VOL 14 | NO 4
Date:10/01/2023
Symposium Brings Together Stakeholders to Discuss Strategies to Advance Health Equity
At its inaugural Health Equity Symposium, the Academy brought together actuaries, health plan experts, and other thought leaders to collaborate on how to improve health equity by incorporating more equity-enhancing elements into health benefit designs.
The Nov. 15 hybrid event was a culmination of four virtual workshops held with thought leaders earlier in the year by the Academy’s Health Equity Committee. View the event recording on the Academy YouTube page.
The workshops and subsequent issue briefs—available on the Health Equity Committee webpage—explored the challenges to incorporating equity-enhancing benefit design features and how to address those challenges. The committee also released a summary issue brief reflecting the key points from this summer’s discussion groups, which were the building blocks of the symposium.
Key Takeaways
- Many employers are working now to implement benefits to address health disparities among their employee population and to collect more information about worker health needs and priorities.
- Evaluating potential benefit changes in terms of cost effectiveness rather than costs could facilitate the adoption of more equity-enhancing benefit features.
- Building trust with plan participants, increasing their health literacy, and tailoring benefit-related communications can improve patient engagement.
- Actuaries have an important role in the benefit design development process and are relied upon by other stakeholders to provide expertise on the impacts of benefit changes.
James (left) makes a point in a symposium panel
Although the workshops and issue briefs focused primarily on benefits in the employer-sponsored insurance market, the symposium also explored related issues in other markets and how lessons could be shared among the different markets. The workshops and symposium also highlighted the importance of actuaries in the benefit design decision-making process and how actuaries can be part of long-term solutions.
“Addressing equity is not just the right thing to do, not simply a moral imperative—it is an economic and business imperative,” Annette James, chairperson of the Health Equity Committee, told those attending the event in person and viewing virtually.
She stated that actuaries must contribute to such discussions given that health disparities cost $135 billion each year in excess medical costs and lost productivity, according to a 2018 Kellogg Foundation report. “We can’t sit on the sidelines; we have to get in the game,” James said.
Speakers Highlight Key Issues
Several speakers highlighted the need to build trust between communities of color, other minority groups, and those in the health and insurance industries. They said communication and education are keys to making sure that employees and plan participants understand and use their health benefits effectively.
Keynote speaker Dr. Lisa Fitzpatrick
Lisa Fitzpatrick, founder and CEO of Grapevine Health—and known as “Dr. Lisa On The Street” for her YouTube series of the same name—said rumors and inuendo in some communities take the place of facts, compromising care in the process.
“Health literacy is the driver of everything,” Fitzpatrick said, noting a lack of knowledge is often behind why people won’t go to appointments or even take their medicine. Misconceptions due to lack of literacy, she said, can be “hard to hear.”
Dr. LaShawn McIver, chief equity officer at AHIP, said there needs to be a commitment from stakeholders in both the public and private sectors to make health equity sustainable and ensure that systemic change happens.
“By doing this work, we are not just helping our friends and our neighbors, but ultimately our family and ourselves,” she said. “The more we talk about it, the more it is in our general consciousness.”
Panels during the symposium focused on such topics as successes and challenges; costs and cost-effectiveness; communicating and educating plan participants; and improved implementation.
During a discussion looking at employers’ efforts to improve health equity, panelists discussed the unique challenges they face with their particular workforces. For some, it meant educating young employees about health benefits because this was their first time receiving them. Others have workers from diverse backgrounds that had different concerns to be addressed.
(L–R) Panelists Dr. Christa-Marie Singleton and Dr. Wayne Rawlins, with attendee Craig Lisk
To meet their needs, using data is essential. Dr. Christa-Marie Singleton, chief medical officer for the U.S. Office of Personnel Management, said using residential data can help identify shortcomings. “We found one ZIP code where we had a clump of employees that had a number of providers there, but worse outcomes,” she said. “Now there is something going on there.”
On cost effectiveness, several representatives said employers and providers need to weigh improved health outcomes from new benefits instead of focusing on initial plan cost. “As actuaries, we have a responsibility to help our stakeholders see beyond that,” said C.J. Wolfe, vice president at Aon.
The key, he said, is taking a long-term view on the issue. “It is absolutely essential for employers to understand when their employees … are at risk and for what.”
But there also has to be a greater effort to explain to plan participants in simple terms how to use their benefits, and to minimize additional user costs. That means having people or navigation tools available that can answer their questions and direct them to the right contacts for care.
“Let’s reach back to our members and co-create with them to understand what kind of detailed information they need as it relates to expected cost and push that out to the member,” said Teresa Money, executive director of care delivery implementation for Blue Cross Blue Shield Association. “Oftentimes this information gets buried.”
To make real gains in health equity, however, there is a need to overcome challenges to implementing equity-enhancing design features. That comes back to having the best data possible so health challenges can be identified and addressed, participants said.
Lina Rashid, senior policy advisor for CMS Center for Consumer Information and Insurance Oversight, said there is a need to build partnerships to share data that address specific racial and ethnic communities.
“All of us have different roles to play,” she said. “We need to leverage that to build data.”
McIver lauded the work of the Academy and actuaries for advancing the dialogue on health equity since taking up the issue several years ago.
“I want to congratulate you because the conversation that we had here today is how we will transform the future of health care,” she said. “So, thank you for gathering and putting people in a room who may not typically be in a room” together.
Academy Presents on Health Issues at NAIC Fall Meeting
Academy volunteers and staff presented at the National Association of Insurance Commissioners (NAIC) Fall National Meeting in Orlando, Fla. in late November and early December.
Senior Health Policy Analyst Matthew Williams gave an update on Health Practice Council (HPC) activity to NAIC’s Health Actuarial (B) Task Force, covering recent HEC workshops and the November symposium; long-term services and supports; tiered risk-based capital (RBC) factor development; and the key HPC 2024 policy priorities (see following item).
Health Practice Council Outlines ’24 Priorities
The Health Practice Council is currently focused on a broad range of health policy issues including:
Health Equity—Actuaries are actively exploring numerous potential contributors to disparities, and ways to address them.
Public Health Challenges—Actuaries continue to provide insight on public health challenges including behavioral health issues and can provide input on integration of behavioral health with overall health; mental health parity in insurance coverage; network adequacy and access; and the economic and impact to the healthcare system.
Insurance Coverage and Benefit Design—Actuaries have specific expertise related to health insurance markets and the Affordable Care Act (ACA), including proposals to reduce uninsurance and underinsurance rates and increase the availability of affordable coverage.
Health Care Costs and Quality—Innovations to health care payment and delivery systems aim to improve health care affordability and health care outcomes.
Medicare Sustainability—Medicare faces near- and long-term financial challenges, and actuaries can help understand the implications of potential Medicare changes on trust fund solvency, program spending, beneficiaries, providers, and taxpayers.
Long-Term Services and Supports—Actuaries play a crucial role in the financing and design of long-term care (LTC) systems—from private LTC insurance to public programs that provide LTC benefits and services. Actuaries can provide insights on the implications of potential financing approaches on access and affordability and how such approaches would align with programs including Medicaid.
Financial Reporting and Solvency—Actuaries provide input to the NAIC and other organizations regarding accounting and auditing issues for health insurance and support regulatory bodies with developing and maintaining capital requirements intended to ensure the solvency of insurers and others responsible for funding and delivery of health benefits.
Professionalism—In support of the Academy’s mission to objectively serve the public, the HPC provides continuing education to actuaries through webcasts, practice notes, and other venues that offer examples of current and emerging approaches to selected actuarial tasks.
Envision Tomorrow Breakout Sessions Look at ACA, Prescription Drug Costs, Behavioral Health
Health practice-area breakout sessions at Envision Tomorrow, the Academy’s 2023 Annual Meeting, provided valuable perspectives on key issues. Speakers, panelists, and attendees discussed many topics over the course of the two-day meeting, interacting in-person and with virtual attendees. See full session introductions and writeups in the November Actuarial Update supplement Envision Tomorrow: A Closer Look.
A packed prescription drug session
Regulating the Affordable Care Act: What’s New for 2024?
CCIIO provided updates on the important regulations governing the Affordable Care Act (ACA) markets and regulations for the 2024 plan year, and how these changes can affect actuarial practice. Topics included an update on the 2023 EDGE Server Data Collection; mental health parity work with the tri-agencies departments of Health & Human Services, Labor, and Treasury); actuarial value (AV) calculator; and state 1332 waivers.
Addressing Prescription Drug Costs: Current Progress and Future Considerations
A prescription drug costs session began with Neuman giving an overview of the Inflation Reduction Act (IRA), and some of the major Medicare prescription drug provisions within it. This includes changes to Medicare Part D benefit design for brand-name drug costs. Ippolito covered what might happen in the next phase of prescription drug pricing proposals via Congress. The session concluded with an Academy perspective by highlighting what actuaries will need to keep in mind when implementing the changes required by the IRA. For the next decade as provisions roll out from the IRA, actuaries will need to pay attention to the second-order effects of the IRA provisions as this is where most of the “work” will be despite the headline-grabbing first-order effects (e.g., capping costs and negotiating prices).
Behavioral Health Care in the U.S.
This session began with an overview of behavioral health—an umbrella term that includes mental health and substance abuse.
Current issues in behavioral health and the work of the Government Accountability Office’s include access to care (Certified Community Behavioral Health Clinics [CCBHC] demonstration) and the behavioral health workforce (peer support). A representative from the Substance Abuse and Mental Health Services Administration (SAMHSA) discussed priorities and cross-cutting principles and provided an overview on what the Biden administration is doing to better meet mental health and substance abuse needs. A representative from the Senate Committee on Finance talked about current work and proposals on behavioral health.
Save the Date: Next Year’s Meeting in October—It’s not too early to save the dates for the 2024 Annual Meeting, which will be held in advance of next year’s presidential election. It’s set for Oct. 15–16 at the Grand Hyatt Washington in the nation’s capital.
Health Volunteers Awarded at Envision Tomorrow
Also at Envision Tomorrow, several Academy health volunteers received annual service and recognition awards.
Health Practice Council (HPC) member and volunteer Jason Karcher received an Outstanding Volunteerism Award for his invaluable contributions and dedication to the Academy’s health policy work, including integral work on key comment letters on benefit and payment parameters, cost-sharing reductions, and health insurance premium drivers. Karcher, a member of the Individual and Small Group Markets Committee, is a past chairperson of the HPC’s Risk Sharing Subcommittee. Read the Academy news release.
This year’s recipients of Rising Actuary Awards—now in its second year—included health practice-area actuaries Megan Brown (Cambia Health Solutions); Alissa Jangula (Prime Therapeutics); Chris Ludwiczak (Cheiron); John Miller (Milliman); Anthony Pistilli (Axene Health Partners); and Justin See (Blue Cross of Idaho). Read more about these actuaries in the November/December issue of Contingencies.
Karcher (right) receives an OVA from outgoing Academy President Ken Kent
Academy Holds Successful LHQ Seminar
Rowen Bell (right) leads a health session
The Academy hosted a successful 2023 Life and Health Qualifications Seminar Nov. 6–9 in Arlington, Va. The sold-out event included sessions on professionalism, actuarial opinions, and interactive case-study breakout sessions that have long been highly valued by attendees.
The event provided training and instruction—and an optional exam fourth-day exam—for qualifications to issue actuarial opinions for NAIC annual statements. For the fourth year, Academy President-Elect Darrell Knapp chaired the subcommittee that organized the seminar.
Visit the Events Calendar to learn more about other CE opportunities.
Health Public Policy News in Brief
- Senior Health Fellow Cori Uccello and Health Equity Committee (HEC) members Ugo Okpewho and Sara Teppema gave an overview of the HEC’s work on equity considerations related to provider contracting and network development to AHIP’s Health Equity Workgroup.
- Uccello and HEC member Rebecca Sheppard also gave a well-received overview of the committee’s work on equity considerations related to health plan pricing to AHIP’s Health Equity Workgroup.
- Uccello gave an overview of the HEC’s work on equity considerations related to benefit design to the Center on Budget and Policy Priorities’ Marketplace Affordability Project.
- The Long-Term Care Reform Committee submitted comments to Washington state’s Office of the State Actuary on key issues related to LTC financing and risk management, providing information on considerations necessary to achieve and maintain long-term services and supports trust solvency for the WA Cares Fund Program.
- The Medicare Committee submitted a comment letter to the Centers for Medicare & Medicaid Services (CMS) on the draft part one guidance for the Maximum Monthly Cap on Cost-Sharing Payments Program.
- The Individual and Small Group Markets Committee, Risk Sharing Subcommittee, and Active Benefits Committee submitted a comment letter to federal agencies on a notice of proposed rulemaking on short-term limited duration insurance, fixed indemnity coverage, level-funded coverage, and critical illness and specified disease coverage.
Highlights From
HealthCheck
Prefer to watch your news? Check out this “Highlights From HealthCheck” video for a quick recap of what you need to know.
Life and Health Law Manual Available for Preorder
Make sure you’re up to date on the latest requirements with the Academy’s Life and Health Valuation Law Manual. Now available for preorder, the law manual contains a concise summary of the valuation laws of all 50 states, the District of Columbia, and Puerto Rico. The law manual will be available for download in January 2024—place your preorder today.
The Individual and Small Group Markets Committee’s health insurance premium drivers issue brief was used to provide context in a Fierce Healthcare story on health plan premium rate changes.
HealthPayerIntelligence cited findings from the Academy health equity issue brief, Removing the Barriers to Successful Implementation.
InsuranceNewsNet covered the behavioral health breakout session at Envision Tomorrow.
Legislative/Regulatory Activity
Federal
The U.S. Department of Health and Human Services (HHS) issued a final rule on Oct. 11 specifying how and when CMS must calculate and impose civil money penalties for Medicare secondary payers that fail to meet federal reporting obligations. The rule applies to group and non-group health plans as well as Responsible Reporting Entities that are responsible for funding a claim payment to someone who’s eligible for Medicare benefits. It takes effect Dec. 11.
CMS announced on Oct. 6 that it will not enforce a recent court decision determining how median in-network payment rates are calculated for about one year. An Aug. 24 decision from U.S. District Judge Jeremy Kernodle in the Eastern District of Texas found that the Biden administration’s rules for calculating payment rates in surprise billing disputes unfairly disadvantaged physicians.
Senate Finance Committee Chairman Ron Wyden and ranking member Sen. Mike Crapo introduced S 2973 on Sept. 28, seeking to bring more transparency, accountability, and competition to pharmacy benefit manager (PBM) practices in the pharmaceutical supply chain. The bill would prohibit PBM compensation in Medicare from being tied to the sticker price of a drug, increases transparency by creating independent audit and enforcement measures, and provides relief to independent community pharmacies for PBM business practices that can be harmful to such pharmacies.
The Senate Health, Education, Labor and Pensions (HELP) Committee passed four health-related bills during a Sept. 21 markup, including: S 2840, a $26 billion bill sponsored by Senate HELP Chairman Bernie Sanders of Vermont to reauthorize and dramatically increase the nation’s investment in community health centers; S 1624, offered by Sen. Tim Kaine, authorizing appropriations for pediatric cancer research at the National Institutes of Health; S 1573 from Sen. Michael Bennet to reauthorize a program aimed at reducing infant mortality and preterm birth; and S 2415 by Sen. Shelley Moore Capito to reauthorize a program that supports state maternal mortality review committees.
HHS finalized a rule on Sept. 18 to make it easier to enroll in Medicare savings programs, the state Medicaid-run programs that cover Medicare premiums and cost-sharing for more than 10 million low-income seniors and people with disabilities. The final rule is expected to make coverage more affordable for an estimated 860,000 people, according to CMS.
A bipartisan collection of lawmakers are supporting HR 5378, legislation that would require additional pricing transparency from medical facilities and PBMs. The bill, unveiled by Rep. Cathy McMorris Rodgers on Sept. 8, would provide statutory authority for regulations that require hospitals to annually publish their prices and related information, including the discounted cash price and negotiated charges.
HHS on Sept. 7 issued a notice of proposed rulemaking prohibiting discrimination on the basis of disability. The rule updates provisions that help persons with disabilities access health and human services under Section 504 of the Rehabilitation Act of 1973.
State
California Gov. Gavin Newsom signed SB 805 into law on Oct. 8, loosening state rules for those who qualify as a qualified autism service professional in the state to include a psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor.
Newsom also signed AB 1048, prohibiting a health care service plan or health insurer that covers dental services from issuing, amending, renewing, or offering a plan contract or policy that imposes a dental waiting period provision or preexisting condition provision, effective January 1, 2025.
On Oct. 7, Newsom signed AB 904, which requires a health care service plan or health insurer develop a maternal and infant health equity program that addresses racial health disparities in maternal and infant health outcomes through the use of doulas by Jan. 1, 2025. Under the bill, a Medi-Cal managed care plan would satisfy that requirement by providing coverage of doula services so long as doula services are a Medi-Cal covered benefit.
That same day, Newsom also signed SB 786, prohibiting a PBM from discriminating against a covered entity or its pharmacy in connection with dispensing a drug subject to federal pricing requirements or preventing a federally qualified health center from retaining the benefit of discounted pricing for those drugs.
Delaware Gov. John Carney signed SB 8 on Sept. 14, protecting patients from unfair debt collection practices for medical debt, including prohibiting large health care facilities from charging interest and late fees, requiring facilities to offer reasonable payment plans, and providing minimum time before certain collections actions may be taken.
Oregon Gov. Tina Kotek signed SB 1041 on Aug. 3, prohibiting health benefit plans that reimburse the cost of diagnostic or supplemental breast examinations from imposing a deductible, coinsurance, copayment, or other out-of-pocket expense for a medically necessary diagnostic or supplemental breast examination.
On July 31, Kotek signed SB 966, requiring the Oregon Health Authority (OHA) to adopt standards for types of data collected for its all-payer, all-claims database that are consistent with standards adopted for collection of data on race, ethnicity, language, disability, sexual orientation, and gender identity. It also allows the OHA to charge a fee for releasing information from the database.
Illinois Gov. J.B. Pritzker signed SB 2195 on Aug. 7, expanding coverage of prosthetic or custom orthotic devices, as determined by the patient’s provider to be the most appropriate model that is medically necessary, allowing the individual to perform physical activities such as running, biking, swimming, and lifting weights, maximizing their whole body health.
Pritzker signed HB 3631 on Aug.4, which states a PBM shall not prohibit a pharmacist or pharmacy from, or indirectly punish a pharmacist or pharmacy for, making any written or oral statement or otherwise disclosing information to any federal, state, county, or municipal official. On the same day, he signed into law SB 1344, requiring state insurance plans to cover abortion, HIV, and hormonal therapy medications. Coverage should include drugs approved by the U.S. FDA that are prescribed or ordered for off-label use as abortifacients.
On July 28, Pritzker signed into law HB 3957, barring a manufacturer or wholesale drug distributor from engaging in price gouging in the sale of an essential off-patent or generic drug. It also empowers the state directors of Healthcare and Family Services or Central Management Services to notify the Illinois Attorney General of increases in the price of essential off-patent or generic drug that amount to price gouging.
Pritzker signed HB 2719, requiring that a hospital screen each uninsured patient for eligibility in state and federal health insurance programs, financial assistance offered by the hospital, and other public programs that may assist with health care costs and provide information about those programs. For insured patients, it requires the hospital to screen the patient for discounted care in specified circumstances.