Top health care issues to monitor for 2022 and beyond
COVID-19 is not the only health care topic employers and their brokers should be focusing on today.
The COVID-19 pandemic is not over, and as sponsors or administrators of health benefit plans (or someone that services them), we should expect an increase in infections – and resultant treatment costs – as society begins to reopen. Naturally, as people emerge from their homes and socialize more frequently, with fewer restrictions in place, we can expect to see an uptick in cases.
Related: 5 factors that can make or break health care spending in 2022
COVID-19 is not the only topic we and our health plans should be focusing on today. Here are some additional issues we anticipate will impact our plans in the coming months and years.
Globalization of health
If there is one thing that the COVID-19 pandemic taught us, it’s that we are not alone. Specifically, a disease that pops up on one side of the globe could soon debilitate the global economy. Infection honors no border, and the world is constantly getting smaller. While this is something we recently experienced in the area of disease, for some time before that, businesses embraced that trend. Yet, their health plans have remained conspicuously domestic.
Indeed, many employers that choose to sponsor a health plan for their employees have employees that travel internationally as part of their job. Still other employees live outside the U.S. This brings with it more opportunities for ailments – that are not well established in the United States – to impact benefit plans sponsored by U.S. companies. Meanwhile, it is common to see a plan document exclude claims arising from treatment received outside the U.S, or fail to address diseases – and treatments – for ailments that are not yet prevalent in this country. Now, as the global reach of many employers – and diseases – grows, or plans must reconsider where the employees are located, their travel, their exposure, and their sources (and locations) of treatment; broadening coverage accordingly.
As benefit plans evolve to be more global, and thereby mirror the international characteristics of the companies that sponsor them (and diseases that threaten us), they should also contemplate the potential for medical tourism as a tool for cost containment – both domestic and international. Indeed, if employment and job duties can send an employee to other nations, and – as we learned with COVID-19 – a disease can travel the globe as well, perhaps the idea of seeking the best care in other locales should no longer be off the table. Many benefit plans still exclude such care, but if a plan participant can secure better care for less cost, and all it takes is a flight and stay at a resort, should the option be considered?
For many plans, this “global” mindset is accomplished through baby steps. Domestic medical tourism – meaning sending someone to a surgical clinic in Oklahoma City rather than a hospital down the road–is the first step in the process.
The cost of deferred care
Sticking with the aftermath of COVID-19, for many, the past two years have been about avoiding illness, and should that fail, securing treatment. Now, it is on us – as the sponsors, administrators, and partners of health benefit plans – to pay for that care. The claims for COVID-19 related treatment have been rolling in, and providers are anxious to be paid. Indeed, as elective procedures were delayed (by choice or by law), and many people opted not to visit their providers during the pandemic, providers found their hospital beds filled with more COVID-19 patients and fewer “other” patients; making their revenue more dependent upon payment for the care of COVID-19. Considering the number of in-patient COVID-19 victims that are more aged (and thus enrolled in Medicare – which notoriously pays pennies on the dollar), providers are understandably desperate to get paid by private payers whenever possible.
This all begs the question: who pays? In most instances, if a patient is covered by a private plan, the provider will happily seek payment from that plan. The onus is thus on the plan administrator to ensure that they are indeed responsible for that claim. As we dig out from COVID-19 and are called upon to coordinate benefits, it will be more important than ever before to flag these claims, and ensure there is/are no other primarily responsible third-party payers.
For instance, in some geographies there exists a presumption by law that – for certain professions – COVID-19 was contracted at work, and thus for those certain careers, treatment of COVID-19 is an occupational expense (and workers’ compensation should be financially responsible). How many health benefit plans are aware of the rules in each state, are identifying plan participants in those states that may qualify for such presumptions, and are flagging COVID-19 claims for subrogation and reimbursement? Not enough.
Legal challenges ramping up
Speaking of missed subrogation opportunities and trends we expect to see in the coming years, the pandemic caused a slow down in the halls of justice. Lawsuits and trials were delayed but are now picking back up. Amongst these stalled, but now restarting litigious proceedings are class actions and lawsuits filed against entities that produced dangerous chemicals or devices years or decades in the past. In those instances, plan participants may have been exposed to these harmful substances or devices quite some time ago. They may have developed illnesses or injuries that are now being linked to those substances or devices, but at the time were deemed to be unrelated.
As the aforementioned class actions and lawsuits start to pick back up today, third parties that are liable for the damages they caused years – or decades – ago, will be called upon to pay. For health benefit plans, this means the time to identify participants that were impacted, and claims paid by these plans for which they are due reimbursement – is now.
Virtual health care on the rise
Many plan participants over the past two years were unable – or chose not to – visit their providers in-person. These patients instead enjoyed the ease and convenience of virtual visits with their providers by phone or web-based meetings. Some have taken to calling this “telehealth,” but in truth – there is a difference between what I describe, and telehealth.
Telehealth is in reality a service that existed well before the pandemic, whereby providers located all over the country, and even the globe, are available to assess and consult on health issues via the phone or web-based meetings. The patient is usually a member of the telehealth program; paying for it out of pocket, or as a benefit offered by their plan or employer. It usually supplements or adds to their existing health care regimen. Usually, telehealth is paid for on a per visit, or per person capitated fee basis.
Unlike telehealth, however, what we saw during the pandemic was a spike in virtual visits. Here, a provider that usually sees the patient in-person conducts a long-distance visit by phone or internet. Unlike telehealth, the provider bills the patient (and the plan) in the same “fee for service” manner as in-person visits. As a result, network terms and other rules that apply to traditional claims apply as well. With the pandemic waning, these providers could return to an in-person methodology, however, many patients became accustomed to the ease and convenience of virtual visits. Many providers are contemplating a hybrid approach, allowing for a mixture of in-person and virtual visits. The burden will be on us to ensure that we spot the difference, when analyzing claims, and avoid overpaying for virtual visits.
There are certainly other costs associated with virtual care. There are many clues providers look for when examining a patient “in-person.” From smells to subtle noises, to signs of discomfort or abnormalities, a person can only convey so much by phone or web meeting. Unfortunately, between this and many people postponing routine screenings, various diseases – and particularly cancers – have gone undiagnosed. Unlike the past, where these issues may have been caught sooner, some cancers are being allowed to progress and spread. By the time the issue has gotten bad enough to see a provider in person, the issue is certainly advanced. Benefit plans are already noticing that while the number of cancer claims hasn’t increased, the severity and cost have exploded.
Growing demand sparks longer wait times
Oncology isn’t the only area of medicine where we’ve seen growth in cost. Mental health and substance abuse, likewise, have seen substantial growth. While many have developed mental ailments as a result of the pandemic, others have had existing issues exacerbated. Either way, the mental health care provider community is overtaxed, as demand steadily outstrips supply. Waitlists for care are months or even years long.
As is often the case, enterprising minds see an opportunity and have taken it. Provider “facilities” have opened in remote locations, offering care for those in need. Unlike many medical service providers, who often seek to secure assurances up-front (pre-treatment) that the care will be covered by the plan, the applicable rate, etc., many of these mental health and substance abuse treatment providers opt not to notify the plan until days or even weeks of inpatient care are provided. They prefer to remain “out of network,” sending a single massive bill to the plan for weeks of expensive care. The plan is then saddled with deciding whether to pay the claims, or, allow the patient to be balance billed.
Making things worse, some patients are actually being med-flighted via air ambulance to facilities that are located hours from their homes. As you likely know, claims for such transportation are much higher than a comparable commercial flight.
Even the most pessimistic amongst us will admit that society will overcome the COVID-19 pandemic, in an effort to return to some sense of normalcy. Yet, even as we return to such a state of normalcy, some new sources of cost and concern for benefit plans–exacerbated by the pandemic–will continue to impact plans for the foreseeable future. New opportunities exist, and new risks arise… and only the benefit plans that adjust now will continue to thrive.
Ron Peck is CLO with The Phia Group, LLC.
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