Health policy priority: Dental screenings, early access

Addressing the social determinants of health

Nearly 60 million people avoided seeking medical care due to lack of funds, and 12 percent of Americans skipped taking prescription drugs, according to a 2018 Federal Reserve report on the economic well-being of U.S. households.

“People fear they won’t be able to pay their bills, keep their homes and support their children. If we don’t take care of people’s poverty, we will never solve the health care cost problem,” said panelist Mark Bertolini, former chairman and CEO of Aetna Inc. who oversaw its merger with CVS Health.

Panelists agreed that shifting mindsets and addressing social determinants of health — such as living conditions and access to health care — are essential to curbing costs.

Bertolini told a story that illustrated this importance. In 2015, a New Jersey woman with asthma visited the emergency room 405 times, resulting in $2.7 million in medical bills. The costs dropped dramatically when her health insurer took an individual approach to her care.

“We went to her home,” said Bertolini. “Her thermostat was set at 60, and she had angora sweaters and blankets there to keep herself warm. Turned out, she was allergic to angora. A year later, she made only one ER visit because we got her new blankets, we paid her heat bill, and we got her transportation for socialization — all cheaper than one ER visit.”

Elizabeth Hertel, senior chief deputy director of the Michigan Department of Health and Human Services, suggested deploying community health workers to ensure people get the care they need to stay out of the hospital and embedding behavioral health workers in primary health clinics to perform screenings.

On the rising costs of prescription drugs

The Michigan Association of Health Plans is focusing on drug price transparency and predictability at the state level to keep people from being priced out of lifesaving and life-extending drugs, said Dominick Pallone, executive director of MAHP, which represents 13 health plans that provide coverage to more than 3.1 million people in Michigan.

On the other hand, MDHSS is exploring directly contracting with prescription drug companies instead of “diffusing the prescription drug authorities through the health plans,” Hertel said. Michigan does this with Hepatitis C medications and hasn’t seen adverse results, said Hertel, adding the move would increase savings through rebates and authorizations.

Bertolini said the reliance on rebates was one reason Aetna partnered with CVS. “Until 60 percent of the buyers of drugs in the U.S. through Medicare and Medicaid decide they are going to get a better price, we are all hostage to what Medicare and Medicaid does.”

Pallone agreed. He said the high cost of drugs is the reason patients, hospitals and payers are chasing rebates and studies show that physical health benefits are harmed when pharmacy health benefits are decoupled.

(Un)surprising medical bills

Nine states already have implemented laws to curb surprise bills and another four recently enacted laws. In Michigan, one bill would require a minimum 24-hour notice to patients undergoing non-emergency, elective procedures that involve a provider who is not part of their health insurer’s care network. The patient would have to consent in writing to an out-of-network care provider.

Another bill addresses emergency situations and would prohibit an out-of-network doctor or care provider from collecting the difference between what they bill a patient and what the insurance company pays, which can sometimes be a large sum. Under the bill, they could only collect 125 percent of the Medicare rate for their service.

Bill Manns, president of St. Joseph Mercy Hospital Ann Arbor and a member of the Michigan Hospital Association Legislative Policy Panel, is confident the health care indus-try can reduce surprise medical bills without legislative oversight.

He said educating the public on the importance of staying within their benefit network and giving providers and insurers the space to negotiate and deal with surprise medical bills are critical.

But, negotiating isn’t easy for smaller provider systems and hospitals, Pallone said, in part because private equity firms that buy private physician groups often force them to make financial rather than human decisions.

Bertolini recommended using cost estimators and notifying patients in advance of costly procedures when possible. Hertel suggested using predictive analytics could also curb costs.

“Unless we can do better as a nation to take cost out of the system, it’s going to be very difficult, I think, to take cost sharing out of the system as well,” said Pallone.

This article appeared in Crain’s Detroit Business. Read more here.