This issue includes a full look at the results of our MHE State of the Industry survey!

Take a Look at our January Issue!

Imagine being the quarterback who is unable to call the play until after the ball is snapped. Think of the chaos as tackles, running backs and other players do their best to advance the ball.  But, with no direction, they are destined to fail.

Health plans and other payers are like that quarterback in terms of timely access to patient data. As patients move from physician to physician and care setting to care setting, a patient’s health plan is the only entity that can see a complete patient picture. The difficulty is that information generally isn’t compiled until a claim is submitted.

Admission, discharge and transfer (ADT) notifications have become more common as federal mandates require notification of a patient’s primary care physician or next healthcare destination as patients are admitted to and discharged from the hospital. But real-time event notifications to health plans, the true quarterbacks of the care process, can benefit patients with multiple health issues and comorbidities. By directing patients to the proper follow-up care, managing preventive screenings, and playing a more active role in patient care, primary care providers utilizing health plan recommendations can reduce costs while increasing the effective management of patient conditions, resulting in overall better health.

Demographic research from the CDC  shows that more than half of American adults (51.8%) have at least one of 10 

, and 27.2% have two or more. The Advisory Board estimates that 

 with one or more chronic conditions whose symptoms are readily ignored — such as uncontrolled high blood pressure — will become a high-risk patient and incur treatment costs far in excess of average. Care management (facilitated by the patient and his/her care provider) can reduce rising-risk patient escalation by one-third, states the Advisory Board, noting that intervention at the provider level is key.

Managing chronic conditions and getting people to receive recommended screenings such as mammograms and colonoscopies was a challenge even before the pandemic hit. During the initial nationwide shutdowns in March 2020, the incidence of preventive screenings dropped by more than 80%, depending on the study and the time frame, and fewer screenings inevitably leads to higher cases of disease.

Estimates from the National Cancer Institute 

 over the next decade from just breast and colorectal cancers. Imagine the cardiology, urology, gastrointestinal, and general practice visits that were missed and the number of emerging conditions that were left undiagnosed. Helping people manage their chronic conditions improves patient health, while reducing the overall cost of care, paradigms that barely existed during the pandemic shutdowns.

More than 90% of health plans in the U.S. — HMOs, POS plans and PPOs —use the Healthcare Effectiveness Data and Information Set (HEDIS) to 

 and care quality. Managed by the National Committee for Quality Assurance (NCQA), HEDIS comprises one portion of NCQA's accreditation process.

For consumers, HEDIS measures are used to compare health plans against others and against regional and national benchmarks that include 70 unique measures of process, structure, outcomes and patient satisfaction. HEDIS measures address the continuum of care from prevention and managing chronic conditions to acute care.

Besides the obvious profitability motive, health plans are invested in the health of their patient populations. Unchecked diabetes, for example, can lead to expensive hospitalizations and other interventions that impact patient quality of life. But caregivers can’t manage care according to a health plan if they don’t know what a patient’s status in a timely manner.

Health plans assist caregivers in learning — eventually — what’s going on with patients, but that’s not sufficient to support the Triple Aim of better individual and population health while reining in costs. Hospitals already must send ADT notifications to downstream providers, and sending real-time information to payers can be accomplished without increasing expense or workload.

Notifications can address critical events including admission, discharge, gaps in care, and abnormal tests that are communicated in real time. Creating visibility into member utilization can help health insurance providers identify gaps in care and improve health outcomes. Current technology allows notifications to seamlessly flow to payer case management systems, so quality of care can be maintained.

Real-time event notifications to an enterprise care management solution can improve payer/provider relationships and speed patient care delivery. Closing critical communication gaps streamlines transitions of care and improves care coordination as a patient navigates the healthcare landscape. Notifications can engage providers within existing workflows, rather than add to administrative burden.

Automated care alerts to providers within their EMR workflow can trigger appropriate follow-up care after a member utilizes an emergency room or inpatient facility. By developing a follow-up process for patients using care plans, 70% of provider sclosed care gaps.

 The benefits are tangible for patients through early diagnoses, leading to timely medication reconciliation and lower readmission rate.

True interoperability has long been the holy grail of healthcare communications. But with so many competing medical information systems that focus on physicians, hospitals, labs, imaging, payers, and more, communication among IT systems remains elusive. To deliver better and more timely care management to patients, payers should work with providers to adopt a technology-agnostic communication strategy to receive real-time event notifications and take their rightful place as quarterbacks of patient health.

 serves as global health IT strategy/chief marketing officer for 

 Consensus: 2021 Industry Trends Survey for Healthcare (2021)

Articles

Real-time notifications accelerate accurate care management. To deliver better and more timely care management to patients, payers should work with providers to adopt a technology-agnostic communication strategy .

Payers Should Be the Quarterbacks of Patient Care

The idea of value-based has been circulating in American healthcare for more than a decade. The ACA’s signature effort to break away from fee for service, the Medicare Shared Savings Program ACOs, started in 2012. The CMS has launched numerous programs designed to calibrate payment value (lower cost care that is of the same or superior quality). The results have been meh: modest savings, some improvement in the metrics designed to measure quality (although whether they really do is another question). The billions of dollars flowing through American healthcare are still channeled mainly through fee for service.

The results of our State of the Industry reflect the tortoise pace of the transition to value-based care. One in 4 (27%) of the 91 respondents to the question about how far along their organization was in the shift away from fee for service to value-based care indicated that the shift hadn’t started yet, and 19% said of the respondents said it was limited to a few cost-only initiatives.

One of the critiques of the current value-based efforts is that they don’t require enough from providers. Many arrangements only include bonuses (“upside risk”) for beating quality and financial benchmarks. According to this critique, value-based care contracts need to include penalties for falling short (“downside risk’) if they are to demonstrably change behavior. Most of the respondents indicated that by the end of the year they expect that less than half of their contracts will include downside risk and 41% said that expect that 25% or less will include downside risk.

Our survey results reflect the reality that American healthcare is inching not galloping to value-based care.

Managed Healthcare Executive®State of Industry Survey: The shift to value-based care is slow going

 may be the main cause of multiple sclerosis (MS), a progressive and incurable neurological disease afflicting 2.8 million people worldwide, a new study reveals.

Results of the study — led by researchers at the Harvard T.H. Chan School of Public Health — were published online in

To explore the potential link between EBV and MS, the Harvard researchers evaluated more than 10 million young adults on active duty in the U.S. military, measuring EBV antibodies in blood serum samples stored by the Department of Defense. They identified 955 service members diagnosed with MS. Those infected with EBV after joining the military had a heightened risk of developing MS compared to those who did not contract the virus.

As a chronic inflammatory disease of the central nervous system, MS wreaks havoc on the myelin sheaths, insulating layers of fatty tissue that safeguard neurons in the brain and spinal cord. EBV is a herpes virus that triggers infectious mononucleosis and continues to lurk inside the body for life. The exact mechanism by which it could cause MS remains unclear. 

Substantiating EBV’s causal role in MS has been fraught with challenges, partly because EBV infections are so common. About 95% of adults get infected with the virus, yet only a tiny fraction of people ever develops MS. Moreover, the onset of MS symptoms occurs, on average, a decade after EBV infection, and some studies have found that MS develops 30 years after the EBV caused mononucleosis, says 

, Sc.D., a senior research scientist at Harvard public health school and one of the study’s two senior co-authors.

“We can consider EBV necessary to developing MS, but there need to be other mitigating factors, such as a genetic predisposition,” says Munger says. Cigarette smoking, vitamin D deficiency and obesity, particularly early in life, could play a role in whether EBV infection leads to MS.

The researchers suspect that that the time lag between EBV infection and MS onset could stem, in part, from the MS symptoms not occurring during the initial pathophysiology. Another factor may be that the relationship between viral infection and the immune system may evolve, with the latent infection reactivating due to persistent stimulation.

There are antiviral medications that can help control infection, but no drugs for MS that specifically target EBV. The researchers expressed hope for development of an EBV vaccine or EBV-specific antiviral drugs — and EBV vaccine may be in the works. In early January, Moderna launched early-stage clinical trials in humans to test an mRNA vaccine against the EBV virus. The company expects to assess the vaccine’s safety and dosage in about 270 participants.

“Moderna is committed to developing a portfolio of first-in-class vaccines against latent viruses for which there are no approved vaccines today,” Stéphane Bancel, the company’s chief executive officer, said in a prepared statement.

If the trial shows that the experimental vaccine is safe and has some efficacy, the same mRNA technology underpinning Moderna’s COVID-19 vaccine could be applied to develop to EBV vaccine.

“A vaccine against EBV may result in the prevention of the majority of MS cases,” Munger says.

A longitudinal study of 10 million people in the U.S. military shows the link. The researchers say genetic predisposition, other factors are likely needed for the viral infection to cause multiple sclerosis.

Harvard Researchers Identify Epstein-Barr Virus as a Cause of MS

Many have claimed that technology – from virtual care solutions to clinical decision support (CDS) systems – will be the great equalizer in healthcare. 

These tools are viewed as an ideal solution for bridging the chasm that has prevented medically underserved communities - racial and ethnic minorities, those who live in rural and socioeconomically disadvantaged areas - from receiving the same quality of care as others. Yet, while technology is purportedly objective and purely data-driven and without prejudice, there can still be inherent biases that hamper the ultimate goal of health equity.

healthcare data accounting for 30% of the world's data volume

, it's no surprise providers can feel overwhelmed at the point of decision making, especially given time constraints. When challenged with assessing too much data in a limited period of time, our brains 

look for patterns and fall back on gut instinct

, which can bring with it unintended biases. 

CDS systems have been designed to help providers assess the vast amounts of data that can play a role in care decisions. But CDS should not be all about guideline-driven care; it should also facilitate health equity. As new technology is developed and current capabilities are advanced, it’s critical we seek to combat bias through the guidelines themselves and the underlying clinical algorithms that drive CDS.

Health equity implies, “a system designed and built for inclusion and equal access to the best health outcomes for all," 

including socioeconomic status, such as education, income and occupation

, according to the Agency for Healthcare Research and Quality (AHRQ). 

However, the agency believes, in reality, the definition is more expansive, referring to "inclusion and best health outcomes for all no matter their physical environment, personal behaviors and abilities, or social circumstances (gender identity, military services, sexual orientation, citizenship status, social status, history of incarceration, culture and tradition, social connectedness, work conditions, early childhood education and development)."

Overcoming all of these factors can be difficult for the average provider. One study utilizing the Implicit Association Test (IAT) revealed that 

80% of sample clinician groups exhibited evidence of implicit bias

. These biases are most pronounced among racial and ethnic groups. 

For example, a groundbreaking Institute of Medicine report found that Black Americans, who are 

only 3% to 6% more likely to deny treatment than other populations

, received significantly less needed care than white Americans, even when controlling for factors such as insurance coverage and patient income.

 from breast cancer, 20% less likely to receive treatment for depression, and two times more likely to receive a less desirable treatment for diabetes, such as limb amputation. 

While much of this problem can stem from providers' attitudes, implicit biases and discrimination, it's likely that clinical algorithms, tools and guidelines are factoring into the biases as well. The 

 noted that algorithms for CDS could introduce bias if they're built on data that is not reflective of a diverse population.

Refining Clinical Decision Support for Greater Health Equity

CDS has been defined as a “process for enhancing health-related decisions” that provides “clinicians, staff, patients or other individuals with 

knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and healthcare

However, to truly support both guideline-driven and equity-driven care, the developers of the algorithms and the CDS systems themselves must strive to eliminate bias.

A study completed in 2019 explained how a 

widely used commercial healthcare algorithm reflected serious racial bias

. Specifically, the risk score used healthcare expenditures as a proxy for health status. Researchers found that Black patients were consistently and significantly sicker than white patients with the same score. Since the algorithm was designed to predict healthcare costs, rather than illness, it was flawed because unequal access to care means that less money is typically spent caring for Black patients than white.

Additionally, the National Kidney Foundation (NKF) recently announced 

 the most widely used kidney test, after many years of pushback from physicians and medical students about the flaws of its race data, which removes the race variable from the equation that estimates kidney function.

In spring of 2021, the AHRQ, at the request of Congress, 

 on clinical algorithms used in medical practice that may introduce bias into decision making or negatively affect access, quality or health outcomes among racial and ethnic minority groups. From the responses, AHRQ plans to commission an evidence review to critically appraise whether race/ethnicity and prior utilization are included as explicit variables in commonly used algorithms, and how algorithms have been developed and validated. They also plan to identify and review approaches to clinical algorithm development that avoid the introduction of racial and ethnic bias into clinical decision making and resulting outcomes.

Done right – through careful design, greater awareness and a thoughtful approach to eliminating potential biases – algorithms and CDS systems can mitigate such problems. And in the process, they can decrease disparities in care to achieve greater health equity. 

Additionally, when algorithms are developed based on data that accurately represents the diversity of the patient population to which it is being applied, they can also achieve greater patient outcomes. Therefore, demographic, clinical, socioeconomic and even patient preference data should be included when leveraging CDS systems. This data may not be available in the EHR directly, and can require retrieving SDOH and PRO data from other sources.

Looking ahead, it is vital that designers of CDS solutions think about and plan for health equity from the start of development. By taking this approach, CDS can truly deliver on the promise of fostering both guideline-driven and equity-driven care that improves outcomes and the overall health of everyone.

, is the Founder and Chief Executive Officer of 

, a leading clinical management platform designed to optimize clinical workflows, enhance patient experiences and achieve quality objectives.

Many have claimed that technology will be the great equalizer in healthcare. While technology is objective and purely data-driven and without prejudice, there can still be inherent biases that hamper the ultimate goal of health equity.

Erasing Bias in Clinical Decision Support to Achieve True Health Equity

: Occasionally, patients will not respond to their oral regimen, and I think we need to make sure when we’re talking about response that we really define what we mean. Many people on oral medications for the management of hyperglycemia and type 2 diabetes will not be meeting their glycemic goals, but they still might be responding to the oral medications. It’s just not enough of an effect from those oral medications to control their blood sugars adequately. In the case where I’m seeing a person with a diagnosis of type 2 diabetes and they’re not responding at all to their oral medications, there are couple of big things that I need to keep in mind.

One would be are they actually taking the medications, because usually medicines for diabetes will do something. They might not do enough, but if it looks like somebody isn’t responding at all, I want to try to identify whether medicines are being filled and taken, and if they’re not, to determine why and see if we can figure out a regimen that’s going to be better suited to that person’s lifestyle. The other thing to keep in mind is that there will be the occasional cases where an adult with newly or recently diagnosed diabetes actually has a kind of diabetes that is autoimmune, or type 1, or related to very significant inability to product insulin. Thus, we need to be on the alert for that condition, and one of the signs would be that the oral medications for glycemic control simply don’t seem to be working.

For many people with type 2 diabetes, they do progress to insulin therapy. I would love to be able to say that if a person were to add insulin to their treatment regimen, that they would be able to easily achieve adequate glycemic control, but we know that’s not true. And in fact, if you look across the landscape of people with type 2 diabetes in this country, unfortunately, people who are on insulin tend to have poorer glycemic control than individuals who aren’t using insulin. That’s probably because those people have longer standing diabetes that’s more difficult to manage, and they may have contraindications to the use of other medications.

Insulin though is a really powerful tool, and I don’t want to downplay its role in the management of type 2 diabetes. But insulin only addresses 1 of the physiologic abnormalities that contributes to hyperglycemia and type 2 diabetes. It only addresses inadequate insulin secretion. It doesn’t address all of the other disordered aspects of metabolism that we know are present in type 2 diabetes. Thus, it alone can often be inadequate to control blood sugars.

The other reason that insulin might not be enough to control blood sugars in someone with type 2 diabetes is that you often reach a point in the insulin dosing where you’re unable to uptitrate the dose because either the person is having hypoglycemia that can’t be alleviated by changes in the dose or timing of the insulin administration, or they’re experiencing an adverse effect such as weight gain that limits your ability to uptitrate further.

Videos

Dr Jennifer Brigitte Green addresses clinical considerations for patients with type 2 diabetes who are not responding to their oral antidiabetic agents and discusses her strategy for insufficient target glycemic control with insulin regimens.

Type 2 Diabetes: Considerations for Achieving Targeted Glycemic Control

One of the major worries during the early days of the COVID-19 pandemic is whether the disease would be especially severe and deadly among people who were immunocompromised, particularly among people with HIV. Suppressed immunity would seem to make people more vulnerable to infection with the SARS-CoV-2 virus that causes COVID-19. There was, however, a significant “on the other hand.” As it became a clear that severe cases of COVID-19 were the result of a dysregulated, hyperinflammatory response, it was possible that a suppressed immune system would be, if not protective, at least be a mitigating factor in having a severe case of COVID-19.

Now, two years into the pandemic, researchers have some insights into people with HIV have been affected by COVID-19. The darkest fears of what might happen have not come to pass. And there is even a silver-lining story that the antiretroviral therapy — 

 (emtricitabine and tenofovir disoproxil fumarate) in particular — that many people with HIV take to control their disease may protect against severe cases of COVID-19.

A group of Spanish researchers led by Julia del Amo, a researcher in the division of HIV, STI, viral hepatitis and TB control in the Spanish ministry of health, published a concise but nuanced review of research and resulting evidence about people with HIV and their vulnerability to COVID-19 in the 

 earlier this month. They organized the review around several important questions. Of course, the studies they reviewed were conducted before omicron because the dominant variant.

Are people with HIV more likely to be tested for COVID-19 than people without HIV?

During the first wave the pandemic, a study among U.S. suggested that the answer is yes. Greater testing might have created a false impression that people with HIV were more likely to get infected.

Are people with HIV at higher risk of SARS-CoV-2 infection than people without HIV?

Del Amo go through the studies, and some suggest the answer is yes, they are. But it is highly qualified “yes: because people with HIV may be at higher risk for COVID-19 because of socioeconomic factors; once statistical adjustments for those confounding factors are made, the difference disappears. The conclusion that Del Amo and her colleagues draw is that evidence so far is that the people with HIV do 

have a greater risk of SARS-CoV-2 infection other than through factors associated with socioeconomic vulnerability and risky behavior.

Are people with HIV at higher risk of serious cases of COVID-19 than people without HIV?

This is, of course, a different and perhaps more important question than whether people with HIV are more vulnerable to infection, which may lead to a mild or even asymptomatic case. Del Amo and her colleagues cite a half-dozen studies that suggest that people with HIV are more likely to experience severe COVID-19, and evidence of higher risk remains in some of those studies even after statistical adjustments for comorbidities. Yet Del Amo and her co-authors come to a hesitant conclusion that the available evidence is “compatible” with people with HIV being more likely to experience severe COVID-19. But they also hit the brakes, cautioning that arriving at a firm conclusion is impossible because of study designs and the difficulties of coming up appropriate comparison groups. They also cite a study that they say is the only one that compared people with HIV with people from the same population that made extensive adjustment for confounding factors. That study did not find a greater risk of severe COVID-19 among people with HIV.

Which factors are associated with severe COVID-19 among people with HIV?

Regardless of whether people with HIV are at the same, higher or lower risk of experiencing a severe case of COVID-19, the factors associated with severe COVID-19 might be different in people with HIV than those without HIV. They review the results of five studies in this section of the review. Their takeaway is that there is nothing special about the factors influencing COVID-19 case severity for people with HIV and that it varies with age and comorbidities in pattern without HIV. Two cases series found an association between low CD4+ counts and a higher risk of COVID-19 , but the reviewers say the evidence for CD4+ counts and HIV viral loads isn’t clear.

What is the role of antiretrovirals in influencing COVID-19 infection and severity?

The role that antiretrovirals might play in protecting people against COVID-19 is an intriguing subplot that has emerged from the research into COVID-19 among people with HIV. Del Amo was the lead author of a study published in the 

in October 2020 that looked at the incidence and severity of COVID among people with HIV taking antiretroviral. The study included 77,590 people with HIV receiving antiretroviral therapy, 236 of whom were diagnosed with COVID-19 and 151 hospitalized. There were 20 deaths from COVID-19. When they analyzed patients by the type of antiretroviral, they found that those taking Truvada were 57% less likely to be diagnosed with COVID-19 than those taking tenofovir alafenamide and emtricitabine, a combination sold under the brand name Descovy, and 48% less likely to be hospitalized. Similarly, they found a lower risk of diagnosis (37%) and hospitalization (20%) among patients at three hospitals that treated patients predominately with Truvada compared with the patients at the 27 hospitals that predominately treated patients with Descovy. In the review, del Amo and her coauthors mention a study in South Africa that also suggested that Truvada fended off SARS-Cov-2.

 study and the review discuss the “biological plausibility” for antiretrovirals providing protection against HIV and for tenofovir, in particular, having properties that might interfere with the virus and also temper the immune response if an infection does occur.











Many of the darkest fears about COVID-19 affect on people with HIV have not come to pass. According to a recent review, some evidence suggests that people with HIV may be more likely to develop a severe case of COVID-19, although it isn’t certain. Antiretroviral therapy, especially Truvada, may provide some protection against infection and severity.









COVID-19 and HIV: What Happens When Two Infectious Diseases Meet?

Brock Ingmire is Director of Health Policy at Centene Corporation.

Janet Walker is senior counsel in Crowell & Moring LLP’s Health Care group.

Roma Sharma is counsel in Crowell & Moring LLP’s Health Care group

The COVID-19 pandemic has brought social and racial inequity to the forefront of public health. In the United States, the pandemic has affected many communities, including racial and ethnic minorities as well as low-income populations, more severely than other groups.

Negative health outcomes are more common among individuals within these groups, and social determinants of health (SDOH) play a significant role. SDOH are the conditions where people are born, live, learn, work, play, worship and age; they are the wider set of forces and systems that affect a broad range of health, functioning, and quality-of-life outcomes and risks. Their importance has become increasingly apparent as research on health outcomes and risks has shown that the care delivered within the walls of a hospital or medical practice impact as little as 10% of an individual’s long-term health with SDOH affecting the remaining 90%. Now Centers for Medicare & Medicaid Services (CMS) and states across the country are playing a leading role in tackling health equity and SDOH.

Center for Medicare and Medication Innovation

 released a white paper titled “Innovation Center Strategy Refresh.” The Innovation Center (it was previously commonly known by its initials, CMMI) supports the development and testing of innovative health care payment and service delivery models, which often focus on value-based care. The white paper is intended to be a blueprint for the next 10 years and highlights five strategic objectives: drive accountable care, advance health equity, support innovation, address affordability, and partner to achieve system transformation. These objectives will further CMS’s vision: “A health system that achieves equitable outcomes through high-quality, affordable and person-centered care.”

The strategy outlined in the white paper aims to embed health equity in every aspect of the Innovation Center’s models and increase focus on underserved populations. To measure progress, all new models will require participants to collect and report the demographic data of their beneficiaries and, as appropriate, data on social needs and SDOH. The new models are also to include patients from historically underserved populations and safety net providers, such as community health centers, and to identify areas for reducing inequities at the population level, such as avoidable admissions and set targets for reducing those inequities.

In the white paper, CMS acknowledges that safety net providers often need dedicated and greater financial and technical assistance to provide equitable care, given they may need to make greater upfront investments if they are to succeed in value-based care arrangements. CMS is considering various incentives to encourage and sustain participation, such as upfront payments, social risk adjustment, benchmark considerations, and payment incentives for reducing disparities or screening for SDOH. There may also be funding for coordinating with community-based organizations that address social needs. These measures will provide new financial opportunities for community health centers, rural health clinics, community-based providers, and public and critical access hospitals, among other providers. The Biden Administration is taking other steps to address health equity, but the Innovation Center is likely to be a prominent part of the effort given the latitude it has to launch and test new payment and delivery models.

States also have a significant opportunity to lead in addressing SDOH because they are closer to their local communities. Some states are driving innovation through traditional levers and asking CMS to enhance Medicaid reimbursement flexibility, expand Medicaid eligibility criteria for certain populations, and approve transformation of SDOH infrastructure to serve Medicaid members.

Oregon’s latest 1115 waiver demonstration application draft released in December 2021 includes a goal to eliminate health inequities by 2030. Oregon hopes to achieve this by ensuring access to SDOH services to vulnerable residents experiencing certain life transitions, providing enhanced continuous eligibility for certain populations, and to use federal savings from a state cost growth target program to invest in community-led infrastructure that will drive equity.

Similarly, New York’s 1115 waiver demonstration concept papers, released in 2021, propose two new collaborative organizations to drive equity infrastructure and interventions: Social Determinants of Health Networks (SDHNs) and Health Equity Regional Organizations (HEROs). SDHNs would formally organize community-based organizations, providers and payers into a coordinated system to drive regional referral networks and organize interventions. HEROs are “mission-based organizations” which would drive the planning and assessment needs of regions to best inform equity investments and interventions.

To build long-term social and physical health structures that are inclusive, effective and sustainable, a majority of states have built coordinating organizations to direct the state’s strategic response to health inequities exacerbated by the COVID-19 pandemic. These coordinating organizations are typically representative of populations impacted by disparity, are time-limited in duration and often tied to the state’s COVID-19 public health emergency declaration. A number of recommendations from these bodies have been incorporated into law. They run the gamut, from requiring implicit bias training for certain providers as part of their continuing education requirements, to state investment in integrating low-cost, sustainable wrap-around community support for Medicaid members that are typically not currently covered (i.e., limited legal services, tenancy support services, risk assessments, job placement assistance, and education services). Other changes include removing scope of practice or supervision barriers to enhance the ability of advanced practice providers to practice more independently to enhance representation of the provider workforce in vulnerable communities, and investment in infrastructure to build interoperable systems for equity data collection.

States are also taking steps to build equity-related requirements into their Medicaid contracts with managed care organizations (MCOs). In recent years, many states have taken consistent steps to build an understanding of inequities in member populations, such as requiring Medicaid MCOs to collect and stratify member and provider data, such as quality measures, by language, race, and ethnicity. However, states are more frequently pivoting to a proactive stance. For instance, in recent Medicaid MCO requests for proposals (RFPs), three states – Indiana, Louisiana and Nevada – joined a limited number of other states who require MCOs to submit annual health equity plans, which illustrate how MCOs are effectively addressing disparities in care that exist in their member population. Other states have required MCOs to hire specific staff dedicated to health equity program development or implicit bias training for member-facing staff.

In 2022 and beyond, CMS and states will likely continue to grapple with two pressing needs. First, as described in the CMS Innovation Center’s white paper and as made evident from these coordinating organizations, continued focus should be given to the lack of integration between health data, social care data, and consistent standards for SDOH data collection. CMS has emphasized the need for increased focus in this area; states should continue to utilize these coordinating organizations to collaborate with providers, payers, and CBOs on a policy framework for implementing a feasible vision for health equity data collection and application. Federal guidelines on the collection of appropriate demographic, health equity, and SDOH data and the purpose and use of such data may help to standardize the collection across states and entities.

Second, states need to consider how they plan to sustain the work of the established coordinating organizations beyond the COVID-19 pandemic. While many of these organizations had a timeline tied to the state’s public health emergency declaration, adequately investing in an infrastructure extending beyond the pandemic will be a requisite to ensure care delivery and social systems sustain transformation in a non-pandemic environment.

Furthermore, private entities such as MCOs and hospital systems can take actions to advance health equity as well by negotiating terms and conditions into contracts that require all parties of the contract to monitor and report to one another health equity efforts, such as community investment, bias training, and diversity of staff.

While such efforts at the federal, state, and private levels are underway, it will be critical to not only collect and analyze data to understand health inequities but to then incentivize or require parties to create solutions that eliminate those inequities over time. While CMS and states across the country will continue to play leading roles in tackling health equity in 2022 and beyond, it is clear that solutions in this space will not come from a single actor, but more broadly from the combined efforts of the entire healthcare infrastructure working together.

is counsel in Crowell & Moring LLP’s Health Care group.

CMS and state officials are using payment incentives, data collection and program requirements to start edging the lofty ideals of health equity toward reality.

Getting Real About Health Equity

PBMs have come in for a lot of criticism, and an industry labeled a “middleman” isn’t going to garner a lot of popular support. But federal regulation of the PBM industry hasn’t gone very far. Increasingly, though, state legislatures and agencies are imposing new rules on PBMs. State regulation got a major legal boost in late 2020 when the Supreme Court ruled in Rutledge v. Pharmaceutical Care Management Association that Arkansas could impose requirements on PBMs.

“The bills filed or passed this year concern the licensing or registration of PBMs, requirements for more transparency in the drug supply chain, and protections for independent pharmacies, which have long complained that PBM practices force them into exploitative arrangements,” the Pew Charitable Trusts reported last year.

The clear majority of the respondents to our State of the Industry survey are in favor of the trend in state regulation.

Nearly two-thirds (65%)  indicated that they were in favor of increased state oversight and regulation of PBMs. Ninety-one of the 100 respondents answered that question.

We also asked about specific state regulations. The results to those questions were not included in our print issue because of space constraints. They showed agreement with the many of the rules and regulations that have been proposed. For example, 73% of strongly or somewhat agreed with disclosure requirements on PBM indirect and direct revenue sources, and 57% agreed with bans on mandatory mail order. 

Almost two-third of the respondents to our survey were in favor of the trend of more state-level regulation of the pharmacy benefit management industry.

Managed Healthcare Executive® State of Industry Survey: Agreement with State Regulation of PBMs

Rodrigo Cerdá, M.D., M.P.H., a member of the 

® editorial advisory board, has been named chief medical officer of Independence Blue Cross in Philadelphia.

Cerdá is succeeding Richard Snyder, M.D., who has been the chief medical officer of the Blues plan since 2010. Snyder will continue with IBX as executive vice president of the facility health networks division of the organization, which focuses on working with health systems and providers.

The company also announced on Wednesday that it had named Victor Caraballo, M.D.,to be the vice president of the quality management and its first chief safety officer, In the same announcement, Diana Lehman, B.S.N., R.N., was named the vice president of case and condition management.

“Independence has the opportunity to help redefine care delivery and promote equitable, whole-person health, and Rodrigo, Vic, and Diana are critical to those efforts,” said Snyder said in the press release.

IBX bills itself as the leading insurer in the Philadelphia region and, counting its affiliates, says it serves more than eight million people. Independence Health Group, the parent company, reported total revenues of $21.8 billion in 2020.

The leadership at the IBX has turned over recently. CEO 

, CPA, CGMA, succeeded long-time Dan Hilferty at the beginning of 2021. Hilferty led the insurer for 10 years and is a prominent civic leader in the Philadelphia region. Juan Lopez, CPA, was named CFO in April 2021, and Crystal E. Ashby, the executive vice president and chief people officer, in July 2021.

Cerdá started with IBX in 2019. As president of clinical care transformation, he has led collaborative efforts with providers focused on value-based care. He also led Independence’s population health, case and condition management, and provider experience teams. 

The news release says that in his new role, Cerdá will continue “this important work and take on accountability for medical management and medical policy, market-facing solutions and support, and health value optimization at Independence.”

Before joining IBX, Cerdá was a managing director for Integrated Health Services at PA Consulting and Aetna International in the United Kingdom and prior to that, worked for McKinsey and Company, the consulting firm. Cerdá earned his M.D. from University of Pennsylvania and his M.PH. from Harvard and was a resident in internal medicine at Massachusetts General Hospital.

 editorial advisory board in November 2020.

Cerdá, a member of the Managed Healthcare Executive® editorial advisory board, is part of a new wave of leadership at the Philadelphia-based insurer led by CEO George Deavens.

Cerdá Promoted to Chief Medical Officer of Independence Blue Cross

Those living with HIV and who abuse drugs experience worse health outcomes than those who aren't using. However, a 

 conducted mid-2021 reported those with HIV who abused drugs and have not had dental care use, experience a greater need of care.

With or without dental care, folks who have HIV and use drugs experience worse health outcomes than their non-using counterparts because substance use can speed disease progression, affect adherence to antiretroviral therapy, and worsen the overall consequences of HIV.

The clinical trial, Project HOPE (Hospital as Opportunity for Prevention and Engagement for HIV Infected Drug Users) sought to improve engagement in HIV outcomes, according to researcher and co-author of the study, 

.  Santella is also professor of Health Administration and Policy, director of the Doctorate of Health Sciences program for the School of Health Sciences, and 

"As a researcher, I used this dental utilization data to assess factors associated with dental care utilization among Project HOPE participants, with a research question focused on understanding the relationship between sociodemographic, HIV care, and risk factors with routine dental care utilization among PLWH (people living with HIV) with substance use disorders," Santella said.

The analysis was part dome with data from a large, national clinical trial of just over 800 people living with HIV with substance use disorders who were inpatients at 11 urban hospitals. In the trial, dental care use was measured at each time point during the study period (baseline, 6 months and/or 12 months). 

It was found that over half (59.4%) reported not having received any dental care at any time point. 

Santella shared those with HIV-related symptoms and an AIDS diagnosis have a greater need for dental care than those with fewer symptoms and without AIDS, but eclipsing needs for physical and mental health services limit their access to dental care. 

He added access to oral health programs has shown to improve physical and mental health. In a sample of low-income people living with HIV, engagement in an oral health program was associated with improvement in overall wellbeing.

In relation to the study, many variables of social determinants of health (SDoH) were looked at to find solutions in HIV care.

For example, participants with less than high school education had lower odds of reporting dental care utilization than those with more than education. Data also revealed those without health insurance also had lower odds of reporting dental care utilization than those with insurance. Higher food insecurity was also associated with having recent dental care utilization as were those from Southern states.

In the study, food insecurity was measured using the Household Food Insecurity Access Scale (HFIAS) which consists of nine items measuring one’s experience with insecure food access - each item scored on a scale of 0 to 3 where 3 represents the highest frequency of occurrence. 

Data found participants who had higher food insecurity had greater odds of reporting recent dental care. Findings from a retrospective analysis of National Health and Nutrition Examination Survey data found an association between food insecurity and unmet dental needs, which may be directly due to oral health problems causing trouble with eating. While the results differ, the dental setting represents an often untapped, but potentially useful venue in the provision of patient education in the subject of food insecurity, he Santella added.

It's recommended that the association between food insecurity and dental care utilization among this population needs further exploration.

Overall, having more access to dental care can better the outcomes of HIV patients who have substance use.

"The mouth is the gateway to the body," Santella said. "Oral health impacts physical health and physical health impacts oral health. Having access to quality, affordable dental care may mean a person is more likely to be linked to and engaged in care which should lead to better health outcomes."

"Research has shown a synergic relationship between oral health and wellness, so the more we can promote oral health in people with HIV (including those who use drugs), the better off they will be in maintaining quality of life."