Health Plan Weekly

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%. 

Challenges with finding transportation is keeping many U.S. adults from accessing necessary health services, according to a recent report from the Urban Institute. Health policy experts tell AIS Health, a division of MMIT, that providing non-emergency medical transportation (NEMT) can benefit payers by enabling people to make their routine appointments and adhere to medications, which lowers the risk of high-cost hospitalizations.  

However, they say that while Medicaid requires NEMT and Medicare Advantage plans are increasingly offering the benefit, NEMT remains uncommon in the commercial, employer-sponsored insurance sector.  

Even when NEMT is available, its usage remains low. For instance, a study released earlier this year from the Medical Transportation Access Coalition (MTAC) found that only 4.6% of Medicaid and Children’s Health Insurance Program beneficiaries used NEMT in 2019. The MTAC, which was formed by three leading NEMT brokers and is managed by Faegre Drinker Consulting, analyzed data from 66 million people enrolled in 32 states and Washington, D.C. 

Primary care practitioners are working through dramatic change in the business of their profession: More PCPs than ever are working under capitation or risk-based reimbursement arrangements. That trend accelerated as physician employment increased during the worst years of the COVID-19 pandemic, with many doctors selling their independent practices to private equity, insurers or hospital systems. 

Although risk-based reimbursement is well established in government books of business, the commercial market is adopting risk-based primary care payment using lessons learned in Medicare Advantage and Medicaid managed care. The transition to commercial risk-based compensation was the subject of a May 23 panel convened by the Primary Care Collaborative, a primary care policy group. 

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.” 

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.