Health Plan Weekly

Why Some Employee Wellness Programs Work, Others Don’t

May 7, 2019

A major wholesaler’s program recently grabbed the national spotlight after researchers studied it, published their findings in JAMA, and told The New York Times there is “a really weak evidence base” on whether such programs are worthwhile. But experts tell AIS Health the study focused on one problematic program, and its tepid results shouldn’t be extrapolated to other workplace wellness initiatives.

The study examined the BJ’s Wholesale Club wellness program after 18 months, and found some positives, including more regular exercise and active weight management among participants than in the control group.

By Judy Packer-Tursman

A major wholesaler’s program recently grabbed the national spotlight after researchers studied it, published their findings in JAMA, and told The New York Times there is “a really weak evidence base” on whether such programs are worthwhile. But experts tell AIS Health the study focused on one problematic program, and its tepid results shouldn’t be extrapolated to other workplace wellness initiatives.

The study examined the BJ’s Wholesale Club wellness program after 18 months, and found some positives, including more regular exercise and active weight management among participants than in the control group.

But the wellness program failed to align with many evidence-based best practices, asserts Jeff Dobro, M.D., strategy and clinical services leader in Mercer’s health care consulting practice. If a wellness program isn’t structured in the right way, by offering a “compelling design” of sufficient duration, along with effective employee communication and engagement, then incentives won’t drive change, he says. Moreover, it typically takes “two years or more to see a real health or financial benefit” from improved behaviors.

Dobro explains there are two main components to health improvement programs. First is the quality of the program itself. Second is the use of incentives for employees to participate. He asserts incentives have been shown to drive people to engage.

Dobro says his advice to employers is to avoid “narrow, rigid” wellness programs. “There is no one design that’s going to work with everybody,” he says, “because an employee population encompasses many types of people.”

Medicaid Churn Adds Burden to Health Plans

May 2, 2019

Newly implemented state paperwork requirements caused around 1.6 million Medicaid beneficiaries to lose coverage in 2018, the advocacy group Families USA says.

State policy decisions to engage in more frequent eligibility redeterminations are responsible for a large part of the enrollment drops, particularly in three states: Tennessee, Arkansas and Missouri, according to the group’s report, “The Return of Churn.”

By Jane Anderson

Newly implemented state paperwork requirements caused around 1.6 million Medicaid beneficiaries to lose coverage in 2018, the advocacy group Families USA says.

State policy decisions to engage in more frequent eligibility redeterminations are responsible for a large part of the enrollment drops, particularly in three states: Tennessee, Arkansas and Missouri, according to the group’s report, “The Return of Churn.”

Federal law and regulations require state Medicaid agencies to renew beneficiaries’ eligibility determinations every 12 months. However, Families USA says some states make this process much more difficult than others, with barriers including significant paperwork requirements and a lack of online enrollment options.

“A health plan’s onboarding process for a new member involves considerable paperwork,” says Meg Murray, Association for Community Affiliated Plans CEO. “This involves significant administrative and overhead costs that would be avoided were a member to be continuously enrolled.”

Increased churn may also result in reduced revenue streams for Medicaid plans where beneficiaries are being dropped from the rolls in large numbers, says Gerard (Jerry) Vitti, founder and CEO of Healthcare Financial, Inc.

“The most vulnerable members are those who are the least able to comply with these onerous roadblocks they are teeing up,” he adds. If these beneficiaries lose coverage, they ultimately may cost the system more money because they may end up with a hospital stay or emergency room visit that might have been prevented, Vitti says.

Still, Alex Shekhdar, founder of Sycamore Creek Healthcare Advisors, notes that enrollment of ineligible people is a significant problem in Medicaid, and the redetermination procedures are designed to address that.

Health Systems Build Micro Hospitals to Provide Care Near Home

April 30, 2019

Health systems are turning to micro hospitals — small inpatient facilities with emergency departments and eight to 25 beds that include full services — as a way to provide community-based care that’s more patient-centric and potentially significantly more cost-effective than traditional emergency care.

When they include these facilities in networks, stakeholders say, payers can drive emergency care to facilities less costly than traditional emergency departments.

By Jane Anderson

Health systems are turning to micro hospitals — small inpatient facilities with emergency departments and eight to 25 beds that include full services — as a way to provide community-based care that’s more patient-centric and potentially significantly more cost-effective than traditional emergency care.

When they include these facilities in networks, stakeholders say, payers can drive emergency care to facilities less costly than traditional emergency departments.

A 2018 report from the Advisory Board found that the long-term clinical and economic results of micro hospitals are still uncertain, but said the facilities could help provider organizations reach new patients, integrate into the community, downscale from older facilities and anchor ambulatory development.

The value proposition for payers is that micro hospitals provide “high-quality, comprehensive care close to home,” says Vic Schmerbeck, executive vice president, strategy and business development for Emerus, the most prolific micro hospital developer in the U.S.

Emerus partnered with Pittsburgh-based Allegheny Health Network (AHN) and Highmark Health to open four micro hospitals later this year. The partnership is aimed at providing emergency care closer to home, says David Hall, vice president of enterprise strategic partnering at AHN parent company Highmark.

Some payers have been less responsive than others to the concept of micro hospitals, Schmerbeck says: “As with anything new, payers frequently have many questions at the outset, but once they understand the value proposition to both the payer and their patients, the process usually goes smoothly.”

CMS Guidance on Rebate Shift Offers Transition for Part D Plans

April 22, 2019

As insurers and PBMs prepared to submit their comments about a proposed overhaul of the prescription drug rebate system, CMS on April 5 issued a guidance document aimed at mitigating at least some of their concerns.

The proposed rule would remove safe-harbor protections under the federal anti-kickback statute for rebates paid by drug manufacturers to PBMs, Part D plans and Medicaid managed care organizations, and it would create a new safe-harbor protection for point-of-sale drug discounts.

By Leslie Small

As insurers and PBMs prepared to submit their comments about a proposed overhaul of the prescription drug rebate system, CMS on April 5 issued a guidance document aimed at mitigating at least some of their concerns.

The proposed rule would remove safe-harbor protections under the federal anti-kickback statute for rebates paid by drug manufacturers to PBMs, Part D plans and Medicaid managed care organizations, and it would create a new safe-harbor protection for point-of-sale drug discounts.

The guidance states that if the administration sticks with its proposed 2020 implementation date for the rule, CMS will “conduct a demonstration that would test an efficient transition for beneficiaries and plans to such a change in the Part D program.” The voluntary demonstration would involve modifying Part D risk corridors so that the government “will essentially take 95% of the risk off the table” for plan sponsors, as Citi analyst Ralph Giacobbe put it.

Giacobbe advised that the memo appears “favorable to the largest PDP players,” including CVS Health Corp., UnitedHealth Group and Humana Inc., and “generally positive for PBMs and health insurers broadly.” He also wrote that “we’d guess everyone would participate” in the two-year Part D demonstration that the administration offered.

But Deb Devereaux, senior vice president of pharmacy at Gorman Health Group, says that may not necessarily be the case.

“It’s mainly fear of the unknown,” she says, when asked why plans might not opt in to the demonstration. Overall, the combination of the pending rebate rule with other new Medicare regulations is making for a tough landscape for insurers, she adds.

Health Care Organizations Embrace ‘Future of Work,’ But More Action May Be Needed

April 17, 2019

When researchers from Deloitte Consulting LLP surveyed health care payer and provider executives about their strategies for the “future of work,” the firm found that more than 75% of respondents indicated they have invested in future-of-work initiatives or plan to do so in the next year or two.

Jennifer Radin, a principal in Deloitte’s life sciences and health care practice, says that finding was “frankly surprising to us — we thought that maybe we’d get a 45%-50% hit rate.”

By Leslie Small

When researchers from Deloitte Consulting LLP surveyed health care payer and provider executives about their strategies for the “future of work,” the firm found that more than 75% of respondents indicated they have invested in future-of-work initiatives or plan to do so in the next year or two.

Jennifer Radin, a principal in Deloitte’s life sciences and health care practice, says that finding was “frankly surprising to us — we thought that maybe we’d get a 45%-50% hit rate.”

So what exactly is the future of work? According to Deloitte’s report, it involves “reimagining the way work gets done” to address generational changes, like millennials’ increased presence in the workforce; new technologies, such as artificial intelligence (AI); new talent models, like increased reliance on gig or contract workers; and increasing consumer demands.

But although 75% of those surveyed are embracing the future of work, “the question is, are they doing something comprehensively?” says Jason Wainstein, a principal in Deloitte’s life sciences and health care practice. “And that’s probably a smaller number.”

The survey results seem to indicate a gap between intention and action. While Deloitte found that 65% of respondents said their organization had created a strategic plan and vision for the future of work, much smaller percentages said their firms had taken steps such as centralizing shared services or testing nontraditional recruiting strategies.

On the plus side, though, “if we were to compare health plans and health care providers, I think health plans have been way ahead of [providers] in terms of the ability to introduce new technologies, particularly things like AI,” Radin says.