Latest / CareTalk: Healthcare. Unfiltered. / How Do Health Plans Ensure Access & Affordability? w/ Massachusetts Association of Health Plans CEO, Lora M. Pellegrini, ESQ | HealthBiz Briefs

Transcript

How Do Health Plans Ensure Access & Affordability? w/ Massachusetts Association of Health Plans CEO, Lora M. Pellegrini, ESQ | HealthBiz Briefs · CareTalk: Healthcare. Unfiltered.

• 0:00
  Health plans play a central role in the US healthcare system, but they also get flak from patients and providers when they try to contain costs.
• 0:07
  But how do health plans see the world and what role do they play in ensuring quality and access at an affordable cost?
• 0:21
  Welcome to Health Biz Briefs.
• 0:22
  I'm David Williams, President of Health Business Group here with Laura Pellegrini, President and CEO of the Massachusetts Association of Health Plans.
• 0:29
  It's a nonprofit that promotes high quality, affordable, and equitable care.
• 0:33
  Welcome, Laura.
• 0:34
  Hi, thanks for having me.
• 0:36
  So Laura, what are the big issues for your members in Massachusetts?
• 0:38
  And is it any different in Massachusetts than in other states?
• 0:41
  Yeah, I think we're all grappling with affordability.
• 0:44
  That is the biggest challenge right now.
• 0:47
  And in Massachusetts, we have some of the best data in the country, if not the best data on the drivers of health care costs.
• 0:53
  And what we know that it's really provider prices, unit price, and prescription drug costs.
• 0:58
  So that is our focus to try to rein in those cost drivers to make health care more affordable for all of our members.
• 1:05
  And we're very sensitive to prices.
• 1:08
  We know how that impacts families.
• 1:10
  Makes sense.
• 1:11
  Now, some people are suspicious of health plans.
• 1:14
  And I wonder, are they right to worry?
• 1:18
  You know, I would say, no, I've been in this industry for over 20 years, at least with the people I've worked with.
• 1:23
  They are trying to take a finite amount of resources and spread them to a vast majority of people that they cover.
• 1:30
  And we're trying to keep this affordable so that employers and individuals can afford to maintain coverage.
• 1:38
  I think the worst place we could be is if people...
• 1:40
  employers can't afford coverage or individuals can't afford coverage and they go on insured and then they can't get the care they need.
• 1:46
  But we have a lot of stakeholders in our world who I think are thinking about profits and thinking about higher reimbursements.
• 1:55
  And the health plans have been demonized, but they've been demonized by all of these groups because we are the gatekeepers.
• 2:01
  We are trying to keep costs down.
• 2:04
  So we are, you know, the principal in the room who's saying no.
• 2:08
  And I think that's why.
• 2:10
  At any given time, I could have 10 different advocacy groups who band together against us.
• 2:16
  But when you look under the hood, it's because they're looking for a higher reimbursement or something that will favor them personally.
• 2:23
  The crisis at Steward HealthCare has been in the news nationally, but there's a particular impact in Massachusetts.
• 2:31
  And I'm wondering how you're seeing that impact on your members in the Commonwealth.
• 2:36
  Yeah, so I think initially our.
• 2:38
  My members, the health insurers were very concerned about the quality of care being delivered at these institutions, particularly with some of the reporting about less than adequate and safe care.
• 2:49
  What has happened since then is the Department of Public Health is now in there with monitors and I believe there's a sharing agreement among hospitals to share equipment and different things that the steward hospitals might need if they don't have it.
• 3:01
  So.
• 3:02
  I think we're feeling better about the quality of care that's being delivered there.
• 3:06
  I think right now the issue is what happens.
• 3:08
  I think if all of these hospitals closed, there would be a crisis in some communities relative to access.
• 3:14
  But I think some of the conventional wisdom, although not popular, is some of these hospitals maybe could close and there's enough capacity to pick up the patients in those regions.
• 3:25
  So I think it really calls for us to have statewide planning so that we understand.
• 3:30
  capacity in different regions and where if a hospital gets in a crisis where it could close and where it would be absolutely paramount that we throw every resource we have to save it.
• 3:40
  So this is a big story.
• 3:41
  It raises a lot of issues around private equity.
• 3:43
  There have been a couple of hearings over the past couple of weeks in the state house and I think it's really going to be the poster child of private equity and health care and what can happen if a state, you know, doesn't have all the information it needs about what's going on.
• 3:57
  I think that's right.
• 3:58
  I mean, one of the things that's notable with Stuart is that it was sort of a surprise last minute thing is there's not a lot of transparency, even though there actually are required under the purchase agreement to be providing more information to the state.
• 4:12
  And so when it comes all at once, you know, you could say on the one hand, it's great to have maybe a rationalization of hospital capacity as part of perhaps a statewide plan over a number of years.
• 4:21
  If all of a sudden there's kind of a gun to your head and these hospitals may all close.
• 4:25
  That's a completely different matter.
• 4:28
  Yeah.
• 4:28
  One of the things we've been talking to state officials about is the plans are very highly regulated in our state.
• 4:33
  We have this little scale of justice where the plans probably have stacked on like 20 requirements.
• 4:38
  The hospitals have one too.
• 4:40
  Pharma has none.
• 4:41
  But what we were talking about the other day to a state official is, you know, why did the plans, why do we have solvency provisions in place?
• 4:47
  Why don't we have risk -based capital requirements where our division of insurance is constantly monitoring the plans?
• 4:54
  And if their risk -based capital is too low, then they're going in and they're doing corrective action plans, et cetera.
• 5:00
  The hospitals don't have something similar.
• 5:02
  And I think we need to tie that to licensure.
• 5:04
  So one of the reasons why I think Stuart was able to get away with what they did is because they were trying to litigate, so they didn't have to show these documents.
• 5:14
  But I think if we tie these things to licensure and have a more robust system of surveillance, we might avoid another Stuart in the future.
• 5:23
  and then more transparency around private equity and private equity's role and when assets are being sold in healthcare.
• 5:31
  I mean, healthcare is very unique as we're seeing from the Stuart situation.
• 5:35
  Well, that's it for the latest Health Biz Brief.
• 5:37
  If you like what you hear, check out my Health Biz podcast for a full length interview with Laura about her life and career.
• 5:43
  Laura Pellegrini, president and CEO of the Massachusetts Association of Health Plans.
• 5:47
  Thanks for joining me on Health Biz Briefs.
• 5:50
  Thank you, David.