Money Will Flow to States for Mental Healthcare

States are about to get help for mental healthcare and substance use treatment because of the Bipartisan Safer Communities Act signed by the President in June. Some of this will flow through Medicaid programs, specifically the Medicaid Certified Community Behavioral Health Clinics (CCBHCs) nationwide created in 2014.

The Act also supports:

  • Increased telehealth flexibility
  • Pediatric mental healthcare and training for pediatricians
  • One-time funding ($150 million) for the existing Suicide and Crisis Lifeline or 988 crisis number, similar to the 911 system. (States have a preexisting July 16 deadline to have these up and running.)
  • School-based mental health services, crisis intervention and violence prevention, and mental health worker training

While mental health advocates are pleased by the new support, there are caveats.

  • Experts agree the mental health and substance use disorder impact of the pandemic has been significant and is still being felt. Future needs are expected to be long-lasting. Some predict the impact to last a generation.
  • A lack of psychiatric beds continues to be an issue. While crisis stabilization can reduce harm and identify resources, inpatient care is hard to come by in most states, resulting in emergency-room boarding and a revolving door through the justice system for the seriously mentally ill, who are often overlooked in mental health programs.
  • Provider shortages continue to be a concern, although telehealth flexibilities may help mitigate them in the short term.
  • Equity continues to be an issue throughout the system and mental health is no exception.

Sensing the opportunity in addressing mental health, private investors had poured $3.1 billion into mental health ventures by the third quarter of 2021 – a third of all digital health funding for that year. Technology isn’t likely to replace the human touch, but innovation and technology can certainly have a role in improving access.

First Inklings of Inflation Reach 2023 Health Cost Calculations

Anticipating inflationary pressures around healthcare costs, the IRS has spiked limits for 2023 on Health Savings Accounts (HSA) by 5.5 percent, much higher than the previous year’s rise of just 1.4 percent. These figures were released in April so payers can get the jump on rate-setting and employers can begin to plan their open enrollment periods.

The new calculations are:

  • Self-only HSA contribution limits – $3,850, up from $3,650 in 2022
  • Family HSA contribution limits – $7,750 up from $7,300 in 2022

The 2023 limits are intended to encourage employers during open enrollment to ease employees into HSAs and to boost employee dollar contributions. Employers are reportedly more interested in financing HSAs than before, especially for lower-paid employees.

More broadly, some of the cost drivers and variables for 2023 include the “table stakes” that employers add or expand mental health coverage to their offerings. Pandemic-related costs for treatment and testing are flattening, but there’s no predicting whether other COVID variants will emerge or whether a fall spike will occur as in previous years. Intuitively, it might seem that provider costs would rise across the board, but many are locked into multi-year arrangements and thus provider inflation trends usually lag the rest of the economy. For the segment of the provider/payer market up for contract renewal, negotiations are expected to be fierce – a major healthcare publication used the word “bloody” to describe the battles ahead.

Other uncertainties hang over the payer ecosystem, especially for possible Medicaid disenrollment and the potential end of pandemic-related subsidies for Affordable Care Act premiums. These effects of these shifts in the risk pool are hard to pinpoint but can draw employer-sponsored plans into inflationary patterns. Some states are requesting that payers submit rate approvals in two sets – one for the scenario in which Congress extends ACA subsidies set to expire at year-end and one in which it does not.

Other variables being mentioned by experts for 2023 are utilization patterns and cost-impacts or savings from telehealth, tweaks to the ACA “family glitch” and movement among small employers to self-funded or level-funded plans.

Employers should be looking now at their health plan options in anticipation of open enrollment this fall Their calculus is a difficult one, just as it is for payers.

ACA and Medicaid Membership Cliffs Loom for Fall and Year-End

There’s likely to be movement among Medicaid and Affordable Care Act (ACA) membership as the nation seems to be inching toward the end of the pandemic, at least from a regulatory standpoint.

Medicaid rolls swelled during the pandemic as relief packages guaranteed coverage for members even if they became ineligible over the course of the Public Health Emergency (PHE). But nothing lasts forever and states are bracing for an end date to the PHE, now expected to occur in mid-October. Political pressure is building to end the PHE, even as various entities plead for more time. If the PHE is not extended for another 90 days this fall, state Medicaid programs will need to begin re-verifying eligibility for members. There won’t likely be immediate disenrollment, but the process will begin and the clock will start ticking. To make things more challenging, the accuracy and success of this is likely to vary greatly according to state budgets and administrative effectiveness. There will be no coordinated, uniform approach. The U.S. Department of Health & Human Services (HHS) has promised a 60-day notice period to states before the PHE expires, so look for the administration to signal mid-August whether the PHE will renew again in October.

At the same time, the end may be in sight for the ACA subsidies legislated under the 2021 American Rescue Plan Act that served as a healthcare cushion for millions of Americans who became newly insured under the March 2021 pandemic stimulus package. The relief package specified that this support would end at the close of 2022, unless Congress acts to extend it. Some 3.4 million people could lose coverage out of a record 14.5 million ACA enrollees. The impact in terms of uninsured is a bit of a moving target, as some enrollees who are currently covered by one program may become eligible for the other. Some may have gained employer-sponsored coverage in the meantime. Either way, the task of contacting, educating, disenrolling and re-enrolling this many people will be daunting.

CMS Administrator Chiquita Brooks-LaSure said June 22 that “time is of the essence” for Congress to extend ACA subsidies in order to be ready for November Open Enrollment.

Providers Struggle with Realities of Transparency

Providers Grapple with Regulatory Realities

Providers appear to be grappling with the regulatory realities of value-based care, especially when it comes to data transparency. Although they claim that the wording of various data transparency regulations is too vague, as one example, it seems obvious that hospitals and health systems find paying fines preferable to disclosing their prices.

A recent KLAS poll of 66 revenue cycle leaders at hospitals and health systems indicated many will do only the bare minimum to comply with pricing transparency rules. Most are not doing even that much 18 months after these rules became law.

Hospitals have been required since January 1, 2021, to post cash prices and negotiated rates with payers for 300 common services. Full compliance demands that information is posted in both machine-readable files (i.e., searchable files) and is formatted in a “shoppable display,” (i.e., a consumer-friendly manner) Yet, a recent JAMA analysis found that half of hospitals don’t adhere to either standard. Fourteen percent have machine-readable files and 30 percent have a shoppable display. All told, just 6 percent of hospitals are compliant with both standards. The least compliant facilities are in highly concentrated markets and those in rural areas.

The Centers for Medicare and Medicaid Services (CMS) said June 9 they would fine a Georgia hospital system more than $1 million for violating federal transparency laws, citing the lack of a “consumer-friendly list of standard charges,” an incomplete list of services and failure to produce these within a single file. The system had been given an opportunity to correct these issues but did not do so. CMS has issued more than 350 warnings to hospitals and systems, but the Georgia fine was the first issued nationwide. Fines can reach $300 daily, but this does not appear to be a sufficient incentive, although a number of providers have changed their tune, but only after receiving corrective action plans from CMS.

Perhaps only in America does this create an entrepreneurial opportunity for companies to gather the posted information, convert it into meaningful formats and sell it back to insurers, employers and others. In a digestible format, this data can provide negotiating leverage for future contracting, so it has distinct value.

Some hospital groups have filed suit against transparency regulations, but so far the rules stand. A coalition of large employers argues the simplest way to gain compliance is to substantially raise the fines. Transparency is inevitable, even if the wheels turn slowly.

‘500 Shoppable Services’ Could Be the Next Healthcare Buzzwords

The healthcare ecosystem is rolling slowly toward greater transparency, but there are many challenges. Among them is predicting consumer behavior in the fog of new health information that is becoming available to them. The latest catch-phrase for consumer empowerment could very well be “500 shoppable services.”

Shoppable services are healthcare services in which consumers can select treatments as single units of care, without the pressure of an emergency situation or receiving care in a “captive” setting where they can’t choose their provider. Think mammograms, imaging and laboratory services.

Three government agencies – the Departments of Health and Human Services, Labor and Treasury – collaborated on the Transparency in Coverage Act, which was released in Final Rule form in late 2020. This set in motion a series of major initiatives that are moving pricing out into the open over a period of years.

Hospitals are already required to post some prices on the internet, but many have not done so. Often, those that have complied have obscured the data in ways that make it difficult to locate and understand.

Payers will be required to publish prices for covered services in a consumer-usable online format for 500 shoppable services by Jan. 1, 2023. The remainder of covered services pricing must be published by Jan. 1, 2024. HealthEdge is working with its health plan customers to support compliance.

The question is, what does it take for consumers to actually shop for lower-cost services? Look to a Kellogg School of Management study that shows consumers will indeed make logical economic choices when price information is presented in simple, apples-to-apples formats. The study revealed that even for serious care, people are often willing to sacrifice hospital prestige or drive to a more distant location to save on cost.

The Kellogg report notes that providers will view the disclosure of prices differently according to their place in the pricing structure. Those in the mid-range stand to lose the most from price transparency, the study author notes. Lower-priced providers will naturally gain more patients; premium providers are often seen as worth the additional cost.

HealthRules Payor provides a robust engine to calculate cost-sharing information that is unique to the member and the provider’s status in real time. The platform can deliver these results via the health plan’s member portal, which allows members to consider price information at the same time they review provider directory data like languages spoken and customer satisfaction ratings. Cost calculations flow from the claims adjudication system; therefore, the risk of results being skewed by stale data is reduced to zero.

‘Gold Card’ Approach to Prior Authorization No Hurdle for HealthEdge

States have been passing legislation in recent years to address the complaints of providers that they are subject to too many prior authorization requirements in advance of patient treatment. This provider abrasion is something health plans are seeking to reduce independent of any legislative initiatives because it can be a labor-intensive process to assure medical necessity. Most requests are eventually approved.

While some states have mandated that payers provide electronic submission options with established turnaround times, Texas and West Virginia are two that have passed “Gold Card” laws using a different approach. At least seven other states are discussing similar legislation.

The gold card method in Texas mandates that over a specified period of time, providers achieving a 90 percent approval rate for prior authorizations achieve special status that waives the need for further approvals on those services for the next year.

HealthEdge has tools in place to meet the challenges of this and other new state laws. For one thing, GuidingCare rolled out an electronic Prior Authorization Portal that was developed in conjunction with both a customer payer and its system providers in 2021. Through this portal providers receive authorizations in a matter of moments, allowing more complex requests to be quickly routed for review of medical necessity. The portal features one-click messaging and eliminates the need for concurrent reviews during inpatient stays. GuidingCare also supports the rules that determine when a provider has reached the threshold for a gold-card status.

HealthRules Payor can easily be configured to waive prior authorization requirements when processing claims for providers who have reached a threshold. This interoperability between HealthRules Payor and GuidingCare is just a preview of what platform integration promises with new companies brought under the HealthEdge banner in the last two years.

Payers disagree even among themselves as to whether gold-card practices are effective, and provider organizations also disagree among themselves. Either way, HealthEdge is ready to support customers in meeting the requirements known to date.

Learn more about Reducing Incorrect Payments Between Payers & Providers in a Claims Wasteland here.