EPISODE 12: RISE West 2022 panelists on the most pressing policy issues facing health plans this year

Five panelists who will speak about health policy at the upcoming RISE West 2022 conference join us for the latest episode of RISE Radio, our podcast series that focuses on issues that impact our three communities: Quality & Revenue; Member Acquisition & Experience; and Social Determinants of Health.

They’ll speak on the first day of RISE West 2022, September 1, at the InterContinental Los Angeles Downtown.

Our guests include:

·       Sean Creighton, managing director of Avalere

·       Michael Adelberg, providers and plans lead,  Faegre Drinker Consulting

·       Dave Meyer, a member of the RISE Risk Adjustment Policy Committee

·       Mikal Sutton, managing director, Medicaid policy, Blue Cross Blue Shield Association

·       Krutika Amin, associate director for program on the ACA for the Kaiser Family Foundation

During this 36-minute podcast, our panelists address a wide range of topics, including Medicare drug pricing negotiations, the uncertainty of Affordable Care Act expansion, Medicare Advantage (MA) equity elements and supplementary benefits that address social determinants of health, RADV, Medicaid redeterminations, Medicaid expansion, the end of the COVID-19 public health emergency, and the future of telehealth flexibilities. 

Transcript

RISE Association’s RISE Radio

Episode title: RISE West 2022 panelists on the most pressing policy issues facing health plans this year

Episode number: 12

Recorded: July 28, 2022

Published: August 2, 2022

Ilene MacDonald: Hello and welcome to the latest episode of RISE Radio. I'm your host, Ilene MacDonald, the editorial director of RISE. I'm excited today to welcome the panelists who will be at the Rise West 2022 in September to provide their perspectives on the most pressing issues facing health plans. 

My guests today are Sean Creighton, managing director of Avalere; Michael Adelberg, practice leader, health care, Faegre Drinker Consulting; Dave Meyer, a member of the RISE Risk Adjustment Policy Committee; Mikal Sutton, managing director, Medicaid policy, Blue Cross Blue Shield Association; and Krutika Amin, associate director for program on the ACA for the Kaiser Family Foundation.

Welcome to you all. In my experience, the session at RISE West, which is going to be taking place the first day of the main conference on September 1st, is one of the most popular sessions because people can really hear the latest policy implications and things that they should be having on their radar. And I know the topics might slightly change because anything can happen between the date of this recording, which for our listeners is July 28th, and the date of the session at RISE on September 1st. So, I'm hoping that we can sort of maybe do the greatest hits of the issues that you think are facing the community right now.

Sean, I'm wondering if you could start with what's been happening with the Build Back Better Act. I know that there's been a lot of up and downs with this, but is there anything in particular that you think that the industry should be paying attention to? 

Sean Creighton: Oh, absolutely, Ilene. The one component of Build Back Better that has maintained consistent support through its various iterations and may even have bipartisan support, despite the fact that almost no Republican will probably vote for it, are the drug negotiation, drug pricing provisions. And allied with that is the redesign of Part D. It's not a complete overhaul, but it certainly introduces some novel elements, such as an out-of-pocket cap, extending to what used to be called the gap discount through the whole benefit increasing liability for health plans. So just on that alone, Build Back Better is incredibly interesting to health plans.

And there are some complexities there because there are actually interactions between the drugs that are negotiated and what happens in Part D, which we will talk about at the session, perhaps in more depth or in other forums. But certainly, just that alone makes it worthy of attention. And then, you know, you add to that the extension of the subsidies under the ACA, which from a health care policy perspective, just those two items alone would make it very interesting.

MacDonald: Krutika, I know you're going to be talking a lot about the ACA expansion on expansion. Is there anything else from the bill before we go on to that section that you have any thoughts to on the BBA? 

Krutika Amin: Yeah. Just yesterday Congress announced with Senator Schumer and mansion come to an agreement about proposals for what will be pieces of the Build Back Better Act and framed into this inflation reduction act and what Sean said and so the developments are happening now and by the time we meet at the conference, we might know more.

There's still a lot of uncertainty, but the announcement yesterday suggests that with the ACA proposal to continue extending the expanded subsidies for ACA marketplaces could be in place for t three more years until 2025. And so we'll see what passes by this. It's developing now. Lots to pay attention to. 

MacDonald: Yeah, there's so much happening. And I know that your work at the Kaiser Family Foundation involves looking at the ACA expansion. Are there any other things that you're looking at or that you think that we should be concerned about or paying attention to in the next year? 

Amin: These are we've been following the rate filings that have been coming in over this initial summer. The proposed rate filings that we looked at for 13 states and D.C. and a bunch other came in yesterday are showing for the 13 states and D.C., about a 10 percent premium increase for next year and that's for ACA markets. Some of the factors that insurers are citing are systemic factors like price and use coming back. We'll see how final rates land. Towards the end of the summer crazy market. But with the uncertainty of ACA expansion, that's a piece of how rates are being determined right now. But other parts of the health sector trends are also affecting future rate.

MacDonald: I wanted to move into and Sean, I was hoping you could talk about what's happening in the Medicare space.  And if there's anything else anyone wants to add into, based on what Sean and Krutika say, please jump in. But is there anything else, Sean, from Medicare that you're looking at? 

Creighton: Yeah, there are a couple of items, Ilene, and I'll start with the big picture here. I've been listening recently to various interviews, podcasts such as this, and other events with, you know, both the CMS administrator Chiquita Brooks-Lasure and the head of the Center for Medicare, Meena Seshamani. It's interesting, particularly Meena's comments and what's interesting is not so much what she's saying but what she's not saying, which is really gotten my attention.

You know, there is a lot of, how can I say it? Anti-MA is sentiment in policy sectors in D.C., particularly around payment. I wouldn't say it's around every aspect of the program, but certainly when it comes to payment, there's a drumbeat that MA is currently being overpaid. There was a session recently where that was, you know, how to reform MA payment given the growing enrollment was the topic and Meena Seshamani, Dr. Seshamani, was on it and she steadfastly refused to engage with the current sort of widespread policy point that MA over paid. She was asked a number of questions on that, refused to answer them, and instead directed the conversation more to the value that MA is providing. Did talk about the need to collect additional information on supplemental benefits and really framed the whole thing around equity. So I think rather than what the good news for the MA program is, rather than jumping to conclusions, it seems like the administration is open to discussion about the equity elements that are embedded in the MA program, such as the fact that, you know, over the last number of years it's become a program that's much more attractive to lower income people, to minorities, to other groups who have social risk factors.

So, you know, that's kind of heartening. And it's so it's actually what she's not saying in a way that's really interesting because in terms of what she is saying, in terms of actual active progressive proposals for changing MA, there isn't really a lot of there, there just yet. So that's one area we could discuss and probably well at the RISE West and the secondary obviously of great concern to everybody right now as RADV, but I will stop there and see if anybody else would like to comment and then we can maybe discuss RADV a little more. 

MacDonald: Any thoughts, Mike? Dave, Mikal?

Mike Adelberg: I was just going to say we should keep our eye on marketing oversight for the fall.

Dave Meyer: I would just echo Sean's comments about, you know, kind of the focus on demonstrating value, collecting additional data. I mean, that was I think that as a trajectory is just welcome to the industry. You know, I think we all recognize the importance, the social determinants, of a really embracing health equity, with all the effort that needs to go into that to take that extremely seriously. And I think gearing up for that, you know is just sort of a relief. And to the degree that trajectory and the talk track continues to focus on that, I think the industry's really going to welcome that.

Mikal Sutton: I would also add, this is Mikal, that, you know, as part of that integration and part of that equity piece, it really is about, again, duals integration with both the Medicare and the Medicaid and really hyper-focusing on that. I think CMS, you know, now for a few years has said health equity is one of their main items that they want to champion. And I think they're really going to start, you know, rubber meet the road sort of, with starting to implement these programs and seeing results. Hopefully that not only have better health outcomes, but also more equitable outcomes.

Creighton: Thank you Mikal. And that's super interesting, I think, because when I think about the Medicare population, you can divide it a lot of different ways. But one way of thinking about it is, you've got roughly 20-plus percent enrollment that is dual. You have another roughly 20 percent of enrollment that are that in employer group waiver plans, EGWs and then you have the individual enrollees. What's interesting to me, in addition to the duals, is to examine more also that EGW population, because I think there is there are assumptions being made about the EGW population because they're retirees and have had probably jobs that are long term careers or long term jobs, often with unionized or state, local government or as the case may be, that they're in a somewhat advantaged position. I am not 100 percent convinced that that's true across the board. I think that's a very broad brush. And I think that, you know, there's definitely room for looking at that population as well and looking at the risk factors among the population, because some of the people who are retirees in these EGW plans also work for relatively low-income jobs all their lives and maybe manual work, which is debilitating physically and otherwise. So, I think there are some assumptions that are being made about certain parts of the population within MA too, that are not duals, that need to be examined. So, I think that will also be a fruitful area to go take a look and see what's going on there, particularly if you compare that population to other subpopulations in the traditional Medicare or fee for service, you know, so such as those on Medigap. So, it’s a really interesting environment, I would say. I agree with Dave's comments entirely.

MacDonald: Did you want to segue now into your thoughts on the RADV, Sean?

Creighton: Just briefly. Obviously, United Health Plans have been in court challenging the overpayment rule for many years now that decision finally came down in the summer and then was appealed to the well, I should say the appeal of the initial court case was decided in the summer by the Circuit Court of Appeals and let me put it this way, there are a lot of complexities to the decision, some things that are very good, such as the court saying that, you know, the standard had to be knowing that there was an issue before the plan has to report it that was very positive and not challenged by DOJ. However, on the other hand, there are also aspects of the decision by the circuit panel that are very troubling, particularly some of the judge's writings on issues such as the fee for service adjuster and but the real underlying next level issue there is this decision applies to the overpayment rule. It does not apply to False Claims Act or IPERIA or any of these. And so, the real next move here will be figuring out if the judge's decision, if they're going to take that logic that the judge used, which is not very helpful to the plans frankly, and port it over to legal battles over RADV, which are probably imminent, because it's quite likely that CMS will drop a RADV rule sometime in the next few months. But that's the word. But whether that actually happens or not, it's anybody's guess. And so, I will leave it there just to say it's a complex it's a complex area with much litigation. And the recent decision hasn't really clarified things particularly but could be read to be not entirely helpful to the industry. 

MacDonald: Thank you. Mikal, I wonder if you could talk a little bit about Medicaid and what you're seeing as the biggest issues in that section of health care?

Sutton: Oh, absolutely. Always. So, there's sort of one large piece. It's sort of sucking up all the air in the room when it comes to Medicaid and that it's sort of twofold. It's not only the end of the public health emergency, but then also the subsequent Medicaid redeterminations that will be coming up because of that. So, there are some other things sort of on the burner, but for the most part, this is really what the administration has been focused on since fall of last year, garnering information from industry groups, issuing some really comprehensive guidance for states around what they need to start preparing for and how they need to integrate a lot of their stakeholders in order to help them. You know, at this point, unfortunately, it's sort of up in the air as far as when the public health emergency will end. The current extension should run through October 13 and that what the HHS is actually given their word that they would give a 60-day notice prior to the end of that public health emergency. So August, the middle of August would be when we find out for sure whether or not the public health emergency will end in October. All that to say that every state is approaching things a little bit differently, both in the preparation and in, I think, the overall planning that they're doing in and again, preparation for the whole redetermination process to start. Most estimates are suggesting that around 15 million people are going to be losing coverage. And of that 15 million, 7 million of those are estimated to be children. So, this is not necessarily something to take lightly and really aligns very well as we spoke earlier about the ACA and the tax credit extensions and how those really marry up significantly during this whole unwinding.

So more to come on that. You know, really, it is sort of a day-by-day information exchange, but we're hopeful that states most states will be following the guidance that CMS has released. And quite honestly, CMS has done a phenomenal job in creating that communication with stakeholders and really making sure that as much as possible that states and those stakeholders are on the same page. So more to come on that. I think some of the other big areas that we can talk about in Medicaid, there's the Telephone Consumer Protection Act. I don't know if many are familiar with the TCPA, but the FCC recently, back in April, actually released an RFI at the behest of HHS, asking if they could what people would want to see, what industry would want to see with regards to texting and Medicaid managed care, all in the context of redeterminations. So, we’re hopeful that there will be a decision on that any day now, and that would allow plans to have the opportunity to text folks directly rather than act as an opt -n program, which, as you probably can guess is a really challenging thing when you're asking people to opt into a program. So, fingers crossed on that. And then, you know, believe it or not, CMS for a couple of years now has been working on a quality rating system for Medicaid. It would be an optional set of quality measures that states could then either add or sort of piecemeal to what they currently have for their quality metrics for Medicaid. But it's meant to really sort of mirror the quality ratings for Medicare. And so, we're slowly seeing that line of integration sort of between the two government programs and how they are, I think, executed ultimately. 

And then finally, I guess there's two other things, and then I am happy to let folks move on. But there are some big conversations, again, similar to the earlier comments around post PHE rate setting and what that's going to look like for plans. I think as we sort of inch closer to the end of the year, that's going to be more and more of a topic of conversation and how states are handling that. It's sort of a big question mark at this point, but definitely, again, as we move forward, we'll hopefully learn more and sort of be able to come to a consensus around what that should look like. 

And then finally, I think the most exciting thing is Medicaid expansion, right? There's still, I think, 11 states that have not expanded Medicaid. We have spoken sort of off the record to several states that are currently sort of working behind the scenes to try and make Medicaid expansion a reality. And if you recall, the ARPA sort of incentives or the incentives, rather, that were included in the ARPA bill are still relevant. They did not have an expiration date. And so, states still that have not expanded really do have an incentive to get more money in order to expand. So, you know, more to come on that. But we're hopeful that if not in the next 16 months or so, that in the next few years we'll see some more of those states start to expand.

MacDonald: I think we could probably have a whole day on this rather than just a quick session, you know? 

Sutton: For sure.

MacDonald: Mike, would you be able to talk a little bit about what's happening with supplemental benefits with MA and just in the industry in general. 

Adelberg: Sure, and MA is sort of the tip of the spear here. But make no mistake, across insurance markets, plans are taking a new look at non-medical services that help medical outcomes and may even in some cases, save some medical money. So, in MA, where we're seeing the continued flowering of creativity, supplemental benefits going beyond that sort of dental, vision, hearing, gym Version 1.0, getting into services that specifically take on social determinants of health, social isolation, lack of transportation, lack of nutrition, etc. and particularly interesting and it's a slow evolution toward it, but the idea of condition-specific benefits. I sometimes discuss podiatry. You're not going to give $0 podiatry to all of your members but for some members with some diseases, it probably makes an awful lot of sense. And the comment was made earlier about really beginning to find out the value of these benefits. We know they have marketing value, no mistake about that, but I believe many of them have very significant health care value. But we got to figure that out. And we also along the way, there's some regulatory provisions that CMS put in effect on the cost of these supplemental benefits that we'll also see soon. More to come here. And with the fall coming, I'm sure they'll be another wave of creativity. Dave, others, I know you all see this from different angles as well.

Meyer: I'll just make a quick comment. I mean, you know, if you think about the earlier comments about, the agency looking for increased transparency around supplemental benefits, you really, I think, crystallized it Michael when you said it. It's not just transparency, it's about value. Right. So that the seeking data right is all about the assessing what the what the actual outcomes value is for this exploration that our industry has been doing for, you know, for the last decade or so. And I'm a big proponent of it. I'm a big supporter of it. But I think that the policy will probably be falling relatively fast over the next couple of years around new forms of data submission, and I think with the goal of getting right to what you're saying, Mike, about value, that's the fundamental question.

Creighton: And there is one question that you may be able to answer from your prior experience, Mike. You know, one of CMS’ hesitancies in this kind of area previously had always been the possibility of discrimination, frankly. And, you know, and so there's that aspect of it and then there's also a societal program integrity aspect.  So, you know, it used to be back in the day when the benefits come in, they were subject to discrimination review to make sure that you aren’t doing anything to discriminate against any population with a particular health condition or like that, right? I can see the same kind of discrimination reviews being necessary for some supplemental benefits. And, not to put too fine a point on it, you know, to the extent that these are triaged through human beings who are making decisions about who gets the benefit and doesn't, you know, there is the possibility that some, you know, that they are channeled or funneled in certain directions, consciously or unconsciously. I don't know that anybody's giving a lot of thought to that right now, but I do think that's an area where CMS might get involved at some point. 

Adelberg: And I think we are learning a lot about a very new area. When we do talk about condition specific benefits, for example, when we talk about the triggers for benefits and should the trigger be individual referral from the care management department, or should the trigger be an ICD-10 code, and there are pros and cons to both. And the question will also at some point arise with one of these supplemental benefits, should Medicare really be paying for X? We are in an environment right now where we are permitting a lot of experimentation. My hunch is the large majority of experimentation has merit to it. But are there are a couple of corners of all of this experimentation that might raise an eyebrow or two? Yeah, there are. 

Creighton: And I think that's particularly true of flex cards, right, that carry cash value. You know, essentially, I think, you know, the analogy I would make in some ways is to the childcare credit program with the IRS and other programs like that, where the significant cash value associated with, could become an area for scrutiny in my mind. You know just in terms of the portability of those things, the uses to which they could be put. I would expect some activity from CPI on that score. 

Adelberg: Yeah, agree.

MacDonald: Mike, while we still have you on the call because I know that you're not going to be able to necessarily join us for the whole time, I wondered if you could touch on some of the other issues affecting with telehealth. 

Adelberg:Sure. Yeah. So, we had enormous need for telehealth in the early months of the COVID public health emergency, Regulators and Congress responded with an unprecedented set of flexibilities in Medicare and Medicaid in the commercial market. All and many of these flexibilities were put in place in a way that they only last for the extent of the public health emergency. The public health emergency, as noted previously, continues to get extended but it won't go on forever. And then what happens afterwards? Well, telehealth utilization has declined from its peak, though, in some areas, particularly behavioral health, there is a very significant utilization continuing. And even in areas where it's peaked, there are at this point, consumers who very much want access to virtual service. I’m one of them. So, the laws and regulations are going to have to catch up with what the public has come to expect and what providers are now able to deliver. It's also worth noting that in general, that the peer reviewed studies we're seeing on the quality of virtual services in general is comparable to traditional services. To Sean’s point, I think we still need to figure out if there are program integrity issues to sort out with telehealth. And I personally wonder about payment parity and whether payment parity requirements make sense for telehealth. If a service can be delivered more cheaply, why shouldn't the market allow it to be delivered more cheaply? But in any event, we're at a very important point in the evolution of telehealth and its permanence in the system and that it is a rapidly evolving part of the health care landscape.

MacDonald: I wish we had more time to talk, so that's why I'm excited that we're going to be able to explore these issues and maybe others more deeply at RISE West. But I wonder before we end this discussion, if there's any final thoughts, any other things we haven't discussed that you'd like our listeners to consider.

Meyer: If you don't mind, I'll just make a quick add on to Adelberg’s comments. If you think about the ending of the public health emergency, that's the ending of the COVID-based public health emergency right? But what we have as a country is a great number of primary care physicians who have left over the last couple of years, right. And we have a rapidly aging population. I don't remember the stat offhand, but it's something like that the percentage of people that will be over the age of 90 in the next decade is going to be greater than at the total number of people that have ever been in that age range for the like the last 50 years or something like that. You get the sense of this hockey stick curve, right? So as the country ages and as care gets more and more difficult to execute in the way that we thought of care, traditionally, and by that I mean maybe, you know, 10, 15, 20 years ago, I think I think the big the big thing that that is on the horizon is what portions of the public health emergency must be permanent because we've made we've made fundamental changes as an industry. I've seen it with my own physician where she's made practice changes, right. And she interacts with me differently now, post-COVID. So, to what degree are those efficiencies? And Mike touched on a couple. To what degree do those efficiencies, should they be captured by the government and encouraged? And then to what degree do we need to make permanent changes to allow for some of those efficiencies to persist, like, you know, medical licensing being, you know, localized versus national? So, I just think there's a lot of fodder there's a lot of opportunity for looking at the upsides of the public health emergency and how we've grown as an industry. And losing that would be just a tragedy, I think, as we deal with the aging of the U.S. population and the fact that less and less primary care is available. So, I think that that'll be fun to watch over the next couple of years and hopefully it ends up being great story. 

Creighton: Thanks again, Dave. Yeah, I think that's a great comment. And I just let me think, there are any number of issues that we don't cover because, you know, they're sort of not in our purview exactly. But the labor issue and the health care industry, the whole move to the home and the site of care delivery models. And I'm just going to say, traditionally, these are not areas we focus a huge amount of attention to in this forum. They're very important issues for the industry, you know, but we tend to have our specialty audience and so on. So, we, we tend to talk about topics in that realm. But yeah, certainly I think Dave makes a great point there about any number of important health care issues that are sort of outside the purview of the authorized policy committee. So, thank you Dave.

MacDonald: Mike, do you have anything to add before we sign off?

Adelberg: Just back to the top topic that Sean discussed, we have a piece of legislation emerging that the details of that, including how, for example, Medicare drug price negotiation would get implemented. Fascinating to think about. Also, in the ACA market, where we may very well have these extended. That's terrific. But the timing of that and the dance that will need to go on between the regulators and plans will be really interesting and worth watching. 

MacDonald: Thank you. What about you Krutika? Anything else that we haven't touched on that you would like to share?

Amin:. Also looking at trends and inflation and how that flows through or if it does to the health care sector or not because of Medicare payment setting, I think perhaps some of it is guarded, but inflation is affecting the health sector, too. And so to others points earlier with labor market, we have seen employment in elderly care has not come back up like in other sectors. And so how the industry changes overall will be interesting to watch. 

MacDonald: Thank you. Mikal?

Sutton: Now, I absolutely agree with that .I realize that one of the big areas that we didn't touch on until the very end was home and community-based services and what states are going to be doing towards that and how with the transition of primary care and what that looks like now, what home and community-based services will sort of flower into in the next 5 to 10 years? I think it's going to be fascinating to see that.

MacDonald: It is. And I am really looking forward to seeing all of you in person at RISE West, which is going to be in LA. We will be there September 1st to 2nd. I'm excited to hear what you all have to say, where we'll be just in a month from now. Thank you.