6
Moderated Panel Discussion to Review Lessons from the Day1
In the workshop’s final panel session, Ruth Parker of Emory University School of Medicine moderated a panel with the following members: Cara James, director of the Office of Minority Health at CMS; Kim Parson, strategic consultant for Proactive Care Strategies at Humana; Mila Kofman, executive director of the DC Health Benefit Exchange Authority; and Laura Morris, assistant health care advocate at the Connecticut Office of the Healthcare Advocate. Over the course of this session, Parker asked a series of questions to draw out the panelists’ thoughts, given their own experience and what they heard during the day. A discussion open to the workshop participants followed the question-and-answer period.
FROM WHERE YOU ARE SITTING, WHAT ARE THE FRONT-LINE LESSONS AND OPPORTUNITIES?
The lesson Cara James mentioned was the value of partnership, something that she and her colleagues at HHS and CMS have gotten better at recognizing, particularly with regard to engaging partners earlier in the process of creating programs. In terms of partnerships, she said the opportunities are to get better at engaging partners in identifying and developing
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1 This section is based on the presentation by Cara James, director of the Office of Minority Health at CMS; Kim Parson, strategic consultant for Proactive Care Strategies at Humana; Mila Kofman, executive director of the DC Health Benefit Exchange Authority; and Laura Morris, assistant project director in Connecticut’s Office of the Healthcare Advocate, and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.
resources and tools and supporting the assisters who are engaging consumers to enroll them. James considers the number of people who have gotten coverage as an obvious success, and while more people are using their insurance, the opportunity exists to make it easier for consumers to understand their coverage and particularly what their costs might be. “How do we help to make those sorts of information more accessible and understandable? I think the navigation, the complication, and the fragmentation of our health care system make that a challenge for us, but within the confines of what we have, I think those are opportunities for us to do that better,” said James.
For Laura Morris, whose standalone state agency works to educate consumers about their rights and responsibilities under their health insurance plans and offers assistance when they encounter problems, her biggest lesson from the day was the importance of having the in-person assister help not only with enrollment but also with education about how to best use the benefits afforded by their plans. One concern Morris has is about securing the funding needed to ensure these in-person assisters remain available to help consumers. Kim Parson agreed with Morris and added that the message was clear throughout the day that navigators are necessary not just when consumers select their plans, but also when they start using them. The reason postenrollment help is so important, she said, is that, “when you are selecting your plan, oftentimes you do not know what you do not know.”
As an example, she explained how her son was diagnosed with attention deficit/hyperactivity disorder (ADHD) during the middle of her plan year. Because she was not aware of this when they selected their health plan, she was not concerned with which ADHD medications were part of her plan’s formulary, and in fact, the drug her son was prescribed was in the highest cost category on her plan’s formulary. “There is no way to plan for that when you are selecting your benefits,” said Parson. “You do not know what you do not know.” Navigators, she added, can be helpful in walking people through these types of challenges and surprises, even for those who have had health insurance all of their lives.
Another time when navigators can prove essential, Parson added, is when an individual is sick and has accompanying cognitive problems that can negatively affect the ability to make good decisions about health insurance benefits. She also referred to the challenge of sustainability and said partnerships are essential to securing long-term funding for navigator programs given that funding from the federal government is not likely to be reliable going forward. Parker then asked Parson who these partners should be, and Parson replied that critical partners are everywhere in the health care system. “For this to be a seamless experience for the consumers, for them to be able to understand what they need in terms of selecting their insurance coverage and then how they can use it and use those benefits,
you need everyone involved at the table,” said Parson. “You need payers. You need pharma. You need health systems. You need all of those who are making policies and rules. I think there is no one that you can leave out.” The most essential partners, she added, are consumers, who, as Amy Cueva stressed in her presentation, need to be involved in designing solutions.
Morris said there are great partnerships in Connecticut with many of the stakeholders, including advocacy organizations, the state’s department of social services, which oversees the Medicaid program, and other state agencies that provide clinical services. The disconnect, she said, is with providers. “We need to do a better job of getting them in and collaborating with us and educating us,” said Morris. She also stressed the importance of involving consumers from all age, culture, and ethnic groups.
The reason getting providers involved is so difficult, said James, is that they are struggling to adapt to all of the other delivery system reform changes that are happening. She said there was strong pushback from providers about spending time helping their patients understand their insurance coverage. However, the social workers and navigators within practices have been good partners in educating patients about their coverage. One opportunity for engaging and educating the newly insured is in the emergency department, said James, because many newly insured individuals still come to the emergency department for their care simply because that is what they are used to doing.
Mila Kofman noted she was the sole representative of state-based health insurance marketplaces and that the Washington, DC, marketplace was one of only four state marketplaces to open on time. One lesson she and her colleagues learned during the DC marketplace’s first year was that its efforts were so focused on the technology piece of the marketplace that little attention was paid to what consumers needed to make the marketplace useful to them. The good news, though, was that she and her colleagues have learned from research of the type presented at this workshop and from the assisters and navigators about what worked and did not work. As a result, they have been able to implement some critical decision support tools, such as the Consumers’ Checkbook plan match tool, to help the marketplace’s customers make better choices from the 26 insurance products for individuals and 136 plans for small groups. The DC marketplace also now has an all-plan provider directory.
Another important lesson she learned is that the DC marketplace would not be successful if it were not for the navigators, in-person assisters, and certified application counselors, and she urged the workshop participants in their individual capacities to figure out ways to provide additional funding for the groups on the ground that are helping consumers understand their health care plans and benefits. She noted that technology can be great for those who are comfortable using it to answer their questions, but many
people, including the technologically savvy, need that in-person contact with a trusted individual.
James noted the importance of health literacy when it comes to individuals who are coming into the health system for the first time, particularly those who are aging into Medicare. This group, she said, includes some of the biggest users of information who are trying to figure out this new world of insured health care. She also pointed to the importance of making information available in an understandable and intuitive way so that consumers can make decisions based on affordability. Parker reminded the workshop that, while the individual mandate is part of the ACA, a longstanding problem has been the large number of people who were eligible for Medicaid or Medicare, but still did not have insurance.
Kofman then shared some preliminary survey data from the DC marketplace’s enrollees. Of the people who enrolled through the marketplace and responded to the survey, more than 50 percent have a graduate degree and another 30 percent have a college degree. Some 5 to 6 percent of these people said they did not know there is an individual requirement to be insured, and a slightly higher percentage did not know there is a tax penalty associated with the individual requirement. “To me, that tells me we should still be educating at the front end and even through the care piece,” said Kofman. “The coverage to care piece is so critical because that medical card is worthless unless people know how to use it.”
She also argued that state-based marketplaces are inherently in a great position to bring together diverse stakeholders. In its first year, the DC marketplace had multiple working groups, and while there are fewer today, the DC marketplace still has a standing advisory board and committees, all of which have representatives from different stakeholders, including consumer and patient advocates, insurance brokers, health plans, business owners, physicians, and hospitals. “What we do is challenge them with a problem to give us a consensus-based solution,” explained Kofman. When she has presented these consensus-based decisions to her executive board, they have adopted all of them.
Kofman also shared that many of the DC marketplace’s customers rely on its website to get answers to their questions. “Some actually do not like to talk to people if they can help it,” she said, noting that this is true across all age groups. Because of the heavy reliance on the website, she and her colleagues have been trying to simplify it and create what someone earlier referred to as the “Amazon experience.” Whereas the initial version of the website had 26 screens for individuals, the current website has 11. Those who use the marketplace to enroll in company-based plans had to navigate through some 20 screens in the original website, and that is now down to 6 screens. Customer feedback has proven valuable to this simplification effort. Today, said Kofman, she has an employee who meets one on one
with the marketplace’s website users to observe how they use it and identify those parts that are confusing or cause trouble. One thing that helps with this change effort is the DC marketplace’s use of open-source software that makes it easy to alter the website on a daily basis if needed. As a final comment, she said the DC marketplace has now added standardized plans with standard benefits, co-pays, co-insurance provisions, and deductibles. “The standardized products are the hottest selling products this year,” said Kofman. “More than 40 percent of my customers choose a standardized product.”
When asked by Parker to describe a standardized plan, Kofman said that all of the benefits, deductibles, co-insurance, and co-pays are the same regardless of which company is selling it or whether it is an HMO or a preferred provider organization plan. For those plans, she said, consumers shop based on premiums and the provider networks. “We are hoping eventually they will also consider quality, but it is an easier way to make decisions,” she said. The DC marketplace also uses reminders to help consumers make wise decisions. “We were finding that people who were eligible for cost-sharing reductions were not enrolling in silver plans and therefore were losing that benefit,” said Kofman. “Now, if a customer is choosing a gold plan instead of silver, there is pop-up window that says ‘You will not receive your cost-sharing reduction if you choose this plan.’” Today, most customers who are eligible for cost-sharing reductions are selecting the silver plan. Another incentive for these same consumers is that the website shows them silver plans first. Referring to Judith Hibbard’s earlier comment that nudges can help people make more informed decisions, Kofman said, “We are seeing firsthand that nudges work.”
WHAT SHOULD WE DO DIFFERENTLY GOING FORWARD TO MAKE HEALTH INSURANCE UNDERSTANDABLE, USABLE, AND NAVIGABLE?
When asking this question, Parker listed standardization as one approach, with which James agreed. James added that the next big push will be to provide just-in-time information, that is, bite-sized pieces of information at specific points in the enrollment-to-use process. “The variation of who is ready for information at a point in time is huge,” she said. “There are some efforts under way to look at what consumers need as they are journeying on that path from coverage to care and as they start to go in or they are getting ready to think about finding a provider.” James also said it would be important to continue reminding people about coming back to the exchanges if they have had a change in circumstance to avoid losing coverage.
Morris pointed to the need to do a better job explaining in a simplified
manner all of the preventive services that are now free, with the emphasis on free. Many among the newly insured, she said, are afraid to take advantage of these preventive services because they may not believe they are free or because the word “prevention” is foreign to them. However, when they understand “free” means that taking advantage of these services does not cost them anything, they do start to use this benefit. Parson agreed that “prevention: is not an easy word for many people to understand, and that free is a foreign concept, too, because everyone’s mother has told them there is no such thing as a free lunch.” In fact, said Parson, these services are not free. “It is part of a benefit to them that is rolled into their premium,” she said. Even among her co-workers, there are those who do not believe these services are available at no cost to them, and they wait until they meet their deductibles before they have their breast cancer screening or their wellness exams.
Kofman, who said she agreed with James and Morris, added that it is important to recognize the diverse populations that are covered. One lesson she and her colleagues learned with enrollment is that having messengers trusted by different segments of the population is important. Peer-to-peer messaging is key, she said, and the same phenomenon appears to be true with how people are using their coverage, particularly with regard to no-cost preventive services. Morris added that, as funding is cut for in-person assisters, community-based organizations will become critical partners in reaching consumers, getting them to the marketplaces, and teaching them how to use their benefits.
HOW CAN WE ENCOURAGE NETWORKING AND THE SHARING OF BEST PRACTICES?
Morris said sharing across states is important and not enough of that is happening yet. Noting how much she learned at this workshop, she said she would like to have some mechanism that would help establish collaborative efforts across the states. James said that CMS has a weekly Friday call open to anyone interested and that she and her staff have gotten better at homing in on the types of information the assisters need and passing that information along. She noted that the Center for Medicare & Medicaid Innovation, part of CMS, has learning collaboratives that could do a better job of sharing the lessons they develop and that perhaps some creativity was needed to make that happen. She added that CMS needs to think more about how to make better use of public libraries to get information to consumers.
Kofman said the DC marketplace has always had a limited budget for outreach and marketing, especially in the context of Washington being an expensive media market, particularly during election season. “We learned that lesson early on,” she said. “In 2013, we had a governor’s election in a
neighboring state and we had to do things for pennies on the dollar.” She said she is fortunate to have a staff member who she characterized as one of the most creative marketing outreach directors in the country, a woman who wrote a college textbook chapter on small-budget marketing. The first thing she did was start an effort to partner with the faith-based community, and on Mondays there were spikes in enrollment. This past year, Kofman’s team went to the movie theaters when Star Wars and The Hunger Games were released and handed out literature to the people standing in line. Her navigators and assisters go to bars and nightclubs, as well as diners in the middle of the night. On Super Bowl Sunday, pizza came with a brochure. “All of those things are relatively inexpensive and they work well,” said Kofman.
She then recognized the Obama administration for doing a great job at organizing calls for the states and stakeholders to pass along that kind of information. She also said she sends her outreach director to the Enroll America meeting every year to share the lessons her program has learned and bring back the lessons others have accumulated. This sharing activity, said Kofman, has paid many dividends.
WHAT DO YOU THINK WE CAN DO TO ENCOURAGE GREATER ALLOCATION OF RESOURCES, FOR EXAMPLE, FOR ONE-ON-ONE APPROACHES?
As a lead-in to this question, Parker noted the importance of in-person assistance and the difficult task of enrolling someone in 90 minutes given how many layers of the onion, as she put it, need to be peeled back to get to the complexity of an individual’s life that is relevant to his or her insurance needs. This may be particularly true, she said, for the population that is still not enrolled and that will never be enrolled with an intensive one-on-one engagement, the type of engagement that requires substantial resources.
James responded that many of those who are not yet enrolled are in states that have not expanded Medicaid, and as long as that is true, reaching those individuals will be a challenge, as will providing the resources to reach those individuals. She then pointed to an organization, the Maricopa Integrated Health System, that has cultural health navigators. These individuals work with and train individuals to conduct home visits to assist members of a largely refugee population. She wondered if it would be possible to make a business case for using this type of organization, which is already reaching into people’s homes, to deliver enrollment support and educate clients about how to use their health insurance. “How do we get creative about connecting people and making that business case?” asked James.
Connecticut, said Morris, used a combination of federal funds and
advocacy organization support for its in-person navigator and assister program, but federal funds are no longer available. Today, the state is faced with some 20,000 adults and caregivers of children who are on Medicaid, but losing their Medicaid coverage and having to go into one of the qualified health plans. This group will be difficult to reach, and the state does not have the assisters on the ground to reach them, said Morris. That group had until the end of July to make that transition, but only 26 percent of those who need to switch had enrolled in a plan at the time of this workshop. “I do not know what the answer is for how we fund something like this, but I think we need to get really creative,” said Morris, who noted that many states are experiencing the same budget crisis. One avenue may be to place an assessment on the carriers to pay for these types of programs, though she acknowledged this would not be popular, and state marketplaces cannot always go to the carriers to fund these types of projects.
Kofman said she has an answer, but it will take the will to make it happen. Getting sick and using insurance to get access to care is not a political thing, she said, so what needs to happen is for elected officials in Congress to be asked for a commitment to fund consumer assistance programs, navigators, and in-person assisters. “If there is a will to do that, then we have a way,” said Kofman. She then noted that her initial budget for in-person assisters included $800,000 in federal grants that are no longer available. She has allocated $500,000 from her budget to continue providing the financial help that her partner groups need to help the DC marketplace reach and help the population it is intended to serve. What may not be appreciated, she added, is how important it is to continue to pull new enrollees into the system in order to keep risk pools stable. Looking forward, Kofman said the next generation of enhancements to the ACA should include provisions for front-end affordability in terms of the premiums, deductibles, and out-of-pocket expenses that continue to keep some people uninsured.
Parker said this community needs to clearly state the issues that exist with regard to affordability and access, “to be an advocate for what we know would work and what is needed.” James suggested that schools of public health could be an untapped resource that could be leveraged to engage the community and to help their students understand the importance of health insurance and the literacy challenges associated with insurance. Parker added that such training could become a competency requirement for getting a degree in public health.
DISCUSSION
Terry Davis started the discussion by noting that she finds standardized plans appealing because they represent a less-is-more approach, similar to
the limited options most businesses offer to their employees. She wondered, though, if Kofman has seen any pushback from consumers. Kofman replied that the DC marketplace also offers non-standardized plans that have the same benefits as the standardized plans, but with different cost-sharing structures, making it more difficult to compare plans. In all, the DC marketplace offers 26 different products, and she said she does not expect there ever to be just a small number of choices. “We do know from our internal research that when our return customers and new customers shopped during the last enrollment period, they usually looked at three plans,” said Kofman. “That was the magic number.”
She then said she was of two minds about limiting choice. On the one hand, she said, it is important to help people narrow their options so they are not overwhelmed, which is why she likes the Consumers’ Checkbook tool so much. On the other hand, people do want access to different types of products, depending on their risk tolerance, their health, and how much they can afford. Kofman noted that the health plans, advocates, and providers worked together to develop a consensus on what the standardized plans should include. She also said that some of the carriers have looked at their own product offerings, concluded there were too many, and are now offering fewer, more popular products. She could not say what the offerings will be at the next open enrollment, but the market itself may evolve naturally to offer fewer choices. Still, she said, “I am a big advocate of having some standardized products because it makes the choice so much easier for a certain segment of our customer base.”
With regard to the plans employers are offering, she said the most popular choices are platinum-level plans that have higher premiums, but lower out-of-pocket costs. The DC marketplace’s website tells employees what their employer’s contribution will be, then the employee makes a selection from all of the carriers’ plans at that level. “You need some level of choice, but it is critical to have the tools that different types of consumers need to make informed decisions,” said Kofman.
MaryLynn Ostrowski from the Aetna Foundation noted she is also a registered lobbyist and licensed broker in Massachusetts. She remarked that the grassroots approaches to enrollment discussed at the workshop work well. She suggested some potential solutions to funding those efforts in a sustainable manner. In Massachusetts, as in most states, there are counselors who work with Medicare beneficiaries. In her state, this program is operated out of the Office of Senior Services. Many counselors are volunteers and many are retired sales executives from health plans, so they understand the enrollment process. Because the Medicare enrollment period is short, it may be possible to convince these counselors to continue volunteering during the open enrollment period for the non-Medicare population. “There is great potential there,” said Ostrowski.
Another possible solution that Massachusetts has developed involves training all financial counselors in hospitals and health centers to be enrollers at the point of service. As a result, a patient who says he or she does not have coverage can enroll in a plan right then and be linked to the right coverage. A third solution is to use the virtual gateway most states have created to access a variety of services—food stamps, heating assistance, and others—as a link to the insurance marketplace. As a final thought, Ostrowski said, she favored the idea of creating a Listserv for best practices.
Jennifer Dillaha with the Arkansas Department of Health referred to a document called “Ten Attributes of Health Literate Health Care Organizations”2 and noted that the 10th attribute says a health-literate health care organization communicates clearly what health plans cover and what individuals will have to pay for services. Thinking about that attribute, Dillaha wondered if there is an opportunity for payers to help clinics communicate with the people they serve, as well as an opportunity to use online portals for the same purpose, particularly with regard to how to use a health plan. “I know we do not like to add tasks for the providers, but many of them are struggling with this anyway, particularly in interfacing with their patient.” Parker thanked Dillaha for mentioning the 10 attributes and said one way payers could help with that attribute would be to be more transparent on how much health care procedures cost. “I just cannot fathom, in a market-driven economy, going to a store without prices on the shelf, but that is kind of what patients do,” said Parker, who added that as a provider she does not have that information either and therefore cannot become part of a shared decision with her patients.
James mentioned Medicare’s Comprehensive Primary Care Plus plan as a place where there is an opportunity to make health literacy a central feature for providing care coordination and engaging families and patients. “You cannot have patient and family engagement if the person does not understand what you are talking about,” said James. The goal of this program is to transform care coordination to make life simpler for a vulnerable population. She also thought opportunities exist to work across state lines on innovation models and to make use of Medicaid waivers to develop new opportunities for coordination and education.
Jay Duhig from AbbVie Inc. commented on the importance of sharing best practices and thought the idea James mentioned about involving schools of public health was a good idea. What he wondered, though, was if there is an existing system of communication that could be leveraged to help these types of discussions and share best practices. The parallel that
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2 Available at https://nam.edu/perspectives-2012-ten-attributes-of-health-literate-health-care-organizations (accessed January 31, 2017).
he mentioned involves disseminating best practices around drugs and the creation of formularies. James said that the weekly calls among the states could be one avenue, and so could CMS’s Health Care Payment Learning and Action Network as well as some of the quality improvement organizations and quality improvement networks. The key, she said, will be to connect all of these different sources of information. She also suggested that medical schools and schools for other allied health professionals could be recruited to train their students about how to navigate through the insurance process.
Jennifer Villani from the Office of Disease Prevention at NIH said she would like to hear more discussion at another workshop on the health literacy challenges associated with using insurance, which were mentioned often, but not discussed to the same extent that enrollment was at this workshop. She stressed the important connection between using health insurance and achieving the better health outcomes everyone wants to see, as well as the importance of price transparency that Parker mentioned. With regard to the latter, she described a recent visit to the pediatrician with her son, who was wheezing. The doctor gave her two choices, rent a nebulizer or use an inhaler, but when Villani asked about the cost of the two choices, the pediatrician had no idea. She added that there are consumer-driven health plans in which the premise is that consumers know the price of care ahead of time and can decide whether to go forward or not based on price.
Steven Rush from UnitedHealth Group pointed out that, legally, the preventive services provided under the ACA cannot be called free because the consumer is paying for them as part of the benefits package. However, from a language and literacy viewpoint, “free” is a word that is simple, understandable, and actionable. He also noted that a number of groups have raised issues with the new uniform glossary of terms because some of the terms are difficult to understand. He commented that the Plain Writing Act of 2010 allows each state to specify a reading level for its information that ranges from third grade to eighth grade, but defining those grade levels is complicated and depends on which of several available scales regulators use. His prescription is to simplify plan language, make it more understandable and protective of everyone in an organization, and by doing so, systems might save a great deal of money, which could then go to health literacy programs that would benefit consumers.
Kofman commented that state-based marketplaces are required to provide extensive notices with a variety of information required by federal laws. In Washington, one of the notices is 16 pages long, and she said she would never read a 16-page notice and does not know a single customer who would. “In some of the comments that we have provided to HHS and other departments who write regulations that require these notices, the sug-
gestion I made was to please focus group your notice and give us a model to use that you know has worked well. That is a very simple request, but it really has not been done and the notices keep getting longer,” she said. “While it is important to give people enough information on their rights to act on them, there needs to be a balance because nobody is reading them as they are currently written.” Morris said she had a similar problem in Connecticut. Today, every notice is sent to advocacy group partners and they conduct focus groups and come back with comments and suggestions. The notices still have to be approved by the marketplace’s legal department and the state social services department, but she said that with the exception of one or two suggestions made by the advocacy groups, the documents are now readable and down to five pages in length.
