Looking A Little Deeper into CMS National Health Expenditure Report

By Clive Riddle, December 20, 2017 The CMS Office of the Actuary recently released their annual National Health Expenditure Data, current and historical through 2016. We thought we’d take a slightly deeper look at data released to expand upon the publicized highlights. CMS found that ”in 2016, overall national health spending increased 4.3 percent following 5.8 percent growth in 2015.” For comparison PwC in their annual Behind The Numbers medical cost trend report pegged the number at 6.8% in 2015; 6.2% in 2016; 6.0% in 2017 and project 6.5% for 2018. Of course overall national health expenditures measured by CMS are not an identical universe to how PwC measures medical cost trend. The portion of national GDP that healthcare consumes has been one of the most used comparative measures of healthcare to the overall economy. CMS found that “During 2014 and 2015, the health spending share of the economy increased 0.5 percentage point from 17.2 percent in 2013 to 17.7 percent in 2015. Health care spending grew 1.5 percentage points faster than the overall economy in 2016, resulting in a 0.2 percentage-point increase in the health spending share of the economy – from 17.7 percent in 2015 to 17.9 percent in 2016.” Looking back into CMS historical files, in 1966 healthcare consumed 5.7% of the national GDP. In 1976 it was 8.1%. In 1986: 10.3; 1996: 13.3%; 2006: 15.5%; and last year to 17.9%. CMS reports that “private health insurance spending increased 5.1 percent to $1.1 trillion in 2016, which was slower than the 6.9 percent growth in 2015.” Private insurance comprised 22% of national health expenditures in 1966, 25% in 1976, 29% in 1986, 32% in 1996, and 34% in 2006 as well as 2016.   Regarding Medicare, CMS states “spending grew 3.6 percent to $672.1 billion in 2016, which was slower growth than the previous two years when spending grew 4.8 percent in 2015 and 4.9 percent in 2014.  Medicare comprised 4% of national health expenditures in 1966, 13% in 1976, 16% in 1986, 18% in 1996, 19% in 2006 and 20% in 2016 For Medicaid, CMS says “expenditures grew 3.2 percent in 2016, while federal Medicaid expenditures increased 4.4 percent in 2016. The slower overall growth in Medicaid spending was much lower than in the previous two years, when Medicaid spending grew 11.5 percent in 2014 and 9.5 percent in 2015.” Medicaid comprised 3% of national health expenditures in 1966, 10% in 1976, 9% in 1986, 14% in 1996 and 2006, and 17% in 2016. CMS tells us that overall “out-of-pocket spending grew 3.9 percent to $352.5 billion in 2016, faster than the 2.8 percent growth in 2015.  Additionally, 2016 was the fastest rate of growth since 2007 and was higher than the average annual growth of 2.0 percent during 2008-15.”Examining out of pocket expenses as a percent of overall health expenditures, we found the percentage has decreased from to 48% in 1960; 33% in 1970; 22% in 1985; 15% in 2000 and 11% in 2016. CMS reported that “retail prescription drug spending slowed in 2016, increasing 1.3 percent to $328.6 billion. The slower growth in 2016 follows two years of significant growth in 2014 and 2015, 12.4 percent and 8.9 percent, respectively” Looking back at historical files for Rx total spending, percentage of overall healthcare spending and the percentage paid out of pocket for the past six decades, we found: 1966: Total $4.0 Billion | 8.6% of Total Health Expenditures | 90.2% paid out of pocket 1976: Total $8.7 Billion | 5.7% of Total Health Expenditures | 74.7% paid out of pocket 1986: Total $24.3 Billion | 5.1% of Total Health Expenditures | 64.8% paid out of pocket 1996: Total $68.1 Billion | 6.3% of Total Health Expenditures | 35.6% paid out of pocket 2006: Total $224.1 Billion | 10.4% of Total Health Expenditures | 22.9% paid out of pocket 2016: Total $328.6 Billion | 9.8% of Total Health Expenditures | 13.7% paid out of pocket.

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week: Good Deals for Some, Sticker Shock for Others As ACA Enrollment Winds Down In most states, Friday night is the last chance to sign up for Affordable Care Act health insurance for 2018. The enrollment period is half as long as last year’s, and it got just a fraction of the marketing budget to tell consumers that. Kaiser Health News Friday, December 15, 2017 HHS greenlights secret pilot for Medicare Advantage to get real-time access to patient discharge records The Department of Health and Human Services' Office of the Inspector General has given permission for a drug company to start a pilot program that will allow a private Medicare Advantage plan real-time access to a hospital's electronic patient discharge records, according to an HHS letter posted December 11. Healthcare Finance Wednesday, December 13, 2017 Hospitals Are Merging to Face Off With Insurers A spate of hospital deals stands to further remake the U.S. health-care landscape, pushing up prices for consumers and insurers and changing how individuals get care. Just this month, health systems with at least 166 hospitals and $39 billion in combined annual revenue have announced merger plans. Bloomberg Physicians argue Anthem's ER policy violates federal law Physicians are concerned about a new policy Anthem is rolling out in Indiana in January, according to WBOI. Under the new policy, which is already effective in three other states, Anthem will review diagnoses after members' emergency room visits. If the condition is determined to be nonemergent, Anthem may not cover the ER visit. Becker's Hospital Review Monday, December 11, 2017 8.8 million Americans face big tax hike if Republicans scrap the medical deduction Anne Hammer is one of millions of elderly Americans who could face a substantial tax hike in 2018 depending on the final negotiations over the Republican tax bill. In her retirement community in Chestertown, Md., it’s the big topic of conversation. The Washington Post Sunday, December 10, 2017 These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.

Welcome, Comrade Patient

By Kim Bellard, December 14, 2017 Capitalism is in big trouble, even in the U.S. and especially among millennials.  So reports Fast Company and The New York Times.  Even capitalism-friendly publications like The Wall Street Journaland Bloomberg warn about it.  The oft-cited reasons include problems like increasing income/wealthy inequity and dimmer outlook for good jobs, but I have to wonder how much of a role our health care system plays in these kinds of attitudes. The WSJ also showed a 2016 Gallop poll in which capitalism and socialism were rated equally favorably (both just over 50%) by respondents ages 18 - 29, which was a stark contrast to every other age group (support for capitalism goes up by age, while support for socialism declines).  Similarly, a 2017 WSJ/NBC News survey found that the 18-29 age group was much more likely to say the government should do more to help people, again in contrast to other age groups.  In some ways, the U.S. health care system is a model of capitalism.  Lots of people are making lots of money, whether they be stockholders in health companies, doctors and health care executives, or even supposedly non-profit parts of the system.  The problem is, though, unless you are one of the lucky ones doing well with our current system -- and maybe even then -- you're probably not too happy with it.  Last year, Senator Bernie Sanders made unexpected headway in his race to be the Democratic candidate for President despite -- or perhaps because of -- his socialist leanings.  One of his key planks was for Medicare for all, an idea that has seen a strong resurgence generally.  Even more popular is the (admittedly vague) push for single payor. A Harvard-Harris poll found that 52% of Americans supported a single payor system, with even 35% of Republicans supporting.  Young people were most supportive.   Perhaps most astonishing is that a Merritt-Hawkins survey found that 56% of physicians now support single payor, a sharp reversal from prior surveys.  42% voiced strong support. Right now, millennials are not as engaged in health care as older age groups because they tend to need it less.  They don't have as many health problems and don't see health professionals as often.  That's why getting them to buy health insurance is a constant struggle, even when they have the lowest premiums.    But as this radicalized generation, who are already frustrated with economic inequity and the prospects for their future, realize how much they will have to pay for older Americans' health needs as well as for their own, push will eventually come to shove.  We have some hard thinking to do about how we finance health care, and for whom.  We have some hard thinking about what the role of profit, competition, and capitalism should be in our health care system.  We have some hard thinking to do about why our health care system is not serving more of us better. It may not be socialized medicine.  It may not be single payor.  It may not even be Medicare-for-all.  But it for sure will not be what we have now.  This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week: House tax writers weigh plan to suspend Obamacare insurer tax House Republican tax writers are considering delaying Obamacare's health insurance tax for only limited markets next year, leaving out small businesses and possibly private Medicaid plans, according to sources on and off Capitol Hill. They would suspend it for all markets in 2019. Politico Thursday, December 7, 2017 Hospitals Find Asthma Hot Spots More Profitable To Neglect Than Fix Months of reporting and rich hospital data portray life in the worst asthma hot spot in one of the worst asthma cities: Baltimore. The medical system knows how to help. But there’s no money in it. Kaiser Health News Wednesday, December 6, 2017 Providers See CMS Continuing Value-Based Care Push Despite Project Rollbacks Though the Trump administration last week rolled back several Obama-era projects designed to shift the U.S. health care system away from fee-for-service care to models that pay doctors and hospitals based on the quality of care, industry groups believe the government is likely to continue with the push toward value-based care. Morning Consult Tuesday, December 5, 2017 States get big Medicaid savings from social services, outreach to sickest patients Some states have achieved dramatic savings in health care costs for their sickest Medicaid patients by providing intensive one-on-one assistance and social services that help the patients better address their multiple, overlapping ailments. USA Today Tuesday, December 5, 2017 CVS likely wants FTC antitrust review, not Justice Department, of Aetna deal It is uncertain who in the U.S. government will carry out an antitrust review of CVS Health Corp’s (CVS.N) deal to buy health insurer Aetna Inc (AET.N), but the drugstore company is likely hoping the potentially more lenient Federal Trade Commission gets the nod, antitrust experts say. Reuters Tuesday, December 5, 2017 These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.

Are your healthcare consumers who they say they are?

By Claire Thayer, December 7, 2017

Verifying healthcare consumer identities has become enormously complex requiring sophisticated advanced authentication technology.  A HIMSS report on Patient Portal Identity Proofing and Authentication, tells us that the National Institute of Standards and Technology (NIST) identifies three factors as the cornerstone of identity authentication:

• Something you know (for example, a password)

• Something you have (for example, an ID badge or a cryptographic key)

• Something you are (for example, a fingerprint or other biometric data)

Multi-factor authentication refers to the use of more than one of the factors listed above, which NIST requires to reach a high level of confidence in authentication.  At least one of the factors must contain a secret that is securely presented to the electronic process that is verifying the user’s identity.  A second factor can be used to protect or activate the first. In this guidance report, the HIMSS Identity Management Task Force suggests that incorporation of smartphones as a second factor into the processes of identity proofing and authentication will significantly improve the security of electronic interactions with patients while minimizing the additional cost and difficulty.

This recent edition of the MCOL Infographic and e-Brief, co-sponsored by LexisNexis, focused on the intricacies, complexities and challenges involved with identity management:

 

MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more here.

Reforms and Innovation Needed to Lower Costs and Improve Quality in Healthcare

By: Tomas Gregorio, Senior Executive Director, Healthcare Delivery Systems iLab, New Jersey Innovation Institute Healthcare in the United States is complicated, inefficient and expensive.  Many individuals and families can no longer afford to see a doctor, fill a prescription or get the most basic medical care without having to sacrifice other essential items such as putting food on the table or paying the mortgage.  These are choices that no American should be forced to make.  Unfortunately, after seemingly endless attempts at reform, the costs of our healthcare system continue to move steadily higher, impervious to all attempts from the government, private companies or other stakeholders to hold back the ever-rising healthcare tide. Healthcare, by its very nature, is resistant to change.  Concerns over privacy and safety often delay the sharing of information or adoption of new technologies that could reduce the costs of care. While these issues are valid, they can and must be addressed as the status quo is no longer acceptable.   This point has not been lost on the U.S. Department of Health and Human Services and the West Health Institute that in a recent whitepaper noted that greater interoperability of healthcare devices alone could help save more than $30 billion a year in wasteful spending.  While the Rand Corporation in an earlier study estimated that full national interoperability could save $77 billion annually. A national network in which all providers have access to medical records is still many years away however, there are steps being taken right now by the Centers for Medicare & Medicaid Services (CMS)  that promise to have a positive impact on healthcare costs and quality.   The initiatives, “Patients Over Paperwork” and “Meaningful Measures” seek to reduce the regulatory and reporting burden on providers. Reducing the amount of time physicians spend on paperwork is goal that I am sure would garner 100 percent support in the healthcare community.  Providers spend countless hours filling out forms or checking boxes that in many cases have no obvious benefit for either the physician or the patient.  Seema Verma, CMS Administrator, noted this problem during remarks on October 30, at a Healthcare Summit when she said, “We publish nearly 11,000 pages of regulations every year. That is a lot of paper, and it’s taking doctors away from what matter most – patients.” Further, the American Hospital Association recently published a report showing that health systems, hospitals and post-acute care providers spend nearly $39 billion a year (let that sink in for a minute) solely on administrative activities. CMS is beginning to address this problem by taking on a full scale review of current regulations by asking some very basic and important questions:  What is the purpose of the regulation? Does this regulation help prevent fraud and abuse? Does the regulation have a meaningful impact on patient care, safety and improving outcomes?   This review alone, and a subsequent role back of regulations has the potential to save untold billions of dollars, improve patient care and restore the sanctity of the provider/patient relationship. CMS’ Measures Management effort is about examining what quality measures should be reported to the government as part of their overall goal of moving our healthcare system from fee-for-service to value-based care. My organization, The New Jersey Innovation Institute (NJII), fully supports this effort and is partnering with CMS through their Transforming Clinical Practices Initiative (TCPI) that seeks to save more than $1 billion in healthcare costs by the end of 2019 by helping physicians adopt value-based care payment models. NJII has recruited a network of nearly 10,000 physicians to be part of the initiative and we are on pace to save more than $135 million in costs and improve the health of more than 500,000 Medicare patients over the life of the program. Meaningful Measures will focus on having providers report only on measures that are most vital to providing high quality care and improving outcomes for patients.   In essence, CMS will focus more on results, less on process, and promote a more market driven health care system. NJII applauds CMS in its efforts to bring innovation to our healthcare system and examine opportunities for advancement.   We encourage healthcare stakeholders at every level to bring their expertise to the table and further the collective effort to lower costs and improve healthcare quality.

The President’s Commission on Combating Drug Addiction and the Opioid Crisis

Sandhya Gardner, MD, Chief Medical Officer, Relias, December 4, 2017

There has been no shortage of attention given to the current opioid abuse and overdose epidemic sweeping the U.S. Near-daily media reports highlight the staggering number of people who are addicted to prescription and illicit opioids and who die from them daily. Nor have suggested remedies been neglected. Federal regulatory agencies, including the FDA and the CDC, professional medical associations, public health organizations, the insurance industry, and others have all recently issued new guidelines and policies on the proper administration of opioids and the treatment of individuals with opioid addiction.

Despite, or perhaps because of this attention, the President’s Commission report was eagerly anticipated. When released in final form on November 1, 2017, the report was widely praised for its comprehensive attention to the many factors that have combined to create the perfect storm that is today’s opioid crisis. There were reservations, however, because the Commission did not recommend any specific funding amounts to implement its recommendations. Moreover, President Trump’s decision to declare the opioid epidemic a public health crisis rather than a national health emergency also meant that no new funding has yet been allocated. The President’s Commission did advocate, however, that an unspecified amount of increased resources be put towards implementing its 56 recommendations.

We will highlight some critique and opinions about these recommendations specifically for healthcare providers and prescribers, organizations, funders and insurers, government and law enforcement agencies, and patients.

Providers and prescribers will see that the recommendations are largely extensions of current practice and therefore are relatively unsurprising. Adopting policies to ensure that patients give informed consent before receiving an opioid is consistent with current practice standards. Physicians should of course always discuss risks, benefits, and alternatives of any intervention they recommend for their patients. The concern here is that the informed consent procedure policies adopted be balanced. Opioids are proven effective analgesics for both acute and, in some instances, chronic pain and there are patients for whom they are clearly indicated. Informed consent procedures should, therefore, not be designed to frighten or discourage patients who need opioids.

Noteworthy, although not a departure from current policies and recommendations, is standardizing guidelines and extending them to specialists. Right now, there is a patchwork of opioid prescribing guidelines that have been created by multiple agencies. Many of them apply only to primary care providers. Currently, some states, like New York, have mandatory opioid continuing education requirements for relicensing and require that prescribers consult the state’s on-line Prescription Drug Monitoring Program (PDMP) before prescribing an opioid. These requirements would be extended to all states and a standardized national opioid prescribing curriculum would be created. It is unclear how effective continuing education programs are in improving opioid prescribing practices, so the benefits must be weighed against the burden it places upon physicians who must spend time taking more courses. Similarly, although there is some evidence that PDMP use reduces opioid abuse, it remains unknown whether this will have a significant effect in stemming opioid abuse.

Physician groups have complained that questions about how pain was handled that are included in patient satisfaction surveys contribute to unnecessary opioid prescribing. Fearing that negative reviews will be held against them; physicians report feeling pressured to prescribe opioids to patients with pain complaints to boost their ratings. The new recommendations mandate that CMS remove pain questions entirely from patient satisfaction surveys. This seems like a very positive step towards reducing inappropriate opioid prescribing.

Current practice is to refer patients reporting to the Emergency Department (ED) with signs and symptoms of opioid abuse or withdrawal to outpatient providers, but this can lead to poor follow-up and/or retention in treatment. Studies have shown that treatment, particularly with medications like buprenorphine/naloxone (Suboxone), can be started in the ED for such patients, who then are much more likely to enter outpatient treatment and remain drug-free for extended periods of time.  Although some emergency physicians in the past have been reluctant to start medication assisted treatment (MAT) for patients in the ED, the recommendation to initiate substance abuse and addiction treatment in the emergency department could substantially improve outcomes for opioid addicted individuals. 

Healthcare insurers will likely see an increase in their costs because of these recommendations. Nevertheless, these recommendations are all consistent with expert opinion. Right now, insurers incentivize physicians to prescribe opioids rather than alternative analgesic interventions, a policy that is widely criticized. For example, it is less expensive for patients to fill a prescription for a generic opioid than it is to have acupuncture or cognitive-behavioral therapy, even though both of the latter are among the non-opioid interventions that can be effective and far less risky in treating pain than opioids. The President’s Commission appropriately recommends modification of rate-setting policies that discourage use of non-opioid treatments for pain. It also calls for insurers to remove barriers for all forms of substance use disorder (SUD) treatment, including MAT. There is widespread agreement among experts that MAT is a safe and effective treatment for SUD and that its use should be expanded significantly. Finally, the recommendations call for stricter enforcement and stiffer penalties for insurers that violate mental health and parity laws. Although this last recommendation will certainly win the approval of advocates, enforcing the parity laws currently in effect has proven to be extremely difficult.

The creation of drug courts in all 93 federal judicial districts has already won widespread approval. Individuals with an SUD who violate parole would be referred to a drug court rather than sent to prison. Sending SUD patients to prison is generally seen as counterproductive and diversion to treatment via drug courts reduces recidivism.

Of course, all the above will have tremendous impact on patients who have pain-related illnesses or who are struggling with problematic opioid use. One recommendation that has not been met with much approbation, however, is for a media campaign to address “the hazards of substance use, the danger of opioids, and the stigma.” Some have criticized this recommendation as being too vague. It is unclear that such a campaign would significantly alter public perception or behavior. It also runs the risk of discouraging people who are legitimately taking opioids for severe pain, such as cancer patients, from adhering to prescribed regimens. The hope is that if a media campaign is pursued, that it is carried out in an evidence-based manner that incorporates what is known from social science about effective methods for changing attitudes and behavior.

Conclusions:

The most immediate concern about the President’s Commission report is that no funding is yet attached to its recommendations. One member of the Commission, former Rhode Island congressman Patrick Kennedy, was quoted as estimating that Congress needs to appropriate at least $10 billion immediately for the Commission’s recommendations to be carried out.   

Another concern is whether the President’s Commission report takes into consideration the need to balance medically-indicated opioid prescribing with abuse/overdose prevention. Opioids are effective analgesics that can be a highly appropriate treatment for severe pain in both acute and chronic situations. But there is no question that they are currently prescribed in many situations for which other, less perilous, alternatives are effective and available. Nor is there any disagreement that opioid misuse and abuse have reached epidemic proportions and that the quantity of opioids prescribed must be reduced. However, patients who need to take opioids must not be stigmatized, nor must physicians be frightened to prescribe them when its necessary.

Overall, barring the concerns about funding and some skepticism around the proposed media campaign, the recommendations have been met with optimism. They provide a multi-prong approach to an enormous problem and include many evidence-based recommendations.

For further information on this topic, a free webinar will be taking place on Tuesday, December 12 at 2pm EST. Titled, Opioid Commission Final Report: Recommendations and Effects on Payers, Insurers, and Providers, the webinar will be led by Susan Kansagra, MD, MBA – Section Chief -  North Carolina Division of Public Health, Chronic Disease and Injury Section, North Carolina Department of Health and Human Services, and Jason E. Vogler, Ph.D., CS SBB, Senior Director - Division of Mental Health, Developmental Disabilities and Substance Abuse Services
North Carolina Department of Health and Human Services. Registration for the webinar is available here.

Recent Uber and Lyft Healthcare Transportation Collaborations

By Clive Riddle, December 1, 2017 

Yesterday (November 30th) Cigna-HealthSpring reported on its collaboration with Lyft for medical transportation of Medicare Advantage members. They stated that "more than 14,500 transports have occurred through this collaboration. Since its introduction in May, 92 percent of Cigna-HealthSpring customers using Lyft have made it their preferred transportation option, according to customer surveys. On average, participants are waiting less than eight minutes for Lyft to take them to or from their appointments." They explain that "the service is for ambulatory customers in non-emergencies only and is only available to Cigna-HealthSpring customers whose benefit plan includes supplemental non-emergent medical transportation coverage through Access2Care at no additional cost. Participants need to contact Access2Care to establish Lyft as their designated transportation provider." 

I decided to check out what other developments have occurred during the past month regarding Uber, Lyft and medical transportation collaborations. 

The AHA during November published a nice 27-page report in their Social Determinants of Health Series on Transportation and the Role of Hospitals. In their chart summarizing transportation strategies, they state that “When transportation is unavailable, health care systems may need to provide transportation directly to patients and staff,” and their recommendations include that hospitals “partner with ride-sharing companies like Uber or Lyft.” 

A November1st Catholic Health World article Ministry systems tackle transportation barriers for vulnerable patients, that included these four examples of Uber and Lyft healthcare transportation collaborations: 

• “St. Vincent Charity Medical Center in Cleveland launched a program in the spring to provide free transportation via the ride-sharing company Uber to patients undergoing addiction treatment in the hospital's Rosary Hall Intensive Outpatient Program.....Between June and September, 30 new clients logged 507 Uber rides, and 29 clients achieved 100 percent participation in the group and individual counseling sessions. In the 30 days before launch, Rosary Hall had 76 percent client participation in group sessions and 62 percent client participation in individual counseling sessions. “
• “Trinity Health of New England has pinpointed pickup and drop-off locations exclusively for Uber riders to and from its five hospital campuses in Connecticut and Massachusetts that can be selected on the Uber smartphone app so the driver knows exactly where to deliver or meet a patient. Uber rides also can be scheduled through each hospital's website....Trinity also uses Uber to transport select patients from its Mandell Center for Multiple Sclerosis in Hartford, Conn., for services at nearby Saint Francis Hospital and Medical Center.”
• “St. Louis-based Ascension was the first health care system to form a partnership with Lyft. Since February, Ascension has put agreements in place in 21 of its markets, and Lyft has provided more than 8,000 rides.....Ascension staff members use Lyft's concierge platform to schedule the rides.”
• “Broomfield, Colo.-based SCL Health announced last month that it is collaborating with Lyft to make nonemergency on-demand or scheduled transport available to its vulnerable patients living in the front range of the Rockies near Denver.”  

The Advisory Board Care Transformation Center Blog featured this post on November 28^th:  5 ways MedStar's nurse-inspired partnership with Uber has paid off, starting off by telling us “Since 2016, Uber has announced partnerships with MedStar Health, Hackensack University Medical Center, and Boston Children's Hospital. Lyft has announced partnerships with transportation service organizations National Medtrans Network and Logisticare, as well as BCBSA. Why have these organization, among others, turned away from more traditional van or cab service? We learned a bit more about MedStar's arrangement with Uber to try and figure it out.” They cite these key benefits of the Medstar/Uber partnership: Patient Transportation Service is now faster; Service is more reliable; Service is less expensive; Clinic staff workflow is more manageable; and Analytics on MedStar transportation support offer new opportunities. 

But there are concerns patients are beginning to use Uber and Lyft in emergent situations. The CBS affiliate in Cincinnati reported on November 9th on The "Uberlance" trend: People turn to Uber to offset high hospital transportation costs.  They tell us that “the new trend is forcing Uber drivers to act as first responders. The drivers asked to not have their identities revealed, but they still wanted to tell their stories of what is now being referred to as ‘Uberlance.’ ‘I said to him ‘why didn't you call an ambulance?’ His hand was bleeding. He goes ‘because you're quicker and you're cheaper,’ said ‘Johnny’, an Uber driver. ‘I've had people get in my car, they're dizzy, they don't feel well, their chest hurts,’ said ‘Brian’, an Uber driver. Drivers say passengers opt for Uber over an ambulance for speed and cost.” 

Despite these concerns of patients taking matters in their own hands and using Uber or Lyft to avoid dispatching an ambulance, some EMS, healthcare and health plan organizations are proactively pursuing such arrangements for urgent care visits to avoid use of ambulances in non-emergencies.  The San Diego Union Tribune on November 5^th ran the story San Diego exploring new emergency response model amid ambulance crisis, stating that EMS officials there were seeking “an alternative model where non-emergency patients could take a taxi or Uber to a clinic or urgent care facility and get reimbursed by private insurers, Medicare or Medi-Cal.” The article cites that “Anthem Health Insurance recently announced it will start covering such alternative modes of transportation in 2018.”

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week: Congress Isn’t Really Done With Health Care — Just Look At What’s In The Tax Bills Having failed to repeal and replace the Affordable Care Act, Congress is now working on a tax overhaul. But it turns out the tax bills in the House and Senate also aim to reshape health care. Kaiser Health News Friday, December 1, 2017 CMS makes it official: Two mandatory bundled-pay models canceled The CMS has finalized its decision to toss two mandatory bundled-payment models and cut down the number of providers required to participate in a third. Modern Healthcare Thursday, November 30, 2017 CVS Nears Deal to Acquire Health Insurer Aetna CVS Health Corp. is nearing an agreement to acquire health insurer Aetna Inc. for more than $65 billion, according to a person familiar with the negotiations, in a deal that could reshape the pharmacy and health insurance industries. Bloomberg Thursday, November 30, 2017 Marketplace Confusion Opens Door To Questions About Skinny Plans Consumers coping with the high cost of health insurance are the target market for new plans claiming to be lower-cost alternatives to the Affordable Care Act that fulfill the law’s requirement for health coverage. Kaiser Health News Monday, November 27, 2017 As Health Care Changes, Insurers, Hospitals and Drugstores Team Up They seem like odd couples: Aetna, one of the nation’s largest health insurers, is in talks to combine with CVS Health, which manages pharmacy benefits. The Cleveland Clinic, a highly regarded health system, joined forces with an insurance start-up, Oscar Health, to offer individuals a health plan in Ohio. NY Times Sunday, November 26, 2017 These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week: Medicaid Expansion Takes A Bite Out Of Medical Debt As the Trump administration and Republicans in Congress look to scale back Medicaid, many voters and state lawmakers across the country are moving to make it bigger. Kaiser Health News Friday, November 17, 2017 Medicare Seeks Comment On Ways To Cut Costs Of Part D Drugs Noting that the true price of a drug is often hidden from consumers, Medicare officials requested comments late Thursday on how to use discounts and rebates to help decrease what enrollees pay for prescriptions. Kaiser Health News Thursday, November 16, 2017 Remembering Health Care Economist Uwe Reinhardt Reinhardt, who died on Monday, helped shape the debate about health care by advocating for individual mandates and universal health care. Originally broadcast in 2009. NPR Thursday, November 16, 2017 Sign-ups hit 1.5 million in first two weeks of ACA open enrollment HealthCare.gov sign-ups continue to outpace last year's, with nearly 1.5 million people selecting plans during the first two weeks of open enrollment. Modern Healthcare Wednesday, November 15, 2017 Bill Gates says big data can help solve the Alzheimer's puzzle Through his foundation, Bill Gates has focused on reducing global poverty, finding cures for infectious diseases, and promoting education and sustainable energy. Now Gates is getting into an area that's new for him: Alzheimer's disease. Monday, November 13, 2017 These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.

Patients Are a Design Problem

by Kim Bellard, November 15, 2017 When I say "patients are a design problem," I don't mean that the people who happen to be patients are a design problem.  They may well be, but that's an issue you'll have to take up with Darwin or your favorite deity (or, all-too-soon, perhaps a CRISPR editor...).  No, I mean that making people into patients is a design problem.  And it's a big one. Consider the following: 1.  Physician Respect: We treat physicians as something special. That white coat is no longer needed and may, in fact, be counterproductive, but serves to remind of us the deference the health care system believes physicians are due.  2.  Patient experience: It's hard to get appointments.  The appointment time is often just a vague indicator of when we'll actually see our doctor.  We may have services done to us that we don't really understand and which not uncommonly are unpleasant, to say the least.   We may be asked to fast unnecessarily for hours before blood work or procedures.  We often are unsure about what is going to happen next, or when. It is not a patient-centered system. 3.  Medicalization:  We talk about the health care system, but we really mean the medical care system.  We almost never include, or pay for, the other things that impact our health, like diet, exercise, and environment.  4.  Better, Soon: We've seen remarkable strides in what medical care can achieve.  We have become a nation of pill-poppers.  When something is wrong with us, we expect to be able to get it fixed, and we expect that to happen quickly.  5.  Confusion reigns: Nothing about health care seems easy.  It's hard to pick a physician, or a health plan.  The terminology makes no pretense at being understandable to anyone not a health care professional.  The bills are practically indecipherable.  If you need multiple doctors, tests, or procedures -- which you almost certainly will -- you'll have to navigate the maze around getting them.  No one, lay or professional, claims to understand the "system." 6.  Responsibility: We've delegated responsibility for our health to our health care professionals, especially our doctors.  It is more established than ever that regular exercise, moderate eating, and a balanced life would do more to improve our health than any regime of medical treatments.  Yet we continue to expect that the results of our increasingly poor habits will be "fixed."  These are why we are "patients."  These are why we are expected to be patient. We will always need physicians (although not always human ones!), and many other health care professionals.  That's a good thing.  They have knowledge and skills that can help us.  They deserve our respect.  But we should design our health care system around us, not them.  Make the "system" simpler.  Focus it around our health, not our care.  Expect us to have responsibility for our own health -- but ensure we have the tools we need to manage it.  Spend money to prevent health issues, not address them once they've happened. If patients are a design problem, then maybe people can come up with a design solution.   This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

The State of Medicaid in the States

by Clive Riddle, November 8, 2017 Mark Farrah Associates has just released their Mid-Year 2017 Medicaid Market and Enrollment Trends report which cites national Medicaid coverage was “74.3 million as of June 2017. This represents approximately 17.5 million more covered lives, a 31% increase, when compared to the population of Medicaid recipients prior to Affordable Care Act (ACA) implementation.” They fix Medicaid managed care enrollment nationally at 48.6 million, and tell us “total year-over-year managed Medicaid grew by only 187,000 members, a substantial difference from the 3.6 million increase between 2Q15 and 2Q16. Most of the top five managed care companies– Centene, Anthem, UnitedHealth, Molina and Wellcare – did however, experience enrollment increases. Among the leaders, Centene commanded 12% of the Medicaid market share as of second quarter 2016, enrolling approximately 6 million members. Anthem and UnitedHealth increased year-over-year membership with both attaining 11% market share. Molina and WellCare rounded out the top five Medicaid managed care leaders accounting for 7 and 5 percent market share, respectively. These top five Medicaid companies control 45% of the overall Medicaid Managed Care market.” Meanwhile, CMS Administrator Seema Verma this week gave a major speech discussing “her vision for the future of Medicaid and unveiled new CMS policies that encourage states to propose innovative Medicaid reforms, reduce federal regulatory burdens, increase efficiency, and promote transparency and accountability.” CMS reports that Verma emphasized “her commitment to ‘turn the page in the Medicaid program’ by giving states more freedom to design innovative programs that achieve positive results for the people they serve and pledged to remove impediments that get in the way of states achieving this goal. She announced several new policies and initiatives that break down the barriers that prevent state innovation and improvement of Medicaid beneficiary health outcomes.” CMS touts that they have published new public website content that reflects “CMS’s willingness to work with state officials requesting flexibility to continue to provide high quality services to their Medicaid beneficiaries, support upward mobility and independence, and advance innovative delivery system and payment models.” Veema emphasized their “commitment to considering proposals that would give states more flexibility to engage with their working-age, able-bodied citizens on Medicaid through demonstrations that will help them rise out of poverty.”  In shorthand, this means that states have a path to impose work requirements on applicable Medicaid beneficiaries and deny continued coverage for those that do not comply.  Other changes CMS shares include: ·         Allowing states to request approval for certain 1115 demonstrations for up to 10 years; ·         Providing for states to more easily pursue “fast track” federal review ·         Reducing certain state 1115 reporting requirements; ·         Expediting SPA and 1915 waiver efforts through a streamlined process and by participating in a new “within 15-day” initial review call with CMS officials. ·         Developing “Scorecards that will provide greater transparency and accountability of the Medicaid program by tracking and publishing state and federal Medicaid outcomes.” Meanwhile, the question of the day is what to make of the Maine election results this week approving Medicaid expansion, with their Governor subsequently stating he will block implementation.

Three Recent Studies and Three Different Perceptions of Value Based Payments

by Clive Riddle, November 3, 2017 Three different recently released studies addressing value based payments fuel three different perceptions: (1) value based payments have solid momentum; (2) that hospitals view value based care is growing more slowly than anticipated; and (3) physicians prefer FFS systems to value based care. The Health Care Payment Learning & Action Network has just released a report with survey results indicating “29% of total U.S. health care payments were tied to alternative payment models (APMs) in 2016 compared to 23% in 2015, an increase of six percentage points.” The Network states that “the survey collected data from over 80 participants, accounting for nearly 245.4 million people, or 84%, of the covered U.S. population.”   While 29% of payments were value based and totaling “approximately $354.5 billion dollars nationally” in 2016, the Network determined that 43% of payments were “traditional FFS or other legacy payments not linked to quality” and 28% was “pay-for-performance or care coordination fees.” Deloitte recently released results from their 2017 Survey of US Health System CEOs which includes are chapter on Population health and value-based care that provides these insights: ·         “Survey participants say the transition to value-based care is happening, but at a slower rate than initially anticipated. Still, many of the CEOs report that they are developing and expanding innovative delivery and payment models, and are focusing on MACRA and physician activation. ·         “Many CEOs also are looking into strategies to generate physician buy-in and encourage behavioral change, which will help them be better prepared for the transition to population health and value-based care.” ·         “Many of the surveyed CEOs express concern about operating under two different payment systems—FFS and value-based care—and having misaligned incentives. Moreover, moving towards population health and bearing financial risk likely will require a large patient population.” ·         “Many CEOs who previously had acquired and invested in physician practices report being more engaged and prepared for MACRA implementation than other survey respondents. “ ·         “In our survey, some respondents indicate they are using tools including clinical integration, employment contracts with incentives, ACOs and risk-sharing agreements, among others to better activate physicians in care delivery transformation.” Meanwhile, Bain & Company recently released their Front Line of Healthcare Report 2017, in which they surveyed 980 physicians and concluded that “more than 60% of the physicians we surveyed believe it will become more difficult to deliver high-quality care in the next two years as they struggle to cope with a complex regulatory environment, increasing administrative burdens and a more difficult reimbursement landscape. After years of experimentation, physicians now want evidence that new models for care management, reimbursement, policy and patient engagement will actually improve clinical outcomes. Without it, they see little reason to alter the status quo and move toward widespread adoption.” Specific to physician receptivity toward value based care, Bain found that physicians very much prefer FFS if they had their druthers: “More than 70% of physicians prefer to use a fee-for-service model, citing concerns about the complexity and quality of care associated with value-based payment models. Fifty-three percent of physicians say that capitation reduces the quality of care, and most see little advantage from pay-for-performance models either. Further, many believe their organizations are not sufficiently prepared for the shift to value-based care.”

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week: House Tax Bill Would Scrap Deduction For Medical Expenses The tax bill unveiled by Republicans in the House on Thursday would not, as had been rumored, eliminate the tax penalty for failure to have health insurance. But it would eliminate a decades-old deduction for people with very high medical costs. Kaiser Health News Thursday, November 2, 2017 Hospital groups to sue CMS over $1.6 billion cut to 340B program Less than an hour after the CMS released the final rule, America's Essential Hospitals, the American Hospital Association and the Association of American Medical Colleges said they believe the agency has overstepped its statutory authority by cutting 340B drug payments by $1.6 billion, or 22.5% less than the average sales price. Modern Healthcare Wednesday, November 1, 2017 Panel Recommends Opioid Solutions but Puts No Price Tag on Them President Trump’s bipartisan commission on the opioid crisis made dozens of final recommendations on Wednesday to combat a deadly addiction epidemic, ranging from creating more drug courts to vastly expanding access to medications that treat addiction, including in jails. The New York Times Wednesday, November 1, 2017 U.S. states allege broad generic drug price-fixing collusion A large group of U.S. states accused key players in the generic drug industry of a broad price-fixing conspiracy, moving on Tuesday to widen an earlier lawsuit to add many more drugmakers and medicines in an action that sent some company shares tumbling. Reuters Tuesday, October 31, 2017 Money For Health Law Navigators Slashed — Except Where It’s Not Despite all the efforts in Congress to repeal the health law this summer and fall, the Affordable Care Act is still the law of the land. People can start signing up for health insurance for 2018 starting Nov. 1. But the landscape for that law has changed a lot. Kaiser Health News Monday, October 30, 2017 These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.

Fighting Healthcare fraud and over-prescriptions with predictive analytics

By Claire Thayer, October 31, 2017

Earlier this summer, the U.S. Department of Justice announced the largest ever health care fraud enforcement action, involving over 412 individuals across 41 federal districts, including 115 doctors, nurses and other licensed medical professionals, for their alleged participation in health care fraud schemes. Of those charged, over 120 defendants, including doctors, were charged for their roles in prescribing and distributing opioids and other dangerous narcotics. Adoption of prescription drug monitoring programs is one way to hold health care providers accountable for overprescribing practices. Use of sophisticated claims analytic tools can help detect suspicious practice patterns as well. A health plan in the Midwest recently uncovered the case of an overprescribing neurologist using peer-to-peer analysis for comparison of practice patterns.

This recent edition of the MCOL Infographic, co-sponsored by LexisNexis, provides highlights from this case study:

CVS, Aetna, Retail Integrated Delivery Systems and the Strange World of Frenemies

by Clive Riddle, October 27, 2017

As widely reported, including in the Wall Street Journal, CVS is making a very serious bid to acquire Aetna for more than $200 a share, equating to $66 billion. The most often cited drivers behind this deal include:

• CVS’s strategic response to Amazon’s potential entry into the pharmacy business
• CVS strategic response seeking growth outside core business, after antitrust regulators rejected Walgreens/Rite Aid merger
• Aetna strategic response seeking growth outside core business after antitrust regulators rejected Aetna/Human and Anthem/Cigna mergers
• Aetna would serve as significant source of members for CVS PBM division, customers for CVS pharmacies and patients for Minute Clinics
• CVS and Aetna’s strategic response to competitors aligning health plans and PBMs such as UnitedHealth acquisition of Catamaran

Much attention has been given to initiatives for integrated delivery systems between hospitals and medical groups that take on purchaser functions. Does this signal a different focus – on retail integrated instead of clinically integrated systems - bringing together pharmacies, retail clinics, health care coverage, wellness services, patient engagement and care coordination?

But Wall Street experts remind us that doesn’t mean this deal is a sure thing.  Things could fall apart simply due to details in the financial terms, or because of new changes in direction by competitors or in the overall market. The Street quotes Jeremy Bryan, a portfolio manager at Gradient Investments, a minor CVS shareholder: "There's just no case study for this. There could be regulatory hurdles. But we have cautious optimism." The Wall Street Journal states “The deal almost surely would attract close scrutiny from U.S. antitrust enforcers who have expressed concern about health-care consolidation.”

Assuming however there is a clear path forward for CVS and Aetna, the question remains for them what lies in wait for them down the road? A few potential concerns include:

• Would the deal jeopardize the recently announced Anthem/CVS relationship whereby CVS will service Anthem’s new PBM?
• Would the deal drive other competing health plans away from the CVS PBM and pharmacies?
• What if CVS is counting on Aetna becoming a more significant force in Medicare Advantage to drive CVS PDP business, and Aetna fails to deliver?
• What if the Trump Administration and Republican Congress succeed in further scaling back Medicaid, causing Aetna’s significant investment in Medicaid business to erode and become a drag on CVS overall performance?
• What if Aetna focuses its pharmacy and retail clinic network offerings on CVS locations, and loses market share to competitor plans with broader offerings?

On the other hand, maybe the deal wouldn’t cause competitors to blow up relationships with CVS or Aetna. The Washington Post quotes Adam Fein, president of Pembroke Consulting: “This is part of the strange world of the health insurance and PBM industry. Many companies are frenemies.”

Top 5 healthcare business news items from the MCOL Weekend edition

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week:

CVS Health's surprising deal for Aetna? It's all about Amazon
Amazon.com Inc has gained approval from a number of state pharmaceutical boards to become a wholesale distributor, St. Louis Post-Dispatch reported on Thursday, citing public records.
CNBC News
Thursday, October 27, 2017

Trump Declares Opioid Crisis a ‘Health Emergency’ but Requests No Funds
President Trump on Thursday directed the Department of Health and Human Services to declare the opioid crisis a public health emergency, taking long-anticipated action to address a rapidly escalating epidemic of drug use.
The New York Times
Thursday, October 26, 2017

Amazon gains wholesale pharmacy licenses in many U.S. states: report
Amazon.com Inc has gained approval from a number of state pharmaceutical boards to become a wholesale distributor, St. Louis Post-Dispatch reported on Thursday, citing public records.
Reuters
Thursday, October 26, 2017

Trump health official Seema Verma has a plan to slash Medicaid rolls
With a broad overhaul of Obamacare stalled in Washington, one of President Trump’s top health care leaders is drawing the outlines of sweeping changes to Medicaid that could pare enrollments and cut costs without congressional approval.
Stat News
Thursday, October 26, 2017

ACA stabilization bill would lower deficit by $3.8B, CBO says
The Senate HELP Committee’s bipartisan Affordable Care Act stabilization bill would lower the federal deficit by $3.8 billion from 2018-2027, according to the Congressional Budget Office.
Fierce Healthcare
Wednesday, October 25, 2017

These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.

Elon, Do We Have a Disaster for You!

By Kim Bellard, October 18, 2017

One of the most interesting twists resulting from Hurricane Maria striking Puerto Rico was Elon Musk's offer that Tesla could help Puerto Rico solve its energy crisis, with a long-term, 21st century fix. 
It is telling that we don't have similar offers to rebuild the Puerto Rico's health care system, which is similarly devastated.  Or, for that matter, our system, which is its own kind of disaster.

Mr. Musk was asked on Twitter if Tesla could help Puerto Rico using solar and battery power, and he responded in the affirmative, saying it had done so on smaller islands but faced no scalablity issues.  Next thing we knew the Governor of Puerto Rico and he were talking.  Now Tesla is starting to deliver their battery systems to the island, so we'll see.

Maybe it is a marketing stunt on Mr. Musk's part -- if so, you have to give him credit for it -- but the idea has merit.  A disaster like Maria is a once-in-a-lifetime opportunity to try bold new ideas instead of blithely rebuilding what was there before.

Still, even Elon Musk isn't bold enough to offer to rebuild their health care system, much less ours.

Sometimes disasters do make us rethink our health care system.  Katrina, for example, has often been credited with creating the impetus for electronic health records (EHRs), since it destroyed countless paper records, wrecking havoc on care for thousands of patients.

But we didn't pay enough attention to even that very visible crisis.  We do have a lot more EHRs now, but less than 30% of hospitals self-report being interoperable.

The records themselves remain largely physician-centered and exclusively medical, although Epic, the nation's largest EHR vendor, is finally saying they will move to a "comprehensive health record" (CHR). . 

I'm glad that in 2017 EHRs vendors are finally realizing there is health outside a medical facility.

It shouldn't take a hurricane -- or an earthquake, or a bickering Congress -- to realize that we have an in-progress disaster with our health care system. 

Let's say we were starting from scratch.  Let's reset what our health care system could be.  Let's say we didn't have all these hospitals, hadn't trained any physicians, hadn't deployed any medical devices or used any prescription drugs, although we could start with the knowledge of what each of those could accomplish.

Would we remake the system as it is, or would we design something new?

In a previous post I enumerated several things about our health care system I was dying to redesign, and in another I gave some specifics about how a re-engineered system might work.  Even those, though, didn't start from entirely scratch, still focusing more on the medical than on the broader health perspective.

We should be spending more on our health needs -- broadly defined -- than on our medical care.  We should be more worried about if people are going to the park than if they are going to the doctor's office.  And when we do get medical care, we should make sure it is care that has solid evidence of working, rather than too often accepting care that might work.

Elon Musk has his hands full saving humanity, not to mention helping Puerto Rico, so we probably can't count on him to offer to reinvent our health care system too.  So who will it be?

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

A Dozen Things To Know About The Trump Healthcare Executive Order and Elimination of CSR Payments

by Clive Riddle, October 13, 2017 1.       Attorney General Jeff Sessions issued a legal opinion to HHS and the Treasury Department that that money appropriated to HHS “cannot be used to fund” Cost Sharing Reduction (CSR) payments.   2.       The Trump administration has filed notice to the U.S. Court of Appeals for the D.C. Circuit, “that the Department of Health & Human Services (HHS) has directed that cost-sharing reduction payments be stopped because it has determined that those payments are not funded by the permanent appropriation for ‘refunding internal revenue collections.” they were not formally appropriated by Congress.   3.       Health Plans still have to provide marketplace subsidized discounts to low-income customers. Without CSR reimbursement, one must assume participating plans will raise premiums as soon as feasible.   4.       A CBO report indicates the decision to end CSR payment payments is likely to cost the federal government more than making the payments due to ACA required subsidies to cover anticipated premium increases.   5.       The health plans most impacted by the CSR elimination include mostly Blue Cross and Blue Shield companies and insurers focused on Medicaid, such as CenteneCorp. and Molina Healthcare Inc.   6.       CSR lawsuits are likely. Impacted health plans may sue. The Hill reports attorneys general from California and New York say they are prepared to sue the Trump administration to protect health-care subsidies that the White House said would be cut off.   7.       As Sam Baker, Axios healthcare editor posts, “Congress can solve this. University of Michigan law professor Nicholas Bagley, an expert on this issue, told me that if Congress appropriates the money for these subsidies, they would begin flowing again immediately.”   8.       The Trump Executive Order does not equate to immediate changes. As healthcare policy expert Timothy Jost posts in Health Affairs, the Executive Order “is a direction to draft rules. Under the Administrative Procedures Act these agencies will first have to publish proposed rules and then receive and respond to public comments before publishing the rules in final form. The fact sheet accompanying the order acknowledges that regulations will proceed through notice and comment rulemaking. This will likely take months. Indeed, rulemaking will likely be proceeded by studies by the affected departments, and any proposed and final rules will likely have to be reviewed by the Office of Management and Budget. Therefore, changes are unlikely to affect plans beginning on January 1 of 2018, although some changes may take effect mid-year.”   9.       The executive order instructs the Department of Labor to expand the availability of association health plans under the Employee Retirement Income Security Act of 1974 (ERISA).   10.   The executive order instructs the Departments of Labor and HHS to pursue expanded Availability of Short-Term, Limited‑Duration Insurance.   11.   The executive order instructs the Departments of Labor, Treasury and HHS to increase the usability of HRAs, to expand employers' ability to offer HRAs to their employees, and to allow HRAs to be used in conjunction with nongroup coverage.   12.   As Timothy Jost notes in another Health Affairs post, small employers already received expanded ability regarding HRAs in 2016, when “Congress adopted in Title XVIII of the [21st Century] Cures Act a new type of arrangement, the Qualified Small Employer HRA (QSEHRA), that is effectively an exception to the HRA prohibition, but only for small employers — employers that have fewer than 50 full-time equivalent employees and therefore are not subject to the large employer mandates. These employers may pay or reimburse employees through a QSEHRA for premiums for health insurance that qualify as minimum essential coverage.” Thus the Executive Order would have more impact on larger employers.

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week: Trump to Issue Stop-Payment Order on Health Care Subsidies In a brash move likely to roil insurance markets, President Donald Trump will "immediately" halt payments to insurers under the Obama-era health care law he has been trying to unravel for months. The Associated Press Friday, October 13, 2017 Trump’s Order Advances GOP Go-To Ideas To Broaden Insurance Choices, Curb Costs The Trump administration Thursday advanced a wide-ranging executive order aimed at expanding lower-cost insurance options, allowing employers to give workers money to buy their own coverage and slowing consolidation in the insurance and hospital industries. Kaiser Health News Thursday, October 12, 2017 House Republicans Ramp Up Scrutiny of Providers in Drug Discount Program House Republicans are intensifying scrutiny of a federal program that gives thousands of safety-net providers hefty discounts on prescription drugs but that they say doesn’t have effective tools to track where the savings are going. Morning Consult Wednesday, October 11, 2017 Long-Term Disability Insurance Gets Little Attention But Can Pay Off Big Time “It won’t happen to me.” Maybe that sentiment explains consumers’ attitude toward long-term disability insurance, which pays a portion of your income if you are unable to work. Sixty-five percent of respondents surveyed this year by LIMRA, an association of financial services and insurance companies, said that most people need disability insurance. Kaiser Health News Tuesday, October 10, 2017 Overlooked By ACA: Many People Paying Full Price For Insurance ‘Getting Slammed’ Paul Melquist of St. Paul, Minn., has a message for the people who wrote the Affordable Care Act: “Quit wrecking my health care.” Teri Goodrich, of Raleigh, N.C., has the same complaint. “We’re getting slammed. We didn’t budget for this,” she said. Kaiser Health News Monday, October 9, 2017 These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.