Magnificent Seven Healthcare Business Trends for 2017

By Clive Riddle, January 3, 2017

Here’s seven trends, in no particular order, that we see weighing heavily on the business of healthcare during 2017. If they all come to pass, of course you should marvel at the wisdom and insight emanating from this blog. If they are well off the mark, well, here’s hoping for short memories and I’ll search for the delete button on this post.

1. Inaction on Several Fronts While Waiting For Other Shoe to Drop

The individual health insurance markets will be in a holding pattern pending the outcome of sorting through the weeds of the Repeal and Replace activities in Congress and the Trump administration. Ditto for Medicaid initiatives. CMS innovations could even end up in a holding pattern.

2. A new Trigger for Prescription Drug Pricing Backlash?

Furor over Mylan EpiPen pricing and other prescription drug cost stories have subsided a little, and it remains to be seen how and if the Trump administration and Congress weigh in on this. But if a new major prescription drug pricing story erupts, and the odds are sooner or later one will, it should trigger a new groundswell of support for some public response.

3. Year of the MACRA

MACRA was separate from the ACA and is somewhat insulated from ACA dismantling. While the framework for Medicare Quality Payment Program MIPS and APMs are already in place, 2017 will witness widespread activity as physicians follow through on positioning themselves.

4. Private Sector Embrace Also Keeps Value Based Care Momentum Strong

Even if ACA repeal goes so far as tearing asunder Medicare ACO initiatives and other public value based purchasing innovations, the private sector’s embrace of all things value based care will ensure an onward march in this direction.

5. Consumer Driven Care Gains New Momentum

The Trump Administration and new Congress policy agenda would seem to favor increased emphasis on all things consumer driven.

6. Aftermath of Health Plan Mega Mergers

The ACA was credited with helping set the stage for mega health plan mergers. It is difficult to imagine further mega merger activity in the current environment. Cigna and Anthem will surely unwind their deal.  Trump administration emphasis on deregulation might cause the DOJ to take the foot off the gas on their opposition to the Aetna-Humana deal, or at least be more prone to negotiation.

7. Impact of New Technology and Innovation

We may not know what the next New Big Thing is, but we should know that there will be one, and then another. And that one or more of these next new big things will have a major impact on the business of healthcare. 

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:

Medicare Penalizes Hospitals In Crackdown On Antibiotic-Resistant Infections

NPR reports: The federal government has cut payments to 769 hospitals with high rates of patient injuries, for the first time counting the spread of antibiotic-resistant germs in assessing penalties.

NPR
Thursday, December 22, 2016

Cleveland Clinic CEO Toby Cosgrove named as contender for Trump's VA pick

Modern Healthcare reports: Cleveland Clinic CEO Dr. Toby Cosgrove was among prospective cabinet picks who met with President-elect Donald Trump on Tuesday. Cosgrove is reportedly a contender to lead the Veterans Affairs Department.

Modern Healthcare
Wednesday, December 21, 2016

Senate report shows Martin Shkreli is just as bad as you think he is

USA Today reports: Staggering hikes — in some cases higher than 5000%— in prices of prescription drugs threaten the health and economic stability of Americans who can't afford vital medicines, a congressional report warned Wednesday.

USA Today

Wednesday, December 21, 2016

Health Exchange Enrollment Jumps, Even as G.O.P. Pledges Repeal

The New York Times reports: About 6.4 million people have signed up for health insurance next year under the Affordable Care Act, the Obama administration said Wednesday, as people rushed to purchase plans regardless of Republican promises that the law will be repealed within months.

The New York Times
Wednesday, December 21, 2016

Women Doctors May Be Better For Patients’ Health

Kaiser Health News reports: When a patient goes to the best hospital, he or she usually hopes for a doctor who is knowledgeable and experienced. Something else to wish for? A woman physician.

Kaiser Health News
Monday, December 19, 2016

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.

Touring Lists of Top Healthcare Trends and Issues for 2017

By Clive Riddle, December 21, 2016

It’s that time of year when healthcare prognosticators point out predictions, priorities, and progressions for the coming year. Here is a tour of some of what is being said about healthcare in the new year, starting with overall trends and then examining some specific topics:

PwC’s Health Research Institute releases an annual list that many stakeholders look to. Here is their Top health industry issues of 2017, which they label as “a year of uncertainty and opportunity.” PwC devides these trends into three components, stating “many of 2017’s Top issues highlight how this shift toward value is occurring, and how traditional health organizations and new entrants are responding to it. There are three main tactics that organizations will use to address this shift to value – they will adapt, they will innovate and they will build new programs and approaches to their work.”

Adapt for value

1.    Under a new administration, the fate of the ACA remains unclear
2.    Pharma’s new strategic partner? Patients
3.    Easing the training wheels off value-based payment
4.    Insert your card here for healthcare

Innovate for value

5.       Paging Dr. Drone: It’s time to prepare for emerging technologies
6.       The battle against infectious diseases sparks invention
7.       Rx cauliflower: Nutrition moves to population health

Build for value

8.       Putting the brakes – gently - on drug prices
9.       A year of new partnerships and collaborations
10.   Preparing medical students for work in a value-based world

Black Book’s year end C-suite polls produced a list of 9 Healthcare Tech Trends in The New Year of Uncertainty:
1.       Technology Budgets Stagnate, Purchases through Q2 largely will be based on current business need.
2.       Electronic Data Warehouses (EDW) move to the top of short term priorities.
3.       Renewed and upgraded Enterprise Resource Planning Systems (ERP) swings back into importance, now for Value Based Care Costing.
4.       Financially stable, regional IDNs are spending big dollars toward extended connectivity while the rest of the pack looks on.
5.       Providers keep watch and wait for Large Scale Healthcare Cyber Attacks before forming a Better Defense.
6.       Hype around the Cloud quiets down as it becomes the primary way to build enterprise architecture.
7.       Focus on Front End and Middle Office Business Office Functions & RCM Outsourcing intensifies.
8.       Skilled hospital tech staff recruitment is even more challenging.
9.       Interest in Precision Medicine initiatives continue but few have commitments to buy for first half of the New Year.

The Medical Futurist Newsletter shared these top technologies with the biggest promise for 2017:

1)      A new era in diabetes care

2)      Precision medicine in oncology

3)      Narrow artificial intelligence in US clinics

4)      Driverless trucks or cars will include health sensors

5)      New service in nutrigenomics

6)      SpaceX and NASA will realize they need a digital health masterplan to reach Mars

7)      The genome editing method CRISPR in clinical trials

8)      A big tech company will step into health

9)      An insurance company launches a wearable sensor package

10)   The surgical robot by Google and Johnson&Johnson will compete with daVinci

11)   Vocal biomarkers: the future of diagnostic medicine

12)   Pharma will start using massive AI in clinical trials and drug research

13)   A company will make the 3D printed cast a real choice

Also on the topic of technology, Becker's ASC Review features an article 5 healthcare technology trends taking center stage in 2017 summarizing a list of “San Mateo, Calif.-based PokitDok predicted technology trends that will impact the healthcare industry in 2017”:

1.       Healthcare will transition from theory to practice in the Blockchain world. The new year will see academic and theoretical discussions move forward into pilots and applications.
2.       Healthcare e-commerce will witness a boost in 2017, with more major health systems collaborating with technology companies for infrastructure with built-in cybersecurity and HIPAA compliance.
3.       Telehealth will no longer be on the outskirts, pushed into the mainstream with expanded reimbursement policies, usage and outreach programs.
4.       President-elect Donald Trump will likely not fulfill his promise to completely repeal the ACA, despite a Republican Party-dominant Congress and Tom Price, MD, (R-Ga.) leading the HHS.
5.       Auto-adjudication will drive providers to interact with EHRs, revenue cycle management and practice management vendors.

Shifting gears, the McKesson Pharmacy Optimization Team released Five Health System Pharmacy Trends to Watch in 2017:

1.       Continued Growth in Specialty Market
2.       Leveraging Pharmacy Analytics to Make Strategic Business Decisions
3.       Health System Pharmacy Seen as a Revenue and Margin Generator
4.       Centralizing Pharmacy Operations and Improving Clinical Services
5.       Future Directions for Reform and the Affordable Care Act (ACA)

Moving on to the employer healthcare world, MediaPlanet published these 6 Trends in Corporate Worksite Wellness for 2017, explaining that “here’s how corporations are using wellness programs (and this year’s lessons) to promote employee health in the coming year:”

1.       Place greater emphasis on sleep
2.       Continue to stay on top of wellness regulations
3.       Embrace new technologies
4.       Focus on total well-being, not just physical health
5.       Give back to the community
6.       Create a healthy work environment

And finally, also in the employer arena, Mercer shares this Top 10 Compliance Issues for 2017 Health Benefit Planning:

1.       Wellness Plans (podcast): More innovative designs make it critical to know the new rules that begin on January 1, 2017.
2.       Essential Health Benefits (podcast): Check those dollar limits and maximum out-of-pocket maximums against updated benchmark plans for 2017.
3.       Mental Health Parity (podcast): Make sure your benefits are aligned with current law and best practices.
4.       Employer Shared Responsibility: Affordability (podcast): Know the impact of opt-out cash and flex credits; 30-hour (podcast): Understand what payments must be converted to hours of service; ACA Reporting (podcast): Make sure it’s right – no more good faith standard and the old deadlines return for the 2016 reporting year.
5.       Preventive care: Modify benefit terms to reflect latest recommendations and guidance on preventive care.
6.       Summary of Benefits and Coverage (podcast): New model SBC must be used for open enrollments on and after April 1, 2017.
7.       FLSA overtime rules: It’s not just a compensation issue – don’t forget to consider the benefits implications.
8.       Expatriate group health plans: Position group health plans covering globally mobile employees to take advantage of ACA relief.
9.       HIPAA privacy, security, and electronic transactions: Revisit health plans’ privacy and security obligations.
10.   DOL fiduciary rule: Assess the impact on welfare plans with an investment component.

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:

 Feds Extend Healthcare.Gov Deadline To Dec. 19, Citing Late Rush

USA Today reports: Federal regulators Thursday night extended the midnight deadline for Affordable Care Act insurance by four days, as consumers fought to get through to call center operators and log onto Healthcare.gov to buy insurance that takes effect Jan. 1.

USA Today, December 16, 2016

G.O.P. Plans to Replace Health Care Law With ‘Universal Access’

The New York Times reports: House Republicans, responding to criticism that repealing the Affordable Care Act would leave millions without health insurance, said on Thursday that their goal in replacing President Obama’s health law was to guarantee “universal access” to health care and coverage, not necessarily to ensure that everyone actually has insurance.

The New York Times, December 16, 2016

 

CMS debuts new ACO model for dual-eligibles

The federal government has introduced a new accountable care organization model aimed at working with states to provide better quality, lower cost care for people enrolled in both Medicare and Medicaid.

Fierce Healthcare, December 15, 2016

Obama administration blocks states from cutting off grants to Planned Parenthood

The Washington Post reports: The Obama administration took steps Wednesday to block states from cutting off federal family planning grants to Planned Parenthood, finalizing a rule that is to take effect just days before the inauguration of President-elect Donald Trump.

The Washington Post, December 14, 2016

Aetna CEO takes stand to defend deal with Humana

In his turn on the witness stand in the Aetna-Humana antitrust trial, Aetna CEO Mark Bertolini sparred with Justice Department lawyers about the central debates surrounding the acquisition—including whether the deal will deliver on its promised efficiencies.

Fierce Healthcare, December 13, 2016

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.

Just Doing Our Jobs

by Kim Bellard, December 14, 2016

Health care fraud is bad.  Everyone agrees about that (except those who profit by it).  We'd similarly agree it is all too pervasive.   Some estimate that fraud could account for up to 10% of health care spending.  But that's chump change: estimates are that other kinds of wasteful spending, such as unnecessary care and excessive administrative costs, are easily double that. 

An op-ed in The Boston Globe may have it right:  we need an overdiagnosis awareness month.The op-ed was a tongue-in-cheek suggestion to highlight the various cancer awareness months, the most famous of which is October's Breast Cancer Awareness.  These campaigns promote the need for the associated screenings, but don't typically also mention how controversial many of them are.  

 
Overdiagnosis goes much further than screenings.  As Atul Gawande wrote last year, we're getting an "avalanche of unnecessary care," getting too many services of not just low value but of at best no value to patients -- and, at worse, actually harmful to them.  Not just pointless tests or unneeded prescriptions, but also too many questionable procedures, such as total knee replacements, heart stents, or spinal fusions. 

The real problem is that most people involved in the "epidemic" of overdiagnosis and over-treatment our health care system, well, they think they're just doing their jobs. 

They don't think they're trying to rip anyone off, they certainly don't think that they're harming anyone, and they most definitely don't think their role is superfluous.  This is all only possible because it is still too hazy about what is the right treatment for who, when, not to mention what a "fair" price might be for anything.  So, when in doubt, do more.

As a result, health care employment is booming.  Some project it will be largest job sector within three years.  Indeed, as the chart below shows, virtually all of the U.S. job growth this century has been in health care jobs.  That, quite simply, is astounding. 

Yet, despite all this growth, there continue to be urgent cries of shortages of key health care professionals.  We just cannot seem to get enough qualified health care workers.  If you're looking for a job, that's good news, but if you're paying the bill for all those jobs, it should be scary.

In health care, we just add more jobs.

Overtreatment works, at least if you're the one doing the treating.

And everyone in health care keeps doing their job.

Look, this fantasy isn't going to continue.  Health care isn't going to become 100% of GDP.  It's not going to get to 50%, or 40%.  At some point the revolt will happen, the revolution will occur, and health care spending will finally slow, stop, and eventually plunge. 

Then all those health care jobs are not safe.  People will lose their jobs.  A lot of people.  People who, until then, thought they were doing good.

So when the next health care innovator comes along, we should try to get past the hype and ask: OK, specifically, what jobs will this eliminate -- which ones, how many, when?  If they don't have answers, or only offer vague promises, well, smile politely and get out your wallet.

In health care, perhaps one way to do your job might just be to find a way to eliminate it.

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

The State of Provider Directory Accuracy

By Claire Thayer, December 13, 2016

Despite a federal mandate for all plans in the health insurance marketplace be required to have current and accurate provider directories, many health plan enrollees are finding that when it comes time to call a provider for their specialty visit or find a new primary care physician willing to take new patients, the information in the directory is often out of date or missing vital information.

We’ve posted a couple of infographics on this topic, one on the Accuracy of Health Provider Directories which outlined data points that CMS requires health plans to monitor and maintain on a monthly basis and the State of Provider Directory Accuracy Across the U.S. which outlined provider penalties that could be incurred for inaccuracies.

Last week, The New York Times published an in-depth article, Insurers’ Flawed Directories Leave Patients Scrambling for In-Network Doctors, highlighting from the consumer perspective just how frustrating the experience can be when you’re the patient shopping for health coverage and trying to find a physician willing to accept new patients.

While health plans participating in the health insurance marketplaces were to be subjected to penalties for directory inaccuracies starting in 2016, research by the New York Times found that while many directories are still incomplete, inaccurate or missing information, so far no plans have been fined or kicked off the enrollment sites for having poor doctor directories, said Aaron Albright, a spokesman for the Centers for Medicare and Medicaid Services, which would enforce the rules. A Health and Human Services Department survey of Medicare plans for those 65 and older that was released in October found errors in nearly half of the listings in doctor directories .

Last week, the MCOL Infographoid, co-sponsored by LexisNexis Health Care, offered a deeper look at the provider directory requirements on a state by state basis in the State of Provider Directory Accuracy, highlighted below:

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.

Urban Institute: Implications of Partial Repeal of the ACA through Reconciliation

By Clive Riddle, December 9, 2016

CNBC called it the Obamacare Doomsday Scenario: the Urban Institute has released a 33-page brief - Implications of Partial Repeal of the ACA through Reconciliation - examining what would happen if the new congress goes forward with an ACA partial repeal with a replace to be named later – using a reconciliation bill similar to one President Obama vetoed in January 2016. Their analysis determined that “the number of uninsured people would rise from 28.9 million to 58.7 million in 2019, an increase of 29.8 million people (103 percent).”

The Urban Institute points out that “there is currently no consensus around alternative health policies to enact as the ACA is repealed; consequently, partial repeal via reconciliation without replacement is possible and merits analysis.” The scenario they lay out is that “Congress is now considering partial repeal of the Affordable Care Act (ACA) through the budget reconciliation process. Since only components of the law with federal budget implications can be changed through reconciliation, this approach would permit elimination of the Medicaid expansion, the federal financial assistance for Marketplace coverage (premium tax credits and cost-sharing reductions), and the individual and employer mandates; it would leave the insurance market reforms (including the nongroup market’s guaranteed issue, prohibition on preexisting condition exclusions, modified community rating, essential health benefit requirements, and actuarial value standards) in place.”

Here’s some highlights from their report of what is in store for us if the scenario takes place:

• The share of nonelderly people without insurance would increase from 11% to 21%
• 22.5 million people will become uninsured as a result of eliminating the premium tax credits, the Medicaid expansion, and the individual mandate
• An additional 7.3 million people will become uninsured because of the near collapse of the nongroup insurance market.
• 82% of the people becoming uninsured would be in working families, and 80% of adults becoming uninsured would not have college degrees.
• 38% becoming uninsured would be ages 18 to 34, and 56% would be non-Hispanic whites.
• There would be 12.9 million fewer people with Medicaid or CHIP coverage in 2019.
• Approximately 9.3 million people who would have received tax credits for private nongroup health coverage in 2019 would no longer receive assistance.
• Federal healthcare spending would be reduced by $109 billion in 2019 and by $1.3 trillion from 2019 to 2028 because Medicaid expansion, premium tax credits, and cost-sharing assistance would be eliminated.
• State spending on Medicaid and CHIP would decrease $76 billion between 2019 and 2028.
• The newly uninsured would seek an additional $1.1 trillion in uncompensated care at the state/local level between 2019 and 2028.
• The 2016 reconciliation bill did not increase funding for uncompensated care beyond current levels.
• If Congress partially repeals the ACA with a reconciliation bill like that vetoed in January 2016 and eliminates the individual and employer mandates immediately, in the midst of an already established plan year, insurers would suffer substantial financial losses (about $3 billion); the number of uninsured would increase right away (by 4.3 million people); at least some insurers would leave the nongroup market midyear.

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

By Claire Thayer, December 9, 2016

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:

1. 5 quick ways a new HHS secretary could change health policy
Kaiser Health News reports: Prospective Health and Human Services secretary Tom Price, currently the chairman of the House Budget Committee, brings a distinctive to-do list to the agency. And, if confirmed by the Senate, he will have tremendous independent power to get things done.
Kaiser Health News via the Washington Post, December 9, 2016

2. HHS Chief Warns Senate Democrats of ‘Chaos’ Under ACA Repeal
Morning Consult reports: The nation’s top health official spoke with Senate Democrats Thursday about the repeal of the Affordable Care Act, warning that undoing the law without having a replacement ready could be disastrous.
Morning Consult, December 8, 2016

3. These drug price hikes cost taxpayers millions
Stat News reports: Drugs to treat cancer, high blood pressure, and seizures experienced large price spikes in 2015, costing taxpayers millions of dollars in added Medicare spending, according to new data released by the federal Centers for Medicare and Medicaid Services.
StatNews, December 8, 2016

4. Health Insurers List Demands if Affordable Care Act Is Killed
The NY Times reports: The nation’s health insurers, resigned to the idea that Republicans will repeal the Affordable Care Act, on Tuesday publicly outlined for the first time what the industry wants to stay in the state marketplaces, which have provided millions of Americans with insurance under the law.
New York Times, December 6, 2016

5. Insurers’ Flawed Directories Leave Patients Scrambling For In-Network Doctors
Kaiser Health News reports: Penny Gentieu did not intend to phone 308 physicians in six different insurance plans when she started shopping for 2017 health coverage.
Kaiser Health News, December 5, 2016

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.

Focus on Value to Survive, Maybe Flourish, for Next Four Years

by Clive Riddle, December 2, 2016

What shall be the fate of value-based care initiatives in the wake of a new administration’s zeal to slash away at all thing Affordable Care Act? The following article: Focus on Value to Survive, Maybe Flourish, for Next Four Years, recently appeared in the Inaugural issue of Value-Based Payment News, Russell Jackson, editor:

The quadrennial change of who’s who in the nation’s capital generally brings with it a shift in focus at the federal regulatory agencies and a reboot of the dynamic between the White House and the Capitol. But despite the magnitude of change that could reverberate throughout the national-level political apparatus this time around, experts pretty much agree that the value- and quality- and other payment reform-related programs – the Medicare Access and CHIP Reauthorization Act included – will likely continue in much their current form, albeit, in some cases, under different names and with, in all likelihood, different, and surprising, claims of original ownership.

Don’t be surprised, in other words, if a newly named Centers for Medicare and Medicaid Innovation turns out to have been the new president’s idea all along. Here’s a sampling of what the policy experts have been telling the press about value-based healthcare programs for the next four years.

“Premier Senior Vice President Blair Childs says Republicans strongly support Accountable Care Organizations. ‘They first ran the ACO demonstrations under the Bush Administration,’ he said by email. ‘They are envisioned in MACRA, of which the Republicans are strong supporters.’”

== ‘Republicans Expected to Spare ACOs, Other Demos from ACA Repeal;’ http://insidehealthpolicy.com/

“Ian Spatz, a senior advisor at Manatt Health, said there is no reason to think Republicans would reverse the trend toward providers sharing risk. He said ACOs and other demonstrations that move away from the fee-for-service system are not partisan. However, Spatz said it’s likely that Republicans will place restrictions on CMMI, such as prohibiting mandatory demonstrations, and they might change the Centers’ name.”

== same article

Gilberg, senior vice president of government affairs for the Medical Group Management Association, said they are advising members to continue preparation for MACRA. ‘We don’t see that that is going to be repealed. It was bipartisan, nearly a unanimous vote.’”

== ‘MACRA will move forward largely untouched when Trump steps in, experts say;’ http://www.healthcarefinancenews.com/news/macra-will-move-forward-largely-untouched-when-trump-steps-experts-say

 “Christopher Kerns, managing director at The Advisory Board, said, ‘MACRA is not in trouble, but mechanisms by which they control spending could change.’ Kerns said there might be a shift away from ACOs as a principal driver of controlling spending, and more toward bundled payments or price controls, cuts or other forms of utilization control in the form of reduction in reimbursement for different kinds of services.”

== same article

“The American Academy of Family Physicians said [it doesn’t] believe MACRA as a whole is in any real danger of repeal. ‘The election of Mr. Trump will have a limited impact on the MACRA law in the short-term,’ said AAFP President John Meigs Jr. ‘Looking forward, this law was supported by 91% of Congress. Based on the bipartisan support, it is difficult to see how there would be any fundamental changes under the Trump Administration.’”

== same article

“’This is a movement that’s happening independent of the ACA, or parallel to it,’ said David Jones, an assistant professor of health law, policy and management at Boston University’s School of Public Health. ‘It’s very unclear when they say they’re going to repeal ObamaCare whether they’re even thinking about things like CMMI or to shift away from things like fee-for-service.’”

== ‘Will value-based payment initiatives continue under Trump?;’ http://www.modernhealthcare.com/article/20161111/MAGAZINE/161109907

On the other hand …

“House Budget Chair Rep. Tom Price (R-GA) has had CMMI in his sights for a while now, and Sen. Orrin Hatch (R-UT) is no big fan. Both claim the center lacks accountability and hasn’t shown clear results. They may try to eliminate mandatory CMMI payment models and could seek to legally trim its sails.”

== ‘CMS CMMI, ONC and AHRQ preparing to take hits;’ https://www.g2xchange.com/statics/cms-cmmi-onc-and-ahrq-preparing-to-take-hits

You can request a sample copy of Value-Based Payment News by going here: http://valuebasedpaymentnews.com/sample.html

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

By Claire Thayer, December 2, 2016

1. The drug industry’s stake in Trumpcare is bigger than you think
StatNews reports: The upcoming fight over repealing and replacing the Affordable Care Act promises to shake up hospitals and insurers, but drug makers also stand to gain — or lose — a lot.
StatNews, December 2, 2016

2. 2,000+ physicians: 'The AMA does not speak for us' in supporting Price for HHS
Becker's Hospital Review reports: More than 2,000 physicians signed an open letter railing against the American Medical Association's support for Rep. Tom Price, MD, R-Ga., chairman of the House Budget Committee, as secretary of HHS.
Becker's Hospital Review, December 1, 2016

3. U.S. House Passes 21st Century Cures Legislation
Healthcare Informatics reports: The U.S. House of Representatives today passed sweeping, bipartisan legislation, called the 21st Century Cures Act, comprised of a $6.3 billion package of medical innovation bills including $4.8 billion to the National Institutes of Health as well as $1 billion in state grants to fight opioid abuse.
Healthcare Informatics, November 30, 2016

4. Price’s Appointment Boosts GOP Plans To Overhaul Medicare And Medicaid
Kaiser Health News reports: President-elect Donald Trump’s selection of Rep. Tom Price to head the Department of Health and Human Services signals that the new administration is all-in on both efforts to repeal the Affordable Care Act and restructure Medicare and Medicaid.
Kaiser Health News, November 29, 2016

5. CMS nominee set up Indiana’s unusual Medicaid expansion
The Washington Post reports: A decade ago, when Indiana had one of the lowest rates of health insurance coverage in the nation, then-Gov. Mitch Daniels (R) turned to a health policy consultant named Seema Verma to help insure more of the state’s poor and working poor.
The Washington Post, November 29, 2016

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

By Claire Thayer, November 18, 2016

1. Study Finds Nearby Retail Clinics Don’t Drive Down ER Visits
Kaiser Health News Reports: Even if there’s a retail health clinic less than a 10-minute drive away, consumers are just as likely to go to the emergency department for low-level problems like bronchitis or urinary tract infections, a recent study found.
Kaiser Health News, November 18, 2016

2. The ultimate Q&A about health care under a Trump presidency
The Washington Post reports: While it's pretty much a given that the Affordable Care Act won't survive a Trump presidency and Republican Congress in its current form, there are sweeping implications of reversing a law that has reached in so many ways into our health care system.
The Washington Post, November 17, 2016

3. Former Valeant and Philidor Executives Charged in Kickback Scheme
The New York Times reports: A secret relationship had made the two men rich: one, the head of a mail-order pharmacy, the other, an executive at a major pharmaceutical company who had promised to funnel millions of dollars to his partner in exchange for receiving millions of his own.
The New York Times, November 17, 2016

4. Landmark report by Surgeon General calls drug crisis ‘a moral test for America’
The Washington Post reports: A landmark report released Thursday by U.S. Surgeon General Vivek H. Murthy places drug and alcohol addiction alongside smoking, AIDS and other public health crises of the past half-century, calling the current epidemic “a moral test for America.”
The Washington Post, November 17, 2016

5. More than 1 million sign up for ObamaCare, HHS says
The Hill reports: More than 1 million people have registered for ObamaCare coverage for 2017 since the sign-up period began Nov. 1, the Obama administration announced Wednesday.
The Hill, November 16, 2016

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.

No Thanks, I Already Have Number

By Kim Bellard, November 17, 2016

Health care has a problem.  Well, of course, it has many problems, but one of them is that the various parties involved in the health care system can't agree on who we are.   Twenty years ago HIPAA called for creation of unique patient identifiers to accomplish this task, but within two years Congress put this on hold until further notice, and we're still waiting.

Everyone used to use social security numbers for this purpose, until we finally figured out the folly of that (especially since that number was never intended to be used as a national identification number).

News flash; we already have a unique, non-government-issued identifier: it's called a cell phone number.

It's obvious why we want a universally accepted patient identifier.  Providers and insurers have to agree on who you are to exchange claims and payments.  Different providers have to agree on who you are if we're ever going to get to interoperability of health information.

We can't/shouldn't use social security numbers, and not everyone has a drivers license number.  Health insurance numbers change whenever you change insurers, or even stay with the same insurance company but change employers.  What to do?

Thus the cell phone number.

According to the Pew Research Center, in 2015 92% of U.S. adults had a cell phone. That's not everyone, but not everyone has a social security number either.  When you do business with almost any organization these days, you are likely to be asked to provide your email and cell number number.

The New York Times reported on how the cell phone numbers have already become a widespread identifier.  As a security consultant told them, it has become "kind of a key into the room of your life and information about you."

As The Times pointed out, there are no legal requirements for companies who have your cell phone number to keep it private, unlike protected health information (PHI).  To be fair, they also noted how poorly protected social security numbers have been as well, leading to billions of dollars in annual fraud losses.  With cell phones, though, hackers have shown that, once they have your number, not only can they link you to various databases, but they can also listen to your phone calls, read your texts, even track your location.

However, it's not all bad news.  You can lock your phone or change your number if you think your cell phone number has been breached.

Like it or not, our cell phones are becoming our lifelines to the world, including but in no way limited to health.  Health care might as well acknowledge that fact, the way that most other industries are already starting to.  You can send money to someone using just their cell phone number; why not file a claim or link electronic records?

Don't want to use your cell phone number as your identifier?  OK, get a free Google Voice number, or use an app like Sideline to add a free second number to your existing mobile phone.

Meanwhile, most systems even in health care already can and probably do store our cell phone numbers.  It'd be just like health care to develop an expensive new solution to a problem.  For once, could we go the obvious route?

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

Changing the conversation from wellness to total wellbeing

By Claire Thayer, November 10, 2016

This week, Robin Bouvier from Aon’s Health Transformation Team, spoke in a HealthcareWebSummit webinar, co-sponsored by WebMD Health Services, on More than Meets the ROI: The Value of Investing in a Healthy Workforce.   Today’s forward thinking companies are moving towards a culture of health and changing the conversation about employee wellness from a ‘benefit’ to instead looking at health as a business imperative that’s integrated across all aspects of the organization.

Robin shares some perspective on general health of the workforce and somewhat surprisingly, the younger generations are not necessarily healthier:

	Baby Boomers (1946-1964)	Generation X (1965 -1978)	Millennials (1979-1996)
Tobacco Use	18%	21.1%	26.5%
Obesity	33.3%	32.8%	30.9%
Depression	16%	16%	20%
Debt	$29,317	$30,039	$23,332

Robin tells us that wellness is evolving to an all encompassing, total wellbeing approach: “Wellbeing means having the appropriate resources, opportunities and commitment needed to achieve optimal function, health and performance for the individual and the organization.” Total wellbeing interconnects:

• Emotional – attitudes and everyday living

• Physical – energy to complete daily living tasks

• Financial – confidently manage everyday and future finances

• Social – connections to others

Robin cited recent study findings of the impact of total wellbeing:

• 81% less like to seek out new employer in next year

• 41% less work missed because of poor health

• 69% of consumers say wellbeing programs health them get or stay healthy

• 22% more profitable as organizations

• 10% higher customer ratings

• ½ point higher performance rating by supervisor

From the new Aon Hewitt 2016 Financial Mindset Study, Robin identifies employee needs by financial stage as:

• Security: 30%

• Foundation: 25%

• Growth: 36%

• Freedom: 9%

The Somewhat Confident but Confused Open Enrollment Consumer

By Clive Riddle, November 4, 2016

This November, many consumers across the country are voting on more than a President, Congressmen and a hot mess of ballot propositions. They are also voting on their health insurance coverage for 2017. And many consumers may be more befuddled about choosing their health plan than their choices at the ballot box.

PolicyGenius has just released their Health Insurance Literacy Survey that “reveals 2017 open enrollment shoppers are overconfident in health insurance knowledge and under prepared to select a new plan.” Here’s an excpert from the infographic PolicyGenius provided on their findings:

Here’s additional PolicyGenius findings from the survey:

• There was 22% gap between women’s self-rated confidence in their knowledge of insurance terms and their actual comprehension, compared with a 29% gap for men.
• Millennials had a 29% gap between their confidence and comprehension.
• 72% of those with non-employer-provided health insurance policies plan to shop on the open marketplace for coverage this year.
• Most insured Americans are satisfied with their current plan, at 70% of total respondents
• People who used their health insurance 2-3 times in the past year are 12% more likely to be satisfied with their plan than those who used it just once
• Millennials are most likely to be satisfied with their health insurance plan, at 77%.
• There is no variation in plan satisfaction between those who have individual insurance versus employer-provided insurance.
• More than half of respondents aren’t very confident in their ability to choose the best health insurance plan for their needs.
• Only one-third of women overall are “very confident” in their ability to choose the best health insurance plan for their needs.
• The two groups that showed the highest confidence in their ability to choose the best plan were men at 58% and millennials at 43%.
• The survey found higher confidence levels in men over women (12% difference) and younger vs older respondents (millennials were most confident at 43%, 10% more than ages 45-55) in their ability to choose the best plan.

Sticking with the confusion theme, Walgreens has just released results of a survey of 1,000 Medicare Part D beneficiaries in advance of the Medicare open enrollment. Here’s what they found:

• 34% aren’t taking time to review their prescription drug plan prior to renewing it
• 19% don’t have a good understanding of their plan
• 22% look at just one component, checking, for example, to see if their own medications are covered, yet not looking at any other important considerations
• 21% falsely believes that all pharmacies charge the same copay
• 33% don’t know they can switch pharmacies outside of the enrollment period, at any time of year.
• 30% said copay costs are the most important factor, followed by pharmacy location (18%) and the opportunity for one-stop shopping (18 percent).

How to Increase Physician Engagement in Value Based Care: Deloitte Survey

By Clive Riddle, October 27, 2016

HHS, commercial health plans, states and health systems continue to advance value based care initiatives at a rapid and accelerating pace. But the question is, as the value based train is leaving the station, are the doctors on board?

Deloitte has released a report: Practicing Value-Based Care, which aims to answer the question “What do doctors need?” based on results from their Deloitte Center for Health Solutions 2016 Survey of U.S. Physicians.

The problem for physicians, Deloitte’s Mitch Morris tells us, is “today there is little incentive for them to change; many are still being paid under fee-for-service models and they're not equipped with tools that could help them deliver high-value care."

The Deloitte physician survey “found that while 3 in 4 physicians have clinical protocols, only 36 percent have access to comprehensive protocols (i.e., for many conditions). Also, only 20 percent of physicians receive data on care costs.”

Additionally, Deloitte findings from the survey indicate financial incentives haven’t changed enough: “Eighty-six percent of physicians reported being compensated under fee-for-service (FFS) or salary arrangements, similar to 2014. Showing no change from 2014, one-half of physicians reported performance bonuses less than or equal to 10 percent of their compensation, and one-third were ineligible for performance bonuses.”

Deloitte advocates that public and private stakeholders should partner with doctors to accomplish three things that would greatly enhance physician engagement:

1. Tie at least 20% of physician compensation to performance
2. Equip physicians with the right tools to help them meet performance goals including “clinical protocols, quality measures that align with their specialties and emphasize outcomes rather than processes of care, and detailed data on their own performance and on physicians to whom they refer patients.”
3. Invest in technology capabilities to connect and integrate the tools

HHS-CMS Share Marketplace Projections and Nine Open Enrollment Strategies

By Clive Riddle, October 21, 2016

Earlier this Week, HHS Secretary Sylvia M. Burwell “announced that she expects 13.8 million individuals to sign up for coverage through the Marketplaces during the upcoming Open Enrollment.” In conjunction with her announcement, the HHS Office of the Assistant Secretary for Planning and Evaluation released a report detailing these 2017 enrollment projections for 2017, telling us:

• The projected enrollment of 13.8 million would represent an increase of 1.1 million from 12.7 million plan selections at the end of 2016’s Open Enrollment.
• They estimate this will net down to monthly effectuated enrollment averaging 11.4 million people during 2017.
• 10.7 million uninsured Americans are eligible for Marketplace coverage. Among them, 85% are potentially income eligible for financial assistance,  and 60% have incomes that would also qualify them for cost-sharing reductions in addition to tax credits
• 40% of the eligible uninsured are 18-34 years old
• 5.1 million eligible for the Marketplace currently purchase off-Marketplace coverage. Of this group, they estimates 2.5 million people could be eligible for financial assistance via Open Enrollment signups for Marketplace coverage

So how are they going to increase the open enrollment signups to 13.8 million? Last week, CMS shared their open enrollment marketing strategies, noting that “nearly half of uninsured adults are unaware of the financial assistance available to help pay for health insurance, even though about 85 percent of Marketplace-eligible uninsured Americans could qualify for financial help.” Their marketing plan includes:

1. Increasing direct mail pieces from 800,000 last year to 10 million this year, targeted to “people who were recently uninsured, recently lost coverage, or sought coverage in the past through HealthCare.gov or a state Medicaid program,” including “people who started to sign up at HealthCare.gov last year, but didn’t complete the process”; “consumers who lost eligibility for Medicaid or CHIP coverage last year, or who applied for Medicaid or CHIP but had incomes too high to qualify.”
2. The IRS “will conduct new outreach to uninsured people who paid the penalty or claimed an exemption, letting them know that tax credits are available for Marketplace coverage and providing information about their health coverage options.”
3. E-Mail marketing will be expanded, as “HealthCare.gov’s email list has grown by over 30 percent” to 20 million+ people
4. Healthcare.gov notes they “learned that simply reminding a consumer about their eligibility for financial assistance in an email increased enrollment rates by 17 percent compared to emails that did not include that information,” and that “emails informing returning consumers of increased costs in their current plan and encouraging them to review their options by shopping increased active renewal rates by 279 percent.”
5. Healthcare.gov also learned merely mentioning a deadline in an email increased enrollment by 14 percent compared to emails that did not mention deadlines.
6. HealthCare.gov will remind consumers about the a penalty for not having coverage, and cite a study in which “consumers who received an email with additional language referencing the penalty were 13 percent more likely to enroll,” and a test that “found that more prominently displaying penalty information with the deadline (for example, in the email subject line) produced a larger lift in enrollment, 97 percent,” and a “message that gave higher-income people information about the higher penalty levels likely to apply to them increased enrollment by 18 percent.”
7. Outreach is being expanded to mobile and streaming platforms, and gaming platforms in order to reach younger audiences. Healthcare.gov cites a partnership with gaming platform Twitch, and notes that they will run ads and sponsor content on YouTube, Instagram and Facebook
8. Healthcare.gov will emphasis optimized search efforts and cite that “CMS increased overall search conversion rates by 24 percent compared to the previous year.”
9. Healthcare.gov  will “double the number of impressions a consumer sees (“Gross Rating Points”) on TV in the week leading up to December 15th compared to the same week last year.”

Will Anyone Notice?

By Kim Bellard October 13, 2016

There's an interesting verbal battle going on between two prominent tech venture capitalists over the future of AI in health care. Marc Andreessen asserted that Vinod Khosla "has written all these stories about how doctors are going to go away...And I think he is completely wrong."  Mr. Khosla was quick to respond:  "Maybe Mr. Andreessen should read what I think before assuming what I said about doctors going away."

It turns out that Mr. Khosla believes that AI will take away 80% of physicians' work, but not necessarily 80% of their jobs, leaving them more time to focus on the "human aspects of medical practice such as empathy and ethical choices."  That is not necessarily much different than Mr. Andreessen's prediction that "the job of a doctor shifts and becomes a higher-level, more important job that pays better as the doctor becomes augmented by smarter computers."

When AIs start replacing physicians, will we notice -- or care?

Personally, I think it is naive to expect that only 20% of physicians' jobs are at risk from AI, or that AI will lead to physicians being paid even more.  The future may be closer than we realize, and "virtual visits" -- telehealth -- may illustrate why.

Recently, Fortune reported that over half of Kaiser Permanente's patient visits were done virtually, via smartphones, videoconferencing, kiosks, etc.  That's over 50 million such visits annually.  

Sherpaa, a health start-up that is trying to replace fee-for-service, in-person doctor visits with virtual visits.  Available with a $40 monthly membership fee, the visits are delivered via their app, tests or emails.  Their physicians can order lab work, prescribe, and make referrals if needed.

How many people would notice if virtual visits were with an AI, not an actual physician?  

Companies in every industry are racing to create chatbots, using AI to provide human-like interactions without humans.  And health care bots are on the way.

Not everyone is convinced we're there yet.  A new study did a direct comparison of human physicians versus 23 commonly used symptom checkers to test diagnostic accuracy, and found that the latter's performance was "clearly inferior."  The symptom checkers listed the correct diagnosis in their top 3 possibilities 51% of the time, versus 84% for humans.  

However, consider the symptom-checkers may be the most commonly used, but may not have been the most state-of-the-art.  And the real test is how the best of those trackers did against the average human physician. Humans still got the diagnosis wrong is at least 16% of the cases.  They're not likely to get much better (at least, not without AI assistance).  AIs, on the other hand, are only going to get better.  

It used to be that physicians were sure that their patients would always rather wait in order to see them in their offices, until retail clinics proved them wrong.  It used to be that physicians were sure patients would always rather see them in person rather than use a virtual visit (possibly with another physician), until telehealth proved them wrong.  And it still is true that most physicians are sure that patients prefer them to AI, but they may soon be proved wrong about that too.

AI is going to play a major role in health care.  Rather using physicians to focus more on empathy and ethical issues, as Mr.  Khosla suggested (or paying them more for it, as Mr. Andreessen suggested), we might be better off using nurses and ethicists, respectively, for those purposes.  So what will physicians do?

The hardest part of using AI in health care may not be developing the AI, but in figuring out what the uniquely human role in providing health care is.

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

It’s Complicated – Navigating Health Care Integrated Delivery Networks

By Claire Thayer, October 7, 2016

Integrated delivery networks (IDNs) are vast and complex. In the U.S. alone, there are more the 626 IDNs operating at 44,000 sites, employing over 412,000 health care providers.  Some IDNs are groups of hospitals, some are regional, some have facilities scattered throughout the country and even internationally – think Kaiser Permanente and the Mayo Clinic – both long standing traditional IDNs. More and more health systems are taking on risk management for their patient populations and in doing so, are looking for ways to collaborate with health plans and providers and related entities to align efficiencies in overall patient care management.  In the not to distant future, expect to see most provider organizations involved at some level with an IDN. 

Navigating IDNs and understanding the scope of their reach is the focus of a recent MCOL infographoid, co-sponsored by LexisNexis Health Care, highlighted below:

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.

Opportunities With Consumer Angst About ACA Exchanges and Out of Pocket Costs

By Clive Riddle, October 7, 2016

GfK has just released updated survey results on consumer health insurance purchasing which found that “one-third of consumers who purchased on ACA exchanges do not expect that their present insurer (33%) – or any other carrier (34%) – will offer insurance through their exchange in 2017. And 32% do not think they will find options on the exchange that meet their needs.”

Additional findings they report include:

• 13% of consumers purchasing through ACA exchanges plan to revert to becoming uninsured if their current coverage was not offered.
• For ACA exchange consumers earning less than $25,000 a year, 34% plan on becoming uninsured if current coverage isn’t available
• 43% of exchange users say they would seek new options through the exchanges – with levels highest among 50 to 64 year olds.
• 35% of exchange users would go directly to an insurer or agent for solutions if their coverage lapses
• 66% say they would choose the best option to meet their needs, regardless of the insurance company
• Only 12% would make a point of staying with their current carrier
• 20% say they would explore coverage through a different insurer

Liz Reyer, GfK Vice President and health insurance lead concludes that “as a ’brand,’ the ACA has taken some hits in 2016. While most observers expected insurance companies to reassess their offerings on the exchanges now and then, the outright defections we have seen have quickly limited consumers’ choices and eroded confidence that the ACA will find ways to meet their needs. We need to see a high-profile campaign making clear the options that consumers still have – so no one goes without insurance unnecessarily – and stronger collaboration between the insurance industry and the government in keeping the ACA viable.”

Health Plans remaining on the ACA exchanges certainly have a market opportunity to mop up the mess left by large national plans exiting the exchanges. Outside the ACA exchanges, plans active in individual markets, and applicable private exchanges have a major opportunity to gain ground with consumers not eligible for subsidies (which are only available through the ACA exchanges.)

Meanwhile, Navicure, in conjunction with Porter Research has just released provider survey results from a study on how healthcare organizations are responding to patient engagement and consumerism, with a focus on consumer concerns about price transparency, financial responsibility and payment options. The survey included hospitals (19%) and medical groups ranging in size (33% in practices with ten providers or less and 21% with 100 providers or more.)

Of the most common questions patients ask about their financial responsibility, provider respondents said “58 percent inquire about payment plans, and 56 percent ask about total treatment cost. Other top questions include asking what balance is due (53%) and what payment options are available (43%).”

67% of provider respondents say patients do not understand their payment responsibility versus their insurance provider’s responsibility, and 42% of providers find that attempting to estimate prices for services is a major problem.

The study found that most healthcare organizations aren’t using available tools to help with consumer confusion over out of pocket costs, with 33% of providers using patient bill estimation tools, 26% sending patients electronic statements, and 25% securely store debit or credit card information on file.

In this era of ever increasing consumer cost sharing, a major market opportunity exists for providers and health plans that can easily answer patient questions on what their out of pocket will be, and offer a range of options for how patients can pay for them.

Prescription Drug Costs on the Public’s Mind – Reductions in the Uninsured Not So Much

By Clive Riddle, September 30, 2016

The just released current Kaiser Family Foundation Tracking Poll finds that while the public continues to be deeply divided on the Affordable Care Act, they are fairly united in backing policy changes to rein in prescription drug costs. The level of bipartisan public support – powered by recent EpiPen pricing headlines among other Rx cost woes in the news -  would seem to offer a prescription paving the way for a rare event these days– legislation that has a chance of being enacted into law when the new Congress convenes next session.

There is widespread agreement on five policy points:

1. 86% support requiring drug companies to release information to the public on how they set drug prices
2. 82% favor allowing the federal government to negotiate with drug companies to get a lower price on medications for people on Medicare
3. 78% approve of limiting the amount drug companies can charge for high-cost drugs for illnesses like hepatitis or cancer
4. 71% like allowing Americans to buy prescription drugs imported from Canada
5. 66% want an independent group that oversees the pricing of prescription drugs

Here’s a graphic Kaiser Family Foundation provided regarding the poll results:

The survey finds that “a large majority (77%) perceive drug costs as unreasonable, while one in five (21%) say they are reasonable. The share who say drug costs are unreasonable is up somewhat from 72 percent a year ago in August 2015.”  The Survey also finds that “about half (55%) of the public report currently taking prescription drugs, and the vast majority (73%) of them say paying for their medications is easy; far fewer (26% of those taking prescription drugs, or 14% of the total population) say it is difficult to pay for their drugs.”

The September tracking poll continues to reflect the deep partisan divide in views on the ACA, which spill over to recognition of a significant drop in the level of the uninsured:

• 47 percent have an unfavorable view of the ACA while 44 percent have a favorable one. 
• 48% say the marketplace in their own state is working well, while 43 percent say it is not working well, but 49% say they are not working well nationally vs. 44% that say they are working well.
• “When asked whether the uninsured rate is at an all-time low or all-time high, a quarter (26%) are aware that it is at an all-time low, while a fifth (21%) say that it is at an all-time high. Democrats and those with a favorable view of the health reform law are more likely to be aware of this; Republicans and those with an unfavorable view are less likely to be aware.”

With regard to the current level of the uninsured, HHS this week released a report indicating “the uninsured rate fell by around 40 percent for Americans in all income groups for 2010 through 2015, including individuals with incomes above 400 percent of the federal poverty level (FPL).”
Here’s the levels of reduction in the rate of uninsured they found during this time period by income levels and age:

• Less than 100% FPL: 39% reduction
• 100-125% FPL: 48% reduction
• 125-250% FPL: 41% reduction
• 250-400% FPL: 37% reduction
• 400% FPL and higher: 42% reduction
• 18-25 year olds: 52% reduction
• 26-34 year olds: 36% reduction
• 35-54 year olds: 39% reduction
• 55-64 year olds: 40% reduction