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.

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:

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

By | Events, Sponsor | No Comments

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.

Recapping: Towards Next-Generation Care: The Digital Musculoskeletal (MSK) Clinic

By | Events, Resources, Sponsor | No Comments

Currently, people with back and joint pain experience a fragmented approach to care. Whether it’s an acute injury, chronic pain, or surgery, members must contend with multiple providers and handoffs between those involved with providing a ‘whole person approach’ to care. From the individuals’ perspective, it feels like no one is looking at their health holistically or acting as their healthcare champion. And with many people increasingly working from home due to the coronavirus pandemic, challenges related to musculoskeletal conditions – increasing back pain and joint pain – are likely to increase.

Our September Webinar Series event was presented by Hinge Health’s CEO Dan Perez and addressed the following:

  • Key MSK Challenges & Trends in 2020 and Beyond
  • Fractured State of MSK Care
  • Towards Next-Generation Care
  • World’s Largest Digital MSK Cohort Clinical Study

This post is a recap of the webinar. Contact Hinge Health for access to the webinar recording

For more information on how a digital musculoskeletal clinic – covering the full continuum of care from prevention to post-surgery – can provide a one-stop-shop for health plans, employer groups, and provider organizations, reach out to Hinge Health.

Highlights from Towards Next-Generation Care: The Digital Musculoskeletal (MSK) Clinic

HCEG’s Executive Director Ferris Taylor kicked off the webinar noting how Hinge Health addresses 4 of the 2020 HCEG Top 10 list of challenges, issues, and opportunities facing healthcare leaders.HInge Health MSK Issues Musculoskeletal conditions

Dan Perez provided an overview of how musculoskeletal conditions continue to be the top health care cost driver and how MSK care will have the highest growth rate of any virtual care services over the next few years – and likely beyond. Dan went on to provide an overview of The Hinge Health Digital MSK Clinic, details on the four distinct Digital Care Pathways across the care continuum, and shared information on evidence-based care guidelines from the CDC and American College of Physicians.

RELATED: Spotlight on Musculoskeletal (MSK) Programs – Hinge Health

Chronic MSK Pain is Both Physical & Mental

Dan shared information, statistics, and Hinge Health insight on the Gold Standard for Addressing Chronic MSK Pain: a biopsychosocial approach that addresses three key components:

Biological Influence

How exercise therapy can help reduce chronic pain by up to 60%

Psychological Influence

How a belief in oneself often leads to lower pain levels – even 1 to 2 years after the initial intervention

Social Influence

How education and 3rd-party support can empower people to overcome chronic pain

Clinical Care Model Surrounding an Individual

The presentation continued with Dan sharing an overview of the clinical care model upon which Hinge Health’s care model is based. He shared a 1-minute video with webinar participants offering a real-world application of the Hinge Health solution.

The World’s Largest Digital MSK Cohort Study

Details on clinical outcomes from a study of 10,264 participants – validated by researchers at Stanford, Vanderbilt, and top consultants addressing key business questions – were shared:

  • 4 out of 5 participants had meaningful improvement in pain reduction
  • More exercise therapy and coaching resulted in more pain reduction
  • 58% Reduction in depression and anxiety scores
  • More than 2 out of 3 surgeries avoided in Year-1

The presentation concluded with key takeaways on how health plans, employer groups, provider organizations, and other healthcare stakeholders can help their members and patients.

Learn How Hinge Health Can Help Address Costly MSK Issues

To access the webinar recording and for more information on how a digital musculoskeletal clinic – covering the full continuum of care from prevention to post-surgery – can provide a one-stop-shop for members and health plans reach out to Hinge Health.

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 stakeholders. Consider joining our newsletter to stay abreast of challenges, issues, and opportunities of importance.

Webinar: Towards Next-Generation Care: The Digital Musculoskeletal (MSK) Clinic

By | Events | No Comments

Currently, health plan members with back and joint pain experience a fragmented approach to care. Whether it’s an acute injury, chronic pain, or surgery, members must contend with multiple providers and handoffs between those involved with providing a ‘whole-person approach’ to care. From the members’ perspective, it feels like no one is looking at their health holistically or acting as their healthcare champion.

Join us and other healthcare leaders for our September Webinar Series Event: Towards Next-Generation Care: The Digital Musculoskeletal (MSK) Clinic on Thursday, September 17, 2020 at 11:00 am PT / 2:00 pm ET.

In this webinar, Hinge Health’s CEO Dan Perez will discuss how a digital musculoskeletal clinic covering the full continuum of care from prevention to post-surgery can provide a one-stop shop for members and health plans. Register today and learn how to improve outcomes, engage your members and lower costs!

Webinar Discussion Topics

  1. Current MSK Challenges
  2. Fragmented Continuum of Care
  3. The Digital MSK Clinic
  4. Deep Dive: Chronic MSK Digital Pathway
  5. Insights from the World’s Largest Digital MSK Cohort Clinical Study
Healthcare Innovation and Disruption, HealthCare Executive Group, HCEG, 16th Annual World Health Care Congress (WHCC), CIO & CTO Strategy Track, innovation, disruption. healthcare champions, Data Analytics, Pharmacy Costs and Transparency, Importance of Useable Technology, Cybersecurity, HCEG Top 10, Center for Healthcare Innovation (CHI), International Association of Innovation Professionals,

To learn more, read about Overcoming Chronic Pain: The Hinge Health Clinical Model of Care.

Presenters

Dan Perez is CEO and Co-Founder of Hinge Health
Dan Perez Ferris Taylor <Announced Soon>
CEO and Co-Founder of Hinge Health Executive Director, HealthCare Executive Group Hinge Health Customer

More About Hinge Health & The Digital Clinical Model of Care

Read this recent Sponsor Spotlight on Musculoskeletal (MSK) Programs to learn more about Hinge Health and how failures in the continuum of MSK care are addressed with a patient-centered Digital Clinic for back & joint pain.Spotlight on Musculoskeletal (MSK) Programs – Hinge Health Contact Hinge Health here

 

Visit Hinge Health’s Website

Connect with Hinge Health on LinkedIn, Twitter, and Facebook