Podcast Episode Transcript: Planning for the future during a time of crisis

With L. Gordon Moore, MD

Dr. Gordon Moore: Welcome to 3M Inside Angle Podcast. This is your host, Dr. Gordon Moore. And with me today is Matt Eyles, the president and CEO of America’s Health Insurance Plans, which we’ll refer to as AHIP. Welcome, Matt.

Matt Eyles: Thanks for having me here, Gordon.

Gordon: I was reading the AHIP Federal News Bulletin that you sent out yesterday, and it’s packed. It is packed with stuff that’s really interesting. And I’m hoping you wouldn’t mind getting into a conversation and starting with, for instance, the first thing on the list, which is racism and equity. Tell me how AHIP is getting into that, what the members are thinking and doing.

Matt: Well, that is a topic that certainly is top of mind, not just for AHIP and our member organizations, but I think across the country. I think the events coming out of Minneapolis and other parts across the country with the death of George Floyd and especially as we’ve been thinking about the impact of the pandemic on communities of color, there’s no more important topic that we can address as a country.

I mean, the impact of systemic racism and discrimination across the country on populations, especially African Americans and other communities of color, is profound. And the recognition that it has to change starting now and putting in place efforts to address it, to make sure that the health inequities are addressed and really are put in place a systemic plan to address them could not be more important than right now. Our member companies have been taken efforts.

We started last year with an effort that we call Project Link that has really morphed now into something much, much bigger. And when you look at the impact of COVID and the rate of hospitalizations and deaths in communities of color, it just screams out for action. And I know that our members are committed to being part of that positive change and looking at how we can have a more diverse, inclusive, equitable healthcare system, and get better health outcomes for communities of color.

Gordon: What is Project Link?

Matt: Project Link is an effort that we started a little more than a year ago at our AHIP Institute to really address social determinants of health and recognizing that your ZIP code is more important than your genetic code for determining your health outcomes. And our members are keenly focused on how they can address these other factors that have a profound effect on health, whether it be safe housing, nutrition, lack of transportation.

So we wanted to put together an industry-wide effort to really address these social determinants of health and share best practices, raise visibility, and develop policy advocacy, really around how we were going to address these challenges. And it has just grown and taken off over time. And I can’t tell you how deep the commitment and interest is across the industry in terms of addressing these issues.

So it’s something we’re going to continue to move forward with. And I’m sure it will evolve just given our environment and how changing it is right now just with what we’re facing with COVID and all of these other really critical social challenges.

Gordon: From reading the bulletin you put out and the links associated, I know that there are just a long list of examples. Can you give me one that you think is representative of the kind of things your members are doing with SDOH and equity?

Matt: I think, right now, nutrition could not be more important, right, as we think about not just the health effects of COVID but the economic impacts, right, and what we’ve seen with the economy falling off a cliff earlier in the part of this country. And hopefully, we’re recovering a bit. But the incidence of hunger has never been greater in this country. And our members have taken actions, again, across the country in Los Angeles, in New York, in rural areas, to make sure that their members have access to healthy food at this time, right, just given so many people being out of work and stuck at home.

And so we’ve seen it in terms of food deliveries, right, to deliver healthy meals to seniors who are more likely to be susceptible to COVID and might be afraid to go to the grocery store or go out in public and understandably so to, again, working age, people who have just lost their livelihoods and maybe they’d been furloughed, but they are still having their health insurance covered through their employer.

Our members are making sure that the consumers that rely on them have access to nutritious healthy food and really working at a community level to understand where those needs are greatest.

Gordon: It fascinates me when I think about that intersection of health care delivery and public health, something that has been in a discussion in the United States for a long time and in value-based payment arrangements as we think about best possible outcomes. There’s been a growing awareness, which is relatively well understood at this point, that the more we can step in and the healthcare delivery side, step into some of those social determinant factors, we can have a beneficial impact on health outcomes and reduce unnecessary spending.

But part of me wonders as we get into things like housing and food and employment and stuff like that, is that sustainable over time? What do you think the future is for your members in this?

Matt: It’s a great question. And I do think it’s sustainable, but we’re going to have to look at it from a more holistic perspective in terms of how we are addressing these needs as a nation and where are we spending our dollars and how are they going to be spent, right? Because when you look at the direct healthcare spending, certainly, we spend a lot of money as a nation. We know we spend proportionally more than almost every other country. So there’s a lot of spending. But when you add up the direct healthcare expenses and then things like housing, transportation, nutrition, right, the needs just grow exponentially.

So we’re going to have to think creatively about how we put together innovative funding streams and tie together different resources to be able to address these systemic needs as a country. I think it’s going to take a while just because it is so complicated and there were so many different programs that have been put in place that we’re going to have to step back and think, again, a little bit differently about healthcare and how it relates to housing, education, transportation, nutrition, behavioral health services.

I mean, there’s a whole host of challenges, but I think as a country, given all that we’re facing right now, I think, coming out of COVID, it’s really going to force us to think a little bit differently from an individual health perspective, from a societal health and public health perspective. And I’m excited to engage in that discussion. I know our members are as well.

Gordon: Yeah, it’s interesting. When I think about the first alarming sense is gee, we don’t have the budget for that kind of thing. But then, I think it may not be in my budget, but globally, we’re spending the money now. We just may not be spending it very wisely. I’ve got a colleague of mine who’s running a patient care intervention center in Houston, Texas. And they’re working with folks who are homeless on the street with schizophrenia and drug abuse, who are being arrested and bouncing in and out of hospitals and treatments and jails.

And when you look at all of those budgets together, getting ahead of somebody’s illness and getting them to be consistent and taking their medication, for instance, reduces not just the unnecessary ED visits and hospitalizations but jail days and arrest days and court days and all of that. And it actually can decompress budgets significantly. Is that the kind of conversation you’re signaling that needs to happen?

Matt: I think over the long-term, it absolutely is, right? I think what we should do though is, in the short-term, focus on those interventions we know that have the greatest direct impact and relationship to health. And then I think we can expand from there as we learn a little bit more over time. But it’s a conversation that absolutely is happening, I think, across the country. When I think to our events and conferences that we’ve had pre-COVID and even post-COVID now, right, social determinants and how we address this has been on the A-list for the past year.

And I think it’s gone from a level of awareness and recognition into one where I think we know we need to take action and we are seeing action. And from there, it’s going to, I think, evolve into a bigger policy and advocacy discussion about how should we address it as a country and what’s the right role of the government, both the federal government and state governments and local governments and the private sector and different parts of the private sector, whether we’re talking about the healthcare system and the role of healthcare providers, what’s happening in the educational system. And it’s incredibly complex, but it’s something that I do believe is on the cusp of a really important national debate over the coming next couple of years.

Gordon: Let’s say you’ve got a plan who’s just getting engaged as a member and they’re asking the question, what are the short term actions that they can take, where do they turn to get some info on that?

Matt: I think our Project Link campaign and initiative is really a great example because it’s about sharing practices across the industry so that we put out materials to our members, we have regular discussions, both among our member companies but also bring in external experts. And I think that’s really a great place.

If you just want an example of a program, I’d say, look at what’s happening in Medicare Advantage over the past couple of years, especially as there’s been a recognition about the importance of so-called supplemental benefits. So everyone’s familiar with the core Medicare benefits, physician services, hospitalization. Medicare Advantage is a little bit different because Medicare Advantage Plans are essentially paid on a capitated basis on a per-member-per month.

So they’re given resources that need to be managed and meet everyone’s direct medical needs, but there’s also an ability to offer these supplemental benefits now. Again, we’ve touched on some of them, transportation benefits, in-home services are really popular, being able to make sure people are able to stay in their home safely, the nutrition benefits, transportation, others, again, so that people can get to the doctor, get to the pharmacy.

And they’re all paid for under the Medicare Advantage program through this capitated basis. And it would be impossible to replicate in a fee-for-service program, like the traditional Medicare program. So I’d say that’s an area really where we can learn a lot, obviously, a high-need, high-touch population. Seniors have among our greatest healthcare needs. Obviously, as we all age and get a little bit older, we know that our healthcare needs change a bit.

But I I’d point people to that program and say, “Look what’s happening there and see what you might be able to replicate, see what you might be able to pour it into other commercial benefits even potentially.”

Gordon: I look at a lot of claims data across Medicare, Medicaid, commercial. And I look at these grids of a population broken out by health status and severity. And I look at rates of hospitalization, ED visits, readmission, complications, and things like that broken up by these rates. And then I put up Medicare population in there. We see rates in the hundreds per thousand members per year for readmissions, hospital admissions, when they start having multiple chronic conditions, it’s no surprise.

If you need examples of where can we demonstrate good effective intervention, you’re going to see it quickly in Medicare Advantage population because you have the innovation possibility with the payment model. And so you have a population that’s quite fragile and has high utilization. So that’s a terrific example.

I’m also thinking though about Medicaid populations. The utilization patterns are a little bit different there. You don’t necessarily see the same overall population burden of high illness. But when you do have people with high illness in Medicaid populations, it’s the same pattern of very high admissions and readmissions. But then, I’m thinking about what’s happening with COVID and state budgets, and they’re going off a cliff in 2021. The state budgets are going to be really awful and states are going to be forced to do some pretty draconian things aside from cutting rates and disenrolling, what can the state do?

Matt: I think you raise a critical point, Gordon, which is the pressure, the economic pressures that so many people are feeling, right, are hitting the states and localities. And Medicaid is usually either one of the top two or three line items in a state budget. And we are incredibly concerned about what is going to happen to state Medicaid programs just given the resource crunch as the Congress has addressed COVID in a couple of different packages.

One of the things they’ve done is to bump up the state’s matching rate, so-called FMAP, by 6.2 percentage points. And we think that’s an important start, and that’s going to last throughout the state of the public health emergency. But it’s not going to be enough as we see the impact of the economic crash over time. We know that state Medicaid programs are going to need to expand.

And we’re already beginning to see the evidence of that by way of enrollment. And so within this next legislative package, so here we are in early August, we know that pressure is on Congress to enact some additional COVID-related relief, whether it’s unemployment benefits but also relief for state and local governments. We think it’s critically important that they increase the FMAP at least up to 12 percentage points additional from the baseline.

It’s something that a broad and diverse cross-section of stakeholders agrees to the national governor’s association. So this is the bipartisan group that represents both Republican and Democratic governors and a number of other different governmental entities. I mean, that’s among their top asks for Congress in this next package of relief because they know what’s coming by way of state enrollment and the impact on state budgets, especially state economy has given the economic decline.

And so that’s one of our top priorities as well is to make sure that the states get the resources they need because people need to stay covered, they need to have the benefits that are necessary to meet their medical needs and cover their health. And Medicaid is a critical program. Most people don’t know that it’s actually after employer-sponsored coverage. I mean, it’s bigger than the Medicare program by the number of people it covers, and that’s only going to grow given what we’ve seen.

You’ve really touched on an important point about Medicaid and why we need to make sure that the states have the resources that they need to make sure that people don’t lose coverage.

Gordon: So states are looking at the various levers they have. They can think about unit price, problem with unit prices, typically, and the healthcare delivery system. If my unit price goes down, I just increase the number of units I produce in a fee-for-service models, so that doesn’t get you anywhere. And plus, if everybody gets angry and cranky, then there’s the enrollment numbers, and we can work with that. But again, that can be pretty tough, especially when we’re dealing with very tough times and people out of work and looking for some kind of medical coverage. And so that could be a tough one.

Have your members looked at other things that they can do that can help reduce the cost but cover more people?

Matt: Absolutely. And I think the move towards greater value-based payment systems at a global level across different specialties even, I think, is an area where there’s a sense that you can help stretch scarce dollars and make them go farther than they can today. Also, by focusing on, I think, prevention, early interventions, wellness, right, that we can get to some of these conditions earlier and hopefully reduce and even maybe bend the cost curve down in some cases and making sure that those preventive treatments and services, a greater focus on cost effective prescription drugs and making sure that we have the flexibility to use generics and other less costly therapeutic alternatives to higher cost-branded drugs.

I mean, there’s a host of different interventions that I know our members are looking at every day to try and stretch those dollars to go as far as they possibly can.

Gordon: There’s some cynicism, I think, in some parts looking at the Affordable Care Act, Accountable Care Organization moves that didn’t result in dramatic improvement. Do these suggestions just to reiterate that or is it different somehow?

Matt: I think it’s different when you’re looking at a managed care model versus an ACO model. I think the incentives, while similar, there’s just a little difference in terms of how they operate. And I think that’s one of the reasons why we haven’t seen necessarily the results from the ACO model that we’ve seen from managed care. It’s just a much more difficult, I think, model to manage. It’s difficult to sometimes know who’s in the ACO model, who’s not, but you know who’s in the health plan, who is and who isn’t.

When you get down to it, it’s not really the core competency of an ACO while there had been phenomenal steps taken. When you get down to it, it’s not necessarily within their DNA in the same way that it is when you talk about a managed care entity. So it can be, I think, a step with ACOs. But I think, ultimately, a managed care is a more effective model long-term.

Gordon: Yeah. So it makes me think about people doing what they know best, how do you put together a network, how do you make sure that it’s all coordinated and that the services are accessible in all parts and get people to them? That’s not something that healthcare delivery system is necessarily all that familiar with. They may know their market, their region, but where do those people live and go for services?

Matt: I think it’s also why, Gordon, we’ve seen some of the systems actually set up health plans, right? I mean, when I look across AHIP’s membership, we represent everyone which makes us, I think, a little different because we have large national for-profit publicly traded companies. We have Blue Cross Blue Shield organizations that operate maybe on a single-state or maybe a multi-state basis. We have regional plans that might just operate in a particular area.

But I really do focus on those provider-sponsored health plans now as one of a faster growing segment because, I think, the health systems, they recognize, let the health system specialize in what they’re going to do. And perhaps we can set up a complementary health insurance organization that partners with our health system. And we’ve seen that be a very rapidly growing segment of our membership.

Gordon: One of the things that was implicit in your description of the Medicare Advantage Plans, which is innovation and trying new things, which is more possible under global budgeting, capitation payments, and value-based payments. One of the innovative things that we’ve seen really rip loose with COVID-19 is telemedicine, telephone, video, and the like. That has for obvious reasons really exploded.

And there are a lot of providers who said, “It’s about time. We’ve been asking for this forever.” What was the hang-up in getting there? And so are we going to see this sustain when COVID hopefully begins to ramp down?

Matt: Yeah. I know our members have been actively advocating for enhanced, expanded telemedicine for several years. And I think that there were parts of the healthcare system that were receptive to it. And then there were other parts that were resistant. When COVID hit, there wasn’t really an option, right? Because as the health care system and the country shut down, people still needed to have access to their healthcare providers. And telemedicine was the logical channel by which to make sure that they had access.

And I think we’re all amazed to see how rapid the growth was. I mean, we’re not just talking 10, 20, 50 percent. We’re talking 500, 5,000 percent increases and across all sorts of different medical specialties, not just primary care, but across different provider types. There were a couple of, I think, barriers to doing it, whether it be things like state licensure, really just public acceptance. But I think, now, it is here to stay.

And we’ve probably seen a greater acceleration in the role of telemedicine in the past five months than we would have seen in the coming five or ten years. And I don’t think that there’s any way we’re going back. Just yesterday, even the president issued an executive order around how do we make sure that we continue to enhance the role of telemedicine to help ensure access, not just to some populations, but all populations, and especially how it could be helpful to rural populations who might have difficulty accessing it because they don’t have broadband or other services that you need.

I don’t think it’s going back to the way it was. I don’t know if it will continue on the current trajectory. I think we will see a logical plateau, especially when we get more COVID therapeutics and vaccines. But the customer satisfaction numbers that I’ve seen for people that have used it are through the roof. I mean, people have had a really great experience overall with the shift to telemedicine.

And I think the level of convenience that it offers when you can get access to a healthcare provider really almost any time of day, I mean, it might be not your own provider 24/7, but at a much more enhanced level, I believe that we’re going to continue down this path. Although I’m sure there’ll be some modifications that we’ll have to get used to as well.

Gordon: Well, one of the concerns I’ve heard in the past is that you don’t know exactly how this is going to impact budgets and quality. Do we see too much in the wrong circumstance, or is it just another mode of billing that doesn’t necessarily change outcomes? I think there’s some early indication that actually is very beneficial to populations that we can actually decompress some of the downstream costs, but that’s really what we’ll need to see in the proof.

Let’s watch and see, with the introduction of telemedicine, what happens to total cost of care, what happens to utilization rates and rates of hospitalization ED visits. That’s going to be the real proof. But you mentioned one piece, which is interesting to me, which is the difficulty in some populations, some groups that don’t necessarily have access to broadband.

I was talking to a healthcare delivery system in Washington, DC, that was hoping that there would be allowance of audio-only televisits because of the number of people that they’re working with, mostly Medicaid populations. And that when used well, was a terrific portal of access and reduced barriers to entry to care. Is that something that’s interesting to your members or is that frightening to them? What do they say to you?

Matt: I think they’re realistic in terms of making sure that an individual has access. You have to make sure that it’s through a channel that they can actually use. While video may be preferable, there are just some instances where audio-only is the only option. And we’ve seen this especially in, I think, Medicaid populations. We’ve seen it in the Medicare population as well.

Some seniors haven’t maybe gotten used to FaceTime or Zoom or other video platforms, or maybe they don’t have a smartphone or other ways that allow them to access it. And we need to make sure that whether it’s seniors or Medicaid beneficiaries or others have access to the care that they need. And in Medicare, right now, we were actually advocating for these audio-only encounters to count for Medicare Advantage risk score purposes.

Now, this gets really weedy very quick. But we’ve seen such a decline in utilization because people were afraid to leave their house and go to the physician, or maybe their physician wasn’t available and their offices were shut. But someone who had an existing condition was working with their healthcare provider and it was only through audio. I mean, as long as there are guardrails and protections against fraud, waste, and abuse, those are the types of things that we think are important to make sure that we’re not going to see an increase in premiums in Medicare Advantage Plans or a reduction in some of these supplemental benefits that we talked about earlier.

Just because people weren’t physically going to the doctor doesn’t mean that someone who had diabetes, hypertension, or some other medical condition and was getting care and treatment from their healthcare professional, I mean, it was a valid way of being treated at that time. And so we think those are examples where audio-only would be completely warranted.

Gordon: Yeah. I’ll give you a couple examples I’ve come across recently for that. There were both children’s hospitals, one in Dallas, Texas, and another one, Nationwide Children’s in Ohio. And when COVID came down, they both saw their sick kids who were going to these academic medical centers not coming in because the parents were rightfully afraid that they could expose their children to COVID by going to the doctor’s office.

Worried that these children are lost to follow-up and things could be going bad because they’re out of view, they used risk-based models to segment the population into those who are at greatest risk of bad outcomes and had telephone visits with them, had their case manager folks call them up and say, “How are you doing? Check in. Let’s see what’s going on. Let’s take care of your needs.”

And I remember doing that in my own practice with sick folks, and for a lot of things, we can actually take care of quite a bit on the phone. And again, I think it needs to be looked at carefully. It doesn’t need to be audited. We need to make sure it’s not abused and it’s done right. And we all need to learn how to do that well.

But you look at the children’s hospitals as examples, and they’ve been doing this for years, they’re doing it very, very elegantly. And we’re very quick to pivot because of their experience using telemedicine with school-based clinics in the past. And I think that’s a terrific battle. So it sounds like your members are really on the ball with that.

So one last thing, I noticed in the letter, you were talking about surprise billing. And I remember looking at something in the paper just a day or so ago where somebody, in one headline, and I don’t know if it’s representative, but I guess that’s part of my question, somebody went to a hospital for something and they forgot to bill for a COVID test, and the person received an out-of-pocket bill of something, an excessive $1,500 for the COVID test. Is that surprise billing? Is that stuff still going on? Haven’t we gotten ahead of that? Where is AHIP’s stand on this?

Matt: Well, I wish we had gotten ahead of it. I mean, surprise bills is still a problem. And I know the article that you’re referring to. I think that was really a mistake in terms of how the provider had coded or submitted claims that it wasn’t clear that the individual had actually been tested for COVID. And to the extent that someone has ordered and received a COVID test, then other treatments and services that are delivered at the same time or as part of the same episode will be covered and generally covered without any cost sharing overall.

But surprise bills, there’s still a problem. I don’t believe it’s likely that surprise bills will be included in any of the efforts around COVID that might happen this summer. But it’s an issue that’s not going away. And we believe a solution that takes patients, consumers out of the middle provides for a fair market-based payment rate for providers is the best approach to make sure that we don’t see surprise bills continuing in our system.

We know some others would like to rely more on arbitration and dispute resolution. There are some evidence out there from states that use dispute resolution, that it hasn’t reduced costs, it hasn’t eliminated the problem. And we know that, like in the state of Texas, which has had a dispute resolution, we’ve seen an explosion in terms of that avenue being pursued. It’s not going to help simplify our healthcare system or make it less expensive. And it’s going to continue to be a problem.

Unfortunately, until, I think, we get a federal solution, it can’t be done on a piecemeal level state by state. We really do need a federal solution for surprise bills.

Gordon: Well, I have to say this has been a fantastic conversation. And I love to see how packed the agenda is for AHIP and what’s interesting to your members and what they’re pushing. Matt Eyles, thank you so much for your time today.

Matt: Well, thank you, Gordon. It’s never boring being in this position, I’ll tell you that, so I appreciate the time.

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