Healthcare Policy Changes. Focus Area Roundtable. HCEG. HealthCare Executive Group. Regulatory. Regulations. Policy. Mandates. Interoperability. Data transparency. Non-Compliance.

Impact of Healthcare Policy Changes & New Regulations – Healthcare Leader Insight & Opinions

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With the new presidential administration, staying abreast of and responding to new and changing healthcare policy changes, legislation, and regulatory activities is more important than ever. And with uncertainties about the longevity and true value of changes forced by the pandemic, the ease in which nontraditional businesses are entering the health care space, and increasing opportunities for employing technology, learning how other health plans, health systems, and healthcare provider organizations are addressing these regulatory and policy impacts affords unique value to healthcare executives.

On Tuesday, May 26th, 2021, a dozen senior executives serving the healthcare industry gathered for our second Focus Area Roundtable on Healthcare Policy & the ACA. In this session moderated by HCEG Executive Director Ferris Taylor and supported by Kevin Deutsch, General Manager & SVP of Health Plan Cloud at Softheon – our Focus Area Partner for Healthcare Policy & ACA – attendees were presented with four questions on which to share their insight, ideas, and questions for each other.Healthcare Policy Changes. Focus Area Roundtable. HCEG. HealthCare Executive Group. Regulatory. Regulations. Policy. Mandates. Interoperability. Data transparency. Non-Compliance.

Highlights of Healthcare Policy Changes – Focus Area Roundtable #2

This post shares some highlights of participants’ responses to the questions shared by Ferris and information shared by Kevin.  Access Healthcare Leaders Focus on Healthcare Policy & ACA – a recap of the 1st Focus Area Roundtable on Healthcare Policy & ACA and read on for more information on participating in future Focus Area Roundtables.

The roundtable kicked off with Ferris asking attendees: What are your expectations for healthcare policy changes over the next 2 to 4 years?

One participant suggested that the most important regulatory/policy areas for the government would be to set clear requirements and clarify the compliance details around interoperability and data transparency.  Policies to encourage and support digital health initiatives that address the practical flow and exchange of data – from the point of view of the regular doctor and patient – were identified as most important. Generating and consuming machine-readable data that includes prices healthcare providers negotiate with payers was identified as a primary challenge – particularly given the reluctance of payers and providers to publicize that type of data. Discussion continued on transparency mandates and policies.

A Backlash for Non-Compliance with Transparency Regulations?Healthcare Price Transparency Focus Area Roundtable

One provider participant suggested the current level of ambiguity regarding the type of pricing information hospital facilities must share, along with the relatively low current penalties for not meeting the requirement, might drive some organizations to simply face the potential cost of penalties versus the cost and implementation challenges associated with compliance. Attendees noted that costs and potential negative impact associated with disclosing contracted prices could be greater than the penalties of non-compliance. In the end, leaders of provider organizations must weigh the potential backlash of non-compliance against meeting detailed requirements of the regulations.

RELATED: Join us for our 2nd roundtable on Price Transparency on June 16th, 2021 at 10:00 AM PT / 1:00 PM ET

Ferris asked participants to share their insight on what the implications for non-compliance might be for the consumer.

A chief executive officer shared that he honestly could not assess how much, if any, of a consumer impact there might be due to current levels of skepticism about the utility of price transparency shopping tools. He noted recent research suggesting that, even if granted more information, people are not very good shoppers of healthcare services. He noted recent, direct experience in reaching out to health plan members with information on the potential to save over $1000 on an imaging exam where only 30% of the consumers accepted the recommendation with the balance going with their originally prescribed venue.

Participants noted that this reluctance from healthcare consumers might change over time and that healthcare organizations need to focus on educating and supporting consumer acceptance and usage of price transparency tools.

Bipartisan Support & Permanency of Pandemic-Induced Healthcare Policy Changes

A CEO participant shared that he was not very optimistic about significant changes to popular areas of policy such as Medicare Buy-In, Public Option, and Medicaid Expansion.  He suggested that the focus would be more about bipartisan issues as opposed to those demanding substantive partisan agreement. Drug pricing was noted as one bipartisan issue that may see some change.

Another area of the discussion centered on the permanency of policies that were temporarily reversed over the last year during the course of the pandemic. Policy extensions for things that probably should have been fixed long ago, telehealth for example which took a pandemic to shine a light on, would likely be made permanent.

Permanency & Impact of Policies Regarding Open Enrollment, Subsidies, & COBRAHealthcare policy changes and regulations. ACA open enrollment subsidies, single payer, public option, Medicare/Medicaid buy-in, block grants, CMS Interoperability and Patient Access

Ferris noted how open enrollment for individual markets had been extended and that eligibility for and levels of subsidies provided to individual members using ACA marketplaces has been expanded over the last year. Ferris queried participants as to whether those policies might be made permanent and what impact might result from reverting back to previous subsidy determinations as compared to the current environment where a million new individuals have enrolled into the ACA Marketplace.

Open enrollment policies were raised by one attendee as conditional based on employment levels and likely influenced by state-level needs and policy determinations.

While one participant noted the potential for more permanent changes to eligibility for subsidies and the level of subsidies, that participant also noted that subsidies related to COBRA coverage would likely not be made permanent because COBRA is directly impacted by the dynamics regarding unemployment and the need for coverage extension.

Impact of Open Enrollment & Subsidies on Underwriting & Reconciliations

Given mid-year changes to open enrollment periods and subsidy levels, a high degree of uncertainty as to what health plan populations look like can exist – all while health plans are building packages for the next benefit year. One participant shared that extended open enrollment periods introduce a variable that plans haven’t seen before and are likely to produce underwriting challenges for health plans in 2022 and beyond.

‘You’re never really closing the books on the one year before you’re getting ready to reload for the next year.’ – Roundtable Participant

RELATED: Healthcare Policy, ACA 2.0, Enrollment Period Lessons, & The Journey to the Exchange

Potential Areas for Healthcare Policy Changes & New Regulations

A number of areas were identified as top of mind for both health systems and health plans and ripe for new regulations and development of formal policies:

  • Payment parity for telehealth services
  • Removal of barriers to site of service and venue for telehealth engagement
  • Alternative payment models
  • Quality measures
  • Health equity
  • Holistic/whole-health care delivery

Cost of Care: A Failure of the ACA & Political Platform in 2022 & 2024?

Regulations and policies regarding eligibility for subsidies and their levels were noted as a symptom that the ACA, while it did a good job addressing coverage, didn’t really address the cost of care. While the cost of premiums can be controlled through greater subsidies, doing so doesn’t solve the problem. The problem is that health care costs too much and that’s driving either premiums up or subsidies up, neither of which are good.

One participant noted that the entry of non-traditional market participants like Amazon are just the results of not addressing the cost of care through the ACA over the last decade.

As one participant asked: ‘Can we really expect the current structure of the federal government to make major policy changes that might affect the cost of care?’ Another participant added: ‘While it may not happen this year or next, it’s possible that you’ll see the political parties run specifically on a cost of care platform for 2022. And certainly for 2024.’

Technology as a Force Multiplier to Address Healthcare Policy Changes

Ferris asked panelists what they see as the role of technology in addressing policy changes and how technology will make an impact beyond the ACA – to consumers, providers, health plans, payers, and hospitals.

One participant’s response:

‘I’m seeing technology as a force multiplier in a competitive advantage – a leveraging of clinicians whether they are acting as a call center coach or a nurse navigator. That model is tough to scale and so clinicians are best focused on high clinical acuity and complex care. And where we’re seeing technology best applied is where it’s being leveraged from a preventative, chronic care, and wellness perspective. You can engage more members and have a personalized experience across a broader swath of either membership and/or lines of business as well as it being a personalized experience.

And that includes leveraging remote patient monitoring capability, wearables, Etc. And so right now for a commercial line of business, you can do, for example, digital coaching and get reimbursed for it. But when it comes to government programs, that’s not been in effect yet. So, I think, as it becomes more commonplace in the commercial market in evolution it will be more common in government programs.’

No Area of Healthcare Will Be Untouched by Technology

A health plan chief executive officer shared:

‘It’s hard to think about any area that won’t be touched by technology. I think technology is going to reinvent the shopping experience in healthcare for both obtaining health insurance as well as care delivery. If we wonder what technology should do, we have to realize that Amazon is a technology company that brought the store to the house. And Netflix is a technology solution. And Uber is a technology solution. So why would we think that isn’t going to happen in healthcare, both on the plan and the care delivery side? I think technology is already revolutionizing care delivery so that much of it can be provided in the home if people want it there, or in the cloud.’

The participant went on to share additional insight on technologies likely impact on shopping, care delivery, and drug development.

RELATED: Healthcare Price Transparency – Leaders Share Insight – Part 1

Need for Ubiquitous Access to Healthcare Services & User Acceptance of Technology’s Limitations

One attendee commented about the need for ubiquitous access to healthcare services in all locations – urban, suburban, and rural – and the growing acceptance of technology-related glitches by healthcare consumers:

‘And the other thing that I really see that I think technology is going to go ahead and really flourish is that when you think about what happened with the pandemic and with people going ahead and deciding to work remotely; for some of them to flee the city’s and go to places where they may not be directly surrounded with a lot of health care options. They’re going to want to have the convenience of obtaining health care through technology because they’re not going to be so close to healthcare service options anymore.

I also see the attitude right now that when people used to say: ‘OK, there was something wrong with the technology and I’m not going to use it.’ Now they say: ‘Okay, well that’s just part of the package, something’s going to happen. There’s going to be a glitch but that’s just part of it’’ And they accept it. So, I think that with more of that type of acceptance, more and more people are just going to, as far as physicians and everyone’s health systems, are just going to accept it.’

Disintermediation – Patient, Physician/Provider, or Payer – All Others BewareHCEG Healthcare Policy Patient Payer Physician Provider Triangle

A chief executive officer of a provider organization offered that there’s going to be a lot of disintermediation between the real customer who’s the patient, the provider who’s the physician, and the health plan who’s the payer. He believes this because the information that’s available via personal digital tools and the movement to at-home care are going to really empower patients – i.e., consumers – to do a lot better with their health. He stressed the importance of focusing digital solutions on what providers and patients need – not on supporting the economics of the healthcare model.

He described a triangle of who’s paying, who’s getting the care, and who’s providing it and opined that companies not in that triangle are going to be disintermediated over the coming years.

Join Our Focus Area Roundtables

If you’re an executive/leader of a health plan, health system, or healthcare provider organization, consider joining one or more of our Focus Area Roundtables. In addition to Healthcare Policy & ACA, we currently have roundtables on Price Transparency, Interoperability, Next Gen/Value Payment Models, M&A/Joint Ventures and are establishing others based on 2021 HCEG Top 10+ focus areas.Join HCEG and/or participate in our Focus Area Roundtables

Complete this short form to share the focus areas you are interested in and how you’d like to participate with the HealthCare Executive Group. We’ll get back to you with information on participation.

For more insight and information on the challenges, issues, and opportunities facing healthcare leaders, subscribe to our newsletter and connect with us on Twitter and LinkedIn.Healthcare Executive Group Focus Area Partners HealthSparq Softheon Surescripts Zelis

Insight on Using Data & Analytics to Address Healthcare Consumer Needs. HCEG Top 10. Member Data. Insights. Pre-Authorization Process. HCEG. WHCC.

Insight on Using Data & Analytics to Address Healthcare Consumer Needs

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Health plans have more data and analytics than they typically know what to do with.  The challenge is to use new types of data and advanced analytics like artificial intelligence and machine learning to derive insights and actionable information that all stakeholders – healthcare consumers, providers, and payers – can use to facilitate access, improve outcomes, and reduce costs. It’s no wonder that Data & Analytics consistently ranks high on the annual HCEG Top 10 list of challenges, issues, and opportunities facing healthcare leaders.

On Wednesday, April 28, 2021, HCEG Executive Director Ferris Taylor moderated “Use Data to Uncover Insights and Create Actionable Strategies that Address Member Needs,” a webinar hosted by our partner World Health Care Congress with the following healthcare leader panelists:

This post shares highlights of some of the insight, expertise, and experiences shared by the above executives during the webinar. Access a recording of the webinar here and hear from the panelists themselves at the [specified recording time] listed with each of the session highlights presented below.

Strategic Focus on Using Data & Analytics to Find New, Actionable Insights

Ferris Taylor kicked off the discussion by asking panelists to introduce themselves and to share, from a strategic point of view, a quick overview of how they are using data and analytics to find new and actionable insights.

Leveraging Social Determinants of Health

Sherri Zink shared her organization’s focus on improving member engagement by leveraging different data across multiple silos – including social determinants of health data from 3rd parties – to help providers engage with plan members on a more holistic basis.  Listen at [00:04:41]

Anticipating Member Needs & Personalizing Interactions via Workflow

Shawn Wang offered how his health plan is better anticipating members’ needs and personalizing interactions via existing workflows.  Listen at [00:07:30] for more on:

  • Importance of embedding data and AI insight into workflows
  • Personalizing member interactions with personalized care plans, personalized news, and personal topics that address member needs.
  • Reducing overall burden by removing complexity from staff member jobs

Earning Trust of Members By Giving Them Something in Return

Mohammad Jouni shared how technology partners can support health plan member’s medical needs and administrative needs as members are interacting with health plans during other customer service events. Listen at [00:09:37]

RELATED: Leadership, Trust & Skills in Overcoming Obstacles to Radical Innovation in HealthcareInsight on Using Data & Analytics to Address Healthcare Consumer Needs. HCEG Top 10. Member Data. Insights. Trust. Process. HCEG. WHCC.

Uncovering Insights & Actionable Information: Opportunities, Challenges, & Points of Pain

Panelists shared information on the pain points and challenges that their health plan or health plan customers have addressed or still trying to address in making data and analytical tools actionable to support the relationships between the health plan, the consumer, and the provider.

Supplying Business Partners with Meaningful, Actionable Data

Sherri conveyed the importance of taking advantage of teachable moments during member interactions with customer service, capturing and leveraging unstructured data presented during interactions, and making data and analytics available in downstream systems and to provider partners. Listen to Sherri at [00:12:22]

Importance of Thinking About Data from Standpoint of Member, Not the Organization

Many health plans organize their company by functions and not around the member. Shawn shared his thoughts on the importance of a cohesive, end-to-end process, using data from the member’s viewpoint and not from an organizational standpoint, and embedding data and analytics into organizational workflows.  Shawn shares at [00:17:30]

Importance of Member Trust & Trust in the Process

Mohammad talked about the need to earn member trust and how vendors who establish trust with plan members can do a lot for the member that health plans or providers might otherwise not easily accomplish.  Listen at [00:33:33]

Applications Having Greatest Impact from Data & Analytics

Sherry shared insight on what applications are having the greatest impact from improved data and analytics, the need for member trust, and how Net Promoter Scores are impacted. Listen at [00:36:13]

Major Impact on Reducing Duration of Pre-Authorization Process

Shawn shared how high-volume, complex back-office processes like pre-authorization and other utilization management functions benefit greatly from improved data and analytical capabilities. Listen at [00:40:48]

RELATED: Healthcare System Interoperability – The Key To The Care We All Strive For

Vendor Interactions Impact on Health Plan Member Satisfaction

Mohammad stated that closing gaps in care is one of the areas seeing the greatest impact from data and analytics. He noted how new insights on member needs and member interactions with 3rd party vendors and their offerings are positively impacting plan member satisfaction and trust. Listen at [00:43:55]

Integrating New Data into Analytics and Tools Provided to Providers and Consumers

Ferris stated that there are lots of different tools out there and that it seems like data and tools are multiplying every six months. Ferris asked: As health plans, how are you integrating new data into the analytics and the tools that you’re providing to your consumers?

LISTEN to Sherri’s thoughts on the following topics at [00:46:55]

  • Insight on downstream operational systems and legacy applications
  • Making sure data produced in upstream systems is available in downstream operational systems
  • Mapping clinical data, financial data, administrative data – structured & unstructured – on-premises & cloud-based
  • Integrating 3rd party data – particularly social determinants of health

LISTEN to Shawn’s thoughts on the following topics at [00:49:43]

  • Organizing and consolidating data – Key to scaling integration capabilities
  • Capturing insight from audio interactions & acting on that insight near real-time
  • Updating analytic models frequently and timely deployment to downstream systems

RELATED: Healthcare Price Transparency – Leaders Share Insight – Part 1

Attendee Questions on Using Data & Analytics to Create Actionable InsightInsight on Using Data & Analytics to Address Healthcare Consumer Needs. HCEG Top 10. Member Data. Insights. Trust. Process. HCEG. WHCC.

Panelists had an opportunity to respond to questions from webinar attendees. Listen in at [00:53:44] to hear panelist responses on questions pertaining to the following:

  • Co-developing a data & analytics strategy with business partners
  • Defining and ranking use cases across all business units
  • Accommodating member/patient communication preferences
  • Example of addressing high-utilizer of ER services
  • Avoid taking a cookie-cutter approach

Panelists Leaders Share One Piece of Advice on Leveraging Data & Analytics

Ferris concluded the discussion by asking panelists to share one piece of advice on the broad topic of data and analytics. Listen at [01:01:58] for panelists responses on the following topics:

  • Ensure alignment with overall strategy & think through the end-to-end process
  • Start with the outcome you want to achieve
  • Demonstrate value early on

Opportunities for Insight and Interaction with Healthcare Leaders

2021 HCEG Top 10+ Focus Areas Interoperability Healthcare Policy

For more insight and information on the challenges, issues, and opportunities facing healthcare leaders, subscribe to our newsletter and check out these on-demand webinars from our partner World Healthcare Congress.

You may also consider joining other healthcare executives and thought leaders for one or more of HCEG’s Focus Area Roundtables. We currently have roundtables on the 2021 HCEG Top 10+ focus areas highlighted in the graphic below and are adding more.

Complete this short form to share which focus areas you are interested in and how you’d like to participate with the HealthCare Executive Group.


Price Transparency Compliance Regulations Mandates. Policies, programs, and tools. Data standards. Operational considerations. Increasing adoption. End-user education and support. Payer-provider relationships.

Beyond Price Transparency Compliance – Stakeholder Thoughts – Part 2

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The Transparency in Coverage Mandate and the No Surprises Act are forcing health plans, health systems, healthcare providers to focus their attention and already overburdened resources on price transparency compliance-related activities. While price transparency mandates and regulations are intended to help make healthcare better and more cost-effective for health plan members and healthcare provider’s patients, there are strategic and tactical reasons to holistically address the following aspects of price transparency:

  • Policies, Programs, & Tools
  • Data Standards, Data Collection & Operational Considerations
  • Increasing End-User Adoption
  • End-user Education & Support
  • Payer-Provider Relationships

In the first post of a two-part series, Healthcare Price Transparency – Leaders Share Insight – Part 1, highlights from our first Focus Area Roundtable on Costs & Transparency held on April 5, 2021 were shared. HCEG members working for health plans, healthcare providers, and healthcare-related technology/service organizations shared their responses to some questions presented by Andy Hoffman and Matt Parker, two thought leaders with our 2021 Focus Area Partner for Costs & Transparency: HealthSparq.

Stakeholder Adoption, End-User Support, & Payer-Provider Relationships

In this second post, comments and insights from Focus Area Roundtable participants on the following aspects of price transparency are presented:

  1. Increasing stakeholder adoption of price transparency tools and services
  2. The importance of end-user education and support
  3. Payer-provider relationships to support access to price transparency information

RELATED: Understanding the Transparency in Coverage Mandate

Increasing Stakeholder Adoption of Price Transparency Tools

I think the concept of just being a liaison will go a long way on either side through this process. (Health Plan)

Go into the prescriber’s workflow with price transparency, going to the physician’s workflow with pricing information that not only saves the system money but that directly affects the consumer in a way that is frictionless. (Industry Analyst)

Whenever these conversations come up, taking a step back and saying [asking] Who’s going to benefit the most? And by that, I mean not just like the individual or the entity but the health system at large. If it doesn’t really waterfall to the whole cost of care and care opportunities, then we’re probably just clogging up the system. Who’s this going to piss off? Who’s going to lose from that deal? Companies taking rebates are going to lose. Companies overcharging and hiding pricing are going to lose. Intermediaries who aren’t necessary may lose. (Industry Analyst)

We’ve kind of assumed that we have to have all of these systems connected and all this interoperability wired in order to do that. But I’ve seen some really successful approaches and getting information into the decision maker’s hands that benefits the end consumer of health. (Industry Analyst)

Take something like hip and knee replacements. There’s an awareness of ambulatory participation, acute participation, post-acute participation on a couple of levels whether that’s brick and mortar and or home on the post-acute side. (Technology Provider)HCEG Focus Area Roundtable. Costs & Price Transparency. Compliance Regulations Mandates. Policies, programs, and tools. Data standards. Operational considerations. Increasing adoption. End-user education and support. Payer-provider relationships.

Health Plan, Health System, & Healthcare Provider Leaders – Click on the Above to Join a Focus Area Roundtable

Importance of End-User Education and Support for Price Transparency

Price transparency has different meanings to different people depending on their roles and expectations. (Provider)

I think hospitals will have to somehow educate patients and that can come in different forms. And whether it’s on a one-on-one setting or more about broader communication, there is an element of patient education that will need to happen. It’s going to be a lot more complex because it’s going to also have to account for the impact of the health plan. So, the education component is going to be large. (Industry Analyst)

I think the reality is most of us don’t really want to solve the problem in terms of us being the recipient of care. So, if I’m a patient, member, consumer, employee, I want the system to fix these things. I want my health plan that I signed up for to be smart. I want my doctor to have information and just do stuff that doesn’t cost me excess money. I want my pharmacist. (Industry Analyst)

We’re in rural areas so that’s a big, big challenge for us. But what does it mean to the consumer? Do they think that when they go in and try this tool that they’re going to understand precisely what the cost of their knee surgery is? And then is it going to be a big dissatisfier when they learned that surgeon had to do something more, or it was more complex than they originally thought? And as a result of that, they disengage. So, will this help or harm them? (Health Plan)

And then there’s the component of things that even an educated consumer might not know about like the anesthesiologist in the acute setting which rarely gets talked about. And then a bill shows up, let alone the medications that are incurred post-acute. (Technology Provider)

We also have a couple, sort of, denominators there. Am I able to figure this out on my own? Do I have search skills? And EOB skills? And ICD-10 code skills? And then the other is: Am I on Medicaid or sort of a capped model where what do I care about the price? (Industry Analyst)

Patient-Physician Relationships May Offset Price Transparency Benefits

I think it’s a personal thing. For surgeries you develop a relationship with your physicians so even if you see a great price somewhere else, I don’t think that people would jump out to go have say like a knee replacement or shoulder replacement or something even more critical with another physician somewhere else. (Provider)

If they have a relation, they tend to sort of stick with what they know. The people that would make the change are not the people that we would see price making the decision from a true consumer choice perspective but those that are just utterly desperate and have, maybe require something that they can’t otherwise get at which is, again, not part of, not really the spirit of the law, per se. (Health Plan/Provider)

RELATED: Healthcare Leaders Focus on Healthcare Policy & ACA

Payer-Provider Relationships Impacts from Price Transparency Compliance

How do you see the relationship between payers and providers in the space of both informing about price transparency but also making sure that the messaging is consistent? Because again, your got contract disputes and a lot of the No Surprise Act is going to come around contract disputes. (Technology Provider)

This [price transparency] could change the relationship between the provider and the payer. And we’re already seeing a lot of movement around mergers and acquisitions and perhaps this would incent that kind of behaviors further – or maybe not. But I think there will be some sort of macro-level impact as this becomes more widespread. (Health Plan)

Well, I think when it comes to that relationship of payer and provider, one key element that’s going to go a long way actually is support. And support probably more for the hospital side because there’s an element of an IT integration of the back end that you have to think about. And how does it all fit together? And what codes they have to integrate through? (Thought Leader)

Join a Focus Area Roundtable – Connect with Healthcare Peers

Additional Focus Area Roundtables on Costs & Transparency – and other 2021 HCEG Top 10+ focus areas such as Healthcare Policy & ACA, Interoperability, and M & A /Joint Ventures, among others – will take place throughout 2021. If you are interested in participating, reach out to us via email or complete this short form to indicate your interests.

To receive recaps of our Focus Area Roundtables and other information of potential use for leaders of health plans, health systems, and healthcare provider organizations, join our newsletter.

Healthcare Price Transparency Price Transparency Regulations & Compliance, Policies, Programs, & Tools, Data Standards & Operational Considerations

Healthcare Price Transparency – Leaders Share Insight – Part 1

By | Events, Resources | One Comment

Healthcare price transparency has a lot of attention and focus right now, especially in the mandate-driven space. But addressing price transparency via compliance with regulations is just a portion of what health plans and healthcare provider organizations should be focusing on to help make healthcare better and more cost-effective for their members and patients.

In our first Focus Area Roundtable on Costs & Transparency held April 5, 2021, a group of HCEG members working for health plans, healthcare providers, and healthcare-related technology/service organizations gathered to discuss some of the challenges, issues, and opportunities associated with addressing price transparency.

Challenges, Issues, & Opportunities Beyond Price Transparency Regulations

Andy Hoffman and Matt Parker, two thought leaders with our Focus Area Partner HealthSparq, shared a timeline overview of the Transparency in Coverage Mandate and the No Surprises Act and facilitated the following questions:

  • How are you thinking about price transparency within a rather heavily regulated space?
  • What do you see as key issues and risks in the price transparency space? What’s the role of the 80/20 rule?Healthcare Price Transparency Regulations & Compliance, Policies, Programs, & Tools, Data Standards & Operational Considerations
  • How can we really focus on what health plan members and provider patients need to make good health care decisions, knowing that members and patients often have to navigate in antagonistic payer-provider environments?
  • How can we balance supporting patient needs and operate as an ongoing business while also informing people what things are going to cost before they have to spend unlimited amounts of money?
  • What unique challenges or strategies are you thinking about with respect to price transparency? And what opportunities are you looking to take advantage of regarding price transparency?

This post shares insight and information shared by roundtable participants on the above questions pertaining to the following categories:

  1. Regulations and compliance including their importance and value to various stakeholders
  2. Price transparency policies, programs, and tools
  3. Data standards and operational considerations to advance price transparency

A second post highlighting participant responses pertaining to the following categories will be shared shortly:

  1. Increasing adoption and the importance of end-user education and support
  2. Payer-provider relationships to support access to price transparency information
  3. Advancing healthcare price transparency and next steps

RELATED: Healthcare Leaders Focus on Healthcare Policy & ACA

Thoughts on Price Transparency Regulations & Compliance

As a payer and provider, I can look at other hospitals across the state and they’re not even using our latest pricing. They’re just putting something out there to meet the requirement. So, if there’s not consistency in the data, it doesn’t actually help anybody. It just creates profound confusion. (Health Plan/Provider)

Some of the things that I hear my peers talk about is: Are we just solving certain regulatory requirements or are we solving something members think they want but won’t actually be able to use in an effective way?  Or are we on a road to something that will be of value to all the parties involved? (Health Plan)

So, what are the different things people are putting out there? How do we then know this is the best? This is what we should be doing versus this is what we are doing. Because I think everybody is just trying to meet the intent of the law or the letter of the law, but a lot of people don’t know how. And so, I think that’s one of the things that we’ve got to [consider] if there’s anything we can do. (Technology/Service Provider)

These are people who are sick and injured and hurt and need health care. And we’ve got to do our part to help them out and we can do that in a way that drives our overall business priorities. This sets the floor. We talk about these mandates being a floor and you build an experience on top of that that supports your member needs and supports your patient’s needs. (Technology/Service Provider)

So, I think it’s a good thing that the conversation has started. But I think that the end product is going to be significantly different from what it is that we’re looking at this point. (Health Plan)

I feel like the price transparency is just a way to get our prices out there – for the most part as individuals [procedures]. Unless it’s very comparative in descriptions, information is really hard to compare apples to apples between hospitals. (Provider)

Healthcare Price Transparency Policies, Programs & Tools

Whenever I used to roll out tools and or guidance, probably two decades ago and in more than one state, you have to understand the nature of what it is that your end goal is. And sort of work backward from that. But just sort of putting some things out there, you end up getting exactly what you put into it. (Health Plan/Provider)

For a lot of these hospitals, putting out their prices shows major vulnerabilities for them when it comes to inappropriate pricing, when it comes to the contracts that they’re having. It does highlight the contracts that they have with their different vendors. (Technology/Service Provider)

I think some plans are in sort of this game of chicken to some extent because the No Surprises Act isn’t finalized yet. (Technology/Service Provider)

And how can we give voice to that as part of the overall conversation with the administration because I think they’re trying but they’re sort of missing the point. So, I think it’s incumbent upon us as an industry to start to respond back on all of those fronts as to how best to rethink how to do that since it started out previously and it’s been through lots of different iterations. But that lack of standards or consistency is just…(Health Plan)

Price Transparency Data Standards & Operational Considerations

From the payer or provider perspective, without somewhat more explicit data structure guidance across the board, it’s [price transparency mandate] not helpful. (Health Plan/Provider)

We need a standardization so that everybody can follow that. (Provider)

I don’t think you can do comparisons. It’s not the latest data. It’s not even the same from hospital to hospital. It’s kind of all over the place. (Health Plan/Provider)

So as an industry, I think whether that’s vendor-specific or provider, payer, or even consumer, I think I’d like to see a conversation around how do we drive to those data standards? (Health Plan/Provider)

I would agree that the majority of people and hospitals are doing that [trying to comply in good faith.] They don’t collect the data internally in ways that’s terribly helpful. So, to publish it [price transparency information] requires an infrastructure that frankly many of them don’t have in a way that makes it useful as say maybe a payer would. (Health Plan/Provider)

Healthcare is local, that’s very much true. So that’ll impact the dynamics and the impact of what price transparency brings to the table. (Thought Leader)

There are operational challenges that we have to address and plan to address to be compliant with the new regulations that the question becomes: How will this look and feel to the consumer because pricing can vary so significantly? (Health Plan)

One of the challenges that we see when we engage with plans is: Who are the folks and entities within the organization that are trying to solve this problem? We’ve got to get fee schedules from your contracting folks, and you need member eligibility and claims verification. You had to pull all these different systems together and that’s been one of the things we’ve seen as a big challenge – especially with bigger payers, these big vast entities that have to solve these problems with groups that really hardly ever talk to each other. (Technology/Service Provider)

Join a Focus Area Roundtable – Connect with Healthcare Peers

Additional Focus Area Roundtables on Costs & Transparency – and other 2021 HCEG Top 10+ focus areas such as Healthcare Policy & ACA, Interoperability, and M & A /Joint Ventures, among others – will take place throughout 2021. If you are interested in participating, reach out to us via email or complete this short form to indicate your interests.

To receive recaps of our Focus Area Roundtables and other information of potential use for leaders of health plans, health systems, and healthcare provider organizations, join our newsletter.

Healthcare Policy ACA Focus Area Roundtable. Medicare/Medicaid beneficiaries. Health Insurance Marketplace. HealthCare Executive Group HCEG. Softheon. American Rescue Plan (ARP). Expanded APTC Eligibility and Subsidy Amounts May Drive Individual Market Growth. real-time prior authorization requirements.

Healthcare Leaders Focus on Healthcare Policy & ACA

By | HCEG Content, Research | 3 Comments

Early indicators of healthcare policies’ prioritization, implementation, and/or likelihood of success can provide a head start to healthcare organizations – particularly those serving Medicare/Medicaid beneficiaries and those operating in the Health Insurance Marketplace or looking to join the Marketplace in 2022. It is in that spirit that the HealthCare Executive Group (HCEG) has created Focus Area Roundtables to promote dialogue among HCEG members on important 2021 HCEG Top 10+ priorities. This post shares highlights of the initial online discussion about Healthcare Policy & ACA and presents additional information regarding future Focus Area Roundtable discussions.

See below for Additional Focus Area Roundtables Currently Being Assembled

Healthcare Leaders Discuss Healthcare Policy & ACA

On March 11th, executives from mid-sized health plans (MSH), an integrated delivery system (IDS), a national specialty care provider (NSP), and a not-for-profit consortium focused on advancing healthcare data and technology transformation (EDC) participated in the roundtable. In a roundtable fashion, these leaders shared their thoughts, ideas, and concerns on Healthcare Policy & ACA and forecasts for how the Biden administration may reshape the American healthcare ecosystem for the years to come.

The session was moderated by HCEG Executive Director Ferris Taylor and supported by Kevin Deutsch, General Manager and SVP of Health Plan Cloud at Softheon, the 2021 Focus Area Partner for Healthcare Policy & ACA.

What are your healthcare policy & ACA-related priorities, thoughts, and concerns?

Dealing with volume and uncertainty of healthcare policy and regulations amid rapidly changing and often unstructured government programs: ACA enrollment/subsidies, single payer, public option, Medicare/Medicaid buy-in, block grants, CMS Interoperability and Patient Access, etc.It was noted that no one has a crystal ball and none of the participants were “inside” of the administration, so discussions of this type help to develop the ability to respond to the many uncertainties.  The needed speed of learning and agility to respond to changes in healthcare policy is the “new normal.”  Specific perspectives were exchanged among the roundtable participants.

MSH: Expressed concern on how to keep premium costs down for members who are largely low-income.

NSP: With $2 billion at risk in value-based programs and whose patients are mostly Medicare beneficiaries with multiple comorbidities, healthcare policy needs to:

  • Facilitate cost-effective access to coverage for Medicare and other beneficiaries.
  • Establish reasonable value-based programs and not just push out a bunch of voluntary risk-sharing programs long on objectives but short on details.
  • Support coverage and payment for virtual care, particularly remote monitoring.

EDC: Shared that consortium members have noted that recently passed rules on Interoperability and Information Blocking are top of mind. These two areas of regulation and the advent of technology standards like FHIR and code sets such as LOINC, SNOMED, and others are helping to establish a common language and ‘gauge’ to help providers to speak the same language – particularly with payers.

What components of the recently passed American Rescue Plan (ARP) are most promising to you?

MSH: As a health plan, we struggle to address premium affordability and overall cost to the member and aim to keep increases to premiums at inflation or lower. Additional costs beyond the member premium often prevent members from accessing needed care. While the pandemic did not materially impact our overall member count, it did impact the composition of members as the number of commercial members decreased while Medicaid members increased.

NSP: Mentioned the need for providers and supply-side organizations to better understand the true cost of the services and products and services they provide. And another participant noted experience with a wide variety of costs and outcomes for services provided to seemingly similar patients.

FACT SHEET: American Rescue Plan and the Marketplace

What are ARP’s Immediate, Mid-Term, & Long-Term Benefits?

Healthcare Policy ACA Focus Area Roundtable. Medicare/Medicaid beneficiaries. Health Insurance Marketplace. HealthCare Executive Group HCEG. Softheon. American Rescue Plan (ARP). Expanded APTC Eligibility and Subsidy Amounts May Drive Individual Market Growth. real-time prior authorization requirements.All participants agreed there is a large and immediate benefit associated with ARP funding for vaccine-related availability, administration, and tracking.

NSP: Increased funding of COBRA premiums at 100% through September 2021 and increases to Medicaid funding seem to be a positive, as more unemployed people will be less likely to forgo or delay needed care.

Longer-term benefits from the funding and attention drawn to mental health services by the ARP were also noted. One participant called out how historically low funding and the stigma associated with mental and behavioral health services has led to a large, undiagnosed population. The need to invest more in mental health now is needed to save more serious issues later.

EDC: Consortium members have noted the importance of funding and policy related to community health centers and the need for policy and standards related to the collection and use of Social Determinants of Health (SDoH) – particularly for Dual-Eligibles.

Softheon’s Kevin Deutsch noted that changes to ACA subsidy thresholds and payment amounts brought about by the ARP will further complicate reconciliation and payment challenges. And that additional changes to subsidies and cost-sharing reductions by the Biden Administration will likely happen, further complicating these already non-trivial plan administration and payment reconciliation challenges.

RELATED: Expanded APTC Eligibility and Subsidy Amounts May Drive Individual Market Growth

Topics for Next Healthcare Policy & ACA Focus Area Roundtable

Healthcare Policy ACA Focus Area Roundtable. Medicare/Medicaid beneficiaries. Health Insurance Marketplace. HealthCare Executive Group HCEG. Softheon. American Rescue Plan (ARP). Expanded APTC Eligibility and Subsidy Amounts May Drive Individual Market Growth. real-time prior authorization requirements.As the allocated time for the roundtable flew by, Ferris moved to close the inaugural Focus Area Roundtable by asking participants what was top-of-mind in regard to Healthcare Policy & ACA and what participants thought would be the most important topics for the next roundtable. Topics raised by participants as having potential value to other HCEG members, that might be addressed in future roundtables, and would benefit from Softheon’s experience and views across their customers include:

  • Addressing policy/regulations in regard to controlling costs – particularly for high-need, high-cost members/patients.
  • Challenges, issues, and opportunities related to direct provider contracting and value-based payment arrangements.
  • Understanding and addressing costs related to internal operations and process modifications.
  • Sharing lessons learned as to what other healthcare stakeholders are doing, and not doing, in response to rapidly changing Healthcare Policy & ACA.
  • Preparing for the many regulatory deadlines (and the frequent adjustments to timelines) such as the 1/1/2022 real-time prior authorization requirements.

Additional Focus Area Roundtables Currently Being Assembled

HCEG is currently assembling roundtable discussions on Costs & Transparency and Interoperability – two other HCEG Top 10+ focus areas closely related to and impacted by Healthcare Policy & ACA.  Additional focus areas will be added in the coming months.

If you’re an executive of a health plan, health system, or healthcare provider organization who’d like to join one of these informal, small group discussions, please reach out to us here or share your contact information via this tool. And consider joining our newsletter to receive information of potential value to healthcare executives including recaps of future Focus Area Roundtables.oin HCEG and/or participate in our Focus Area Roundtables

RELATED: Healthcare Policy, ACA 2.0, Enrollment Period Lessons, & The Journey to the Exchange

Healthcare Policy, ACA 2.0, ACA Enrollment Period Lessons Learned, The Journey to the Exchange. Open Enrollment Period. Special Open Enrollment Period. Federally-Facilitated Marketplace (FFM). State-based Exchanges (SBE) Softheon. 2021 HCEG Top 10+. Expanded APTC Eligibility. Subsidy. Subsidies.

Healthcare Policy, ACA 2.0, Enrollment Period Lessons, & The Journey to the Exchange

By | HCEG Top 10 | 2 Comments

The real and potential impact of Biden administration healthcare policy, the next iteration of the ACA, the Open Enrollment Period that closed in December 2020, the Special Open Enrollment Period that began February 15th, 2021, and opportunities for leveraging the Federally-Facilitated Marketplace (FFM) and State-based Exchanges (SBE) are all current healthcare policy topics that are top of mind for leaders of many healthcare organizations.

Earlier last week our Executive Director Ferris Taylor and Kevin Deutsch, General Manager & Senior Vice President, Health Plan Cloud of HCEG technology sponsor Softheon met to discuss these and related topics. The goal was to identify and create a framework for additional discussion and exchange over the next few months. This post shares an overview of the call, shares a small portion of the discussion, describes content and presentations to be shared over the next few months, and offers an opportunity to engage with other healthcare leaders on the Healthcare Policy/ACA focus area of the 2021 HCEG Top 10+ list.

See the end of this post for information on upcoming events on Healthcare Policy/ACA 2.0 and an opportunity to participate in our Focus Area Workgroups.

The ACA Revolution – Healthcare Policy from ObamaCare to TrumpCare to BidenCare

Ferris kicked off the discussion by noting that the elephant in the middle of the table is that everything seems to have changed with respect to the ACA and healthcare policy. There have been a few different iterations of the ACA at this point. If the ACA focus of the Obama administration was to ‘Pass & Implement’ and the Trump administration mantra was ‘Repeal & Replace,’ Kevin suggests that the goal of the Biden administration is to ‘Advance & Grow’ the ACA.

Kevin shared that a number of health plans that left the marketplace after participating the first couple of years, as well as plans that hesitated to join due to political and other uncertainties, are now rejoining the Exchange or planning to join for the 2022 plan year.

RELATED: “Considerations for Health Plans as we approach ACA 2.0 and Bidencare”

Expanded APTC Eligibility and Subsidy Amounts May Drive Individual Market Growth

The likely expansion of eligibility for Advance Payment Tax Credits (APTC) and increased amounts of APTC subsidies by the Biden administration will create the opportunity for millions of new consumers to enter the individual market.

This is a key consideration – the impact of near-term changes to subsidy levels and APTC eligibility. From the discussion, it appears that retroactive subsidy changes could happen in the next couple of months and undergo additional change over the next couple of years. Kevin shared experience as to how data exchange/interoperability with CMS and having the right controls in place surrounding subsidy determination and reconciliation are critical to sustaining plan performance and scaling enrollment processes.

2021 Open Enrollment and Special Enrollment Period: Lessons Learned & to Be Learned

Perspectives on what health plans and technology providers could (or should) learn from the 2021 Open Enrollment Period that closed in December 2020 were exchanged. Kevin also shared some considerations on the Special Enrollment Period (SEP) recently opened on February 15, 2021 and what we might learn.

See lessons learned from the 2021 Open Enrollment Period in this recent blog post and the recent press release about how Softheon Simplifies Operations and Reduces Administrative Burdens for Health Plans During Special Enrollment Period and Beyond.

RELATED: Bidencare & the Latest on the Special Enrollment Period

New Marketplace Entrants – Partnering to Advance & Grow

In addition to traditional health plans, Kevin shared that Softheon is seeing technology companies focused on personalized care delivery models AND large, established technology firms, becoming an issuer offering plans on the exchange and/or developing products focused on helping others establish a presence on the ACA marketplace.

While some of those technology companies may have the technical expertise, they don’t necessarily have the depth of understanding as it relates to the marketplace requirements and being a Qualified Health Plan on the exchange. They are quickly learning that nuances within the exchange workings and platform – like EDI enrollment processing, billing and payment, integration with claims platforms, and enrollment/subsidy reconciliation – are good areas in which to partner.

Related: Google to establish Minnesota office as projects with Mayo Clinic expand and mature

2022 Enhanced Direct Enrollment – Facilitating Preparations

Ferris mentioned a January 2021 CMS report “Impact of Enhanced Direct Enrollment During the Open Enrollment Period for 2021 Coverage” that noted how the successful full-scale implementation of Enhanced Direct Enrollment (EDE) over the past two years has yielded outstanding results for the Federally-Facilitated Marketplace.

Since Softheon is one of only a few CMS-approved providers of EDE Phase 3 technology, Kevin shared his understanding of the challenges, issues, and opportunities that companies looking to get on the exchange, or improve their existing FFM exchange operations, should be aware of, including:

  • Keeping consumers on your own health plan branded platform throughout the entire enrollment process.
  • Improving member experience by providing customer service staff and insurance brokers with tools to assist with not only the initial enrollment process but also with additional life event-related transactions throughout the plan year.
  • Planning for increased traffic volumes and the exchange of more personal information between systems, companies, and individuals requires a robust identity management strategy and threat detection measures.
  • Meeting significant security, compliance, and other technical requirements, on top of business-related audits and reporting.

The Issuer Journey to the Marketplace Exchange

There are a lot of decisions, steps, shortcuts, and possible detours along the journey to a presence on the healthcare exchange. Beyond plan definition, market positioning, pricing, and CMS submittal efforts currently underway, many organizations wanting to offer plans on the exchange in 2022 are in the early stages of adopting new technology platforms and figuring out how those platforms need to integrate with their existing ecosystem.

Kevin shared that while requirements for a sustainable presence on the exchange are generally consistent across all issuers, the individual steps and specific pathways through the roadmap to get on the exchange may vary. Given the scope of this topic, additional information will be shared in future posts and a special podcast planned after this SEP closes as noted below.

HCEG, Softheon and the Healthcare Policy/ACA Focus Area

In addition to more details on each of the above issues, the exchange between Ferris and Kevin covered a lot of other topics including the following:

  • Trend toward moving from FFM to state-based exchanges.
  • What happens when the state that you’re in, or you’re planning to get into, converts from the FFM into a state-based exchange a year from now?
  • Unique challenges and opportunities in getting on state-based exchanges.
  • Special considerations for State/CMS-qualified Medicaid programs
  • Timelines and steps to be on the exchange in 2022
  • Growing alignment between consumers and their health plans, especially with COVID
  • Increasing retention of plan members across enrollment periods

Upcoming Opportunities for More Information, Insight, & Ideas

Between now and the end of May, HCEG will be working with members, other healthcare executives, industry thought leaders, and sponsor partners to create, curate, and present additional information and insight on various focus areas of the 2021 HCEG Top 10+.

The following Healthcare Policy and related topics are scheduled to be presented with Softheon, the focus area thought leader for Healthcare Policy:

Week of Information/Event
Now HCEG Focus Area Workgroups

HCEG members are encouraged to join small roundtable workgroups on the Healthcare Policy/ACA topic. Click here to join the Focus Area Group discussions.

3/15/21 The Issuer Journey to the Marketplace Exchange

A podcast presenting a roadmap addressing key challenges, issues, and opportunities to establish a presence on the exchange including maximizing plan distribution channels.

3/29/21 Top Questions on Building Your Exchange-related Technology Infrastructure

A digital presentation of technical and technology-related approaches and considerations related to the exchange.

4/12/21 Key Success Factors for Your 2022 Exchange Operations

A blog post presenting learnings gathered from the 2021 Open Enrollment Period, recent exchange implementations, HCEG members, and industry experts.

5/3/21 Topics and Questions to Be Addressed in Upcoming Webinar Series Event

An ongoing, digitally interactive Q & A process collecting and addressing questions from the HCEG network and other industry leaders and participants on current healthcare policy developments, ACA 2.0, and lessons learned from Open Enrollment & Special Enrollment Periods

5/17/21 Webinar: Healthcare Policy Developments, ACA 2.0, and Recapping Open Enrollment & Special Enrollment Periods

A webinar presenting a summary of all the information, insight, and ideas collected in the above events.

June 2021 Summary/Whitepaper on Lessons learned in preparing for the ACA Revolution/Revitalization

To receive announcements and information on all of the above and other information of potential value to healthcare executives and leaders, subscribe to our newsletter today. And reach out to us here if you have any questions and/or would like to share information and/or your insight on these and other HCEG Top 10+ topics.

Interim 2021 HCEG Top 10 List Healthcare Leader Priorities

Identifying COVID-19 Impact on Healthcare Leader Priorities

By | HCEG Top 10, Resources | No Comments

The healthcare industry has faced tremendous change and uncertainty for decades. Each year over the last decade, the challenges, issues, and opportunities facing HCEG members have been used to create the HCEG Top 10 list – a list of challenges, issues, and opportunities. Although most healthcare executives were likely comfortable about their priorities at the start of 2020, those healthcare leader priorities were certainly and quickly turned upside down by the emerging coronavirus pandemic. The best-laid plans demanded quick review, understanding, and revision as 2020 progressed.

COVID-19 Impact to Healthcare Leader Priorities

Accordingly, HCEG and our sponsor Change Healthcare performed a ‘flash survey’ of 228 healthcare leaders through June and July of last year to assess how COVID-19 impacted the priorities identified in the 10th Annual Industry Pulse research report – a research survey based on the 2020 HCEG Top 10 list.

The results of this COVID-19 flash survey update to the 2020 Industry Pulse were released in September of 2020. Since COVID-19 prevented the HealthCare Executive Group from hosting its 2020 Annual Forum that same month of September, a formal 2021 HCEG Top 10 list was not created but rather an Interim 2021 HCEG Top 10+ list was assembled using findings from the flash survey and discussion among HCEG’s network of healthcare executives and industry leaders.

Updating Healthcare Leader Priorities as 2021 Unfolds

As 2020 ended and 2021 began, HCEG has been collecting additional information and insight into how the coronavirus pandemic and the 2020 presidential election have impacted the priorities of new and existing HCEG members and our network of partners and associates. We are also reviewing a list of 2021 healthcare predictions and trends shared by industry leaders.

Over the last few weeks, HCEG contacted the 120+ new members who joined HCEG since early December to collect feedback on their current priorities.

HCEG Healthcare Executive Group Annual Forum Healthcare leader priorities

New HCEG Members Share Their Top Priorities

While we are still collecting additional feedback from our members and performing a comparative analysis of information collected from our members to 2021 predictions and trends shared by industry leaders, it’s clear that the pandemic has resulted in new and changed priorities for health plans, health systems, and healthcare providers. Some initial findings based on the feedback provided by new HCEG members include:

  • Consumer Experience” (#1) and “Costs & Transparency” (#2) were the most frequently noted priorities of new members.
  • Data & Analytics” (#5) was the 3rd most referenced top priority. We’re reaching out to our members to gather more specifics about this foundational priority – among other priorities that were shared.
  • Next Generation Payment Models” (#9) was the 4th most frequently noted priority.
  • COVID-19 & Pandemic Preparedness” (#11) was frequently referenced with some new members adding “Patient & Healthcare Worker Safety” as a priority.
  • Holistic Individual Health” (#7) was referenced by only two new members – both healthcare providers.
  • Reimbursement Issues,” “Addressing Underfunding of Primary Care” and “Administrative Expense” – perhaps all considered a subset of “Next Generation Payment Models” – were listed as ‘new priorities’ – mostly by members associated with health systems and healthcare providers.

RELATED: Physician Perspectives on COVID-19 Impact on the Fall Season

How has COVID-19 Impacted YOUR Priorities as a Healthcare Leader?

To help us further refine our Interim 2021 HCEG Top 10+ list, please consider sharing your priorities for 2021 via this simple, one-page survey. We’ll use your responses to create a more complete 2021 HCEG Top 10+ list and to help guide and create additional content as 2021 continues. You may also email us at [email protected].

Connect with the HealthCare Executive Group

Consider joining our newsletter to receive additional information, ideas, and insight for healthcare executives and change-makers.

Please reach out to us at [email protected] if you have any questions or comments. If you are an executive of a health plan, health system, or healthcare provider organization, reach out to us at [email protected] for information on a special membership offer available through the end of January.

Healthcare System Interoperability – The Key To The Care We All Strive For

By | Events, Resources, Sponsor | No Comments

What does it feel like to be a patient, provider, pharmacist, and payer in a world where interoperability is not always a reality? What improvements can be expected by healthcare stakeholders in a world where interoperability is vast?

In our October Webinar Series event – The Care We All Strive For: The Impact of Interoperability – our sponsor Surescripts helped to address the two above questions via a short two-act skit. Four fictional healthcare stakeholders – a patient, a provider, a pharmacist, and a health plan executive – each shared their experiences with how interoperability helps to address the Quadruple Aim: enriching the patient experience, improving outcomes, addressing costs, and maintaining provider well-being.Surescripts. The Care We All Strive For – Navigating an Interoperable Healthcare System. HCEG Webinar Series October 2020. Specialty Pharmacy. Interoperability. Prior Authorizations. Quadruple Aim Triple Aim.This blog post recaps a portion of this two-act skit and presents some highlights.

Access the entire recording here.

Two-Acts: Healthcare System Interoperability – Before & After

In Act I of the skit, each of the actors shared their experience in a world where interoperability is not a widespread reality – a world that most healthcare stakeholders experience today. In Act II, they shared how enhanced interoperability can improve the experience and well-being of not only patients and but also providers while reducing administrative and financial burdens and enhancing clinical outcomes – the four goals of the Quadruple Aim.

Highlights of Act I – Navigating Today’s Processes (Before)

Each stakeholder shared their experience living and working in a healthcare environment where interoperability is lacking:

Patient Carlos Garcia expressed his experience and concerns about alternative medication availability and cost:

  1. Need to repeat medical and medication history with each new provider
  2. Difficulty obtaining info on more cost-effective medication alternatives
  3. Lapses in medication adherence due to cost and/or delays at the pharmacySurescripts. The Care We All Strive For – Navigating an Interoperable Healthcare System. HCEG Webinar Series October 2020. Specialty Pharmacy. Interoperability. Prior Authorizations. Quadruple Aim Triple Aim.

Physician Dr. Natalie Pinter, Carlos Garcia’s PCP, noted difficult prior authorization processes and lack of access to benefits information:

  1. Administrative processes take time away from patient interaction
  2. Lack of benefits information makes identifying cheaper therapeutic alternatives more difficult
  3. Cumbersome prior authorization processes – particularly for specialty medications

Pharmacist Keisha Wright also expressed concerns about over-reliance on faxes and administrative burdens:

  1. Challenges with incomplete patient information
  2. Delays in filling prescriptions – particularly specialty medications – due to unwieldy prior authorization processes

VP of Pharmacy at Carlos’s health plan, Oscar Gustafsson, noted impacts his health plan pharmacy operations:

  1. Involve a heavy, over-reliance on faxes to communicate with physicians and pharmacists
  2. Challenges assisting with member medication adherence and addressing gaps
  3. Difficulty assisting members with optimizing the use of their health plan benefits

Navigating Today’s Healthcare Process is a Challenge for Everyone

After Act I, the emcee of the performance – Melissa Warnke, Director PBM-Pharmacy, Health Plan Segment Marketing of Surescripts – shared some recent statistics supporting how insufficient interoperability impacts patients, providers, pharmacists, and health plan payers.Surescripts. The Care We All Strive For – Navigating an Interoperable Healthcare System. HCEG Webinar Series October 2020. Specialty Pharmacy. Interoperability. Prior Authorizations. Quadruple Aim Triple Aim.

Access the entire recording here.

Highlights of Act II – The Care We All Strive For (After)

In the 2nd act, the healthcare stakeholders shared how broad healthcare system interoperability would change stakeholder experience:

Health plan VP of Pharmacy Oscar noted improvements and efficiencies gained in health plan operations:

  1. Allows for timely delivery of medication adherence gaps directly into the workflow of physicians
  2. Ability to share member-specific benefit information to physicians at the point of care
  3. Faster, “faxless” processing and turnaround of prior authorizations

Patient Carlos noted positive impacts on his physician office visit, cost of his medications, and obtaining his medications:

  1. Ability to provide patient medical and medication history to new physicians and pharmacists
  2. Faster, less administratively intense prescriptions – particularly specialty medications – and refills of existing prescriptions
  3. Opportunity to save money with therapeutic alternatives

Physician Dr. Natalie revealed improved ability patient information, reduced administrative work, & more time with her patient:

  1. Patient medical info, medication history, and adherence gaps available electronically in advance of a patient encounter
  2. Electronically accessible benefit plan information facilitates identification and prescription of more cost-effective medication and treatment alternatives
  3. Submitting prior authorizations electronically without faxing
  4. Submitting prescriptions for specialty medications electronically to the pharmacy

Pharmacist Keisha Wright noted reduced patient data collection and streamlined medication processing:

  1. Complete patient and prior authorization info received electronically
  2. More timely processing – especially with specialty medications – allows for more time counseling patients

The Care We All Strive For – The Vast Reality of Improved Healthcare System Interoperability

At the conclusion of Act II, Surescripts Melissa Warnke shared an overview of the vast impact that improved interoperability can have on increasing the transactions that help address the Quadruple Aim. Melissa also shared some additional statistics showing the growing pervasiveness of interoperability. Click images to expand.

Surescripts. The Care We All Strive For – Navigating an Interoperable Healthcare System. HCEG Webinar Series October 2020. Specialty Pharmacy. Interoperability. Prior Authorizations. Quadruple Aim Triple Aim. Surescripts. The Care We All Strive For – Navigating an Interoperable Healthcare System. HCEG Webinar Series October 2020. Specialty Pharmacy. Interoperability is a Reality. Prior Authorizations. Quadruple Aim Triple Aim.

A Faxless Future: Dare We Dream?

After Melissa recapped Act II, a short, light-hearted video was played showing how fax machines might be re-purposed for a useful life after they retire from their long-running service to the healthcare industry. The following are a few examples of how fax machines might serve a new role.  See the short video “A Faxless Future: Dare We Dream.”

Surescripts. The Faxless Future. Artifax. The Care We All Strive For – Navigating an Interoperable Healthcare System. Specialty Pharmacy. Interoperability is a Reality. Surescripts. The Faxless Future. Artifax. The Care We All Strive For – Navigating an Interoperable Healthcare System. Specialty Pharmacy. Interoperability is a Reality. Surescripts. The Faxless Future. Artifax. The Care We All Strive For – Navigating an Interoperable Healthcare System. Specialty Pharmacy. Interoperability is a Reality.

Questions from the Audience on Healthcare System Interoperability

After the video was played, emcee Melissa Warnke fielded some questions submitted by attendees. Here are a few of the questions and their responses:

  1. What have you seen as the best practices for driving the kind of behavior change from providers, pharmacists, and others that obtaining maximum value from increased interoperability takes?

Answer: 32:03 to 34:50

  1. Without a sales pitch, what are the new tools that the provider and pharmacist actors are alluding to that to speed the implementation and adoption of interoperability?

Answer: 37:08 to 40:07

  1. How has COVID-19 impacted the transaction counts (real-time benefit inquiries, medication history transmittals, clinical direct messages) you presented after Act II?

Answer: 41:45 to 45:16

  1. Can pharmacists see the same real-time prescription benefit info as providers?

Answer: 45:39 to 47:33

Connect & Interact w/ Our Sponsor Surescripts & HealthCare Executive Group

Our Webinar Series events are one example of how the HealthCare Executive Group helps to share information and promote collaboration between healthcare leaders, change-makers, and other stakeholders serving the healthcare industry.

For more information on the topics presented by Surescripts in our October Webinar Series:

Learn more about the HealthCare Executive Group and to stay abreast of challenges, issues, and opportunities facing the healthcare industry in 2021 and beyond:

Physician Perspectives on COVID-19 Impact on the Fall Season. HCEG HealthCare Executive Group. Lessons Learned. Experiences from Southern Hemisphere – Seasonal Viruses at All-Time Lows. Value of Encouraging Use of Masks. ‘Long Haulers’ – The Unknown, Long-Term Impact of COVID-19. Financial Impact on Providers, Employer Groups, & Payers. New Reimbursement Models

Physician Perspectives on COVID-19 Impact on the Fall Season (Part 3)

By | HCEG Content, Resources | 2 Comments

This is the final post of a 3-part series sharing physician perspectives on COVID-19 impact on the fall season. The information, insight, and ideas presented in this series originated from an informal discussion Ferris Taylor of the HealthCare Executive Group had with three physician executives:

HCEG board member Dr. David Diloreto, MD, a board-certified ophthalmologist, ophthalmic plastic surgeon, a principal at Vizient/Sg2 and prior senior vice-president at GE Healthcare Camden was joined by:

Dr. Johanna Vidal-Phelan, MD, Senior Medical Director in Pediatrics at the University of Pittsburgh Medical Center Health Plan and a practicing pediatrician at Hamilton Health Center, an FQHC in Harrisburg, PA and

Dr. Jason Woo, MD a practicing board-certified obstetrician/gynecologist, a veteran with 31 years in the Commissioned Corps of the U.S. Public Health Service and a consultant at the Arbinger Institute.

COVID-19 Impact to Healthcare: Topics Discussed in This Series

The trio of physician executives discussed the following topics in the first and second posts of the series:

Part 1 Topics

Part 2 Topics

– Impact Factors Affecting Utilization of Services
– Balancing Treatment to Avoid Ongoing Destruction of Demand for Non-COVID Services
– Returning to School & Addressing Disadvantaged Populations
– A Pediatric Physician on Sending Kids – Including Her Own – Back to School
– Impacts on Minorities & Underserved Populations
– Uncertainty in Testing and Understanding Prevalence
– How Long Will We Be Dealing with COVID-19?
– COVID-10 Vaccines & Importance of Fall Flu Shots
– Avoiding Other Illnesses or a Different Pandemic – Maintain Immunizations
– Vaccinations for Underserved Populations – Messaging is Key
– The Change to Telehealth: New Opportunities for Providers to Connect with Patients
– Rethinking the Healthcare Supply-Chain – PPE as a Matter of Trust

Listen to the entire recording here

Be sure to subscribe to our newsletter for more information of potential value to healthcare leaders and change-makers.

Live, Interactive Chat and Q&A – October 13th, 2020

On Tuesday, October 13, 2020, at 11:00 am PT/2:00 pm ET, Doctors DiLoreto, Vidal-Phelan, and Woo will present additional details and current insight on what can be expected for the coming fall season under COVID-19.

Join us for a live, interactive discussion and Q&A. Questions and requests for additional information shared by registrants prior to and/or during the live chat will be fielded by the panelists. Reserve your seat and submit your questions and comments today!

Lessons Learned and Lessons to Be Learned

Lessons learned during the coronavirus pandemic can help to drive innovation that transforms preparedness, care delivery, quality, safety, efficiency, and patient experience over the coming months and years. The discussion continued with the physicians sharing some lessons learned and lessons to be learned.

Experiences from Southern Hemisphere – Seasonal Viruses at All-Time Lows

Dr. David:

COVID-19 Experiences from Southern Hemisphere – Seasonal Viruses at All-Time Lows“We’re also working with folks in the southern hemisphere right now. It’s very interesting they’re in the depths of winter in the southern hemisphere. The pandemic is certainly spreading and hitting places very hard; whether it’s Melbourne Australia, Santiago Chile, Johannesburg South Africa.

What’s interesting is that the incidence of other seasonal viruses is at an all-time low – historic lows. And it’s across a long spectrum so influenza, RSV, pneumococcus remains extraordinarily low suggesting that, obviously, measures such as social distancing, mask-wearing, hand washing are going to be more important than ever. And obviously vaccinating against flu and pneumococcus for older patients is going to be important.

Hopefully in North America, as we enter into winter, we’ll get similar effects that will suppress – like we did in the spring – some of the seasonal virus activity.”

Value of Encouraging Use of Masks

Dr. Johanna:

“And I think one important point about this is mask-wearing. And so, for example, places like Australia you just mentioned. In Chile, people are being compliant with using masks. So this is a message that we really need to also share with our community and the population that wearing your mask is important not only for COVID-19 but it does prevent the exposure to other viruses and illnesses.

And that I tell my pediatric patients wearing your masses showing your love is caring and so they do it, they do it very well.”

RELATED: Surviving Coronavirus Pandemic & Thriving on the Other Side: Rapid Innovation & Telehealth

‘Long Haulers’ – The Unknown, Long-Term Impact of COVID-19

Dr. David Diloreto:

“I’d like to get your insights into are some of the issues we’re seeing with long haulers – folks who actually are continuing to demonstrate symptoms, troubling symptoms, for many weeks or months and potentially for some of them it could be long term.‘Long Haulers’ – The Unknown, Long-Term Impact of COVID-19

We’re seeing widespread neurologic complications, cardiovascular complications – obviously there are aspects of this disease we don’t quite fully understand.”

Dr. David prompted fellow panelists to share a little bit about their concerns in younger individuals who may have had minimal symptomatology but have persistent symptoms going forward that don’t seem to be resolving.

Dr. Jason responded:

“One of the challenges is that when folks say “oh, this is a hoax or this is not real,” I think part of it is just recognizing what they’re seeing right and then what’s relevant to them. The challenge is when we have all this uncertainty when we have so many different messages, and there are all these aspects about the COVID-19 virus and its pathology in the body.

We are only beginning to get a sense that folks aren’t dying from pneumonia, they’re dying from micro infarctions throughout their lungs where it’s overwhelming the immune response. That’s killing them not the typical virus reproduction. And then the neurologic symptoms and the muscle symptoms where the virus is infecting whole body systems.

COVID-19 and Its Uncertain Pathology

We just have no knowledge of that. So, when folks see things it’s recognizing there’s still a lot of uncertainty about this. What’s right for you is what is going to be right for you. But do you want to do that in a vacuum or do you want to do that with better information? So how do we help better inform you about what those risks are because we know that the data is constantly evolving?

And how do we help you be alive for that so that we’re working together to figure it out because one person going back to work by themselves is not going to fix the economy? It’s how do we do this together and how do we address all the different concerns that people are going to be having – be it their economic ones or if they’re elder parents there are long-term consequences for the individual. How do we be alive to the things that are the highest priority for them in terms of what’s the information that they need to make a better decision?”

RELATED: COVID-19 Resources for Health Plans, Health Systems, & Medical Service Providers

Financial Impact on Providers, Employer Groups, & Payers

The coronavirus pandemic has had a significant negative impact to the financial status of hospitals, physicians in private practice, and physicians employed by health systems. With patient volumes cut 60% or worse and with so many healthcare providers paid based on volume, many physicians have taken unprecedented hits to their revenue, and many organizations have furloughed or laid-off employees.

Dr. David shared how the coronavirus pandemic has likely forced all stakeholders – providers, employer groups, and payers including federal and state healthcare programs like Medicaid – into pursuing new value-based reimbursement models.

Employers Forced into New Reimbursement Models

Financial Impact on Providers, Employer Groups, & Payers Employers Forced into New Reimbursement Models“And employers who are really not that interested in thinking about value-based care – they just wanted to make sure their employees were happy with health insurance – now are looking at all kinds of – and these are small and medium-sized employers – anything they can do to eliminate costs now.

They’re much more interested in episode of care bundles and basically looking at structural reimbursement models that deliver their risk going forward. So our projections are that we (as individuals) and obviously state governments have been shielded to some degree from the economic impact by federal subsidies.

But if the economy is shut down in certain states and the tax base erodes, they’re going to have to look at their Medicaid programs in about 18 months totally differently. So there’s going to be much more cost reduction in that space.”

RELATED: Modifying the Focus of Medicaid Value-Based Payment in the Context of COVID-19

Delayed Demand for Non-COVID Services

“So the folks that are also interesting to me are payers. If you look at what’s happened in 2020, many of them obviously – with the demand destruction – now are actually looking at significant surpluses on their financials for 2020. And they’re trying to really look at certain reserving capabilities including a reserve I never knew that existed called the premium discount reserve.

But it’s a way, in this instance, of being able to move these positive income statement effects off your books and onto your balance sheet and release it in future periods. But anyway, that’s probably not for this group.”

COVID-19 Forcing Physicians to Reevaluate Reimbursement

Dr. Jason Woo asked Dr. David Diloreto how the shift in the reimbursement payment system is going to affect our ability to be able to be more comprehensive in our coverage of the population?

Dr. David Diloreto responded:

“This is one of the most interesting aspects that for almost all of my clinical career, which is 30 years now, physicians generally viewed the least risky way to get paid was on a service basis. What’s really interesting is right now in large physician groups and in single-specialty groups and health system employee groups many specialists are thinking differently. They’ve been in situations now that seen demand from elective procedures (drop significantly) and they’re worried about the future.

If you can imagine being a bariatric surgeon with a large mortgage and trying to save money for college education, the world change doesn’t look like the world is going to come back that way. So they’re having grown-up discussions about changing the reimbursement models more to deliver that risk by going to employment; to going to safer ways of getting paid including fixed fees.”

Supporting & Caring for Front-Line Providers

In addition to financial impacts which were discussed later in the session, the physician panelists shared how the coronavirus pandemic has placed a huge physical and emotional burden on many frontline providers. Ferris prompted the physician panelists to share their thoughts on this quadrant of the Quadruple Aim:

What would be effective measures to decrease the burnout rate of physicians and everyone else fighting the coronavirus pandemic?

Dr. Jason:HCEG COVID-19 Supporting Caring for Front-Line Providers

“I think that in a lot of ways it’s going to be very healthy for health care providers to be able to connect to their patient’s. I think on the other side, those frontline providers that are still stuck with trying to take care of the folks that are coming through the ER or into the ICU is where there’s still not a lot of good information. And the struggle that they’re going to go through of trying to do the best that they can with all the uncertainty in the limitations that we have. I think for those folks we have to be really mindful that there’s a great burden that our traditional thought about what the role of the provider is. We have to help see beyond right and get into that.

What’s the best that you can do? What is not the best outcome that you’re going to be able to get, wish for every patient, but what’s the best that you can do within your circumstances. And being more for more mindful of the limitations that your role is going to be, that it is going to have. I think it’s hard because be it the lack of the supply chain, the lack of PPE, the challenges of what tests are available, or not available. Until that gets standardized, until there’s been able to get some trust in the data that they have and the testing methods that they, and the treatments available it’s just going to be hard to be a frontline provider.”

Dr. David added

“I think what we do need to get is the impact on providers, front line providers, who have been through the ringer. If you just think about what they’ve had to do throughout the spring into the summer – even in outpatient practices. Now all the PPE requirements on and off; all the changes in your practice; this is really taking a toll on providers right now.”

Get Your COVID-19 Questions Answered on October 13th

The discussion ended with a general agreement that the discussion could go on for hours. Accordingly, the three physicians agreed to make themselves available for a live, interactive follow-on chat with a Q & A opportunity on October 13, 2020 at 11:00 am PT / 2:00 pm ET.

Reserve your seat and submit your questions and comments today!

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Webinar: The Care We All Strive For: The Impact of Interoperability

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Has 2020 given you webinar fatigue? The seemingly endless run of virtual events and webinars would certainly justify it. And while moving everything to the digital world has its challenges, society is embracing technology and making the most of the situation. Healthcare is no exception. With the expanded use of technology, healthcare has been reminded of the importance of being able to communicate with each other quickly, efficiently, and easily.

In our October Webinar Series event, The Care We All Strive For: The Impact of Interoperability, we will help fight that webinar fatigue by taking a break from the traditional webinar structure and take time to revisit our shared purpose – to make healthcare run better for everyone.

Please join us on Wednesday, October 28th at 11:00 am PT / 2:00 pm ET to hear the story of what it feels like to be a patient, provider, pharmacist, and payer in a world where interoperability is a reality.

Our sponsor Surescripts will be joined by four healthcare stakeholders who will share their take on the difference interoperability makes on the experience of a patient, provider, pharmacist, and payer. The panelists will examine how sharing information across stakeholders can reduce administrative burden and improve member experience.*:

Carlos Garcia Dr. Natalie Pinter Keisha Wright, RPh Oscar Gustafsson
Patient with Rheumatoid Arthritis & Hypertension Provider Pharmacist, Specialty Pharmacy Vice President of Pharmacy, Payer

Over the next four weeks leading up to the live webinar on October 28th, we’ll be sharing more information on how patients, providers, pharmacists, and payers all benefit from enhanced interoperability of data and systems. In the meantime, learn more about how Surescripts addresses healthcare interoperability challenges here.

* These are imaginary personas whose role in this webinar will be performed by employees of our sponsor Surescripts.