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Action Needed for Market Stability, Access to Health Coverage

July 18, 2018
11:24 am

There is a consensus in this country that people who are struggling with illnesses and have a greater need for healthcare services should not be prevented from acquiring health insurance.  Recent actions at the federal level, though, need to be addressed in order for that ideal to be met.

Risk adjustment payments provide financial stability to insurance providers that provide coverage to relatively high numbers of sicker, higher-cost consumers.  Without those payments, premiums would become unaffordable for millions of Americans who buy their coverage through small businesses or on their own in the individual insurance market.

And that brings us to the current dilemma.

A federal district court judge ruled in February that the Department of Health and Human Service’s methodology for calculating risk adjustment payments was flawed and impermissible.  Subsequently, on July 7, the Centers for Medicare and Medicaid Services (CMS) announced that payments under the risk adjustment program, including amounts already owed for the 2017 benefit year, would be suspended.

This is an issue that carries extraordinary ramifications.  It will create more market instability – at a time in which we need just the opposite – and the potential for reduced coverage options for those who have the greatest need for healthcare access.  Further, it could result in increased costs to taxpayers if the federal government has to increase premium subsidies.

An analysis by Change Healthcare, a major technology and analytics firm, found that the individual health insurance market attracts an extremely wide range of enrollees in terms of healthcare utilization.  In fact, according to Change, the health plans attracting the sickest patients have health costs at least 450 percent higher than the plans with the healthiest clientele.  Thus, the need for risk adjustment payments.

CMS has asked the district court judge to reconsider his ruling.  We hope he will.  Americans with serious healthcare needs should have affordable coverage.

A Public Health Crisis Requires a Roadmap of Solutions

July 12, 2018
2:50 pm

It’s indisputable that the opioid addiction crisis with which America is currently grappling is one of historic magnitude.  We’re losing more than 115 people per day from opioid overdoses.  Families and communities are being devastated and public resources – healthcare, social services, law enforcement – are being stretched thin.

This is a serious problem, but it is not an insolvable one.  Recently, the Healthcare Leadership Council, working with over 70 organizations from the healthcare, employer, patient advocacy, and addiction treatment sectors, released a “Roadmap for Action” consisting of over 30 achievable, high-impact solutions to address opioid misuse and addiction.  The Roadmap is the product of several weeks of deliberations, idea sharing and consensus building and represents a collaboration of unprecedented breadth to address a national public health crisis.

The Roadmap identifies five key priorities as essential, including:

•    Improving healthcare system approaches to pain management
•    Improving current approaches to prevent opioid misuse
•    Expanding access to evidence-based substance use disorder treatment and behavioral health services
•    Promoting improved care coordination through data access and analytics
•    Developing sustainable payment systems that support coordination and quality care

This package of solution addresses both regulatory and legislative priorities but, just as importantly, it includes actions that healthcare leaders should take.  Winning this battle will require a public-private effort.  And the recommendations we’re offering, some of which are detailed in the following paragraphs, reflect this broad-based strategy.

Health sector leaders have a responsibility to improve access to evidence-based, non-opioid and non-pharmacological pain management therapies. (It’s vital to recognize that, in taking on the opioid crisis, we cannot place obstacles between millions of Americans suffering from chronic and acute pain and the treatments they need.) Developing and evaluating these treatments will require long-term evidence generation and data collection, but their proliferation will cut costs and improve outcomes for patients in the long run.

We must also focus on improving data-driven coordinated care, and in order to do this we must create access to real-time prescribing data within the clinician workflow. Improving critical data access must also include legislative action to change a law known as 42 CFR Part 2 to allow confidential information sharing on SUD diagnosis history while still adhering to the Health Insurance Portability and Accountability Act (HIPAA). It is important that patients’ privacy be protected, but it is also vital that care providers understand their patients’ substance abuse histories if they are to provide them with the well-informed care that they need.

And we must develop sustainable payment frameworks that prioritize quality, coordinated, value-based care connecting patients with the medical resources they need, whether that be a pharmacist, primary care provider, nurse practitioner, licensed addiction treatment professional, or certified peer recovery specialist.  In fact, we must engage the full community of medical professionals in coordinated care to treat patients struggling with substance use disorder.

This is just a sample of the comprehensive, multi-faceted plan we’re going to be advancing.  No single organization, regulatory agency or legislative body can solve this crisis by themselves.  Working together, though, we have the ability to save lives and prevent tragedies.  The time for bold and decisive action is now.