Group Health Plans Research Articles

Reducing nonprofit fiduciary liability: Mitigating your organization's risks

Nonprofit organizations and their leaders, as sponsors and fiduciaries of group health and welfare plans, operate within a fluid regulatory environment. They must generally adhere to the same federal, state and local laws as their for‐profit counterparts, but sometimes do so with less‐stringent governance. They often rely on well‐intentioned volunteer boards, streamlined human resource structures and a mission‐driven focus that can overshadow meticulous attention to regulatory details.

Employee response to employer-sponsored direct primary care

AbstractHealth benefits represent employers’ fastest growing operating expense. Efforts from human resources to control healthcare spending through restrictive plan design changes and corporate wellness programs may not achieve employer health and financial goals and may negatively impact employee outcomes. Employers are increasingly contracting directly with providers in order to access quality medical care and to control spending. The purpose of this practice-focused paper is to provide survey data collected from 10 employers as part of the quality improvement activities of a direct primary care (DPC) program. Overall, survey responses of employees engaged with DPC had higher patient satisfaction, group health plan rating, perceived organizational support, and job satisfaction than survey responses of those registered into the program but not yet engaged with a DPC physician. Implementation considerations and DPC characteristics are provided.

Trends in Premiums, Claims, and Enrollment for Fully Insured Large Group, Small Group, and Individual Health Plans From 2011 to 2021

This economic evaluation compares trends in premiums, claims, and enrollment among fully insured large group, small group, and individual health plans in the US from 2001 to 2021.

APA’s Government, Policy, and Advocacy Update (September 2022)

Back to table of contents Previous article Next article Government & LegalFull AccessAPA’s Government, Policy, and Advocacy Update (September 2022)Search for more papers by this authorPublished Online:25 Aug 2022https://doi.org/10.1176/appi.pn.2022.09.9.28Health Care Groups Release Statement Opposing Legislative Interference in CareJoined by more than 75 other organizations representing health care professionals, APA issued a statement emphasizing its opposition to all legislative interference in the patient-clinician relationship. The statement was made as the country’s health care system enters the post-Roe v. Wade era and abortion bans have gone into effect across the country.The wave of abortion bans “will harm patients, impair the integrity of the medical profession, and have a devastating and unquantifiable impact on the patients and clinicians it affects,” the statement reads. “People in at least half the states will now face a cruel choice between traveling hundreds of miles to receive abortion care (which is simply impossible for those who lack the resources, means, and opportunity) or being forced to continue with a pregnancy that may threaten their health, well-being, and future.”Clinicians practicing in those states will similarly face an untenable decision, the statement continues: risk criminal prosecution by providing evidence-based care or withholding safe and effective reproductive health care from patients in need.“More Than 75 Health Care Organizations Release Joint Statement in Opposition to Legislative Interference” APA Provides Comments on Patient Experience Survey for Mental Health SettingsThe Agency for Healthcare Research and Quality (AHRQ) is developing a version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, a tool for assessing patients’ experiences with health care, for use in inpatient mental health settings.Versions of the CAHPS survey are used in a variety of other health care settings and have been incorporated into federal quality and payment programs, such as the Centers for Medicare and Medicaid Services’ Merit-Based Incentive Payment System and the Hospital Value-Based Purchasing Program.APA responded to a request for information that AHRQ released, providing input and suggestions. For example, APA advised that in an inpatient mental health setting, the survey should address patient involvement in care, including questions such as, “Do you feel like staff listened to you and respected you?” APA also noted the benefits and limitations of a patient experience survey in an inpatient mental health setting. Many patients are admitted involuntarily or their illness may affect their insight about the need for hospitalization or understanding of survey questions. Nonetheless, these patients should be surveyed to help lead to targeted interventions to improve the experience of patients like them, APA advised.APA’s comments Medical Groups Sound Alarm on Lawsuit Threatening Preventive CareAPA joined 60 other organizations, including the AMA, in issuing a statement warning that a federal court case could cause millions of Americans to lose access to preventive services.Kelley v. Becerra, filed in the Northern District of Texas, “could significantly jeopardize the coverage of preventive health care services for millions of Americans with private health insurances,” the statement reads. The lawsuit questions the constitutionality of section 2713 of the Affordable Care Act, which requires insurers and group health plans to cover more than 100 preventive health services at no cost to patients.“Our patients cannot afford to lose this critical access to preventive health care services,” the statement reads. “Rolling back this access would reverse important progress and make it harder for physicians to diagnose and treat diseases and medical conditions that, if caught early, are significantly more manageable.”The news release APA Expresses Support for REDI Act, Suicide Prevention ActIn July, APA signed on to letters to Congress expressing support for two pieces of legislation that would address high student loan debts and suicide prevention.The Resident Education Deferred Interest (REDI) Act (S 3658/HR 4122) would allow borrowers to qualify for interest-free deferment on their student loans while completing a medical or dental internship or residency program.“This bill would prevent medical and dental residents from being penalized during residency and save them thousands of dollars in interest,” the letter reads. It was sent to leaders of the Senate Health, Education, Labor, and Pensions Committee and the House Committee on Education and Labor.Additionally, APA joined a letter to Sens. Jack Reed (D-R.I.) and Jerry Moran (R-Kan.), cosponsors of the Suicide Prevention Act (S 4448). The bill would expand data collection and surveillance of suicide attempts and other instances of self-harm in state and local health departments, “allowing for a more timely and accurate response to concerning public health trends,” the letter states.The Suicide Prevention Act would also create a grant program to fund suicide prevention programs in hospital emergency rooms. “Equipping emergency department staff with the tools and training needed to recognize suicide risk in patients and refer them for appropriate follow-up is vital in ensuring that patients are being treated swiftly and given the care they need,” the letter states. ■ ISSUES NewArchived

ACA Heads Back To Supreme Court.

The high court will consider risk corridors payments as developments continue in areas like HRAs and contraceptive coverage.

Mental Health Expenditures: Association With Workplace Incivility and Bullying Among Hospital Patient Care Workers.

Bullied workers have poor self-reported mental health; monetary costs of bullying exposure are unknown. We tested associations between bullying and health plan claims for mental health diagnoses. We used data from 793 hospital workers who answered questions about bullying in a survey and subscribed to the group health plan. We used two-part models to test associations between types of incivility/bullying and mental health expenditures. Workers experiencing incivility or bullying had greater odds of any mental health claims. Among claimants, unexposed workers spent $792, those experiencing one type of incivility or bullying spent $1557 (P for difference from unexposed = 0.016), those experiencing two types spent $928 (P = 0.503), and those experiencing three types spent $1446 (P = 0.040). Workplace incivility and bullying may carry monetary costs to employers, which could be controlled through work environment modification.

Health Policy Was Bustin' Out All Over.

The Trump administration refused to defend important provisions of the ACA in court and pursued rules that could open the door to less-regulated insurance options.

Planos privados individuais de saúde: o consumidor ainda tem poder de escolha?

Objetivo: Estudou-se o fenômeno da redução da oferta de planos de saúde privados de assistência médica individuais/familiares. Metodologia: Tratou-se de estudo com abordagem quali-quantitativa, descritivo e explicativo, realizado por intermédio de procedimentos de pesquisa documental e bibliográfica. Resultados: Os planos individuais e coletivos têm características diferentes; as regras aplicáveis aos contratos individuais são mais rígidas; o mercado de planos individuais está altamente concentrado; há pouca oferta desse tipo de produto pelas operadoras, sobretudo de abrangência nacional. Conclusão: A redução da oferta de planos individuais/familiares e a comercialização de produtos mais restritos afetam o direito à saúde visto que reduz o poder de escolha do consumidor, as possibilidades de mobilidade, e dificulta a contratação de planos por aqueles que estão fora do mercado de trabalho formal, principalmente os idosos.

Claims-shifting: The problem of parallel reimbursement regimes

Parallel reimbursement regimes, under which providers have some discretion over which payer gets billed for patient treatment, are a common feature of health care markets. In the U.S., the largest such system is under Workers’ Compensation (WC), where the treatment workers with injuries that are not definitively tied to a work accident may be billed either under group health insurance plans or under WC. We document that there is significant reclassification of injuries from group health plans into WC, or “claims shifting”, when the financial incentives to do so are strongest. In particular, we find that injuries to workers enrolled in capitated group health plans (such as HMOs) see a higher incidence of their claims for soft-tissue injuries (which are hard to classify specifically as work related) under WC than under group health, relative to those in non-capitated plans. Such a pattern is not evident for workers with traumatic injuries. Moreover, we find that such reclassification is more common in states with higher WC fees, once again for soft tissue but not traumatic injuries. Our results imply that a significant shift towards capitated reimbursement, or reimbursement reductions, under GH could lead to a large rise in the cost of WC plans.

The incidence, prevalence, and outcomes of glomerulonephritis derived from a large retrospective analysis

The incidence and period prevalence of glomerulonephritis (GN) with resultant rates of death and end-stage renal disease (ESRD) in the United States are unknown. Therefore, we assessed the presumptive burden of GN ina20% Medicare sample, 5,442,495 individuals, and an Optum Clinformatics Employer Group Health Plan sample of 13,712,946 individuals. GN was established using International Classification of Diseases, Ninth Revision, Clinical Modification claims-based algorithms. Outcomes were all-cause mortality and ESRD rates. Cox proportional hazards modeling was used to determine factors associated with outcomes in incident patients. For secondary (systemic immunologic disease) and primary GN, respectively, incidence rates per 100,000 patient-years were 134 (95% CI: 132-136) and 57 (56-58) in the Medicare cohort, and 10 (9-10) and 20 (19-21) in the health plan cohort. Period prevalence per 100,000 individuals was 917 (909-952) and 306 (302-311) in Medicare and 52 (51-54) and 70 (68-71) in the health plan. Death rates in incident Medicare patients were 3.9-fold higher for secondary and 2.7-fold higher for primary GN compared with no GN. ESRD rates were typically 1 to 2 orders of magnitude higher compared with no GN. In the Medicare cohort, women withincident secondary GN were less likely than men to progress to ESRD (hazard ratio: 0.70; 95% CI: 0.62-0.80) and death (0.82; 0.79-0.86). Black patients were more likely than white patients to progress to ESRD (secondary GN, 1.56; 1.31-1.85; primary GN, 1.57; 1.35-1.83), but not to death. Thus, in the United States, GN based on health claims data is associated with increased likelihood of progression to ESRD and death.

The Impact of Opioid Risk Reduction Initiatives on High-Dose Opioid Prescribing for Patients on Chronic Opioid Therapy

Avoiding high opioid doses may reduce chronic opioid therapy (COT) risks, but the feasibility of reducing opioid doses in community practice is unknown. Washington State and a health plan's group practice implemented initiatives to reduce high-dose COT prescribing. The group practice physicians were exposed to both initiatives, whereas contracted physicians were exposed only to statewide changes. Using interrupted time series analyses, we assessed whether these initiatives reduced opioid doses among COT patients in group practice (n = 16,653) and contracted care settings (n = 5,552). From 2006 to June 2014, the percentage of COT patients receiving ≥120 mg morphine equivalent dose declined from 16.8% to 6.3% in the group practice versus 20.6 to 13.6% among COT patients of contracted physicians. The proportion receiving excess opioid days supplied declined from 24.0 to 10.4% among group practice COT patients and from 20.1 to 14.7% among COT patients of contracted physicians. Reductions in prescribing of high opioid dose and excess opioid days supplied followed state and health plan initiatives to change opioid prescribing. Reductions were substantially greater in the group practice setting that implemented additional initiatives to alter shared physician expectations regarding appropriate COT prescribing, compared with the contracted physicians' patients. PerspectiveWashington State and a health plan's group practice implemented initiatives to reduce high-dose COT prescribing. Group practice physicians were exposed to both initiatives, whereas the health plan's contracted physicians were exposed to only the statewide changes. Reductions in prescribing of high opioid dose, average daily dose, and excess opioid days supplied followed state and health plan initiatives to change opioid prescribing. Reductions were substantially greater in the group practice setting that implemented additional initiatives to alter shared physician expectations regarding appropriate COT prescribing, compared with the contracted physicians' patients.

Anatomy of a Slow-Motion Health Insurance Death Spiral

Adverse selection death spirals in health insurance are dramatic and, so far, exotic economic events. The possibility of death spirals has garnered recent policy and popular attention because the pricing regulations in the Affordable Care Act (ACA) of 2010 make health plans more vulnerable to them (though some other aspects of the ACA limit them). Most death spirals tracked in the literature have involved selection against a group health plan that was dropped quickly by the employer. In this article, we empirically document a death spiral in individual health insurance that was apparently triggered by a block closure in 1981 and developed slowly because the insurer partially subsidized the block. We show that premiums rose dramatically from around the time of the block closure to at least 2009 (the last year of available data). By 2009, some, but very few, policyholders remained in the block, and premiums were roughly seven times that of a yardstick we developed. The history of this slow-moving event is directly relevant to current policy discussions because of both adverse selection in general and the particular problems induced by closing a block.

Rate of congenital toxoplasmosis in large integrated health care setting, California, USA, 1998-2012.

To the Editor: Although congenital toxoplasmosis occurs throughout the United States, little information is available about the rates of diagnosed illness in most of the nation, including California. Infection usually occurs by ingestion of undercooked meat and unwashed fruits and vegetables or exposure to soil or water contaminated with cat feces. Congenital transmission can occur when a woman is infected with Toxoplasma gondii during, or just before, pregnancy. Approximately 91% of women of childbearing age in the United States are susceptible to T. gondii infection (1). The United States has a low prevalence of T. gondii infection compared with many areas of the world (2). Severe congenital toxoplasmosis can result in hydrocephalus, retinochoroiditis that affects vision, microcephalus, seizures, hepatosplenomegaly, icterus, psychomotor retardation, and other sequelae (3). Infants with congenital toxoplasmosis are most often asymptomatic at birth; however, when severe symptoms occur, they are usually recognized and the condition diagnosed by the time the child is 2 years of age (3). Our goal was to determine the rate of clinically identified cases of congenital toxoplasmosis in children from birth to 2 years of age within the Northern California Kaiser Permanente Medical Care Program (KPNC) during a 15-year period. KPNC is a group health plan that provides care for >3.2 million residents of northern California. The KPNC membership represents ≈30% of the insured population in the region and is demographically similar to the residents of the counties served except that the very poor and very wealthy are underrepresented (4). We studied live births and infants during 1998–2012, the most recent 15-year period for which records were available and considered complete. We identified potential cases from KPNC electronic medical record databases and confirmed them by reviewing electronic and paper records. The system documents outside services, identified by the corresponding diagnostic codes or laboratory test codes. Eligible case-patients were infants, defined as 1 of 23 specific KPNC laboratory codes for related serologic and PCR tests. We considered clinically confirmed case-patients to be infants with positive T. gondii IgM and/or IgA tests at 12 months of age, PCR–positive results for T. gondii, or diagnosis and care of toxoplasmosis-related conditions. To calculate 95% confidence intervals for rates, we used the exact binomial method. During the 15-year study period, there were 521,655 live births at KPNC facilities and 2,010 infants received >1 test for toxoplasmosis. Ten infants met the potential case criteria of diagnostic codes; no additional patients met any of the case criteria by age 2 years. After electronic and paper charts were reviewed, 2 cases of congenital toxoplasmosis were confirmed. One case was diagnosed in 2003, the other in 2011. Both case-patients were girls: 1 was of Hispanic ethnicity and the other was of mixed Filipino-White heritage; both had IgG persistently detected beyond 12 months of age and were monitored clinically for retinochoroiditis. Their charts contained no information regarding maternal exposure or risk factors. During the 15-year period, the rate of diagnosed congenital toxoplasmosis was 3.8 (95% CI 1.5–9.2) per million live births. There were no infant deaths for which congenital toxoplasmosis was recorded as a cause. We were unable to study fetal deaths because the corresponding cause-of-death codes were not readily available. Historically, the lowest prevalence of T. gondii infection has been recorded in the western United States (5). The rate of clinically apparent congenital toxoplasmosis in this study was lower than that found during the late 1980s through early 1990s in the New England Newborn Screening Program initially after birth (2 per 521,555 live births [3.8 per million] versus 5 per 635,000 live births [7.9 per million], respectively) (6). However, the prevalence of T. gondii infection has decreased in the United States since the 1990s (1). Our study is subject to several limitations. Our approach would only detect clinically apparent cases, and the results should be considered a minimal estimate of congenital infection. Some cases may not have been recorded in the electronic system, but this omission is not likely for severe illness, repeated hospital or clinic visits, or outside consultation. The small number of cases makes the rate of diagnosed congenital toxoplasmosis somewhat imprecise; a few missed cases would increase the rate considerably. In addition, we were not able to evaluate fetal deaths; however, stillbirth is reportedly a rare complication of congenital toxoplasmosis (7). Although we found a low rate of diagnosed congenital toxoplasmosis in northern California, population-based studies to evaluate rates of the disease in other geographic areas would be beneficial.

Health insurance is dead; long live health insurance.

Upon the death of a king or queen, the proclamation “the king is dead, long live the king” announces a new monarch’s accession to the throne, preserving the sovereign order. As the Patient Protection and Affordable Care Act (ACA) is implemented, it is tempting to proclaim the reign of a new system of health insurance. But, will it preserve the old order or initiate a new form of governance? As states and insurers grapple with new rules and regulations being issued from the Department of Health and Human Services, the Treasury Department and the Department of Labor, one might believe an entirely new health insurance system is being built. Yet, the ACA is designed to preserve existing forms of public and private health insurance, such as Medicare and private employer group health plans, which will continue to operate much as they have in the recent past. What has changed is the role that insurance will play and how that will shape the way we think about health policy.

APA Presses for Enforcement of Mental Health Parity Law

APA Presses for Enforcement of Mental Health Parity Law

When Might Does Not Create Religious Rights: For-Profit Corporations’ Employees and the Contraceptive Coverage Mandate

B. The Religious Freedom Restoration Act All of courts have addressed for-profit plaintiffs' RFRA claim, diverging primarily between courts which have found no substantial burden and therefore no merit to plaintiffs' claim, and those which have found a substantial burden as well as no clear compelling interest in applying mandate to plaintiffs and therefore have granted plaintiffs' preliminary injunctive relief. Eleven district courts found that plaintiffs had failed to prove a substantial burden under RFRA. (143) Five district courts, on other hand, granted plaintiffs a preliminary injunction after finding that government had provided too many exemptions to contraceptive coverage mandate for a compelling government interest to exist. (144) Lastly, three district courts granted plaintiffs preliminary relief because courts' uncertainty on merits warranted maintaining status quo. (145) The circuit courts have also differed: Seventh, Eighth, Tenth, and District of Columbia Circuits granted two, two, three, and one preliminary injunctions each respectively, while Third and Sixth Circuits, and Circuit Justice Sonia Sotomayor reviewing Tenth Circuit's decision, denied one, two, and one each respectively. In two of its three decisions, Tenth Circuit remanded to district court for further consideration on two remaining preliminary injunction factors. (146) This section will focus on courts' consistent points of tension. 1. Substantial Burden The linchpin for courts under substantial burden prong is deciding what is specific burden that contraceptive coverage mandate imposes on a for-profit plaintiff's religious exercise, and whether burden is a sufficiently direct imposition on an action rather than a belief to qualify as substantial. (147) The courts have most diverged over this prong, with courts that have found a substantial burden subsequently finding that contraceptive coverage mandate fails RFRA, while courts that have found that there is no substantial burden necessarily finding that mandate survives RFRA scrutiny. Eleven district courts, first Third Circuit opinion, Sixth Circuit, and first Tenth Circuit opinion found that contraceptive coverage mandate did not violate RFRA because there was no substantial burden on corporate plaintiff. (148) This result followed from characterizing burden complained of as being that the funds, which plaintiffs will contribute to a group health plan, might, after a series of independent decisions by healthcare providers and [employees] covered by [the plaintiff]'s plan, subsidize someone else's participation in an activity that is condemned by plaintiff's religion. (149) None of these courts found anything in regulations that required plaintiffs to personally participate in activity to which they objected, or to change their behavior, or to change their religious exercise. (150) One court analogized plaintiff's argument to asking court to find a burden because an employee spends her salary on something of which employer does not approve; another emphasized that choice to use contraceptives ultimately rested not with corporation or its owners, but with employees. (151) A third court found this situation to be comparable to situation in Lee, stressing that both were concerned with effect of employer's religion on employees. (152) The courts concluded that contraceptive coverage mandate was degrees from imposing a burden on corporation, even further removed from imposing one on corporate owner who benefited from corporate form, and that such a claim could not support a finding of substantial burden as required by RFRA. (153) This burden was too attenuated to be substantial. By contrast, courts that have found that there is a substantial burden on corporate plaintiffs have done so by accepting plaintiff's characterization of that burden without independently scrutinizing burden for substantiality. …

Smoking, Obesity, Health Insurance, and Health Incentives in the Affordable Care Act

-tection and Affordable Care Act (ACA) was toweaken the link between health status and in-surance coverage. Issuers of individual policieswill no longer be able to charge higher premiums to the se-riously ill or turn away unhealthy enrollees. By adding theseprotections, the ACA brings individual policies more in linewith other forms of insurance. Neither Medicare nor Medic-aid charges higher premiums for individuals in poor health,and the Health Insurance Portability and Accountability Actof 1996 (HIPAA) prohibits group health plans from condi-tioning employee eligibility or premiums on health status–related factors such as cancer, heart disease, or diabetes.

Stakeholder perspectives on the implementation of shared decision making: a qualitative data analysis

BackgroundShared decision making (SDM), in which health care providers share the risks and benefits of treatment options and patients share their values and lifestyle preferences, is increasingly being adopted. SDM is often supported by decision aids (DAs), which are patient-friendly, balanced, evidence-based informational materials that explain treatment options. Stakeholder perspectives strongly influence how successful SDM implementation is.MethodsSemi-structured interviews were conducted with major stakeholder groups, including medical group executives, clinicians, project managers, health plans, and medical malpractice insurers. The interviews were transcribed, coded, and analyzed thematically.ResultsEight themes emerged: (1) patient engagement, (2) barriers to implementation, (3) facilitators to implementation, (4) benefits of SDM and DAs, (5) reimbursement structures, (6) the effects of Washington State's malpractice law, (7) perceived value of SDM and DAs, and (8) general observations about DAs.Stakeholder groups had differing perceptions of the purpose and benefits of SDM. Though conceptual support was strong, many implementation challenges were experienced. Barriers included time pressure, reimbursement disincentives, and competing priorities. Facilitators included engaged clinical and staff champions, integration of SDM within existing workflow, and reimbursement incentives.ConclusionsUnderstanding stakeholders' perspectives on the challenges, opportunities, and benefits of SDM can help in implementing SDM and DAs.

Religious Exemptions to the Contraception Mandate in the Affordable Care Act

At the center of the controversy surrounding the legislation of the Patient Protection and Affordable Care Act (ACA) the contraception mandate calls for group health plans to cover contraception costs. The mandate part of a seemingly straightforward effort to enhance preventive care for women has elicited criticism from religious and conservative groups who believe it violates certain employers’ religious freedoms. In the wake of the objections that covering contraception costs would violate some religious freedoms interim final rules were published in August 2011 announcing that churches would be exempt from the mandate. Further compromises have been made and guidelines for religious exemption drafted to accommodate self-insured religious institutions while ensuring that women receive contraceptive coverage. The author discusses challenges to the current legislation and the multitude of lawsuits faced by the government as well as the current status of the mandate. It is likely that there will be further adjustments to the contraception mandate down the road.

The Future of Health Care Reform Remains in Federal Court

National Federation of Independent Business v. Sebelius did not mark the end of litigation challenging the Patient Protection and Affordable Care Act (PPACA) against constitutional attack. To the contrary, PPACA litigation continues apace and could well increase in the years to come as federal agencies seek to implement the health care reform law. This essay provides a brief overview of how continuing litigation in federal court will affect the implementation – and perhaps even the ultimate viability – of Congress’s latest and most ambitious health care reform effort. Topics discussed include legal challenges to the availability of tax credits in federally run health insurance exchanges and a requirement that group health plans cover contraception, and prospective challenges to the Independent Payment Advisory Board and revisions to the individual mandate penalty.