What Is the No Surprises Act?

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What Is the No Surprises Act? from Patient Empowerment Network on Vimeo.

Ashira Vantrees, JD of Aimed Alliance explains what surprise billing is and discusses how the No Surprises Act can affect different patients.  

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Transcript

Mary Leer:  

In terms of fighting surprise billing or the No Surprise Act. What is surprise billing? 

Ashira Vantrees:  

Yeah, so surprise billing occurs when a patient visits a hospital or a doctor’s office that is in network, but then once there, they’re treated by an out-of-network provider. So, often the patient doesn’t know that when they’re in a network facility, they’re being treated by an out-of-network provider, and so then after the fact, after they received care from this out-of-network provider, they are sent a bill to the out-of-network costs for the care that they received. So, this is called Surprise billing, ’cause often patients are unaware that they even receive care from an out-of-network provider, and are expected to pay the full out-of-network costs for that care. So that’s one way we see surprise billing. Another way that we see surprise billing often occur is during surgical procedures, so if the patient is going to get a surgery and then they’re at in-network surgeon in-network hospital, but then during their surgery an out-of-network anesthesiologist used that out of network anesthesiologist they get a whole bill for that. So, it’s not even within the patient’s control, and they don’t even know, so, those are the two kind of big ways we see surprise billing occur. 

Mary Leer:  

Very important to know. Can you briefly describe the No Surprises Act and what does it impact, or how might it impact the insured or the uninsured? 

Ashira Vantrees:  

Yeah, absolutely. So, in December 2021, the Department of Health and Human Services also called HHS. They issued an interim final rule called the No Surprises Act, that would prohibit surprise billing for emergency services, prohibit out-of-network charges for ancillary services like the anesthesiologist during the surgery, and it would prohibit non-emergency services from charging out-of-network rates without obtaining notice and consent from patients. So, this rule became effective on January 1, 2022, and it applies to individuals who have group health insurance plans or individual health insurance plans, but it’s not going to apply to individuals who have Medicare, Medicaid, received care through the Indian Health Services or through the Veteran Affairs Administration because surprise billing has already been banned in those programs. It also does not provide any protection for individuals who are uninsured, but for individuals who are uninsured, it does require that when they’re out of doctor’s office or hospital, that the hospital or doctor’s office gives them a good base estimate of what the cost of that care is going to be before they receive the care. 

Mary Leer:  

Does the No Surprises Act supersede state laws? Could you explain that? 

Ashira Vantrees: 

Yeah, so sometimes that’s kind of the always lawyer answer maybe. So, the No Surprises Act supersedes state laws that provide less protection. So, the No Surprises Act is intended to act like a floor for protection, so if a state has a state law on surprise billing that provides greater protection than the No Surprise Act, that the law will prevail over the No Surprises Act, but any law that provides less protection, the No Surprises Act is going to supersede that law, but what’s also really important to note about the No Surprises Act is that it doesn’t limit state legislators’ ability, so if they have a law that is currently providing less protection than the No Surprises Act, it doesn’t limit their ability to create laws that provide greater protection than the No Surprises Act.

What Are the Differences between Health Care Reform, Patient Protection, ACA, and ObamaCare?

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What Are the Differences between Health Care Reform, Patient Protection, ACA, and ObamaCare? from Patient Empowerment Network on Vimeo.

Ashira Vantrees, JD of Aimed Alliance discusses the differences between Healthcare Reform, ObamaCare, Patient Protection and the ACA and how each impact patients differently.

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Transcript

Mary Leer:  

What is the difference between the following things that most of us have heard about, the healthcare reform, the Affordable Care Act, Patient Protection and the ACA and ObamaCare? 

Ashira Vantrees:  

Yeah, so I think there’s a lot of terms that are used at the moment, when we’re talking about health care reform, our current health care system, so I think it’s important that we can break this down so we really understand exactly what we’re talking about. So first, the ACA. So the ACA stands for, the full bill name is the Patient Protection and Affordable Care Act, but it’s also been referred to as other names, so the Patient Protection and the ACA or ObamaCare, regardless of which name is used, when we use those words that we’re talking about, is that 2010 bill that was passed that created really important programs and protection for patients. And then when we talk about healthcare reform, what we’re talking about is really this larger issue of how we can really change and revise our healthcare system to address things like the increasing cost of healthcare, the number of people who are uninsured, or really the quality of care that we’re receiving and healthcare reform. I think it’s important to note that it can occur in a number of ways. So I think one of the biggest pieces of healthcare reform that we have in the last decade is the ACA, the Patient Protection, Affordable Care Act, and that came in the form of federal legislation, but we can also see health care reform come in through state legislation, so one way that we’re seeing healthcare reform now at a state level is through states passing laws to provide greater protection against burdensome prior authorization step therapy protocols, and requiring copay assistance to count towards meeting patients’ deductible and annual out of pocket limit.

What Is the Affordable Care Act?

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What Is the Affordable Care Act? from Patient Empowerment Network on Vimeo.

Ashira Vantrees, JD of Aimed Alliance explains what the Affordable Care Act entails and also what it does not cover.  

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Transcript

Mary Leer:  

Okay, thinking of the Affordable Care Act, can you briefly describe what the Affordable Care Act or ACA is, and what are the goals of this law? And what does it cover? 

Ashira Vantrees:  

Absolutely. So, the ACA formal name is the Patient Protection and Affordable Care Act, and it was passed in 2010, and what it’s intended to do is to expand access to healthcare from many Americans. And so, the ACA has been able to do this in a number of ways. So for example, the ACA created tax credit for individuals living between 100% to 400%, below the federal poverty line to help provide them some financial assistance to ensure they could be able to get healthcare coverage, and it also created really important protections that require health plans cover the cost of preventative services like cancer screenings for free, and it also requires health plans, or it also prohibits health plans from charging a higher cost for healthcare coverage if they have a pre-existing condition like cancer.  

Mary Leer:  

Wow. Is there anything the Affordable Care Act does not cover? 

Ashira Vantrees:  

Yeah. So, there are limits to what the affordable care act does cover. I should mention that the Affordable Care Act does have what it calls the 10 essential health benefits, and so these 10 essential health benefits are things that health plans that are on with a federal exchange are required to include. That includes coverage for things like prescription drugs, maternity and newborn care, hospitalization costs and other really important things that are really just at the core of our healthcare, but those do have limits. So, the ACA does not cover the cost of long-term care such as living in an assisted living facility or home health care, and it also doesn’t cover the cost of things like cosmetic surgery, weight loss surgery, infertility treatments, or dental and vision for adults.

Which States Have Oral Parity Laws?

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Which States Have Oral Parity Laws? from Patient Empowerment Network on Vimeo.

Ashira Vantrees, JD of Aimed Alliance discuss which states have oral parity laws and how to learn more.  

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Transcript

Mary Leer:  

What states have laws that cover something like oral parity? 

 Ashira Vantrees:  

Yeah, there’s actually quite a few. There’s currently over 40 states that have passed oral parity legislation, and also the District of Columbia has passed oral parity legislation. Aimed Alliance also has an oral parity fact sheet on his website, that’s a really good resource for individuals trying to learn more about this issue, and the fact sheet covers oral parity like we just discussed it, and really why there is a need for federal legislation and in the coming months we’re also creating oral parity mapping on our website, so we’ll have updated maps that are going to be a great resource for patients, that are going to show you where oral parity laws have been enacted and in what state legislators there is currently oral per legislation. 

 Mary Leer:

Wow, I can’t wait to tell people about this because I didn’t have oral chemo, and I think about during covid, like how that would have been a choice of preference, and then not realizing you get hit with that extra expense.

What Is the Cancer Drug Parity Act?

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What Is the Cancer Drug Parity Act? from Patient Empowerment Network on Vimeo.

Ashira Vantrees, JD of Aimed Alliance discuss what the Cancer Drug Parity Act is and how it impacts various issues in oncology.

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Transcript

Mary Leer:  

Could you briefly describe what the Cancer Drug Parity Act is? 

 Ashira Vantrees:  

Absolutely. So, the Cancer Drug Parity Act has been introduced in the Senate by Senator Tina Smith, and it’s been introduced in the House of Representatives by Representative Brian Higgins, and it’s federal legislation that if passed, would require health plans to have the same cost sharing requirements, that’s your co-pay, or your co-insurance, for oral chemotherapy treatments, IV chemotherapy treatments. 

Mary Leer:  

So, are there other issues in oncology that the Cancer Drug Parity Act addresses? 

Ashira Vantrees:  

So, the Cancer Drug Parity Act primarily addresses the issue of co-pay parity. So, the issue of copay parity is that some health plans required different cost sharing and typically a higher cost sharing for oral treatment compared to IV treatments, and co-pay parity requires that health plan provide the same cost sharing requirements for the oral and IV treatment. And really the issue of copay parity really came up when health plans started charging patients with cancer a higher copay for oral chemotherapy treatments compared to their IV chemotherapy treatment, and so obviously, this is really upsetting for patients with cancer who had come to this decision with their healthcare provider that this oral chemotherapy treatment was the best option for them. And then what was happening is they would go to collect their medication, and then be hit with this unexpectedly higher copay, than what they were used to. So, in response to this practice by insurers and health plans, states are passing Oral Parity Laws which prohibited health plans from charging a higher cost sharing, so a co-pay or a co-insurance for oral chemotherapy compared to IV chemotherapy and the Cancer Drug Parity Act is the federal version of that state legislation. 

And the reason federal legislation is needed is because while state laws are great, state laws don’t regulate all types of insurance. So, for example, state laws don’t regulate insurance that individuals get from their employer, federal legislation can do that, and so that’s why we need the Cancer Drug Parity Act to pass to ensure that patients with cancer when they’re choosing which treatment is the best for them, that’s not a decision they’re forced to make based on their cost sharing requirements.

How to Stay Up to Date on Telehealth Guidelines

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How to Stay Up to Date on Telehealth Guidelines from Patient Empowerment Network on Vimeo.

 Joe Kvedar, MD from the American Telemedicine Association shares how patients can stay aware of current telehealth guidelines at their specific health centers and gives insight into how access to telemedicine will be in a post-pandemic society.  

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Transcript

Mary Leer:  

How can patients find state guidelines about telehealth options? Can I see a Telehealth provider outside of my state?  

Joe Kvedar:  

In some states, you can. There is something called the Licensure Compact that I think 23 states have signed on to. During the beginning of the pandemic, it was, you could do anything now it’s much less wild, wild west, if I can use that term. So, in certain states, in some states, for instance, the four corner states, Colorado, Utah, and Wyoming, and I forget the forth, they all have a relationship with one another, so that it’s easy for doctors to get licensed in the other states. So, where there’s a lot of rurality and less doctors, these things tend to happen more often, whereas in a place like New York city or Boston, where you have a lot of physicians, there’s less interest in opening it up. So, it’s a complicated answer. I wish we could do better on licensure. I think it’s a very outmoded concept, but there’s so many entrenched interests that want to keep it going, I don’t think any time soon we’re going to see the state licensure paradigm change for physicians.  

Mary Leer:  

How can patients identify if their health centers have telehealth options? 

Joe Kvedar:  

Well, these days, everyone, almost everyone does, but everyone has a website, everyone has a patient onboards-man, a patient intake, a patient portal, and any of those resources typically will have…And it used to be prior to the pandemic that you… Those services were often available, but you really had to dig to find them, whereas now it’s pretty much on the front page of again, every hospital website or their portal, or you can call a phone number and get scheduled for someone, it is important for folks to realize that not every problem is suited to telehealth. So, if you ask for a telehealth visit and you get told the doctor would rather see you in person, it may be for a very good reason, it may be that there’s some aspect to that evaluation that really does need to happen in the office. So just to keep that in mind. 

Mary Leer: 

What will telemedicine look like in a post-pandemic society? That is, is my medical team likely to continue with virtual visits? 

Joe Kvedar:

Well, I wish I had a clear answer to that, I can speculate, and a lot of it has to do with this idea of reimbursement. If reimbursement continues to be reasonable from the doctor’s perspective, then you’ll likely see them doing this. And I want to just add that doesn’t mean that doctors are greedy or, but generally people like to get paid for the work that they do. That’s just a general thing. And so, if they have two channels to deliver your service in-person or virtual, and someone says, we can do either, but we’re not going to pay you to do virtual, the chances are they’re going to suggest that you come in for the in-person service. It’s just human nature. And anyway, so I think that’s the big one and how we integrate them. Hospitals are still ambivalent about this, they actually, hospitals do better if you come into the facility for a lot of reasons, so there are a few kinks to work out, but I actually think that the last CMS administrator in the Trump administration, a woman named Seema Verma said it best when she said, “The genie’s out of the bottle and we’re not putting it back.” And I think that’s really how we want to view this; it’s going to happen. We still have a little bit of an uphill battle policy-wise to make it happen, but it will and it’ll be better for our patients as a result.  

How Can the Future of Telemedicine Impact Survivorship?

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How Can the Future of Telemedicine Impact Survivorship? from Patient Empowerment Network on Vimeo.

Joe Kvedar, MD from the American Telemedicine Association explains how the future of telehealth technologies can impact the survivorship of patients with chronic illnesses.

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Transcript

Mary Leer:  

How might the future of telemedicine impact survivorship, especially for people living with cancer or anyone with a chronic condition?  

Joe Kvedar:

Well, some of us feel that telehealth is ideally suited to care for folks with chronic conditions. think cancer is a special case, but one of the fundamental things about telehealth, if you do it right, and I’m not just talking about video now, but audio, what we call asynchronous, which is more like a text exchange, remote patient monitoring, where you’re monitoring people in the home with various technologies, etcetera. If you use the right tool to solve the problem, what you get is more continuous care. So, for our cancer patients, that is more touches to the system, more inputs that they can give, more fine-tuning of how they feel, what their regimen is, how comfortable they feel when they’re on treatment, all can be done better because you’re obviating the need to physically get up, travel somewhere, set in a waiting room, you’re doing it much more rapid fire. And for chronic conditions, I think it’s just a match being in heaven because once you find out, for instance, you have, I would say type 2 diabetes, then it’s not about the diagnosis it’s about management and management again, is lots of little feedback with lots of conversations, you measure your glucose three times a day, that data goes into a cloud and then software will tell you maybe you should eat a little bit less of this or that, these days, we have tools that match a smart glucometer to an insulin pump to create almost what’s like an artificial pancreas, those are all a form of telehealth, and it enables us to manage those conditions much more effectively. 

Again, conditions like high blood pressure, congestive heart failure, and diabetes are all perfect candidates to be managed in this, what I call  little bite way of doing it, as opposed to once every three months, whether you need it or not.

How Can Telehealth Broaden Access to Quality Care?

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How Can Telehealth Broaden Access to Quality Care? from Patient Empowerment Network on Vimeo.

Joe Kvedar, MD from the American Telemedicine Association discusses how telehealth technologies can broaden access to quality care for vulnerable populations.  

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Transcript

Mary Leer:  

How does telehealth broaden access to quality care for various populations?  

Joe Kvedar:  

You know, I’m so glad you asked that because people… One of the things that we’ve also worked on at the ATA is this idea of bridging the digital divide and tackling disparities, I think we now all know that the pandemic did a lot to highlight inequity and disparities in health care delivery across the country in so many ways, and we really wanted telehealth to be viewed as a solution and not part of the problem. But as it stands, if we’re, for instance, doing most of this care through video visits, and you don’t have access to broadband or a computer or a smart device, you’re locked out and so that’s a problem, which is something that I want to emphasize, which is audio only telehealth that is doing what we can with a phone call that was never paid for prior to the pandemic, and it has been. And that’s another thing that we’re urging the Government to continue to pay for his audio only because it helps us cross the digital divide. I mean, there are many other aspects to it, it’s not a straightforward, simple solution, we want to have broadband penetration, we want to have more smart device availability, more health literacy, etcetera, there’s a lot of aspects to it, but if you take that one exception, and it is a big one, but if you take that away and just look at the idea of time and place independent care, which is what telehealth is, then it gives access to so many people. I do my sessions on Tuesday afternoon every week, and at least once a week, a patient will say to me, You mean that’s it? I don’t have to travel? I don’t have to do anything? I get to get this care service right where I am. 

I mean, I have people who are shut-ins who can’t get out of their apartments, I have patients who are, it takes this one particular patient who is a special needs child, he’s 20-something years old, it takes literally an army of people to get him into the office. So that access is amazing, and of course, we wany to see that continue as well, but we have to talk… I’m sorry, we have to address the inequity part very much as well. So, it’s a two-part answer, I guess.

Does the CARES Act Impact Telehealth Technologies?

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Does the CARES Act Impact Telehealth Technologies? from Patient Empowerment Network on Vimeo.

Joe Kvedar, MD from the American Telemedicine Association shares how the CARES Act has impacted telehealth technologies and what the expiration of the CARES Act means for patients.

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Transcript

Mary Leer:  

How does the CARES Act impact telehealth technologies?  

Joe Kvedar:  

Well, so this gets back to whether we can do these sort of, any software story now, and it’s really, I think it officially still says in the law that you can use, again, Google Meets, you can use FaceTime, you can use whatever you want. But in practicality, the good news is that the industry has really responded in a way that allows us as clinicians to offer our patients a secure solution almost always, and so most of the medical record vendors have integrated a video conferencing tool into their suite. We use Epic where I work, and ZOOM is integrated into Epic, so that I can launch a call from Epic, the patient can request a video call from our patient portal, and it’s all done securely, but even for those doctors who don’t have that kind of fancy software, there’s a tool called Doximity, which is a social network fundamentally for doctors, and it’s free and Doximity has something within it called a dialer function, and what it allows you to do is place a video call. It’s very patient-friendly and it is secure. So really the need for us to use some of these other tools that are less secure has gone away now, and I think anyone that’s doing this kind of work should be using tools that are secure, of course, for the good of our patients as well. 

 Mary Leer:  

Wow, that’s very reassuring. Did the CARES Act expire? If so, when and why? 

Joe Kvedar:  

Well, a lot of the provisions went away last December, the CARES Act was a broad set of policy changes having to do with the virus, but the good news… We’re talking about telehealth. The good news is that all of the telehealth provisions are still in place, and the government just passed a few weeks ago, an omnibus spending bill, and within that omnibus spending bill was a large section of legislation around how we’re handling telehealth, at least in the first few months, after the public health emergency expires. So, the reason for the CARES Act was because there was a public health emergency and right now, we’re still in the public health emergency and it gets renewed every 90 days. The government has said to us that they’ll give us a 60-day notice if they’re not going to remit, they just renewed April 1st through April, May and June. So, the next time it comes up will be July 1, so in early May, if they’re not going to renew it, we will know, and the rule or the law that just was passed in the omnibus spending bill extends all of those telehealth regulations that we talked about earlier. 

Extends the reimbursement, extends the technology provisions through 100, it’s a weird thing, but 150 days after the public health emergency is lifted. So, we think optimistically that gives us to at least the end of this calendar year to figure out and convince Congress to do something that has more longevity to it. Their two main concerns are number one, cost, they feel like possibly telehealth is going to add so much to Medicare that it will be a drain on the trust fund, I’m being a little bit hyperbolic, but there is worry, and I think as providers we need to reassure them that we’re not adding services, but substituting for in-office services. In fact, it should be cheaper, but anyway, they’re worried about cost. The second thing though that is even harder to convince them is not a problem, is fraud and abuse, somehow people have this sense that because it’s electronic, it’s easier for people to commit fraud, it’s no easier than… And there’s a lot of, unfortunately, fraud that  goes on in Medicare and office-based practices as well, so we’re battling them on that one, but that’s what they want to do, steady for five months after the public health emergency is lifted and come up with a longer-term solution. 

So we consider that a victory. As I said, the public health emergency may not be lifted in July, we don’t know yet, but if it is, we still have a good six months to figure out how to extend as much of this relaxed regulatory environment run telehealth as we can.  

If we do in fact run out of runway to do this, it will be like going back into the ice age right now, are patients… I have to say this is, I’ve been at this almost 30 years, and when I go to the physical office and see patients, and I had mentioned to them, we could do your follow-up by telehealth, and they nod their head, they know what I’m talking about. That’s an amazing thing for me. I used to have to explain what it was, how to do it, etcetera. There’s like, no problem, we get it. So patients are now used to this and it’s a good thing, and we as I think somewhere… I don’t know whether it’s 5% of claims now, but I don’t know how much of healthcare is delivered this way, but a substantial amount, and so we risk that going away is the big risk, why is that? Because if Medicare does not get… Well, it’s called the Originating Site Rule Change, and that was given up during the pandemic, it was part of the care regulations that Medicare, as a Medicare recipient, you can be in your home and receive telehealth, you can be in an urban environment and receive telehealth. Before the pandemic, you had to live in a rural area, a very, very tight geographic restriction, and you had to go to a facility, so it was much more regulated and therefore there was much less activity. 

That’s the big one for us. There’s a few other things like federally qualified health centers, being able to use telehealth, very important, but the big one for us is this idea that if we don’t change the law to allow what’s called the originating site to be the patient’s home, then it could very well be in high siege, unfortunately, because the other thing that we should probably note is that if Medicare makes a payment decision, this is just generally, doesn’t have to be telehealth, but if Medicare makes a payment decision, most private payers will follow suit. So if Medicare makes a decision to continue to reimburse telehealth, you’ll find most private payers will feel compelled to do that if Medicare makes a decision. Well, and again, it’s Congress because it’s a law. So, if Congress doesn’t pass a new law, then we’ll find that Medicare has to go back to that very restrictive, geographic limited way and the private payers will say, oh great, we don’t have to pay for this. We’ll go back to our old ways. So that’s why I call an ice age, and where I am Chairman of the Board at the ATA, we’re working very hard to make sure that doesn’t happen.

How Have Telehealth Regulations Changed?

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How Have Telehealth Regulations Changed? from Patient Empowerment Network on Vimeo.

Joe Kvedar, MD from the American Telemedicine Association discusses how telehealth regulations have changed since the start of the COVID-19 pandemic.  

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Transcript

Mary Leer:  

Can you briefly describe how telehealth regulations changed during the beginning of the pandemic? 

 Joe Kvedar:  

Yes, so as part of the original CARES Act, there were several things that happened. Some had to do with technology, some had to do with reimbursement, some had to do with privacy. And the whole idea was telehealth had to happen overnight, as you know, we sort of went into locked down them immediately in the middle of the month of March of 2020, and the government had the forthrightness to do some of these things. So, I’ll just tick them off at a high level, number one was Medicare and really all private payers began to pay for video visits with your doctor at the same rate they pay for an office visit. So that was a big one. The second one was that the doctor could use and the patient could use any technology, whether it be FaceTime, Google Meets, etcetera, Skype, to do those visits at the time, knowing full well that not all of those were HIPAA-compliant or exceptional privacy, but in order to get that going. That by the way, has since changed, perhaps we’ll come back to that later. And the third big one had to do with licensure and states, and so at the time, you could, as a doctor, I could practice across state lines. Again, that’s been whittled back subsequently as well, but the big one that stood the test of time has been about reimbursement, and that one has really led to about a 24-fold increase in the amount of telehealth that’s going on since if you compare April of 2022 with April of 2019, it’s about a 24-fold increase, extraordinary. And it’s been quite consistent over the last year or so, that we continue to see that, so it’s what we call two-channel healthcare delivery, and it’s been a wonderful thing to see happen.

Value Assessments From Patient and Provider Perspectives

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The cost of some cancer drugs and lack of healthcare access are shocking to some patients. Fortunately, a tool called value assessments are now being utilized to gather and analyze various aspects of healthcare. Some possibilities for improvements could include things like lower drug costs, more effective cancer treatments, and improved healthcare access. To advance positive change, value assessments must include patient and provider perspectives in their analysis process.

Jennifer Bright, Chief Executive Officer of the Innovation and Value Initiative, stated about the importance of the patient perspective, “…the cost of healthcare, drugs or otherwise, is seldom based on its actual value. But while payers understand value largely in the context of utilization, efficacy, and cost, we still lack the ability (and the will) to understand and account for value from the perspective of patients, especially those living with chronic diseases.”

Value assessments are being used by healthcare policymakers to gather information to drive collaborative research and partnerships toward positive changes. It’s important to gather information from patients and healthcare providers to ensure that different perspectives are captured for analysis.

Value assessments analyze a variety of factors, some of which include:

  • Patient and provider preferences
  • Novel methods of value
  • Value assessment model development

Since healthcare methods are developing rapidly, it’s vital for value assessments to be carried out for tests, treatments, vaccines, and non-medical care.

Value Assessments for Treatments

The factors that are evaluated in clinical trials and the number of factors are key to the success of drug treatments that become approved from clinical trials. Clinical trial designs that fall short in accounting for enough potential patient situations will set themselves up to fail certain patients. For example, if a clinical trial evaluates treatment response in newly diagnosed cancer patients but fails to examine response for patients in whom other treatments have failed, the clinical trial has a failure in the data for those patients who haven’t responded to other treatments.

Or another value assessment scenario could look only at the factors of cost and performance compared to other drugs. If value assessments fail to examine other factors like patient age, patient medical conditions (comorbidities), and method of treatment delivery; then the drug could end up as a relative failure compared to its projected performance before its full release to patients.

Value Assessments for Healthcare Access

Healthcare access is another area of value assessment that can benefit from patient and provider perspectives. By taking action on patient requests, healthcare providers can reach more patients and diagnose patient conditions sooner compared to patients who were previously going unserved or underrepresented. Some examples of improved healthcare access in response to patient needs include:

  • Telemedicine as an option for healthcare appointments
  • Remote monitoring to decrease risk of viral infections
  • Healthcare providers talking to patients in community spaces like barbershops and churches to raise awareness about cancer screening

 Looking at the other side, some healthcare access has been hindered by failing to consider the impact to some patient populations including:

  • Older patients or patients in need of improving their technology literacy
  • Patients lacking access to high bandwidth Internet service
  • Patients without access to technology devices
  • Patients lacking English language proficiency

Value Assessments for Healthcare Technology

Healthcare technology has been growing by leaps and bounds as technology innovation continues. Patients and providers have both benefited from technology innovations such as:

  • Patient portals to refill prescriptions, send test results, and schedule healthcare appointments
  • Remote monitoring tools for checking patient heart function, lung function, activity levels, and brain activity
  • Using technology to replace tedious manual tasks to free up more time to spend with patients and to learn about new treatments
  • Translation services that provide printouts in foreign languages

Of course, as with most things, not all technology innovations are positive experiences. Some technology upgrades are rolled out by technology companies that fail to gather healthcare provider feedback during technology testing phases. And some of these technologies then cause more stress to providers. This undue stress can then result in both less time and lower quality time spent with patients who providers are trying to serve.

Value assessments are a vital tool to improve patient and provider experiences in healthcare. As healthcare policymakers drive collaborative efforts toward positive change, more patient and healthcare provider perspectives can be included to the benefit of both groups. The future could make possibilities like more affordable, effective drugs, improved healthcare access for all patient groups, and more focused appointments with healthcare providers a reality. But to reach these goals, value assessments must continue to incorporate diverse perspectives on healthcare from patients and healthcare providers.

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Sources

https://www.thevalueinitiative.org

https://www.healtheconomics.com/industry-news/innovation-and-value-initiatives-ivi-jennifer-bright-on-value-assessment-and-transparency

https://www.ajmc.com/view/how-to-make-value-assessment-more-relevant-to-healthcare-decisions

What Role Does Health Policy Play in Value Assessment?

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What Role Does Health Policy Play in Value Assessment? from Patient Empowerment Network on Vimeo.

 Jennifer Bright, CEO of Innovation and Value Initiative explains what role health policy plays in value assessment and health technology.

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Transcript

Mary Leer:

What role does health policy play in value assessment/health technology assessment? 

Jennifer Bright:

Policy has a really important role to play, especially at this time here in the US, as I pointed out earlier in our discussion, that there is a debate about best methods and what data and information we really need at our fingertips in order to make good decisions. And that’s not just at the health plan level or at the employer level, it’s also at the policy level, and so IVI does a lot of work in communicating about the work we do in the changing health economic modeling and doing different evaluations about patient preferences and how they have an impact on value assessment. We’re trying to communicate to the policy maker community writ large, why, because their decision-making about what the rules of road are in determining value here in the US is a really important missing voice. So, for example, we have a lot of CMS, we have employers, we have a lot of health plans that are coming out and talking about the importance of health equity. It’s a big topic and it’s an appropriate topic for us to be talking about. In our view at IVI, health equity is potentially could be worsened if we do not approach value assessment and health technology assessment with the patient perspective in mind, why? 

Because if we already have clinical data that is missing representativeness, and if we already have used economic evaluation methods that kind of eliminate the perspective of patients and families and their real experience in care, we are really at risk of hard-coding disparities in decision making in what you have access to as a patient, and that’s a very dangerous thing. And so that reason of that topic area of health equity is probably one of the biggest reasons why policy makers need to be understanding this landscape and the challenges from a scientific standpoint, and what the gaps are, and policy makers have a huge role to play, especially in championing the importance of having patient perspective represented in clinical trials represented in the line of value assessment, in having ability to calculate the cost on not just the patient, but the family and the caregiver. What’s the impact on their ability to work? All of those things are very complex, but they are all part of that value picture, and right now, there’s a bit of the tug of war in the health economics community about who’s got the best method, and we have a community that’s very used to doing value assessment the way they’ve always done it. 

And we believe at IVI that policy makers have a really important role in being a lever for change and kind of advocating for, pushing scientists to use different methods, but most importantly, to make sure that patient, family and caregiver voices are always at the table.

How Does Telemedicine Add to the Value of Care for Patients?

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How Does Telemedicine Add to the Value of Care for Patients? from Patient Empowerment Network on Vimeo.

Jennifer Bright, CEO of Innovation and Value Initiative explains how telehealth technologies and digital wearables can add to the value of care for patients.   

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Transcript

Mary Leer:

How are current trends such as telemedicine and our data wearables adding value to the overall care of patients? 

Jennifer Bright:  

Well, it’s such an interesting conversation. We at IVI, we do a lot of work in this space, thinking about incorporating new sources of data, so for example, we’re working on a major depressive disorder now, and as you know, there’s this burgeoning realm of telehealth and wearables and apps used in the behavioral health field. And so the reason that’s top of mind to me is that one of the challenges of… There’s these new technologies coming to market that allow us to bring care closer to the individual patients, which is exciting, but there’s two problems, one is we don’t have good ways of incorporating data from those types of interventions, wearables in other ways, we don’t have a good pathway to pull that data into value assessment, to really understand how does, how do these digital therapies and digital ways of delivering care make a difference to patient outcomes? So that’s one problem. And the other problem is there’s so much churn going on in wearables and apps and things like that, we don’t have a good handle on what are the metrics that we’re looking for that will tell us which thing has the most impact on the outcome. 

 So, a wearable is great for monitoring, you know it can monitor heart rate, monitor even A1C levels and things like that, can remind an oncology patient maybe to take a medication or to provide symptom monitoring back to their oncologist if that’s… They’re on chemotherapy or something, so there’s all these exciting ways of using that technology, but we lack a set of criteria in which we understand how does that benefit the patient, and how does that benefit the clinical outcome, and that to me, is going to create another bubble of fighting about value further down the road. Because if we don’t agree up front what’s the value to the patient and to their outcome, their life outcome, we’re not going to be able to measure it actively, and so then when we have this field of 100 different apps all of which are seeking to get bandwidth and money to be used, we don’t have a good way, we don’t have a good understanding of how to talk about the value of one versus the other.

Patient or Caregiver: What is My Role in Value Assessment?

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Patient or Caregiver: What is My role in Value Assessment? from Patient Empowerment Network on Vimeo.

As a patient, caregiver or an advocate, how can you play a role in value assessment? Jennifer Bright, CEO of Innovation and Value shares how we can improve the space of value assessment.

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Transcript

Mary Leer:

What is the role of the patient, the caregiver or the family in value assessment, and how can they improve it? 

Jennifer Bright:  

That is one of my favorite questions. One of the biggest parts that I feel needs to be improved in the space of value assessment, health technology assessment is the de facto involvement and presence of patient, family and caregiver perspectives. So I referenced the fact that in its simplest form, value assessment is really about understanding the clinical benefit of an intervention versus its cost, but as we know, clinical research, even today, does not capture so many of the things that patients and families and caregivers may deal with on a daily basis. It may not be representative of under-represented populations, it may not be representative of gender, how often do we hear that women are not well-represented in clinical trials, for example. So, because the clinical trial data may not represent fully represent a real population of individuals who are dealing with a certain type of cancer, for example, it automatically assess that whether the analysis of benefit versus cost is really reflective of the patient population for whom that decision is going to have an impact on what choice they have in treatment. Same goes for things like impact on family and caregivers. When we talk about cost, often when we talk about patient costs, the assumption is that we’re only talking about out-of-pocket, so co-payments or co-insurance. 

But what we know, especially in the realm of cancer treatment, there are myriad financial impacts that are not captured in clinical research, that are not captured in any kind of research, but that have absolutely have germaneness to decision-making to the ability to access care and to the outcomes, because you can have the best drug in the world, but if someone can’t get to it, if it’s an infusion therapy that’s covered by their health plan, but they can’t get to the infusion center on a consistent basis, then we are spending money on things that don’t match up with patient family, real experience. And so that’s a big gap in this area is that we don’t have a good mechanism for measuring aspects of care that are really important to patients and families, and then incorporating that into our economic analysis, so that’s a gap. And the way we need to improve it is in two ways, one is on the side of the researchers and the decision make our community, they are obligated and need to do a much better job of bringing patient and family and caregiver perspectives to the table at the front end of doing value assessment and health technology assessment. In other words, ask what’s important, what are the questions, what are the treatment options, what are the trade-offs those communities are dealing with in real time, and how do we measure the value to those needs? And then when we think about how can patients and families and caregivers improve like what’s the active role of the patient community, it’s being educated about this field, driving and asking for their participation, making sure that patients and families understand is the data that’s represented in this value assessment that says, this drug is better than this drug from a cost-effectiveness standpoint, ask the question, Does this reflect my experience? Does this reflect my community? Does this research look like me and my experience in care? And if the answer is no, speak loudly and to be under place at the table, and I think that that’s an advocacy at its core, but I think that change will come when both things happen, it can’t be an either or, there has to be changed from the research pipeline and the decision-maker side, and there has to be kind of that grassroots stand up and say, This is not a good decision because it doesn’t reflect real experience.

How Does Value Assessment Impact Patients?

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How Does Value Assessment Impact Patients? from Patient Empowerment Network on Vimeo.

Jennifer Bright, CEO of Innovation and Value Initiative breaks down how value and health technology assessment can impact patients and their families.

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Transcript

Mary Leer:

How is value assessment/health technology assessment used and how does it impact patients? 

Jennifer Bright:  

Well, I think there’s two levels to that answer internationally, health technology assessment has been on the radar for many years, most European countries and other countries use processes of health technology assessments to make decisions about how they allocate their resources. What’s unique is in most other countries, they’re dealing with a very different healthcare system than we are here in the US, and so what we have in the United States is a very fragmented system, and by that I mean we don’t have one single payer, we have many payers, we have people who are paying their own out of pocket, we have Medicare, we have Medicaid, we have commercial insurers, we have self-insurers, and each one of those decision-maker actors have different decision points, different patient populations that they covered lives that they’re responsible for, so each of those entities are trying to make decisions about allocation of their resources for their covered life population. And so, what we end up with, there’s lots of different methods, lots of different philosophies about how to way benefits and costs, and lack of consensus, and I think that’s probably the biggest comment I would make is here in the US, we don’t have one way of doing this, we don’t have agreement on the best way to assess existing technologies, we don’t have an agreement about the best way to assess emerging technologies, whether that’s a drug or a device or other kind of intervention. 

 And so that means there’s a lot of discussion and a lot of debates and a lot of research that’s coming out that may be confusing to particularly to patient populations, So, they look at all of this data and economic analysis and they’re left wondering, what does this mean for my treatments, what does this mean for my decision with my doctor? And I think that’s one of the advantages of the patient engagement network is to be able to… Patient Empowerment Network, to be able to educate patient communities about What is this process and does it represent the things that are important to me in my community on my journey with whatever cancer diagnosis that they’re dealing with.