Reimbursement Rounds



Reimbursement Rounds | Oscar Health, Humana, Mario Schlosser, AMA, American Medical Association, AHA, American Hospital Association, David Barbe, Tom Nickels, CMS, Centers for Medicare & Medicaid Services

Mario Schlosser

New Player/Payer in Town

Oscar Health, a technology-driven health insurance startup based in New York has entered a strategic partnership with industry giant Humana to offer commercial health insurance to small businesses in the Nashville MSA. The announcement follows the recent launch of Oscar for Business in April 2017. The new plans will be available this fall, pending regulatory approval.

This partnership leverages Humana's experience in provider collaboration, coordinated care, and health and wellness with Oscar's technology and data-driven approach to member engagement. The combined goal of the pairing is to make healthcare an easier, more reliable and affordable experience for small businesses members through technology and connected care. The health insurance product features Oscar's concierge care teams that use data-driven alerts to help members with their care, 24/7 access to telemedicine and care search tools, and a mobile experience to empower members to manage their health.

"We started Oscar for Business to bring a seamless, consumer-focused health experience to more Americans, and we're excited to have the opportunity to work with Humana to serve members in the Nashville area," said Mario Schlosser, CEO and co-founder of Oscar Health.

"This partnership is about coming together to reimagine health care coverage for small businesses and their employees, with an emphasis on simplicity and the end-to-end consumer experience," noted Humana Group and Specialty Segment President Beth Bierbower.

Officials with Humana and Oscar said they chose to introduce this partnership in Nashville because it is home to one of the fastest growing small business communities in the country and has established itself as a hotbed for health technology innovation. Under the Nashville partnership, Humana and Oscar will initially focus on commercial health insurance for small businesses with 50 or fewer employees in the nine-county Nashville area.

CMS Payment Proposals Garner Mixed Reactions

Key stakeholders have mixed reactions about several new payment proposals from the Centers for Medicare & Medicaid Services for calendar year 2018.

One the plus side, both the American Hospital Association (AHA) and American Medical Association (AMA) are pleased with the added flexibility in implementing MACRA to help avoid penalties under the Quality Payment Program. Additionally, Tom Nickels, executive vice president of the AHA said, "We also encourage CMS to provide additional opportunities for clinicians to earn incentives for partnering with hospitals to provide better quality, more efficient care through advanced alternative payment models."

The AMA generally had a positive reaction to the CMS update of the physician fee schedule proposed rule. "The annual physician fee schedule update is a chance for CMS to modify Medicare policy to ensure the best possible treatment options for patients," said AMA President David O. Barbe, MD. "The AMA is encouraged by many of the proposed changes and applauds the Administration for working with the AMA to address physician concerns."

The AMA supported the invitation for public comment on regulatory relief and commended CMS for moving forward to expand coverage of the Medicare Diabetes Prevention Program (DPP) model to Medicare patients at risk of developing type 2 diabetes. Additionally, the AMA expressed appreciation that CMS made an effort to address concerns that the proposed payment model was too restrictive in linking payments to performance over a short period of time by extending the time period for patients to meet weight-loss targets.

On the flip side, the AHA was displeased with CMS proposals to slash 340B drug payment rates and payments provided in off-campus outpatient departments.

Nickels released a statement saying CMS had issued "several poorly designed policies that will do real damage to patients' access to care."

He noted, "For 25 years, the 340B Drug Pricing program - which enjoys broad, bipartisan support - has been critical in expanding access to lifesaving prescription drugs to low-income patients in communities across the country. The patients who benefit from the much-needed 340B program are the ones who will have their access to care threatened.

"Cutting Medicare payments for hospital services in the 340B program is not based on sound policy. Additionally, this proposed rule punishes hospitals for a policy outside of CMS' jurisdiction. It is unclear why the Administration would choose to punitively target 340B safety-net hospitals serving vulnerable patients, including those in rural areas, rather than addressing the real issue: the skyrocketing cost of pharmaceuticals."

Additionally, Nickels said, "CMS at the same time is proposing further cuts to Medicare rates for services hospitals provide in 'new' off-campus hospital outpatient departments. This proposal also appears to have a questionable policy basis and is yet another blow to access to care for patients, including many in vulnerable communities without other sources of healthcare."