Our Ask of Rural-Friendly Health Insurers By Tim Size

For most of us in health care, 2020 was the most challenging year we have ever faced. But many for-profit insurers reported record profits for the full year of 2020 because their members did not visit the hospital or see their physicians at usual levels.

It is a mystery to many of us why some insurers are now choosing this time to come down so hard on rural healthcare. In any event, these behaviors have led RWHC members and staff to establish a set of expectations for health insurers which will drive our advocacy.

By Tim Size, RWHC Executive Director - posted with permission

• From RWHC Eye On Health, 6/15/21 Page 2 Eye On Health is the monthly newsletter of the Rural Wisconsin Health Cooperative. Begun in 1979, RWHC has as its Mission that rural Wisconsin communities will be the healthiest in America. Our Vision is that... RWHC is a strong and innovative cooperative of diversified rural hospitals... it is the “rural advocate of choice” for its Members... it develops and manages a variety of products and services... it assists Members to offer high quality, cost-effective healthcare… assists Members in partnerships to make their communities healthier… generates additional revenue by services to non-Members… ongoing use of strategic alliances in pursuit of its Vision. Tim Size , Editor, 880 Independence Lane, Sauk City, WI 53583 www.RWHC.com Email [email protected] with subscribe on the subject line for a free e-subscription.

Continuing...

Rural hospitals and clinics have dedicated staff that assist patients with accessing the care they need and to understand how their health insurance will help pay for it. This includes: assuring their provider is in network, what prior authorizations are required, calculating deductibles/copays and identifying how ancillary services such as lab, x-ray and rehab therapies are accessed and the associated costs. Given that most rural facilities have more than 20 health plan contracts, this is a complex resource to establish for their patients. The intent of the following priorities is to share how health insurers can contribute to their rural recipients receiving the care they need close to home while maximizing the coverage of their health insurance.

Support Network Adequacy

Insurers provide adequate selection and inclusion of caregivers at a local level, not just regionally. Insurers provide adequate selection and inclusion of all types of clinicians–from ER to family med to specialists and complementary services. Insurers recognize the need for newly recruited clinicians to overlap with retiring clinicians to maintain local health care.

Example: Hospitals, Primary Care and Specialists (i.e., radiologists, ER physicians, anesthesiologists and other specialists) are available within a patient’s local community and needed referrals align with normal practices and standards in the geographic area.

Assure Equitable Credentialing

Inclusion of all qualified providers, including all hospital employed, The Joint Commission/CMS approved providers, without random limits placed on who the insurer will credential. Providers have geographic credentialing uniformity–approval should be of their credentials and not vary by location.

Example: An ENT who is credentialed by an insurance company at one practice location should be credentialed by that insurance company at every contracted rural location in which they provide care.

Avoid Cherry Picking or Steerage from Rural Hospitals

All services (lab, pharmacy, therapy, etc.) should be covered at locations where care is provided. No payer preference should be demonstrated between rural specialists and urban specialists.

Example: Creation of a new diagnostic provider designation that is not financially viable for rural hospitals and affects continuity of care for patients by leading lab services to no longer being paid for at local institutions of care is not rural-friendly.

Recognize the Actual Cost of Efficient Rural Care

Insurers provide economically viable reimbursement rates for sustainability of rural hospital and healthcare services into the future. Any efficiency incentives are transparent and rural relevant.

Example: Insurers understand that the cost of providing care is different between rural and urban providers due to differing economies of scale and patient volumes and so should resulting reimbursement rates. Incentives that are not transparent cannot be improved upon and too often become arbitrary penalties.

Utilize Rural Relevant Quality Measures

The methodology used by insurers in quality programs should be transparent and not skewed towards metrics designed for higher volume providers. Example: Insurers need to use quality metrics for which rural hospitals can achieve reliable and valid measurement results, as have been developed by the National Quality Forum Measure Applications Partnership Rural Health Workgroup.

Engage in Good Faith Contracting

Insurers come to the negotiating table as a cooperative partner looking for the best outcome for the community in question, not just the insurance company. Example: Hospital and insurer approach contracting transparently with contract language mutually understood and agreed upon. Changes to policies and protocols which affect contractual obligations or performance are fully disclosed and the resulting impact is taken into consideration.

Assure Administrative Consistency Throughout the Plan Year

Insurers provide adequate notice and the option for re-enrollment when changes arise. Example: If the insurer changes their specialty drug policy during the plan year, hospitals are given timely notice and have the ability to renegotiate and members have the ability to re-enroll.

Offer Appropriate Employer/Subscriber Education

Insurers and hospitals cooperatively make it a priority to promote understanding of plan network and benefit inclusions and exclusions. Individuals understand what their insurance covers and does not cover. Insurance plans present their coverages in easy-to-understand language decipherable to the everyday enrollee.

Example: When a business or individual subscriber chooses a plan, they are fully aware of whether or not their existing doctor, specialists, and their local hospital, are covered or not covered under the plan.

Subscribers Informed of All Local Options

Insurer ensures that subscribers are aware of all options for local services that might not be disclosed to patient at discharge by an out-of-area provider (e.g., home health, hospice, therapies, etc.) Example: Subscribers upon enrollment and annually are provided with a listing of locally available services including home care, hospice, therapy centers, etc.

Assure Responsiveness & Transparency

Insurer provides subscribers and providers with timely, accurate and up-to-date information and all public postings are regularly maintained.

Example: Participating Provider directories posted on payer web-sites are current and accurately reflect providers who are participating. Payers are available and provide timely responses to prior authorizations, care denials, claims resolution and general inquiries.

Approve Medically-Necessary Care by Qualified Providers

Insurers cover medically necessary care and therapy for beneficiaries that are referred by physicians to qualified therapy providers. Example: Insurers follow medical judgment and the care plan set forth by the physician, which is both medically necessary and in the best care path for the beneficiary.

Engage in Community and Population Health

Insurers are looking beyond the individual enrollee to how their coverage affects the overall health of the community.

Example: Insurers recognize the importance of rural providers and support their role in working to improve the health of the community and work collaboratively with local providers to assure local access to care and preventive services that are in the best interest of not only the insured member but the community as a whole.

Acknowledge Economic Impact of Local Care

Insurers should understand that local delivery of care is vital to local economic activity. Hospitals are large drivers of rural economic activity and continuing to deliver care in rural settings has far-reaching economic impacts that should not be overlooked.

Example: One rural primary care physician equates to $1.4 million in wages, salaries & benefits and 26.3 jobs in a local community with a hospital. One job in a Critical Access Hospital equates to .34 jobs created in other local businesses and a Critical Access Hospital generates an average of $1.8 million in taxable local retail sales. An average Critical Access Hospital generates 170 jobs and $7.1 million in salaries, wages and benefits. $1 spent by a hospital supports $2.30 of additional, local business activity.

The Future of Rural Hospitals is Up to All of Us

“Over 500 rural hospitals in the U.S. were at immediate risk of closure before the COVID-19 pandemic and now more than 800 hospitals–40 percent of all rural hospitals in the country–are either at immediate or high risk of closure” according to a recent report from the Center for Healthcare Quality and Payment Reform. It would be foolish for Wisconsin to assume we are immune from these trends.

My Comments

Posted as it is so that you can see at least some of the obstacles that the US health care design erects and maintains and worsens that take out health care where most Americans most need care.

But if you have not been there or done that, you cannot figure this out - which is how the designers continue to make the situations worse for most Americans.

https://basichealthaccess.blogspot.com/2018/07/youre-killing-us-smalls.html