Peter Wehrwein

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MHE's Peter Wehrwein talks with Lloyd Dean, CEO of Dignity Health and CommonSpirit, and Valerie Montgomery Rice, M.D., FACOG, president of Morehouse School of Medicine, in this new episode of MHE Talks: Improving Patient Access podcast series. The three discuss the lack of Black physicians in the United States. Of the 22,000 medical school applicants in the U.S. every year, only 1,600 are Black. Dean and Rice created a program that seeks to cross barriers of healthcare and racial disparities by offering more opportunities for students of color in medical school programs.

Morehouse School of Medicine, CommonSpirit Tackle Healthcare Disparities in new Scholar Program 

The post office has been a source of instability in a rather unstable time in general. So did you change how you got that medication delivered to people's homes as a result of concerns about the capacity of the post office?

 So we certainly discussed it in the early days. And we discussed it really in two ways: one is relative to mail and postal service and delivery and logistically the options around that, and geographic differences, because one might like to think that it's a national problem. But really, it might be limited to one community versus another. So a very operational and granular approach is taken to make sure that's managed from a logistics point of view. 

But I think, in addition to that, we thought about retail and mail in the same setting, and because if you were, let's say in a stay-at-home order, you couldn't go to your retail pharmacy. And at the beginning, if we again reflect back to the beginning of this, many of them were closed, whether it be the social unrest that happened or the early days of stay-at-home order, you couldn't even go to the retail pharmacy to get it. 

So what we did there in terms of change, we moved very quickly. Another area that I'm quite proud of, is we removed any refill too soon - requirements that may have prevented someone from getting an extra script. And we did it through a system change. So you didn't have to call in the early days. The call volumes were really high. We wanted to avoid that disruption for the members so they could get an extra prescription and have it on hand. And so we changed the policy, we informed our members and a number of members were able to then have extra supply, which then mitigated some of the issues that you raised around how long it would take for a medicine to come in terms of home infusion and the increased use of home infusion. 

 Have you seen any sort of increase in the number of prescriptions for antidepressants or anti anxiety drugs that would reflect be a data point that would verify this concern that people have about the effects of the pandemic?

 What we've seen is anti-depressants are up over 10%. So to your point, people are feeling the effects of this pandemic, the stress of the pandemic, the economic toll that many of our fellow Americans are experiencing. And being empathic, cognizant, and then having resources to help, again is, it's a privilege to be in a position to be able to do that.

 What two or three things you see as having sort of staying power, where you discovered something about the way your business works that is going to continue, even as life returns to a new normal?

Well, I think we should start by this, we're having this conversation in a way that most likely would have been in person before. And I can tell you as we end 2020, versus when we began, that the connection that I can develop with you, in this way, is much better and deeper than than I thought it could ever be. And that's directly applicable to how we serve our patients. 

As organizations increasingly have taken to resources that do not require face-to-face, interaction that's aligned with how we've invested in the business, and the capabilities we've developed, specifically digital capabilities, around getting information around price of drugs, being able to order drugs, and also offering services that are not necessarily just prescription drugs, but adjacent needs to our optimum store, those are all capabilities that are important.

Videos

Sumit Dutta, MD, MBA, of OptumRx, talks to MHE about drug use among Americans during the COVID-19 pandemic and about vaccine distribution to its members in this part two of a two-part video interview series.

Drug use, Distribution Among Members of OptumRx

There currently aren't enough vaccines in the United States, and between the Pfizer and Moderna vaccines, the two are very important to get their hands on, according to Sumit Dutta, MD, MBA, of OptumRx.

Dutta, senior vice president and chief medical officer, told MHE during the video interview it's crucial for frontline workers and people most at risk to have access to these FDA approved vaccines, which have been reported to work well.

In this conversation he shares some of the vaccine differences and the responsibilities of OptumRx to educate their members on them.

Q: It's my understanding that the Moderna vaccine doesn't need to be kept at the super cold temperature that the Pfizer vaccine does. It's been shared that for that reason, (Moderna is) more likely to be distributed and administered by pharmacies. Is that correct?

A: The Pfizer biotech vaccine that's available today needs to be stored in a colder fashion. It has refrigeration requirements that are very cold: minus 70 degrees celsius and beyond, versus the Moderna vaccine that will be slightly warmer temperatures. 

Q: Does OptumRx have a direct role to play in terms of the vaccine distribution and administration?

A: So today, we have processed claims for the Pfizer vaccine that's available on the market. So that highlights the readiness in terms of claims processing that's required. And in fact, it educates the listeners to all of the work behind the scenes that may seem arcane, that allow actually someone to get a vaccine beyond the physical vaccination. 

So let me start with that and move further back and talk about all of the ways that we've monitored:  we listen to the FDA comments, we advise our clients about vaccines, we recently had a call with over 650 people on it. We've done that all the way through the pandemic, to make sure that people are aware. We (also) have an important role in making sure our members understand the value of taking the vaccine, which I think is a very important societal role.

Q: Have you used any particular communication channels to talk to your members about vaccines?

Q: We do calls with our clients and the consultant community to educate them, and make sure that they have the information that they need to communicate to their membership. We also have many communications that we put together from our drug intelligence group that then get repurposed for content for our members. We inform our call center representatives, for example, for questions that come in. This is all a part of the work that is behind the scenes to make sure that we're prepared for the inevitable questions that people might have around reactions to the vaccine: How does it get paid for? etc.

I think there's another important thing that we're working on that I'm I'm excited about and proud about, which is using our analytics to make sure that people get that second dose. So as you know, there are two vaccinations that are required approximately a month apart, and using our data to ensure that we're doing everything possible along with the stakeholders, so that our members get that second dose and drive that adherence is another important thing we're working on.

Q: Could you just tell us a little bit about that pivot OptumRx had to make by virtue of healthcare delivery in this case? You know, medication delivery has shifted as a result of the Covid-19 pandemic.

A: I think you rightfully point out that the pandemic has changed all of us. And certainly, we here at OptumRx, in some ways, it has reinforced what we already do. You know, we are really purpose-built for situations like this pandemic. It may be like the behind the scenes piece that I mentioned around making sure that our claims system can adjudicate. It can also be our community behavioral health pharmacies, when there's more vaccines available, may be a part of the solution in administering the vaccination. But it is also this point that you're making around how people see, to get care and have services delivered to them. 

As we think back and reflect towards the early days of the pandemic, there were many stay at home orders, a lot of fear and misinformation. That was an opportunity to have people get their medications at home, sort of a renewed understanding that home delivery of medications is a valuable way to get medications. What we found is really interesting: One, we found that member satisfaction improved. During this period getting medications from home, we measured the net promoter score went up 12%. 

The second thing is we found our adherence improving. So mail has delivered, improved adherence by getting your medicines at home. It's one less thing you have to think about.

There currently aren't enough vaccines in the United States, and between the Pfizer and Moderna vaccines, the two are very important to get their hands on, Sumit Dutta, MD, MBA, of OptumRx, says in this part one of a two-part video interview series.

Sumit Dutta of OptumRx Discusses COVID Vaccines, How PBM was Affected by the Pandemic

When the Congress finally passed legislation to end surprise billing in December, it settled on a final-offer arbitration process for settling cases when providers and health plans can’t agree on amount to be paid for an out-of-network service. Final-offer arbitration, which is used to settle pay disputes in major league baseball and by certain unions and employers, means the arbitrator must select the amount proposed by the provider or health plan; there’s no compromising on a middle amount.

States have also set up final-offer arbitration for settling surprising billing disputes. In this month’s issue of 

 of New Jersey’s final-arbitration system that showed the median arbitration award in 2019 was 5.7 times higher than the median in-network price for the same procedure. Even when health plans won the arbitration, they paid, at the median, 1.76 times the median in-network price.

, an associate fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, and his colleagues found that 85 (5%) of the 1,695 cases in their study had awards that were 25 times the median in-network price and nine cases settled at prices that more than 100 times the median in-network price. They found that 82 of the 85 awards that were 25 times larger than the median in-network price were cases when the provider’s final bid was picked by the arbitrator and that most (72) of those cases were from plastic surgeons, general surgeons or orthopedists.

Chartock and his colleagues note that arbitrators in New Jersey are shown and instructed to consider amounts that are the 80th percentile of billed charges and that they found evidence that the 80th percentile level “may have served as a strong guidepost for arbitration decisions.” They noted the mean arbitration decision in New Jersey was 107% of the 80th percentile of billed charges.

One of the major policy debates about eliminating surprise billing and settling disputed bills is whether to use arbitration (which is generally favored by providers) to settle the disputed bills or to use a benchmark instead that would be tied to, say, a percentage of the Medicare rate.

Chartock et al. say regardless of whether the method to resolve disputes is arbitration or some kind of benchmark, federal and state policy makers “should recognize that any reliance on any reliance on provider charges, either to define an out-of-network benchmark or as guidance given to arbitrators for consideration can induce perverse incentives that maybe harmful to the market.” In their conclusion they amplify on the point: “Arbitrators should be prohibited from considering provider charges, which are unilaterally set, are largely untethered by market forces, and tend to be extremely high.” Instead, they said arbitrators should look to commercial in-network prices and Medicare payments for guidance.

Under the New Jersey surprise billing law, insurers make payments to providers and the patients are not supposed to pay more in cost-sharing amounts that they would if they had been cared for by an in-network provider. Arbitration is triggered if the difference between the insurer’s payment and the provider’s bill is more than $1,000.

Under New Jersey's final-offer arbitration system, median arbitration award was 5.7 times median in-network price. Researchers say use of billed charges leads to high awards. 

Peter Wehrwein

Articles

Morehouse School of Medicine, CommonSpirit Tackle Healthcare Disparities in new Scholar Program

Drug use, Distribution Among Members of OptumRx

Sumit Dutta of OptumRx Discusses COVID Vaccines, How PBM was Affected by the Pandemic

Researchers: Billed charges shouldn’t be used to settle surprise billing disputes