprise medical bills have been a common problem for people with health insurance, all the more irritating because most patients might have thought they were protected. Charges running from hundreds to tens of thousands of dollars came from doctors and hospitals outside the network of patients’ health insurance plans. It’s estimated that about 1 in 5 emergency visits and 1 in 6 inpatient admissions triggered a surprise bill.

Although many states already have curbs on surprise billing, federal action was needed to protect patients covered by large employer plans, which are regulated at the national level. A 2020 law signed by then-President Donald Trump laid out a bipartisan strategy for resolving the issue, and the Biden administration filled in critical details.

The idea was to take patients and their families out of the financial equation by limiting what they can be billed for out-of-network services to a fee that’s based on in-network charges. That amount gets counted toward their in-network annual deductible.

The law’s new protections are aimed at:

— Protecting patients from surprise bills arising from emergency medical care. Protections apply if the patient is seen at an out-of-network facility, or if they are treated by an out-of-network clinician at an in-network hospital. In either case, the patient can only be billed based on their plan’s in-network rate.

— Protecting patients admitted to an in-network hospital for a planned procedure when an out-of-network clinician gets involved and submits a bill.

— Requiring out-of-network service providers to give patients 72-hour notice of their estimated charges. Patients would have to agree to receive out-of-network care for the hospital or doctor to then bill them.

— Barring air ambulance services from sending patients surprise bills for more than the in-network cost sharing amount.

Before the ban on surprise billing, patients usually had to take the initiative themselves to work out unexpected charges. In many cases the hospital or doctor would go back and forth with the insurance company until they reached an agreement. But there was no guarantee that would happen, and patients were at risk of being placed into collection proceedings in situations they had no control over.

Some health care industry groups have urged the Biden administration to take more time to set up the new arbitration system. Officials said Thursday they remain committed to the Jan. 1 effective date and said 50 organizations have expressed interest in taking on the role of arbitrators.

Telehealth Use Is Surging But Patient Satisfaction With The Service Has Declined, New Study Finds

Telehealth use is surging but patient satisfaction with the service has  declined, new study finds | FierceHealthcareSource: Fierce Healthcare, by Anastassia Gliadkovskaya

As the use of telehealth has become more widespread, consumer satisfaction has fallen, according to a recent survey.

J.D. Power conducted a telehealth satisfaction study, looking at factors including customer service, consultation, enrollment and billing among direct-to-consumer and payer-sponsored telehealth services. More than 4,600 consumers who used a telehealth service in the past year, from June 2020 through July 2021, responded.

The study found that despite 36% of patients using telehealth, four times higher than the previous year, they also report limited services and inconsistent care and lower satisfaction than in 2020.

“As the industry grows, it is critical to address these challenges,” said James Beem, managing director of global healthcare intelligence at J.D. Power, in a statement.

Services that ranked highest in terms of patient telehealth satisfaction among direct-to-consumer brands are Teladoc, MDLive and MyTelemedicine, respectively. Among payers, UnitedHealthcare ranked highest, followed by Humana and Kaiser Foundation Health Plan tied for second place.

More than half of all customers reported using telehealth because of convenience, nearly half because of swift access to care and more than a third because of safety. The highest usage of telehealth services in the past year was among Generation Y and Pre-Boomers, J.D. Power found.

But patient satisfaction with telehealth services has declined as pain points emerge. Apart from barriers like limited services and inconsistent care, consumers also reported not being aware of costs while using telehealth, confusing technology and a lack of provider details.

Patients who said they are healthier also reported higher degrees of satisfaction with their care and diagnoses than those who reported having poorer health.

J.D. Power’s study is the latest among others looking into patient satisfaction and the COVID-19 pandemic’s impact on telehealth. In general, data has shown consistent similarities, such as increased demand for the services alongside inconsistencies in delivery and spotty access to helpful information.

Here Are 3 Major Policy Areas That Health Industry Groups Are Closely Watching In $3.5T Infrastructure Bill

Here are 3 major policy areas that health industry groups are closely  watching in $3.5T infrastructure bill | FierceHealthcare

Source: Fierce Healthcare, by Robert King

The Senate is getting into the nitty-gritty of what exactly will be included in a massive $3.5 trillion infrastructure package that seeks to make major reforms to Medicare.

And that means healthcare industry groups are watching very closely.

Democrats have called for the $3.5 trillion package to tackle drug prices and add dental, hearing and vision benefits to Medicare, as well as efforts to expand coverage. But the actual legislation on how to do that will now be crafted by Senate committees and considered by lawmakers when they return from their August recess next month.

Democrats aim to use a procedural pathway called reconciliation that lets budget bills pass the Senate via a simple majority and avoid a legislative filibuster. The Senate took its first step toward creating the package when it approved a budget resolution earlier this week.

Here are some of the major issues several payer and provider groups are keeping an eye on and what they want to include in the final package.

Expanding healthcare coverage

Several provisions in the $3.5 trillion package aim to expand health insurance coverage, but how that can happen is still going to be hammered out.

Payers and provider groups were in favor of making permanent enhanced income-based subsidies for Affordable Care Act (ACA) exchange coverage. The American Rescue Plan Act boosted subsidies but only for the 2021 and 2022 coverage years.

But the ACA enhancements aren’t the only coverage expansions that Congress is mulling.

The framework for the $3.5 trillion package calls for legislation to close the Medicaid coverage gap, which refers to low-income residents that don’t qualify for ACA income-based subsidies but reside in states that didn’t expand Medicaid under the ACA.

Some groups were surprised the issue has gotten so much traction in Congress over the past several months.

“The momentum for that has been pretty impressive,” said Dan Jones, vice president of federal affairs for the Alliance of Community Health Plans (ACHP), which represents nonprofit health plans.

But now committees will decide how the coverage gap gets filled, and some groups are pushing for a quick solution to the issue.

Several Senate Democrats introduced legislation last month that would create a new program resembling Medicaid through which residents in states that didn’t expand the program can get coverage. However, such a program could take a while to set up, said Chip Kahn, president and CEO of the Federation of American Hospitals (FAH).

Kahn instead endorsed a stopgap that would make people in the coverage gap eligible for subsidies on the ACA’s exchanges.

“If we make these people eligible, they would be fully subsidized and have good coverage,” he told Fierce Healthcare.

The additional subsidies could run for a few years and give more states time to expand Medicaid under the ACA, Kahn said. The American Rescue Plan Act did increase the federal matching rate for Medicaid for newly expanded states, but the sweetener hasn’t enticed more states.

“The great opposition to ACA is blowing over to an extent,” he said. “We will have to wait and see how it plays out, but we could find other ways to get those other states to move.”

Finally tackling drug prices, but how?

Senate Democrats signaled that they want to address drug prices in the infrastructure bill, but to what degree remains uncertain.

Progressive lawmakers want to give Medicare broad authority to negotiate for lower drug prices, a desire shared by President Joe Biden. Implementing price negotiation authority could also produce savings that could help pay for the package. But more moderate members could balk at broad negotiation authority.

Some groups see an opportunity to get more bipartisan proposals to be included into the bill.

The advocacy group Campaign for Sustainable Rx Pricing is pushing lawmakers to adopt a series of bipartisan reforms that include capping out-of-pocket drug costs for seniors. The campaign is a coalition of hospital, pharmacy, payer and other provider groups as well as advocacy groups such as AARP.

“We called for action on solutions that have garnered bipartisan support in the past,” said spokesman Jon Conradi in an interview with Fierce Healthcare.

Another potential issue is forcing drugmakers to pay a larger share of coverage in the catastrophic phase in Medicare Part D. Drugmakers now cover 50% of the costs of their products when a beneficiary reaches the catastrophic phase, which is the maximum out-of-pocket limit beneficiaries pay for drugs.

“Now is the time for action,” Conradi said. “There is truly unprecedented momentum for Congress to act on prescription drug prices.”

Ditching the rebate rule for good

Drug price negotiations isn’t the only item Congress has identified as a potential pay-for to help cover the costs of the package.

Several payer groups are hoping Congress also decides to fully repeal a controversial Trump-era rule that eliminates safe harbor protections for Medicare Part D drug rebates and creates a new safe harbor for discounts at the point of sale.

The bipartisan infrastructure package that passed the Senate recently includes a three-year delay in implementing the rule until 2026. The delay netted roughly $50 billion in savings for the package.

Now, payers are hoping to put the final nail in the coffin.

Conradi said the campaign wants the rule to be fully repealed because it can “increase overall drug costs.”

The Pharmaceutical Care Management Association, which represents pharmacy benefit managers, called for a permanent repeal.

“We are encouraged that there is bipartisan support for repealing the Medicare rebate rule, which if allowed to take effect will drastically increase premiums for seniors and other Medicare Part D beneficiaries,” said President and CEO JC Scott in a statement after passage of the bipartisan infrastructure package.

Payer and provider groups are also keeping a watchful eye on any other pay-fors that could be employed as committees start drafting the legislation.

“Any changes to the Medicare Advantage program are things we are paying close attention to,” said Jones of ACHP. “Those are always things that we want to keep a close eye on.”

FAH was disappointed that the bipartisan infrastructure package restarted a 2% sequester cut to Medicare payments next year as a pay-for.

“I don’t anticipate on the hospital front any major changes on the payment side of this bill,” Kahn said. “Until the fat lady sings, you need be wary.”

430 Groups Demand Congressional Action On Permanently Expanding Telehealth Flexibilities

US capitol building

Source: Fierce Healthcare, by Robert King

More than 400 advocacy groups are calling for Congress to act quickly to permanently expand flexibilities for telehealth that could go away after the end of the COVID-19 public health emergency expected to run through 2021.

The 430 groups sent a letter to congressional leadership on Monday underscoring the urgency for action now amid concerns from providers that expanded telehealth access could expire abruptly after the emergency ends.

“Once it expires all bets are off,” Jen Covich Bordenick, CEO of the eHealth Initiative, told Fierce Healthcare in an interview. The initiative is one of the 430 groups that signed onto the letter.

At the onset of the pandemic, the Department of Health and Human Services removed several barriers to telehealth reimbursement under Medicare. The move helped fuel a massive explosion in telehealth use among providers as patients were afraid to get care for fear of contracting COVID-19.

Some of the initial barriers that were lifted include a requirement for an in-person visit from the patient before going through telehealth.

Other restrictions included a requirement that a provider be in the same geographic area as the patient.

“We want patients to access care wherever they are,” Covich said.

Lawmakers in both the House and Senate have introduced legislation to remove barriers such as the originating site requirement.

But it remains unclear when Congress could act on the issue, such as whether the fix is included in a major infrastructure push being negotiated now or during an end-of-year spending package.

Currently, the Senate is considering a roughly $1 trillion bipartisan infrastructure package and a $3.5 trillion package intended to pass via reconciliation, a procedural move that ensures budget bills can bypass a filibuster and pass via a simple majority.

“It is a fully bipartisan issue,” said Krista Drobac, executive director of the Alliance for Connected Care, another group signed onto the letter. “That alone should bring it to the top of the agenda for Congress.”

Other groups who signed onto the letter include the American Medical Association, American College of Physicians and the Health Information and Management Systems Society.

Advocates also hope that any legislation approved by Congress gives regulatory flexibility to HHS and Centers for Medicare & Medicaid Services.

The agencies, for example, should determine which types of providers should get reimbursement from Medicare for telehealth services.

“Rather than have that in the legislation, we want CMS to make those decisions in regulation rather than having to go back to Congress to make changes,” Covich said.

Telehealth Use Falls Nationally For Third Month In A Row: Fair Health

Telehealth Will Be Free, No Copays, They Said. But Angry Patients Are  Getting Billed. | Kaiser Health News

Source: Healthcare Dive, by Rebecca Pifer

Dive Brief:

  • * Telehealth claim lines as a percentage of all medical claims dropped 13% in April, marking the third straight month of declines, according to new data from nonprofit Fair Health.
  • * The dip was greater than the drop of 5.1% in March, but not as large as the decrease of almost 16% in February. However, overall utilization remains significantly higher than pre-COVID-19 levels.
  • * The decline appears to be driven by a rebound in in-person services, researchers said. Mental health conditions bucked the trend, however, as the percentage of telehealth claim lines associated with mental conditions — the No. 1 telehealth diagnosis — continued to rise nationally and in every U.S. region.

Dive Insight:

The coronavirus spurred an unprecedented increase in telehealth utilization early last year. But early data from 2021 suggests demand is slowing as vaccinations ramp up and COVID-19 cases decrease across the U.S.

Fair Health has used its database of over 33 billion private claims records to analyze the monthly evolution of telehealth since May last year. Telehealth usage peaked among the privately insured population last April, before easing through September and re-accelerating starting in October, as the coronavirus found a renewed foothold in the U.S.

In January, virtual care claims made up 7% of all medical claim lines, but that fell to 5.9% in February, 5.6% in March and just 4.9% in April, suggesting a steady deceleration in telehealth demand.

The deceleration in April was seen in all U.S. regions, but was particularly pronounced in the South, Fair Health said, which saw a 12.2% decrease in virtual care claims.

The trend doesn’t bode well for the ballooning virtual care sector, which has enjoyed historic levels of funding during COVID-19. Just halfway through the year, 2021 has already blown past 2020’s  record for digital health funding, with a whopping $14.7 billion. This latest data suggests dampening utilization could throw cold water on the red-hot marketplace.

And policymakers are still mulling how many telehealth flexibilities should be allowed after the public health emergency expires, expected at the end of this year. Virtual care enjoys broad support on both sides of the aisle and the Biden administration’s top health policy regulators, including CMS administrator Chiquita Brooks-LaSure, have said they support permanently adopting virtual care coverage waivers, but returned restrictions on telehealth access could also stymie use.

Fair Health also found that nationally, mental health conditions increased from 57% from all telehealth claims in March to 59% in April. That month, psychotherapeutic/psychiatric codes jumped nationally as a percentage of telehealth procedure codes, while evaluation and management codes dropped, suggesting a continued need for virtual access to mental health services, which can be some of the rarest and most expensive medical services to find in one’s own geographic area.

Also in April, acute respiratory diseases and infections increased as a percentage of claim lines nationally, and in the Midwest and South, while general signs and symptoms joined the top five telehealth diagnoses in the West. Both trends suggest a return to non-COVID-19 respiratory conditions, like colds and bronchitis, and more ‘normal’ conditions like stomach viruses, researchers said.

Telehealth Use Falls 37% From Pandemic Highs, While Demand For Healthcare Services Projected To Flatten: Report

close up of a mother and daughter consulting with their doctor over a video call on their digital tablet

Source: Fierce Healthcare, by Heather Landi

Future demand for healthcare services will be relatively flat to declining, with little to no effect from the COVID-19 pandemic, according to a new forecast report.

At the same time, hospitals and health systems are facing increasing competition from consumer businesses such as Amazon and Walmart, retail behemoths that are rapidly expanding the supply of healthcare services.

The implications of softening demand and increasing supply suggest that pricing trends are ultimately unsustainable for healthcare providers, according to a new report from health system analytics company Trilliant Health.

The company’s analysis, based on 70 billion medical claims across 309 million patient visits, contradicts the commonly held belief that the demand for healthcare services nationwide is rising, according to Sanjula Jain, Ph.D., senior vice president of market strategy and chief research officer at Trilliant Health.

“As Americans are developing more chronic conditions, there is a perception in the healthcare industry that as the disease burden is so large, volumes and utilization rates and the need and demand for healthcare services by those comorbid individuals will be 1:1, that it’s increasing in tandem,” Jain told Fierce Healthcare. “What we find when looking at the data is that burden of disease is not correlated there.”

Almost all growth in demand for healthcare services will be from Medicare beneficiaries, not from the increasing burden of disease in America, according to the report’s analysis.

Trilliant Health’s report looks at macro trends impacting the $4 trillion dollar health economy post-COVID-19. Underlying the company’s research is the premise that the U.S. healthcare economy represents the largest sector of the world’s largest economy globally but, for decades, the industry has not operated according to the basic economic principles of supply, demand and yield.

“This report was meant to offer the industry a starting point, some basic facts, to reorient some of these myths that have been talked about in the industry,” as healthcare executives work to steer their organizations through the recovery from the COVID-19 pandemic, said Jain, who is a health economist.

Annual inpatient admissions have declined from 2008 through 2016, according to data from the American Hospital Association (AHA), while the number of hospitalists has almost doubled in the same time period. Looking ahead, Trilliant forecasts the average rate of growth for surgical services to range between 0.7% to 1.9% year over year through 2025, which is lower than the 3% annual growth assumption commonly held.

“I work with hospital CFOs and they make budget decisions based on that assumption of 3% year-over-year growth projections. This might seem like a minor percentage but when we translate that to volumes and utilization, it’s pretty significant,” Jain said.

The company forecasts that demand for vascular surgical services will grow by 1.4% annually through 2025, while neuro/spine surgery demand will only grow by 1.2%, orthopedic services will rise just 1.1% and ob/gyn surgical services will be flat at 0.4% annual growth in the next four years.

The report also projects that future demand will not be meaningfully impacted by COVID-19 or by the increasing obesity of Americans, but primarily by population migration and shifting demographics. Some of the fastest-growing markets are in the South and Sunbelt, such as Dallas, Houston, Phoenix, Austin, Nashville, and Charlotte and Raleigh, North Carolina, and those areas could see a corresponding rise in demand for healthcare services, the report said.

The report’s analysis calls into question whether the U.S. does, in fact, need 20% more physicians, as some healthcare organizations have projected. The Association of American Medical Colleges (AAMC) estimates that the U.S. is going to have a massive shortage of physicians in primary and specialty care by 2034.

Trilliant Health’s analysis corresponds with an unreported finding from the AAMC: the projected demand for surgeons has been declining for years.

“While much has been made of increasing demand and decreasing physician supply, a longitudinal analysis of the AAMC’s Physician Workforce Projections has consistently revised their surgeon demand projections, as an example, downward over time,” Jain said.

Telehealth becoming a ‘commodity-type’ service

Despite the buzz about telehealth and massive investment in virtual care, the use of telehealth is beginning to taper off, declining as much as 37% from peak-pandemic highs in some states, according to Trilliant Health’s report.

In California, telehealth utilization is down 24% and virtual care visits are down 30% in Louisiana, the report’s analysis finds.

Delineating between total telehealth visits and the discrete number of unique individuals who used telehealth, the research concludes that only about 13% of Americans used telehealth during the pandemic, according to Jain.

“The actual share of Americans that used telehealth is smaller than we all think,” Jain said. “There are a lot of numbers floating around in the industry that are actually looking at total visits; they are not looking at the actual share of patients generating those visits.”

Trilliant Health’s analysis found that during the pandemic telehealth was primarily used for behavioral health, especially by commercially insured women between the ages of 20-49.

“The increase in capital investments in tele-based companies and the expansion of more providers into telehealth, like Amazon, that we saw during COVID-19 is catering to very small consumer segments of corresponding demand,” Jain said.

“Within this already crowded market of telehealth suppliers, traditional providers—notably hospitals and health systems—are going to be hard-pressed to compete with new market entrants that have longstanding relationships with consumers.”

Given these trends, hospitals and health systems should be partnering with telehealth providers not building capabilities internally, Jain said.

“They are chasing after a consumer population that is not conducive to coming to them already. They are not going to be able to attract them, they are not attracting them now. [Telehealth] is a commodity-type service. Walmart and other consumer brands are going to beat them,” she said.

These new market entrants like Walmart and Amazon have pre-existing “sticky” relationships with consumers that will make it very challenging for health systems to win when it comes to consumer loyalty.

“It’s not a play for the traditional health system and hospital business,” she said.

Moving into the post-COVID economy, health systems and hospital executives need to understand local-level supply and demand.

“The industry needs to stop making decisions and assumptions based on what we think are national numbers that only affect 10 to 15% of the population and look at what’s happening in that specific patient population or market they are operating in,” Jain said.

Doctors’ Lobby Scores ‘Major Victory’ on Bill to Hold Physicians Accountable

Doctors' lobby scores 'major victory' on state bill that tries to hold  physicians accountable - The San Diego Union-Tribune

Source: Kaiser Health News, by Samantha Young

The board that licenses and disciplines doctors in California is failing to hold bad actors accountable, endangering patients in the process.

That’s the verdict of state lawmakers and patient advocates who have been working for years to reform the Medical Board of California.

But an attempt this year to give the board more money and power to investigate complaints of fraud, gross negligence, sexual misconduct and other misbehavior is under attack from one of the most politically potent forces in California’s Capitol: doctors themselves.

And so far, it seems, the doctors are winning.

The California Medical Association (CMA), whose top lobbyist sat next to Gov. Gavin Newsom at the infamous French Laundry dinner last fall, swooped in to slash a proposed hike on physicians’ licensing fees even though the board, which relies on those fees, is teetering on insolvency. It also beat back a proposal to put more non-physician members of the public on the board, which would have diminished the influence of the doctors who represent a majority.

“The strength and the power of the CMA is that they are able to deflect and obstruct the beneficial and necessary legislation to protect the consumer and to ensure the success of the medical board,” said former state Sen. Jerry Hill, who four years ago lost his push to overhaul the board. “That’s what I found, and that’s what I see occurring this year.”

This year’s bill was approved by the state Senate after it was amended under pressure from the doctors’ group. The measure is now before the state Assembly, where it remains a target of the California Medical Association. As currently written, SB 806 would authorize a smaller licensing fee increase, restore the board’s authority to recoup investigative costs from doctors who have been disciplined and create an independent monitor to evaluate the board’s complaint and disciplinary processes.

The mission of the medical board, composed of eight physicians and seven members of the public, is to license and discipline doctors. But critics say the board has allowed some doctors who have committed wrongdoing to keep their licenses, despite reports of egregious behavior, while families complain they’ve been left in the dark for years.

The board received 10,868 complaints in the 2019-20 fiscal year. During that period, it initiated 1,956 investigations, revoked 35 physician licenses, put 170 doctors on probation and reprimanded 108 doctors, according to the board’s 2019-2020 Annual Report. An additional 96 physicians surrendered their licenses.

In his independent review of cases that came before the panel last year, board member Eserick “TJ” Watkins told lawmakers the board had settled 84% of complaints, with a bias toward allowing doctors to continue to practice without real rehabilitation.

“This board’s value is we protect the doctors, and we’ll go over and above in order to do so,” said Watkins, one of the board’s members representing the public.

Earlier this year, the board’s executive director told lawmakers the board is taking longer to investigate complex cases than it did six years ago, in part because of more complaints and vacancies among the board’s support staff. In fiscal year 2019-20, those cases took an average of 548 days from start to end, he said, compared with 310 in fiscal year 2013-14.

Patients and their families who have testified at legislative hearings describe an unresponsive and uncommunicative board that usually allows doctors accused of negligence or malpractice to continue to practice.

“I thought there would be a lot of integrity and thoroughness to the investigation process, and I didn’t get a sense that the medical board really looked at the matter,” said Alka Airy, who in 2019 filed a complaint of unprofessional conduct and potential negligence against the University of California-San Francisco’s Lung Transplant Program after her sister, Shilpa Airy, died the year before.

According to the complaint, doctors who treated Shilpa Airy between 2015 and 2018 failed to evaluate how her lung failure affected her heart or refer her to a cardiologist. She died of end-stage heart failure while waiting for a lung transplant. Airy said the board closed the complaint without taking action. The board declined to comment.

By comparison, when Alka Airy filed a complaint with the California Board of Registered Nursing, she said, she was interviewed by an investigator who requested additional records beyond what the doctors or hospital may have provided. Airy said she is still waiting to learn the outcome of the case.

A UCSF spokesperson said its clinicians have fully cooperated with all investigators and could not comment on pending investigations.

“I think my experience was very similar to thousands of other folks who sent in complaints to the medical board,” Airy said. “It’s not a transparent process. So much happens behind closed doors.”

Board spokesperson Carlos Villatoro said the board bases its disciplinary decisions “on the facts and circumstances of each case” to determine whether revoking a physician’s license is necessary.

“The board does not have the authority to punish a licensee by imposing a level of discipline that goes beyond what is necessary to protect the public,” Villatoro said via email.

Advocates for patients and even some board members believe that tipping the board’s balance of power to public members could regain some of the public’s trust. But that provision was removed from this year’s bill after the California Medical Association argued the panel — like other comparable state boards — needed the expertise of people in the profession it regulates.

Dr. Howard Krauss, himself a former trustee of the CMA, has been on the board for eight years. In that time, he said, he’s never witnessed a decision that pitted physicians on the board against public members.

“The optics of having a board with one more public member than a physician might be of benefit,” Krauss said at an emergency hearing this month.

Critics say the board also lacks the resources and the ability to pursue timely investigations, hamstrung by a legislature beholden to the CMA, whose 50,000 pediatricians, surgeons and other physicians are influential members of every lawmaker’s district.

The California Medical Association is one of the most prolific campaign contributors in Sacramento and has given to Newsom and all but one of the 119 lawmakers currently serving in the state legislature.

In addition to making campaign contributions directly to lawmakers, the association spent $18.6 million between Jan. 1, 2011, and March 30, 2021, lobbying lawmakers and state agencies on a variety of issues, from flavored tobacco to medical malpractice caps, according to records filed with the California secretary of state’s office. It employs its own lobbyists and hires outside lobbying firms.

The group routinely scores access to the state’s top leaders. Among the movers and shakers at the French Laundry dinner party in Napa Valley in November were the association’s top lobbyist, Janus Norman, and CEO, Dustin Corcoran.

CMA spokesperson Anthony York said the organization is “like any other group in the Capitol” that advocates for its members. He said the $367 increase in licensing fees that lawmakers initially proposed — from $783 to $1,150 — would have been too big a burden on doctors who fought to stay open during the pandemic.

Family medicine physicians in California earned an average annual wage of $220,240 as of the first quarter of this year, according to the state Employment Development Department. “A lot of physician practices are struggling to keep their doors open,” York said. “Now is not the time for a fee increase.”

After state Sen. Richard Roth (D-Riverside) introduced the legislature’s must-pass bill to reauthorize the medical board in May, the CMA issued an “action alert” to its members, urging doctors to call, text and email their senators to voice their opposition. Eight days later, it declared a partial victory when Roth amended his bill to lower the fee increase to $863 and eliminate a requirement that the board be controlled by public members, a provision that had been backed by Senate leader Toni Atkins.

“While the bill is not perfect,” the association wrote on its website, the removal of those provisions “was a major victory.”

Despite repeated requests from the medical board, lawmakers haven’t approved a licensing fee increase in 16 years, even though the fees are the board’s primary source of income. The CMA agreed to the last fee increase in 2005 as part of a deal that also took away the board’s ability to recover legal and investigative costs for cases in which doctors had been disciplined.

York said the association remains opposed to the provision that would restore the board’s ability to recoup investigative costs and has concerns about the role of the independent monitor.

In its report to the legislature, the medical board projected it would be insolvent by the end of 2021-22 without an increase in licensing fees.

Doctors “just don’t want to pay for it,” said Bridget Gramme, an attorney at the Center for Public Interest Law at the University of San Diego School of Law. “What is the money going for? It’s going for a stronger discipline system, which they don’t want.”

Roth, who chairs the Senate Business, Professions and Economic Development Committee, said the CMA’s influence wasn’t the reason he amended the bill to reduce the fee increase. Rather, he said the board hadn’t justified the large fee increase — even though he included it in the original version of the bill — and could make do with a modest fee increase combined with better money management.

“Everybody had an opportunity to voice their perspective,” Roth said, pointing out that the bill still includes provisions that doctors oppose. “The goal is to make sure that we have a medical board that is functioning effectively and efficiently, that the enforcement process does the right thing at the right time for the right reasons, and that we squeeze every bit of operational efficiency that we can afford.”

As he watches from afar, Hill, the former legislator, said he doesn’t think the California Medical Association will give up until it kills every provision it opposes.

“This whole thing is part of CMA’s playbook. It’s how they operate,” Hill said. “They hire just about every available lobbyist in Sacramento to remove the rest of what was in the bill.”

New House, Senate Bills Aim To Make Telehealth Expansion Permanent In Medicare, Medicaid

New House, Senate bills aim to make telehealth expansion permanent in  Medicare, Medicaid | FierceHealthcare

Source: Fierce Healthcare, by Robert King

A pair of bills recently introduced in the House and Senate aim to ensure that a boom in telehealth use during the pandemic does not go away.

A House bill introduced Monday and a Senate bill introduced Tuesday both aim to make certain telehealth flexibilities permanent for Medicaid and Medicare beneficiaries.

“The pandemic has created challenges for everyone, but it’s also shown us that technology can provide safe and dependable communication between patients and their doctors,” said Rep. Jason Smith, R-Missouri, one of the co-sponsors of the House bill alongside Rep. Josh Gottenheimer, D-New Jersey. “Innovations including telehealth and audio-only capabilities will improve efficiency, reduce costs and increase access to healthcare providers.”

At the onset of the pandemic, the Centers for Medicare & Medicaid Services waived key barriers to telehealth use, enabling providers to offer audio-only telehealth services and ensuring that originating site requirements were removed. The new flexibility helped greatly expand the use of telehealth as providers could get Medicare reimbursement and help patients scared of going to the doctor’s office or hospital for fear of contracting COVID-19.

But the telehealth flexibilities will only last through the extent of the COVID-19 public health emergency, which will eventually lapse as the pandemic gets under control.

CMS officials have said that they need Congress’ help to make the flexibilities permanent.

The House’s Permanency for Audio-Only Telehealth Act would enable audio-only telehealth services for Medicare enrollees.

The legislation would also remove geographic and originating site restrictions to ensure that Medicare beneficiaries’ homes can be telehealth originating sites for audio-only services.

The Medical Group Management Association applauded the legislation.

“During the COVID-19 pandemic, audio-only visits have provided a lifeline to patients who are unable to attend visits in person or participate in telehealth visits due to lack of broadband access or necessary equipment to facilitate the visits,” said Anders Gilberg, MGMA’s senior vice president of government affairs.

The bill builds on similar legislation introduced in the House in March that would enable audio-only telehealth services for Medicare Advantage plans. Currently, providers can offer telehealth services under MA plans but only if they involve a video component.

Congress is not just looking at how to expand access to telehealth for Medicare.

Sens. Tom Carper, D-Delaware, and John Cornyn, R-Texas, introduced legislation on Tuesday that seeks to increase telehealth access for Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries, according to a report in Politico.

The legislation would require the Department of Health and Human Services (HHS) to give guidance to states to increase telehealth access for CHIP and Medicaid. This would include outlining what services can be reimbursed by telehealth.

The bipartisan nature of both the House and Senate legislation underscores the likelihood they could get through Congress and signed into law.

HHS Secretary Xavier Becerra has repeatedly underscored the need for legislative help if the boom in telehealth wants to continue.

“COVID has taught us so much,” Becerra said during his confirmation hearing in February. If we don’t learn from COVID how telehealth can save lives then we are going to be in trouble.”

Last Updated 10/20/2021

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