Health Plan Weekly

Internal equity and diversity programs could be a powerful business strategy for plans that serve under-resourced populations, two experts say.

But to make these programs truly effective, organizations must start at the top and embed equity and diversity principles in everything they do, moving beyond a mere “box-checking” mentality, said Sachin Jain, M.D., president and CEO of SCAN Group and SCAN Health Plan, based in Long Beach, Calif.

The University of Pittsburgh Medical Center is the largest employer in the Pittsburgh area, with hundreds of job openings on any given day. At the same time, the integrated network’s UPMC Health Plan covers nearly one in five Medicaid beneficiaries in the state of Pennsylvania.

So when the health plan launched its Pathways to Work program this July, it made sense for Medicaid members to be a focal point of the program’s workforce development efforts.

by Jinghong Chen

The year 2020 has been filled with unpredictability amid all the changes ushered in by the COVID-19 pandemic. Because of the pandemic-driven economic crisis and ballooning unemployment, member enrollment has seen significant shifts from commercial health coverage toward managed Medicaid plans, according to AIS’s Directory of Health Plans. Though insurers are required to cover coronavirus testing and many chose to waive out-of-pocket costs for coronavirus treatment, their gross margins soared compared to 2019 as a result of significant drops in elective and routine care utilization.

After years of failed attempts, Congress has finally come to an agreement on a measure to end the practice of surprise medical billing — leaving experts debating whether the new policy can slow the growing cost of health care and the inflation of premiums. The legislation is part of the Dec. 21 Consolidated Appropriations Act, a coronavirus economic relief bill that was passed by Congress but at press time faced an uncertain future after President Donald Trump on Dec. 23 condemned the bill’s $600 direct payments to Americans as too low.

Surprise billing, also known as balance billing, is the practice of charging patients for out-of-network procedures that insurers refuse to pay for in whole or in part. Often, patients incur these balance bills without their knowledge: Some patients are incapacitated when treated by an out-of-network specialist like an anesthesiologist and cannot consent to the procedure they receive. The new legislation would ban providers from sending such a bill to patients, and would instead require providers to negotiate reimbursement with the patient’s insurer or submit the dispute to a binding arbitration process. The measure would not apply retroactively.