Drug pricing is the hottest topic in healthcare, and ICER founder Dr. Steve Pearson is the coolest person to discuss it with.
In this episode of the HealthBiz podcast, Steve describes how the Institute for Clinical and Economic Review (ICER) compiles and analyzes clinical evidence to estimate the fair value of treatments for cancer and other serious illnesses. ICER has been especially active during the pandemic, developing a pricing model for remdesivir and other COVID-19 therapies that’s being used in the United States and by health technology assessment agencies around the world.
When Dave Terry started his career in healthcare three decades ago, he noticed something odd and disturbing. The fee-for-service model meant doctors were paid for quantity, not for quality or cost effectiveness. Since then he’s been working to do something about it: for the first twenty years at American Practice Management, then Partners Healthcare and Harborside Healthcare. He made progress, but also learned the limitations of acting against entrenched interests.
For the last decade he’s gotten even more serious, co-founding Remedy Partners in the wake of the Affordable Care Act and then Archway Health, where he is CEO. Archway helps physicians jump into the meaningful risk-based payment models that are finally on offer from the Feds and private carriers.
I compared Dave’s quest to the Thirty Years’ War, but reminded him that there was a Hundred Years’ War, too, so he better gird himself.
I received a couple of ominous looking letters from Boston Children’s hospital, letting me know that my claim has “been suspended” by my insurance carrier, Blue Cross Blue Shield of Massachusetts.
Unlike a couple months ago, when Blue Cross accidentally cancelled my family’s entire policy (oops!) while trying to remove an adult dependent at my request, this time it was due to a “coordination of benefits” issue.
Here’s the situation. Another dependent of mine is a college student in a different state. Our Blue Cross HMO doesn’t work out of state, so we buy an additional insurance plan from the college. (Also one more policy for varsity athletic participation, but that’s another story!)
When this dependent had services at Boston Children’s, we listed the Massachusetts plan as primary. But at least according to the BCBS MA rep I spoke with today, the out-of-state plan should be primary because my dependent is the subscriber, unlike on our family plan where they are listed as a dependent. So even though the out-of-state plan is likely to deny the Massachusetts claim as out-of-network, we need that denial first before submitting to BCBS MA. Make sense?
Oh, and to make things a little more complex, the rep said I need to ask the other plan if they follow the “standard coordination of benefits rules.” Apparently some student plans don’t.
Medicare eligible Americans have borne the brunt of coronavirus. Some of the immediate impact on Medicare Advantage plans is obvious. They are covering telehealth and paying for acute hospital stays.
But there are longer term implications, too. Their risk adjustment scores are thrown off by the lack of visits. Certain supplemental benefits (think gym membership!) no longer sound so healthy, while others (meal delivery) become super valuable.
The 21st Century Cures Act (signed by President Obama in 2016) set out to make healthcare more patient-centric and increase patient access to medical records held by health plans. Implementation is occurring this year and health insurers need to improve interoperability in order to meet the requirements.
In this podcast interview, Karen Kobelski, who runs Wolters Kluwer Health’s Clinical Surveillance, Compliance & Data Solutions business unit explains what plans are doing and how her organization is helping.
Here are some of the topics we covered:
What are some of the key challenges health plans face in gathering and managing data?
There has been talk of interoperability for many years —but seemingly little progress. What does interoperability mean in the context of health plans?
The 21st Century Cures Act addressed interoperability. What was the aim? How are the rules being implemented?
COVID-19 is affecting everything in healthcare and in society more broadly. How does the interoperability imperative for payers change when viewed through the lens of the pandemic?
What role does Wolters Kluwer Health play in interoperability for health plans? Can you give me an example of a client success story?