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

Before the Change Healthcare cyberattack, hospitals were already grappling with insurers' tactics of delaying and denying payments for patient care. The cyberattack only amplified the challenges providers face—not just in delivering care, but also in getting reimbursed for that care. Despite the crisis, insurers continued to use these tactics. Now, six months later, Matt Szaflarski, a director and revenue cycle intelligence leader at Kodiak Solutions, and his team have uncovered something alarming: a surge in insurers’ initial Request for Information (RFI) claim denials.Kodiak’s latest report, “Death By A Thousand Requests,” highlights the growing trend of payors denying initial claims due to RFIs, creating an enormous administrative burden on hospitals and providers. In 2024 alone, these tactics are projected to cost hospitals $4.6 billion. Szaflarski returns to the show to explain the impact of these denials on the hospital revenue cycle, which ultimately impacts the hospital’s ability to provide care.In this episode, Szaflarski discusses:Updates on the Change Healthcare cyberattack;Rising trends in claim delays and denials, particularly RFI denials;Revenue cycle data insights;Medicare Advantage, the two-midnight rule, and observation stay challenges; andRecommendations for improving processes between insurers and providers.

In June, the Supreme Court issued a 6-3 decision in Loper Bright Enterprises v. Raimondo,  overturning the 40-year-old legal precedent known as the "Chevron doctrine." This doctrine  had allowed federal agencies to interpret ambiguous statutes within their jurisdiction. The  ruling marks a significant shift in the regulatory landscape, with major implications for how  federal agencies operate and how regulations are enforced—particularly in health care.  The decision presents both challenges and opportunities for the health care industry,  making it crucial for policymakers, health care leaders, and businesses to understand the  evolving regulatory environment. Joining Hospitals in Focus to unpack the potential effects of this ruling on health care  policy making is Thomas Barker, a partner at Foley Hoag and former General Counsel at  CMS and Acting General Counsel at HHS.  In this episode, we explore: Impact on Congress: How does the ruling affect Congress’s legislative process and its  relationship with federal agencies? Will the ruling force Congress to write more precise  laws? Changes for Federal Agencies: What does the ruling mean for federal agencies, like CMS  and HHS, which have relied on Chevron deference to implement and enforce regulations?  Judicial Implications: Will courts, particularly lower courts, take on a larger role in  interpreting statutes? How could this influence future rulings on health and business  regulations? Business and Regulatory Implications and Challenges: What will be the effect on businesses, especially those operating in highly regulated sectors like health care, and  what are the potential retroactive effects of the Loper Bright decision?

The work, dedication, and resilience of hospital providers and staff is centered on providing high-quality care for their patients. In this special episode of Hospitals in Focus, we spotlight two compelling stories of patient care from the frontlines, offering unique perspectives from both a health care provider and patient. Join us as we hear firsthand from Amy Capella Smith, CEO of Foundations Behavioral Health, a UHS hospital in Doylestown, Pennsylvania, as she navigates the challenges and rewards of providing behavioral health services to children, adolescents, and young adults.  We also share Jenna Tanner’s story, who survived what is often called the “widow maker,” a massive heart attack, while home alone. Jenna was able to call 911 and get the emergency medical help she needed at Hillcrest Hospital, an Ardent Health hospital, where she received lifesaving care. Her experience serves as a universal message about heart health and the importance of recognizing the early signs of a heart attack. 

Today, we are celebrating the 59th anniversary of Medicare and Medicaid being signed into law by President Lyndon B. Johnson and discussing the profound effect these programs have had in providing health care coverage to the country’s most vulnerable populations.Medicare and Medicaid laid the foundation for public health insurance in the United States, ensuring that the elderly, low-income families, and individuals with disabilities receive essential health care services. The Affordable Care Act (ACA), enacted in 2010, built upon this foundation by expanding Medicaid eligibility, providing subsidies lower-income individuals and families to purchase private insurance on exchanges, and implementing protections for people with pre-existing conditions. Medicare, Medicaid, and the ACA have created a more comprehensive safety net for millions of Americans, significantly reducing the uninsured rate and improving access to care.Our guest, Larry Levitt, oversees policy work on Medicaid, Medicare, the ACA, and the health care marketplace for one of the nation’s leading health policy organizations. Larry’s extensive knowledge will guide us through the following topics:·         Medicaid Coverage: Expansion and post-pandemic redeterminations in the states;·         Evolution of the ACA: The development and impact of enhanced subsidies;·         ACA Challenges: Addressing concerns about bad actors and program issues; and·         Future of Coverage: Insights on the upcoming election and its implications for health care coverage. More: Larry Levitt is the executive vice president for health policy, overseeing KFF’s policy work on Medicare, Medicaid, the health care marketplace, the Affordable Care Act, racial equity, women’s health, and global health. He previously was editor-in-chief of kaisernetwork.org, which was KFF’s online health policy news and information service and directed KFF’s communications. Prior to joining KFF, Levitt served as a senior health policy adviser to the White House and the Department of Health and Human Services, working on the development of the Clinton Administration’s Health Security Act and other health policy initiatives. Earlier, he was the special assistant for health policy with California Insurance Commissioner John Garamendi, a medical economist with Kaiser Permanente, and served in a number of positions in Massachusetts state government. Levitt holds a bachelor’s degree in economics from the University of California, Berkeley, and a master’s degree in public policy from the Kennedy School of Government at Harvard University. 

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, we'll 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/