health care utilization

Report Examines Utilization, Spending Growth of U.S. Health Care Services

By the end of the third year of the COVID-19 pandemic, health services utilization had returned to their pre-pandemic levels overall, but some shifts have occurred. That’s just one of the findings of the IQVIA Institute for Human Data Science’s The Use of Medicines in the U.S. 2023: Usage and Spending Trends and Outlook to 2027 recently released report. And while spending on medications will continue to grow, driven by new oncology drugs, traditional areas of growth such as immunology and diabetes will instead help to slow that growth.

Since the beginning of the COVID-19 pandemic, the institute has tracked patient visits, including both telehealth and in-person ones; screening and diagnostic tests; elective procedures; and new prescriptions for its IQVIA Health Services Utilization Index. Speaking at a May 18 webinar on the report’s findings, Michael Kleinrock, research director for the IQVIA Institute for Human Data Science, explained that overall, those services have returned to 100% of pre-pandemic levels as of the fourth quarter of 2022. However, some shifts among the four elements have occurred.


Rising Rate of Claims Denials Suggests Need for Better Payer-Provider Relations

It is getting harder and harder for health care providers to get claims approved and get paid on time by commercial health insurance plans, according to a new report from Crowe, a company that provides revenue cycle intelligence for providers. One of the report’s authors says that it’s difficult to parse what exactly is driving the trend, but she pointed out that Crowe’s data indicates many initially denied claims eventually get resolved — suggesting insurers are aiming to “hold on to the money a little bit longer.”

Commercial payers reimburse providers at higher rates than Medicare or Medicaid, which usually leads organizations to prefer a payer mix that skews more toward the privately insured, the Crowe report noted. Yet that comes with a downside: The firm found that compared to government payers, private insurers “take the longest to pay, require providers to jump through more administrative hoops to get paid,” such as prior authorization, and “delay payments to providers via claim denials at a higher frequency.”


Retail Clinic Volume Boomed During Pandemic — and Could Stay High

According to a new report, retail clinic claims have boomed since the onset of the COVID-19 pandemic — and heavy utilization seems like it’s here to stay. Experts tell AIS Health, a division of MMIT, that retail clinics can help improve access and convenience for patients, but they also caution that retail clinics aren’t a substitute for high-quality primary care and could induce demand for low-value encounters.

The report, prepared by health care consultancy Definitive Healthcare LLC, found that retail clinic claim volume increased by 200% between 2017 and 2022, according to information sourced from the firm’s proprietary all-payer claims database. During the same period, urgent care claims increased by 70%, emergency room claims decreased by 1%, and primary care physician claims decreased by 13%.


Transportation Barriers Keep Many Americans From Accessing Care

More than 1 in 5 adults without access to a vehicle or public transportation missed or skipped a health care visit in the previous year, according to a recent Urban Institute study.

Using June 2022 data from the Urban Institute’s Health Reform Monitoring Survey, the researchers found that overall, about 5% of non-elderly adults reported forgoing medical care due to transportation barriers in the previous year. The experience was more common among Black and Hispanic/Latinx adults, individuals from low-income families, people with disabilities and those using public insurance.


Through VBID Model, MAOs Tailor Interventions to Enrollees’ Evolving Social Needs

From CMS’s expanded definition of primarily health-related supplemental benefits to the introduction of Special Supplemental Benefits for the Chronically Ill (SSBCI), Medicare Advantage plans have gained increasing flexibility over the last few years to offer supplemental benefits that can address social needs. Through the ongoing MA Value-Based Insurance Design (VBID) model — the only MA-focused demonstration being tested by the CMS Innovation Center — MA organizations have even more flexibility to target and tailor a variety of interventions. During a recent virtual panel of the Fourth National Medicare Advantage Summit, several longtime participants of the model agreed that such flexibility is critical to meeting beneficiaries’ evolving health-related and other social needs.

CMS first tested the model on a limited basis in 2017, allowing sponsors to offer reduced cost sharing for medications and offer high-value services to beneficiaries with select chronic conditions. Today, the model allows MAOs to tailor their MA plan offerings using several approaches and has 52 MAOs offering services to an estimated 6 million enrollees.


Engaging Family Caregivers Can Help MA Insurers Achieve Triple Aim

Family caregivers have long been regarded as an important part of care teams for high-needs Medicare beneficiaries, especially those enrolled in Dual Eligible Special Needs Plans (D-SNPs). But there are strong cases for Medicare Advantage insurers to support caregivers as part of their broader care management strategy, as they can help improve outcomes, reduce costs and enhance member experience, according to speakers at a session of the AHIP 2023 Medicare, Medicaid, Duals & Commercial Markets Forum, held March 14-16 in Washington, D.C.

Although there is “concurrent public policy and private solution[s] and investment going on in the caregiver space,” multiple challenges exist with activating them, from identifying potential caregivers to supporting them with the training they need to identify issues such as a change in condition, observed John Mach, M.D., founder and general manager of Mach Health Care Strategies, LLC, during the panel discussion, “Achieving the Triple Aim for Medicare Members by Activating Family Caregivers.”


Uber Health Expands Same-Day Prescription Service, Faces Stiff Competition

Uber Technologies, Inc. announced late last month that it would embed same-day prescription delivery on its Uber Health app, expanding the offerings available to its health care provider and payer customers. Although the feature could help patients adhere to their medications and save costs for employers, PBMs and health plans, Uber faces numerous competitors in a crowded field and could have challenges getting the delivery feature covered, according to health care experts who spoke with AIS Health.

Uber Health, which launched in 2018, is primarily used for coordinating non-emergency medical transportation of patients to and from hospitals and other health care facilities. The company entered the prescription delivery business in August 2020 through a partnership with NimbleRx in Seattle and Dallas. And two years ago, the company formed a partnership with ScriptDrop to make Uber the default delivery app for a network of grocery stores and independent pharmacies in 37 states. Those stores and pharmacies already had deals with ScriptDrop, a health care information technology company founded in 2016, so they gained access to Uber’s network of drivers.


People Are Seeing Benefits From Biomarker Testing, but Barriers to Coverage Remain

Biomarker testing is an important tool in cancer care, but a recent survey found payer coverage issues are creating access barriers. According to CancerCare, researchers found that biomarkers helped providers offer personalized care for various cancers for nearly all — 93% — respondents. Twenty percent of surveyed patients were able to forgo unneeded chemotherapy and/or radiation, while 10% found that they were eligible for a clinical trial.

However, the survey also found that 29% of people who had biomarker testing had insurance that did not cover it, prompting them to undergo appeals, obtain financial assistance or pay out of pocket for the service. In addition, 25% of patients said that their insurer required prior authorization (PA) for the process, a tactic that can delay access to treatment.


Prime, Magellan Studies Reveal Ways to Squeeze More Value From Specialty Drugs

Prime Therapeutics LLC and Magellan Rx Management, a Prime company as of the end of last year, recently presented findings from a series of studies that used integrated medical and pharmacy claims to assess real-world drug use. Their findings show that different strategies can help identify potential member issues that could impact payer costs.

The studies were presented at the Academy of Managed Care Pharmacy (AMCP) Annual Meeting, held in San Antonio, Texas, March 21 to 24.


Coverage of Certain Cancer Screenings, PrEP Are at Risk After Ruling

A judge recently struck down certain preventive services coverage mandated by the Affordable Care Act (ACA). If upheld, the decision could upend access to potentially life-saving services that have been provided for free for more than a decade.

Judge Reed O’Connor from the U.S. District Court for the Northern District of Texas issued the ruling in Braidwood Management v. Becerra (No. 4:20-cv-00283-O) on March 30. The following day, the Justice Department said it was appealing the decision, sending the case to the U.S. Court of Appeals for the Fifth Circuit, potentially reaching the Supreme Court.