Health insurance markets in the United States are evolving with an increased emphasis on achieving the Triple Aim of improved patient experience of care, reduced healthcare costs, and improved population health. For health plans, that comes with an increased focus on quality standards and outcomes, and recognition that investment in quality accreditation is becoming essential to business success.
A growing number of state Medicaid contracts are requiring a focus on quality outcomes and quality accreditation by recognized accrediting organizations. One of these organizations, the National Committee for Quality Assurance (NCQA) continues to gain significance as Medicare and Medicaid increase quality requirements tied to NCQA. Regardless of the accrediting organization, achieving accreditation typically requires a significant commitment of time and resources, and follows a similar process.
In this paper, Milliman’s Barbara Culley, Penny Edlund, and Maureen Tressel Lewis provide information about the pursuit of quality accreditation as an essential investment that can have a positive impact on multiple health plan priorities, including quality of care, member satisfaction, and market viability.
The coronavirus pandemic will have a significant and
long-lasting effect on healthcare systems around the world. Health insurers,
managed care organizations, and third-party administrators provide
infrastructure that facilitates the flow of information and funds throughout
the healthcare value chain. Payers answer benefit and coverage questions,
connect patients to healthcare services, provide reimbursement for services
rendered, facilitate financing, and manage relationships with purchasers.
In the current care delivery and financing paradigm, these day-to-day administrative activities are key to making the U.S. healthcare system work. However, the status quo is threatened as customers and providers experience business interruption on a massive scale due to COVID-19.
In this paper, Milliman’s Barbara Culley, Maureen Lewis, and Andrew Naugle identify five key payer functions that are likely to be affected by the COVID-19 pandemic along with actions payers can take to ensure business continuity while enhancing their contributions to the value chain.
Opioid use, misuse, and overdose are serious health problems in the United States, and the impact on employers cannot be ignored. According to a 2017 report from the National Safety Council, 10% to 12% of employees are under the influence of drugs while at work, and 70% of employers reported negative effects from opioid use within their employee population.
Opioid use and abuse among workers has several significant effects on U.S. employers, including reduced economic growth, increased operating costs, lower quality, and decreased productivity. Anecdotal reports in the United States indicate that employers are not only having difficulty finding skilled workers, but also workers who have the necessary skills and can pass a drug test.
Less than 20% of human resources staff say they are well prepared to deal with the personnel issues related to opioid use and misuse. This readiness gap is driven by the absence of appropriate policies, insurance, and benefits structured to address addiction, by the lack of processes to support workers in recovery, and by missing procedures to support managers and supervisors as they address opioid-related job performance issues.
How can employers prepare for and address this challenge? Employer involvement with staff opioid use covers new ground, requiring the thoughtful development of programs and areas of emphasis.
In this article, Milliman’s Barbara Culley and Christine Castle present an overview of the challenges facing employers, discuss opioid use and misuse effects in the workplace, review data to inform program development, and explore actions employers can take to tackle this growing program.
The growth of direct-to-consumer (DTC) genetic testing presents several medical and financial implications for the healthcare industry to consider. In this article, Milliman consultant Barbara Culley examines the demand for DTC genetic testing and industry concerns. The excerpt below highlights a few of them.
Providers and regulators have expressed concerns about the DTC process, including the absence of healthcare providers from it, concerns for unnecessary testing, patient anxiety, erroneous test results, and misinterpretation of test results by untrained consumers. Insurers have concerns about the possibility of adverse selection. If a person knows they have a positive indicator for a disease, will those people seek insurance in greater numbers than those without any genetic concerns?
One key factor driving concerns is that not all persons with a positive genetic test will develop the indicated disease. Many variables, including environment, personal lifestyle choices, and other genetic factors, have a significant impact on health. Concern exists that genetic test results may lead to unnecessary treatment. In the case of false positive and false negative outcomes, the added concern is that treatment choices may be made in error. In a 2012 study13 of 179 people from four countries, the average person was found to have about 400 defects in their genes, some associated with disease. However, these people were well. Even if results cause people to seek insurance or care, they may never develop the disease indicated by genetic testing.
Concerns have been raised about the potential for DTC testing to create added costs and consume resources in the healthcare system with little value. For example, positive DTC genetic testing results may lead consumers to follow up with their physicians for treatment based on a test result that may not indicate a genuine health issue.
Barbara also provides some actionable measures that health plans can take to respond effectively to the evolving DTC genetic testing market. The following excerpt summarizes her considerations.
Continued growth in the marketplace is probable with the recent FTC approvals for DTC genetic testing and health risk reporting for diseases. Growing consumer use and subsequent follow-up with healthcare providers and insurers can be anticipated.
Data trends indicate consumers are likely to seek information perceived as helpful in self-management of health. Health plans may wish to consider how to best respond to the evolving impact of DTC genetic testing and subsequent member expectations with education, tools, and medical policy that optimize the use of these tests and support member engagement in their health.