When it comes to looking at the near future for healthcare payers, a technology shift theme emerges.  Like all businesses, the need for technology updates is not necessarily a new topic in healthcare payer news, but some of the recent developments are interesting.  The “blockchain” opportunity is one example we explore in this roundup of latest happenings in the industry, along with new value strategies, and CMS policy changes.

Healthcare Payer News

Healthcare payer news shows a technology shift for the reimbursement process, along with policy and strategic changes.

Cancer Care remains a challenge for payers. An article in Modern Medicine points out that, “operationalizing and implementing a value paradigm for cancer care remains a complex challenge, according to a speaker at the AMCP Managed Care & Specialty Pharmacy Annual Meeting, in Denver”, which was held in March of this year.  Quoted in the article is Jeremy Schafer, PharmD, MBA, a senior vice president and director of specialty solutions at Precision for Valuea “group of former payers, academics, health economists, researchers, data analysts, medical reviewers, and marketing gurus”.  Schafer notes that, “under Medicare Part D regulation, oncology is a protected class and payers are required to accept clinical guidelines by professional bodies like the National Comprehensive Cancer Network (NCCN).”  He also points to rapidly changing treatment paradigms as a key part of the payer challenge.

Help for underinsured patients with movement disorders:  HealthPayerIntelligence.com is reporting that, “the HealthWell Foundation has launched the Movement Disorders Fund to provide financial support for those patients unable to pay insurance premiums or copays for necessary chronic care management. The fund is available to qualifying Medicare members with annual household incomes up to 500 percent of the poverty level. ”  According to the HealthWell website, eligibility is based on an individual’s medical, financial and insurance situation, and to qualify for assistance, applicants must meet stated requirements, including the patient’s income level.

What emergency care should payers cover?  Meanwhile, also in March, Health Payer Intelligence reported that the “poll from the American College Of Emergency Physicians (ACEP) and Morning Consult found that 95 percent of healthcare consumers say payers should cover emergency services.”   The poll resulted in an official statement which explains a stance by the ACEP for what should be covered by payers.  “When asked if someone visited the emergency department because they believed they were having a heart attack, but were later diagnosed with a panic attack, more than 8 in 10 (83 percent) Americans said that patient’s health insurance should cover that emergency visit. The principle of covering medical care based on symptoms that most people would consider potentially life-threatening, rather than the final diagnosis, is called the ‘prudent layperson’ standard. This was codified into federal law, including the Affordable Care Act, following years of denials of coverage for emergency care by health insurance companies.”  As their headline reads, the “Public Overwhelmingly Wants Insurance Companies To Cover Emergency Care and To Be Transparent.”

CMS has issued a final rule to “increase choices and encourage stability” in the health insurance marketplace for 2018.  In mid-April, CMS, noted that Individuals obtaining coverage in the Marketplace created by the Affordable Care Act have faced double-digit premium increases, and fewer plans to choose from. Therefore, they made some policy changes which include:

  • The final rule adjusts the annual open enrollment period for 2018 to more closely align with Medicare and the private market.
  • The final rule promotes program integrity by requiring individuals to submit supporting documentation for special enrollment periods and ensures that only those who are eligible are able to enroll.
  • The final rule promotes personal responsibility by allowing issuers to require individuals to pay back past due premiums before enrolling into a plan with the same issuer the following year.
  • For the 2018 plan year and beyond, the final rule allows issuers additional actuarial value flexibility to develop more choices with lower premium options for consumers.

Technology shift coming?  EHR Intelligence reports that “A growing number of healthcare organizations have set 2018 as the year for putting their digital information initiatives into place, according to recent findings from IDC Health Insights.” The survey of more than 280 providers and 50 payers focused on investments across five areas.  The article goes on to note that “one in ten providers and payers are currently in the process of implementing digital technologies primarily related to cloud services, cybersecurity, big data, and analytics,” and that “other digital technologies likely to garner attention include mobile applications and devices as well as wearable technology.”

When it comes to managing the hospital revenue cycle, the weather can seem a bit stormy lately!  Join us on May 24, 2017 for our webinar “Weathering the Storm: Best Practices for Patient Collections,” where Nick Davis, Product Manager for our Patient Access Modules will discuss best practices & tactics for successfully increasing patient collections.

Is the “blockchain” a solution for transparency in the link between payer and provider?  Healthcare Finance carried a recent article making the claim that, “blockchain is poised to become the next big healthcare innovation, and both insurance and provider organizations see real value in it.”  Blockchain may be understood as a distributed database that maintains a continuously growing list of records, called blocks, secured from tampering and revision.  The keys are security and distribution, and a recent Wired article gives one specific example that helps explain how it can benefit healthcare workers:

“Say that one medical record shows a patient takes aspirin. In another it says they’re taking Tylenol. Maybe another says they’re on Motrin and Lipitor. The problem today is that each EHR is only a snapshot; it doesn’t necessarily tell the doctor what the patient is taking right now. But with blockchain, each prescription is like a deposit, and when doctor discontinues a medication, they take a withdrawal. Looking at a blockchain, a doctor wouldn’t have to comb through all the deposits and withdrawals—they would just see the balance.” — from, “Moving Patient Data Is Messy, But Blockchain Is Here to Help” – Wired Magazine.

Putting it more concisely in a Healthcare Finance article, “Humana’s Chief Innovation Officer Chris Kay said blockchain eliminates the need for a third party to leverage and distribute data. Transactions can close in real time.”

Value paradigms, blockchains, and cloud services seem to be in the wind this year as the whole technology landscape shifts.  Will lower premiums materialize and be a help to the hospital revenue cycle?  CMS is angling in that direction and we will continue to review healthcare payer news and report as we move toward 2018.