Passion Drives Advocacy
By Robert Hall, JD, MPAff
Heightened emotions have been driving our country for the past year, at least, as we navigate emotionally and politically charged challenges tied to the pandemic. The loss to our country and — even more tragically — American families has been devastating. Consequently, I am angry.
Sometimes it’s overwhelming and makes continuing to advocate seem that much more like repeatedly running into a brick wall, but I also am angry in a very different way at the private payers who are profiteering from the tragedy of the pandemic. As I have said in multiple venues for PPS, insurers are not seeing decreased payments from members, also known as premiums, during this time. And the other way that many of them make money — by investing in sometimes-questionable stocks (like tobacco1 and fast food companies2) — is generally booming. And yet private practice physical therapy businesses are still experiencing the same frustrations with billing, coding, administrative burden, payments to you, and ultimately the access of patients to your high-quality and low-cost services.
Take the recently-addressed issue of the Correct Coding Initiative (CCI) edits. These edits forced changes in coding for commonly-used physical therapy services provided on the same day that were flagged and caused denials for months by many large payers. Thousands of these denials had to be appealed. What a waste. Thanks to some of the good work by my colleagues in Washington and Alexandria, the core issue that caused so many denials appears to have been addressed. But during the implementation of the edits, at least one large payer followed the example of Humana and implemented changes that amplified your administrative burden during a pandemic. Three payers have implemented different rules, Aetna requiring you to refile claims through 2020, CIGNA not honoring the change until January 1, 2021, and Humana making the change retroactive through 2020 and not requiring refiling. This variability can be maddening and is too burdensome.
Three other data points have emerged that also help to flesh out the impact of the pandemic and further inspire the passion that fuels the advocacy fire. First was a report from the Kaiser Family Foundation3 that was echoed in Axios4: US expenditures on health care actually decreased compared to the year prior. That has never happened since the start of this type of data collection. As the analysis points out, “At its low point in April when the pandemic first really hit, spending on health services had fallen an eye popping 32% on an annualized basis.”4 Also of note, the slow-down was mostly in outpatient and elective services, and telehealth “visits increased dramatically but did not make up all of the difference.” Insurers are collecting the same premiums even though utilization has plummeted.
The second data point5 speaks to the social determinants of health and breaks down in terms of COVID-19 infection, hospitalization, and morbidity. In comparison to non-Hispanic whites, the CDC reports that if you are American Indian, Hispanic or Latino, or African American you are significantly more likely to contract, be hospitalized for, and die from COVID-19.6 According to APM Research Labs,7 depending on a person’s race or ethnicity, morbidity may be 150% more likely than non-white individuals. We have huge work to do as a country to better address issues of health equity and adequacy of health care access.
The third data point spans a longer period and comes from an analysis by the Commonwealth Fund.8 It shows that the cost of health care remains unaffordable for too many Americans and businesses and that employers, payers, and providers have triangulated cost increases for patients over the last decade. The ACA defines when insurance is unaffordable for families, and part of this definition is the cause of the so-called “Family Glitch,” which limits coverage for millions of spouses and children for complicated reasons.9 However, the ACA definition is a moving target. Right now, the ACA affordability threshold has grown to 9.83% of household income. When the ACA was implemented, care was considered unaffordable if it cost more than 9.5% of household income. The threshold has increased because average premiums and out-of-pocket costs have increased, but where does it end? Ten percent? Fifteen percent? Increasing health care costs continue to outpace wage growth and underlines a fundamental problem: health care affordability is a challenge for many Americans but is particularly unaffordable for folks at the lower end of the income scale.
So, what to do with all of this gall, anger and frustration? Advocate. These data points illustrate the vital role advocacy plays not just for our practices, but our patients. Advocacy is the outlet for our passion for providing affordable health care and leading successful business. While there are still drawbacks, the Medical Loss Ratio rules of the ACA will force some of the insurers’ financial benefits from COVID-19 to be shared with enrollees, though accounting rules mean that it will take time for most patients to benefit from that help. Personally, I would like to see insurers share some of those premium dollars by investing in physical therapy practices through more reasonable payment rates and support for the transition to the infrastructure required for value-based care. Just as many of you already have done in 2020, this will be where I focus my passion in the year ahead.
1Boyd JW, Himmelstein D, Woolhandler S. Insurance-Industry Investments in Tobacco. N Engl J Med. 2009; 360:2483-2484.
2Mohan AV, McCormick D, Woolhandler S, Himmelstein DU, Boyd JW. Life and health insurance industry investments in fast food. Am J Public Health. 2010;100(6):1029-1030. doi:10.2105/AJPH.2009.178020
3Altman D. COVID-19 Is Causing Health Spending To Go Down. Kaiser Family Foundation website. https://www.kff.org/coronavirus-covid-19/perspective/covid-19-is-causing-health-spending-to-go-down/. Published December 2, 2020.
4Altman D. The pandemic is causing an unprecedented drop in health spending. Axios. https://www.axios.com/the-pandemic-is-causing-an-unprecedented-drop-in-health-spending-b4801ec8-8da5-42a5-a66c-68c78dbd6e13.html. Published December 2, 2020.
5The COVID Racial Data Tracker. The Atlantic. https://covidtracking.com/race. Published December 22, 2020.
6US Centers for Disease Control and Prevention. Hospitalization and Death by Race/Ethnicity. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html. Updated November 30, 2020.
7APM Research Lab. The Color of Coronavirus: COVID-19 Deaths By Race And Ethnicity In The U.S. https://www.apmresearchlab.org/covid/deaths-by-race. Published January 7, 2021.
8Collins SR, Radley DC, Baumgartner JC. State Trends in Employer Premiums and Deductibles, 2010–2019. The Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/state-trends-employer-premiums-deductibles-2010-2019#.X7u_KoGIPNg.twitter. Published November 20, 2020.
9Norris L. How millions were left behind by ACA’s ‘family glitch’. HealthInsurance.org. https://www.healthinsurance.org/obamacare/no-family-left-behind-by-obamacare/. Published December 1, 2019.
Robert Hall, JD, MPAff, is a senior consultant for PPS working to advocate with private payers. He may be reached at email@example.com.