$906: The average out-of-pocket cost for people with employer-sponsored insurance in 2019, compared to just $737 in 2013. A new analysis by the Employee Benefit Research Institute shows that the share of medical expenses paid by people enrolled in employer-sponsored coverage increased from 17.4% in 2013 to 19% in 2019. Out-of-pocket expenses dipped in 2020, probably due to the pandemic, but as these costs continue to rise, more and more insured patients are likely struggling to afford healthcare visits and procedures on top of their monthly premiums. This could lead to deferred care, potentially resulting in costlier health problems.
Warranty For Outcomes: Quit Genius, a digital clinic for treating substance abuse disorders is doubling down on its belief in its clinical model. The company has recently moved to a full risk pricing model, meaning that they only get paid if they meet certain clinical, engagement, satisfaction, and operational performance goals. They previously put up to 50% of their fees at risk, but cite the move to 100% risk as a “natural evolution in our mission to help 100 million people conquer their substance abuse addictions”.
Cardiology’s New Partner: It is astounding that we haven’t seen more partnerships between OBGYNs, women’s health specialists and cardiologists. In our poll of OBGYNs, 65% say they are interested in bringing in a cardiology specialist. This could be helpful particularly around menopause or pregnancy. “We try to refer but there can be long wait times given the hospitals control so many of the cardiologists,” says Val Youmans. There is often underdiagnosis and undertreatment, particularly related to high blood pressure, low-density lipoprotein, diabetes and obesity. Reach out if interested in discussing.
Heat Wave: Cigna is offering MA members rides to community cooling centers and other public areas with air conditioning. Around 354,000 seniors have this benefit through Cigna, but the rides are typically used for trips to physician offices and pharmacies.
Universal VBC Pay Model: Six healthcare organizations in California—Aetna, Blue Shield of California, Health Net, Oscar, UnitedHealthcare and PCP value-based player Aledade have signed a memo of understanding to increase investment in “advanced primary care” that, if successful, could lead to greater transparency into VBC models and quality reporting, adoption of an agreed upon value-based payment model, and technical assistance to primary care practices to implement clinical and business models for success. This could have sweeping implications for physician groups. The effort, known as the California Advanced Primary Care Initiative, is led by the California Quality Collaborative and the Integrated Healthcare Association.
Lines Unblurred? Humana announced during its recent earnings call that it plans to realign its business into two segments, an insurance segment and its healthcare services segment, CenterWell, by 2023. Humana built out CenterWell extensively over the last few years, with acquisitions like Kindred at Home. The move follows the lead of United/Optum, Cigna/Evernorth, and the newly branded Elevance (aka Anthem) and their healthcare services business, Carelon.
Hospital At Home Claims: On August 1, Elevance in Virginia (formerly Anthem) began recognizing and accepting claims for acute Hospital in Home services for their commercial and Medicare Advantage plans. The plan is encouraging qualified hospitals or other entities that meet the Hospital in Home requirements to reach out to their health plan contractor to get an appropriate participation agreement.
High Success: 86% of eligible contracted PCPs participate in Highmark’s True Performance value-based reimbursement program that the plan says has saved $2.5 billion in avoided costs since 2017, largely from fewer ED and IP admissions. Highmark recently signed a new 3-year value deal with Bridges Health Partners for Medicare Advantage members in western PA. The agreement creates a joint care management team that will use data to manage care.
Insulin Cost Change: Optum is partnering with Sanofi to offer lower-cost insulin for uninsured people living with diabetes through their online health retailer Optum Store. People with valid insulin prescriptions can access the website to determine whether their insulin is part of the new program, get qualified and download an insulin savings card, and then fill their prescription for $35 at any retail pharmacy. A mail-service option will soon be available for home delivery. Last month, Optum’s parent, UHC, announced plans to make insulin free for fully insured commercial members starting next year.
Extra Point: Cancer treatment cost U.S. families $16 billion out of pocket and nearly $5 billion in patient time costs traveling, waiting for care, and receiving care back in 2021 alone. It is staggering – my neighbor spent so much last year ($35,000+) that she had to tell her son that he had to leave the Ivy League and transfer to community college this fall. Every summer since 2010 my own family has tried to do a small part riding in the Pan Mass Challenge, a 100+ mile bike ride for Dana Farber and The Jimmy Fund. My son Jack and I will ride this weekend, and though we usually get lost each year along the route, the survivors and the moms and dads with a kid in treatment line the streets, cheering, hoping for a cure and a miracle. My 3 days of knee pain and nausea at mile 60 are a small price.