Contacts
For questions and media inquiries, contact Karen Poston, Gateway Business Health Coalition, (314)721-7800 ext. 105 or kposton@gatewaybhc.org.

Highlights from the St. Louis Hospital Industry Overview:

1. Overall quality and safety of St. Louis hospitals declined from the previous year, with fewer hospitals achieving 4- and 5-star CMS ratings and “A” and “B” Leapfrog Safety Grades. (Page 5 and 6)
   
   
2. Three St. Louis hospitals received an “A” Leapfrog Safety Grade in Spring 2025. (Page 5)
   • Mercy Hospital Jefferson – 2 consecutive “A” Safety Grades
   • Mercy Hospital Washington – 4 consecutive “A” Safety Grades
   • OSF St. Anthony’s Health Center – 3 consecutive “A” Safety Grades
     
     
3. Two hospitals, both part of BJC HealthCare, achieved 5-Star Overall Star Ratings in 2024. (Page 6)
   • Missouri Baptist Medical Center – 4 consecutive 5-star ratings
   • Barnes-Jewish St. Peters Hospital
     
     
4. Though overall quality saw a decline from the previous year, St. Louis hospitals improved for the three healthcare-associated infection (HAI) measures that BHC examined: CAUTI, C. diff, and MRSA. Nineteen hospitals (68%) in St. Louis performed better than the national benchmark for C. diff infections, and 9 hospitals (43%) performed better for CAUTIs. (Page 7, 8, 9).
   
   
5. St. Louis hospital discharges increased 7.1% and adjusted discharges, a proxy measure of volume that includes inpatient and outpatient, increased 11.4% from 2022 to 2023. (Page 15)
   
   
6. St. Louis hospitals’ net patient revenue increased 9.9%, while operating expenses increased by 6.1% from 2022 to 2023. This shifted 2022’s patient service loss of $73 million to a patient service income of $289 million in 2023, a patient service profit margin of 2.1%. (Page 16)
   
   
7. Net income across all hospitals, which includes non-operating revenue and expenses, totaled nearly $865 million in 2023, over 3.5 times higher than $232 million in 2022, for a total profit margin of 6.2%. (Page 16)

1. Act solely in the interests of plan participants and beneficiaries;
2. Carry out their duties prudently;
3. Follow the plan documents (unless inconsistent with ERISA);
4. Hold plan assets (if the plan has any) in trust; and
   
5. Pay only reasonable plan expenses.
   

Every ERISA plan must have at least one person identified and accountable for having decision-making power over the health plan’s fiduciary actions. The duty to act prudently, a central theme of ERISA oversight, focuses on the diligence exercised in the processes and evaluations leading to fiduciary decisions. It requires expertise in a variety of areas and the ability to seek the best value on behalf of plan participants. 

Accepting this responsibility, employers invest heavily in the education and training of their internal team and enlist the expert guidance of an array of benefit consultants, actuaries, and clinicians. When selecting an administrative partner, such as a PBM, numerous vendors are thoroughly evaluated, extensive financial modeling occurs, and prices and contract terms aggressively negotiated. 

Benefit managers, HR professionals, executive leaders, and Boards of Directors fully appreciate the seriousness of their fiduciary responsibilities in administering a health benefit plan under ERISA and the potential liability that exists if they are found not to act in the best interest of plan enrollees. Some organizations name an administrative committee or their Board of Directors as their fiduciary, and most require the final approval of fiduciary benefit decisions to be reviewed and approved at the highest levels of the organization before enacted. 

So, it is incredibly frustrating when legislative bodies bring forth bills that directly interfere with an employer's fiduciary responsibility to its plan participants, such as Missouri Senate Bill 45. This bill places the financial interest of independent pharmacists over the financial interest of Missouri employers, workers, and their families. It disregards the commitment and effort undertaken by ERISA plan sponsors to act solely in the interest of plan participants and carry out their duties prudently. On behalf of its members, the BHC has submitted a testimony to the Senate Families, Seniors and Health Committee opposing Senate Bill 45. The testimony outlined BHC’s concerns surrounding reduced pharmaceutical competition, increased costs, and constrained plan management strategies.

While advocating on behalf of Missouri employers, we recognize the difficult challenges faced by brick-and-mortar retailers and empathize with the small independent pharmacies. These are difficult times for most businesses and many families. But it is not the time to pass legislation which favors one business model over another, especially when consumer behavior trends clearly demonstrate a continued and accelerated preference for online and home delivery services. It is not the time to take programs demonstrated to be effective in reducing cost off the table.

We will continue to follow this and other legislation that puts employer benefit plan design at risk and threatens their role as fiduciaries. We welcome your input and engagement—please reach out with any questions you may have or to share your thoughts. 

• U.S. cancer deaths increased almost every year during the 20th century. It’s hard to imagine but the percent of Americans that smoked in the 1960s was over 40 percent. Gallup reports that 12 percent of Americans smoke in 2023. 
   
• Cancer deaths peaked in 1991, when 215 out of every 100,000 deaths were caused by cancer and then began to fall each year. 
   
• The overall cancer death rate in the U.S. fell 32 percent between 1991 and 2019 resulting in almost 3.5 million fewer cancer deaths. The steepest annual declines occurred in the immediate pre-pandemic years, dropping about 2% a year from 2015 through 2019 compared to 1% a year during the 1990s.
   
• To put today’s incidence and mortality in perspective, 2020 statistics show that one in every five deaths in the U.S. is due to cancer and one in every three people are expected to have cancer in their lifetime.
  
  

The drop in tobacco use is credited with the large reductions in cancer deaths at the end of the last century and demonstrates the power of prevention. The more we learn about cancer the more we understand the potential to further reduce cancer deaths by focusing on lifestyle choices. Community Form speaker, Dr. Dawn Mussallen, Integrative Oncologist and Cancer Survivor, Mayo Clinic, will share research findings that link lifestyle choices to reduced cancer incidence and sustain cancer survivorship today. 

Increased attention to screening and earlier detection, as well as a better understanding of how cancers grow and spread, have also contributed to a reduce rate of cancer deaths. The latter has led to more precise treatments that can control and even cure some cancers. Targeted chemotherapy, immunotherapy, and powerful combination treatments can give patients greater quality of life and longer lives. Director, Center for Gene and Cellular Immunotherapy at Washington University School of Medicine, Dr. John DiPersio, will simplify and share the promise of immunotherapy and precision medicine. 

Accelerating declines in the cancer death rate show the power of knowledge and actions to move closer to a world without cancer. Please join with other BHC and community members for this important conversation.
 
Warm regards,

Louise Y. Probst
BHC Executive Director

The St. Louis Area Business Health Coalition (BHC)  has recently connected with the American College of Lifestyle Medicine (ACLM). A national professional society headquartered in Chesterfield, ACLM represents more than 10,000 physicians and other health professionals across all 50 states. ACLM members are united in their dedication to identify and eradicate the root causes of chronic disease, with the clinical outcome goal of health restoration. A query of ACLM’s online search tool to help patients connect with clinicians certified to practice lifestyle medicine returns only about a half-dozen names in the St. Louis area—with few being primary care clinicians. While BHC understands that physicians are well informed on the science that connects lifestyle behaviors to disease progression, we share this information in case the ACLM programs, tools  and other resources would be helpful to you and your team. 

Who is the American College of Lifestyle Medicine (ACLM)?
As the nation’s only medical professional association representing the interdisciplinary field of lifestyle medicine, ACLM represents a galvanized force for change; members are united in their dedication to identify and eradicate the root causes of chronic disease, with the clinical outcome goal of health restoration rather than merely disease management. ACLM closes the gap in evidence-based education in lifestyle medicine across the spectrum of pre- and post-professional training.

How does a commitment to lifestyle medicine  benefit clinicians?
Lifestyle medicine can address up to 80% of chronic diseases. A lifestyle medicine approach to population care has the potential to arrest the decades-long rise in the prevalence of chronic conditions and their burdensome costs. Patient and provider satisfaction often results from a lifestyle medicine approach, which strongly aligns the field with the Quintuple Aim of better health outcomes, lower cost, improved patient satisfaction, improved provider well-being and advancement of health equity, in addition to its alignment with planetary health. Some evidence suggests that practicing lifestyle medicine can help clinicians avoid burnout by providing increased feelings of accomplishment and meaningfulness.

How prevalent is lifestyle medicine throughout the United States?
Interest in lifestyle medicine is growing. More than 100  health systems nationally, including notable names like Mayo Clinic, New York Health + Hospitals and Kaiser Permanente, have joined ACLM’s Health Systems Council, a network collaborating on the systematic implementation of lifestyle  medicine. Locally, Barnes-Jewish Hospital/Washington University and Mercy Hospital St. Louis are members.  Almost 6,700 physicians and other health professionals worldwide have earned certification in lifestyle medicine  since it was first offered in 2017. 

How can I become involved with ACLM?
ACLM, in support of the White House Conference on Hunger, Nutrition and Health, is providing 5.5 complimentary hours  of continuing medical education in lifestyle medicine and  food as medicine to 200,000 health professionals. Already, 34,000 have taken advantage of the offer and signed up. It’s an excellent first step to explore the field, establish a foundation of knowledge and see if lifestyle medicine appeals to you. ACLM also offers an extensive list of expert-led and created lifestyle medicine courses and curricular resources across the education spectrum. ACLM also hosts an annual conference that draws more than 3,200 physicians, health professionals and health system leaders. The conference includes practical “how-to” sessions on integrating lifestyle medicine, building a business case for lifestyle medicine and pursuing fair reimbursement. The 2024 conference will be held Oct. 27-30 in Orlando, Fla. and will include a virtual attendance option for those who cannot attend in person.

For more information on the American College of Lifestyle Medicine and to sign up for its lifestyle medicine courses, visit lifestylemedicine.org.

The Committee for a Responsible Federal Budget (CFRB) identifies additional factors that contributed to Medicare’s improved solvency projections. The expected sharp uptick in services driven by pent-up demand during the pandemic did not occur. Also, the passage of the Inflation Reduction Act brought new prescription drug savings to future spending projections. As a leader in reforming the health care payment system to improve efficiency, Medicare has outperformed private health insurance in holding down the growth of health costs. Knowing that any policy fix takes years to implement and refine, CMS is expected to continue to focus attention on solutions that will slow the progression of chronic disease and make Medicare spending more efficient.  

CFRB’s Health Saver’s Initiative offers a series of proposals for cutting Medicare costs including:

• §negotiating lower payments for drugs and medical services
• reducing Medicare Advantage overpayments so as not to stifle these federally funded private health plans’ incentives for improving care quality and efficiency
• engaging primary care first to reduce overuse
• equalizing payments regardless of the site of service – also known as “site neutral payments”

Understanding their parallel role in driving higher value healthcare and reducing more expensive hospital care, private sector purchasers employ strategies to encourage preventive care and effective primary care relationships for employees. Health savings accounts or other forms of consumer-driven healthcare encourage employees to take a more active role in managing their healthcare costs. With comparative information on cost and quality differences in health care more readily available than ever, employers can support enrollees in understanding how to access useful and trusted information when it is needed for themselves and their loved ones. Employers can also encourage their health plan partner to track CMS’ successful initiatives and adopt them in their commercial contracting strategies, such as site neutral payments for services or limits on specialty drug reimbursement. Healthcare costs already significantly burden employers and workers, we all need to stay focused on realizing lower cost and higher value care. 

Warm regards,

Louise Y. Probst,
BHC Executive Director

James Klein President American Benefits Council	Jonalan Smith Senior Vice President Lockton Companies

Warm regards,

Louise Y. Probst,
BHC Executive Director

1. Strengthen Social Infrastructure 
2. Decrease Screentime and be More Present
3. Take Measures to Connect with Others in Society

Loneliness and the Workplace 
The loneliness epidemic is not new, but the COVID-19 pandemic heightened social isolation and anxiety for many. While some workers thrive while working remotely, citing more time for exercising and bonding with family, others report being less active and feeling isolated and depressed . For those that do not make specific time for exercise, commuting to work, taking the stairs at the office, and walking to lunch and meetings boosts their steps and overall activity for the day. Referred to as Non-Exercise Activity Thermogenesis, or NEAT, this portion of daily energy expenditures resulting from spontaneous physical activity that is not specially the result of voluntary exercise, can help prevent disease and promote well-being. Levels of NEAT add up over days and weeks and can vary to 2000 kilocalories per day, contributing meaningfully to the health and wellbeing of workers. A pillar of Lifestyle Medicine, movement reduces our risk of chronic diseases, anxiety, and depression, and improves longevity. 

Connections Large and Small
While fostering meaningful connections with family and close friends is one tool for combating loneliness, research suggests that smaller connections, or “weak ties” are just as vital. Weak ties, such as the friendly chats you have with strangers in public or general acquaintances, like exchanging pleasantries at the office, have a steep impact on your well-being. According to a study conducted by Gillian Sandstrom of the University of British Columbia, weak tie relationships help decrease depressed moods, increase overall happiness, and create a greater sense of belonging among individuals. They also tend to keep us sharp, as these exposures have been found to bring introductions to new ideas and people that are important to our sense of self, growth, and work. 

Opportunities to Strengthen Connections and Increase Movement 
The workplace, whether in person or virtual, offers opportunities to support workers via movement and social connections. Be mindful of actions to increase non-voluntary exercise while at work, whether you are in person or remote. Walking meetings or fitness challenges can make a difference for employees mental and physical health, which in turn reduces health care spending. Recognize the value in small talk and take a few minutes to engage with coworkers and express interest in their well-being. A study conducted by Psychological Science that explores the way that empathy impacts well-being and aids in fostering relationships found that people who experienced empathy for the positive emotions of others were subject to higher levels of well-being. “Fruedenfreude,” or the ability to find pleasure in another person’s success—can function as a sort of second hand positivity. This is applicable within weak-tie connections just as it is in close relationships. The way we view connection and actively interact with others directly impacts their and our state of health. 

BHC meetings offer a great opportunity to connect with old friends and make new ones, we look forward to seeing you soon. 

Warm regards,

Louise Y. Probst

BHC Executive Director

Lung cancer screening in Missouri’s commercially insured population was the focus of a recent Midwest Health Initiative report, Lung Cancer Screening: The Missouri Story. While lung cancer screening rates in Missouri doubled between 2018 and 2021 - they remain low at about 6.6% of eligible adults.

Like other cancers, lung cancer survival is greatly improved when the cancer is detected early, as treatment options are less likely to be curative once the cancer has spread. In an effort to reach a broader and more inclusive population of at-risk patients sooner, the U.S. Preventive Services Task Force (USPSTF) changed lung cancer screening guidelines in 2021: low-dose CT screening is now recommended annually for current smokers, or those that quit within the past 15 years, aged 50 to 80, with a history of 20 or more pack-years.

Although early detection of lung cancer is critical, the decision to partake in screening is more complex than it may initially seem. There are potential risks, such as false test results, low doses of radiation exposure, and overdiagnosis. Patients should be counseled on these prior to being screened. Additionally, lung cancer screening is not appropriate for patients who are unwilling or unable, due to other health conditions, to undergo treatment if lung cancer is found. Early detection won’t change the outcome for patients who will not be treated, but screening and diagnosis may cause emotional or physical harm. 

Missouri and other states’ lung cancer statistics can be compared on this American Lung Association interactive website. 

• Overall, patients in Missouri are diagnosed early at a similar rate to patients nationally, except for Latino Americans, who were least likely to be diagnosed early in Missouri.
  
  
• People diagnosed with lung cancer in Missouri are less likely to undergo surgery or other treatment.  
  
  
• Missouri’s five-year survival rate for lung cancer is meaningfully below the national average.

While surgery remains the ideal first-line treatment for patients with early-stage lung cancer, patients who are not healthy enough to undergo the procedure or whose cancer has spread may not be candidates. Other treatments may be recommended, such as chemotherapy, radiation, targeted therapy, or immunotherapy. Recent improvements in survivability are likely due in part to advancements in immunotherapy and targeted treatments informed by biomarker testing.

A new and rapidly evolving field, biomarker testing, enables medical professionals to study tumor cells and characterize their genetic mutations, protein expression, and tissue environment in order to identify treatments that can target the specific molecular pathways of cancer cells. Clinical stage, biomarkers, tumor histology, and several other factors all contribute to the treatment decision. In lung cancer, testing is primarily utilized for late-stage non-small cell lung cancer.

An MHI report coming soon will provide additional insights into targeted therapy and coverage for lung cancer biomarker testing. MHI analysts reviewed clinical guidelines across Missouri’s major health plans and summary plan documents (SPDs) from a handful of self-insured employers and found no barriers to these evolving and game-changing biomarker tests. All Missouri major health plans’ biomarker policies were consistent with national standards. While employer SPDs were generally silent on “biomarker” testing, they explicitly covered medically necessary diagnostic services and genetic testing. Employers may benefit by referencing the National Comprehensive Cancer Network® (NCCN®) in their plan documents. This collaboration of 33 leading cancer treatment centers across the U.S., including Siteman Cancer Center in St. Louis, has established “a comprehensive set of guidelines detailing the sequential management decisions and interventions that currently apply to 97 percent of cancers affecting patients in the United States.” Employers could simply state that their plan provides coverage for biomarker testing consistent with NCCN guidelines, much like the way they state their plan covers preventative screenings recommended by the USPSTF, and rest assured that their coverage will remain consistent with best practices and evolving science overtime.

What else can employers do?  

1. Connect employees with Missouri Department of Health and Senior Services’ free Missouri Tobacco Quit Services. This confidential service is an effective way to help Missourians quit all forms of tobacco, including e-cigarettes and smokeless tobacco. Prevention is always the best policy.
   
   
2. Educate eligible tobacco users and their family members on the importance of annual screenings and early detection, noting the importance among Latino populations and emphasizing the fact that lung cancer screenings have first dollar coverage. 
   
   
3. Educate employees on available support programs, such as those offered through your EAP, which can help with issues like depression and anxiety, coping with emotions, and even managing money issues.
   
   
4. Support employees and their dependents in achieving their best health, and encourage protective factors to boost resilience, such as a nutrient-dense diet, improved physical activity, and healthy sleep habits.
   
   
5. Join BHC members for the April 12th community forum, “Building Immunity: The Science of Healthy Living” for an update on this science. Register here.

Warm regards,

Louist Y. Probst

BHC Executive Director

Confirmed speakers include: 

	Susan Benigas Executive Director American College of Lifestyle Medicine
	Mark Cunningham-Hill, MD Medical Director Northeast Business Group on Health
	Matthew Herzberg Managing Partner Principled Transformation
	Devyani Hunt, MD Medical Director Washington University Living Well Center

Conference attendees will learn about the latest immune system research; the promise of evidence-based, lifestyle medicine in treating (or even reversing) chronic conditions; and how employers are redefining well-being to build employee and organizational immunity in a post-pandemic world. We are excited to return to our long-standing venue at the Donald Danforth Plant Science Center for a morning of education and networking with nearly 300 business and health care leaders.

BHC members receive complimentary registration for this event. To access, please click here and sign in to your website profile, or use the promo code BHCCF2023 at checkout. Travel stipends are also available to assist out-of-town employer members in joining us in St. Louis for the event. For questions regarding registration, please contact Todd Boedeker at tboedeker@stlbhc.org. 

We look forward to seeing you there!

The Process

Throughout the multiyear process, 22 council members reviewed the literature, consulted health care and economic experts, and evaluated the practicality and impact of a wide variety of proposed interventions. The Road Map for Action clarifies that the Council’s analysis considered several drivers of health care cost: administrative waste, excess prices, clinical waste, regulatory burden, supply chain profits, clinician earnings, and fraud and abuse. 

The publication also notes that the growth in U.S. health care spending relative to Gross Domestic Product (increasing from 6.9% in 1970 to 17.7% in 2019) seriously crowds out the ability of government and families to afford other necessary services. Council leaders urged that the extent of the U.S. health care spending problem must not lead to inaction. To show the magnitude of opportunity and the risk of doing nothing, research by Dartmouth health economist Jonathan Skinner and colleagues was referenced. It estimated that if health care’s share of GDP could be stabilized to the 2019 level of growth and remain there until 2031 (rather than following its rising trajectory since 1980) then health care spending would be $3 trillion dollars less.

The Recommendations

In addition to stating the Council’s objectives, the road map also makes clear what is not a focus of its work: social determinants of health, low-value care, and pharmaceutical pricing and spending. The rationale for intentionally excluding these areas is not a lack of concern for these issues, rather a clarity of focus and knowledge of efforts underway elsewhere. There is also a detailed discussion of the roles of federal and state government, with a seeming preference for state action with federal alignment and support. The road map includes a ranking of policy recommendations, which fall into four areas: 

1. Administrative streamlining
   
   
2. Price regulations and supports for competition
   
   
3. Spending growth targets
   
   
4. Value-based payments 

Why It Matters
In reading this work, I celebrated the alignment between the national experts’ deliberations and the conversations that have evolved during a similar local, multi-stakeholder effort over the last two years. Published last month, the Midwest Health Initiative’s new report Realizing Effective and Affordable Change in Health Care details the process of achieving shared commitments to health care spending growth targets in St. Louis for the 2023, 2024, and 2025 years. Resulting from a partnership of nearly 30 public and private employers, labor unions, health plans, health systems, and medical groups, the REACH workgroup will guide regional efforts to mitigate rising health care costs, while also monitoring advancements in primary care.  

National-Local Alignment
Both the Council’s and REACH’s efforts are intentional and centrally focused on bending the health care cost curve. Although the road map calls for statewide, mandated strategies, REACH is unique in its voluntary, regional approach. Yet, there are other important parallels to point out:

• The national road map suggests “collective action” has been a missing ingredient from U.S. actions to stem spending and calls for multi-stakeholder governance. At the outset, the REACH workgroup acknowledged the importance of an “all-in” approach, seeking commitments from every major St. Louis medical group and health system to align actions in flattening spending growth.
  
  
• The road map emphasizes that data for target setting must be readily available so that spending growth can be calibrated below key economic indicators, such as gross state product, household income, wages, or Consumer Price Index. REACH participants evaluated the same list of economic indicators and selected state domestic product as the preferred metric to provide a context for understanding regional health care spending growth.
  
  
• The road map notes that centralized data collection is essential and also recommends that states analyze (transparently) areas of high spending, spending variation, and spending growth rates to determine potential drivers, such as outlier prices, practice patterns, population characteristics, or other factors. REACH partners have agreed upon measures and methodologies to assess cost and quality performance among St. Louis medical groups, which will be published in future public reports. 

As a next step for REACH, a series of meetings to support stakeholders in realizing these shared goals will begin next month. Participation is open to interested BHC employer members. Please contact me or Allison Ball to get involved in this important work.

Warm Regards,

Louise Y. Probst

BHC Executive Director

1. Educate employees and their family members on lower-priced insulin options that are available.  
   
2. Consider the impact of cost-sharing for preventive and maintenance medications on your population, especially lower income workers.
3. Monitor insulin adherence with your health plan or PBM and explore clinical programs available to enhance diabetes management. 
4. Amplify the purchaser voice surrounding medication affordability and monitor regulatory actions on a state and federal level.
   

In a country where drug prices continue to make headlines, insulin rationing reminds us that this problem is not just about numbers…it’s about lives. And as with many challenges facing our health care system, it will take the collaboration of many stakeholders to find the right solution. In the meantime, the BHC looks forward to supporting our employer members in their benefit, well-being, and advocacy efforts. For other resources to prevent, better manage, and reverse diabetes in your workforce populations, visit the BHC’s Defeat Diabetes Campaign webpage. 

Warm Regards,

Lauren Remspecher, MPH, CHES

BHC Senior Director, Member Engagement & Communications

The Problem

Despite being pushed off the front pages by the pandemic and our nation’s recent economic woes, deaths from opioid use disorder (OUD) have soared to new levels over the past few years, having a profoundly negative impact on families, communities, and workplaces. According to the Centers for Disease Control and Prevention, drug overdose is a leading cause of injury-related death in the US, and in Missouri, the leading cause of death for those ages 18-44 years. In 2021, opioids were associated with 70% of all overdoses in the state, at the cost of 1,583 Missouri lives, according to Missouri Department of Health and Senior Services (DHSS) data.

Missouri Resident Overdose Deaths, 2016-2021

Source: Missouri Department of Health and Senior Services

The opioid class of drugs includes heroin, fentanyl, methadone, morphine, oxycodone, and many other prescription and non-prescription pain relievers. As the chart above illustrates, the types of opioids implicated in death from overdose are changing. Synthetic opioids, predominantly illicit fentanyl, surpassed prescription opioids and heroin as drivers of overdose-related morality rates in 2016. Much more potent than heroin, fentanyl and its analogues can take the form of powders, tablets, and liquids, which severely challenges efforts to stem opioid misuse. This enables contamination of a range of illicit drugs, including heroin and counterfeit pills, and has elevated the risk of overdose among low-frequency users and increased both fatal and nonfatal overdose rates.

Reporting from the Midwest Health Initiative demonstrates that opioid scripts per 1,000 in the commercially insured population in St. Louis have been trending downward, dropping by nearly 25% between 2018 and 2021, likely due to employer, pharmacy benefit manager, and public sector interventions. But this should not be seen as a signal that that all is well at the worksite.

Workplace Impact

According to the Substance Abuse and Mental Health Services Administration, approximately 66% of adults who misuse opioids are employed. OUD and other substance use disorders increase accidents, turnover, poor job performance, and health care costs. Each employee who recovers from a substance use disorder saves an employer $8,500 annually, according to the National Safety Council (NSC). The NSC Substance Use Calculator uses workforce size, industry, and location to calculate the costs of substance abuse for individual businesses.

Employer Action

The drug epidemic affects all genders, races, economic statuses, and age groups in both rural and urban communities.  In addition to workers themselves, any employee may have a partner, child, or family member that is struggling with a substance use disorder. Given the widening scope and continuing urgency of the problem, employers can review and update their strategies for combatting this serious disease. 

1. Ensure benefit plans provide supportive counseling and behavioral health services.
2. Train managers and workers to identify signs and symptoms of a substance use disorder and connect impacted persons to appropriate treatment and recovery supports.
3. Keep naloxone in the workplace and train employees on how to properly administer it. Naloxone reverses the effect of opioids and can save a life, if administered in time. It is available in most states, including Missouri, without a prescription.
4. Help employees find the treatment and recovery programs with the highest likelihood of success. Medication -assisted therapy (MAT) is a comprehensive approach that combines the use of medication with counseling and behavioral therapies to meet the unique needs of individuals.

Missouri DHSS has been working to combat unnecessary death and suffering due to substance abuse, including advancing the number of treatment resources and identifying MAT Treatment Centers statewide. For employers in other markets, SAMSHA has a search tool which delivers information on approved treatment programs by zip code. Use care in getting to the actual federal agency site if not using the link provided, as a lot of treatment centers have created “official-looking” sites that promote their own treatment center. 

Resources

Employers hold legal obligations when addressing any type of substance use disorder with an employee. The Americans with Disabilities Act (ADA) protects qualified employees with disabilities from employment discrimination and may apply to individuals in recovery from substance use disorders. Luckily, there are many resources to guide employers in their efforts, including:

• SAMHSA’s Drug-free Workplace Toolkit, for advice on complying with federal guidelines.
• SAMHSA’s Guide for Employers to Identify and Prevent Opioid Misuse, a comprehensive and valuable resource for employers seeking effective policies and practices.
• The Society for Human Resource Management has created a library of resources on the topic, including this article on employer treatment approaches to combat rising substance abuse post-pandemic.
• The Minnesota Department of Health’s Opioid Epidemic Response Employer Toolkit, which includes sample emails, social media, and other resources for communicating with employees about proper disposal of prescription medications and other issues related to opioid misuse.

When employers respond to the opioid epidemic, it benefits employees, the people that surround them, businesses, and society in general. The BHC hosted an educational program on this topic in August 2018 and looks forward to continuing to support employers in addressing this concerning public health issue. Please let us know how we can be a resource to your teams.

Warm Regards,

Louise Y. Probst,

BHC Executive Director

About The Leapfrog Group
Founded in 2000 by large employers and other purchasers, The Leapfrog Group is a national non-profit organization driving a movement for giant leaps forward in the quality and safety of American health care. The flagship Leapfrog Hospital Survey and new Leapfrog Ambulatory Surgery Center (ASC) Survey collect and transparently report hospital and ASC performance, empowering purchasers to find the highest-value care and giving consumers the lifesaving information they need to make informed decisions. The Leapfrog Hospital Safety Grade, Leapfrog's other main initiative, assigns letter grades to hospitals based on their record of patient safety, helping consumers protect themselves and their families from errors, injuries, accidents, and infections.

About the St. Louis Area Business Health Coalition

The St. Louis Area Business Health Coalition (BHC) is a non-profit organization representing nearly 70 leading employers, which provide health benefits to thousands of lives in Missouri and millions nationally. For 40 years, the BHC has worked to achieve its mission of supporting employer efforts to improve the well-being of their employees and enhance the quality and overall value of their investments in health benefits. To accomplish these aims, the BHC centers its work on providing pertinent research, resources, and educational opportunities to help employers understand best practices for the strategic design (and informed use) of benefits to facilitate high-quality, affordable health care. To learn more, please visit www.stlbhc.org.

ST. LOUIS, Missouri, November 18, 2022 – First Busey Corporation (Busey) was announced as the winner of the 2022 Business Health Culture Award at the St. Louis Area Business Health Coalition’s (BHC) 40th Annual Meeting today. With over 1,500 associates nationwide, Busey has established a robust strategy to support holistic well-being, boasting an 89% participation rate among employees.

“It’s more important than ever to take care of ourselves, and Busey’s B Well program provides easy opportunities to do so,” says Van Dukeman, Chairman and CEO of First Busey Corporation. “I’m proud that we prioritize wellness and foster a culture that impacts the health and well-being of our associates and their families."

Empowering associates is core to Busey's mission, vision, and values, and the B Well program is driven by that very passion. Benefits include a 24/7 fitness center, gym reimbursements, online stress management, financial literacy resources, wellness coaches, and a wellness champion network of employees aptly titled “Well-beings.”

“As a BHC member, First Busey Corporation has consistently demonstrated itself as a leader in advancing well-being in the workplace and in our community,” explained Louise Probst, Executive Director of the St. Louis Area Business Health Coalition. “Busey supports their associates in every dimension of wellness, contributing to a healthy organizational culture that helps individuals to thrive."

Created in 2014 by employers of the BHC’s Wellness Roundtable, the Business Health Culture Award recognizes organizations for their innovative and comprehensive approaches to improving the well-being of employees and their family members. The award application was modeled with careful consideration of best practices in the corporate wellness field, as defined by national research organizations, academia, and the employer sector.

To learn more about the award process and resources to support employee and community health, please visit www.stlbhc.org.

Interestingly, advancing the use of generic medications has been a decades-long cost reduction strategy in the US, ushered in by the Drug Price Competition and Patent Term Restoration Act of 1984. Better known as the Hatch-Waxman Act, unfortunately, this legislation also paved the way for the high-priced brand drug problem the US experiences today. The legislation lengthened the monopolies on brand prescription drugs by up to seven years, despite opposing research that longer patents would substantially increase prescription drug costs to consumers. In an effort to increase the supply of generics and appease the opposition, Hatch-Waxman also enabled manufacturers to make drugs that had gone off patent without having to replicate the same expensive clinical trials. An interesting look back shares the story of how lengthening drug monopolies became the political price for permitting the abbreviated generic drug approval process and the expansion of generic drug use in the US. 

Although generic drugs are among the best deals in the US health care system, the generic drug supply has been plagued with problems: dangerous drug shortages, medications tainted with hazardous materials, manufacturers falsifying safety records, and steep price increases for some drugs, including price gouging schemes. It seems that generic prices have become so low that companies have stop making them or cut corners to be able to sustain their business. Few generic drugs are manufactured in the US any longer – making adherence to US quality standards hard to ensure and inspect. According to this New York Times overview of the problem, “competition for market share at rock-bottom price points has led to chronic shortages, unpredictable price-spikes, allegations of illegal price-fixing, and substandard and even dangerous practices.”  

According to the article cited above, of the top 100 generic medicines that Americans consume, 83 had no US source of active pharmaceutical ingredients, and no American source existed for 97% of the most commonly prescribed antivirals and 92% of the most commonly prescribed antibiotics. Sudden severe generic drug price spikes, consolidation among drug manufacturers, and access to life-saving drugs for US patients during periods of international unrest have garnered the concern of the federal government, which has been working to shape solutions. An interagency report led by the Food and Drug Administration, entitled Drug Shortages: Root Causes and Potential Solutions, three root causes were identified for drug shortages:

(1) Lack of incentives for manufacturers to produce less profitable drugs;
(2) Market failure to recognize and reward manufacturers for “mature quality systems” that focus on continuous improvement and early detection of supply chain issues; and
(3) Logistical and regulatory challenges that make it difficult for the market to recover from a disruption.

The generic drug supply chain problems demand attention and collaboration from all stakeholders, not just government. Many hospital systems in the private sector have come together to take action, employing a uniquely American solution: competition. The product of their efforts, Civica Rx, now delivers high-quality and fairly priced generic medications produced on US soil. SSM Health is one of the founders of this critical collaboration. Join us at the BHC’s 2022 Annual Meeting where you can learn more about Civica Rx's progress from West Health CEO, Shelley Lyford. Focused on philanthropic efforts to lower health care costs and enable successful aging, West Health will also share the results of their recent research with Gallup focused on American perceptions of health care in the post-COVID era.

Warm Regards,

Louise Y. Probst,

BHC Executive Director

Advancing price transparency has become a priority on both sides of the congressional aisle, as well as among many public and private organizations. Federal cost reporting requirements for hospitals, health plans, and employers that have been designed and implemented recently all seek to make it easier for patients to price shop. Hospitals must report their actual prices with insurers in a consumer-friendly and machine-readable format. Similar regulations on health plans and employer plan sponsors went into effect this past year, and more are set to come. Although many organizations were slow to comply and the reporting is not standardized, the efforts have provided a national source of hospital prices, ready to be used by patients, employers, and the press to compare care. 

Health care claims are the best information source for understanding spending and resource use. They document the care billed by a provider for a patient population. Analyses such as per member per month (PMPM) spending, percent of Medicare facility reimbursement, provider practice patterns and expertise, resource use, and adherence to quality guidelines all hold important insights for driving better value care. BHC's regional partner, the Midwest Health Initiative, engages in these types of commercial claims analyses, as do state all payer claims databases (APCDs).

The National Academy of State Health Policy has undertaken the effort of downloading and organizing data from Medicare cost reports for most US hospitals, including summaries of hospital revenues, expenses, efficiency, breakeven points, charity care, and other financial details. This information is quite useful to employers when comparing hospitals within a community and collaborating with local health systems toward better value care. Thanks to the Centers for Medicare and Medicaid Services, the Leapfrog Group, National Committee for Quality Assurance, and National Quality Forum, hospital-specific findings for a rich set of quality, safety, and patient experience measures are also readily available.

All of this information has the potential to create meaningful competition across medical groups and health systems, driving quality up and prices down. But only if the data get used. Employers are critical to ensuring that our new-found transparency delivers on its promise. Now that we know, or could know, the insights that these data sources hold, we have a greater obligation to act. The BHC is working to organize available data sources nationally and support members in using these insights.

If your organization is ready to take action, here are some steps to get you started: (1) listen to this month’s BHC podcast episode with Mike Thompson of the National Alliance of Healthcare Purchaser Coalitions to be inspired by the possibilities; (2) prepare to talk with your employees about their role in using health care information to be a knowledgeable consumer; (3) join us for the BHC Annual Meeting on November 18th to learn how Americans' perceptions of health care can inform our collective commitment to a better future.

Warm regards,

Louise Y. Probst,

BHC Executive Director

She gave the example of Duexis, a FDA-approved medication that combines Pepcid and Ibuprofen into one pill, and is known to most employers as a prime example of a low-value pharmaceutical. When purchased over the counter, this therapy would cost about $11 per month, but when written by a physician as a single prescription, the cost is over $2,300 a month. Dr. Rosenthal asks the important question, "Why do we allow this?" She noted that no other nation would.

She also cautions patients, that when being told that you may need to spend a night in the hospital, to confirm that your services will be classified as an inpatient stay and not an observation visit. Although the room and level of care is the same, an observation visit is considered outpatient care and will likely be subject to much higher patient cost sharing than an inpatient stay. 

Altarum, a nonprofit research organization, fielded its Consumer Healthcare Experience State Survey to more than 1,100 Missouri adults during April 2022. The survey results unmask Missourians’ perceptions on a wide range of health system issues, including prescription drug costs and health care affordability. A few of the key findings include: 

• 62% of respondents experienced at least one health care affordability burden in the past year, including 51% of respondents with family incomes more than $100,000.
• 82% worry about affording health care in the future;
• 60% of uninsured adults under the age of 65 say they have postponed getting the health care they needed due to cost, as did about half (48%) of insured adults.
• Lower-income respondents and respondents with disabilities reported higher rates of going without care and incurring debt due to health care costs. 
• Adults ages 25-34 years rationed medication due to cost more often than any other age group. 
  

More than two-thirds of respondents believe Missouri’s health care system needs to change. Respondents, across party lines, express strong support for government-led solutions. They cited drug companies, hospitals, and insurance companies as the main drivers of out-of-control costs and identified a number of ways the government could tackle these issues. Sheldon Weisgrau, Missouri Foundation for Health’s Vice President of Health Policy stated, “This is not a partisan issue. Missourians want policymakers working together on solutions that will make a real difference in their lives and ensure people get the care they need at a price they can afford.” Curious about survey results in other states where you may have employees? Check out Altarum’s Healthcare Value Hub. 

The good news is that many provider, health plan, labor union, and employer leaders agree. In fact, over the summer they have been meeting to discuss shared opportunities to improve health care affordability and quality. To learn more about the American public’s perceptions of health care and efforts to reduce the growth in health care spending, we invite you to attend our 2022 Annual Meeting on Friday, November 18, in St. Louis, Missouri. Tickets are complimentary for BHC members, and travel stipends are available to assist out-of-town members in attending. We look forward to sharing our progress with you and celebrating our 40th anniversary as employer partners in health care.

Warm regards,

Louise Y. Probst,

BHC Executive Director

So what exactly are Digital Therapeutics? 

According to the non-profit trade association, Digital Therapeutics Alliance, DTx deliver medical interventions directly to patients using evidence-based, clinically evaluated software to treat, manage, and prevent a broad spectrum of diseases and disorders. DTx services are distinct from the many health and wellness apps that simply track calories or count steps in that they are specifically designed to treat disease. Early DTx have focused on asthma, anxiety, diabetes, post-traumatic stress disorder, and ADHD, with solutions for a wider range of conditions under development. DTx may use sensors and AI-based algorithms to provide real-time feedback to patients and providers or offer customized coaching.  

What are Prescription Digital Therapeutics?
Prescription Digital Therapeutics (PDT) are subject to peer-review clinical trials that confirm their ability to improve peoples' lives. They receive FDA approval and are prescribed by a clinician. PDT can be used in conjunction with other medications or therapies, or as standalone treatments under a clinician’s oversight. A few leading, FDA-approved PDT include: 

• Pear Therapeutics has three prescription software treatments for substance use disorders and insomnia.
  
  
• Akili’s EndeavorRx prescription videogame treatment helps children with ADHD improve attention function by navigating a space ship through obstacles. 
  
  
• EaseVRx, by Applied VR, is a virtual reality software that uses cognitive behavioral therapy to reduce lower back pain with relaxation techniques, distraction, and behavior modification.
  
  
• BlueStar, developed by Welldoc, is prescribed for adults with Type 1 or Type 2 diabetes to suggest in real-time when users should test their blood sugar and how to control it by adjusting food intake and exercise. 

What should be considered when evaluating DTx?

DTx advocates think most disease conditions will include a software solution as a first-line therapy in the next decade. Yet, payers and providers have been slow to embrace these technologies. Eager to create pathways for reimbursement, product innovators have pursued distribution through the major Pharmacy Benefit Managers, some of which now offer PDT formularies. Early-adopter employers are beginning their due diligence in evaluating available PDT with the following questions: 

(1) Clinical and Cost-Effectiveness - Is the evidence strong enough to pay for treatments that resemble free or low-cost smartphone apps? How will cost-effectiveness be measured and reported? What is the expected duration of treatment and cost? Given their newness, a standard FDA process for vetting PDT does not exist. As the controversy surrounding Biogen's Alzheimer's drug made clear, employers cannot always use FDA approval as a proxy for clinical effectiveness. Fortunately, PDT innovators are hustling to amass an evidence base for their products. Employers should expect evidence of clinical trials and value to exist, along with indicators of patient acceptance. Kaia Health, for example, points to a randomized controlled trial showing that patients using its solution to treat lower back pain had medical claim costs that were 80% lower than those using standard therapy. Performance guarantee should be expected. Bipartisan legislation in the pipeline may expand Medicare coverage of PDT. If this passes, the coverage of specific products by the Centers for Medicare and Medicaid Services could be a helpful indicator of clinical and cost-effectiveness.

(2) Purchasing Intermediary and Process - A digital “formulary” is a catalogue of vetted apps that PBMs or health plans offer. Would your organization prefer to go through one of these intermediaries to purchase or go direct? Do PDT have rebates and administrative fees, and are these disclosed? Does your health plan or PBM contract ensure that all revenues earned from products or services used by your enrollees are returned to the plan sponsor? 

(3) Patient Cost and Plan Design - Does your plan design language need to be updated to account for PDT and DTx? How will patient cost sharing being structured and the benefit of PDT be communicated? 

Ready to explore further?

While DTx and PDT could be attractive solutions for patients, physicians, plans, and employers, many questions remain to be answered. BHC members looking to learn more are invited to attend our next Pharmacy Meeting on September 13 at 2:00 PM (CT) as we discuss the PDT and DTx landscape, offerings currently available through PBMs, and considerations for employers prior to implementation.

Warm regards,

Louise Y. Probst,

BHC Executive Director

Warm regards, 

Louise Y. Probst

BHC Executive Director

In an impressive display of collaboration and an unprecedented timeframe for change in health care, the National Kidney Foundation (NKF), National Committee for Quality Assurance, and other national organizations have aligned their levers to build important groundwork to improve the diagnosis and prognosis for people with or at risk of chronic kidney disease. NKF is now turning to physicians, health plans, employers, and patients to pick up the cause. Read on to learn about the diagnosis and treatment of kidney disease, connect with resources, and understand how you can take actions to protect your workforce and the people important to you from chronic kidney disease. 

The kidneys are vital to life. They remove excess toxins from the blood, balance key electrolytes and fluid volume, and excrete hormones that help regulate blood pressure, red blood cell production, activate vitamin D, and support bone strength. The primary cause of kidney disease is diabetes, followed by hypertension. CKD increases the risks of heart disease, stroke, and early death, in addition to kidney failure. Many people with CKD die of a heart attack because of the strain that kidney failure places on their heart. 

Practice guidelines now recommend two screenings, a blood and a urine test, annually to assess for kidney disease among people with diabetes, hypertension, or other risk factors for CKD. The blood test is the estimated glomerular filtration rate (eGFR) and it assesses kidney function. The urine Albumin-to-Creatinine Ratio (uACR) assesses kidney damage. Both are needed. In 2020, major laboratories collaborated to create a standardized kidney profile that bundles the eGFR and uARC into one request, which more easily enables clinicians to order and compare results across labs. 

It’s not a urine dipstick. Convenient and commonly used in the physician office to check for protein in the urine, dipstick urine tests do not detect lower albumin and creatinine levels and are not recommended for assessing kidney damage. Often the earliest sign of CKD, an elevated uACR (≥30 mg/day) can detect kidney damage about 10 years before a decline in eGFR is observed, so at-risk patients should get an uACR. 

To improve treatment outcomes, race is no longer included in the eGFR equation. African Americans and Hispanics are disproportionately affected by CKD and are more likely to progress to kidney failure than Whites. However, it has been recognized that race is a social and not biological construct, including race when assessing screening results could unintentionally worsen disparities in care. This led to a taskforce recommendation that the adjustment for race be removed. African American and Hispanic patients may find changes in their kidney disease status or stage when they are first tested by a lab which has completed this transition.  

A single quality measure now includes both tests. The Kidney Health Evaluation for Patients with Diabetes was developed by the National Kidney Foundation and the National Committee for Quality Assurance (NCQA) for implementation in 2021, and public reporting of results is expected in 2022. The Centers for Medicare & Medicaid Services has also begun to transition a similar measure into its Merit-based Incentive Payment Systems (MIPS) programs. Due to recent debate around the numerical definition of hypertension, NCQA was unable to include people with hypertension in the measure denominator at this time. Screening rates in people with hypertension need further attention.

Screening rates are way too low. The average testing rate for people with diabetes is less than 50% nationally, which leaves an enormous number of people in the dark about their disease. Kidney screening rates in Missouri lag the nation. With support from Bayer, the Midwest Health Initiative (MHI) was able to apply the new NCQA measure to statewide data, learning that in 2021 only 40.9% of commercially insured adult Missourians with a diagnosis of diabetes received these two kidney tests. Congratulations to Esse Health for a top screening rate of 67.8% in the St. Louis region.

The US Preventive Services Task Force announced last month that due to new evidence and treatments that support assessing asymptomatic patients, it would re-evaluate adding screening for chronic kidney disease (CKD) to its list of preventive services.  

Employers have an important role to play in advancing screening. Early diagnosis and treatment can meaningfully reduce suffering, save lives, and lower spending. Ask your health plan to provide a baseline screening rate for your at-risk population. Align your health education and wellness strategies with those of your vendors to increase screening rates. Talk with your physician, friends, and family about kidney screening. These changes have occurred recently and rapidly. Not all providers are aware of them, so it’s important for patients at risk to request the tests. 

Education and resources from the CDC, NKF, and a toolkit from NCQA and Bayer are also available. The BHC stands ready to support your efforts. Please reach out with any questions or requests.

Warm Regards,

Louise Y. Probst,

BHC Executive Director

Here are a few of the highlights: 

1. Negative perceptions of the US health care system related to cost, quality, and access grew dramatically over the course of the COVID-19 pandemic. Nearly half of all Americans surveyed (48%) say their view of the US health care system worsened due to the pandemic. 
   
   
2. An estimated 38 million Americans (15%) report that their ability to pay for health care has become worse due to the pandemic, resulting in a greater portion of Americans delaying and deferring needed care.
   
   
3. Few Americans believe they receive good value when weighing the quality of care against the cost. An overwhelming majority of Americans (93%) agree citizens across the country are paying too much for the quality of care received. This view is consistent across all income groups and has increased significantly throughout the year.
   
   
4. More than a third (35%) of respondents say they are “more worried” about affording health care in the future, a concern shared by at least one in five households making more than $90,000 a year. One-fifth of Americans (21%) report a time in the prior 12 months when they or a household member had a health problem worsen after postponing care, with Medicaid beneficiaries (37%) reaching nearly the same level as the uninsured (39%). Black adults are twice as likely as White adults to know someone who died because cost kept health care out of reach.
   
   
5. When falling ill, 73% of Americans report being somewhat or very worried about insurance covering the cost of treatment. Among respondents, there is more concern about the cost of care than missing work or finding a provider to treat the illness. For many Americans, the cost of care may worsen their health conditions due to both care avoidance and added anxiety.
   
   
6. More than two-thirds of Americans, regardless of party affiliation, say they are pessimistic about the federal government enacting policies to reduce health care costs in the coming year. Two-thirds of US adults (66%) think voters have very little to no power in reducing the cost of health care in the US, but nearly nine in 10 think American businesses, corporations, and US Congress do.  

The report points out that this overwhelmingly negative public sentiment has been years in the making. Tim Lash, President of West Health, sums the report up like this: “Bottom line – Americans are increasingly getting priced out of the system, and many of those who can still afford to pay don’t think they’re getting their money’s worth relative to the cost. We must begin to change this trajectory with smarter policies that put patients over profits.” So what happens next? Will politicians in Washington and across state governments feel the public's pain and finally take meaningful action to lower costs, improve access, and reduce inequities? The BHC will continue advocating on behalf of purchasers, businesses, and workers that they do.

Warm Regards,

Louise Y. Probst

BHC Executive Director

Leapfrog's advocacy started with a simple three-question survey of hospitals. If implemented, each recommendation represented a potential giant leap forward for patient safety. So straightforward and obviously important from today’s lens, it’s hard to understand the pushback that was initially received, with hospitals discrediting the “science” and boycotting the survey. Leapfrog knew all too well that what is was asking was expensive and that the technology was not perfect. Yet, it also understood that the technology would not get better until it was used and that the cost of not acting was both expensive and harmful.  

Leapfrog's first three leaps are still included in its annual, voluntary hospital questionnaire. With results available publicly online, patients, purchasers, and providers can all ask if their hospital has:

(1) Computerized Physician Order Entry (CPOE)
With federal financial support, more than 95% of hospitals have implemented Electronic Health Records (EHRs). Few would consider going back to the old ways of handwritten orders. One report suggests that medical errors have decreased 52% as a result of online ordering, and three times as many physicians reported that their EHR prevented a potential medication error rather than cause one. Yet, there is more to be done. A November 2021 report finds that 7,000 to 9,000 Americans die due to a medication error each year. The total cost of looking after patients with medication-associated errors exceeds $40 billion each year, with over seven million patients affected. 

(2) ICUs staffed with intensivist physicians during daytime hours (can be partially met with telemedicine)
The benefit of having patients cared for by physicians trained in critical care has been well-researched and found to reduce ICU mortality and spending. A recent study published in the Journal of Thoracic and Cardiovascular Surgery found that 24-hour intensivist coverage was associated with lower mortality, lower rates of cardiac arrest, and shorter durations of mechanical ventilation. Interestingly, the practice of a trained intensivist physician assuming responsibility for ICU patients' care has been the mainstay in Europe for decades. According to a 2016 report, only about half of hospitals in the US meet this criteria, and practices vary widely by state.   

(3) Enough surgical volume to safely perform certain high-risk procedures
Unknowingly, patients are often at greater risk of death and complications because their surgical teams do too few procedures (even common ones) for doctors, nurses, and technicians to maintain their skills. For 10 high-risk surgeries, Leapfrog asks hospitals to report their case volumes annually. In 2015, knowing that patients in the hands of low-volume surgeons or hospitals tend to fare worse, a group of leading academic institutions asked all hospitals to “Take the Volume Pledge” to improve surgical outcomes. Johns Hopkins, a leader in this initiative, explains the importance of surgical volume to its potential patients and lists the frequency of 11 procedures performed at its hospitals on its website. 

The evidence that volume matters to surgical outcomes is strong. This 2015 US News and World Report article discusses the issue from a variety of perspectives and provides examples of the importance of volume for surgical cases, including for common surgeries such as a knee replacement.  

The takeaway: a low volume surgeon or hospital may provide a good outcome, but overall patients are likely to have fewer complications and better outcomes in the hands of an experienced surgeon and facility. While it would be nice, we do not have to wait for hospitals to take the volume pledge. Don’t be shy about asking a surgeon directly, or the physician that refers you to a surgeon, for the number of times that they completed this surgery at the recommended facility in the past year. 

Leapfrog was founded to shine a light on hospital performance so that employers and patients could use their purchasing power to reward the top achievers and foster a marketplace for high-value care. Leapfrog reporting has expanded. Today you will find a letter safety grade for every general hospital in the US, as well as measures of infection rates, Cesarean section rates, and health equity. 

Leapfrog’s success depends on all of us using information to seek the safest and best quality care. The BHC is proud to support this effort as a Leapfrog Regional Leader in the St. Louis area. We will continue to highlight Leapfrog advancements and support employer members and the public in accessing and understanding the information. Please let us know how we can assist as you explore the available data.

Warm Regards,

Louise Y. Probst

BHC Executive Director

Click here to read the full article.

By way of background, Wegovy is a once a week injectable semaglutide, a medication that mimics the GLP-1 hormone (glucagon-like peptide-1). Released after eating, GLP-1 suppresses appetite and slows gastric motility, making people feel full longer and eat less. Clinical trial data show that participants lost on average 12% more of their body weight compared to a placebo over a 68-week period. Weight loss was found to be higher when combined with a supervised weight loss program. Studies have shown that weight returns, though, when the medication is stopped, suggesting this would be a lifelong treatment. Since its June 2021 US Food and Drug Administration (FDA) approval, Novo has experienced supply chain issues which have limited the drug's availability and postponed its marketing efforts to physicians. Supply chain issues are expected to be resolved in the coming months. Early indications suggest that patient success and physician acceptance is favorable and that product awareness and use are beginning to pick up.

The FDA approved Wegovy for use, in addition to a reduced calorie diet and increased physical activity, for patients with at least one weight-related ailment and a body mass index (BMI) of 27 kg/m2 or greater, as well as for people with or without an obesity comorbidity at a BMI of 30 kg/m2 or greater. Weight-related conditions include high blood pressure, type 2 diabetes, or high cholesterol. 

NICE’s independent appraisal committee recommended that Wegovy be considered as an option for weight management when offered alongside a supervised weight-loss program for a maximum of two years. Patients must have at least one weight-related condition and a BMI of 35 kg/m2 or greater. With exception, patients with a BMI of 30.0 kg/m2 to 34.9 kg/m2 may be considered if they meet certain additional criteria. Individuals from a South Asian, Chinese, and Black African or Caribbean background (known to experience higher rates of preventable premature death) were recommended for consideration at a lower BMI (usually reduced by 2.5 kg/m2).

But what about the price differences?  

Novo has set the list price for Wegovy in the US at $1,349 for a four-week supply. Rebates are generally understood to be about 20% to 22% of the list price. This means that net of rebates, Wegovy will cost over $13,000 per patient per year in the US.   

In the UK, not so much. Wegovy has a list price of about $99.08 (£73.25) for a four-week supply, or just under $1,300 per patient per year. So before any negotiations off of the list price, the annual cost in the UK is less than a one-month, after-rebate supply in the US.

We all know that the US has a very different and cumbersome supply chain, especially when compared to a single-payer system like that in the UK. So I was prepared for a price that was double, triple, or maybe quadruple – but not ten times or more.  

Why is it priced so much higher in the US? Well, it seems that it is the usual answer…“because it can." Wegovy is but one example of a problem we see often in the US pharmaceutical industry. 

The Institute for Clinical and Economic Review (ICER), the US' non-profit, private-sector response to the UK’s NICE, has announced that it will undertake a review of Wegovy this fall. Using an open, transparent, and independent consensus-based process, ICER reviews medications and establishes a fair price for use in the US. ICER leaders have been giving a lot of thought to how employers in the US could leverage this work to achieve better value for their investments in pharmaceuticals. Several possible solutions in their forthcoming Purchaser Playbook hold appeal. BHC members can get a sneak peek at these recommendations, and we look forward to receiving your feedback. Let’s not despair. Let’s take action.

Warm Regards,

Louise Y. Probst

BHC Executive Director

1. Act solely in the interests of plan participants and beneficiaries;
2. Carry out their duties prudently;
3. Follow the plan documents (unless inconsistent with ERISA);
4. Hold plan assets (if the plan has any) in trust; and
5. Pay only reasonable plan expenses.

Every ERISA plan must have at least one person identified and accountable for having decision-making power over the health plan’s fiduciary actions. The duty to act prudently, a central theme of ERISA oversight, focuses on the diligence exercised in the processes and evaluations leading to fiduciary decisions. It requires expertise in a variety of areas and the ability to seek the best value on behalf of plan participants. 

Accepting this responsibility, employers invest heavily in the education and training of their internal team and also enlist the expert guidance of an array of benefit consultants, actuaries, and clinicians. When selecting an administrative partner, such as a PBM, a number of vendors are thoroughly evaluated, extensive financial modeling occurs, and prices and contract terms aggressively negotiated. 

Benefit managers, HR professionals, executive leaders, and Boards of Directors fully appreciate the seriousness of their fiduciary responsibilities in administering a health benefit plan under ERISA and the potential liability that exists if they are found not to act in the best interest of plan enrollees. Some organizations name an administrative committee or their Board of Directors as their fiduciary, and most require the final approval of fiduciary benefit decisions to be reviewed and approved at the highest levels of the organization before enacted. 

So it is incredibly frustrating when legislative bodies bring forth bills that directly interfere with an employer's fiduciary responsibility to its plan participants. Yet, this is exactly what Missouri House Bill 1677 does. It places the financial interest of independent pharmacists over the financial interest of Missouri workers, their families, and the state’s employers. It disregards the commitment and effort undertaken by ERISA plan sponsors to act solely in the interest of plan participants and carry out their duties prudently. It is also hard to see how the legislature can enact legislation which would increase health benefit costs for workers, without some fiduciary responsibility. 

At the direction of the BHC Board and on behalf of members, small businesses, and all Missouri workers, the BHC has submitted a letter to the Health and Mental Health Policy Committee of the Missouri House of Representatives opposing House Bill 1677. The letter outlines BHC’s concern in three areas that we feel threaten to reduce pharmaceutical competition, increase costs, and constrain plan management strategies. We will continue to follow this and other legislation, some that more directly targets employers’ ability to overcome the significant mark-up on specialty medications administered in the medical benefit. We welcome your input and engagement after you review the legislation and BHC’s letter. Please reach out to share your thoughts and support. 

We recognize the difficult challenges faced by brick and mortar retailers and empathize with the small independent pharmacies. These are difficult times for most businesses and many families. But it is not the time to pass legislation which favors one business model over another, especially when consumer behavior trends clearly demonstrate a continued and accelerated preference for online and home delivery services. It is not the time to take programs demonstrated to be effective in reducing cost off the table.

Warm Regards,

Louise Y. Probst,

BHC Executive Director

ST. LOUIS, Missouri, January 26, 2022 – The St. Louis Area Business Health Coalition (BHC), the region’s only organization focused solely on representing the purchaser perspective on health care, is celebrating its 40th year. Founded in 1982 by a small group of leading employers, the coalition now serves nearly 70 member organizations across the U.S. that provide health benefits to thousands of lives in Missouri and millions nationally. In collaboration with local health system, health plan, and other community partners, the BHC has worked to advance its mission of supporting employer efforts to improve workforce well-being and the value of health benefit investments.

The coalition’s history and success would not be possible without the guidance of its Board of Directors, comprised of experienced human resources and benefits professionals from the region’s top businesses. The New Year kicked off with the announcement of new Executive Committee leadership, as the BHC welcomes 2022-2023 Board President, Dave Toben, Director of Benefits, for Bi-State Development/Metro Transit.

"The BHC has played an important role in advancing health care in our region for decades, and I am honored to serve as Board President during such a momentous time in the organization's history," said Dave Toben. "As we embark on our 40th year, I am eager to continue strong collaborations with fellow employer purchasers, seeking higher quality and more affordable health benefits for our employees and their family members."

Other Executive Committee leaders include Vice President  John Ziegler (Arch Resources), Treasurer Marla Langenhorst  (Ameren Corporation), and Member-at-Large Bryan Kassing (Concordia Plan Services). The BHC also looks forward to insights from four new Board members, inducted for their first three-year terms:

Linda Brady
Healthcare Strategy & Policy
The Boeing Company

Valerie Peters
Vice President, Human Resources
Olin Corporation

Margo Quinlan
VP, Total Rewards/Payroll HCM
Schnuck Markets, Inc.

Chad Thompson
Corporate General Manager of HR
North American Lighting, Inc.

In addition to serving its employer members with education/networking events, group-purchased benefit offerings, well-being programming, and data benchmarking tools, the BHC will focus on several priority projects during the 2022 year. These include multi-stakeholder partnerships to improve overall health and the value of health care across our region. The BHC and its Board are also engaged in health policy and legislative discussions on a state and national level, ensuring that the interests of those buying and using employer-sponsored health coverage are represented. 

To stay informed of these efforts or to view a full list of BHC’s Board of Directors and membership, please visit www.stlbhc.org. Community partners are also encouraged to follow the BHC on Twitter and LinkedIn to join in this year’s anniversary celebration using the hashtag #BHCturns40.

But today, there is a severe shortage in our nation’s blood supply. Donor turnout, which has declined over the past decade, has now also been dramatically impacted by the pandemic. Blood centers across the country are reporting less than a one-day’s supply of blood — a call to action for all of us. Dr. Rhonda Cooke, Chief of Pathology at St. Louis’ Missouri Baptist Hospital, has reached out to solicit businesses’ help to spread the word about the dangerously low blood supply and to encourage employees to prioritize blood donation in Missouri, nationally, and around the world. 

“I have never seen blood shortages as severe as what we are currently experiencing. If the nation’s blood supply does not stabilize soon, life-saving blood may not be available for some patients when needed,” says Dr. Cooke, who has practiced transfusion medicine for more than 10 years. The American Red Cross (ARC) informed hospitals in December that they will not be able to fill orders for Group O blood for at least the next 4 to 6 weeks. Physicians have been notified that a triage process is in place and that some patients may need to delay surgeries and will likely not have access to transfusions.

Blood use has dropped by about a third in the past decade, largely because of improvements in surgical technique and blood conservation efforts, according to Kaiser Health News. But this has not been enough to offset the declines in donation, as many regular donors age. For people who grew up during World War II — and their children, the Baby Boomers — blood donation was a civic duty that became a lifelong habit, said James AuBuchon, President and Chief Executive of Bloodworks Northwest in Seattle. Nearly 60% of blood donations come from people over 40 according to the AABB, an international non-profit focused on transfusion medicine and cellular therapies. Increasingly, blood industry experts report that there are too few young people lining up to replace them.

Our nation’s blood supply is almost entirely dependent on volunteer donors and the network of 66 federally regulated non-profit blood centers. While only 37 percent of the U.S. population is eligible to donate blood, less than 10 percent do annually. Donors must be at least 18 years old (16- and 17-year-olds must have written parental consent). There is no upper age limit. COVID vaccination does not prevent or defer donation, as long as you are healthy and symptom-free.     

Typically, the blood comes from an anonymous person. However, people may donate blood to directly benefit a friend or loved one, and in some cases, themselves. Given the shortages, this may be something to consider.

What can YOU do? First, if you can, please donate. Giving blood is a charitable act, and like other charitable acts, it strengthens values and helps the donor feel good. Organizing incentives or steps to make it easier for or to reward your employees who make this donation can be beneficial for their health and well-being. Here are some other recommended actions:

1. Help prioritize blood donation as a national imperative by increasing public awareness and education around blood donation, especially for younger and diverse donors.
2. Reach out to BHC for sample articles and periodic reminders to inform your workers and encourage their donation throughout the year. Be sure to include information about donation centers and eligibility criteria. For more details, visit the websites of the ARC, AABB, or ABC.
3. Inform your employees of organized opportunities that may spur their donation. This month, the American Red Cross is raffling off Super Bowl tickets to those that donate. The St. Louis Cardinals host an annual blood drive among their fans, and the 2022 BIG Heart Blood Battle was recently launched across four Big Ten schools: Michigan, Michigan State, Penn State, and Wisconsin. 
4. Consider sponsoring a competitive challenge across the divisions of your organization or with a supplier or another employer. If you go this route, BHC is here to assist you in finding resources to support your planning and execution.  

Thank you for your actions to sustain America’s blood supply.

Warm regards,

Louise Y. Probst

BHC Executive Director

Congress directed federal agencies, including the U.S. Department of Health and Human Services (HHS), to establish a federal Independent Dispute Resolution (IDR) system to be available for use after thirty days of unsuccessful negotiations between a payer and air ambulance provider. Under the proposed IDR system, an approved arbitrator entity would receive information about each party’s claim, additional requested information, and the “qualified payment amount” (QPA) or the plan’s median in-network payment. Modeled after the “baseball-style” arbitration, the IDR entity selects one offer, which becomes binding on both parties. The losing party must pay the fees associated with the IDR process.

Recognizing that billed charges can be inflationary and that public program rates are significantly lower than commercial payments, Congress barred the IDR arbitrators from considering: (1) a provider or facility’s usual and customary charge or the billed charge; or (2) reimbursement rates paid by public payers. The law lists the QPA as a must-be considered factor and gives the IDR the authority to determine how other factors influence their determination. These other “additional factors” likely include geography, market share, service expertise or level, etc. The IDR entity is also required to explain their decisions when selecting an offer that is higher than the QPA.

Both the Association of Air Medical Services (AAMS) and the Texas Hospital Association have filed suits in federal court challenging the proposed rules. According to a December 6th Health Affairs blog post, both suits claim that the agencies have given priority to the QPA, and as such, the new federal IDR process favors insurers. The lawsuits claim that the rules are not consistent with what Congress intended because of the heavy weight placed on the qualifying payment amount in the arbitration process.

Administration officials, purchasers, plans, and patients believe that the agencies did what Congress instructed. Their goal was for the IDR process to help to lower health care spending, and they find that many of the provisions are necessary to encourage the parties to work together in earnest to resolve their dispute, rather than relying the arbitration process. If QPA is not considered, they fear that patients, employers, and public insurance programs could face higher premiums. 

Hotly debated and lobbied political issues are a strong indication of the amount of money on the table. Operating as an “out-of-network” provider has brought price-setting power to air ambulance companies and hefty profits. Research from the USC-Brookings Schaeffer Initiative for Health Policy revealed that by 2017, two private equity firms controlled nearly two-thirds of the national Medicare market for both fixed-wing and helicopter air ambulance transports and that transports delivered by private equity and publicly-traded firms were the most expensive, often reimbursed at 50 percent more.  

According to Heathcare Dive, Congress is also weighing in on the rules, with 152 lawmakers signing a letter on November 5 stating the latest rules "do not reflect the way the law was written, do not reflect a policy that could have passed Congress…” Besides stating the obvious, since these issues were debated for months in Congress, before the details were assigned to the federal agencies to determine, their letter seems to value the financial interest of the private equity firms above that of the American public. The Healthcare Dive article links you to the letter and 152 Congressional signors. Take a look and see what you think.  

Stay tuned. Resolution of these pending lawsuits is expected in early 2022. 

Warm regards,

Louise Y. Probst

BHC Executive Director

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About the St. Louis Area Business Health Coalition
The St. Louis Area Business Health Coalition (BHC) is a nonprofit organization representing over 70 leading employers, which provide health benefits to thousands of lives locally and millions nationally. For 39 years, the BHC has worked to achieve its mission of supporting employer efforts to improve the well-being of their employees and enhance the quality and overall value of their investments in health benefits. To accomplish these aims, the BHC centers its work on providing pertinent research, resources, and educational opportunities to help employers understand best practices for the strategic design (and informed use) of benefits to facilitate high-quality, affordable health care. To learn more, please visit www.stlbhc.org or follow the BHC on Twitter and LinkedIn.

The independent grading system assigns an “A,” “B,” “C,” “D,” or “F” grade to general hospitals across the country based on over thirty national measures of preventable errors, injuries, accidents, and infections. The fall 2021 Hospital Safety Grade represents the largest set of hospitals ever graded, with grades assigned to 2,901 facilities across the country.

In the St. Louis and surrounding region, twenty-six (26) hospitals were graded, and ten (10) earned an “A,” five (5) earned a “B,” eight (8) earned a “C,” one (1) earned a "D," one (1) earned an “F,” and one (1) was not graded.

The local hospitals that earned an “A” include HSHS St. Elizabeth's Hospital, Mercy Hospital Jefferson, Mercy Hospital South, Mercy Hospital St. Louis, Mercy Hospital Washington, OSF Saint Anthony's Health Center, SSM Health St. Clare Hospital – Fenton, SSM Health St. Joseph Hospital – Lake St. Louis, St. Luke’s Des Peres Hospital, and St. Luke’s Hospital.

The Leapfrog Hospital Safety Grade is the only hospital ratings program based exclusively on hospital prevention of medical errors and harms to patients. The grading system is peer-reviewed, fully transparent and free to the public. Grades are updated twice annually, in the fall and spring. 

“The Leapfrog Group thanks the health care workers in St. Louis and nationwide who work so hard for their communities. It’s important we recognize excellence, especially in times like these. But it’s also important to know when hospitals fall short, because lives are at stake,” said Leah Binder, president and CEO of The Leapfrog Group. “We see every day how hospitals can and will improve their safety when patients make clear it’s important to them.”

For more information about the Leapfrog Hospital Safety Grade, as well as individual hospital grades and state rankings, please visit HospitalSafetyGrade.org.

About The Leapfrog Group
Founded in 2000 by large employers and other purchasers, The Leapfrog Group  is a national non-profit organization driving a movement for giant leaps forward in the quality and safety of American health care. The flagship Leapfrog Hospital Survey and new Leapfrog Ambulatory Surgery Center (ASC) Survey collect and transparently report hospital and ASC performance, empowering purchasers to find the highest-value care and giving consumers the lifesaving information they need to make informed decisions. The Leapfrog Hospital Safety Grade, Leapfrog's other main initiative, assigns letter grades to hospitals based on their record of patient safety, helping consumers protect themselves and their families from errors, injuries, accidents, and infections.

About the St. Louis Area Business Health Coalition

The St. Louis Area Business Health Coalition (BHC) is a non-profit organization representing over 70 leading employers, which provide health benefits to thousands of lives in Missouri and millions nationally. For 39 years, the BHC has worked to achieve its mission of supporting employer efforts to improve the well-being of their employees and enhance the quality and overall value of their investments in health benefits. To accomplish these aims, the BHC centers its work on providing pertinent research, resources, and educational opportunities to help employers understand best practices for the strategic design (and informed use) of benefits to facilitate high-quality, affordable health care. To learn more, please visit www.stlbhc.org or follow the BHC on Twitter and LinkedIn. 

To aid in this, BHC has enlisted Adam J. Fein, PhD, as a keynote speaking during our November 18th Annual Meeting. Dr Fein is the CEO of Pembroke’s Drug Channels Institute and one of the country’s foremost experts on pharmaceutical economics and the drug distribution system. He is regularly quoted in such national publications as The Wall Street Journal, The New York Times, The Washington Post, Forbes, and many others. I look forward to seeing you at the event (either in person or virtually) and learning together.

Warm regards,

Louise Y. Probst
BHC Executive Director

MHPAEA prohibits group health plans from applying financial requirements and conditions for mental health and substance use disorder benefits less favorable than those in place for medical and surgical services. Congress first enacted mental health parity in 1996 and reinforced it in 2008. Yet, concerns remain, as outlined in this 2019 Milliman report, that enrollees needing mental health and substance use disorder services too often face barriers to accessing needed care. Current concerns stem from restrictions in the way benefits are applied: the non-quantitative treatment limitations (NQTLs), such as prior authorization, step therapy, or “must fail-first” conditions, and provider credentialing requirements which may lead to inadequate network coverage for certain services.

Hence, the December 2021 Consolidated Appropriations Act (CAA) imposed new requirements on group health plans to ensure their compliance. It requires group health plans to perform and document comparative analyses of the design and application of NQTLs to ensure parity. Plan sponsors must be prepared to submit sound evidence of compliance to the secretaries of the Department of Health and Human Services, the DOL, and the Department of the Treasury within 45 days of a request.

The CAA is clear in its intent to hold federal agencies, employers, insurers, and other plan administrators responsible for closing the gap. It requires federal agencies to request detailed comparative analyses from at least 20 group health plans and/or health insurance issuers each year. The agencies are also required to issue a report to Congress each year, and make publicly available information about the comparative analyses, including the names of the group health plans selected, whether the group health plans submitted sufficient information, and whether any of the plans were found not to be in compliance with the MHPAEA. Plans unable to successfully demonstrate parity in the required timeframe are likely to receive a corrective action plan and could be subject to public shaming and financial penalties.

Unlike many of the other provisions of the CAA that affect group health plans, the MHPAEA requirements of plan sponsors under CAA section 203 went into effect on February 10, 2021. The DOL has created a self-compliance tool to support plans and insurance companies in meeting the law’s requirements. However, specific guidance on how to quantify and compare the impact of NQTLs is not yet available. These are expected by June 2022. Your plan administrator, PBM, and consulting partner will also have resources to support you on the path to ensuring and confirming mental health and substance abuse parity in your benefit offering.

Best,

Louise Y. Probst

BHC Executive Director

1. Should employers mandate COVID-19 vaccination as a condition of employment or business relationship? If yes, considerations must be made in defining, implementing, and approving exemptions for employees, customers, or business partners, particularly for those with justified medical concerns or strongly held religious beliefs. For those terminated as a result of vaccine status, SHRM weighs in on their ability to collect unemployment.
   
   
2. What is the best process for identifying and establishing requirements for unvaccinated employees? Some options may include weekly testing, masking, and social distancing to ensure adequate protection of other individuals in the workplace.
   
   
3. What is the appropriate approach for balancing the rights and interests of vaccinated and unvaccinated workers when setting policies and designing plan coverage? Delta Airlines has announced that it will be charging higher premium contributions for unvaccinated employees. Other private insurers are no longer waiving the employee cost share for COVID-19 hospital admissions, as was standard at the beginning of the pandemic.

As employers consider their response, the several recent and thoughtful articles that follow might be helpful in exploring these issues.

Legality of Vaccine Mandates

Private employers have an absolute right to mandate the COVID-19 vaccine according to workplace attorney, Helen Rella, as quoted in this CBS article . Other recent media attention is making this legality clear to the public, and perhaps, nudging vaccine uptake. The EEOC COVID-19 technical assistance also seeks to clarify federal laws and support employers in navigating pandemic protocols.

Some Missouri legislators have called for legislation to stop Missouri employers from mandating vaccination. The BHC has expressed its opposition to any legislative intrusion on the rights of employers to provide for the health and safety of their workers and ensure operational and fiscal sustainability.

Public Opinion Poll Results – Call for Employer Action

Most Americans favor a mandate for those attending crowded public events; half think people should be fully vaccinated in order to go to a bar or restaurant; and vaccinated adults report being more likely than unvaccinated adults to wear masks in public settings and avoid large group settings. These findings, from an August 2021 poll conducted by the Associated Press and NORC at the University of Chicago, suggest that businesses and workplaces may gain favor by taking action, including making customers and workers fully aware when another worker or customer is unvaccinated.

According to an August 2021 poll by Axios, vaccine-resistant Americans are rethinking their position. The proportion of Americans highly resistant to getting the coronavirus vaccine has decreased to 14%. The poll also found that more than three-quarters of Americans either have been vaccinated or say they are likely to be, up two percentage points from mid-July, according to the index.

Costs and Hospitalizations Among Unvaccinated

COVID-19 hospitalizations among unvaccinated adults cost the U.S. health system billions of dollars in June and July 2021 alone, despite vaccines being freely and widely available in every state. The statistic is even more startling considering that the analysis used a seemingly conservative Medicare price estimate (commercially insured payments exceed Medicare rates). Like all health care, this is a societal cost that weighs heavily on American workers. 

Dr. Clay Dunagan, Senior Vice President and Chief Clinical Officer of BJC HealthCare, recently presented to BHC members , blending current science with the impact of the Delta variant on unvaccinated Missourians and the waning resilience of our region's health care systems and their employees. This firsthand account of the challenges health care workers face offers its own call to action. The positive news is that hospitalization rates may peak sooner rather than later, but ultimately, our ability to mitigate spread and achieve immunity will determine the course of the pandemic.

Closing Thoughts

As with many things in health care, COVID-19 has again poised employers to have a significant impact on employee behavior. While none of these decisions are quick or easy, taking action offers an important opportunity to build trust as an organization that values safety and evidence-based public health measures. Curious how your BHC peers are addressing vaccine requirements? Join us for our next COVID-19 Coffee Chat on September 27 to hear from fellow members and to learn more about treatment options for high-risk COVID patients.

Warm regards,

Louise Y. Probst

BHC Executive Director

Traditionally, CMS and private health plans have been willing to pay significantly more for outpatient services performed at a hospital-owned site of care than at a physician or non-hospital owned site of care. This was done to recognize that hospital-owned facilities may be staffed or equipped for higher risk patients and may be subject to stricter regulations. In April 2021, AHA released a study which showed that Medicare patients who received care in a hospital outpatient department were more likely to be poorer and have more severe chronic conditions than Medicare patients treated in an independent physician office.

Yet, there is another side of the story. Medicare Payment Advisory Commission research, conducted in response to a request from Congress, found that paying hospital outpatient departments at a higher rate has driven provider consolidation and created havoc in the marketplace for health care services. Responding to incentives to maximize profit, hospitals have gobbled up physician practices and dramatically expanded the number of sites billing as hospital outpatient departments.

According to the Alliance for Site Neutral Payments, these misaligned payment policies have greatly diminished the number of independent physician practices nationwide and driven costs higher for patients, employers, and taxpayers.  

The savings opportunity ushered in by this Supreme Court decision comes without impacting quality or reducing coverage and brings financial benefit to employees as well. In fact, Families USA calls it an overlooked victory for consumers.

We encourage you to talk to your health plan about their transition to site-neutral payments and to stay tuned for strategies to inform and engage employees in capturing this opportunity.

Warm regards,

Louise Y. Probst

BHC Executive Director

The COVID Stops Here campaign recognizes Missouri workplaces that have achieved widespread vaccination against COVID-19. Businesses that have achieved at least a 70% vaccination rate are eligible to receive a designation.  

"As an organization dedicated to improving health in our community and nationally, we are committed to stopping the spread of COVID, and widespread vaccination is a key step in achieving that goal," said Lauren Remspecher, Senior Director, Member Engagement & Communications, for the BHC. "Our employer members share this vision, and we look forward to continuing to support them in keeping their employees (and their family members) safe during the pandemic."

The Missouri Chamber of Commerce and Industry developed the COVID Stops Here campaign as a way to celebrate workplaces that are leading the fight to stop COVID-19, and to encourage more organizations to join their ranks.

“The COVID-19 vaccine is Missouri’s pathway to recovery. The St. Louis Area Business Health Coalition is helping set the bar for vaccination in Missouri by achieving Gold COVID Stops Here status — meaning 100% of their employees are now vaccinated against COVID-19. This is a great achievement and we thank them for helping our state stop this dangerous virus,” said Daniel P. Mehan, president and CEO of the Missouri Chamber. “Employers are playing a very important role as we work to encourage vaccination in Missouri. In order to finally put this virus behind us, we need Missourians to get vaccinated as soon as possible. Together we can stop this virus - let’s make sure that COVID stops here!”

Learn more at mochamber.com/CovidStopsHere.

About the St. Louis Area Business Health Coalition

The St. Louis Area Business Health Coalition (BHC) is a nonprofit organization representing nearly 70 leading employers, which provide health benefits to thousands of lives locally and millions nationally. For 39 years, the BHC has worked to achieve its mission of supporting employer efforts to improve the well-being of their employees and enhance the quality and overall value of their investments in health benefits. To accomplish these aims, the BHC centers its work on providing pertinent research, resources, and educational opportunities to help employers understand best practices for the strategic design (and informed use) of benefits to facilitate high-quality, affordable health care. To learn more, please visit  www.stlbhc.org  or follow the BHC on Twitter  and LinkedIn.

Of the 11 physician researchers and clinical experts on the independent FDA advisory panel, 10 voted against approval and one voted uncertain. They claimed that the available evidence created significant doubt that the drug will slow the progression of AD and may bring potentially serious adverse effects, with their own impact on cognition, such as brain swelling, brain bleeds, headaches, confusion, dizziness, and falling. The side effects are common and potentially serious enough to require all patients taking Aduhelm be monitored with routine MRI scans. Three members of the advisory panel resigned over the FDA’s disregard for the science, failure to communicate its change in position regarding endorsement, and a concern that the approval would slow meaningful progress in combating AD.

It seems that significant research targeting amyloid over the past twenty years has failed to produce convincing evidence of causality. Biogen had abandoned Aduhelm, stopping two clinical trials before their completion due to disappointing results. Only later upon closer examination did it note that findings in one of its studies suggested a slowing of the disease for patients with early cognitive decline. As part of its approval, the FDA will require Biogen to conduct a new randomized, controlled clinical trial to verify the drug’s clinical benefit. It has given them 9 years to complete the research. If the trial fails to verify clinical benefit, the FDA may initiate proceedings to withdraw approval of the drug. Eli Lilly and others had invested in and shelved their drugs to treat the amyloid present in AD due to disappointing results. Lilly has now announced that it will seek approval for Donanemab during 2021 under the FDA’s accelerated approval process. Other similar drugs, previously shelved, are expected to also be presented for approval.

There is an ongoing debate about the clinical relevance of amyloid in cognitive decline. While amyloid plaques and protein tangles are commonly found in patients with AD, evidence that they cause the disease’s devastating memory loss or that reducing the amyloid will yield clinical improvement has yet to be demonstrated. Some researchers fear that approval of these drugs and their potential blockbuster profits will consume resources and research dollars better directed toward other causative factors, such as blood pressure or inflammation. Follow up interviews with members of the FDA advisory panel reveal that in November 2020 the FDA told them that it would not be counting the drug’s ability to reduce amyloid as an indication that Aduhelm might be effective, but in June and without further communication to or evaluation by advisory panel members, the FDA reversed course. Esteemed neurologists, other physicians, researchers, policy experts, and journalists are speaking out about the FDA’s action. Congress has initiated hearings into the relationship between Biogen and the FDA. 

Biogen has priced the drug at $56,000 annually per patient and projected it would be used by 1 to 2 million patients per year. With related imaging and other treatment costs, the expense is expected to be $100,000 per patient. While some think this utilization estimate is overstated, most agree that the expense is out of reach for even Medicare. Depending on the numbers, the drug is projected to add between $6 to $29 billion to Medicare Part B drug spending, more than the U.S. spends each year on NASA or the Environmental Protection Agency. Many claim that dollars would be better spent on developing better evidence for other therapeutic interventions that reduce the burden of disease. 

There is more to come on the outcome of this FDA decision. The Centers for Medicare and Medicaid is considering its options with regard to coverage of these unproven medications. While employer-based plans will have less demand for treatment and immediate financial impact than Medicare, we know all too well that the cost of U.S. health care is borne by all and most directly shouldered by American workers. Self-insured employers will want to discuss coverage options with their insurance partner and watch for CMS’ decision and the outcome of further investigations of the FDA’s decision. One thing seems clear, employers may need to reconsider their use of FDA approval as a standard for the efficacy and safety of a medication. Time will tell.

For those interested in the aging brain, 60 Minutes did a six-year update of findings from a NIH-funded research study at the University of California Irvine last fall. It provides a fascinating look at the lives of several nonagenarians and potentially instructive real world insight into the presence and impact of amyloid on memory and cognition. 

Warm regards, 

Louise Y. Probst

BHC Executive Director

In the early months of the pandemic, concern arose over the long-term impact of delayed and forgone care. While it is too soon to fully understand the clinical consequences, Milliman suggests that much of the deferred care may actually have been eliminated, noting that lifestyle and care access changes ushered in by the pandemic may have reduced short-term health care needs. Social distancing practices led to an uptick in utilization of digital health, telemedicine, and mail order pharmacy services, which also likely contributed to overall lower utilization of other services. Yet, the potential for increased utilization driven by pent-up demand for treatment of ongoing disease conditions lingers.

The MMI reports that the 2021 cost for a hypothetical American family of four in an employer-sponsored PPO plan is $28,256. The cost represents a projected growth of 8.4% over 2020, a rate higher than seen in many years. A forecasted rebound in health care utilization and continued uncertainty drive this trend. Vaccine rates and efficacy, increased demand for care, changes in work routines and personal health behaviors, public health and provider response and practices, and the prevalence and effectiveness of care management in the months ahead all contribute to this uncertainty. Ensuring convenient and affordable primary care access and coordinating care to leverage employees’ new-found health habits are important opportunities for employers to realize a flatter cost trend while supporting better health.

Cost varies by the population and region. Milliman offers an interactive tool that employers can use to create a MMI for various metro areas and their average family definition. The table included below compares the projections for St. Louis and several other metro areas where BHC members have employees.

The BHC will continue to monitor local and national trends and looks forward to hearing from members on their successes and experiences. The BHC has also hired Milliman to analyze Midwest Health Initiative (MHI) data and provide St. Louis market and provider-specific spending and cost trends for 2020 and the preceding years. Output is being planned for fall 2021. The BHC is eager to share these results with members and to engage with health plan and health system leaders on shared opportunities to realize better population health and lower health care spending trends.

Warm Regards,

Louise Y. Probst

BHC Executive Director

Significant concern for health care spending and cost growth is widespread among employers. While organizations believe that they have some ability to control costs, such as with plan and payment design, they recognize that many solutions are outside of their control. Uncertain of how much longer they will be able to shoulder the growing financial burden without government intervention, business executives did not assign one factor as the predominant driver of excessive cost or identify a “silver bullet” solution. The survey asked the executives to rate four contributing factors to high costs: fee-for-service payments, provider consolidation, drug costs, and unhealthy behaviors. Provider consolidation is an area where the government has clearly failed the American public over the past several decades. Ninety-four percent of respondents felt it was a very large, considerable, or moderate factor in driving high health care costs.  

Historically, business executives have been believed to prefer market-based solutions in order to transform health care, and they likely still do. Yet, health care industry insiders have held significant power over the regulatory and other mechanisms that enable markets to work effectively. As a result, Americans pay between two to four times more for prescription drugs than citizens of other countries and reimbursements from businesses and their workers are two to three times above those of Medicare. These recognitions may be the financial sense behind changing employer attitudes. In some way, those higher prices have been a hidden tax imposed by health systems and other suppliers on American workers, while policymakers pretended not to notice.  

The survey is important because little research has attempted to identify and quantify the attitudes of business executives on the cost of providing health benefits. Even with these results, much remains to be understood about businesses’ health policy preferences, although it cannot be ignored that a surprising 83% of respondents reported that a greater government role in providing coverage and containing costs would benefit their business. 

These results come in conjunction with the end of the Biden Administration’s first 100 days in office, turning attention to its social and health care policy agendas. Although not included in the President’s American Families Plan announced last week, it is expected that initiatives, such as those to lower the eligibility age for Medicare, expand the range of covered health services, and empower the government to negotiate prescription drug prices are in the wings. So buckle up for a fierce debate of ideas before the November 2022 mid-term election when all 435 seats in the United States House of Representatives and 34 of the 100 seats in the United States Senate will be contested.

Warm Regards,

Louise Y. Probst

BHC Executive Director

With this in mind, it is clear that financial well-being programs are a must-have for programs designed to support worker health and productivity. As we emerge from the pandemic and its lingering economic outcomes, it is time to consider new ways to support employees’ financial well-being.

Even before COVID-19, research found that concerns about personal finances distracted one in three employees while at work, and other research from the Federal Reserve, published in May of 2019, revealed that 40% of Americans would have to borrow money or sell something to cover a $400 emergency expense, 17% of U.S. adults were unable to pay all of their bills every month, and 25% of Americans skipped necessary medical care because of cost concerns.

An effective workplace financial well-being program requires an understanding of employees’ financial lives. We all perceive the amount of money needed to support a feeling of financial security differently, so a common definition of financial well-being is necessary to design effective workplace programs and assess progress made over time. Research from the Consumer Financial Protection Bureau (CFPB) defines financial well-being as a state of being wherein a person:

1. Has control over day-to-day, month-to-month finances;
2. Has the capacity to absorb a financial shock;
3. Is on track to meet financial goals; and
4. Has the financial freedom to make the choices that allow him or her to enjoy life.

This toolkit from CFPB includes case studies and tips for starting financial well-being conversations with employees and cultivating this level of understanding.

Employee financial well-being programs offer an array of financial education programs and services, such as loan and financial counseling, that can support employees through tough financial situations. The Social Policy Institute at Washington University in St. Louis and the National Fund for Workforce Solutions have collaborated on a Guide to Employee Financial Wellness to help employers identify the best program for their team. The guide combines four years of research and best practices collected from a wide range of employers. It outlines six steps to selecting and implementing an employee financial well-being program.

Additionally, a trip to the Social Policy Institute’s website finds several new tools to support worker’s financial well-being, like this app that enables easy payroll savings deductions or this research paper on short-term, zero interest loans for low and moderate wage workers.

Warm Regards,

Louise Y. Probst

BHC Executive Director

A quick look at this NPR site shows the severity of each state's coronavirus outbreak, with an easy toggle to track vaccines, new cases, hospitalizations, and deaths. New infection rates vary across the country and are organized into four risk categories of  green, yellow, orange, or red based upon the number of new daily cases per 100,000 people. Categorized as yellow, Missouri is reported to have eight new cases per 100,000 people and 476 average daily cases as of March 3, indicating the need for continued social distancing and mask usage. Along with Oregon and Hawaii, Missouri is among the lowest states for new infections, although community spread has yet to be stopped. All of Missouri’s bordering states are experiencing higher rates of new infections, ranging from 13 to 30 new daily cases per 100,000. Arkansas is categorized as a red risk level, having unchecked community spread, along with ten other states. New York and New Jersey tie for the highest at 38 new daily cases per 100,000 people.

As of the date of this post, COVID-19 vaccines have reached 15% of Americans, and about 1.7 million vaccines are being administered per day. Missouri lags a bit at only 13.6% of residents having had one or more vaccine, with state leaders expecting that everyone who wants a vaccine will be able to get one by July. Dr. Fauci reports that if 75-80% of Americans accept vaccination when offered, the U.S. should reach herd immunity by the end of second quarter 2021 and be close to our previous “normal” by the end of 2021. 

The current data on new infections suggests that Missouri’s collective commitment to prevention is working. Thanks to everyone for remaining vigilant. The data also shows that the rate of spread in states can change from week to week. Staying the course is essential. So is building our reserves so as to be positioned for the next novel virus or other public health challenge. 

The BHC's Community Forum on April 29 has been designed to identify steps that we can take as individuals, businesses, and communities to build resilience in a post-pandemic world. Keynote speaker Dr. Martin Seligman (also known as the "father of positive psychology") will share the science of fostering personal and organizational resilience, as well as growth following trauma, rather than stress. The CDC’s Deputy Director for Infectious Diseases, Dr. Jay Butler, will follow with insights on lessons learned from COVID-19 and opportunities to strengthen our public health and primary care infrastructures for future infectious threats. A panel of local leaders will close the event, reflecting on a shared to-do list to support recovery in the St. Louis region, including economic stability, health care strategies, and technological innovation. Registration for this virtual conference is free for BHC members, and we hope that you will join us for an upbeat morning focused on creating a better future. 

Warm Regards,

Louise Y. Probst,

BHC Executive Director

In the first 24 hours, the United States reversed its prior decision to leave the World Health Organization (WHO) effective July 2021 and rejoined its consortium to share coronavirus vaccines fairly around the globe. Honored, Dr. Fauci announced this decision to a virtual and cheering audience of the world’s public health leaders. He shared that the U.S. will work with them to strengthen and transform WHO, transparently investigate the organization’s initial response to the pandemic, and prevent the next outbreak from becoming a pandemic.

A COVID-19 Taskforce of experienced public health and infectious disease leaders was established, as was the COVID-19 Response Office, responsible for coordinating the pandemic response across all federal departments and agencies. The new National COVID-19 Coordinator will report directly to President Biden.

Day two, Biden released a 200-page document, National Strategy for the COVID-19 Response and Pandemic Preparedness. While those that have been following the national dialogue on pandemic response will not find much new, it is an organized plan with clearly stated goals, with a commitment to follow science-based interventions, be transparent, and coordinate actions. Importantly, it recognizes testing as a critical public health tool in tracking and fighting this and future pandemics and commits to expanding testing supplies. The federal government’s role in ensuring the production and supply of adequate protective equipment is defined. 

An Executive Order directs the Occupational Safety and Health Administration (OSHA) to create standards to ensure the safe reopening of schools, businesses, and travel. Most businesses and schools have already taken many of the steps to protect their workers and customers, as outlined in OSHA’s Protecting Workers: Guidance on Mitigating and Preventing the Spread of COVID-19 in the Workplace. Yet, employers will want to monitor these as they may be expanded and become requirements, rather than recommendations.

The Biden administration aspires to fixing more than COVID-19 when it comes to health care. Expanding coverage through increased federal subsidies, particularly among those residing in states that have yet to expand Medicaid, is included in Biden’s stimulus plan, and a recent Executive Order reopened and made changes to support broader enrollment in the Affordable Care Act (ACA) marketplaces. While these needed actions make access to care more affordable and equitable for low-income families, they do little to reduce health care spending.

Prominent in Biden’s campaign claims were furthering transparency, bringing accountability to drug pricing, and the more controversial additions of a public option and reducing the eligibility age for Medicare. There is only so much that can be done by Executive Order. Steps needed to reduce health care inflation to levels at or below overall economic growth will require legislative action and be more difficult to achieve, even with the recent Democratic wins in both chambers of Congress. While off to a good start, it’s too soon to tell if the bipartisan support needed to finally transform American health care into the high-value system we all want and deserve has arrived.

Warm Regards,

Louise Y. Probst,

BHC Executive Director

Most Surprise Medical Bills Soon to be Stopped

After years of failed legislative efforts, Congress acted late December to protect patients from most surprise bills. Beginning January 1, 2022, patients will no longer be able to be charged more than they would have paid for an in-network service in two types of scenarios: (1) when they find themselves in an out-of-network facility or air ambulance in an emergency situation, or (2) when they use the service of an out-of-network provider while seeking care in an in-network facility. Ground ambulances, the most common type of surprise bills, were left out. This was due to congressional leaders’ inability to understand the impact on the diverse types of ambulance companies, particularly those serving small municipalities. In an effort to stop these as well, a commission to study surprise bills for ground ambulances was established. The law now requires the out-of-network provider and insurance company to arbitrate and set guidance for the factors to be considered by the independent arbitrator in establishing a fair price.

Hospital Transparency is Expanded
Widely contested price transparency measures went into effect January 1, 2021, after the courts fail to be swayed by the American Hospital Associations’ claims of unfair burden and upheld the Trump administration’s rules for price transparency. Facilities must post the following information on their website for each service and product: (1) charges, (2) negotiated rates with insurance company, noting the lowest and highest negotiated price, without disclosing which insurer received which rate, (3) self-pay price offered to patients without coverage or paying their own claim, and (4) the bundled price for 300 common “shoppable” procedures or services, 70 of which have been defined in the rule by HHS. These are to be posted online, in a machine-reasonable and consumer-friendly format. A quick look at several local hospital websites did not find them to be fully compliant. Yet, there are signs that they are moving to become more transparent. Similar regulations, effective January 2022, have been imposed on insurers.

Payment Alignment Lays Foundation for Stronger Primary Care 

CMS has prevailed in making changes to the CPT coding system and payment rules designed to streamline provider documentation and realign payments to better reward physicians for their time spent in evaluation and management of patients, as compared to the time spent doing procedures. It went into effect January 1. Devised to be budget neutral, the expected $9.9 billion in higher payments has been offset by decreases in the conversion factors for some services. The AMA estimates the impact to provider practices will range between a decrease of 10 percent and an increase of 16 percent. This is a long-awaited and important step in advancing primary care in the U.S. health system. More details can be found here .

Moving into the New Year, the BHC will continue to monitor legislative activities on a local, state, and federal level that have an impact on health care quality, affordability, and safety, as well as employer-sponsored benefit plans. We welcome the opportunity to connect with your organization’s policy leaders to discuss priorities and shared action that can be taken in 2021.

Warm Regards,

Louise Y. Probst,
BHC Executive Director

“At Concordia Plans our vision is healthy and engaged workers serving in thriving ministries,” said James Sanft, President and CEO of Concordia Plan Services of The Lutheran Church–Missouri Synod. “Our team does a fantastic job of supporting those workers through their life events and stepped up in 2020 to serve a membership that faced unprecedented challenges. We are dedicated to providing resources that care for the health and well-being of our own team and their families and that can positively impact the way they serve and all aspects of their lives. We are very thankful for this great honor.”

Created in 2014 by employers of the BHC’s Wellness Roundtable, the Business Health Culture Award recognizes organizations for their innovative and comprehensive approaches to improving the well-being of employees and their family members. The award application was modeled with careful consideration of best practices in the corporate wellness field, as defined by national research organizations, academia, and the employer sector.

“As a BHC member and local employer, Concordia Plans has consistently demonstrated itself as a leader in advancing well-being in the workplace and in our community,” explained Louise Probst, Executive Director of the St. Louis Area Business Health Coalition. “Concordia Plans has successfully created a culture of health for its workers and families by embedding wellness into its organizational mission and strategic goals. In 2020, Concordia Plans quickly adapted to the challenges as a result of the COVID-19 pandemic to continue supporting the physical, mental, emotional, financial, and social factors that impact employee health and happiness on a daily basis.”

To learn more about the award process and resources to support employee and community health, please visit www.stlbhc.org/page/WorkplaceWell-being.

About the St. Louis Area Business Health Coalition
The St. Louis Area Business Health Coalition (BHC) is a nonprofit organization representing over 70 leading employers, which provide health benefits to thousands of lives locally and millions nationally. For 38 years, the BHC has worked to achieve its mission of supporting employer efforts to improve the well-being of their employees and enhance the quality and overall value of their investments in health benefits. To accomplish these aims, the BHC centers its work on providing pertinent research, resources, and educational opportunities to help employers understand best practices for the strategic design (and informed use) of benefits to facilitate high-quality, affordable health care. To learn more, please visit www.stlbhc.org or follow the BHC on Twitter and LinkedIn.

Aside from the administrative logistics, hurdles remain in the form of awareness and misinformation. All of us have a role to play in dispelling myths and getting out the facts. Here are five things everyone should know about the COVID-19 vaccine:

(1) Is it normal to feel sick after getting vaccinated? When people feel bad after a vaccine, they often claim they got sick from the vaccine or had a bad reaction. Vaccines work by giving the body a preview of the virus so that the immune system can recognize it and develop antibodies to fight it. Chills, fever, and muscle aches are common following a vaccine and a sign that it is working.

(2) Does the shortened approval process for a COVID-19 vaccine compromise safety? The FDA is expediting vaccine availability through Emergency Use Authorization (EUA). EUA is used in a public health emergency when the benefits of a product that hasn’t received full FDA approval outweigh any risks. It is important to emphasize that all COVID-19 vaccines are rigorously tested on tens of thousands of people in multi-phase clinical trials that are overseen by established safety control boards and protocols. Additionally, the CDC follows long-established protocols to ensure the safety of COVID-19 vaccines.

(3) When can I get a vaccine? Following CDC guidance, the state of Missouri has created a COVID-19 Vaccination Plan laying out a phased rollout to priority populations. Early doses will target frontline health care workers and long-term care facility staff. The focus then moves to critical infrastructure workers, those ages 65 and up, and communities at higher risk of severe COVID-19 outcomes. Supplies are expected to expand substantially in 2021. It is anticipated that 90 to 180 days after initiation the vaccine will become broadly available to any adult who wants one.

(4) Who will pay for the vaccine? The federal government is using taxpayer dollars to distribute the vaccine and ancillary personal protective equipment (PPE) to providers at no cost. Anyone who wants and needs a vaccine can get one free of charge. Providers may charge a fee to cover the cost of administering the vaccine and seek reimbursement from private and public health insurers.

(5) How many doses are needed? The first vaccines likely will require TWO doses. This is standard for many FDA-approved vaccines. The second shot boosts a vaccine’s effectiveness, especially for older people. Unfortunately, this brings a potential drop-off rate after the first dose. Educating employees and the public about this upfront will reduce this occurrence.

COVID-19 vaccine administration plans are being updated regularly. The BHC is tracking the CDC and Missouri plans – stay tuned for more information as it become available.

Warm Regards,

Louise Y. Probst,
BHC Executive Director

Despite promising news on vaccines, the pandemic continues its grip on Missouri and the St. Louis region. Our state reported 6,346 new COVID-19 cases on Saturday, the most by far since the pandemic began in March. The COVID-created health and economic challenges are likely to persist for months to come, experts say. The only thing that remains unknown is how we as a region and a state will react to it.

Last week, the St. Louis Metropolitan Pandemic Task Force and the Missouri Hospital Association separately called on state officials to provide greater leadership on pandemic issues, including support for a statewide mask mandate and creation of “safer-at-home” programs to slow or stop the spread of infection.

Hospital admissions have typically followed spikes in new cases by about two weeks, doctors across the country have reported. As hospitals in the St. Louis region already grapple with “unsustainable” levels of COVID-19 cases, doctors worry that the worst is yet to come. “At that point, we would not have the capacity we need to sufficiently care for our patients. Not just COVID patients, but all patients,” said Dr. Alex Garza, an emergency medicine physician and chairman of the pandemic task force.

Gov. Mike Parson has repeatedly said that while he does not support a statewide mask mandate, “It is imperative that Missourians take personal responsibility and social distance, wear a mask, practice personal hygiene and limit their gatherings.”

Some may see tradeoffs: supporting our economy or taking on the virus. But that’s a false dichotomy. Both issues must be addressed together. Only then will the economy be able to resume growing and the health and well-being of Missourians be best supported.

The St. Louis Area Business Health Coalition (BHC) commends the work of the Pandemic Taskforce and hospital leaders and our local elected officials as they mobilize to stop the spread of the virus.  Like others, BHC would like to put these problems in our past. To do this, we must slow the spread of infection now, to avoid overwhelming hospitals and health care providers during the weeks to come.

Aligned leadership from state and regional officials is important, but it is absolutely crucial that citizens lead the way. The ask of us is really simple: Mask up, wash your hands frequently, take care of your health, and limit social gatherings to those in your personal bubble.

In St. Louis County, new restrictions went into effect on November 17. But parts of Missouri with the highest rates of new infections are currently rural, sparely populated counties where no mask mandates are in place and where basic infection control practices are rarely publicly practiced. Counties with the highest rates of new cases as of Monday morning were Gentry, Perry, and Moniteau, where case rates are about double that of St. Louis County. Jefferson and St. Charles counties also had higher rates than St. Louis County.

Heading into winter, the stakes are high for everyone in our region and across our state. We recognize that small businesses and restaurants are hurting. But allowing the virus to continue spreading unchecked will only prolong the pain and, in a very literal sense, the suffering of those who become infected.

We should all be doing what we can to support those small businesses, and to thank the thousands of health care workers in our communities who have put their personal lives on hold to battle against the virus on the front lines.

Most of all, we have to work together defeat this virus. The choice is in everyone’s hands.

Many thanks to the state and local public officials and employees, and the army of volunteers that made casting our votes in this election both safe and convenient, including the newly available drive-by voting for people infected with COVID-19, which I happened to see this morning. The large number of cars lined up and volunteers in protective gear was a pleasant reminder of American’s shared commitment to democracy, and also, a sad reminder of COVID-19’s reach.

Again, health care registers as a top issue among voters. ACA rules that expand access to coverage and remove barriers to those with pre-existing conditions are valued by most people. Estimates find that 135 million Americans had some preexisting condition pre-pandemic; that number is likely to have grown as a result of COVID-19’s lingering symptoms. Fortunately, both presidential candidates have vowed to keep the ACA provisions which enable this. 

Gaining insight into the federal health policy agenda post-election will require additional days, weeks, and months. The outcome of the Supreme Court’s deliberation of California vs. Texas, a case challenging the ACA’s constitutionality, is expected mid-2021.

As an expansive piece of legislation, the ACA has enough provisions for most people to find things that they deeply appreciate and others that they strongly oppose. The list is long. What I find most often underappreciated about the ACA is the enormous amount of effort contributed by American employers toward its successful implementation. Just think about your HR team’s work agenda in the years preceding 2014. While collectively I do not know your opinions on its repeal – I expect few self-insured employers would wish for the ACA to be repealed, in its entirety, now that these health benefits changes have become the norm in your workplace. If you have an opinion to share, please reach out. In the meantime, we will be advocating for thoughtful and transparent policy deliberations, opportunities for public comment, and long lead times for the implementation of any changes.

Warm Regards,

Louise Y. Probst
BHC Executive Director

COVID-19 ushered in previously unimaginable changes in every sector of the American economy and life. During the early months, health care providers found themselves simultaneously on the front lines confronting the virus while responding to steep revenue losses from unprecedented declines in elective services. Locally, many businesses have had their operations and revenue models upended and find their financial futures placed in question. Likewise, many families find themselves in dire financial need and looking for employment in an uncertain economy. Eight months into the pandemic, infections continue to surge and the end is not yet in sight.

The overuse of low value health care services, previously thought to be unstoppable, dropped overnight. Although this created short-term surpluses in employer health spending accounts, several potentially bothersome scenarios remained: worsening employee health due to missed or delayed diagnosis and treatments, steep health care price escalation, and a return to the rampant overuse of medical services with little or no clinical value.

Concerned about the pandemic’s lasting effects on our community, BHC leaders joined together to share learnings and explore options to realize better health for employees and the community and better value from our region’s collective and significant investments in health care coverage. From these conversations, and on behalf of its members and all employers, BHC sent correspondence to local health plan and health system leaders urging them to keep health care prices flat, consistent with current economic conditions and for their leadership in shaping a new, higher value health care system for our region.  BHC also invited their suggestions for steps purchasers can take in supporting their transition to higher value.

Meanwhile, BHC is actively exploring the successes of other purchasers and leading states on the path to better health and value health care. Some of you with worksites in Massachusetts may already have evidenced the State’s meaningful progress toward more affordable, higher value.  Leaving behind a long tradition of being one of the nation’s most expensive health care states, statewide spending targets have enabled it achieve spending well below the national average. In fact, as the Massachusetts Health Policy Commission slide demonstrates, between 2013 – 2018, just the savings from being below the national spending average, freed-up more than $7.2 billion to be spent on other goods and services.  We welcome your observations and suggestions.

According to the CDC, the 2019 – 2020 flu season was mild. Still, there were between 39 million to 56 million cases of the flu, up to 740,000 hospitalizations and between 24,000 to 62,000 deaths. Add COVID-19 infections and this potential “twindemic,” or simultaneous outbreak of these two serious infections, could overtax regional health care systems and be catastrophic for patients trying to fight off both conditions at once.

Some fear that with COVID-19 center stage the public may forego the annual flu vaccine. Stay at home orders, fewer workers coming into the office and hesitancy to utilize elective medical services while COVID-19 looms could all deter people from getting their flu vaccine this year. As it is, in a normal year, only about half of the population gets a flu shot.

Employers can help bolster these numbers by helping employees understand that, in the face of the pandemic, the flu shot is an essential part of protecting their and their family’s health and fulfilling their civic duty. Taking definitive action, the University of California system recently in the face of the pandemic announced that because of the pandemic, it is requiring all 230,000 employees and 280,000 students to get the flu vaccine by November 1.

The potential of vaccines is enormous; it is one way we can each make a difference in our community. To find educational resources to share with your employees and to learn about discounted flu shot pricing available from BHC preferred vendors, please click here.

Warm Regards,

Louise Y. Probst
BHC Executive Director

There is mounting evidence that Americans are experiencing COVID-19 as a serious threat to their mental health. A study by Express Scripts found that the use of prescription drugs to treat anxiety, depression, and insomnia spiked between mid-February and mid-March of this year, with prescriptions for anti-anxiety medications alone rising 34%. Of the prescriptions issued during this period, more than three-quarters were new prescriptions. Just months into the pandemic, more than a third of households contacted by the Census Bureau reported symptoms of clinical anxiety or depression.

It’s clear that the pandemic is exacting a tremendous psychological toll, which can severely impact employee focus and retention. Many Americans worry that they or a loved one will get infected. Juggling work and childcare, fear of job loss, and loneliness are other common sources of stress. Experts say people with pre-existing mental health or substance use disorders are at increased risk.

Workplaces have diligently implemented new routines to prevent the spread of infection, with checklists that include social distancing, temperature checks, and a doubling down on disinfectant. Yet there is a gap in guidelines for navigating the pandemic’s psychological effects.

In fact, the COVID-19 crisis has exposed the cracks in our already fragile mental health system. Unfortunately, the workplace is often the last place where mental health is discussed. According to the National Alliance on Mental Illness (NAMI), roughly 85% of employees' mental health conditions were undiagnosed or untreated before the virus struck. This despite estimates that mental health conditions cost employers more than $100 billion and 217 million lost workdays each year.  

Fortunately, there are many resources available for employers who want to step up and effectively support their employees, and the BHC’s 2020 Summer Forum is a great place to start. Join over 300 benefit and wellness leaders to learn about best practices for increasing awareness, decreasing stigma, and creating a culture of health. Featured speakers will include Dr. Charles Zorumski, Head of the Department of Psychiatry at the Washington University School of Medicine, and Mettie Spiess, CEO and Founder of A World Without Suicide. To learn more and to register for the virtual conference, please click here.

Warm regards,

Louise Y. Probst

BHC Executive Director

Considerable recent attention has focused on the federal grants to health systems across the nation to offset COVID-related losses. The conversations highlight the disparities among hospitals in terms of the populations they serve, their reserve balances, and ownership. The May 25th New York Times article, Wealthiest Hospitals Got Billions in Bailout for Struggling Health Providers, offers a detailed look into issues of equity across “have” and “have not” institutions.  

For me, the article underscores two things: (1) the political difficulties inherent in attempting to distribute money quickly, equitably, and thoughtfully, and (2) how very large and resource-rich some of our non-profit health systems have become. Multiple billions of dollars in reserves might only translate to months of operating income for many health systems.  

Missing from the conversation, and of critical importance, is how the federal government can use these lifelines to nudge our health care system toward long-term and widely-shared goals. These could include such things as payback requirements with forgiveness provisions for:

1. Investments that yield more primary care physicians;
   
   
2. Better chronic care management, as evidenced by low rates of hospital admissions or emergency department visits for treatable chronic conditions;
   
   
3. Adherence to evidence-based guidelines of care, demonstrated by decreases in services known to have little or no clinical value and that place patients at risk of physical, emotional, or financial harm; and
   
   
4. Limits on the levels of future price increases to private sector payers, already known to be significantly higher than government-sponsored health plans.

The pandemic is still with us. Its full economic impact lies ahead for most of us. The federal government has the opportunity to allocate taxpayers’ precious financial resources in ways that will best serve the American people and economy – ensuring a future in which all enjoy high-quality and affordable health care.

Warm regards,

Louise Y. Probst

BHC Executive Director

On Monday afternoon, I almost tuned out the reports of vastly higher numbers of people in the United States projected to become infected or die from COVID-19. Shared across all major news outlets, the statistics were stunning, predicting that the U.S. death toll could exceed 3,000 lives per day by June 1^st, with the growth in new cases to rise to 200,000 per day, up from the current daily rate of 25,000. I felt a bit betrayed. We are all doing our part to prevent the spread by sheltering in place, wearing masks in public, and washing our hands. We had been assured that these measures were working – so what had changed?

Testing, which still lags behind what is need to meaningfully defeat COVID-19, has increased. Several clusters have been detected in meatpacking plants and other food processing settings. New cases throughout communities, many in the Midwest, have made it clear that the virus is still here and that the risk of transmission remains high.

Perhaps, lulled by early progress reported in flattening the curve, Americans have been on the move. Monitoring of cell phone locations has found people to be more mobile over the past few weeks. Several states have entered or are about to enter early phases of reopening their economies, despite failing to achieve the White House pandemic team’s recommended criteria to do so.

A caution offered by Milliman’s actuarial team during a recent presentation came to my mind and brought relief from any pending dread: “Models are rarely correct, but often useful.” These numbers are predictions – indicators of what could happen, but not what will or has to happen.

We must resist becoming numb to the risk, lulled into complacency, and overwhelmed by feelings of helplessness. We have the power to ensure that these assumptions are incorrect and never come to be. To see the latest tools to combat this disease, visit the BHC’s COVID-19 employer resource page and join us each Wednesday in May at 3:00 PM (CST) for a member-only COVID-19 Coffee Chat on evolving strategies. Each of us has a role to play, and together, we can keep ourselves, our loved ones, and our organizations safe.

Warm Regards,

Louise Y. Probst,

BHC Executive Director

1. "No Visitor" policies are consistent across hospitals. Please be understanding of the importance of these precautions in keeping everyone as safe as possible.
   
   
2. Each health system has COVID-19 testing centers. Information about these centers can be found on their websites, along with virtual screening tools through BJC HealthCare and SSM Health. Unfortunately, supplies remain limited, so please call your hospital or health care provider ahead of time and understand that you may be asked to self-isolate at home, unless or until you have trouble breathing.
   
   
3. Please continue to be vigilant with hand washing and social distancing. Remember to stay active, eat healthy, sleep well, and connect virtually with family and friends in order to remain healthy and resilient.
   
   

To support well-being, the Midwest Health Initiative continues to update the LiveWellSTL website with online and at-home resources to move more, eat better, lose weight, and feel well. BHC members are also encouraged to visit our COVID-19 resource page and join fellow employers for weekly coffee chats in April to discuss evolving responses.

While there is much that we do not know about COVID-19, one thing is clear. We are in this together, and everyone has a critical role to play in slowing the spread of this virus. Social distancing will be necessary for longer than initially expected. We must stay the course. We owe this to those on the front line of health care serving our community.

Warm regards,

Louise Y. Probst,
BHC Executive Director

Spread through sneezes, coughs, and contaminated surfaces, symptoms include fever, cough, and difficulty breathing. Symptoms can take between two to fourteen days to appear, suggesting that people may pass on the virus even before they aware that they are sick. Milder cases may resemble the flu or a bad cold.

While we learn more each day about the virus, how the outbreak will affect our lives is far from clear. This uncertainty creates stress and can make employees less capable of coping. Yet, all of us have effective tools to prevent the spread of communicable diseases. 

One of employers’ many roles is to help employees understand that frequent handwashing and other public health essentials are their best defense from COVID-19’s potential harms. Since mucous membranes are the passage ways of viruses into the body, avoiding the habit of touching the face (including eyes, nose, and mouth) without clean hands is critical. As a reminder, it is okay to warmly decline a handshake, as this may further protect people.

Another important employer responsibility is to develop and communicate benefit policies and business continuation plans should large numbers of employees become ill or public health officials call for social distancing. The CDC’s guidance to businesses and the public is a very good resource and can be found at this landing page.

At times like these, it is important to remain connected, learn together, and support one another. This is what builds resilience. One BHC member reported that they were considering waiving certain copays related to testing for the virus. Local health care providers have indicated that it would be very helpful for patients thinking that they may have the disease to consult with their primary care provider first and phone the facility ahead of time, so the team can be appropriately prepared and meet them at the door. Please share your learnings and interventions with BHC so we can pass them on. Stay tuned for an upcoming webinar featuring SSM Health's Chief Medical Officer and public health expert, Dr. Alexander Garza, and most importantly, stay healthy.

Warm regards,

Louise Y. Probst

BHC Executive Director

The ACP calls for a transition to a full-scale, single-payer health insurance program or a government-run health plan, competing alongside regulated, private insurance plans. While ACP acknowledges that there are advantages and disadvantages to each approach, it believes either solution could achieve universal and affordable coverage, while realizing ACP’s vision statements for the U.S. health care system. ACP encourages other organizations to also make a serious and transparent effort to define what would make a better health care system, evaluate options, and recommend action. 

While ACP’s support for a single-payer system may or may not align with that of an individual employer, several of its vision statements are spot-on, particularly, ACP’s call for greater investments in primary care and mental health services. Employers recognize that having a primary care relationship can translate to fewer hospitalizations and emergency department visits, earlier diagnosis, reduced overall spending, and happier patients. Several BHC members have already taken steps to support their employees in accessing and engaging with effective primary care and mental health services, while others are in the process of working toward this aim. If your organization is interested in joining in these efforts, please let Lauren Remspecher know.

In order to better support members’ interest in advanced primary care and mental health services, the BHC is pleased to announce that it has joined the Primary Care Collaborative (PCC). PCC is a national, multi-stakeholder membership organization that facilitates connections, resource development, and research focused on enhancing primary care in the U.S. Learn more by clicking here.

Adding to this conversation, the 2020 BHC Spring Forum on April 30 will highlight opportunities for employers to improve mental well-being in the workplace. In addition to examining mental health trends and treatment innovations in the field, speakers will provide actionable strategies for suicide prevention, stigma reduction, and the application of health benefits, policies, and programs to create a culture of support. Register to attend by clicking here. We look forward to seeing you there.

Warm regards,

Louise Y. Probst

BHC Executive Director

Harris, then California’s Attorney General, began investigating whether Sutter Health’s market power led to predatory pricing and unfair financial burden on the people and businesses of Northern California. Sutter Health’s sprawling network of hospitals, surgery centers, and urgent care clinics makes it one of the nation’s largest health systems, with annual revenue of about $13 billion. 

The price hikes were striking in Sutter Health’s case. Health care costs in Northern California run 20% to 30% higher than in Southern California, with patient admissions averaging $4,000 more than at other hospitals around the state. A cesarean delivery in Sacramento costs $27,067, nearly double the price in Los Angeles and New York. Health care economists view Sutter Health’s actions as part of an alarming consequence of hospital consolidation that has resulted in higher prices. 

Harris’ successor, Attorney General Xavier Becerra, joined a class action suit by unions and over 1,500 self-funded employers. The case, expected to deliver about $2.5 billion in damages, was settled in October 2019. Details of the final agreement show that Sutter Health agreed to:

• Make a $575 million payment to compensate employers, unions, and the state and federal governments, without any admission of wrongdoing;
• Stop "all-or-nothing" contracting deals with insurers and cease anticompetitive bundling of services and products;
• Limit what it charges patients for out-of-network services; and
• Be subject to a court-approved compliance monitor to oversee its contracting practices for the next 10 years.   

We all know that initiating legal action such as this takes significant investment and fortitude. UFCW & Employers Benefit, the group of unions and employers who brought this suit, deserve our recognition. They said in a statement: “From the outset, our goal has been to not only achieve justice for the members of the class, but to also put an end to the anticompetitive behavior that has allowed Sutter to charge inflated prices.” 

California Attorney General Becerra claimed, "When one health care provider can dominate the market, those who shoulder the cost of care — patients, employers, insurers — are the biggest losers. Today’s settlement will be a game changer for restoring competition in our health care markets."

While the impact of this case and the other pending anticompetitive suits will take time to fully appreciate, let us hope it spurs much-needed competition in health care. It is the first sign that courts and antitrust regulators are ready to focus on the impact of health care consolidation on the American public.

Warm regards,

Louise Y. Probst

BHC Executive Director

Dr. Wendy Levinson, Chair of Choosing Wisely Canada and Choosing Wisely International, reminded us that "more is not always better," especially when it comes to health care. Using educational toolkits and creative messaging, the Choosing Wisely campaign offers practical tips for engaging patients and physicians in reducing the culture of overuse in health care. Dr. Levinson reminded us that this is a problem across nations, not just in the United States, and offered several examples of success that has been achieved in provinces across Canada, other nations, and in many medical schools. Along with the St. Louis Metropolitan Medical Society and the Midwest Health Intiative, BHC has been working to identity situations of overuse in regional data and prioritize possible target areas for attention. A community collaboration to tackle overuse through diverse stakeholder engagement is preparing to launch in spring 2020. The work will align with the BHC Board's priority to develop a communication campaign to help the public become more informed consumers of health care. We would welcome your team's participation in this important initiative - please contact the BHC if you are interested in getting involved.

Linda Brady, Boeing’s health care strategy leader, provided an update on Boeing’s Accountable Care Organizations, advanced primary care efforts, and other strategies to achieve better value. She underscored the importance of leveraging relationships with health plan or provider partners to understand and influence care enhancements for employees. While a direct ACO contract is not feasible for all employers, there are many opportunities for employers with smaller or geographically-diverse populations to leverage puchasing power for better value. Moving into the coming year, the BHC’s new Value-based Purchasing Roundtable will explore advanced primary care solutions, including a visit to two local sites that have taken this approach.

Incoming BHC Board President and Chief Operating Officer for Francis Howell School District, Kevin Supple, closed the Annual Meeting with a heartfelt reminder of how peoples' lives are impacted by employer-provided health benefits and the difficult challenges that are faced by many patients. He inspired all of us to use our influence to make health care work better for employees, their families, and our community members. The BHC looks forward to answering this call in 2020 in collaboration with you.

Warm regards,

Louise Y. Probst

BHC Executive Director

According to Harvard professor Dr. Clayton Christensen, the hallmarks of an industry ripe for disruption are high cost and uneven levels of access. He explains disruption as a process by which “simple applications take root at the bottom of a market—typically by being less expensive and more accessible—and then relentlessly move upmarket, eventually displacing established market leaders.” Successful disruptive innovators are comfortable challenging the status quo. Examples of success from other industries illustrate the concept well: the iPhone, Amazon, Uber, and Airbnb, to name a few.

Could Walmart be health care’s disruptive innovator, decreasing cost and closing the care gap while wowing customers? In September, Walmart announced that it would begin covering costs for any of its 1.5 million U.S. workers who want to earn a health care degree. For a fee of $1.00 a day, employees can apply for bachelor’s degrees in seven different programs, such as health care management and supply chain logistics, and two career diplomas—as pharmacy technicians or opticians. The program will help the company recruit employees and also staff its growing line of retail health clinics. It’s the latest in a series of moves that show Walmart’s potential to disrupt our dysfunctional health care system, and perhaps, higher education as well.

Consider this: Together, Walmart and Sam’s Club operate more than 5,000 retail pharmacies, 3,000 vision centers, and 400 hearing centers, and provide low-cost Quest Diagnostics lab services. The big box behemoth is accelerating its push to co-locate health clinics by its stores, most recently launching a Walmart Health Center that offers a full menu of primary care, dental, and even mental health services to customers in the underserved region of Dallas, Georgia. Walmart says its new clinic will serve consumers regardless of insurance status and offer convenient, online scheduling and transparent, low pricing. Consumers can also access resources for preventive health and wellness.

Rising health care costs and poor outcomes disproportionately hurt lower-income and middle-class families. Walmart wants to bring affordable services to underserved people right where they shop, including preventive care for the chronic conditions that bust health care budgets. Their retail health care model could improve population health on a broad scale while putting downward pressure on prices. If they succeed, that could be a game changer for our health care delivery system.

Join us at the 2019 BHC Annual Meeting to learn what employers can do to spur disruptive innovation in health care.

Warm regards,

Louise Probst
BHC Executive Director

According to the Patient-Centered Primary Care Collaborative (PCPCC), overall U.S. health care spending on primary care is assumed to be between 5% to 7%, half or less that which is spent in other developed nations. A recent study by the Milbank Memorial Fund found that primary care spending in Medicare was only 2% to 4% of its overall spending.  

Yet, considerable evidence has shown that a strong primary care foundation is essential for a high-performing health system. By example, regions with a higher ratio of primary care physicians have better health and lower rates of mortality from heart disease, cancer, stroke, and other causes, even after controlling for sociodemographic measures. Data from the Midwest Health Initiative confirms that commercially insured patients in St. Louis who regularly see a primary care physician are less likely to visit the emergency department.

Since it takes about a decade to train a primary care physician, and demand for their services is growing faster than the supply of new primary care providers, the time for action is now. Below are examples of truly meaningful strategies that warrant our attention and support.

(1) CMS recently announced that it is considering using different E&M (Evaluation and Management) codes for primary care and medical subspecialist physicians compared to those used for surgeons and other procedure-based physicians. The use of separate codes would enable CMS and private sector payers to begin to rebalance payments by offering higher increases to primary care providers, without automatically increasing reimbursements to other specialists. These codes would also better enable measurement of primary care spending relative to other specialties. On behalf of employers, the BHC recently offered its support for this proposal to CMS Adminstrator, Seema Verma.  

(2) State governments are taking real actions to require greater investment in primary care. By example, between 2009 and 2014, as a condition of having their rates approved, Rhode Island required commercial insurers to raise their primary care spending rate by one percentage point per year (in ways other than by increasing fee-for-service rates). The state’s primary care spending was 5.7% in 2008 and increased to 9.1% in 2012, while total health care expenditures fell 14%. Check out this quick summary of Rhode Island’s and five other state's efforts. 

(3) The PCPCC issued a call for a consensus process to define a common definition and standardized measurement of primary care spending. This would enable the value of primary care to be quantified over time, as well as comparisons across states, health plans, and accountable care organizations. It would also help guide future investments and the evaluation of new value-based payment models across payers and payer types. Read PCPCC’s call to action here. 

The BHC recognizes that many of its members have taken action to strengthen primary care through ACO arrangements, worksite clinics, or other health plan programs. If you are interested in sharing what you are doing or connecting with others on this path, please let me know. 

Warm regards,

Louise Probst
BHC Executive Director

Looking for returns on investment of 2.5:1 to 4:1, private equity firms can find a lot to like in the health care environment, including high margins, service fragmentation, and aging baby boomers with multiple chronic illnesses. To top it off, the recession-proof nature of health care makes these investments less risky compared to others.

So what is in it for physicians? Private physician practices, particularly those that seek to remain independent of a local health system or insurer, find it increasingly difficult to raise capital for new technologies, enter into risk-sharing contracts, negotiate favorable rates with insurers, and otherwise manage the business of their practice. Private equity offers them investment capital and greater advantage in all of these areas, including some hope of remaining clinically independent. Physicians also benefit from a lucrative financial agreement with the potential for sizeable future payouts.

Specialty practices, such as dermatology, orthopedics, gastroenterology, and ophthalmology, have been early private equity targets, especially when combined with the opportunity to own ambulatory surgery, imaging, lab, pathology, or other service centers acting as referral sites for these practices. Corporate and private equity acquisitions are becoming more diverse, including investments in mental health and autism services, new health care technology companies, clinical research organizations, convenient care, and long-term care services.

Those in favor claim that private equity firms bring better and more efficient business practices to an industry with little cost management discipline. Yet, not all physicians think private equity is a good thing for patients or the profession of medicine. Some claim that ownership relationships pressure physicians to provide unneeded care, diminish the patient-physician relationship, and lessen professional autonomy.

An optimist might say that this is a sign that the health care industry is feeling the heat to produce better quality care at more affordable prices. The skeptic might suggest it simply a way to share the wealth with a new set of players. What do you think? Will private equity firms deliver higher value care and a better patient experience?

Warm regards,

Louise Probst

BHC Executive Director

1. Cap hospital prices for commercial payers at 140% of Medicare (a more than adequate payment for any hospital).
   
   
2. Enact an immediate 10% reduction in drug prices. While not as large of a reduction as needed—the U.S. would still remain the nation with the highest drug prices—it would reduce spending by about $50 billion annually, or almost $700 per family.
   
   
3. Require standardized claims forms and administrative procedures across carriers to achieve seamless claims processing, freeing up administrative waste and aiding physician offices.
   
   
4. Require all insurers who participate in Medicare or Medicaid to have at least 50% of their payments across all products be an alternative to fee-for-service, with upside and downside risk.

Dr. Emanuel’s recommendation to cap hospital payments from commercial plans at a percentage of Medicare is getting a lot of traction among state employee benefit plans. With two years under their belt, Montana’s state employee program is leading the way, and Oregon’s plan is starting this fall. North Carolina, supported by the State Treasurer, is in the throes of a very public debate that has seen substantial pushback from hospitals that say they will go out of business.

Join other BHC employers for the August 13th Member Meeting to see the results of a recent national study by RAND Corporation of commercial plan payments as a percentage of Medicare, including all of St. Louis’ major hospitals. The lead study author, Dr. Chapin White, will also discuss opportunities for employers to apply this data to benefit plan strategies to achieve higher value. We hope to see you there in-person or via our webinar option (please contact Todd Boedeker with registration questions).

Warm regards,

Louise Probst

BHC Executive Director

Health policy and consumer researchers from two California academic institutions conducted 15 focus groups with 125 price-sensitive (low-mid income) health plan enrollees to assess their understanding and preferences toward three potential waste-minimizing solutions: narrow networks, reference pricing, and value-based insurance designs (lower copayments for higher value services). The full article can be found in the March 2019 Health Affairs Journal, Consumers’ Perceptions and Choices Related to Three Value-Based Insurance Design Approaches.

Researchers learned that price-sensitive consumers: 

• Highly value choice; however, when they are given information on cost, they are willing to trade choice for lower spending.
• Do not understand that health care costs can vary widely from hospital to hospital. 
• Believe there is a correlation between cost and quality and are unaware that equal or better quality could be had at a lower price. 
• Are skeptical and mistrusting of plan designs that require them to rely on their health plan to define “high-value health care."
• Take little meaning from existing quality measures and are generally unwilling to consider quality measures that conflict with their personal experience with their physicians.

The different interventions were explained to the group, and participants were asked to rate their preference for each strategy. The results are below: 

To encourage openness to these common strategies, researchers recommend supplying consumers with consistent support through educational tools regarding plan options, providers, and health care spending. Consumers value information on clinic location, office hours, patient experience, etc. Therefore, it can be helpful to juxtapose these items next to quality measures.

These findings underscore what BHC members have consistently identified as a top challenge: engaging their workforce to take an active role in managing their own health and using their consumer power to drive safer and higher value health care. The findings also provide direction to BHC’s goal of developing effective communication strategies for the working public.

Warm regards,

Louise Probst

BHC Executive Director
 

Key findings from the report: 

1. On average, commercial plans paid hospitals 241% of Medicare payments, with wide variation.
   
   
2. Low-range payments were 150% to 200% of Medicare, found in Michigan, Kentucky, New York, and Pennsylvania. High-range states included Colorado, Illinois, Maine, Montana, Wisconsin, and Wyoming, at 250% to over 300% of Medicare.
   
   
3. Missouri was somewhere in the middle range at 221%.
   
   
4. Relative to Medicare payments, commercial plans paid hospitals considerably more for outpatient services than for inpatient care in 17 of the 25 states, including Missouri.

Since Medicare payments are sufficient to cover a hospital’s expenses with a fair margin, these high payment levels are worth noting. Research dispels the myth of “cost shifting” by demonstrating that many hospitals make money on Medicare payments. Yet, those with “market clout” and plenty of commercially-insured lives in their market tend to add more expenses of marginal value and extract higher prices from commercial payers to cover them. The increased payments are needed to cover their inefficiencies. This article from Health Affairs explains this phenomenon.

Findings for the major St. Louis hospitals are consolidated for your review (BHC member-only access). The sample size for the St. Louis area is particularly small, and while the aggregate and directional findings are reliable, limited comparison should be made across individual hospital findings. Another important nuance is that Medicare payments for hospitals can be different. For instance, an inner-city teaching hospital’s payment will be larger than a community hospital. The percent of Medicare payment shown is based on the hospital’s actual Medicare payment amount. As you will see, the research finding about Medicare payments and market power is actually supported by the reimbursement levels in the St. Louis example.

So what can be done? RAND recommends that private insurers:

• Shift to contracting models that are based on a percent of Medicare or similarly fixed prices.
  
  
• Share data with state all-payer claims databases in order to increase transparency.
  
  
• Support the 2020 Hospital Payment Comparison by sharing data with RAND now. The more employers contributing data, the more accurate the results.

The BHC encourages employers to get engaged with the 2020 RAND analysis, and we are available to assist. Contact Michael Hely, BHC’s Senior Director, Legal & Policy Services, at mhely@stlbhc.org to learn more.

Warm regards, 

Louise Probst
BHC Executive Director

STL Made works to brand St. Louis globally as an inclusive and innovative community undergoing a “renaissance." A three-year, multi-million-dollar effort will highlight the people of the area, encouraging them to tell their stories and share what they like most about living in the region. Connecting with the St. Louis Economic Development Partnership and the St. Louis Regional Chamber, there is strong interest in attracting young talent to the region. STL Made will monitor the community for increases in commercial expansion as an indication of the success of the initiative’s efforts.

St. Louis’ Better Together program seeks to unite St. Louis City and County in ways that preserve the unique personalities of the region’s communities while building an integrated, innovative, and united approach to capturing opportunities and addressing concerns. Conversations paused on May 7th, but keep an eye out for the reinvention of this well-intended endeavor.
 

Global STL aims to attract innovative international companies seeking access to U.S. markets. Their annual summit, featuring “elevator pitches” from potential recruits, will be June 5th, and BHC members are invited. BJC’s new President and CEO, Richard Liekweg, will keynote the event. Anyone wanting to attend the summit is asked to please contact me at lprobst@stlbhc.org.

It is only a matter of time before Medicare or another entity ranks regions on health care value, exposing the impact of variations in safety, quality, and cost of health care on corporate productivity and profitability. Data indicates that with some improvements in safety and quality performance, St. Louis’ health care value would be top tier. Let’s build St. Louis' brand as a high-value health care community - another lever for economic development. 

Warm regards, 

Louise Probst
BHC Executive Director
  

The federal government has been given primary responsibility for the current situation. A belief in the power of EHRs to make health care safer and less wasteful, combined with the 2008 financial crisis, encouraged the government to invest in a $36 billion dollar “stimulus” for EHRs. Doctors and hospitals were financially incentivized to adopt EHRs, before the products were mature and without adequate industry oversight to ensure interoperability and data sharing.

Last month, as a remedy, the U.S. Department of Health and Human Services proposed new rules to remove barriers to data sharing. EHR vendors will have to fashion their systems to easily enable a complete medical record to be exported, and health systems must give patients their exported medical records for free. Gag clauses that keep doctors from discussing software problems and potential for medical errors will be prohibited. The Senate is currently considering these and other actions. While these steps are positive, these is still much to be done to remove the safety risks introduced by EHRs. In the meantime, it is advisable that patients monitor and correct the information in their medical records, ensure that they receive recommended care, and speak up if anything seems amiss.

Warm regards,

Louise Probst

BHC Executive Director

New Employer Partnership Aims to Prevent, Better Manage, and Reverse Type 2 Diabetes in St. Louis Community

ST. LOUIS, March 26, 2019 – Sixty employers are leading the charge to prevent, better manage, and reverse type 2 diabetes through a new community-wide initiative with the St. Louis Area Business Health Coalition (BHC). Co-chaired by local employers Anheuser-Busch Companies, LLC and Bi-State Development, the Defeat Diabetes STL campaign will explore opportunities to align health care, benefit, and well-being strategies to support employees and family members with prediabetes and diabetes. Over 100 million U.S. adults are impacted by these chronic conditions, with diabetes now ranked as the 7^th leading cause of death nationally.

"As a local organization, Bi-State Development is dedicated to advancing the well-being of the St. Louis community through our people, businesses, and economic development. Our employees are critical to this mission, and we recognize that in order to have a positive impact, our team members must feel their best physically, emotionally, and socially. Defeating diabetes is an important step towards achieving this goal,” explained campaign co-chair, Dave Toben, Director of Benefits for Bi-State Development.

Through collaborative workgroup meetings, BHC employer members have identified four objectives to form the foundation for campaign activities:

(1) Deciphering the Data: Understand differences in the ways that vendors define metrics to assess prediabetes and diabetes using available data sources. Establish more consistent reporting and access to appropriate commercial benchmarks.

(2) Finding the Right Partners: Delineate key characteristics of effective programs for diabetes prevention, management, and reversal. Evaluate vendors and community programs and organize results into a meaningful comparison tool for employers to match preferences and needs in selecting potential partners.

(3) Learning From One Another: Share best practices and employer case studies on what is working (and not working) for diabetes prevention, management, and reversal, as well as tips for how employers can overcome common barriers and challenges.

(4) Getting to Action: Discuss and/or develop new communication and engagement strategies to increase awareness, participation, and personal accountability among employees and the community in addressing prediabetes and diabetes.

Campaign co-chair Brian Haschmann, Director, Health & Welfare, at Anheuser-Busch Companies, LLC echoed the importance this campaign for employers, “At Anheuser-Busch, we pride ourselves on our high ambitions and go-getter mentalities, but without good health we can’t be our best—at home, at work, or in the community. Our strength is in our people, and by defeating diabetes, we’re bringing people together for a better world.”

The two-year campaign will formally kick off during the BHC’s upcoming Spring Forum on April 10. The event will bring together top researchers, health care providers, employers, and well-being experts to discuss the latest science in diabetes prevention, management, and reversal. In addition to businesses, this community dialogue seeks to engage other stakeholders moving the needle of diabetes care management in the St. Louis community, including health system, insurance, pharmaceutical, and policy leaders. To learn more about this event and the campaign efforts, please visit www.stlbhc.org/page/DefeatDiabetesSTL.

The BHC is deeply appreciative of campaign sponsors, the Missouri Department of Health and Senior Services, Novo Nordisk Inc., and Naturally Slim^®, for their generous support in making these activities possible. “It’s a privilege to partner with the St. Louis Area Business Health Coalition and its members to raise awareness of the importance of diabetes prevention across the region and beyond,” said Dr. Tim Church, MD, MPH, PhD, and Chief Medical Officer of Naturally Slim^®. “Employers are on the front lines in America’s fight to improve population health and reduce health care spending from diabetes and obesity-related chronic disease, and Naturally Slim^® is proud to stand shoulder to shoulder with them in this journey.”

About the St. Louis Area Business Health Coalition

The St. Louis Area Business Health Coalition (BHC) is a nonprofit organization representing 60 leading employers, which provide health benefits to thousands of lives locally and millions nationally. For 37 years, the BHC has worked to achieve its mission of supporting employer efforts to improve the well-being of their employees and enhance the quality and overall value of their investments in health benefits. To accomplish these aims, the BHC centers its work on providing pertinent research, resources, and educational opportunities to help employers understand best practices for the strategic design (and informed use) of benefits to facilitate high-quality, affordable health care. To learn more, please visit www.stlbhc.org or follow the BHC on Twitter and LinkedIn.

A thought-provoking discussion is bubbling in the medical community about the role and responsibility of physicians to bring lifestyle medicine into their practices. Is a physician falling short of their Hippocratic Oath when treating the symptoms of disease rather than the root cause? Could the personal belief of physicians that people will never change their lifestyle be putting some patients at risk of harm? Measures of physician quality, designed to determine if care is being provided in accordance with evidence-based standards, often look to testing and prescribing. Will the therapeutic use of lifestyle modifications to treat disease cause physicians to appear less effective?

In an aging society with high rates of chronic illness, medical spending twice that of most nations, and too much physician burnout, lifestyle medicine may be a silver bullet. The American College of Lifestyle Medicine (ACLM), a fairly new medical specialty society, happens to be located in Chesterfield, Missouri. They grew by 400% in 2018, confirming that physicians are turning to lifestyle science for therapeutic interventions. BHC staff met with a few ACLM leaders last week. Their enthusiasm for the role of physicians in supporting patients to live a healthier, better quality life was palpable. Lifestyle medicine may also be a cure for the profession. Grateful for the opportunity to truly help their patients find a cure, ACLM’s doctors seemed immune to the job dissatisfaction that so many providers claim to feel. Little else holds as much promise for chronically ill patients, physicians losing their joy, and a nation in physical and financial crisis.

ACLM leader, Dr. James Loomis, will share his personal and professional transformation during the BHC's April 10th Spring Forum. Please join us.

Warm regards,

Louise Probst

BHC Executive Director

Under the rule, rebates offered in exchange for formulary position would be banished. Two new safe harbors are created to enable price reductions at the point of sale and PBMs to be paid flat service fees by manufacturers. HHS believes that these actions will create strong incentives for drug manufacturers to reduce prices, as they are designed to deliver the “discounts” directly to patients at the pharmacy counter. This is what many drug companies have been calling for - a diminished role for middlemen and lower prices for patients. It could also stop bad behaviors by some pharmaceutical companies that use rebates to create barriers to competition for biosimilars, generics, and other new drugs.

Out for comment, the proposal suggests an effective date of 2020. Given the industry complexity and uncertain stakeholder response, it is hard to assess the potential impact. Like all sweeping changes, initially there will be winners and losers. Most agree Part D premiums will go up. HHS expects overall cost to patients and the government to go down and the long-term market effects to be positive.

While the rule only applies to Medicare and Medicaid plans, it would be naive to ignore the potential impact on commercially insured plans. Some expect the ripples of this action to shrink rebates in the private sector and lead to new purchasing models. Changes to the current business model seem almost certain. The focus on rebates and misaligned incentives has consumed public conversation, breeding widespread mistrust for too long. The BHC will stay informed, working to leverage stronger competition and refocus the conversation on fair pricing and achieving the best value.

Warm regards,

Louise Probst
BHC Executive Director

By shining a light on charges, CMS hopes to make health systems more financially accountable to the public. Ideally, this regulation will dampen cost inflation and heighten hospitals’ consumer-friendly communications, as patients navigate charges across facilities, determining their potential financial liability. While not required, hospitals may post quality ratings or other additional information, and some local hospitals have included the average length of stay and charge by diagnosis-related group. The format for reporting is left up to the hospital, as long as the information represents current standard charges and is updated annually in a machine-readable format.

A common criticism of the regulation, particularly from hospital executives, is “Nobody pays charges.” While most patients do not pay charges, it would be naive to think that higher charges are unrelated to future revenue increases, albeit not in a 1:1 ratio. Click here to see the trend in St. Louis hospital aggregate charges and revenues from the BHC’s most recent St. Louis Health Care Industry Overview Report (page 10). Patients finding themselves at an out-of-network facility are billed charges, and some insurers still contract on a percent of billed charges for certain services - commonly outpatient services. To get a better sense of how charges might be affecting your plan cost, you may want to ask your insurer for a breakdown of the percent of your total facility claim dollars paid under a per diem, a flat rate per case, or a percent of billed charges contract.

St. Louis hospitals are in compliance with this new law, but you may want to wait before making comparisons. Chargemasters frequently contain tens of thousands of items, with numerical codes representing technical names. Sometimes, multiple prices are listed across seemingly identical services with the charge code as the only distinguishing factor, and patients often do not know which code will cover their services. If you want to take a look, you can click on Mercy, SSM, BJC or St. Luke’s for links to their online chargemasters.

As time goes on, things will improve. Transparency vendors, researchers, and groups like the BHC will organize and interpret the data for easily-consumed, direct comparisons and encourage hospitals to standardize report formats. While we still have far to go, this is an important step toward tackling the complex issue of transparency in health care.

Warm regards,

Louise Probst
BHC Executive Director

It was authored by two Towers Watson Consultants, Sylvester J. Schieber (retired) and Steven Nyce, and supported by the Council for Affordable Coverage. Analysis of wage and health care premium data from the 1980s onward, is used to demonstrate that the out-of-control growth in the cost of employer-provided health benefits has had a significant and negative impact on American workers. It shrinks workers' wage growth, erodes contributions to their retirement savings, and fuels growing income inequality.

All workers have been impacted; however, lower income earners have suffered the most. Rising health care costs have completely wiped out pay increases for the bottom 60% of U.S. workers over a thirty-plus year period. In 2001, 42% of the dollars spent to provide employee benefits went to health care and 58% to retirement. In 2015, 63.5% went to health benefits and 36% to retirement.

"So why has the United States, a nation that has led the world in productivity, done such a miserable job in organizing and delivering health care?"

The authors not only ask but also answer this question. Using both stories and statistics, they reveal how the organization and delivery of health care services in the U.S. is designed to sustain high cost. The failure of the federal government over this period to protect the public from anti-competitive mergers and the subsequent out-of-control price inflation is called out as a major contributor.

The final call to action is focused on employers: "While we all contribute to the problem to some degree - providers, purchasers, and consumers alike - only employers have both the means and the incentive to improve a value proposition in a health market that is so completely skewed toward the sellers and away from the buyers."

It's a long and worthwhile read (click here to view full report). Your thoughts and insights are appreciated.

Warm regards,

Louise Probst
BHC Executive Director

After taking public comment, CMS revised its rating system in 2017. As a result, the number of five-star rated hospitals increased from just 83 to 337. Yet, a five-star ranking remains exceptional. Out of the more than 4,000 hospitals rated nationally, less than 8% of hospitals have achieved this distinction. The rating program covers 57 quality measures across seven areas of performance: 1) mortality, 2) safety of care, 3) readmission, 4) patient experience, 5) effectiveness of care, 6) timeliness of care and 7) efficient use of medical imaging. Another 67 considered measures were excluded due to overlap and/or fewer than 100 hospitals reporting on them. Additional methodologic changes were also made.

Performance varies across hospitals by measure and category. Not all top-rated hospitals receive the highest scores in every area. Since mortality, safety, readmissions and patient experience are more heavily weighted than the other three measures of performance, top-rated hospitals generally operate well in those categories. The public release of the CMS star ratings for hospitals was not available when MHI was creating ChooseWellSTL.org. As a new program, MHI decided to consider adding hospital stars in a future site update. The user-friendly CMS site shows hospital comparisons in an easily understood five-point scale, while also enabling users to scrutinize hospital performance further on specific, individual criteria, according to their interests.

Warm regards,

Louise Probst

BHC Executive Director

Louise Probst
BHC Executive Director

Wishing you all the best in the New Year,  

Louise Probst
BHC Executive Director

BHC Executive Director

BHC Executive Director

Warm regards,

Louise Probst

BHC Executive Director

Louise Probst

BHC Executive Director

1. Members support repealing both the employer and individual mandate provisions of the ACA, though the margins were not large. Results indicate less opposition to the individual mandate for health coverage than to the employer mandate.
    
2. Members strongly oppose the Cadillac Tax and taxing individuals on the value of their health benefits. In fact, sixty four percent (64%) of respondents disagree with the idea that individuals should be taxed on the value of their health benefits, even if a tax is necessary to "provide needed access."
    
3. Members do not believe that the high cost of care is adequately addressed by either the ACA or current GOP proposals.  
    
4. When it comes to Medicaid expansion, more members are positive or neutral than are actively opposed. 
5. Members strongly agree that employers have a role to play in driving better value health care.  

While BHC engages with policy makers on specific health policy issues that would weaken ERISA protections, mandate benefits, or impact the quality and affordability of health care, it does not advocate for or against broad health care reform packages. The survey was conducted to enable BHC leaders, members, and staff to understand the range of opinions held by individual members on key issues of federal health policy, particularly those related to taxation and coverage mandates.

As many of your responses noted in various ways, the fiscal health of our nation will depend on health care purchasers, including employers and the government, having the courage to pursue better value through advocacy and contracting. I was pleased to see such strong recognition of this opportunity by members. Let's support one another in picking up the pace. 

Thank you for the work you do every day to make health care better for your employees and our community.

Warm regards,

Louise Probst

BHC Executive Director