5 Things Washington: Total cost of care report, Topical Agenda, Student mental health


Emily Boerger


This week we released our Topical Agenda for the 2022 Inland Northwest State of Reform Health Policy Conference. It’s an exciting and important milestone as we prepare for the September 8th event! We have more details on the agenda below.

Also in this edition, we feature a Q&A on student mental health, take a look at WHA’s new Total Cost of Care report, and highlight a KFF analysis on in-network claim denials.

Thanks you for your support!

Emily Boerger
State of Reform


1. WHA releases Total Cost of Care report

The Washington Health Alliance released its Total Cost of Care report last week, breaking down service costs on a per patient per month basis based on insurance type, medical group/clinic, and service setting. The data indicates that costs can vary widely, with the most expensive patients being those managing multiple or complex health conditions. WHA says these patients are “small in number but account for approximately 13% of all health care costs.

WHA Executive Director Nancy Giunto says this level of detail on Washington’s health care spending is the first of its kind and is a “crucial starting point” in tackling health care affordability. In a statement, Dr. Pete Rutherford, CEO of Confluence Health, said, “I’m very excited to see the next steps of this analysis, so the Alliance can explain the drivers of what is contributing to these costs, and the variability across the state and then we can start to take steps to reduce it.”


2. ICYMI: Topical Agenda now available

In case you missed it, on Tuesday we released the Topical Agenda for the 2022 Inland Northwest State of Reform Health Policy Conference coming up on September 8th. It’s a set of topics pulled together from hours of conversations with our Convening Panel, key stakeholders, and sponsors.

During the event, we’ll explore politics and policy in health care, discuss initiatives to support and grow the workforce, and dive deep into behavioral health, the cost of care, and the future of Medicaid. You can view the Topical Agenda here for a sense of the conversations we have teed up, and if you have suggestions for speakers let us know. If you haven’t already registered, we’d be honored to have you join us!

3. Q&A: Dr. Susan Leveridge, WMHCA

Starting in the upcoming school year, Washington students will be able to take mental health days off from classes thanks to legislation passed during the 2022 session. State of Reform recently caught up with Dr. Susan Leveridge, President of the Washington Mental Health Counselors Association, for a conversation on student mental health, the stressors students face, and the potential impacts of the new law.

Leveridge says the pandemic, academic pressures, competition among students, and interpersonal relationships are all stressors facing students. “Research tells us that emotional regulation is primary to mental well-being,” Leveridge says. “By being aware of the level of stress a child is carrying, and learning to take a self-care day, we are teaching children to self-regulate. This is a life-long skill and needed well into old age.”

4. CMS rescinds pharmacy state plan amendment

In an announcement late last month, CMS rescinded its approval of Washington’s Medicaid state plan amendment that proposed changes to the way pharmacies are reimbursed for Medicaid patients. In its decision, CMS said the plan amendment was inconsistent with the requirement that “States have a State plan that provides such methods and procedures to assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available to the general population of the geographic area.”

The Washington State Pharmacy Association voiced their support for the decision, arguing that the amendment would reimburse “pharmacies for Medicaid patients far below the actual cost of dispensing prescriptions.” They argued that approval of the amendment was inconsistent with CMS’s previous position on the amendment.


5. About 18% of HealthCare.gov in-network claims denied in US

A recent Kaiser Family Foundation analysis found that 18% of claims submitted for in-network services in the US were denied by HealthCare.gov marketplace insurers during the 2020 plan year. According to the analysis, national denial rates for in-network claims ranged from 1% to 80%.

About 10% of denials were due to lack of prior authorization or referral, 16% were for excluded services, and 72% were for “all other reasons.” KFF’s evaluation also notes that consumers rarely appeal denied claims, stating: “Of the more than 42 million denied in-network claims in 2020, marketplace enrollees appealed fewer than 61,000 – an appeal rate of about one-tenth of one percent.”