Health­care com­pa­nies aim to con­vert par­ti­san grid­lock into progress

Modern Healthcare - - NEWS - By Shelby Liv­ingston and Alex Kacik

In a show of un­prece­dented unity, health­care providers and pay­ers banded to­gether to de­feat Se­nate Repub­li­cans’ lat­est at­tempt to re­peal the Af­ford­able Care Act.

They breathed a col­lec­tive sigh of re­lief af­ter Se­nate lead­ers de­cided Sept. 25 not to vote on the Gra­ham-Cas­sidy bill, which would have con­verted the ACA’s fund­ing for pre­mium and cost-shar­ing re­duc­tion sub­si­dies and Med­i­caid ex­pan­sion into $1.2 tril­lion in state block grants through 2026 and let states de­sign their own sys­tems, with few lim­i­ta­tions.

But pay­ers’ and providers’ work isn’t over. Now that the re­peal at­tempt has stalled, hos­pi­tals and health in­sur­ers hope to build on that suc­cess by bring­ing back bi­par­ti­san ef­forts to sta­bi­lize the trou­bled in­di­vid­ual in­sur­ance mar­ket and turn­ing law­mak­ers’ fo­cus to re­duc­ing costs in the U.S. health­care sys­tem.

“We are not ad­dress­ing the root cause of the prob­lem, which is the es­ca­lat­ing cost of health­care,” said Dr. Toby Cos­grove, pres­i­dent and CEO of the Cleve­land Clinic. “We need to fo­cus on what makes our sys­tem in­ef­fi­cient—the ris­ing cost of drugs, lack of in­ter­op­er­abil­ity, over-reg­u­la­tion, tort is­sues across the coun­try. How we are go­ing to get the coun­try healthy re­quires a closer look at smok­ing, obe­sity and the opi­oid cri­sis.”

Providers said the on­go­ing leg­isla­tive debate over the re­peal of the ACA led politi­cians to lose fo­cus of health­care’s key tenet—what’s best for the pa­tient.

“We stopped think­ing about the in­di­vid­ual,” said Stephen Rosen­thal, se­nior vice pres­i­dent of pop­u­la­tion health man­age­ment for Mon­te­fiore Health Sys­tem in New York. “We are harm­ing the pa­tient by our in­de­ci­sion and

We are not ad­dress­ing the root cause of the prob­lem, which is the es­ca­lat­ing cost of health­care. We need to fo­cus on what makes our sys­tem in­ef­fi­cient—the ris­ing cost of drugs, lack of in­ter­op­er­abil­ity, over­reg­u­la­tion, tort is­sues across the coun­try. Dr. Toby Cos­grove Pres­i­dent and CEO Cleve­land Clinic

will­ing­ness to elim­i­nate all the dol­lars as­so­ci­ated with ben­e­fits in place, par­tic­u­larly Med­i­caid. We have moved away from the sin­gu­lar thought of keep­ing the pa­tient first.”

Dr. Ken­neth Davis, CEO of Mount Si­nai Health Sys­tem in New York, agreed, say­ing, “There is a chasm be­tween the de­bates go­ing on in the Se­nate and House and the re­al­ity of what we face day-to-day and what fixes are re­quired to re­ally change the na­ture of health­care de­liv­ery.”

The un­cer­tainty sur­round­ing the ACA’s fu­ture has af­fected providers’ bot­tom lines. Sys­tems like Mount Si­nai have lim­ited spend­ing on re­sources and in­fra­struc­ture that would ul­ti­mately im­prove care and lower costs, Davis said, adding that ad­min­is­tra­tive or con­gres­sional ac­tion can put a sys­tem with a small pos­i­tive mar­gin deep into the red.

“It makes plan­ning ex­ceed­ingly dif­fi­cult,” he said. “The un­cer­tainty that we face makes it hard to en­vi­sion the kind of cap­i­tal ex­pen­di­tures nec­es­sary to mod­ern­ize a lot of as­pects of our health­care sys­tem that ad­van­tage pa­tients.”

That un­cer­tainty has yet to sub­side. Hos­pi­tal and in­sur­ance ex­ec­u­tives stressed the im­por­tance of se­cur­ing fund­ing for cost-shar­ing sub­si­dies that lower co­pay­ments and de­ductibles for low-in­come Amer­i­cans who buy cover­age through the in­sur­ance ex­changes.

While the sub­si­dies are be­ing paid on a monthly ba­sis, Pres­i­dent Don­ald Trump has re­peat­edly threat­ened to end them. With­out a guar­an­tee that the sub­si­dies would con­tinue through next year, many in­sur­ers filed rates with an added sur­charge of as much as 20% to ac­count for the po­ten­tial loss of those pay­ments.

“That causes the pre­mi­ums that are go­ing to come out to be higher than they would need to be oth­er­wise ... un­less there is sort of the last-minute res­cue,” said UPMC Health Plan CEO Diane Holder. “I think most of us are not con­fi­dent that is go­ing to hap­pen.”

Ceci Con­nolly, pres­i­dent of the Al­liance of Com­mu­nity Health Plans, said there is a “real dan­ger” in not ad­dress­ing CSR pay­ments. “If the CSRs go away and many of those work­ing fam­i­lies

de­cide they can’t af­ford cover­age with­out that help, that has real neg­a­tive ef­fects on the risk pool, which will in turn have neg­a­tive ef­fects on health plans, which will in turn have neg­a­tive ef­fects on the mar­ket. It is a frag­ile as­sem­bly of pieces that could fall apart very quickly.”

In­sur­ance com­pa­nies also face the prospect that Trump may sign an ex­ec­u­tive or­der soon to al­low cross-state in­sur­ance sales. Ex­perts have long warned that such a pol­icy would weaken consumer pro­tec­tions and fur­ther dam­age the in­di­vid­ual mar­ket.

Michael Conse­dine, CEO of the Na­tional As­so­ci­a­tion of In­sur­ance Com­mis­sion­ers, said in a state­ment that the NAIC “has long been op­posed to any at­tempt to re­duce or pre-empt state au­thor­ity or weaken consumer pro­tec­tions.” He noted that in­sur­ers al­ready are able to sell plans in mul­ti­ple states.

In­sur­ance com­pa­nies are also press­ing the Trump ad­min­is­tra­tion to con­tinue en­forc­ing the in­di­vid­ual man­date, which re­quires most peo­ple to en­roll in cover­age, and re­in­state fund­ing for Oba­macare mar­ket­ing and outreach. HHS an­nounced in Au­gust that it would slash the mar­ket­ing bud­get, and many plans worry those cuts, cou­pled with a weakly en­forced man­date, will lead to lower en­roll­ment. Now, 10.3 mil­lion Amer­i­cans are en­rolled in ACA mar­ket­place cover­age.

Providers, in­sur­ers and state in­sur­ance de­part­ments are step­ping up their outreach ef­forts in the wake of the loss of fed­eral fund­ing.

“We have the same mech­a­nisms in place to sup­port en­roll­ment in exchange plans or Med­i­caid ex­pan­sion and con­tinue those ef­forts, not­with­stand­ing the ad­min­is­tra­tion’s ef­forts around de­creas­ing fund­ing for nav­i­ga­tors,” said Dr. Richard Gil­fil­lan, CEO of Catholic-spon­sored sys­tem Trin­ity Health, based in Livo­nia, Mich.

Not-for-profit safety net health plans in the As­so­ci­a­tion for Com­mu­nity Af­fil­i­ated Plans will also do their own mar­ket­ing, ac­cord­ing to as­so­ci­a­tion CEO Mar­garet Mur­ray. She added that her or­ga­ni­za­tion is push­ing for re­duc­ing the num­ber of plans that don’t com­ply with the ACA, such as grand­fa­thered health plans, which she said help to desta­bi­lize the in­di­vid­ual mar­ket and in­crease pre­mi­ums.

Health­care com­pa­nies are hope­ful a bi­par­ti­san so­lu­tion to sta­bi­lize the ACA mar­ket­place can be reached. They are urg­ing Sens. La­mar Alexan­der (R-Tenn.) and Patty Mur­ray (D-Wash.) to re­visit their bi­par­ti­san talks to shore up the in­di­vid­ual in­sur­ance mar­ket­places in time for open en­roll­ment, which be­gins Nov. 1.

In Septem­ber, the two se­na­tors held a se­ries of hear­ings be­fore the Health, Ed­u­ca­tion, La­bor and Pen­sions Com­mit­tee on how to sta­bi­lize the mar­ket, but the con­ver­sa­tion was aban­doned when Repub­li­cans re­turned their at­ten­tion to re­peal­ing the ACA.

“I hope that there will be a more bi­par­ti­san ap­proach to look­ing at the kinds of things that can im­prove mar­ket sta­bil­ity,” UPMC’s Holder said. “When in­sur­ance mar­kets are sta­ble or more sta­ble, it al­lows (in­sur­ers) to plan more ef­fec­tively.”

Dr. David Barbe, pres­i­dent of the Amer­i­can Med­i­cal As­so­ci­a­tion, said the at­tempts to dis­man­tle the ACA gal­va­nized sup­port for com­pro­mise. “I’m hope­ful that the groups we have formed speak with one voice for changes go­ing for­ward. I hope that we will stay fo­cused on how all this im­pacts the pa­tient.”

In the mean­time, the ACA should be tweaked to make a big­ger dent in the ad­min­is­tra­tive bur­den that bogs down the en­tire in­dus­try, Mount Si­nai’s Davis said, sug­gest­ing that up to 10% of health­care costs are ex­ces­sive due to un­nec­es­sary ad­min­is­tra­tive tasks.

“What we lost sight of in the ACA is stip­u­la­tion of ad­min­is­tra­tive sim­pli­fi­ca­tion,” Davis said. “It all has to do with the in­ter­face be­tween pa­tients, providers and pay­ers.”

While Repub­li­can se­na­tors have re­treated from the lat­est bat­tle to undo the ACA, the fight is far from over, health­care ex­ec­u­tives said. “We need to build on the progress we have made over the last seven years, not dis­man­tle it,” Gil­fil­lan said.

Leg­is­la­tors should re­form the health­care law in a way that both par­ties can sup­port, UPMC’s Holder said. “You don’t want a ping­pong ball that every elec­tion means you are go­ing to whip­saw peo­ple and their health­care sit­u­a­tion,” he said.

We have the same mech­a­nisms in place to sup­port en­roll­ment in exchange plans or Med­i­caid ex­pan­sion and con­tinue those ef­forts, not­with­stand­ing the ad­min­is­tra­tion’s ef­forts around de­creas­ing fund­ing for nav­i­ga­tors. Dr. Richard Gil­fil­lan CEO Trin­ity Health If the CSRs go away and many of those work­ing fam­i­lies de­cide they can’t af­ford cover­age with­out that help, that has real neg­a­tive ef­fects on the risk pool, which will in turn have neg­a­tive ef­fects on health plans, which will in turn have neg­a­tive ef­fects on the mar­ket. It is a frag­ile as­sem­bly of pieces that could fall apart very quickly. Ceci Con­nolly Pres­i­dent Al­liance of Com­mu­nity Health Plans

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