🤔Confused? Don't worry, you're not the only one

What’s in for today:

• Confusion about picking a health plan

• AI in healthcare: Google’s healthcare strategy

• Best hospitals ranking, digital health coverage, & No Surprises Act audit

LET’S TALK!

There are several reasons why healthcare is confusing, starting with:

The challenge of choosing the right health plan

It's generally good to have options, but too many choices can be overwhelming. On the ACA marketplace alone, there are over 100 options to pick from, which can lead to a lot of confusion. This complexity sometimes causes people to just give up and choose a plan without fully understanding it. Many folks have a hard time figuring out the differences between HMOs, PPOs, EPOs, and HDHPs, which makes it tough to pick a plan that works best for them financially and meets their needs.

For instance, some folks might go for a low-cost health insurance plan because they're in good health at the moment and don't anticipate needing much medical attention. At first, it seems like a wise money move as it reduces monthly expenses. However, it could turn into a big financial issue if unexpected medical bills pop up.

In-network vs. out-of-network:

Even after selecting a healthcare plan, understanding the specific benefits it offers can be challenging. According to a 2023 survey conducted by KFF, which involved 3605 respondents, it was found that 6 out of 10 insured adults encountered difficulties while using their health insurance in the past year.

The challenge lies in understanding the services that are covered, the network of healthcare providers, and the extent of coverage for prescriptions, specialist visits, and emergency care. For example, a patient might undergo surgery with a recommended specialist only to discover afterward that the specialist is out-of-network, resulting in unanticipated high charges.

In 2022, almost 60% of ground ambulances were found to be out-of-network. During emergency visits, when patients are distressed, checking whether the emergency services are in-network is the last task they want to handle.

What is being done?

Recognizing the widespread confusion and complexity, various organizations and policymakers are working to simplify the process and provide clearer guidance to consumers.

• Standardized Plan Options: Some states and insurance marketplaces have introduced standardized plan options. These plans have uniform structures, making it easier for consumers to compare key features such as deductibles, co-pays, and out-of-pocket maximums.

  Since 2023, silver-standardized plans have waived the deductible for all primary care visits to a flat $40 copay, compared to non-standardized silver plans, which have copays ranging from $0 to $105. Standardization helps reduce the complexity and variability among different plans, enabling more straightforward comparisons.

• Assistance Programs: Many states and insurance marketplaces offer consumer assistance programs. These programs provide the following services:

  Workshops and Webinars: Educational sessions that explain the details of different health plans, how to evaluate them, and what factors to consider when making a decision.

  Personalized Assistance: In 2022, the HHS invested $98.9 million in funding for healthcare navigators to assist with health plan enrollment. These are trained advisors who can help assist in understanding your options and choosing the right plan based on your needs and financial situation.

• Regulatory Changes: Policymakers are constantly striving to enhance the transparency and simplicity of the healthcare system. Some of the efforts include:

  Transparency in Coverage: Insurers are required to provide clear summaries of benefits and coverage to help consumers comprehend what each plan offers.

  No Surprises Act: This act protects individuals with insurance from receiving unexpected medical bills when they receive most emergency services, as well as non-emergency services from out-of-network providers at in-network facilities.

Why should you care?

Understanding how healthcare and insurance work is important for patients to make smart choices about their health and money. Here's why it's important:

• Financial Protection: Knowing what your insurance covers can help you avoid unexpected medical bills and ensure you get the care you need without financial stress.

• Reduced Stress and Anxiety: Familiarity with your insurance plan and understanding the healthcare system can help reduce stress and anxiety during medical visits and procedures, leading to a better overall healthcare experience.

• Empowered Decision-Making: When you are informed, you can advocate for yourself and make choices that fit your health needs and personal values.

TRACKING: AI IN HEALTHCARE

Google is expanding its healthcare efforts using digital platforms, partnerships with agencies and providers, and disease prevention initiatives. Generative AI is a key tool in these efforts. However, Karen DeSalvo, Google's chief health officer, stresses that AI is just one of many tools needed for effective healthcare.

Technology, particularly AI, is driving medical advancements and making health access more universal, similar to how penicillin revolutionized treatment. Google's focus is on providing cloud services and health information platforms, emphasizing the importance of accurate information dissemination, especially during crises like the COVID-19 pandemic.

DeSalvo highlights Google's role in empowering healthcare providers rather than directly delivering healthcare, with examples such as AI-driven tools for mammography and chest X-ray readings and AlphaFold for accelerating drug discovery (Read More).

POLICY & INDUSTRY NEWS

🩺The U.S. News Best Hospitals rankings for 2024-2025 have been released, highlighting the top-performing medical institutions across the nation. This year's list showcases excellence in patient care, advanced research, and cutting-edge treatments.

🏥The 2025 physician fee schedule proposed by CMS introduces new payments and coverage for digital health services, such as digital therapeutics and telehealth. The proposal includes continued payment for audio-only telehealth in rural health clinics and federally qualified health centers, and also offers increased flexibility for opioid treatment programs to use telehealth.

🥼No Surprises Act audit: A recent audit of Aetna Health in Texas by the CMS found that insurers may be manipulating payments for out-of-network services, especially air ambulance services. The audit uncovered errors in the calculation of payment amounts, leading to both overestimates and underestimates. Aetna was also found to be not meeting the requirements of the No Surprises Act, as they did not adequately disclose information to providers, making the arbitration process more complicated and causing delays in dispute resolution.