Delayed Care & Bad Outcomes - How Insurers' Use of Prior Authorization Harms Patients w/ Todd Askew, AMA

Measles, eradicated in the United States in 2000, is making a comeback. Meanwhile, an  estimated 300,000 people died from COVID-19 in cases that could have been prevented  through vaccination. Why are we seeing an uptick in conspiracy theories, misinformation,  and outright science denial? The consequences of losing trust in science are harmful and  even deadly. Dr. Reed Tuckson, MD, FACP, has dedicated his career to restoring public confidence in  scientific research and health care. He joins Chip on the latest episode of Hospitals in  Focus to explore the current social climate influencing science denial and how it is  exacerbated by those who seek to sow mischief and discontent. Topics discussed include:  • Tribalism and the “Us vs. Them” mentality; • Social media’s role as a dissemination mechanism; • Patient-level impacts on health, particularly on society’s most vulnerable; • Covid-19 and the mistakes made with the best intentions; and  • Bridging the gap to regain trust and promote science literacy. More/Dr. Tuckson’s Bio:  Reed V. Tuckson, MD, FACP, is Managing Director of Tuckson Health Connections, LLC, a  vehicle to advance initiatives that support optimal health and wellbeing. Currently, Dr. Tuckson’s focus is on his role as a Co- Convener of the Coalition For Trust In  Health & Science, which is dedicated to bringing together the entire health related  ecosystem to address mistrust and misinformation. In addition, he continues to advance  his work as a co-founder of the Black Coalition Against COVID, a multi-stakeholder and  interdisciplinary effort working to mitigate the COVID-19 pandemic in Washington D.C. and  nationally by coordinating the four historically Black medical schools, the NMA, the  National Black Nurses Association, the National Urban League, and BlackDoctor.org.

Artificial intelligence (AI) is dominating headlines and conversations, from how it will change our day-to-day routines to the debate on how far regulation of the ever-changing technology should go. AI's impact on health care is profound, promising advancements in diagnostics, treatment plans, and patient care, but also raising questions about privacy, bias, and the role of human oversight.Our guest, Dr. Michael Schlosser, MD, MBA, Senior Vice President, Care Transformation and Innovation at HCA Healthcare, is a leading expert in AI applications within the health sector. In this episode, he and Chip delve into the multifaceted world of AI. Dr. Schlosser's insights will guide us through the complexities of integrating AI into medical practices, highlighting both the transformative benefits and the critical safeguards needed to ensure ethical and effective use.Topics discussed include: Defining AI – whether we should anticipate a better future or be worried Leveraging AI – use cases in health care A human-centric approach – understanding risks and ways to mitigate harm and biasThe federal government – finding the sweet spot for regulation Future of AI – the benefits of incorporating AI into health care for providers and caregiversMore: Michael Schlosser, MD, MBA, is Senior Vice President, Care Transformation and Innovation for HCA Healthcare. Reporting directly to the CEO of HCA, he is responsible for leading care delivery innovation and transformation for the enterprise. His department’s vision is to design, develop, integrate, implement, and optimize technology and processes that drive care delivery with the common goal of improving the experience and outcomes for HCA Healthcare's leaders, care teams, and patients. As part of this strategy, he leads the implementation and optimization of HCA Healthcare’s electronic health record systems, the data science and data strategy teams, and the enterprise Responsible AI program.Prior to this role, he served as group Chief Medical Officer, leading the clinical operations for 100 HCA hospitals, overseeing quality, patient outcomes, and clinical strategy. He has also previously served as the chief medical officer for Healthtrust.Dr. Schlosser is a neurosurgeon and completed his residency and fellowship at Johns Hopkins, has served as a medical officer with the FDA, and holds a degree in chemical engineering from MIT and an MBA from Vanderbilt.

Maryland’s 50-year experiment with the hospital rate-setting system stands out as a unique and long-lasting initiative – but has it accomplished its goal of reducing health care costs? This rate-setting scheme has been sustained due to additional Medicare funds supplementing the model, an additional $20.6 billion through 2017. It’s also inspired CMS’s All-Payer Health Equity Approaches and Development (or AHEAD) pilot program. The Maryland model has come under scrutiny with a paper published in HFM Magazine entitled “Maryland’s example is no solution to healthcare’s true crises.” It finds that the state’s health costs remain higher than the national average, even though the system was designed to reduce hospital and overall health care costs.Our guest is the author of the paper and president of Health Futures, Inc. - Jeff Goldsmith. In this episode, will discuss the history of the Maryland model, the findings of his paper, the impact on hospitals and health care costs, and propose alternative solutions for reducing costs.Topics discussed include:Implications for the state – findings from Goldsmith’s paperEmulating the scheme – feasibility of replicating the Maryland model elsewhere and cautionary notes for policymakersRefocusing health care goals – what solutions to access and cost should CMS be considering instead?What’s next – the future for hospitals More: Jeff Goldsmith is the President of Health Futures, Inc. He speaks on the future of health care- covering topics like technology, economics, leadership health care trends and policy analysis. Goldsmith is also a strategist and mentor to leaders in the health care industry.  He has also taught at several prestigious universities and worked in the private sector as a consultant. 

Cybersecurity is a central part of every nation’s infrastructure – especially when it comes to health care. The availability and free flow of health information is critical to providing care. Unfortunately, patient information isn’t just valuable to caregivers, it’s also becoming a primary target for criminals across the globe.In this special episode, Chip Kahn moderates a panel of cybersecurity experts, with significant experience in the health care sector, from around the world. The discussion, entitled 'Navigating Today's Cyber Threats for Tomorrow's Healthcare,' was organized by Future of Health, a group made up of thought leaders from hospital systems, academia, policymaking, payers and patient advocacy.Topics discussed include:Current state of cyber defenses today – vulnerabilities, variabilities across the worldGoals of cybercriminals targeting health care entities – money, data, or mayhem Paying ransom – views from different countriesPolitical implications – how to react when cyber breaches become geopolitical events Proper role of governments in cyber defense and attack mitigation – the role of mandates and the threat of penaltiesLasting advice – the one thing health care entities must do to protect themselves.The virtual panel:US: Meredith Griffanti, Senior Managing Director, Global Head of Cybersecurity & Data Privacy Communications, FTI ConsultingUK: Dr. Saif Abed, Director of Cybersecurity Advisory Services, The AbedGraham Group and Cybersecurity Consultant, World Health Organization Singapore: Kim Chuan, Group Chief Information Security Officer, SingHealthIsrael: Alon Rozen, CEO of Elements Group, and former Chief of Staff at the Israeli Ministry of Defense and Director General of the Israeli Homefront Defense MinistryMore: Established in 2018, Future of Health's diverse membership represents the foremost health organizations and thought leaders from hospital systems, academia, policymaking, payers, industry, and patient advocacy. Each year, FOH members address, through discussion and research process, pivotal issues facing health care across the world. From this process FOH develops insights and recommendations disseminating findings through published papers which serve as a blueprint for a common vision for the future of health.

With zero-dollar premiums, caps on out-of-pocket costs, and perks that range from meal delivery to gym memberships – even loaded debit cards – membership in Medicare Advantage (MA) plans is surging in enrollment and popularity among seniors.  In fact, earlier this year, enrollment in Medicare Advantage plans surpassed enrollment in traditional Medicare, with more than 50 percent of eligible seniors now choosing this privatized version of coverage.  However, aggressive marketing campaigns and a lack of transparency in coverage often hide the downsides of Medicare Advantage, which include limited networks and strict prior authorization policies that make it harder for millions of seniors to quickly get the care they need. As we explore in this episode, these downsides also impact care providers, like hospitals, as well as the taxpayers who are footing the bill.Our guest, Tricia Neuman, is the executive director of KFF’s Program on Medicare Policy and has been with the organization for almost 30 years. She looks back on the creation of MA, discusses the program’s unexpected rapid growth, examines its impact on the health care system, and shares what she thinks comes next for seniors’ coverage.Topics discussed include:Evolution of Medicare Advantage – popularity and benefitsFlooding the airwaves – impact of overzealous marketingWhat’s in it for insurers? – how insurers game the system Impact on patients– from narrow networks to excessive prior authorizations Problems for providers – limitations on care from denials and delays Taxpayers pay the price – MA now spends more per beneficiary than Traditional MedicareWhat’s next – the future of Medicare Advantage More:KFF is an independent source for health policy research, polling, and journalism. Its stated mission is to serve as a nonpartisan source of information for policymakers, the media, the health policy community, and the public.KFF has four major program areas: KFF Policy; KFF Polling; KFF Health News (formerly known as Kaiser Health News, or KHN); and KFF Social Impact Media, which conducts specialized public health information campaigns.

The recent cyberattack on Change Healthcare exposed fissures in the American health care system that are still reverberating - impacting patients and providers alike months after it was exposed.As hospitals, physicians, and other providers get back on their feet, they're also improving their cyber defenses to stay one step ahead of increasingly persistent hackers.This crisis also sparked conversations among policymakers weighing the implementation of new regulations on health care entities, including potential penalties for those who have been victimized.In this episode, Lynn Sessions looks at the cyber-security issues facing hospitals and health care organizations, from evolving threats to how we need to think about mitigation and resiliency. Lynn is a partner at the law firm BakerHostetler and leads the Healthcare Privacy and Compliance practice, where she has handled more than 1,000 health care data breaches and ransomware attacks.Topics discussed include:Evolving efforts of hospitals to increase cybersecurity protectionsThe anatomy of a health care cyberattack – effects of ransomware vs. malwareVulnerability of 3rd party entities in health care – like Change HealthcareRole of the federal government – protecting hospitals, penalizing bad actorsMoving forward – fighting the next generation of cybercriminals More:BakerHostetler has a diverse team with wide experience in counseling health systems, physician groups, insurers and employers across the country regarding risk assessments, developing comprehensive incident response plans, and responding in a timely and accurate manner to privacy and security incidents, from lost paper files and laptops to the largest cyber incident ever reported involving medical information.More here - https://www.bakerlaw.com/services/digital-assets-and-data-management/healthcare-privacy-and-compliance/ 

Good health care depends on good health coverage, particularly for the most vulnerable. The Affordable Care Act expanded Medicaid eligibility and created exchanges where many Americans could access health insurance, often at a subsidized price. These new pathways to affordable coverage led to the uninsured rate dropping to record lows.Unfortunately, those recent gains in coverage and access now face new hurdles. After the end of the Covid public health emergency, states began a process of redetermining Medicaid eligibility which caused tens of millions to lose coverage. Many were forced to find a new source of insurance coverage, or lost it completely. The passage of the Inflation Reduction Act created enhanced subsidies for individuals seeking insurance on the ACA marketplace exchanges, leading to a record high enrollment this year. Those subsidies are set to expire in 2025.  Unless Congress steps in, this could increase premiums, making coverage too expensive for many, threatening access to health care. In this episode, Stan Dorn, who has worked on coverage issues for almost 40 years and currently serves as the Director of the Health Policy Project at UnidosUS, explains what these dual threats to coverage mean for individuals and their families.Topics discussed include:Current state of the Medicaid redetermination process and its impact on coverage for recipientsCongressional action needed to avoid looming marketplace coverage cliff  Long-term policy changes that will improve the ACA by protecting Medicaid expansion and continuing affordability in the exchange marketplaceMORE: UnidosUS, previously known as NCLR (National Council of La Raza), is the nation’s largest Hispanic civil rights and advocacy organization. Through a unique combination of expert research, advocacy programs, and an Affiliate Network of nearly 300 community-based organizations across the United States and Puerto Rico, UnidosUS simultaneously challenges the social, economic, and political barriers that affect Latinos at the national and local levels. When it comes to health care, the group is focused on ensuring access to affordable coverage with an emphasis on helping people through the Medicaid unwinding process and enrolling them in exchange plans.

The Change Healthcare cyberattack on February 21st upended a huge slice of the U.S. health care system, virtually crippling all aspects of the patient care continuum when the clearinghouse’s services were hacked. That is because Change Healthcare processes 15 billion claims totaling more than $1.5 trillion a year and may handle 50 percent of all medical claims in the country. The impact has been devastating for many patients, hospitals, and providers, particularly those already operating under financial constraints. Having an understanding of the size and scale of this cyberattack has been critically important to ensuring lawmakers and regulators understand the outsized impact on providers. Enter Matt Szaflarski, a revenue cycle intelligence leader at Kodiak Solutions. In the aftermath of the attack, Matt has become a leading voice in clarifying the role, scale, and impact within the care continuum and quantifying its impact. In this episode, Szaflarski discusses:The role of a clearinghouse in patient care from start to finish;A breakdown of the Change Healthcare cyberattack and subsequent fallout, including the effect on patients and loss of provider safety nets; andFuture of health care and recovering from the hack.More: Kodiak Solutions is a leading technology and tech-enabled services company that simplifies complex business problems.Kodiak has built a high-performing business for healthcare provider organizations revolving around a proprietary net revenue reporting solution, Revenue Cycle Analytics, and expanded to a broad suite of software and services in support of CFOs. Kodiak’s 400 employees engage with more than 1,850 hospitals and 250,000 practice-based physicians across all 50 states.Learn more here: https://www.kodiaksolutions.io/

There are two Americas - rural and urban – particularly when you look at access to health care.  With roughly 60 million people, or one in five Americans, living in small communities from coast to coast, how do we ensure patients have access to the care they need when they need it? And what policies can help bridge the gap? Former Senator Heidi Heitkamp has dedicated her life to representing the interests of rural America and fighting to save this way of life. She currently serves as founder and board chair of the One Country Project, an organization dedicated to advancing rural America through and ensuring its priorities and values are represented and reflected in Washington, D.C.  In this episode, Sen. Heitkamp discusses the issues facing small communities and how lawmakers can help solve health inequities between rural and urban areas.  Topics include: Unique health care challenges faced by rural Americans Hospital closure crisis Impact of public programs like Medicare, Medicaid, and the Affordable Care Act Threat of funding cuts to rural health care programs, like site-neutral, low-volume and Medicare-dependent hospitals  Unintended consequences of Medicare Advantage Mission of the One Country Project MORE:   The One Country Project is dedicated to reopening the dialogue with rural communities, rebuilding trust and respect, and advancing an opportunity agenda for rural Americans. Its mission is to ensure rural America’s priorities and values are heard, understood, well-represented and reflected in policy in Washington.  Learn more here: https://onecountryproject.com 

GUEST: Dr. Jonathan Perlin, President and CEO, The Joint Commission IN THIS EPISODE:  The Joint Commission is possibly the most impactful health care quality and performance organization in the world. With the rise of AI and concerns growing over issues like environmental sustainability, its mission has never been more critical.Dr. Jonathan Perlin, in his second year at the helm of The Joint Commission, is on a quest to reshape safety and performance measurement and its impact on care delivery for hospitals and other settings.In this episode, Dr. Perlin outlines his H.E.L.P agenda and explains how the acronym is a guide for the organization as it aims to better ensure patients’ safety and effective hospital care.H.E.L.P Agenda includes: Health EquityEnvironmental Sustainability  Learning Health Care/AIPerformance Improvement and Integration MORE: The mission of The Joint Commission is to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.It aims to accomplish this goal by setting quality standards, evaluating an organization’s performance, and providing an interactive educative experience that provides innovative solutions and resources to support continuous improvement.Learn more here: https://www.jointcommission.org/