Aine Cryts

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Multiple sclerosis (MS), a disease characterized by damage to the myelin sheath encasing nerves in the central nervous system, is often unpredictable for the people who have the condition. Flare-ups and the symptoms they cause — loss of muscle control, balance issues, vision problems — often don’t have any easily discernible pattern.

But for insurers and others responsible for managing the cost of healthcare, MS is predictably one of the costliest chronic diseases despite it being a relatively rare condition. A study published earlier this year in 

 found that the all-cause costs for patients with severe MS relapses was almost $88,000 per year, most ($70,000) of which was related to MS. Prime Therapeutics says MS is the fourth-highest drug-spend category among its commercially insured members.

The priorities when treating patients with MS are forestalling further injury to the nerves and managing symptoms, says Nicholas Lannen, M.D., a neurologist at Spectrum Health, a healthcare system headquartered in Grand Rapids, Michigan. Lannen says preventing further damage to the nerves may give a patient’s brain a chance to repair itself through neuroplasticity.

Here are three things healthcare executives need to know about treating MS while managing costs:

Generics may not be such a good deal for patients

Switching to generics is a well-worn path to lowering prescription costs. Lannen says he’s not opposed to generics provided they benefit the patient. But a generic may mean higher out-of-pocket costs for a patient because of coupons and other measures that insulate patients from the cost of brand-name equivalents.

Robert Bermel, M.D., a staff neurologist and director of the Mellen Center for Multiple Sclerosis at Cleveland Clinic, says the “patient gets lost in the middle of this.” Bermel says the generics are often only “marginally less expensive” than brand-name drugs.

Some imaging and office visits are unnecessary

Ensuring patients receive an accurate diagnosis is one way to reduce costs, says Bermel, who advocates for having diagnoses made at healthcare centers with expertise diagnosing and treating MS, such as the Cleveland Clinic, for that reason. Reducing the number of imaging tests and office visits can also save money. Although both are helpful particularly after initial diagnosis, their value decreases over time, Bermel says. He also recommends home care, shared visits and virtual visits as lower-cost alternatives to physician visit.

There are cost-effective options to consider

The price of disease-modifying agents increased annually at rates five to seven times higher than prescription drug inflation, according to a 2015 study published in 

Bermel says the average wholesale cost of an oral agent is approximately $80,000 to $90,000 a year. Ocrevus (ocrelizumab), which is administered intravenously twice a year, costs about $60,000 to $65,000, and rituximab is one-third the cost of ocrelizumab. A review paper published in the

 earlier this year said that there is a growing body of evidence supporting rituximab as a treatment for MS, although it has not been approved by the FDA as treatment for MS.

Aine Cryts is a freelance writer in the Boston area.

Articles

Multiple sclerosis is dependably among the most expensive chronic diseases to treat, but there are ways to reduce the size of the bill. 


3 Takeaways About Managing the Cost of MS

One of the hard truths about the COVID-19 pandemic is the disproportionate effect it has on people with diabetes, a group that includes more than 34 million in the United States, or roughly 10% of the population.

 in August 2020 found that one-third of hospital COVID-19 deaths occurred among people with diabetes. Getting patients on a statin seems to help, according to a study published in the 

Journal of the American Heart Association

. Researchers at Montefiore Medical Center in Bronx, New York, found that patients with diabetes who were hospitalized with COVID-19 experienced a 12% lower (adjusted) risk of in-hospital mortality if they were taking a statin.

Catherine Rolih, M.D., medical director at Novant Health’s Diabetes Center of Excellence in Winston-Salem, North Carolina, says that diabetes, coronary heart disease, obesity and chronic obstructive pulmonary disease are the top four comorbidities associated with mortality due to COVID-19. Among Novant Health’s patients, diabetes is the most prevalent chronic condition associated with mortality and COVID-19. Rolih tells her patients that the impact of diabetes starts with the immune system. Various organ systems are damaged as a result of poorly controlled diabetes — everything from blood vessels in the eyes to a person’s nerves — and that can lead to a greater likelihood of infection in general.

Paul Sherman, M.D., chief medical officer at Community Health Plan of Washington in Seattle, a nonprofit insurer that markets Medicaid and Medicare managed care plans, says that “providers and insurers face the probability of their patients (and) members with diabetes having a much higher disease burden, worse outcomes and greatly increased healthcare expenses. This will increase the burden on already overtaxed primary care systems and hospitals, including (intensive care units).”

Targeting the right patients for outreach is a good first step, says Robert Gabbay, M.D., Ph.D., chief scientific and medical officer for the American Diabetes Association. The first question to ask: “Which patients with diabetes haven’t been seen in the last six months?” Within that patient population, he recommends focusing resources on patients whose last glycated hemoglobin (A1C) level was greater than 9%. “If their diabetes was poorly controlled then, they really need help. Then staff at provider organizations need to hit the phones to set up video and telephone visits with patients,” Gabbay says. He also suggests providing free delivery of medications to patients.

Priority Health in Grand Rapids, which covers 1 million Michigan residents, embraced this approach early in the pandemic, says James Forshee, M.D., the insurer’s senior vice president of medical affairs and chief medical officer. In addition to eliminating copays and coinsurance on care related to COVID-19, the nonprofit health insurer coordinated with large pharmacy chains in the state to provide free delivery of medications to patients.

Many patients with diabetes have gained weight; Rolih calls it the “COVID 20.” That’s in addition to losing control of their diabetes and high blood pressure and missing screenings for complications. She says payers should maintain coverage for telehealth-based care and expand access to diabetes education for the duration of the pandemic.

Rolih has facts to back up her suggestions. In 2019, participants in Novant Health’s class for people with type 2 diabetes experienced a 1.4% reduction in their A1C levels, exceeding the 1% reduction typically seen with many medications. The health system’s diabetes education program includes an initial 60- to 90-minute assessment between a patient and a diabetes educator. Also included are eight hours in a group class that covers the ADA-specified curriculum. Before the pandemic, there were approximately 10 to 20 people in each in-person group, according to Rolih. Currently, patients participate in the program virtually, and there are fewer participants in each group. More than 2,000 patients completed at least part of Novant Health’s program in 2019. Participation is down this year, presumably due to the pandemic.

However, coverage by payers is iffy at best. Some payers may not continue with telehealth coverage except by arrangement with individual employers, says Rolih. “This may cause many issues, especially since it’s clear COVID-19 will be around for a while, and poor diabetes management is a big risk factor for poor COVID-19 outcomes.”

Andrew Ahmann, M.D., director of the Harold Schnitzer Diabetes Health Center at Oregon Health & Science University, says that provider organizations should be assessed on their ability to track patients with prediabetes and diabetes and direct them to education programs in much the same way they’re held accountable for tracking patients’ cholesterol and blood pressure levels. The CDC defines prediabetes as a serious health condition in which blood sugar levels are higher than normal but not high enough to be diagnosed as type 2 diabetes. About one-third of Americans meet the criteria for prediabetes. Ahmann says managing prediabetes is especially important now because of the pandemic and the vulnerability of people with diabetes to serious cases and death. The pandemic may tip some people with prediabetes into full-blown diabetes because of lack of exercise and less healthful eating habits.

Ahmann says payers should waive copays for prediabetes and diabetes education after the pandemic. Gabbay at the ADA agrees, while praising diabetes educators: “Diabetes education specialists are worth their weight in gold. They’re underappreciated and underreferred to, but they’re a part of helping (patients) deal with the overwhelmingness of (managing their diabetes).”

Ahmann says the diabetes prevention education program at his facility follows the CDC’s National Diabetes Prevention Program. Educators teach the participants about caloric intake, healthy eating, increasing physical activity, managing negative thought patterns, healthy approaches when eating out, managing stress and staying motivated.

During the pandemic, patients have participated in education sessions on Zoom video calls. While class facilitators prefer in-person meetings, attendance and interaction have been successful on Zoom, says Ahmann, a contributor to the ADA’s “Standards of Medical Care in Diabetes,” a compilation of the association’s prevention, screening and treatment recommendations. Three separate groups of between 10 and 20 patients participate virtually in the diabetes prevention program, says Ahmann. Participants are required to upload reports from their insulin pumps, sensors and meters.

The pivot to virtual education for patients with prediabetes and diabetes first required training and certifying diabetes educators on the virtual platforms. During the pandemic, diabetes education has transitioned between virtual and face-to-face formats. For example, in late June, participants were moved to 25% face-to-face and 75% virtual interactions. Ahmann says he expects a hybrid of in-person and online sessions to be the model in the future.

Keeping the virtual platform “as simple as possible for patients” is important, says Ahmann. He’s confident that virtual delivery of diabetes education will increase access to care, while improving patient knowledge and adherence to care plans. Payers are currently covering virtual visits and diabetes education, but Ahmann says he doesn’t know if this will continue after the pandemic.

Aine Cryts is a healthcare writer in the Boston area.

Diabetes education has shifted from in-person classes to Zoom meetings. 

Inside Chronic Diseases: COVID-19 and Diabetes

What a strange time it has been for American healthcare payers and providers.

When the nation’s governors issued stay-at-home order and advisories in March and April, routine healthcare came to a grinding halt. Elective procedures were canceled or postponed. Hospitals had created capacity for what many expected to be a huge influx of patients with COVID-19 who could overwhelm their finite supply of hospital beds, intensive care units, respirators and personal protective equipment. In some hotspots and at some hospitals in those hotspots, that influx occurred, and there was another surge of cases in some parts of the country in July. But in other places and for many providers, the COVID-19 pandemic led to a precipitous decline in use and with that drop, a drop in revenue.

About 1.4 million healthcare workers lost their jobs in April. The American Hospital Association said that collectively, the country’s hospitals suffered $200 billion in financial losses because of COVID-19 from the beginning of March through the end of June. Lou Ellen Horwitz, CEO of the Urgent Care Association, says urgent care centers were a “ghost town” in March and April. Based on its financial and other data from a representative sample of 800 hospitals, Kaufman Hall said that hospital operating margins fell by nearly 300% in April 2020 relative to April 2019. In its August “flash report” on hospitals, the Chicago-based consulting firm said hospital operating margins were down 96% compared with the first seven months of 2019.

Of course, for payers the lack of utilization had just the opposite effect on their finances. By and large, premiums dollars kept on flowing in and claims, and therefore healthcare expenditures, disappeared. As a result, insurers enjoyed huge margins, especially in the second quarter and likely in the third, although probably not as large. Research by Adam Block, Ph.D., an assistant professor of public health at New York Medical College, on the Managed Healthcare Executive® website shows that net operating income in the second quarter of this year had increased by an average of 136.7% relative to the second quarter of 2019 for five publicly traded insurers (UnitedHealth Group, Anthem, Cigna, Centene Corporation and Molina Healthcare).

“It makes a lot of sense because if all of the elective procedures went away and we are all still paying (the) same premiums that we were…earlier in the year, pre-COVID(-19), that money all stays as retained earnings for the health plans,” Block said in an interview.

Many providers have received federal funding through the Paycheck Protection Program and Health Care Enhancement Act and the Coronavirus Aid, Relief, and Economic Security (CARES) Act, which allocated $175 billion for healthcare providers. Kaufman Hall’s calculation of the relative decrease in operating margin for the first half of the year compared with 2019 goes from 96% to 28% once CARES Act money is included. That’s still a significant drop in operating margin, but it also shows that the CARES Act has made a significant difference.

Relatively early on in the pandemic, many payers announced that they were helping out struggling providers by making advance payments with the short-term goal of shoring up their liquidity. UnitedHealthcare, for example, made $2 billion in funds available. Premera Blue Cross in Washington state announced advance payments of $100 million, and Blue Cross and Blue Shield of Minnesota pushed out $80 million.

Joseph Restuccia, Dr.PH., M.P.H., a professor at Boston University’s Questrom School of Business, says that payers “fronting this money” to providers is “the right thing to do from an ethical, social justice and moral perspective.” He also sees it as an opportunity for payers to develop closer relationships with providers and support the move toward value-based care and payment arrangements that include some form of capitation.

More recently, payers have been announcing a flurry of “premium relief” measures for employers and individuals, often in the form of a 10% to 25% discount on a future month’s premium. UnitedHealth publicized a plan in May about premium credits and the waiving of cost sharing that it said added up to $1.5 billion. Anthem announced premium discounts in June that according to the company added up to $2.5 billion. Many of the Blues’ plans are on the premium-relief bandwagon; for example, Blue Cross and Blue Shield of Minnesota announced a plan in August that included $38 million in premium relief and $31 million in advanced 2019 medical-loss ratio (MLR) payments. “It is doing our part to help a community in need,” said Craig E. Samitt, M.D., MBA, company president and CEO, of the Minnesota Blues’ plan.

Sabrina Corlette, J.D., founder and co-director of the Center on Health Insurance Reforms at Georgetown University’s McCourt School of Public Policy, says insurers are well aware that legislators and policymakers know they have had a very good year financially so far. “I think to the extent that they can generate some good will and some good public relations by offering premium holidays and premium discounts that is helpful to them.” Corlette says MLR calculations may also be a factor. Under the ACA, insurers are required to spend 80% of the premium dollar on healthcare in the individual and small group market and 85% in the large employer market. With healthcare expenditures down, so are MLRs. If an insurer can boost their MLR by getting a bit less in premiums revenue, that means paying back less in MLR rebates later, she explains. “I think a lot of carriers are thinking, ‘We are going to owe this money back to the policyholders anyway’ and right now people are suffering, people maybe have lost their jobs or lost income,” says Corlette.

The uptick in COVID-19 cases in July added some wobble to the uncertainty about the epidemic’s course, but patients are coming back and getting healthcare services. Horwitz, whose association represents about 4,500 urgent care centers, says her members are busier than ever with the normal run of problems seen at urgent care centers along with testing and care associated with COVID-19. Kaufman Hall’s August report showed increases from June to July in almost every measure of volume (discharges, patient days, operating room minutes and so on) and relatively modest differences between July of this year and July 2019. 

One exception is emergency department (ED) visits, which according to the Kaufman Hall tally are down by about 17% from last year. Jim Blake, Kaufman Hall managing director and chief author of the company’s flash reports, says the reasons for decline in ED visits are still unclear, but one possibility is that people are choosing to go elsewhere for less serious emergencies or are getting care through telehealth.

One wildcard in the resumption of routine, in-person healthcare services is the public’s perception of safety regarding visiting a doctor’s office or hospital. Many providers are going to great lengths to make their facilities as safe as possible with sanitizing, spacing and parking lots that are now doubling as in-your-car waiting rooms. More than a few providers are using social media to show off their efforts in hopes of assuaging fears. But they are working against a baseline of apprehension. When the Society for Cardiovascular Angiography and Interventions conducted a survey this spring, it found that about a third (36%) of the respondents viewed a hospital visit as “risky behavior,” and 61% reported believing they were somewhat or very likely to acquire COVID-19. Granted, much has changed since this spring. Presumably the worry has subsided somewhat. But if the pandemic has a second wave, as many expect, and a reliable vaccine isn’t available, the fear will likely to return.

Ashraf Shehata, national sector leader for healthcare and life sciences at KPMG, the consulting firm, says the only way to make patients feel safe is to implement protocols designed by local and federal public health bodies and educate patients and community leaders about these efforts. That is what Beth Israel Lahey Health, the eastern Massachusetts healthcare system, did back in May when it emailed patients about what to expect during in-person visits:

Designating specific areas of the office for patients with suspected or positive COVID-19

Seeing high-risk patients during specific hours of the day

Minimizing patients’ time in the traditional waiting area by asking them to wait in their cars until their appointment time, or escorting patients from the building lobby directly into their exam room

Asking about COVID-19 symptoms or exposure multiple times before the appointment takes place with a set of screening questions

Requiring all staff and patients to wear masks

Asking all employees, including primary care providers and care teams, to report any symptoms and to stay home if they are ill

Using approved cleaning products that are effective against human coronaviruses to disinfect settings such as exam rooms and common areas

Shehata also advises hospitals and practices to call patients to welcome them back for routine and preventive care, such as mammograms and colonoscopies. To increase a sense of safety, patients might be greeted at the entrance of a facility by a “navigator” who walks with them to their appointment, says Restuccia. There are also apps for guiding patients.

But this fall, healthcare providers are facing a whole new set of troubles on top of those posed by COVID-19. The prospective of a second wave of COVID-19 and a serious flu season is a source of dread, although the public health measures designed to reduce COVID-19 transmission (social distancing, masks, school- and work-from-home arrangements, the lack of international travel) could help make for a mild flu season. Hurricane Laura weakened fairly quickly and turned into a tropical storm, but there is still a lot of the hurricane season ahead.

“All of these things will continue to hamper and affect (providers’) ability to respond and bring back patients,” says Shehata.

Employment and the overall economy are another large variable in the complicated equation that will determine healthcare use and the return of patients. COVID-19 is proving to be a lumpy pandemic with disproportionate effects on certain populations (older people, males, Black Americans) and certain parts of the economy (restaurants, airlines). Massive job loss may lead to millions of people losing employment-based coverage, although many of the disappearing jobs are on the lower rungs of the economy and didn’t have health insurance as a benefit.

Moreover, the ACA does provide some cushion against the loss of health insurance. Thirty-nine states expanded Medicaid under the 2010 law, and roughly 11 million Americans have purchased coverage on the ACA exchanges. Commentators have noted that the ACA could be one of the many factors that will stave off a more serious economic downturn from COVID-19.

The death toll is too high (more than 180,000 in the U.S. and 830,000 worldwide) and the disruption too great to sound any kind of celebratory notes about COVID-19. Still, the pandemic has had unintended consequences that could have long-term benefits for providers and payers — and let’s not forget patients. Probably the most talked about topic is the sudden, why-didn’t-we-do-this-sooner adoption of telehealth and remote care.

Others see the payer-provider
dynamics of the pandemic accelerating the adoption of value-based care. Corlette says it makes logical sense that some sort of capitated payment would become more attractive. But she also notes the lack of data on any shift to value-based care and a long-standing reluctance to take on downside risk. “I just haven’t heard that there has been a real shift on that front, but this may just be one of those things that takes time to play out.”

Keely Macmillan, senior vice president of policy and solutions management at Archway Health, a Boston consulting firm that specializes in bundled payments and value-based care, is more sanguine.

“Providers in capitated or semi-capitated arrangements that had predetermined amounts to care for their patients, …were actually faring much (better) during the public health emergency. (They) were financially better equipped to provide care for their patients and implement telehealth and weren’t forced to furlough their staff like many providers who were reliant on fee-for-service revenue,” Macmillan said in an interview.She noted that CMS has launched several alternative payment models recently (models that include some degree of capitation). “COVID-19, in many ways, makes some of these alternative payment models more attractive.”

Aine Cryts is a healthcare writer based in the Boston area. Peter Wehrwein is senior editor of Managed Healthcare Executive®.

The pandemic has had dramatically different consequences for the finances of payers and providers. 

COVID-19 Imbalance

Our social lives are now fraught with challenges because of COVID-19 and social distancing. Even simple gestures and mores need to be navigated. The perfunctory hug — and especially the handshake — seem like relics of the past, invitations to transmission and infection rather than signals of goodwill or a deal struck.

So what will fill the void, particularly in business settings?

The elbow bump, when each person bumps the other’s elbow, may enter the mainstream as a friendly gesture, say healthcare executives. The toe tap or foot shake?Umm, maybe not in a business setting. And there’s the shaka symbol, which more people would recognize — the three middle fingers curled over with the thumb and pinky extended — than know its name. The gesture is better known as “hang loose,” “right on” or “take it easy” and was associated with Hawaii and surfer circles before people in the mainstream started to use it ironically. The knuckles facing outward to show enthusiasm are optional.

Embracing these or other symbolic greeting gestures will require a culture change, says Kevin Ronneberg, M.D., vice president and medical director of health initiatives at HealthPartners, a not-for-profit healthcare organization in Minnesota. Letting go of the handshake will be hard for many people. Ronneberg, a member of the 

® editorial advisory board, said his grandfather instilled in him the need for a “firm handshake ... where you look people in the eye.”

Peter Coelho, M.D, a physician executive at St. Louise Regional Hospital in Northern California, says he “kind of cringed” when someone tried to hug him recently. But he understands the need to hug. “There’s been a fracture. We feel that in all of our society,” says Coelho.

What follows is some advice from healthcare executives on alternatives to the handshake and strategies for building and strengthening bonds with colleagues and patients.

Ronneberg says it’s not about the handshake or another physical gesture. Instead, he’s focused on the message he wants to convey and on meaningful ways to connect with colleagues and patients. Unless they’re doing a physical exam, doctors aren’t touching patients these days, but they can still greet patients with joy — or express condolences— through words, says Ronneberg. Emotional intelligence helps with this, as does using words to articulate what you’re feeling and the importance of the connection you’re making. This strategy also works with colleagues, he says. For example, a colleague can feel validated when a team member acknowledges that they’re having a bad day.

Joan Budden, president and CEO at Priority Health, a nonprofit health insurance provider in Grand Rapids, Michigan, jokes that some of Priority Health’s employees are thrilled that the payer has deemed itself a “no hugging” workplace.

Budden has four more suggestions for alternatives to the handshake:

Is the V-shaped gesture that was popular in the ’60s and ’70s about to make a comeback because of the COVID-19 pandemic? Baby boomers, however, may be wary about dating themselves and inducing millennial eye rolls.

Like the shaka symbol, many more people would recognize namaste (pronounced NAH-muh-stay) than know its name. It involves bringing the palms of the hands together with the fingers pointing up and bowing slightly at the waist. “Namaste”is a Sanskrit word that means “I bow to you,” according to the 

This is very close to a wave hello. The hand is raised up with the palm out. The open palm is an ancient display of honesty, according to 

The gesture is formed by putting one hand on top of the other with the fingers pointed away from body and wiggling the thumbs. Not exactly a greeting, it’s used to signal an awkward moment — in a somewhat awkward way.



Budden is partial to the namaste, thanks to her yoga class. “It means the light in me recognizes the light in you. That ‘I hear you.’ ‘I was present,’” she says. The namaste can also be a farewell gesture that expresses trust and sincerity.

One not-minor problem with these gestures is that they are not universally understood. The senders may know what they mean, but if those on the receiving end don’t, the purpose of the greeting is undercut, especially if the two people don’t know each other. That’s why it will continue to be important to be present with colleagues and pay attention to physical interactions, says Budden.

Leonard Kalman, M.D., executive deputy director and chief medical officer at Miami Cancer Institute, plans to continue to tell stories and inject humor into work meetings and during patient interactions. It allows people to relax while still respecting physical distancing, he explains.

But the lack of human touch when greeting patients and colleagues isn’t entirely comfortable for him, he says. “In my Jewish background, we’re big handshakers, huggers and kissers. It’s just part of the typical greeting, even with strangers.”

As a member of Miami Cancer Institute’s leadership team, Kalman has continued to physically go to the office during the pandemic. He and his physician-colleagues have embraced elbow bumps. His advice? “Turn your head away. There’s not as much risk (of transmitting the virus).”

Coelho knows he won’t be using the side hug — shoulder to shoulder, facing forward — to connect with colleagues or patients in healthcare settings. Coelho says the side hug is appropriate when he meets his wife’s friends because he wants to respect their space, but it doesn’t feel right at work. Kalman agrees: There’s no way to do a side hug while maintaining six-feet distance, he observes.

Budden won’t even go there. And she says that the traditional handshake now “seems kind of gross.” The handshake was safely appropriate before the COVID-19 outbreak, even though in some situations it seemed formal and too businesslike. But politicians “pressed the flesh” to connect voters, and American businesspeople shook hands as meetings started and sometimes when they ended.

Now, says Budden, she can’t stop thinking about where that other person’s hand has been.

The fist bump, which was popularized by pro athletes, doesn’t respect social distancing, but it is a good deal less “germy” than the handshake because the contact is brief.

A group of West Virginia University surgeons found that handshakes expose more than three times as much skin surface area as fist bumps; in addition, contact lasts 2.7 times longer with handshakes. And an infectious disease expert told 

 that fist bumps can help prevent the spread of diseases such as methicillin-resistant 

, which can result in bloodstream infections, pneumonia or surgical site infections in healthcare settings, according to the CDC. He also observed that fist bumps have “the advantage of being kind of cool ... Perhaps our patients will appreciate our attention not only to their health but also to hipness.”

Aine Cryts is a healthcare writer based in the Boston area.

Because COVID-19 has put the gesture in a different light, healthcare executives are coming up with other ways to greet people.

Aine Cryts

Articles

3 Takeaways About Managing the Cost of MS

Inside Chronic Diseases: COVID-19 and Diabetes

COVID-19 Imbalance

Is the Handshake a Thing of the Past?