Impact of Healthcare Policy. Legislation. ACA exchange marketplace. Individual Small Group Market. SEP. extended enrollment. Subsidy. American Rescue Plan. open enrollment period. Softheon.

Impact of Healthcare Policy on ACA Marketplace – Leadership Discussion

By | Focus Area Roundtable, HCEG Content | No Comments

The new administration and the pandemic have significantly impacted the United States healthcare delivery system with many changes to health care regulations and policy – particularly in regards to the Affordable Care Act (ACA). In an effort to support the discussion of the challenges, issues, and opportunities facing healthcare leaders and changemakers, the HealthCare Executive Group has hosted a series of Focus Area Roundtables. The 3rd roundtable on Healthcare Policy & the ACA took place on August 12th, 2021 with 16 leaders of health plans, care provider organizations, and other stakeholders sharing information, insight, and opinions on the impact of healthcare policy on the ACA and the healthcare delivery system.

See recaps of first roundtable and second roundtable on Healthcare Policy & ACA held in March and May.

This post recaps this roundtable 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.

Webinar – Recapping Roundtables & Impact to 2022/2023 ACA Marketplace

Something Old, Something New: Two Health Plan Executives Share Their Experiences in the ACA Marketplace.Join us on Tuesday, Sept 21 at 1:00 PM EDT for “Something Old, Something New: Two Health Plan Executives Share Their  Experiences in the ACA Marketplace as a Veteran & a New Entrant.” Leaders of two health plans operating on the ACA Marketplace will discuss topics raised during the string of Healthcare Policy & ACA roundtables AND their experiences with exchange-related services, cost savings, compliance, member growth, privacy, and more.

Impact of Healthcare Policy on ACA’s Individual and Small Group Market

Ferris kicked off the discussion by asking Kevin Deutsch to share his perspective on how recent legislation has impacted the ACA – especially the individual and small group market. Kevin shared some information on new enrollment from the special extended 2021 enrollment period that started in February; and the impact of changes to subsidy levels in the favor of the consumer.

2.5 Million New Individual Exchange Members Added Since January 1st, 2021

Some of those in the special enrollment period were those that were affected by COVID, may have lost their jobs, and went on to the ACA Exchange to get individual insurance. And there was another change that eliminated the 400% federal poverty level – the Cliff – at the end of the subsidy. And made that a longer tail of enrollees. And it may be too early to get any sense of what types of other people have come on in this 2.5. Million.

Kevin offered that upcoming health plan rate filings for 2022 should reveal quite a few new payers in the marketplace – as enrollment number grows and the government becomes responsible for a greater share of overall costs of coverage.

2021’s Special Enrollment Periods & SubsidiesACA exchange marketplace. Individual Small Group Market. SEP. extended enrollment. Subsidy. American Rescue Plan. open enrollment period.

Another participant elaborated on the impacts of the American Rescue Plan’s elimination of the subsidy cliff and the expansion of subsidies, as well as impacts from the extension of the open enrollment period. He noted that actuarial/risk management functions are having to rise to a new level and more effectively communicate the pre-COVID, COVID, and post-COVID activity in terms of claims and utilization.  The fact that more enrollees have been drawn to the ACA’s individual market via the exchange should add financial stability standpoint with a more sizable, stable risk pool.

After one participant noted a CMS 2022 notice proposing to extend the annual open enrollment period from 45 days (currently November 1st to December 15) to 75 days (November 1st to January 15). This proposed 30-day extension received quite a bit of discussion. One participant noted this as a potentially good change in that December is typically viewed as a holiday month and that’s not when people are focused on their health care. Another noted that many individuals will just procrastinate. Another noted a concern about the potential for a shortened coverage period for those enrolling in January.

A significant part of the roundtable discussion revolved around challenges with inadequate explanations of and consumer understanding of changes to enrollment periods and subsidy levels. All participants noted that payers, brokers – and even the provider community – need to help increase consumer literacy regarding subsidies and financial impact.

Listen here for more on the impact of healthcare policy on ACA enrollment. [3 mins 49 secs]

Increased Retroactivity Scenarios & More Complex Reconciliation

Participants discussed the impact that special enrollment periods and extending enrollment periods will have on increased retroactivity and reconciliation scenarios health plans must deal with. Another shared that if you look at 2021 in particular, many members are switching between plans at a greater frequency than what’s consistently been the case with ACA enrollees prior to the pandemic. Discussion continued with operational and back-office challenges health plans are going to continue to face in relation to all these changes.

Ongoing Issues with Member/Patient Literacy – Enrollment and AccessHealthcare consumer literacy. Education. Enrollment periods. Subsidy. Open enrollment period.

Participants discussed how increased choice and opportunity created by extended enrollment periods and increased subsidy levels have not been well understood by individuals and have amplified the need for health plans, brokers, and even care providers to help increase healthcare literacy among members, consumers, and patients. One participant noted that the industry as a whole has got a lot of work to do to help improve member literacy and experience.

Lack of Consumer Awareness of Increased Subsidy Levels

Kevin noted that the 30-page ACA application for individual insurance contains one question about subsidies changed as part of the American Rescue Plan Act. And that CMS hasn’t done much at all in the awareness and education area to help individuals understand what’s available to them.  And shared that he thought that is part of why CMS is going to auto-reallocate subsidies to individuals who haven’t gone out and done it. Listen here as Kevin Deutsch explains challenges with recent subsidy changes. [1 min 09 secs]

Taking Time to Educate Consumers & Health Plan Members

One participant recalled that the Kaiser Family Foundation provided an ongoing or monthly outreach and learned that 35 to 40 percent of people did not know when open enrollment started, didn’t know what it meant, and didn’t know that it had an end to it. The participant opined: “I don’t think that’s on the consumer, that’s on the industry.”

In response, another participant shared that a primary directive at his company – a community-based health plan organization – is to make a special effort for its members to receive and understand what options and opportunities are available to them and to assist their members with access to care.

Educating Members About Coverage & Access: Taking a Page from the Medicaid Segment

Participants discussed the importance of educating enrollees with dedicated community outreach that incorporates an appreciation of the social determinants impacting enrollees. One participant, a health plan leader, emphasized that health plans, whether for-profit or non-profit, should dedicate a portion of their operating budget to educating their members in a sustained fashion on how members can make the most of the benefits that they receive from a health plan. Listen here to a health plan leader on the need for plans to educate plan members [2 mins 23 secs]

Extending Enrollment Periods and Human Nature to Procrastinate

This same participant continued sharing the importance of doing a better job of providing people with good information about enrollment, financial costs, and subsidies, and facilitating access to care was universally acknowledged by all participants. This participant, a health plan leader having P&L responsibility for 300k lives over a 10-year period noted that anywhere from 25 to 30 percent of their enrollment for net, new enrollment came in the last three days of the eligible period. He closed out his comment by stating “So, if you want to talk about procrastination, there it is.” Roundtable participant shares on the impact of extending open enrollment periods here. [1 min 5 secs]ACA exchange marketplace. Open Enrollment Period. Special Enrollment Period. Annual Enrollment Period. OEP. AEP. SEP.

Impact of Healthcare Policy: State vs. Federal and State-by-State Variations

Two participants – one operating in New York and the other in Hawaii – discussed the importance of addressing enrollment periods, premium rates, subsidy amounts, eligibility levels, and access at the state-by-date and federal vs. state levels. In New York, which operates a state-based exchange, enrollment periods, eligibility and financial subsidies are more generous at the state level and not impacted by changes at the federal level. While in Hawaii, a state operating on the federal exchange, plans must comply with less generous federal regulations.

RELATED: How the End of the Public Health Emergency (PHE) will Impact Health Insurers

Variances in Access to Care – To Be Addressed by Healthcare Policy?

Both the New York and Hawaii-based participants noted that access to care is a challenge and that enrollees who expect to have access to whole-person care will have a difficult time accessing care. Hawaii has a severe shortage of PCPs and New York suffers from a similar challenge in the rural, western New York area. Hawaii has cost of living issues and access in Western New York is similar to many rural areas experiencing shortages. These shortages existed pre-COVID and have gotten worse with the pandemic.

One participant noted that provider network teams are struggling to add physicians and they have even had to help subsidize some of the providers in the area to keep them afloat, especially PCP’s.

Behavioral Health Issues and Lack of Providers

One care provider participant noted the increased need for behavioral health services and the dearth of providers – a need that existed prior to the pandemic and which, as widely reported, has gotten worse due to the pandemic. While not directly related to the impact of healthcare policy on the ACA, a short discussion on the importance of considering behavioral health and social determinants of health data such as financial status and where people live. Listen here to participants discuss care challenges related to location and access. [4 min 39 secs]

Release of Pent-Up Demand – Delays Creating Advanced Medical Issues

Ferris asked participants whether they are seeing patients they haven’t seen before? And whether these new enrollee patients were more healthy or less healthy.

A participant noted that the second-quarter financials of most of the health insurance companies indicated a significant decline in earnings as many more patients and consumers have started to come in for care. And that some health systems have many more patients coming in, especially patients with chronic conditions patients with cancer. Many of these patients, unfortunately, put off screenings, put off a number of therapies. And so, we have seen a big increase in patients coming in for screenings.

She also noted a push from a lot of organizations and health systems to get patients in for screenings. And that, especially in the oncology space, providers are seeing patients coming in with more advanced disease because they have put off care during the pandemic and they’re coming in with more progressed disease and therefore having more challenges. Listen here to participants discuss delays in care creating sicker, more costly patients. [1 min 29 secs]

Telehealth Dropping from Peak Usage & Non-Traditional Stakeholders as Gateways to Access

In response to the increase in patients with advanced stages of disease due to not being seen over the pandemic, another participant reminded the roundtable that one of the positive things that have come out of COVID is the growth and wider acceptance of telehealth and telemedicine and its significant uptake – even with recent pullbacks from peak telehealth usages during the pandemic.

Impact of Healthcare Policy. Legislation. ACA exchange marketplace. Individual Small Group Market. SEP. extended enrollment. Subsidy. American Rescue Plan. open enrollment period. Softheon. Impact of Healthcare Policy. Legislation. ACA exchange marketplace. Individual Small Group Market. SEP. extended enrollment. Subsidy. American Rescue Plan. open enrollment period. Softheon.

Listen here to participants discuss telehealth and non-traditional stakeholders. [2 mins 25 secs]

Chronic Care Management – Digital Care to Manage Transitions of Care

One participant noted the opportunity for using telehealth and virtual care technologies in the area of Chronic Care Management to better manage available resources and prevent costly transitions of care. He described digital care technologies can be used to anchor individuals in the home and provide care across the care continuum while preventing individuals from re-entering the care cycle – particularly more costly, often less-effective settings like the emergency department. Hear more here about leveraging digital care technologies to achieve Quadruple Aim [3 mins 39 secs]Intelligent Care Management Technology: Driving Alignment Towards the Quadruple Aim

Click here or the above image to learn more about Intelligent Care Management Technology

Pandemic-Driven Impact of Healthcare Policy: Innovation, Consumer-Centricity, & Access to Care

One participant related that prior to the pandemic there was a lot of pushback from their provider community when the health plan wanted to move toward increasing the use of telehealth. Then the pandemic started and there was much more acceptance of not only telehealth providers but providers offering virtual visits themselves with their own practices.

He noted that one of the good things that came out of the pandemic is that the entire industry, across the entire spectrum, has started to become more willing to be innovative and experiment with things. And be a lot more focused on members. Listen here to a health plan leader on what plan members need beyond health care [1 min 37 secs]

“I’ve spent my whole career listening to strategy folks talk about how this year we’re going to put the focus on the member. This year we’re going to be consumer-centric this year. We’re going to be member-centric. It’s sort of a challenge because when I make board presentations or do advisory work, we hardly ever talk about the member.” – Health Plan Leader

Webinar – Recapping Impact of Healthcare Policy & ACA Marketplace in 2022 & 2023

Join us on Tuesday, September 21, 2021, at 10:00 AM PT / 1:00 PM ET for Something Old, Something New: Two Health Plan Executives Share Their Experiences in the ACA Marketplace. In this webinar, two health plan executives will join Ferris and Kevin to address key challenges, issues, and opportunities raised in the roundtable series and which will help ensure health plan organizations are well-positioned for growth in 2022 and 2023 as subsidies expand, programs stabilize, and opportunities.Something Old, Something New: Two Health Plan Executives Share Their Experiences in the ACA MarketplaceIf 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. We currently have a number of roundtables based on 2021 HCEG Top 10+ focus areas scheduled with additional roundtables being planned.

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 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

By | Focus Area Roundtable, Resources, Sponsor | No Comments

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

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Healthcare Leaders Focus on Healthcare Policy & ACA

By | Focus Area Roundtable, HCEG Content, Research | 4 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