Economic Impact Of Health Insurance Reforms: Lessons From European Experiences – Authors: Mark McClellan, Rahul Rajkumar, Marion Koch, Diane Holder, Peter Long, Rhonda Meadows, Amal Navate, Mai Pham, Louis Sandy, William Shrank and Mark Smith
Unlike other high-income countries, health insurance coverage and payment in the United States is highly fragmented. The US multipayer system includes a set of entities, including publicly funded programs (eg, Medicare, Medicaid) and commercial insurers and health plans.
Economic Impact Of Health Insurance Reforms: Lessons From European Experiences
Provides an overview of the different types of payers and populations in the United States [1] This article focuses on the perspective of payers covered by Medicare, Medicaid, and adults with fully insured employer health plans, which comprise the majority of Americans.
A Lesson For America?
These payers aim to provide several functions in the US health care system, including providing protection against the financial impact of unexpected health events, providing patients with access to a broad array of health services provided by a network of health care professionals, coordinating those services, and use measurement and incentives to increase the cost-effectiveness and quality of care delivery [2]. However, shared payer functions can take many forms with respect to operating arrangements (eg, stand-alone plans versus joint ventures with delivery organizations), benefit design (eg, covered services, cost-sharing), and payment methods (eg, volume). have – versus population-based payments). A key area of change for payers over the past decade has been the rise of so-called “value-based care,” in which payers in the public and private sectors have sought to move away from fee-for-service (FFS). Arrangements for alternative payment models (APMs) that link reimbursement to the quality and outcomes of care delivery [3].
It is in the midst of this period of architectural modernization of the US health care system that COVID-19 struck. The public health emergency—which continues at the time of this article’s publication—has had dramatic consequences for the health of the American public and the financial stability of the American health care system. During Spring 2020, payers will take steps to expand access to health services for both COVID-19 and non-Covid-19 health conditions (eg, waiver of administrative requirements, telehealth reimbursement) based on regulatory requirements and recommendations. They gave. Many payers also independently leveraged financial support and capital to stabilize providers, and leveraged their technological capabilities and social relationships to support the outbreak response, from coordinating nonmedical services to supporting immunization campaigns.
However, payers’ pandemic response capabilities and their obligations to regulators, employers, providers, and patients evolved as caseloads persisted and the downstream consequences of COVID-19 began to emerge. For example, as the outbreak intensified during 2020, trends in medical spending and utilization changed. Payers initially experienced cost reductions due to delays in care, but then due to increased COVID-19 patient volumes and delayed resumption of care. The unpredictability of a pandemic created significant challenges for payers’ operations in 2021 (eg, pricing, enrollment).
In this article, payer sector leaders seek to describe the experience of health insurers during COVID-19 and identify key challenges and opportunities learned from the pandemic and beyond. It is important to acknowledge that as an ongoing public health emergency, empirical evidence on health care costs and payment policies for COVID-19 is currently emerging, and data on specific payment measures are emerging. Providers may vary based on differences in health insurance products. Local Market Needs and Regulatory Requirements Nevertheless, one year into the pandemic, it is clear that the unprecedented disruption to the healthcare system as a result of COVID-19 presents a unique opportunity for payers to improve the efficiency and equity of healthcare financing in America. . Consequently, the purpose of this article is to provide an initial review of payers’ experiences during COVID-19 to date and to highlight key lessons about how payers and regulators can navigate the uncertainties of COVID-19 and take advantage of the new momentum for healthcare. do, is Reforms, with a particular focus on improving affordability and access.
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The COVID-19 pandemic delivered a sudden and significant shock to America’s fragmented health care system. While the volatility of COVID-19 created challenges for payers (eg, actuarial forecasting), the unprecedented decline in health care costs led to improved financial performance for many health insurers during 2020. Many payers used their resources and roles to advocate for patients, providers. and other stakeholders as the health care system evolved at an unprecedented rate. For example, insurers facilitated the management and delivery of non-pandemic and covid-19 health services across multiple care delivery partners. Likewise, health plans worked to compile and coordinate new federal and state mandates, rules, waivers, and guidance on traditional health services (e.g., prescriptions, benefits) and COVID-19-related care (e.g., testing, treatment). In addition, payers partnered with providers and collaborated with other sectors (eg, public health, community-based organizations) to support the implementation of new flexibilities, communicate key changes, and Help patients, the public, and employers navigate the rapidly changing delivery. Environment.
This section of the article seeks to highlight the main areas for the payer sector’s response to the pandemic. While it is difficult to determine the evidence for the scale and effects of payer actions at this stage, given that COVID-19 remains an evolving public health emergency at the time of this article’s publication, and its generalization Challenging given America’s multifarious nature. In the paying environment, writers seek to provide outstanding examples of their point of view. Key aspects of payers’ response to COVID-19 include:
Amidst an uncertain information landscape, payers have struggled to synthesize evidence and provide education and training services to help patients stay safe during the pandemic [4]. In the public sector, the Centers for Medicare and Medicaid Services (CMS) sent regular updates to beneficiary FAQs and issued proactive guidance to Medicare Advantage organizations, Part D sponsors, and Medicare-Medicaid plans about flexibilities (eg, changes). to benefits, cost-sharing waivers) available to health plans that cover Medicare beneficiaries during a public health emergency [5]. In the private sector, some insurers developed patient-facing web portals to collect real-time information about coverage options for special enrollees, which often differed across the individual, employer, Medicaid, and Medicare insurance markets [ 6 ].
Health plans also used their customer service teams to disseminate and answer coverage-related questions from patients and employers using multiple methods. For example, some payers dispatched their own patient service representatives to provide patients with the latest information on applicable government mandates. Other payers organized virtual town halls with a particular focus on access to high-risk patients (eg, the elderly) [7]. Payer outreach efforts also extended beyond information sources to direct clinical contributions. Examples include supporting virtual clinical assessments and facilitating communication with providers. Some programs even deployed care managers to network hospitals that were hit hard to help coordinate post-acute care.
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In addition to complying with federally mandated coverage requirements for many components of COVID-19 diagnosis and treatment, payers have also sought to reduce financial barriers to covering non-COVID-19 care during the duration of a public health emergency [8, 9]. In the public sector, CMS requires Medicare Advantage organizations to waive certain referral requirements and cost-sharing policies, all without 30-day notice periods, so that beneficiaries can access the care they need. Likewise, some state Medicaid programs have expanded eligibility and benefits for long-term services and supports for the elderly and patients with disabilities [10]. For employer-sponsored insurance, many plans eliminated late fees, extended eligibility benefits for furloughed employees, and introduced premium deferral mechanisms to balance employers’ concerns about financial sustainability with the need to provide short-term relief to maintain coverage. members presented [11, 12]]. However, the waivers for coverage and cost-sharing do not extend to out-of-network billing for COVID-19 and non-COVID-19 health services. Additionally, adoption of these policies varies among self-insured entities, which comprise the majority of covered workers and are beyond the scope of this article.
A major area of focus for payers across the sector was reducing potential disruptions in patient access to prescription drugs (eg, due to shortages or shelter restrictions) [13]. CMS issued guidance to Part D sponsors, including reimbursement for out-of-network pharmacies and authorization for home delivery and prior authorizations [14]. In the private sector, many insurers (e.g., all 36 Blue Cross Blue Association companies) temporarily waived the initial restrictions on 30-day maintenance drug prescriptions and extended prior authorizations for 90-day drug supplies [ 15 , 16 ].
COVID-19 exposed and exacerbated many long-standing health disparities in the United States, and the pandemic disproportionately affected racial and ethnic minorities and economically and socially disadvantaged populations. Payers have taken several steps to respond to these disparities.
First, at the policy level, CMS issued guidance that the agency use executive discretion to increase mid-year benefits by Medicare Advantage organizations, including benefits to address community needs (eg, meal delivery, transportation services) [17]. While data on mid-year changes is still emerging, the number of Medicare Advantage plans offering special supplemental benefits for chronically ill patients more than tripled between 2020 and 2021 [18]. Most states also implemented new initiatives to address the social determinants of health through their Medicaid programs, with some programs in conjunction with insurers [19]. For example, Pennsylvania implemented new requirements for Medicaid
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