Consumer / Employer


The World Health Organization now considers social determinants of health to comprise the better part of healthcare. This is long overdue, but as pioneers of the population health movement, my colleagues and I consider this an understatement.

We estimate that 80 percent of individual health is due to non-medical factors, including crime, poverty, education and opioid abuse. The silver lining of Covid is that people are finally paying attention to the large-scale social, economic, and environmental issues that impact health outcomes of disparate groups of people — population health — but this is just a start.

An “engine of inequality”

In April of 2020, professors Anne Case and Angus Deaton wrote in The New York Times that the current healthcare system is an “engine of inequality.” Sadly, they got it exactly right. The pandemic exposed the primacy of social determinants in terms of who lives and who does not. Now, we in the healthcare business must ask some very tough questions that have been avoided for far too long. For example, how do we care for populations that may put us at economic risk? How do we stratify care among populations? How do we coordinate care between communities?

In the past, these were considered public health questions. They now fall under the “roof” of population health. The central pillar supporting this roof is composed of epidemiology, behavioral science, and the environment — all of the key tenets of the traditional public health approach. However, there are other pillars, including the quality and safety of the care we deliver, its cost, and public policy considerations.

During the height of the pandemic, the lines for food exceeded the lines for medical help here in Philadelphia. The inherent inequality in our system ensured that the death rate for people of color would be much higher than for others. Covid was a witches’ brew of catastrophe and increased mortality for minority populations.


While it is too late to declare victory over Covid — and, sadly, we already have another population health crisis on our hands — let’s not wait to recognize the scope and depth of the problems we face. Moreover, let’s address them with the appropriate tools. If our core business is improving health, then let’s reinforce all of those pillars in order to improve the roof over our heads. Of course, this begs yet another question: how are we going to get paid to implement these changes?

Healthcare is a $4 trillion business, and at least $1 trillion of this amount adds no value — except corporate profits. So, one idea could be to redirect those funds to actual healthcare.


Aside from a small minority, most doctors feel like outsiders victimized by the healthcare system. Almost 42% of physicians report symptoms of burnout, especially the physicians in critical care, emergency medicine, family medicine, internal medicine, neurology, and urology. I have a daughter who was on the frontlines of Covid as an attending physician. I get it; expecting doctors to heal themselves is simplistic during and after a pandemic.

In contrast, research says that we can reduce burnout if we give providers the opportunity to ameliorate social determinants. Why not allow doctors to write a prescription for food, connect patients to community organizations for help, and mandate behavioral consultations? If we can give providers the tools to help the underserved, burnout decreases. We know doctors aren’t social workers, but they can (and should) be leading the charge to implement the population health paradigm. All they need is a voice and the right tools.


For example, it’s critical that providers at a minimum have a unique and unified patient record. Especially as we adapt to telehealth and virtual care, organizations need to have a framework that can enable a swift exchange of data among members of care teams. Indeed, population health intelligence is another vital pillar, as well as an important subset of population health that subsumes predictive analytics, augmented intelligence, and artificial intelligence. We can and should be creating a registry of patients with Covid that protects privacy. From the tsunami of data gained, we would glean actionable information about at risk populations. I’m also hopeful that we’ll see digital healthcare that continues to reduce marginal costs. This will enable us to reach much larger populations at a lower cost than ever before.

Strategic shifts

Imagine if we could go upstream to shut off that faucet of disease, rather than constantly mopping up the floor. What if the population of Philadelphia had been healthier pre-Covid? If we had paid more attention to social determinants, we would have been far more proactive. The chance of reducing the unbelievable death rate in minority populations would have been far greater if we had paid attention to obesity, smoking, heart disease, exercise, nutrition, and other “soft” issues. Why didn’t we do this? No one was leading the way, probably because there was no profit incentive.

We know that healthcare is big business, but even more than that, it is the final common pathway to all social determinants. It is constantly reframing what it means to take good care of the population. I firmly believe that we can still establish an exemplary model of population health — a system that promotes inclusion of all factors associated with a patient’s health in order to provide as much comprehensive care as possible.

Photo: marchmeena29, Getty Images

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Many of us first tried virtual care during the pandemic, often because we had no other choice. We connected with our primary care physicians about Covid and other health questions, holding our elbows and ears up to webcams to show where it hurts. This was Virtual Care 1.0, and it was little more than a doctor’s visit via video.

Not only did these early days of “doctors at a distance” meet our needs, but most of us found the experience convenient and time-saving. The vast majority of us are ready to use virtual care on a regular basis, and providers and insurers are poised to build on this wellspring of enthusiasm for telehealth: Virtual Care 2.0 is right around the corner.

Timely, specific, and personal

If you’ve ever stood in the rain trying to hail a cab, you may have wondered “why are there NO taxis?” What you didn’t know was that there were several cabs available at that very moment—just out of sight, just around the corner. The problem wasn’t a lack of taxis, but rather a lack of taxis where and when you needed them. Uber solved this problem by connecting customers and cabs instantly and at the exact location where a ride was needed. As customers and drivers came to understand the power of the model, new uses emerged, including UberEats and other “off-label” errand services.

Uber created a new category of service by leveraging inefficiencies in the transportation system. By creating a marketplace for drivers with idle cars or empty seats, they dramatically increased the convenience and efficiency of transport, while lowering the cost and improving satisfaction. Both drivers and riders have benefited. Uber’s story shows how virtual systems can connect people to real world services—and it serves as a powerful metaphor for the future delivery of healthcare via Virtual Care 2.0.

Not Just an Appointment by Video

Several platforms have emerged that strive to be the Uber of healthcare, but not all are made the same. Most continue to focus on urgent or primary care—replicating a traditional doctor’s visit via video. Such replication fails to leverage the true power of the technology and does little to mitigate megatrends in the healthcare marketplace:

  • Traditional doctor visits contain very little doctor time. The average hourlong appointment contains only 15-20 minutes of care from physicians. The rest of the appointment visit is filled with PA and nurse consultations, vitals collection, clerical needs, and (mostly) waiting. Often the “result” of a visit is a referral to a specialist, where after a long wait for an appointment, the cycle repeats.
  • The US faces a drought of doctors and nurses. As the shortage of health-care workers worsens over the next decade, wait times and scheduling delays will increase, putting patient health at risk. Gains in efficiency and organizational capacity are the only available methods for addressing this shortage in the near term.
  • Healthcare needs are growing. Aging Baby Boomers will burden our healthcare systems for at least the next two decades, and given their financial resources, they are likely to expand the market for innovative geriatric care and lifestyle medicine. To this trend, add a larger, long-term health crisis in America, signified by declining life expectancy. Lastly, Covid-19 is likely only an early example in a future pattern of pandemics.

To address these industry challenges, improve efficiency, build capacity—and deliver better healthcare experiences—Virtual Care 2.0 must leverage patient enthusiasm for tech, exploring and inventing new models. The result will be an utter reshaping of the marketplace towards virtual specialty care.

Specialty care is the core of Virtual Care 2.0

By providing frictionless access to a network of specialist physicians, virtual specialty care can relieve pressure on physicians and speed access to high quality specialists. Assisted by technology that facilitates understanding of medical history and follow-up, virtual specialty care shifts the conversation from urgent care to longitudinal care, including lifestyle medicine. Specialists, connected directly to the patient, attuned to nuance, and supported with powerful information systems, can analyze a patient’s entire journey across any health topic, large or small, common or rare. Here’s how it works:

  1. Employers purchase membership in a virtual care network and provide access as an employment benefit; their employees are now “members” of the network.
  2. Most members first use virtual specialty care because they have a specific health question or concern. When connecting to a healthcare concierge on this first topic, they initiate a relationship with the network that can grow and deepen over time.
  3. The healthcare concierge fields the member’s query and leverages technology to identify a highly-skilled specialist physician.
  4. A consultation with the specialist physician is scheduled within days—and sometimes, hours—of the initial member inquiry. The healthcare concierge may also help the member prepare for the consultation, guiding them to assemble medical records and imagery the specialist might need—and even coaching members to formulate meaningful questions for the physician.
  5. Follow-up conversations are scheduled, introducing the member to the benefits of longitudinal care, lifestyle medicine, and other telehealth opportunities that arise from a sustained relationship with the network.

The efficiency of this model is a win for everyone involved:

  • Patients see the right doctors sooner, which results in better health outcomes. On one network, 52% of patients changed their approach to treatment based on physician guidance gained through virtual specialty care.
  • Employers who offer virtual specialty care as a benefit see a healthier, happier, more productive workforce with fewer sick days. In addition, they see dramatic savings in healthcare costs as a result of quicker, more accurate diagnosis. Specialty care platforms have provided up to $7,150 in average savings per member engagement, resulting in a 3:1 return on investment.
  • Physicians get to spend more time with patients. With the average patient engagement lasting 44 minutes, physicians can spend more time with each patient directly listening and engaging.

Managing the whole journey

Virtual Care 2.0 will restore the human connection between patients and the collective wisdom of the medical community. Using new tools, patients and specialists will collaborate to quickly identify healthcare challenges and map out a journey towards well-being.

Virtual specialty care networks may provide the sort of longitudinal healthcare relationship we haven’t seen since the era of house calls and doctors’ bags—benefiting patients and physicians alike. Employers, who sponsor virtual specialty care for their employees, will see a happier, more productive workforce, higher retention, and reduced costs.

Photo: Feodora Chiosea, Getty Images

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People taking their mental health into their own hands via the use of psychedelics. Recent college graduates entering the workforce without ever stepping foot in an office. Individuals who make investment decisions based on Reddit. 

These newly emerging populations represent the forces that are shaping the future of health today, and healthcare organizations that pay attention to these new pivotal groups will stay relevant in a post-pandemic world.

These new populations are best exemplified by the archetypal personas I met Monday at an interactive event in Chicago. The event, titled Inspiration Experience: Renaissance 2022,” took place Monday at the Oliver Wyman’s Health Innovation Summit. Billed as an “immersive experience,” it was more an interactive event that featured presentations from actors and members of Oliver Wyman’s health and life sciences team.

The event summarized Oliver Wyman’s consumer research and explored four major trends that will play critical roles in accelerating digitization within major industries such as healthcare, technology, science, technology, manufacturing and education. The presentations also introduced new names for emerging consumer and employee populations, such as “digital bloomers” and “citizens of the metaverse.”

To conduct the research that informed the interactive event, Oliver Wyman surveyed more than 100,000 respondents across nine countries from August 2020 to December 2021. The countries were the U.S., U.K., Mexico, Brazil, Germany, Italy, Spain, France and China.

Dr. Who? Dr. Me

In this section, we met three characters who embodied the country’s changing health behaviors. The first was Ruchir, a young man using ketamine therapy to treat his depression. After years of unsuccessful treatments — including SSRIs (selective serotonin reuptake inhibitors) and transcranial magnetic stimulation — he began the psychedelic therapy and is finally seeing progress for his condition.

Though his mental health is improving, he is plagued with endless back-and-forths with his health plan, begging it to cover his treatment given it is the only thing that is working for him. It is doubly frustrating for him given the therapy has been proven to be effective. He is also bothered by the fact that ketamine therapy was not widely available at mental health facilities. 

Next, we met Hannah, an expecting mother who is on her way to meet with her doula. This is Hannah’s first pregnancy, and she knows she needs a doula to help guide her through the emotional and oftentimes overwhelming process of preparing for childbirth. She is grateful that she is able to afford the doula, but expresses resentment and confusion as to why her insurer didn’t cover the services. Research proves that expectant mothers who are matched with a doula have better birth outcomes — Hannah felt like her health plan didn’t prioritize her best interest of her child’s health. 

Jay, the final character, is an athlete focused on optimizing his physical performance. He is willing to try every new and existing technology available to strengthen the full spectrum of his wellbeing. However, he said that when he brought up sleep tracking technology and the other wearables that he used to understand his health to his physician, she was dismissive of his efforts to learn from his health data. 

Each of these characters represents a society that is becoming more educated and aware of “alternative” therapies and ways to measure their health. They demonstrate a frustration that more and more patients are feeling: Why should I listen to my doctor when they don’t even know all of my options? The presentation recommended that healthcare companies respond to these consumer trends by keeping their operating models up to date as new research and care delivery breakthroughs continue to emerge.

Influencers over Institutions

As exemplified by Ruchir, Hannah and Jay, patients have more health information at their fingertips than ever before. Oliver Wyman’s research revealed that people gather the bulk of this information through the Internet. It also found that distrust in experts and corporate organizations is at a high. Rather than turning to institutions, people prefer to get their information — whether it be health advice, political guidance or briefings on current events — from influencers and friends on social media, according to Oliver Wyman’s health and life sciences team.

Investors are not immune to this trend as exemplified in the concept of the “hivemind investor,” a persona representing those whose investment decisions are driven by social media. This character entered mainstream consciousness in January 2021, when the “WallStreetBets” subreddit rallied around stocks that traditional investors on Wall Street had expected to do poorly, such as Gamestop and AMC. Oliver Wyman’s research showed that this community-based approach to investing is unlikely to go away soon, so startups and companies preparing for their IPOs should be aware of this trend.

I also met the “specter of disinformation” as part of the experience. I did this by looking into a mirror — it was meant to reveal the skeptic that lives inside all of us. The presentation reminded me that in a world in which we curate our own information from the vastness of the Internet, it’s imperative that we be discerning when consuming news online. 

I was shown various TikToks and Instagram reels in which users spouted their expertise on disease outbreaks and health maintenance. Some of these videos were more outlandish than others — such as the one that argued raw milk is the only healthy coffee additive — but they all contained health information that was questionable and unvetted. It was then revealed that the accounts I was watching all had more followers than the Centers for Disease Control and Prevention. More Instagram followers, that is — so far the CDC doesn’t even have a TikTok account.

People are more likely to trust information when it is delivered by someone they can relate to, the research showed. For a growing number of people, a TikToker uploading content from their home is much more relatable than Anthony Fauci delivering information in a suit. This is a prime area where healthcare companies need to innovate — they are still struggling to handle disinformation and its effects on their customers, Oliver Wyman’s presenters said.

Mobilizing the Metaverse  

Just like social media isn’t going away, neither are digital modes of care delivery. In this session, I learned about two distinct groups: digital bloomers and citizens of the metaverse. 

Digital bloomers are people, mainly those over age 45, who entered the digital ecosystem because of the pandemic. Until then, they did things the analog way and saw no reason to change. Now, this group is becoming increasingly willing to digitize necessities, such as their healthcare interactions, banking and grocery shopping, the research revealed.

The presentation suggested that healthcare companies need to capitalize on this newly emerged group by scaling up their digital offerings and focusing on convenience for the end user. This becomes even more imperative when we think about reaching citizens of the metaverse, a term which refers to people who are willing to participate in a wholly virtual world without hesitation. 

As more and more people become comfortable with the metaverse, healthcare companies have the opportunity to tailor their products and services toward the convergence of virtual and physical reality. This could be as simple as offering more telehealth visits, or as complex as creating virtual reality experiences for physical therapy. During the interactive portion of this session, I was given the chance to take part in various VR experiences, such as a physical therapy session in which patients slash virtual balloons with virtual swords to help regain muscle strength.

The Great Renegotiation

In addition to new consumer preferences, healthcare companies also need to start adapting to new types of employees that have entered the workforce over the past couple years. For example, the workforce has seen an influx of workers who are virtual natives, meaning they graduated during the pandemic and have since taken jobs where they work almost exclusively remotely. 

Without knowing it, this group of young people have reinvented what a white collar job can look like. Many prefer remote work, enjoying the fact that they rarely have to leave the comfort of their homes and pets. Others are unsure whether they enjoy it, finding it strange to have never met your boss in person, according to the research. 

This group has a complicated relationship with returning to the office. In the survey, 87% said they do (or would) enjoy going to the office, and 86% said they would quit or look for another job if they were required to return to the office full-time. As a 2020 graduate and virtual native myself, I can attest to this — my peers and I have mixed feelings on remote work. Conducting more research to understand this population’s unique wants and needs will help healthcare companies discover ways to improve white-collar retention and build employee loyalty, the presentation recommended.

Another employee group that has emerged during the pandemic is blue collar workers who taught themselves new skills that helped them land a white collar job. As these workers shift to white collar positions and blue collar baby boomers continue to retire, the blue collar labor shortage is being exacerbated, according to the research. This will force healthcare companies to fully embrace automation and figure out how humans and machines can best work alongside each other.

During this presentation, I saw two actors have a conversation as Gen Z employees. They worked as call center employees at a regional health plan, and they were on their lunch break. The women talked about remote work concerns and how they were unsure how to advocate for better pay. One of these characters also said she “didn’t even understand” which benefits her employer was offering, claiming that the company needed to do a better job of educating her about them.

From these bemused young workers to hivemind investors to psychedelic explorers, all of these new personas are worth healthcare companies’ attention, according to Oliver Wyman’s presenters. Successful healthcare companies must continually reassess their strategies to keep up with these changing consumer and employee preferences — or they may fall behind.

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Improving health equity is rapidly becoming a top priority across the healthcare industry. In the U.S., many disadvantaged populations experience systemic healthcare disparities that result in higher rates of disease, disability, and death. Members of these groups face pervasive obstacles due to their socioeconomic status, racial or ethnic identity, age, gender, location, and/or native language, and are more likely to have poor health status as well as more limited means and ability to access care.

In orthopedics, disparities in care manifest primarily as lower utilization rates among lower-income and minority populations. While the prevalence of knee and hip osteoarthritis does not vary greatly by race or ethnicity in the U.S., the data indicates that Black patients are more than 30% less likely to receive a total hip or knee replacement than White patients, even after adjustments are made for age, sex, and income.

Patients with state-funded Medicaid and federally funded Medicare encounter various barriers to securing musculoskeletal (MSK) care, including lower referral rates to orthopedic surgeons. Even after Medicaid expansion was codified into law by the Patient Protection and Affordable Care Act, one study found that patients with commercial insurance were twice as likely to be accepted for an orthopedic appointment as patients with Medicaid.

For patients living with daily pain, the cost of not having surgery can be tremendous, leading to significant functional impairment in the activities of daily living. Anyone who has suffered from low back pain understands how debilitating orthopedic conditions can be. When it is painful to get up and move, patients can become depressed and sedentary, leading to an increased risk of developing related comorbidities, including obesity, diabetes, and cardiovascular disease.

To reduce these healthcare disparities, orthopedic practices must consider how they engage disadvantaged populations. By identifying new processes, policies, and technology, orthopedic practices can promote greater health equity in the communities they serve.

Improving patient access to care

Federal legislation can help remove barriers to orthopedic care for lower-income patients. For example, in the two years after the Affordable Care Act was passed, utilization of Medicaid-funded total hip and total knee arthroplasty procedures increased by 19% in states that expanded Medicaid coverage.

New bundled payment models can also alleviate some of the reimbursement disparity that results from increasing a practice’s percentage of federally funded patients. The American Academy of Orthopaedic Surgeons recommends that orthopedic episodes of care be risk-adjusted for patient demographics, socioeconomic status, comorbidities, and severity of illness to compensate for variable treatment costs.

Evolving reimbursement policies, including federal incentives to provide accessible digital care management tools, can also improve orthopedic care utilization among disadvantaged populations. Implementing remote care management, monitoring, and messaging tools eliminates the need for patients to attend multiple in-person appointments, and keeps patients connected to their care teams regardless of their geographical location. In-person preoperative appointments can be replaced with virtual education classes, while virtual physical therapy (PT) can supplement or replace traditional outpatient PT, saving patients co-pays, travel costs, and logistical challenges.

According to the American Hospital Association, transportation barriers—including long travel distances, poor mobility, and the lack of a vehicle—are one of the leading causes of missed medical appointments for elderly patients. Digital care management tools make care more accessible for a variety of vulnerable populations, including patients in rural communities, patients who rely on a walker or other assistive device, and patients whose work or childcare circumstances limit their availability for in-person appointments.

Ensuring technology is accessible for all populations

In many rural and low-income communities, limited high-speed internet and insufficient access to a computer impedes the use of digital care, telehealth, and remote monitoring solutions. According to the Pew Research Center, almost a third (27%) of adults living in households earning less than $30,000 a year are smartphone-only internet users.

The technological infrastructure of a care management platform must support all patient populations, including the 43% of lower-income adults without broadband services at home; it  must also be mobile-friendly and SMS-enabled. Multimodal access, including two-way text messaging, is ideal for engaging patients with complex healthcare needs. Compared to other forms of communication, texting has the greatest reach, with open rates of 95% or above.

Digital care management tools must also be easy to use for all populations, regardless of health literacy, technological prowess, or English proficiency. Older age, minority membership, and low socioeconomic status are disproportionately correlated with poor health literacy in both urban and rural populations. For patients who are not native English speakers, the language barrier only compounds these challenges. A multi-year study on healthcare utilization among Hispanic adults found that limited English proficiency functions as a major barrier to care, resulting in the underuse of medical services.

Delivering relevant content at the right moment in time

Delivering clear care management instructions on a digital platform, in the patient’s native language, can improve the comprehension gap patients experience. One study found that 51% of patients failed to recall their physician’s oral recommendations and treatment guidance, due to limited participation during in-person appointments and a lack of effective follow-up communications.

An effective digital care management system will push out relevant information at the optimal point in the patient’s care journey. Segmented, phased content delivery drives continued patient engagement, as does the ability to link caregivers or care partners to the patient’s account. For example, providing the adult child of an elderly postoperative patient with access to their parent’s care plan can help ensure better clinical outcomes.

Remote monitoring and physician messaging tools can keep patients connected to their care team throughout an episode of care, enabling targeted interventions when necessary. For example, physicians can be notified in real time when a postoperative patient experiences a setback. By monitoring patients from afar, orthopedic practices can determine which patients are adhering to their care plan and which require extra support. This optimizes the workflow of time-starved navigators and nurses, who can then spend their time on the patients who need them most.

Direct physician/patient messaging tools can also help to reduce avoidable readmissions, as patients have an open line of communication with their care team. Educating patients on what constitutes a medical emergency for their condition can prevent them from heading immediately to the ER or urgent care clinic with a non-emergent issue.

Preparing for a more equitable future

CMS recently issued its proposed Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System rule for fiscal year 2023, which includes three health equity-focused measures for adoption in the Hospital Inpatient Quality Reporting program. As health equity becomes a major focus of federal policy, orthopedic departments, practices, and ambulatory surgical centers will need to prepare for regulatory changes.

In the near future, healthcare organizations will likely need to document how they collect health equity data, screen patients for social determinants of health, and address disparities in care.

Orthopedic teams must also build strong relationships with their patients, especially members of at-risk populations who are likely to need additional support. Implementing accessible digital care management, remote monitoring, and messaging applications can help orthopedic providers scale their business while consistently supporting all patients throughout their recovery.

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How is the patient journey impacted when individuals have an estimate of care costs before their visit?

Providers are under increased pressure to publicly disclose the price of products and services they offer, in part driven by recent federal price transparency regulations. For example, the Hospital Price Transparency rule took effect on January 1, 2021, and is intended to make it easier for consumers to shop and compare prices across hospitals, as well as estimate the cost of care before going to the hospital. The rule stipulates that hospitals’ standard charges, including the rates they negotiate with insurance companies and the discounted price they are willing to accept directly from a patient if paid in cash, must be publicly available, free of charge, and presented in a consumer-friendly display.

While the federal rule applies to hospitals, it highlights the increased awareness and growing demand for price transparency across all care settings. Adding to consumers’ awareness around price transparency is the No Surprises Act, which took effect Jan. 1, 2022. This act is intended to protect consumers from excessive out-of-pocket costs when getting emergency care and non-emergency care from out-of-network providers at in-network facilities. As more providers seek to comply with new laws, healthcare consumers are likely to obtain a heightened awareness of price transparency and expect more transparency from their providers, regardless of care setting.

For outpatient practices, providers have an opportunity to get ahead of this evolution in healthcare consumer expectations by offering patients a new type of care journey that includes an option for pre-service cost estimates.

Two patient journeys

To understand the difference that pre-service cost estimates can deliver for patients, providers, and staff, consider two separate journeys that patients might follow: One is a more traditional route with the patient only paying their co-pay at the time of service. The other journey provides the patient with a cost estimate for care at the time of check-in.

In the traditional journey, the patient shows up for an appointment and upon check-in at the front desk is asked to provide her co-pay amount, without regard for other charges that could be paid up-front. Insurance companies have shifted their plan design away from copay-driven plans to high-deductible health plans, with deductibles routinely being in the $3,000 to$5,000 range (and sometimes as high as $12,000). When a patient is on a high-deductible health plan, the provider collects $0 before or immediately after the service is rendered, with the rest left at risk. After the visit is complete, a staff member files a claim with the patient’s insurance company, the patient is billed for the balance due – and then begins the provider’s waiting game to receive payment for the funds they are owed.

Some patients may pay their providers the day they receive a bill; however, a far more likely outcome is that payment is delayed because patients generally prioritize payments for rent, car payments, groceries and other monthly expenses over medical bills. Surprise bills can be particularly problematic for patients who have high-deductible plans and learn they owe significant out-of-pocket costs. Surprise bills can also be costly for providers, who often must devote valuable staff resources to work collections and chase down payments.

In contrast, consider the journey of a patient who has the option of taking advantage of digital tools that estimate the out-of-pocket costs before the visit, based on expected visit type and past history. With this approach, providers can collect not only co-pay due at check-in but, also the probable out-of-pocket cost estimate. In addition, staff can store the patient’s credit card information at the time of service, then automatically bill for any balance due after the claim is adjudicated.

For patients, this greater price transparency can yield better, more-informed decision-making and facilitate budgeting for medical costs. For example, when informed of expected costs up-front, the patient is in a much better position to decide if they should move forward with treatment now, or if they could postpone until a future date, and budget accordingly. Having the cost information prior to treatment also enables patients and clinicians to have a frank conversation about treatment options and timing.

Providers that collect the patient’s full payment at the time of service get their money sooner and also free staff members from time-consuming collection efforts. Fewer accounts have to be turned over to collection agencies, meaning a greater portion of collections stay with the practice.

Pre-service cost estimates are an essential component of providers’ broader pre-service check-in process and facilitate a more automated patient journey that delivers greater price transparency, reduces financial friction for patients, and increases the likelihood for prompt collections.

Photo: champc, Getty Images

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private equity, investments,

Average costs for U.S. employers that pay for their employees’ healthcare will rise by 6.5% in 2023, global professional services firm Aon found Thursday. Costs per employee will be $13,800, up from $13,020 in 2022.

The report used information from Aon’s Health Value Initiative database, which includes healthcare costs and benefit designs for almost 700 U.S. employers. These organizations employ 5.6 million employees and represent $76 billion in 2022 healthcare spending.

The projected 6.5% increase in average costs for U.S. employers is more than double the 3% increase employers experienced in 2022, the report said. However, the increase is below the 9.1% increase in the Consumer Price Index, which was reported Thursday by the U.S. Bureau of Labor Statistics

Medical claims were lower in the beginning of the pandemic as many patients postponed care, creating a smaller budget in 2022. But now claims are slowly returning to normal levels for employers and inflation is rising, the report said.

“In complete contrast over the last decades, we are measuring that healthcare budgets for U.S. employers will come in nearly three times lower than the Consumer Price Index this calendar year,” Debbie Ashford, the North America chief actuary for health solutions at Aon, said in a news release. “Despite this historic occurrence, employer health costs are expected to increase 6.5% in 2023 due to economic inflation pressures.”

Inflation is usually slow to affect healthcare because of the multi-year nature of contracts between providers and payers, but it will likely become more prevalent in the coming year, Ashford added.

To combat an increase in costs, Aon recommends employers address the expense burden associated with patients with chronic and complex healthcare conditions. Ashford said “it is not uncommon” for 1% of membership to drive 40% of employers’ healthcare spending in any given year. Collecting data and analytics on these conditions may help plan sponsors mitigate costs. 

“The effect of chronic conditions has far-reaching implications beyond what we see with healthcare costs, out to the other areas of the business, like absence and productivity, disability and worker’s compensation,” said Farheen Dam, Aon’s North America health solutions leader. “By focusing on chronic conditions, not only are we improving the health and happiness of employees, but we’re helping to improve the way they live and work.”

Photo: Ta Nu, Getty Images

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The U.S. Department of Health and Human Services and the Centers for Medicare & Medicaid Services approved the extension of postpartum Medicaid and Children’s Health Insurance Program (CHIP) coverage in Hawaii, Maryland and Ohio on Tuesday. One advocate said all states should follow.

Through the American Rescue Plan, states have the option to extend postpartum coverage in their Medicaid and CHIP programs from the current mandatory 60-day timeline to 12 months following pregnancy. States can make the change through a State Plan Amendment, which is a proposed change to Medicaid plans. This option took effect April 1 and is available for five years, according to Kaiser Family Foundation. Before April 1, states extended postpartum coverage through a section 1115 waiver or by using state funds.

There’s a need for the extension, said Dr. Jen Villavicencio, lead for equity transformation at the American College of Obstetricians and Gynecologists (ACOG). The organization has been a major advocate for extending postpartum Medicaid coverage to one year. About one-third of all maternal deaths happen between a week and a year after delivery, she said.

“The weeks following birth are a critical health period for an individual … The postpartum period must include ongoing access to healthcare, rather than a single encounter, with services and support — especially for patients with chronic medical conditions — tailored to each individual’s needs,” Villavicencio said. “This requires timely follow-up and ongoing coordination of care with other healthcare specialists in order to set the stage for long-term health and well-being. Yet, people will have a difficult time accessing this care if they do not have health insurance.”

So far, 21 states and the District of Columbia are implementing a postpartum coverage extension, while nine states are ready to implement it pending CMS approval, according to a tracker by the ACOG. 

Medicaid covers 42% of all births in the nation. With Tuesday’s approval, an additional 34,000 people annually are eligible for postpartum Medicaid and CHIP coverage for 12 months after pregnancy, HHS said in a news release. This includes about 2,000 people in Hawaii, 11,000 in Maryland and 21,000 in Ohio. In total, approximately 318,000 Americans annually are eligible, HHS stated.

Out of the 12 states that have chosen to not fully expand Medicaid, nine have sought or plan to seek an extension of postpartum Medicaid coverage, Kaiser Health News reported in June. But some politicians in non-expansion states, such as Wyoming, South Dakota and Mississippi, don’t want any form of Medicaid expansion, including with postpartum coverage.

If all states adopted the 12-month postpartum option, about 720,000 Americans annually would be guaranteed Medicaid and CHIP coverage for a year after pregnancy, HHS said.

“Through the American Rescue Plan Act, Congress has made available a simpler pathway for states to extend Medicaid coverage for pregnant people,” Villavicencio said. “Every state should be taking advantage of this opportunity.” 

Under the Covid-19 public health emergency, states are required to provide continuous coverage to Medicaid enrollees, KFF said. Therefore, postpartum coverage has been continuous throughout the pandemic.

Photo credit: Blue Planet Studio, Getty Images

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White pharmaceutical pills spilling from prescription bottle over American map

Dr. B has raised $8 million in seed funding for its newly launched telehealth prescription service now available in 41 states. The company is named after CEO and Founder Cyrus Massoumi’s grandfather, who was nicknamed Dr. Bubba and became a doctor during the 1918 Spanish flu.

Founded at the height of Covid-19 in 2021, New York City-based Dr. B started as an online business that matched people with unused vaccines. It was able to offer vaccines to more than 1 million people in 37 states by partnering with more than 700 healthcare providers, according to a news release. Now as vaccines are more readily available, the company is switching gears. It now aims to improve the limited access to at-home Covid-19 treatments, starting with Paxlovid and molnupiravir.

“While Covid-19 antiviral pills have been available for several months and there is a lot of demand, many people still have a hard time accessing them because they require a prescription,” Massoumi said. “Patients need flexible options for getting that prescription, which is why we started by providing Covid-19 antiviral prescriptions.”

Although the company is starting with these prescriptions, the funding will help it expand to other treatments beyond Covid-19, Massoumi said. This includes treatments for heart health, dermatology and reproductive care. The startup will also work to offer its service in languages other than Spanish and English, he added.

To receive prescription medications, Dr. B patients fill out an online assessment through its website. They have to submit a photo of a positive Covid-19 test and answer questions about symptoms, pre-existing conditions and medications they’re currently taking. Then a board-certified doctor reviews the responses and if the physician finds the patient is eligible, a prescription is sent to the patient’s pharmacy of choice.

“We solve a key pain point in the process — the need to get a doctor prescription within five days of testing positive,” Massoumi said. “Our platform offers a hassle-free way to get prescriptions online, without the need for an appointment.”

The company is focused on providing low-cost — or sometimes no-cost — care to patients, said Massoumi, who previously founded Zocdoc, an online service that allows people to find and book medical appointments.

“I’m proud of the work we accomplished while I was at Zocdoc, but one of my biggest regrets is that we didn’t do enough to improve access to healthcare for everyone,” he said. “I’m trying to correct that with Dr. B.”

Most patients pay a $15 consultation fee. But people who need it can receive the services for free, as long as they qualify. These patients have to fill out a questionnaire about their monthly income to determine if they’re eligible.

Massoumi added that while the fee “is less than the average insurance copay” it still helps Dr. B to provide “no-cost care for lower-income patients.”

Other online prescription companies include GeniusRx and Amazon Pharmacy, but Massoumi said Dr. B differs from competitors by providing this no-cost option.

Photo: Stuart Ritchie, Getty Images

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Blue Cross Blue Shield of Michigan is partnering with Maven Clinic, a digital family health platform, to offer members additional family and maternity support, the health plan announced Wednesday. Maven Clinic’s platform will be available for the 2023 open enrollment period.

Members of the insurer can use New York City-based Maven’s app. Once they log on and confirm they are part of BCBSM, they get access to 24/7 virtual care with Maven’s care advocates, who answer questions and help direct users to their needed services. Members can receive virtual clinical support from specialty providers, including obstetricians, pediatricians, lactation consultants, pediatric sleep coaches and psychologists.

The platform includes care matching, in which users can find care advocates and virtual coaches based on identity, race, ethnicity, faith-based orientation and LBGTQ status, said Aji Abraham, senior vice president of health plan business innovation and market solutions at BCBSM.

“Our goal is to support all paths to parenthood including support for expectant moms, dads, same-sex partners, transgender people and single parents,” Abraham said.

Maven offers three programs through the platform: family building, maternity, and parenting and pediatrics, according to a news release. The family building program provides resources for fertility treatment, preconception care, egg freezing, adoption and surrogacy. The maternity program, which spans 12 months, gives resources for prenatal and postpartum care, NICU support and high-risk pregnancies. The parenting and pediatrics program is intended for parents with children ages 1 through 10 in need of pediatric care, parent coaching and special needs support.

A reimbursement tool, called Maven Wallet, is available on the app, which allows employees of self-funded employers to get reimbursed for expenses.

If members need in-person care, the clinic directs users to in-network providers. Maven’s resources are meant to be an extension of BCBSM’s current benefits and to provide additional support in between regular in-person appointments.

Employer groups will only pay for members who are using the Maven platform, rather than based on total membership, Abraham said. BCBSM will then pay Maven and process claims for members who are cared for. The payment model is a departure from how several employee benefits companies get paid from employers who offer their products and services to employers. Usually, employers pay them on a per member per month rate based on total employees irrespective of how many are actually using the product. 

Maven, which achieved unicorn status last year, isn’t the only company in the digital maternity and parenthood space. Other companies include Ovia Health and Progyny.

BCBSM chose to work with Maven because of its proven track record, Abraham said. In its eight years of experience, the tech company has achieved a 20% reduction in cesarean sections and a 28% decrease in NICU stays.

Other than impressive outcomes, Abraham was also struck by the company’s mission. He added that BCBSM and Maven have a “shared mission in health equity and investment in community partnerships to address racial disparities and improve maternal and infant health care and outcomes.”

BCBSM’s ultimate goal in partnering with Maven Clinic is to provide inclusive, flexible and affordable benefits to members. It also wants to improve employee retention, productivity and healthcare costs for employers, Abraham added.

“We want our members to have the easiest and most successful path to building a family,” Abraham declared. “Starting or growing a family is one of the biggest decisions a person or family can make. There are cost factors to consider as well as the health for both parent and child. Positive outcomes are only possible by having access to the appropriate resources and care.”

Photo credit: Knape, Getty Images

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The national uninsured rate reached 8% in early 2022, a record low with 5.2 million people gaining coverage since 2020, according to a Department of Health and Human Services report released Tuesday.

The report analyzed data from the National Health Interview Survey and the American Community Survey.

“Our new report shows that the uninsured rate in the country reached an all-time low this year – welcome news and proof that our efforts to protect and expand on the Affordable Care Act are paying off,” HHS Secretary Xavier Becerra said in a news release. “As we move forward, the Department of Health and Human Services will continue to do everything we can to protect, expand, and strengthen the programs that provide the quality, affordable health care Americans rely on and deserve.”

The uninsured rate significantly declined in 2021 and early 2022, reaching 8% in the first quarter from January to March. The previous record was 9% in 2016, according to the report. 

Of the 5.2 million people gaining coverage since 2020, 4.1 million adults ages 18 to 63 became insured and 1 million children ages 0 to 17 became insured. This increase is largely because of the enhanced marketplace subsidies and an extended 2021 enrollment period under the American Rescue Plan, according to the report. 

Additionally, there were several state Medicaid expansions. When looking at state-specific analyses for low-income adults from 2018 to 2020, 18 states saw a decline in uninsured rates, 15 of which expanded Medicaid. Of the five states that expanded Medicaid from 2019 to 2020, all of them saw a decline in uninsured rates. Idaho saw the biggest decline of 8.4% from 2018 to 2020. Data after 2020 aren’t available yet.

Uninsured rates of those ages 18 to 64 fell from 14.5% in late 2020 to 11.8% in early 2022. For those ages 0 to 17, uninsured rates fell from 6.4% in late 2020 to 3.7% in early 2022.

Adults covered by marketplace rose from 4.4% in 2020 to 5.4% in early 2022, representing about 2 million adults.

The largest changes in uninsured rates were in the poorest demographic groups. Among individuals 100% below the federal poverty level, the uninsured rate went from 20% in the first quarter of 2021 to 15.5% in the first quarter of 2022. For those between 100% and 200% the federal poverty level, the rate went from 16.6% to 16%. In those between 200% and 400% the federal poverty level, the rate went from 11.7% to 9.7%. The smallest decrease was among those above 400% the federal poverty level, from 4.2% to 3.7%.

“I’m hopeful that with Congressional action we can continue the work to lower costs for more Americans by both extending the enhanced Affordable Care Act tax credits that have helped drive the uninsured rate to an all-time low and increasing the affordability of prescription drugs for Medicare beneficiaries — reducing their cost sharing and allowing Medicare to negotiate a better deal on prescription drug prices,” Becerra said.

Photo: YinYang, Getty Images

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