In this episode of the "MHE Talks: Improving Patient Access" series, MHE speaks with Harvey Kaufman of Quest Diagnostics. The two discussed a recent Quest Diagnostics Health Trends report examining healthcare disparities.

MHE Talks: Looking Deeper Into Healthcare Disparities Through Quest Diagnostics Health Trends Report

COVID-19 incidence and mortality has dropped significantly since the beginning of the effort to vaccinate nursing home residents and staff, according to a 

The newspaper’s analysis of federal data found that new cases among nursing home residents fell by 80% from late December through early February and that the deaths decreased by 65%.

Nursing homes were hit hard early on during the pandemic and through much of 2020. The Kaiser Family Foundation reported in November that the death toll of long-term care residents and staff had reached 100,000.

From the beginning of April through the end of July, deaths among nursing home residents and staff accounted for about 40.6% of all COVID-19-related deaths in the U.S.

That proportion was calculated by taking the foundation’s tally of 62,718 long-term care facility deaths as of July 2020 as a percentage of the John Hopkins Coronavirus Resource Center’s cumulative COVID-19 death total of 154,500 at the end of July 31, 2020.

Articles

A New York Times analysis of federal data shows that deaths declined by 65% between late December and early February. 

Sharp downturn in nursing home COVID-19 cases, death after vaccinations started

Many Americans who receive Medicare benefits seem to lack knowledge and awareness on all of the options available to them, especially those who are older, according to a recent study by GoHealth.

Even while Medicare Advantage enrollment across the country has been much higher than it has ever been, the study shares many Medicare beneficiaries do not understand all of Medicare's benefits and services from Medicare Supplement; Part A,B and D, to Medicare Advantage.

Part A and Part B are significant health resources for many seniors, but original Medicare alone doesn’t cover all healthcare costs. Outside of adding a Part D prescription drug plan and a Medicare Supplement plan to a Medicare plan, a growing number of seniors are instead enrolling in Medicare Advantage (Part C), the study said.

However, of 1,000 Medicare Advantage beneficiaries and 1,000 original Medicare beneficiaries, there is a difference in their knowledge of options. Of the 2,000 U.S. citizens aged 65 and older polled, original Medicare beneficiaries were less knowledgeable than Medicare Advantage beneficiaries in several areas. 



According to the study, some of these areas include:

78% of Medicare Advantage beneficiaries cite cost savings as a reason for their choice.

30% of Original Medicare beneficiaries believe Medicare Advantage is more expensive.

65% of Original Medicare beneficiaries don’t know that Medicare Advantage plans provide Part A and Part B coverage.

86% of Original Medicare respondents believe Original Medicare alone provides out-of-pocket maximum (it does not).

"Such misconceptions can be harmful if they cause a person not to seek out the coverage and care they need," said GoHealth Chief Medical Officer, Paul Hain, MD. "We've always aimed to educate our customers first. For many people, we're their only point of contact regarding Medicare and how it works. Clearing up misconceptions and providing helpful information has always been at the forefront of what we do. However, we are starting to see just how negatively those misconceptions can affect the average Medicare-aged American. How can we help the 21% who have never reviewed their plan, or the 11% who only do so every few years?"

A significant group impacted by this knowledge gap appears to be original Medicare enrollees. 

40% of Original Medicare beneficiaries weren't also enrolled in either a Medicare Supplement or Part D plan, or weren't sure.

36% of Original Medicare beneficiaries do not know that Medicare Advantage has benefits Original Medicare does not offer.

35% of Original Medicare beneficiaries will not switch to Medicare Advantage because they fear losing their coverage.

62% believe that Medicare Advantage plans can change without informing the beneficiary.

In all, just 18% of Original Medicare enrollees said they were "very familiar" with Medicare Advantage; 30% are either unsure or not at all familiar with Part C plans.

53% falsely believe their Original Medicare covers long-term care, which may set them up for a costly disappointment if a serious medical issue arises.

While Medicare Advantage enrollees seem to be more knowledgeable about Part C in general, engagement with their plans often ends when they enroll in Medicare Advantage.

61% immediately enrolled in Medicare Advantage when they were first eligible for Medicare Parts A and B.

70% of Medicare Advantage enrollees have never switched to another Part C plan

This issue points to a lack of engagement in their policy. While beneficiaries may have taken the extra steps to learn about and enroll in a Medicare Advantage plan in the past, the same plan beyond year one may not be the most health- or cost-effective option available to them as their health needs, provider networks and circumstances change.

Perhaps most telling is that 19% of respondents with Medicare Advantage worry they are not getting maximum cost savings from their plans, and 53% of them are not aware of any resources to help find the answers they need.

"The fact that so many people don't know whom to ask when they have questions, to me, was startling," said Hain. "It's clear that while Medicare Advantage enrollment is growing each year, there's still a sizable gap in what the average American knows about it. That also extends to those in Original Medicare who don't know they may have better options available."

Recent GoHealth survey suggests many Medicare enrollees, especially older Americans, could be leaving valuable services and cost savings on the table.

Knowledge, Awareness of Medicare Advantage Plans Remain Low Despite High Enrollment

Former Secretary of the Department of Health and Human Services Alex Azar’s implementation of new work requirements failed to consider the negative health impacts the loss of Medicaid coverage would have on women, particularly women of color, according to a recent 

 filed by the Lawyers’ Committee for Civil Rights Under Law, the National Women’s Law Center and Holland & Knight law firm. 

“We must protect access to healthcare for women and communities of color, especially during a pandemic,” said Dorian Spence, director of Special Litigation and Advocacy at the

Lawyers’ Committee for Civil Rights Under Law

 “Medicaid is essential coverage that should be inclusive, equitable and upheld at all costs. While COVID-19 ravages Black and Latinx communities, unnecessary barriers to healthcare coverage could mean the difference between life and death and have to be eliminated.”

Medicaid serves as a critical lifeline, providing medical insurance coverage to hundreds of thousands of low-income people across the country. Following the passage of the Patient Protection and Affordable Care Act (ACA), Medicaid coverage was extended to thousands of additional low-income, non-elderly adults who would normally not qualify. Work requirement programs permit states to use employment as a perquisite for Medicaid eligibility and could lead to more than 600,000 individuals losing their coverage if adopted nationwide.

“Work requirements are outrageous, illegal, and founded in racist, sexist stereotypes, and must be eliminated for good. People deserve essential, often lifesaving, health coverage and shouldn’t have to fight against barriers for this vital care,” said 

, ‎Director of Reproductive Rights and Health Litigation at the 

 “Medicaid was designed to help people, and strengthen families and communities. It should live up to this mission, free from work requirements.”

Medicaid beneficiaries who do not fulfill the work requirements could lose their Medicaid coverage

 under the New Hampshire and Arkansas programs. In fact, over 18,000 beneficiaries in Arkansas lost their coverage when the work requirement program was in effect before the court struck it down.

The brief focuses on the devastating impact that Medicaid work requirements would have on women and communities of color, specifically Black women. These communities critically rely on Medicaid for their healthcare. 

As noted in the brief, “the majority of adult Medicaid beneficiaries are women, and women of color make up well over half of women on Medicaid." The brief goes on to note that “nearly 60% of Medicaid enrollees are people of color.” 

These requirements would serve as an undue burden on populations that have historically faced intersectional challenges to health care coverage, including being more likely to live in poverty and work in low-wage jobs that do not provide benefits. 

Healthcare access and protections are especially critical during a global pandemic. By providing health coverage to women and their families exclusive of employment, Medicaid allows women the flexibility to change jobs, engage in job training, or make career changes that provide higher wages or better opportunities. Secretary Azar’s failure to consider how the approval of work requirements would affect coverage must be recognized and eliminated. The decision of the lower courts must be upheld to protect Medicaid access and coverage for all. 

National Lawyers’ Committee files joint amicus brief to oppose discriminatory employment policies encouraged by HHS. 


National Civil Rights Groups Challenge Medicaid Work Requirements     

Results of a large study conducted in Israel show that after a two weeks, a single dose of the 

 COVID-19 vaccine is 62% effective at preventing severe cases of the disease.

The Pfizer-BioNTech vaccine is currently approved as a two-dose regimen, and the findings reported in the 

today (Feb. 24) show that it is considerably more effective at two doses. But the results are good enough for the single dose that they may invite some consideration of using the Pfizer-BoNTech vaccine as a single dose or, at the very least, a reason to space out the interval between the first and second doses. A longer interval between does could speed vaccination and achieve herd immunity faster.

 were based on a large study of members of Clalit Health Services, an integrated healthcare organization in Israel. The researchers matched 596,618 vaccinated members to the same number of unvaccinated members to assess the effectiveness of the vaccine in preventing a variety of different COVID-19-related outcomes. 

In the abstract the researchers reported the vaccine’s effectiveness for several COVID-19-related outcomes at days 14–20 after the first dose and compared those figures to ithe effectiveness at seven or more days after a second dose was administered.

 (Feb. 24) that it had completed manufacture of a version of its approved mRNA vaccine that is designed to combat the variant of the SARS-CoV-2 virus that emerged in South Africa.

The company said the tweaked vaccine, named mRNA-1273.351, had been shipped to the NIH in anticipation of starting a phase 1 trial that will involve injecting it in a small group of people to assess its safety.

The Cambridge, Massachusetts, biotech company said the tweaked vaccine may be used by itself as booster or combined into a single dose along with the company’s authorized vaccine, mRNA-1273. Moderna is calling that combined, “multivalent booster” mRNA-1273.211.

The company’s press release said it plans to evaluate mRNA-1273.351 and mRNA-1273.211 as a primary vaccination series.

seems likely to get an emergency use authorization (EUA_ from the FDA, perhaps early next week. 

A briefing document prepared by the agency staff that was made public today (Feb. 24) that said company trial data show the vaccine is 66.1% effective against laboratory-confirmed moderate-to-severe COVID-19 and has “favorable safety profile with no specific safety concerns identified that would preclude issuance of an EUA.“

The briefing document was prepared for the much-anticipated meeting 

Vaccines and Related Biological Products Advisory Committee

 meeting on Friday (Feb. 26.) The committee’s role is advisory — the FDA has the final word on the EUA — but influential. The document that came out today is just a briefing document for the committee but the lack of any red flags points to a committee endorsement and then an agency OK early next week.  

Israeli study shows good results for just a single dose of Pfizer-BioNTech; Moderna has made a version to combat the South African variant; and J&J's single-dose vaccine seems headed for an EUA. 

Good news about the Pfizer-BioNTech, Moderna and J&J COVID-19 vaccines

Dark skin is significantly underrepresented in medical literature and curricula, comprising an average of just 4.5% of images in medical textbooks. In response, clinicians of all licensures and specialties are often insufficiently trained to recognize disease patterns in patients of color. To confront this issue, Project IMPACT was created to raise awareness and adoption of educational and clinical resources and solutions that strengthen clinicians’ ability to accurately diagnose disease in black and brown skin and improve health equity.

 developed Project IMPACT (Improving Medicine’s Power to Address Care and Treatment) with help from thought leaders on skin of color and diagnostic accuracy from renowned organizations such as the 

(SOCS) and New England Journal of Medicine (

“Dermatologic and systemic diseases present with varying shades of color, erythema, and patterns in patients of color with melanin-rich skin," said Lynn McKinley-Grant, MD, FAAD, board-certified dermatologist, SOCS President, Associate Professor, Department of Dermatology, Howard University College of Medicine and Former Vice-Chair for Diversity and Community Engagement at Duke University College of Medicine, Department of Dermatology. "The Skin of Color Society (SOCS) has been working to advance healthcare equity, education, research and mentoring since our founding in 2004. We now are honored to collaborate and share the expertise of our members with VisualDx and NEJM Group on this vitally important initiative."

For more than twenty years, VisualDx has worked with board-certified physicians across the globe to collect hundreds of thousands of professional medical images displaying the full spectrum of disease presentations across skin types. As a result, 

 of images in its platform represent dark skin types. 

 also indicate that clinicians leveraging VisualDx at the point of care can improve diagnostic accuracy as well as patient education and engagement, particularly for traditionally marginalized groups.

“Lack of sufficient medical education on darker skin has had direct implications on health disparities in patients of color,” said Nada Elbuluk, MD, MSc, FAAD, a board-certified dermatologist and Director of Clinical Impact at VisualDx. “Project IMPACT was created with the understanding that a far-reaching, collaborative effort is needed to eliminate systemic racism in healthcare. I’m honored to lead this charge and help build a global community dedicated to transforming medicine for the good of all patients.”

Students, educators, clinicians, and patients working toward greater health equity are encouraged to take the pledge to make an impact and to share their stories on social media using the hashtag #ProjectIMPACT. 

Addressing Racism and Implicit Bias in Medicine

Below is an excerpt Q&A from conversation with Rob:

 So now in your field of healthcare, how do you see remote monitoring and IoT advancing?

 Yeah, so I think to get to the advancing part, we need to take a little step back to frame everyone. So, you know, pacemakers have been around for 60 years. And one of the really cool things about them is they're dynamic, right? You can program them and change them. And the second thing is they collect information about themselves, how they're performing, and the patient they're in. And so through the years, there's been this need to interact with the device. So years and years ago, the interaction would have been, ironically, sticking a needle into the chest to put into the device and turn to change it. 

That quickly went away, fortunately, to programmers that could interact. That's evolved through the years to sophisticated programmers, and then remote monitoring. So now we actually have some patients, we have programmers that are not just our own proprietary programmers, but we use a tablet-based consumer tablet as our platform. So that has huge advantages for the ability to to scale and leverage all the benefits of how those tablets work. 

We can also now not only have monitors at a patient's bedside that automatically do that interaction with the device, but we've even shifted through Bluetooth signals coming from the device to have a secure connection between a patient their device and their iPhone to transmit that information.

 So obviously, this is just to reach patients faster or track something quicker?

 Exactly, exactly. So again, it used to be that a patient would have to come into the office every three to six months. And you, you could check the device and if there was a surprise waiting for you, you had to deal with it. Now, what's amazing is within minutes, two hours, if there's something going on with the patient or the device, the office can know about it and act on it and contact the patient and set up the next, you know, change of care plan if need be.

 Why is remote tech gaining more adoption for patients who have chronic conditions like heart failure, COPD and diabetes? 

: This represents kind of the shift, right? Initially, remote monitoring was being done, so that I could know what was going on with the device. And if something was needed to be changed or altered or something was going wrong, I could act on it quickly. There's a whole array of information that remote monitoring was better than these office visits. Now you add that the devices can detect things like: is the activity level going down, is something about the patient's respiratory rate changing that says, "hey, they might have an impending heart failure exacerbation or a lung problem?" Now we can get that information sooner. 

So again, typically, you'd have to say, you know, a patient has to call in the office, if they're not feeling well, or you wait till they've arrived at the office not feeling well, or they're sick enough they come to the emergency room. These devices now give the opportunity to kind of catch this cycle even before the patient is feeling bad and for example, we have a with an algorithm and our device that integrates a bunch of the initial to try to send a signal to the clinic to say, "Hey, take a look at this patient, because their likelihood of coming into the hospital 30 days from now is going up compared to the background." And when we do that we can try to bend that curve and hopefully act before they need to come in.

Podcasts

In this week's episode of Tuning In to the C-Suite podcast, MHE's Briana Contreras spoke with Dr. Rob Kowal, chief medical officer of the Cardiac Rhythm and Heart Failure division at Medtronic. The two discussed how remote monitoring and IoT is changing healthcare and how remote technology is also gaining a wide-spread adoption to monitor patients at home who have chronic conditions like heart failure, chronic obstructive pulmonary disease and diabetes.

Remote Care Advancement for Heart Failure, COPD and Diabetes Patients

The technology infrastructure of many health plans today could be described as costly, fragmented and siloed. Rather than focusing on the customer experience, growth and transformation, these plans are responding reactively to business needs and market shifts. However, we are seeing innovative CIOs at health plans transforming their traditional operating models to leverage technology that enables the strategic goals of the enterprise while dramatically reducing costs.

A major focus on this journey is establishing a future technology foundation that supports a digitally enabled enterprise. This requires a leader who can assess the current organization's technology; create a roadmap that is business-aligned and clear; build a groundswell of support; and then implement and innovate. Equally important is the significant culture change associated with this shift. This may also necessitate the need for additional talent to enact the roadmap. A high priority is ensuring appropriate security safeguards are in place alongside service delivery and financial stewardship.

Health plan CIOs who are asked to embark on this journey are guided by the principles of improving their members' lives through products, services and reducing costs. These leaders optimize and leverage cutting-edge technology motivated by improving health outcomes for their members. Experienced CIOs at health plans are passionate about improving healthcare, possess deep knowledge of the healthcare landscape, are stewards of their members' time and money and are able to build and lead their teams to advance and innovate technology that is aligned with the business of their health plans.

In our work recruiting for these positions, we have found the core responsibilities of a successful, forward-thinking health plan CIO to include the following:

Mentor, recruit, retain and develop high-performing, actively engaged IT leaders and staff; create a positive workplace environment; and foster a culture of collaboration.

Maintain effective and collaborative relationships with senior leaders, operational leaders, clinical leaders and external partners/stakeholders.

Partner with those clinicians and leaders that oversee the data ecosystem and analytics strategy.

Implement technologies that enable a mobile, flexible workforce while improving collaboration capabilities and employee productivity.

Evaluate and recommend opportunities for technology to advance member and provider experience, regulatory requirements and organizational efficiency.

Ensure the organization's systems and data are secure and consistent with regulatory requirements and organizational standards; provide updates on the status of the security program to executives and Board members.

Develop and oversee implementation of the system-wide strategic plan for long-term information systems resourcing, including capital requirements, financial performance targets and timelines.

Ensure alignment of the IT function with the plan's business strategies including in the areas of growth, innovation, health outcomes/health equity, consumer engagement and digital transformation.

Develop, monitor and communicate metrics to measure IT services; identify areas of continual improvement and develop strategies to raise the bar for new technology.

Some of the ways we are seeing CIOs improve their subscriber's experience is buying over building, organizing data into actionable insights and knowledge, investing in digital transformation and talent, and being agile.

Health plans are seeking dynamic executives to lead information technology that will evolve and grow with the needs of their members. Their mandate is to focus on the customer experience, value-based care, new products and services.

We believe the critical qualities for these leaders are as follows:

 They have the ability to communicate effectively and build relationships with diverse stakeholders; they also must connect with those around them and build high-functioning teams

CIOs are much more strategy-focused than in the past, and much of that relies upon careful analysis of organizational claims and patient data

With their responsibilities raised, CIOs must have the confidence, calm demeanor and gravitas to gain the respect of peers and staff across the C-suite to the front line

 Health plan CIOs must demonstrate an appropriate sense of urgency about affecting change quickly rather than waiting, and show a willingness to take calculated risks as appropriate

 Most of all, CIOs need to be humane and accessible to those team members under their guidance; they must be good listeners, thoughtful and show the ability to put others first

 Health plan IT is a rapidly shifting landscape; the CIO must show a passion for exploring trends and bringing forward technologies that will help shape the future of their organization to meet the shifting needs of the industry

Today's health plan CIOs must possess technical knowledge of their field, but more importantly they must show the personality to innovate, engage others in change and take leadership in creating market advantages for their organizations.

 is a managing partner and leader of WittKieffer's Information Technology Practice. 

 is a senior associate in the practice. WittKieffer is a global executive search firm dedicated exclusively to organizations that improve quality of life in health care, education, the life sciences and the not-for-profit sector.

The technology infrastructure of many health plans today could be described as costly, fragmented and siloed. Rather than focusing on the customer experience, growth and transformation, these plans are responding reactively to business needs and market shifts.

Health Plan CIOs: Essential Elements for Success

Here are excerpts from a transcript of our "

Talks Improved Patient Access" podcast with Bourdette. They have been edited for length and clarity and include some answers to follow-up questions that were sent by email.

I started treating people with MS in 1983, so o a decade before the first disease-modifying therapy came on the market. And we really didn't have much in the way of access problems because we didn't have 

 drugs to prescribe. And actually, when I first started, MRI scans weren't available. So the first access issue we ran into was when the MRIs became available — justifying obtaining them, in people either with MS or suspected MS. 

I think payers got used to having to cover that cost, and we gained more experience using them.

So I would say in general access was not an issue that we worried a whole lot about, aside from occasionally needing to get permission for coverage of an MRI scan. But did change dramatically. In 1993, when the first MS disease-modifying therapy, Betaseron, was approved.

Shock at a $8,000 price tag; documentation wasn’t too onerous

People were shocked that the annual price which was $8,000 a year. Not only were payers shocked, but I think physicians were as well. There was a lot of discussion amongst neurologists whether this drug was really worth the cost.

Then there were two more drugs approved the next few years, Avonex and Copazone (glatiramer acetate). So for a number of years, we had three drugs to choose from and their prices were pretty stable, running between $8,000 and $10,000 wholesale a year. The payers required documentation but but it wasn't too onerous.

The documentation was really pretty simple. They wanted a copy of our office note in which we stated that the patient had relapsing,  remitting MS, which is the indication for the drugs. And that's about it. We would we fax those in; it's surprising that some insurers still use fax. I didn't really think it was that onerous frankly. And nor did my staff.

prices start to climb; natalizumab enters the scene

Increases began in 2002 with release of third interferon, Rebif, which was brought on market 50% higher than first three drugs. Natalizumab (Tysabri) was re-released in 2006 and there was another upward inflection in prices. Prices increased again in 2010 with release of first oral drug, Gilenya (fingolimod).

The payers began to require more documentation, and then ultimately started coming up with tier systems that complicated our care of our patients and actually ended up taking more and more of our staff time with the documentation and appeals process

Clinical advances, a “palette of drugs” to choose from…

From my standpoint, as a physician, 10 years, I had nothing really, besides hope to offer patients I saw many people becoming disabled, having their from the disease, so I knew about the ravages of MS.

But we started having these drugs to use. And over time, it became quite apparent that we were having a positive effect on the disease course.

But it also became apparent that we needed better drugs and more choices because some people had trouble with self-injections or had problems with interferon side effects. So as a physician, treating people with a complex illness having more choices meant I had available to me to a palette of drugs, that had different mechanisms, different side effect profiles, and that we should be able to customize therapy for most, if not all, all patients. So that's the wonder of it, the excitement of it. 

I think one of the tremendous advances in therapeutics in neurology has been the MS therapeutics, because we now have the data that indicates that we're decreasing the likelihood that people will become disabled long term if we get therapy started early. So we're really altering the natural history of

But there’s administrative burden for getting permission even for tier one drugs (on a formulary). we have to get preauthorization. And the tier one drugs for a given insurance company might not be appropriate for a given patient given the severity of their disease.

Also, it's very frustrating to have every insurance company having their own rules and regulations that are often quite opaque or difficult to understand. So we have now in our, our clinic, somebody who spends almost full time dealing with paperwork related to getting medication preauthorized and appealing decisions not to cover things.

There are issues now with regards to where people can get infusions, because some of the drugs are infusible. They want patients to use outpatient facilities or home infusion. where there's no physician available to deal with side effects. So it's become very frustrating.

On the administrative end, I think the brunt of it ends up on our administrative staff. So we had an RN that is doing most of this works. It's expensive and it is unreimbursed expense. So it so it is frustrating to have both the ability to alter people's lives favorably with these drugs, and at the same time, have to struggle to get them on the right medication, or coverage for the right medication.

Do patients have access to the medications they need?

I believe the patients that are seen by us at our MS center with varying degrees of difficulty get the right medication. But we'll see a lot of patients who are initially receiving the care in the community by community neurologists who just do not have the infrastructure or time to go to bat for the patients

On a change that could be made: Getting rid of preauthorization for tier one drugs.

Step therapy, there are financial reasons for that. It has to do with contracts that are made between either the PBM or the insurance company and the drug manufacturer. There are understandable reasons for cost control and that's one way to do it.

I think some of the frustrations could be dealt with. I think requiring, if you have a tier one, requiring us to go through the paperwork and preauthorization for one of those drugs is a big waste of time. And yet, we have to get preauthorization and reauthorization once a year for the tier one drugs. That's an administrative hassle that is not understandable because they're going to approve it.

On a change that could be made: Smoothing approval for subset of patients who should be put on higher efficacy drugs from the start

There's a big controversy among MS specialists regarding how early you go with a higher efficacy drug.

There's a group of MS specialist that thinks everybody needs to go on higher efficacy drug because that's how we're going to control the disease. We take a more nuanced approach, because there are clearly people who will do well with safer lower efficacy drugs long term. So I'm often comfortable putting somebody on a tier one drug. I'm typically comfortable with that initially, as we follow the patient very carefully. But there are some patients, based upon the characteristics of their MS, how many lesions. We know that they're not going to do well, unless they get on a high efficacy drug upfront, and then we often have problems getting approval for that. So it would be good if there was a way to at least have some more easy flexibility for the subset of patients — it is about 25% of new patients — who meet certain criteria regarding disease activity, so that we don't have to step through two or three failures before we get access to the higher efficacy drugs, which include the monoclonal antibodies and cladibrine (Mavenclad).

On a change that could be made: More communication between physicians and payers

One of the ironies is that the drug companies and biotech companies have all these representatives that meet with physicians — they're pretty restricted in what they can do at an academic center — but they build relationships for reasons that are obvious. The insurance companies don't do that. Physicians have terrible, terrible relationships with the insurance companies because of all the administrative hassles I've been alluding. 

In fact, we should be having a partnership with insurers because I think most physicians believe in helping control costs. We understand that's a problem. We just would like to be more engaged by an insurance companies rather than having these decisions made that perhaps aren't nearly as logical as they (the insurers) think they are.

In this latest episode of MHE Talks: Improving Patient Access podcast, Dennis Bourdette, M.D., professor emeritus of neurology in the School of Medicine at the Oregon Health & Science University, spoke with Peter Wehrwein, senior editor of MHE. Bourdette, a nationally recognized expert on multiple sclerosis, discussed step therapy, tiers, insurance approvals and the need for greater communication between physicians and insurers. 

MHE Talks: The Greater Need of Patient Access for Patients with Multiple Sclerosis

Democrats will need to commit to campaign promises to make the Affordable Care Act (ACA) marketplace coverage more affordable since winning control of the Senate. 

 introduced in the Ways and Means Committee on February 8 would reduce the percentage of income paid by marketplace enrollees for a “benchmark” silver plan at every income level, and remove the cap on subsidy eligibility, so no one who lacks access to other insurance would pay more than 8.5% of income for the benchmark plan. 

Those changes would remain in effect for two years, and Democrats will likely attempt to make similar subsidy boosts permanent in subsequent legislation, the report says.

While reducing premiums, the COVID relief legislation does not touch out-of-pocket costs. The Biden administration can take regulatory action, however, to offer affordability, providing a functional equivalent to Biden’s 

 proposal to raise the value of a “benchmark” plan from silver—70% actuarial value (AV)—to gold (80% AV). 

While the silver benchmark is set by statute, the Centers for Medicare and Medicaid Services (CMS) can craft regulations ensuring that everyone has access to a gold plan for less than the cost of the benchmark silver plan. The door to such action was opened, ironically, by an earlier regulatory move by the Trump administration.

These changes would be a major improvement for families earning between 200% and 400% of the Federal Poverty Level (FPL). Below that income threshold (about $25,000 per year for an individual), cost-sharing reduction (CSR) subsidies reduce out-of-pocket costs in silver plans to roughly 10% of expected medical costs on average—the equivalent of a “platinum” level with an AV of 90%, more generous than most employer-sponsored plans. (CSR subsidies are available at incomes up to 250% FPL but decline significantly in value for incomes above 200% FPL. CSR raises the actuarial value of a silver plan to 94% for enrollees with incomes up to 150% of FPL, and to 87% for enrollees with incomes in the 150-200% of FPL range. Because annual out-of-pocket costs are capped, enrollees who require extensive care skew the averages upward, as a billionaire entering a bar skews the average income of those present. For most enrollees, plans cover a lower percentage of costs than the AV suggests.)

At incomes above 200%, coverage with reasonable deductibles is out of reach for most buyers. Subsidies are set against a silver benchmark. The average deductible for a silver plan without CSR in 2021 is $4,816. Gold plan deductibles average a third of that, $1,648. (Many silver and gold plans do exempt considerable services from the deductible). High out-of-pocket costs for the half of current ACA marketplace enrollees who don’t qualify for maximum CSR subsidies constitute as severe an impediment to affordable coverage as high premiums.

A Regulatory Opening—Courtesy Of Donald Trump

The opportunity to make gold plans available for less than silver plans, and bronze plans at lower prices than today, comes from President Trump’s October 2017 decision to cut off direct federal reimbursement to insurers for CSR subsidies, which insurers are obligated to provide to low-income enrollees who select silver plans.

With the subsidies no longer directly reimbursed, most state insurance regulators allowed insurers to price the value of CSR into silver plan premiums only, since CSR is available only with silver plans. This came to be known as "silver loading." Since ACA premium subsidies are designed so the enrollee pays a fixed percentage of income for the benchmark (second-cheapest) silver plan, inflated silver premiums meant inflated subsidies—and discounts in bronze and gold plans. 

In 2018, the first year in which silver loading took effect, enrollees with incomes above 200% FPL responded, abandoning silver plans in favor of cheap bronze plans, and sometimes heavily discounted gold plans, the report said. At a time when enrollment was being depressed by other Republican actions—including the threat of repeal and the Trump administration's gutting of funding for enrollment assistance and 

—silver loading boosted enrollment, roughly by about 

But silver loading has stopped halfway. Those who analyzed the likely effects of a cutoff of direct CSR funding anticipated that gold plans would become consistently cheaper than silver. That's because CSR raises the average, blended value of silver plans above that of gold plans. CBO forecast that silver loading would boost enrollment by about a million.

In practice, discounts generated by silver loading have been partial and haphazard. They're available in one zip code and not the next; they appear one year and disappear the next. Gold plans priced below the silver benchmark are available in some but not most markets.

Market watchers have identified two likely causes for the only-partial effect. First, competitive pressures drive insurers to underprice silver plans, when allowed. A majority of on-exchange enrollees are eligible for CSR, and the cheapest silver plans gain an outsized share of enrollment.

The second factor is the risk adjustment program that CMS administers to deter insurers from trying to attract the healthiest enrollees. The current formula, based on usage in employer-sponsored insurance, favors silver plans, at the expense of gold and bronze plans, by assuming that CSR will stimulate more usage of medical services than has proved to be the case. That's probably because CSR enrollees have lower incomes than those in employer plans, and even the reduced out-of-pocket costs inhibit care more than anticipated. Insurers that attract too much enrollment at other metal levels may suffer in the zero-sum risk adjustment game.

Regulatory actions that would maximize silver loading and thus render ACA marketplace coverage significantly more affordable are not hard to find.

First, fix the risk adjustment formula so that it reflects the experience of ACA marketplace enrollees rather than beneficiaries of employer-sponsored insurance. This would mean comparatively higher risk-adjustment payments to insurers who attract more gold- and bronze-plan enrollees, as opposed to silver-plan enrollees, increasing access to both higher-AV and lower-priced plans, including $0 premium plans.

Then, require insurers to price plans at each metal level in strict proportion to their actuarial value. That could entail pricing silver plans at the average AV obtained by all of an insurer’s enrollees. Alternatively actuaries Greg Fann and David Cruz have 

 pricing silver as if all enrollees obtain 94% or 87% AV. If silver is so priced, gold plans with characteristics similar to a silver plan from the same insurer will be less expensive for enrollees with incomes over 200 percent FPL.

Since more than half of all on-exchange marketplace enrollees have incomes below 200 percent FPL, where CSR-enhanced silver would remain the best value, insurers under these new regulations would still be motivated to offer the cheapest silver plans. But premiums for their bronze and gold plans would have to be proportionate.

Strict silver loading—which means strict pricing according to real value—would make coverage not only more affordable, but more predictable. Gold plans would consistently be priced below silver plans. Every subsidy-eligible enrollee would have access to a plan with an actuarial value of 80% or higher priced lower than the benchmark. Bronze plans discounts would also expand.

Democrats will need to commit to campaign promises to make the Affordable Care Act (ACA) marketplace coverage more affordable since winning control of the Senate. 









How Biden Administration Can Make Care More Affordable

Disease modelers projected back in October that more than half a million people in the U.S. would die from COVID-19 by the end of February.

Their grim projections came true today. The Associated Press reported at 4:57 p.m. Eastern Time that the U.S. death toll had exceeded 500,000.

The AP said the count came from Johns Hopkins University. The university's Coronavirus Resource Center has become an oft-visited resource for U.S. and international counts of COVID-19 cases and deaths.

The CDC’s count of cumulative COVID-19  deaths is at 497, 415, but it was last updated at 12:24 p.m. today.

The American Medical Association, the American Hospital Association and the American Nurses Association put out a joint statement yesterday in anticipation of today’s news: “We mourn the loss of 500,000 people in this country, a toll that has left gaping holes in the lives of those they left behind,” the statement said in part. “We also recognize the significant 

 our country has experienced, largely as a result of the pandemic.”

The joint statement also sounded a hopeful note the COVID-19 vaccines: “We encourage everyone to get the COVID-19 vaccine when it’s your turn. Vaccines are safe, effective, prevent illness and save lives, and are key to protecting you from COVID-19 and ending the pandemic.”

According to a Johns Hopkins tally that was late updated this morning at 3 a.m., 64,177, 474 COVID-19 vaccines have been administered to people in the U.S. and 19,438,495 have been fully vaccinated, which works out to 5.94% of the population.