Home

Don’t Backpedal on Progress: Fix Proposed Changes to Medicare Advantage Before Beneficiaries Feel the Effects

March 09, 2023
3:41 pm

It’s no wonder why Medicare Advantage (MA) is so popular among America’s seniors, with a greater share of the Medicare population choosing MA plans as its coverage of choice each year. MA has consistently outperformed conventional fee-for-service Medicare in reducing avoidable hospitalizations, lowering hospital readmissions, and encouraging utilization of preventive services. Patients have benefited from supplemental benefits such as vision and dental care as well as programs to affect the social determinants of health, addressing food insecurity, social isolation and transportation needs, to name a few examples.

This progress should be encouraged. So, needless to say, we were concerned at the proposed changes from the Centers for Medicare and Medicaid Services (CMS) for the 2024 plan year. Three changes – revisions in the MA risk model resulting in a 3.12 percent reduction, reduced quality bonus payments under the Medicare Star Ratings program of 1.24 percent, and a 2.09 percent benchmark, which is less than half of the five percent projected per-enrollee growth in Medicare costs – would result in an average 2.27 percent reduction in MA payment rates in 2024. While not all plans would be affected equally, many enrollees could see higher premiums or a loss of programs and benefits that have a direct impact on health outcomes.

As well, there are concerns about proposed changes to health data, specifically the precision that enables providers to identify a patient’s condition and administer effective treatment. The CMS regulatory proposal would remove nearly 2,300 ICD-10 diagnosis codes. Restricting the ability to recognize asymptomatic diseases would result in an unwanted increase in avoidable emergency room visits and hospital admissions. We could see physician revenue cuts and the closure of clinics in underserved urban and rural areas.

The solutions here are evident.  The proposed MA payment growth rate for 2024 should be adjusted to reflect document increases, including inflation, in Medicare costs. Other proposed changes should be delayed in order to gather stakeholder input and fully understand the potential impact on health providers and patients. We have an opportunity to continue the momentum that MA plans have successfully generated, enabling the 65-and-older population to live healthier lives and better manage the chronic illnesses that become more prevalent as we age. CMS should make the adjustments to ensure that we don’t take an unnecessary step backward.

Cybersecurity in a Highly Regulated Industry

February 27, 2023
6:33 pm

The Healthcare Leadership Council hosted a webinar entitled, “Cybersecurity Playbook for Healthcare,” in conjunction with the Confidentiality Coalition. The discussion brought clarity to the current federal infrastructure around cybersecurity, existing tensions around breach notifications in the healthcare industry, and recommendations to improve cybersecurity practices within and beyond healthcare. Four speakers joined the panel:

  • Marilyn Zigmund Luke, Vice President, AHIP
  • Alicia Bowers, Senior Vice President and Enterprise Chief Privacy and Compliance Officer, Atrium Health (now part of Advocate Health)
  • Todd Greene, Vice President & Enterprise Chief Information Security Officer, Atrium Health
  • Allison Miller, Global Chief Information Security Officer and Senior Vice President for Optum, a division of UnitedHealth Group

Infrastructure

The healthcare system is one of 17 national critical infrastructures. As cybersecurity stretches across federal agencies, money is allocated to various agencies to maintain cybersecurity capabilities. Within the U.S. Department of Homeland Security, the Cybersecurity and Infrastructure Security Agency (CISA), was established to receive reports from critical infrastructure sectors. The public is awaiting future regulations from CISA of how to proceed with that reporting process. The Healthcare and Public Health Sector Coordinating Council Cybersecurity Working Group identifies and mitigates systemic risks that affect patient safety, security, privacy, and national confidence in the health system.

The Problem with Breach Notifications

As healthcare is a highly regulated industry, organizations who comply with one law run the risk of violating another law because the federal agencies and states have not adequately communicated with each other regarding the larger operational impact of what they are trying to accomplish. There are unintended consequences to conflicting laws, and the burden of reporting a breach is significant. The panel noted the juxtaposition of portability and security of data, as tension arises between becoming increasingly transparent and connected while protecting patient privacy and securing data.

Breach notification requires contacting both patients and the media. Patients who receive these notifications are either confused or desensitized by the mass mailings, and are generally not concerned unless their social security number was compromised. Media outlets generally go for the more sensational headline and stories are frequently reported inaccurately. Often, the primary organization is named in the breach even though the actual breach involved a business associate or vendor. It has become clear that the majority of patients take no action after a notification, and media coverage actually helps cyber criminals and plaintiff attorneys target an organization that has just been victimized. Healthcare entities are spending more resources on class action defense rather than proactive measures due to the punitive ramifications of how breach notifications are designed.

Recommendations

The majority of breaches are not due to negligence, and the compromised entities are victims of a crime. The “Wall of Shame”, posted by the U.S. Department of Health & Services Office for Civil Rights, should come down. There is stigma associated with this and the primary organization is listed even if a vendor was breached. Healthcare is a complex industry, and multiple vendors are required to fulfill all the responsibilities that come with delivering care. Vendors should be held directly responsible, and other sectors should have the same reporting standards as healthcare.

Reduce the administrative burden and use an exclusive reporting route instead of involving multiple agencies. Avoiding creating duplicative processes and tearing down commodity channels would allow sectors to effectively communicate valuable information about cyber threats and defend against them collaboratively in a timely fashion. An additional approach to reducing the burden of unnecessary notifications is to redefine what is considered protected health information, as routinely disclosed data is easily found online outside of healthcare.

 

Exploring the Changing Landscape of Cancer Care

January 24, 2023
2:01 pm

Cancer is one of the leading causes of death across the globe and affects the lives of millions every year in the United States. As advances have been made in screening, diagnosing and therapeutics, providers have been able to utilize new technologies and precision medicine to achieve improved outcomes. The Healthcare Leadership Council hosted a webinar to highlight the commitment to medical research and discovery and the most recent accomplishments of some of its member companies. The webinar, “What’s New in Cancer Innovation?”, included three panelists:

  • Dr. Qasim Ahmad, Head of US Oncology Medical Affairs, Novartis
  • Dr. Harlan Levine, President, Health Innovation and Policy, City of Hope
  • Victoria Raymond, Senior Director of Medical Affairs, Guardant Health

Ms. Raymond described Guardant’s focus on blood-based diagnostics as a less invasive way to screen for specific cancers. This method of screening can assist in early detection as well as ensuring appropriate therapy selection. Dr. Ahmad concurred that there has been a shift from making the patient fit the treatment, to making the treatment fit the patient. He presented Novartis’s strategy to harness the power of targeted therapy, immunotherapy, cell and gene therapy, and radioligand therapy to attack cancer using multiple approaches and provide the best outcomes for patients at every stage of the disease.

Dr. Levine noted that the rate of change in oncology exceeds the ability for most oncologists to keep up with the advances in each subtype of cancer or surgical technique. He stated that while with precision medicine and genomics we are able to identify tumor types and DNA signals, we still address value-based oncology with tools that were developed decades ago as though cancer is a single specialty with only a handful of chemotherapy agents. Reliance on these generic tools will limit the benefit of emerging technology and propagate disparities.

The discussion underscored the lack of diversity across clinical trial sites, doctors, study investigators and trial participants. A map was provided as a visual to portray how one’s survival is directly impacted by one’s zip code. The need to innovate the system so that it is accessible and equitable is vital to improving cancer care. The panelists acknowledged efforts to increase diversity in clinical trials and addressing barriers that hinder trial participation and access to treatment. Educating the public on opportunities is just one piece of the puzzle. Finding easier ways for people to follow through with what they know they need to do is the next challenge.

Finally, the Inflation Reduction Act (IRA) was raised as a hindrance to cancer research, which require long-term commitments and significant investments.  There is a need for broader understanding of the investment required to subsidize clinical trials for cell-based therapies and the potential impact of the IRA in discouraging that investment. Policy measures that result in reduced research and fewer trials, ultimately limiting access to new therapies, is harmful to patients and society as a whole.

American Healthcare: The Challenge to Stay on Top

November 17, 2022
4:45 pm

The Healthcare Leadership Council hosted a webinar which highlighted the relationship between intellectual property (IP) and innovation, a linkage that is critically important in healthcare. The panel was comprised of:

  • Joe Allen, Executive Director of the Bayh-Dole Coalition
  • Eric Aaronson, Pfizer’s Chief Counsel for Corporate Affairs, Intellectual Property and Intellectual Property Enforcement Departments
  • Catherine Burch, Vice President of Innovation at ChristianaCare Health System
  • Paul Higgins, Vice President of Law, Head of Global IP Policy at Johnson & Johnson

The webinar was an open discussion covering the history and role of IP laws, as well as the importance of partnerships and collaboration in achieving new discoveries. It was acknowledged that not all that long ago the United States not the world’s global leader in life sciences, as it is today. The Bayh-Dole Act, enacted in 1980, decentralized technology from Washington bureaucracy and allowed the people creating biopharmaceutical and medical technology innovations to own and manage them, integrating incentives into the patent-and-licensing process and jumpstarting a renaissance in healthcare innovation.

The panelists agreed that the IP system encouraged investment in risk. A robust IP system provides two key benefits: (1) the assurance of intellectual property rights that are protected from bad actors who would diminish their value, and  (2) the creation of mechanism to transfer knowledge to those who can commercialize it for the greater public good. It enables collaboration between innovators, governments, universities, research partners, all of which are focused on exchanging information to speed up progress to finding solutions. Innovation is iterative and enables scientists to build off the discovery of others. Collaborations are key because it they enable to essential distribution of risk. It can require 10-15 years to develop a drug, cost upwards of $2.6 billion on average, and only about 10 percent of drugs evaluated in Phase 1 clinical trials are ever approved. Entities will not take on this level of risk without strong IP protections.

The pro-competitive nature of IP was also emphasized. Given that a drug or medicine may not be best option for every patient, having multiple solutions is important. Once the exclusivity period expires for a drug, it facilitates low-cost generic entry. There are those who like to pit the innovator versus generics, but it is really two sides of the same coin. To encourage new generics getting to market there must be support for strong IP systems, because the generic pipeline is the innovator pipeline.

The concept of march-in rights, a provision in the Bayh-Dole Act was also discussed. It was inserted to ensure that inventions didn’t sit dormant and were licensed to serve the public good; otherwise the government could “march in” and license them to entities who would move forward with production. Recently, there has been a push to use march-in rights to force price reductions for pharmaceuticals by shifting licensing from the current manufacturer to a company that could presumably make the drug cheaper. All petitions using this theory have been rejected by multiple administrations, because it is not what the Bayh-Dole authors intended. This would create a slippery slope in which holders of any intellectual property for which government funding played a role at some point in the process could have their license taken away. This would destabilize a system that has made the U.S. the technological innovation center of the world by discouraging investment in research and development.

Given the level of exchange of technologies that are required for the fast-paced collaboration and eventual production of the COVID-19 vaccine, none of the current vaccines would have occurred without an IP system that supported incentives and created an environment where information could be exchanged so that the iterative scientific process of discovery could work to the benefit everyone. Not only the discovery, but scaling the supply once a drug is approved requires researching manufacturing sites globally to find partners that are able to produce safe and effective vaccines to meet global demands. Every one of those partnerships rely on a sound and robust IP system.

Here’s How Insurers Can Take a More Strategic Approach to Community Investment

July 20, 2022
3:31 pm

This is a guest post by John Lumpkin, M.D., President of the Blue Cross and Blue Shield of North Carolina Foundation and Vice President, Drivers of Health.

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) has been committed to engagement with the communities we serve for nearly a century. This work is not about writing checks or “giving back.” Instead, we think of our community support as “investing in.” In recent years, we have thought strategically about how to expand and maximize the impact of these efforts.

Good health happens where people live, work and play. We know that food, healthy housing, companionship, transportation and other resources play a far more significant role in a person’s health and well-being than what happens during those few hours per year spent in a provider’s office. And yet, not everyone has equal access to these resources. Putting people in contact with the resources they need for health and well-being is the right thing to do … it’s also the logical thing to do from a business perspective. Making these investments helps prevent, correct or manage trouble spots before they escalate into complex, expensive and painful health issues.

This investment mindset is apparent in the language we use to describe this work. Blue Cross NC made the conscious choice to abandon the common industry terminology, “social determinants of health,” in favor of “drivers of health.” We have argued for this change in part because we recognize the importance of giving agency to individuals and communities. No one’s well-being is pre-determined. With strong commitment and strategic thinking, individuals, communities and the health care industry can knock down barriers to good health.

But smart investment needs to be informed by data and guided by rigorous reasoning. Neither of these is necessarily easy to come by at this historical moment. Our industry is only just starting to acknowledge the important role a drivers of health strategy can play improving health outcomes and promoting health equity. Insurers don’t yet have the solid knowledge base to help them develop and implement the programs that will have the most impact.

The Blue Cross and Blue Shield of North Carolina Foundation was established in 2000 to improve the health and well-being of communities across the state. Further, Blue Cross NC’s Community and Diversity Engagement team offers additional widescale support for nonprofit organizations and health entities committed to connecting communities with the resources they need. To go further in addressing drivers of health through business practices and to close the knowledge gap, Blue Cross NC formally established its Drivers of Health Strategy team in 2019. The Drivers of Health Strategy team has a focus to implement innovative intervention models, measure their long-term impact and share these findings to promote informed and systemic change across our lines of business and across the industry.

Since 2020, the Drivers of Health Strategy team has launched four test and learn models, focused on food security, social isolation and transportation. More are on the way. We launched these pilots with the understanding that we couldn’t predict which would have the most significant impact. Our goal is to gather quantifiable evidence of long-term health impacts, overall member experience and savings from preventable medical expenses. Data from these models will start to roll in this year. In addition to testing these models internally, Blue Cross NC is collaborating with UNC Health Alliance and the Sheps Center at UNC-Chapel Hill to conduct a clinical research study to establish sustainable best practices for helping individuals improve health through nutritious food. Which is more effective, food vouchers or delivery? Does health coaching improve the efficacy of food interventions? What is the optimum length for a food intervention program?

In essence, our Drivers of Health Strategy team functions as a research, development, and implementation group to help Blue Cross NC identify viable drivers of health programs that will improve outcomes for our members, make the company more competitive and attract new members. Our findings will help guide evidence-based product decisions. And, as we share our insights externally, we will help build the evidence base other insurers will need to make informed decisions about their own products and programs.

This investment-minded approach is guided by a fundamental recognition that drivers of health impact us all, not just those who face barriers to vital resources. Greater access to these resources will help prevent, reverse or better manage chronic disease. A healthier population will reduce the strain on our health system and reliance on emergency department visits. Ultimately, this proactive approach will lower health care costs for everyone.

As an industry, we are at a critical time. Making a concerted effort to move toward a more comprehensive, data-driven approach to addressing drivers of health needs will lead to more sustainable models with greater reach and a measurable impact on individual, family and community health.