Strategic Positioning

Note: This piece was originally published over the weekend in our Sunday newsletter. Want content like this delivered to your inbox before it hits our blog? Subscribe here.

The Big Story: Health insurers soak in pandemic-fueled Medicaid growth

As Americans lost jobs and suffered major financial hits last year, Medicaid rolls swelled. Insurance companies are reaping the benefits because they now manage roughly 70 percent of Medicaid enrollees.

Our Take

(2-minute read)

It’s a strange time. More than eight in 10 adults think healthcare is too expensive, but who to blame? Everyone’s trying to figure out where to point the finger, and everyone in our industry is jockeying to position themselves as THE patient advocate.

But what do patients think? You know, those people actually receiving the care being offered and funded by our $3 trillion industry.

We decided to ask them through a quick survey of 500 U.S. adults.

Easy stuff first: In a predictable landslide, 85 percent said that healthcare is too expensive.

Next question: Who is primarily responsible for the high cost of care? Almost twice as many respondents (30 percent) blamed insurance companies vs. the next biggest culprit, “the system as a whole” (16 percent). About 13 percent cited hospitals. Women – the primary healthcare decision makers – were more likely to blame insurance companies than were men. On the other hand, men distributed their ire a bit more evenly among the various options, though insurance companies still edged out the dubious win.

It’s an intriguing wrinkle in a moment where we’re hearing of mixed results in payer-provider negotiations – some talks are collaborative; others are gloves-off, with payers squeezing hospitals for lower reimbursements. Meanwhile, insurance companies are enjoying the profits they accuse hospitals of pursuing and growing their revenue through increased management of and enrollees in ACA plans, as noted in The Big Story.

All of these pieces – and there seem to be a lot of them lately – add to the imbalance between insurance companies and those who are actually, well, providing healthcare. (Of course, even that distinction is blurring as insurance companies pursue vertical integration).

So, let’s look at a few facts to help balance the conversation:

• Rural hospitals across the country are at increasing risk for closure, potentially leaving wider and wider gaps in care.
• Safety net hospitals are barely hanging on.
• Payers managing the Medicaid population seem to be doing just fine.
• The five biggest health insurance companies control 44 percent of the market.
• Medicare Advantage and Managed Medicaid grew from 26.8 percent of payer revenues in 2007 to 51.6 percent 10 years later, per Axios. That means they’re making more money from managed care even as providers make less relative to private insurance due to lower reimbursement.
• Seventeen percent of in-network claims in ACA marketplace plans were denied in 2019, and only a fraction of a percent are ever appealed, according to a Kaiser Family Foundation study. That means insurance companies managing those marketplace plans are putting consumers on the hook for the cost of care.
• MACPAC reported that “There is no definitive conclusion as to whether managed care improves or worsens access to or quality of care for beneficiaries.” More on that story can be found in this article from NPR, also linked in the Axios piece above.

There’s a campaign taking shape against providers in the halls of Washington and the pages of the press.

In a sense, it’s an effort to change the survey results you see above. Will it take hold? Time will tell. For now, though, we see that people are more likely to point the finger at insurance than hospitals. Hospitals have a solid reserve of goodwill earned from their long history and pandemic heroism. That’s a reserve they must not squander.

Note: This piece was originally published over the weekend in our Sunday newsletter. Want content like this delivered to your inbox before it hits our blog? Subscribe here.

The Big Story: 178 hospital workers suspended for not complying with coronavirus vaccination policy

Houston Methodist took a hard line on employee vaccinations for COVID-19 and is under fire for enforcing that rule. Neither the mandate nor the protest is a surprise – a big talking point all year has been, “Can and should healthcare organizations mandate COVID-19 vaccines?”

Our Take

(3-minute read)

The bad news: No matter what you do, someone isn’t going to be happy about it.

The good news: There’s a certain freedom and clarity in knowing that you can’t please everyone. When grounded in mission, it’s an opportunity to do the best you possibly can and then rest assured.

Advice: Mandates are a tough call for healthcare leaders. Whatever you choose be clear.

Now let’s get down to brass tacks. Most people want healthcare workers to be vaccinated. Our own poll from Spring found that 79 percent of Americans believe healthcare workers should be required to be vaccinated. Out of Houston Methodist’s roughly 26,000 staff members, 99 percent got their shot – just over 600 received an exemption or were allowed to defer and 178 refused. Pretty impressive.

Yet questions are swirling as to whether vaccine mandates are legal. Just check out the lawsuits making their way through the courts. One look at the protests at Houston Methodist and you can quickly discern that not all healthcare workers are keen to comply.

This isn’t an easy call. We spoke with David Pate, MD, JD, former CEO of St. Luke’s Health System and our resident expert on this dicey and consequential topic. From that conversation and what we’re hearing from our client network, we know that many leadership teams are making that call based on the following decision framework:

1. What legitimate reasons do you have as a healthcare provider for mandating staff vaccination? For staff, patients and community.
2. What other vaccinations are currently required?
3. Who does the mandate cover – from physicians to vendors to volunteers?
4. What exemptions are there?
5. Will vaccinated employees be identified? How?
6. What changes to current precautions will be permitted for the fully vaccinated?
7. Who will be educating your workforce about the process for vaccination and answering questions about its safety and efficacy?
8. Should you first seek voluntary compliance with incentives?
9. What are the consequences for refusal to get vaccinated?
10. Do state laws against vaccine passports apply to healthcare employers?

Once you’ve made a decision on your organization’s position, consider these seven communications practices before uttering a sentence or sending your first “Dear Colleagues” email. Above all, know that tension grows when communication is confusing. Inconsistency breaks trust.

• Explain clearly and often the reasoning and logic behind your decision.
• Connect your decision with your mission of care for patients and employees.
• Provide venues for those who feel negatively impacted to voice concerns. Acknowledge their insight, it’s valuable, even if you are staying the course.
• Define the terms to avoid: “Why does this apply to me and not to them?” Don’t let nuanced decisions appear to be arbitrary double-standards.
• Prepare for pushback and special requests. Patients may ask to see clinicians who are vaccinated – or demand proof. Have procedures and messaging in place to respond.
• Put the decision in context. Discuss what other measures you’re taking. If mandating the vaccine, explain who is exempt and any additional precautions they must take. If you’re not requiring vaccinations, lay out plans to keep patients and staff safe.
• Give people steps they can take. Encourage actions that will promote public health. Reinforce existing guidelines and best practices, voluntary vaccination. Educate people on the benefits of doing so: getting back to “normal.”

Want this information in an easy-to-use resource? Download the one-page checklist here.

Note: This piece was originally published over the weekend in our Sunday newsletter. Want content like this delivered to your inbox before it hits our blog? Subscribe here.

The Big Story: Seesawing Perceptions on the Payer-Provider Playground

This week Modern Healthcare cast providers as potential bullies, taking advantage of COVID-19 to pressure payers for higher rates and bigger margins. This followed on the heels of a tough review of hospital consolidation in The New York Times while America’s Health Insurance Plans rebranded themselves to just “AHIP” as they become providers, too. We’re noticing a thread here.

Our Take

2020 was a banner year for insurance companies, even with a costly Q4. So payers celebrated by rebranding. As the Good Guys. As the ones “guiding greater health.”

This week saw America’s Health Insurance Plans convert to the simple “AHIP.” Very hip to ditch an apparently unpopular word from the moniker. We note, as Modern Healthcare did, what the Edelman Trust Index says about the trust consumers have for “insurance” companies today.

With their reframe, AHIP smartly took a page right out of the provider playbook by using mission-oriented, self-descriptive language such as “champions of care,” and “advancing mental and physical health.”

This blurring of lines might work. Still, wasn’t it jarring to see the news sitting atop the flagship trade publication for, ahem, providers? A sign of the times…and of an opportunity not to be missed.

Each of our picks for The Big Story painted healthcare providers, in part, as bad guys using their size, clout, public goodwill and financial resources to wield power over smaller hospitals and/or insurance companies to boost profits and plump their margins.

This ink is the latest in an accumulating narrative that pins blame for healthcare’s myriad problems – cost, price, pick your poison – on providers. And then elevates payers as the patient-focused advocates for a healthy society.

But that’s not the whole story, of course.

To be clear: Hospitals and health systems are not blameless victims. There are plenty of head-scratching examples of bad practices by providers and, frankly, providers don’t always do the best job of telling their side of the story even when they do the right thing (ahem again).

But there’s another side of the story to tell. One that explores how major insurance companies are raising premiums while pushing for steady or even lower reimbursement to providers. And one pointing out that provider rates are increasing with single-digit speed, while premiums jump by double digits.

It’s an awkward, sometimes contentious moment for providers. We’re not looking to flip the script, but a conversation that will truly make healthcare better needs more balance. An all-around honest and self-reflective look at our healthcare system and how it’s paid for is needed. Because we can’t improve the system without fully diagnosing the problems – all of them.

It’s a big challenge for those covering our overheated industry.

It’s an opportunity and an obligation for providers, too.

So what’s our advice for providers who find their organizations in the middle of these stories? Or who are having to duke out tense negotiations with payers both behind closed doors and in the court of public opinion? Approach it this way:

Steel yourself. Be aware. The tactics and lines of argument used in mainstream media for national stories will make their way into your next local negotiation. One side of this equation (sad that we’re even positioning our healthcare system as having “sides”) has been building a clear narrative and telegraphing that they’ll use it. No provider should be caught off guard. Tune into news like the stories above for the playbook’s X’s and O’s.

Be honest. Engage in some serious self-reflection on how you’re providing care, supporting your teams and doing what you can to fulfill your mission. Don’t let the perception of unfair coverage distract from any real issues that may need to be addressed.

Keep going. If the insurance industry is jockeying for position as the patient advocate, that means it’s a provider’s space to lose. Let payers roll out their new branding. Hospitals and clinics and medical practices are where people go for care, not insurance offices. Nurses and doctors and techs and LPNs touch patients, not actuaries. That’s the story you need to tell.

Get Engaged. It’s a long story. The insurance industry won’t remake their image overnight and providers won’t balance the conversation overnight either. But providers must begin by speaking with a collective voice about their value and engaging in a real, ongoing conversation about the balance our industry must achieve to serve.

Questions about your managed care strategy? We can help.

Note: This piece was originally published over the weekend in our Sunday newsletter. Want content like this delivered to your inbox before it hits our blog? Subscribe here or at the link below.

The Standout News: Brought to You By People Who Are Smarter Than We Are

Jimmy Kimmel, who’s used his talk show to speak on healthcare and politics numerous times, jumped in again last week with a pro-vaccine montage. It featured a handful of physicians who flashed their credentials (and student debt) and insulted people who haven’t gotten the shot. It was self-righteous, hilarious and very cathartic. But not helpful.

Our Take

(2.5-minute read)

We’re offering the white coats a little free communications advice: Skip Plan A – “A” for Aggression – when trying to change behavior. When we talk about using doctors and nurses to advocate and inform because they’re your most trusted voices…this isn’t what we’re recommending. Put simply: Don’t go all Kimmel on your patients. Leave the biting comedy to the pros.

Look, we get it. The absolutely legitimate frustration your caregivers feel having experienced firsthand the trauma COVID-19 can cause and continuing to hear people railing against the vaccines or still denying the virus is an issue.

Even so, wanna make someone dig in their heels? Insult them. Make fun of them. Piss them off.

Of course, Kimmel’s doing a bit, not offering an actual public health PSA (as far as we know). We haven’t seen any of you take his approach. But don’t let it rub off. Don’t let the frustration you feel about stagnant vaccination numbers cloud your pro-vaccine communications going forward. As much as you’d like to verbally throttle people who aren’t inclined to contribute to herd immunity, just…don’t.

Experts say the next 100 million doses will be harder to give than everything we’ve done up to this point. A recent STAT News article titled Vaccinations are plateauing. Don’t blame it on ‘resistance’ put it this way: “As daily vaccination rates settle and the country’s progress toward herd immunity slows down, let’s not rush to the same misguided conclusion that this is mostly about lack of vaccine confidence.” Labeling those who buy into falsehoods “as hesitant or resisters only hardens their viewpoints.”

So how do we make this easier? Well, the CDC’s lifting of the mask mandate is certainly a significant carrot (vs. stick) that ought to go a long way. Otherwise, here’s some advice from your favorite spin doctors – that’d be us – about how to get people to roll up their sleeves.

Listen to understand. You knew we’d include “listen” here. There’s a lot of research out there about what’s keeping people from getting vaccinated. Digest it. Consider what it means for the specific communities you serve. Go to those communities and ask about their experience with the vaccine – why they got it or why they didn’t. Check with influential leaders like clergy and teachers to get a sense of what their communities are thinking and feeling.

Recognize that data only goes so far. Numbers are good to back the position you’re advocating. Combine those with real-life anecdotes for a one-two punch that brings home understanding. Stories resonate far more than bar charts, which is something people who intentionally mislead know well. So as healthcare providers, tell stories about what the vaccine allows people to do, the peace of mind it brings – and back them up with good data. People aren’t asking, “What are the numbers?” They’re asking, “How will this affect me?” Paint the picture.

Set expectations with your clinicians. Doctors and nurses have a lot on them already, so arm them to inform, educate and advocate. Give them the tools they need to do so – whether it’s talking points, collateral, access to your organization’s channels or coaching on how to engage with people who have a contrarian view. Remind them that what they say about this issue reflects on the organization, even when speaking on their own time and channels. This isn’t to say you should take action against a physician who speaks out in a way you don’t approve of; instead, be proactive in reminding people about their role, their mission and the trust people have in them.

Remember that carrot. The CDC lifting mask mandates for those who have been vaccinated is an incentive for those who haven’t. The promise of returning to normalcy should be more effective than threats and insults for those who are still on the fence. Reinforce messages focused on the benefits of vaccination.

Stick with it. We know this is yet another frustration in a year full of them. Hang in there. We may not be able to convince all, but with persistence and calm patience we can convince many. A positive approach – and even a little good-natured humor – will go a long way toward getting more jabs in arms.