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: 

As Hospitals Post Sticker Prices Online, Most Patients Will Remain Befuddled 

As of Jan. 1, in the name of transparency, the Trump administration required that all hospitals post their list prices online.

Kaiser Health News

Friday, January 4, 2019

Bristol-Myers to Acquire Celgene in Deal Worth $74 Billion

Bristol-Myers Squibb said on Thursday that it would buy Celgene, a maker of cancer-fighting drugs, in a cash-and-stock deal valued at $74 billion, the first major pharmaceutical deal of 2019.

NY Times

Friday, January 4, 2019

Drug companies greet 2019 with U.S. price hikes

Drugmakers kicked off 2019 with price increases in the United States on more than 250 prescription drugs, including the world’s top-selling medicine, Humira, although the pace of price hikes was slower than last year.

Reuters

Thursday, January 3, 2019 

Ransomware, phishing attacks top new HHS list of cyberthreats in healthcare

Email phishing attacks, ransomware attacks and attacks against connected medical devices are among the greatest cyberthreats that health systems need to protect against, according to new cybersecurity guidance for health systems from the Department of Health and Human Services.

Fierce Healthcare

Wednesday, January 2, 2019

Link between readmission rates, mortality rates back under scrutiny

A new study shows a statistically significant correlation between lower readmission rates and higher mortality rates for patients with heart failure and pneumonia, renewing questions about the efficacy of the Center for Medicare and Medicaid Services' Hospital Readmissions Reduction Program (HRRP).

Fierce Healthcare

Wednesday, January 2, 2019

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: 

CMS finalizes ACO overhaul, shortening pathway for financial risk

The Centers for Medicare & Medicaid Services (CMS) finalized substantial changes to the Medicare Shared Savings Program (MSSP), an overhaul that will truncate the time that Accountable Care Organizations can remain in one-sided risk models.

FierceHealthcare

Friday, December 21, 2018

Year One Of KHN’s ‘Bill Of The Month’: A Kaleidoscope Of Financial Challenges

In 2018, KHN and NPR launched “Bill of the Month,” a crowdsourced investigation in which we dissect, investigate and explain medical bills you send us. In telling the story behind one patient’s bill each month, our goal is to understand the genesis of the often exorbitant and baffling charges that pervade the American medical system.

Kaiser Health News

Friday, December 21, 2018

Cigna closes $54 billion purchase of Express Scripts

Cigna Corp (CI.N) on Thursday closed its $54-billion deal to buy Express Scripts Holding Co, creating one of the biggest providers of pharmacy benefits and insurance plans in the United States, a combination it says will help it improve healthcare coordination and cut costs.

Reuters

Friday, December 21, 2018

Obama health law sign-ups beat forecast despite headwinds

The Affordable Care Act has yet again beaten predictions of its downfall, as government figures released Wednesday showed unexpectedly solid sign-ups for health coverage next year.

Associated Press

Thursday, December 20, 2018

Most hospitals still use mail or fax to exchange data

Health systems use numerous methods to exchange patient medical records, but providers continue to rely heavily on the old-fashioned approach of mail or fax, according to new federal data on interoperability.

FierceHealthcare

Wednesday, December 19, 2018

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.

What College Can Teach Healthcare

by Kim Bellard, December 19, 2018 

Mitch Daniels, the former Governor of Indiana and current President of Purdue University, gave an interesting interview to The Wall Street Journal about what Purdue has been up to during his watch. Mr. Daniels — who knows a thing or two about healthcare — drew an explicit parallel to healthcare in the interview: 

“You’re selling something, a college diploma, that’s deemed a necessity. And you have total pricing power.” Better than that, “when you raise your prices, you not only don’t lower customers, you may actually attract new ones.” For lack of objective measures, “people associate the sticker price with quality: ‘If school A costs more than B, I guess it’s a better school.’” A third-party payer, the government, funds it all, so that “the customer — that is, the student and the family — feels insulated against the cost. A perfect formula for complacency.” 

Higher education is one area where prices seem to be rising even faster than in healthcare, and both much faster than wages. Student debt just hit a record $1.465 trillion — yes, trillion — and now trails only mortgage debt in size. 

We spend a lot more — nearly twice as much per student annually — on higher education than almost any other developed country, according to OECD. Yep, sounds like U.S. healthcare all right. 

Mr. Daniels is trying to change that. For one thing, he’s focused on holding the line on costs, such as by bringing Amazon in to help lower textbook prices. Purdue had raised tuition 36 years in a row prior to his arrival, and now has not raised them since 2012. 

But here’s what really caught my eye. Purdue pioneered the use of Income Share Agreements (ISAs), an idea attributed to economist Milton Friedman. Students don’t owe tuition during college, but six months after graduation they begin to pay a percentage of their income for a fixed number of years (e.g., 10 years). Repayment is capped at 2.5 the initial funding. Several other universities are now rolling out their own versions. 

The application of ISAs to healthcare may not be obvious. In an earlier post, for example, I suggested treating our health as a capital asset. We would seek to spend — invest — money on things that increase it, and avoid things that decrease it. It would, admittedly, be hard to quantify any of this, but doing so would force us to measure and to track. 

Perhaps a Healthcare Share Agreement (HCSA) would have a healthcare organization make a quantifiable prediction about your health, and what you pay each year would depend on how they do against that prediction. We’d have to agree on how to measure it, over what period of time, but both the prediction and the measurement are feasible (e.g., QALY). 

The payment could be in lieu of health insurance premiums or health care organization’s charges. The healthier-than-expected you are, the more you pay; the worse-than-expected you are, the less you pay. It’s value-based payment at the next level. It could be done as agreements with individuals and organizations, or, say, between health plans and health organizations at a population level. 

The key thing is for healthcare organizations to do what Purdue is doing: bet on their ability to actually make a positive impact in the lives of the people they serve. 

I don’t know how it would work. I don’t know if it can work. But I’d sure like for someone to give it a try, because the existing business models sure don’t seem to be working.

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: 

Health Insurance Costs Crushing Many People Who Don’t Get Federal Subsidies

Like millions of Americans in this final week of open enrollment for the Affordable Care Act marketplaces, Diane McCabe is shopping for health insurance.

Kaiser Health News

Friday, December 14, 2018

$67B Cigna-Express Scripts merger faces one more hurdle

New York and California approved the $67 billion acquisition of Express Scripts by Cigna on Dec. 13, but New Jersey has yet to give its approval, according to a public filing.

Healthexec.com

Friday, December 14, 2018

Thursday, December 13, 2018

“Landmark” Maternal Health Legislation Clears Major Hurdle

Congress moved a big step closer on Tuesday toward addressing one of the most fundamental problems underlying the maternal mortality crisis in the United States: the shortage of reliable data about what kills American mothers.

Propublica

Thursday, December 13, 2018

Health care disruption: Thinking broadly about regulation and innovation

2018 has been a breakout year for health innovation. Major tech companies plunged fully into the health care arena, hiring teams of health care experts and launching major initiatives.

Politico

Monday, December 10, 2018

House set to vote on bill cracking down on drug companies overcharging Medicaid

The House is expected to vote next week on a bill to crack down on drug companies that overcharge the government, according to two House aides.

The Hill

Monday, December 10, 2018

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.

Nine Healthcare Business Trends for 2019

By Clive Riddle, December 14, 2018 

Here’s nine trends to keep a close watch on as we stand on the precipice of 2019:

1. The Year of SDOH

Health Plans, Health Systems and Public Agencies all will invest more heavily in Social Determinants of Health initiatives for their at risk populations. The number, scope, and resources involved in programs will significantly escalate, using a wide range of approaches. Some will be touted as quite successful, some will be deemed as failures, many will need much more time before conclusions can be drawn.

2. Continued Uptick in Uninsured

The Commonwealth Fund cites “The uninsured rates among lower-income adults rose from 20.9 percent in 2016 to 25.7 percent in March 2018.” The news won’t get better in 2019. The ongoing federal chipping away at the ACA in various forms will continue to yield a rising rate in the uninsured.

3. Much Ado About Prescriptions

PBMs, Specialty Drugs, and Pharmaceutical price hikes have been everyone’s punching bag. And the punching will continue with much noise in 2019. But what further policy changes might one expect out of Washington with the current climate? And just released National Health Expenditure data indicates “per capita prescription drug spending slightly decreased (down 0.3%) for the first time since 2012.” While Rx costs are projected to be troublesome in the coming years, the current stall in costs will likely stall momentum for actual change.

4. Amazon and CVS Will Be Busy Bees

CVS and Aetna are now out of the gate, and have already put forth transformational plans.Amazon isn’t just positioning for the pharmacy arena – they’re into healthcare tech and much more, let alone their venture with their employer driven triumvirate with Berkshire and JP Morgan.

5. Increased Focus on Million Dollar+ Claims

Even though general healthcare costs are increasing in the lower single digits, the real high end is not finding a ceiling. Million-dollar+ medical claims increase 87 percent from 2014-2017. Technological and clinical advances will keep pushing this forward, and an increasing amount of attention will be paid on how to deal with the highest end claims. 

6. EHR: Physician Pushback and Response

A Medical Economics magazine article this month starts off with: “It’s no secret that dissatisfaction with EHR systems has been a major concern for physicians. In fact, several recent surveys report as much as a 25 to 30 percent unhappiness level among doctors and practices.”  The pushback will not subside in 2019, and vendors have a major opportunity to promote how they can make physician’s work lives easier, if they truly can come up with some innovative responses. 

7. Employee Cost Sharing: Large Group and Small Group In Different Directions

The Commonwealth Fund reported this month that “premium and deductible costs amounted to nearly 12 percent of median income in 2017. Added together, the total cost of premiums to workers and potential spending on deductibles for both single and family policies climbed to $7,240 a year in 2017.” While e cost sharing in its many forms just continues to exact a growing burden on employees, large groups are shifting strategies away from increased cost sharing, while the small group market may see no respite in 2019. 

8. Cybersecurity Stakes Rise as Healthcare Data Breaches Continue

Its not very risk to predict high risk of more major healthcare data breaches in 2019. Healthcare cybersecurity investments will continue to grow in 2019.

9. Value Based Healthcare is Everywhere

The challenge in 2019: to find a healthcare organization that doesn’t have the words value-based emblazoned throughout its communications.

Four Questions for CoxHealth: Post-Webinar Interview

Recently, DNV GL Healthcare and CoxHealth participated in a Healthcare Web Summit webinar discussion on Unconventional Paths to Reducing Patient Readmissions. If you missed this informative webinar presentation, watch the On-Demand version here. After the webinar, we interviewed the CoxHealth team on four key takeaways from the webinar: 

1. Your study looked at readmission rates for congestive heart failure patients, how did you identify physicians with higher than average readmission rates? 

CoxHealth: We are currently identifying CHF patients who have readmitted for a second time and enrolling them in the Advanced Practice Paramedic Program.  Our data showed that if a person readmits once, they are more likely to readmit a second, third, etc time.  We felt our best use of resources was to stop the multiple readmitters. 

2. From a case management perspective, what were lessons learned from skilled nursing facilities? 

CoxHealth: We brought a few different skilled nursing facilities together and diet was determined to be the single largest item that helped keep readmission rates low.  Our APPs have a great focus on diet with the patient and the patient’s family when they enroll. 

3. Describe your Advanced Practice Paramedics program and key successes with this program in managing emergency department high utilizers. 

CoxHealth: We identify a high utilizer as anyone who visits the ED 5 or more times in a 12 month period.  One of our keys of success, that we learned because we didn’t start this way, is to have an APP in the ED to visit with the patients real-time and enroll them.  We started with a social worker doing this and we weren’t having the acceptance we were hoping for.  When we had the paramedic, who would then be coming into their home, visit about the program, our acceptance rate increased drastically.  

Another key to our success is our goal is to graduate patients from the program in approximately 90 days.  We continue to track the ED utilization after the enrollment period to ensure we don’t need to touch base again with the patient, but our goal is to work with them on what interventions can be implemented so they don’t have to visit the ED as often.  If our APPs didn’t graduate patients, we wouldn’t be able to enroll new patients and continue to grow our success. 

Our final keys to success is to not overly prescribe to the APP what they should be doing for the patient.  We have individualized care plans and encourage the APPs to think outside the box when providing care. 

4. Who pays for the APP program? 

CoxHealth: CoxHealth pays for the program.  We are proving the program’s worth through cost avoidance of low reimbursement patients in the ED as well as decreasing readmissions cost.  We are currently in discussions with two large payers to begin reimbursement for APP visits.

Premium and Deductible Cost Sharing: A Dozen Key Findings from the Commonwealth Fund

by Clive Riddle, December 7, 2018 

CMS has just touted the National Health Expenditure growth of 3.9% for 2017 is at historic low levels, with the Office of the Actuary stating “prior to the coverage expansions and temporary high growth in prescription drug spending during that same period, health spending was growing at historically low rates. In 2017, health care spending growth returned to these lower rates and the health spending share of GDP stabilized for the first time since 2013.” 

Meanwhile, The Commonwealth Fund paints a different picture from another perspective, and has just released a 21-page DataBrief: The Cost of Employer Insurance Is a Growing Burden for Middle Income Families, with lead author Sara Collins commenting “The cost of employer health insurance premiums and deductibles continues to outpace growth in workers’ wages. This is concerning, because it may put both coverage and health care out of reach for people who need it most — people with low incomes and those with health problems. Policies that would reduce health care burdens on employees include fixing the Affordable Care Act’s family coverage glitch, requiring employers to exclude some services from the deductible, and increasing the required minimum value of employer plans.” 

The Commonwealth Fund tells us their study uses “the latest data from the federal Medical Expenditure Panel Survey–Insurance Component (MEPS–IC) to examine trends in employer premiums at the state level to see how much workers and their families are paying for their employer coverage in terms of premium contributions and deductibles. We examine the size of these costs relative to income for those at the midrange of income distribution.” 

Here’s a dozen key findings: 

1. Average employee premium contributions for single and family plans amounted to nearly 7 percent of U.S. median income in 2017, up from 5 percent in 2008. 
2. In 11 states (Arizona, Delaware, Florida, Georgia, Louisiana, Mississippi, Nevada, New Mexico, North Carolina, Oklahoma, Texas), premium contributions were 8 percent of median income or more, with a high of 10.2 percent in Louisiana.
3. Premium and deductible costs amounted to nearly 12 percent of median income in 2017. Added together, the total cost of premiums to workers and potential spending on deductibles for both single and family policies climbed to $7,240 a year in 2017. 
4. This combined cost ranged from a low of $4,664 in Hawaii to a high of more than $8,000 in eight states (Alaska, Arizona, Delaware, New Hampshire, North Carolina, South Dakota, Texas, Virginia). 
5. In two states, Mississippi and Louisiana, these combined costs rose to 15 percent or more of median income.
6. Premiums for employer health plans rose sharply in nearly every state in 2017. After climbing modestly between 2011 and 2016, overall premiums for employer health plans (employer and employee share) grew more sharply in 2017, by 4.4 percent for single plans and 5.5 percent for family plans. 
7. Annual single person premiums rose above $7,000 in eight states (Alaska, Connecticut, Delaware, Massachusetts, New Jersey, New York, Rhode Island, Wyoming) and family premiums were $20,000 or higher in seven states (Alaska, Connecticut, Massachusetts, New Jersey, New York, West Virginia, Wyoming) and the District of Columbia. 
8. Average premiums for families increased overall in 44 states and the District of Columbia.
9. As employer premiums have risen, so have workers’ contributions. Between 2016 and 2017, employee premium contributions rose by 6.8 percent to $1,415 for single-person plans and by 5.3 percent to $5,218 for family plans.
10. Contributions for single plans increased in 32 states, ranging from a low of $675 in Hawaii to a high of $1,747 in Massachusetts. 
11. Contributions for family plans rose in 35 states and the District of Columbia, with the lowest increase in Michigan ($3,646) and the highest in Delaware ($6,533).
12. The average deductible for single policies rose to $1,808 in 2017, a 6.6 percent increase. Average deductibles rose in 35 states and the District of Columbia, ranging from a low of $863 in Hawaii to a high of about $2,300 in Maine and New Hampshire.

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:

Providing Supervised Medical-Grade Heroin to Heavy Users Can Reduce Harms; Approach Merits Pilot Study in U.S. 

Providing supervised access to medical-grade heroin to people whose use continues after trying multiple traditional treatments has been successful in other countries, and should be piloted and studied in the United States, according to a new RAND Corporation study.

RAND

Thursday, December 6, 2018

A new way to curb harmful medical errors: talk more to patients and families 

A new study suggests a simple idea could go a long way toward curbing dangerous medical errors: looping in patients and families about what’s happening with their care.

Stat News

Thursday, December 6, 2018

ObamaCare enrollment down 11 percent from last year 

Enrollment in ObamaCare plans is down by 11 percent compared to last year, according to new sign up numbers released by the Trump administration.

The Hill

Thursday, December 6, 2018

Judge adds new hurdle to CVS-Aetna merger 

A federal judge could throw a wrench into the mega-merger between health giants CVS and Aetna.

The Hill

Thursday, December 6, 2018

Employers Change Tactics to Curb Health-Insurance Costs 

Company leaders are grappling with how to deal with the rising cost of health insurance in ways that get beyond the longtime strategy of simply passing on more of the burden to workers.

Wall Street Journal

Monday, December 3, 2018

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.

EHR and Patient Self-Pay: A Tale of Two Provider Woes

By Clive Riddle, November 30, 2018

In the provider administrative world, two continuing challenges causing large audible sighs are dealing with EHRs and ever-increasing levels of patient cost-sharing. An 11-page report just released on the annual HFMA/Navigant survey tackles these topics, providing findings from responses of 107 hospital and health system CFOs and revenue cycle management executives.

On the EHR front, we are told that 56% of executives “said their organizations can’t keep up with EHR upgrades or underuse available EHR functions, up from 51% last year. Moreover, 56% of executives suggested EHR adoption challenges have been equal to or outweighed benefits specific to their organization’s revenue cycle performance.”

Timothy Kinney, managing director at Navigant, says “hospitals and health systems have invested a significant amount of time and money into their EHRs, but the technology’s complexity is preventing them from realizing an immediate return on their investments.”

The survey found that 44% quickly adapt to EHR functional release, and the above cited 56% includes 39% that underutilize available EHR functions, and 17% can’t keep up with EHR functions. Regarding adoption challenges and benefits, the also above cited 56% includes 34% stating benefits and challenges are equal, and 22% who feel challenges outweigh benefits.

Regarding patient self-pay, the report tells us that 81% of executives “believe the increase in consumer responsibility for costs will continue to affect their organizations, down from 92% last year. Among them, 22% think that impact will be significant, compared to 40% last year. Executives from health systems and larger hospitals believe their organizations will be more heavily impacted by consumer self-pay.”

Navigant Managing Director James McHugh comments that “the impact of consumer self-pay on providers will only increase with the popularity of high-deductible health plans and negative changes to the economy. Providers must take advantage of opportunities to more holistically educate patients on out-of-pocket costs, predict their propensity to pay as early as possible, and secure alternative payers or financing when needed.”

The survey results seem to indicate self-pay continues to be a big issue, yet is more manageable now than a year ago. Time will tell if that trend continues.

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:

U.S. judge raises prospect of not approving CVS-Aetna deal

In an unusual move on Thursday, a federal judge raised the prospect of not approving CVS Health Corp’s deal to buy insurer Aetna Inc, which closed earlier this week, during a routine portion of the legal process.

Reuters

Friday, November 30, 2018

Trump to Let States Divert Obamacare Funds to Other Health Plans

The Trump administration plans to allow states to direct billions of dollars of Obamacare subsidies to health plans that don’t meet the law’s requirements.

Bloomberg

Friday, November 30, 2018

HHS finalizes long-awaited 340B drug price rule

HHS on Thursday said it will allow a rule imposing ceiling prices on the 340B drug discount program to go into effect next year, after years of delays. The long-postponed rule will go into effect on Jan. 1, instead of the earlier-announced July 1, 2019 date, according to a finalized rulemaking.

Modern Healthcare

Thursday, November 29, 2018

Big Tech Expands Footprint in Health

Amazon.com Inc. is starting to sell software that mines patient medical records for information doctors and hospitals could use to improve treatment and cut costs. The move is the latest by a big technology company into health care, an industry where it sees opportunities for growth.

Wall Street Journal

Wednesday, November 28, 2018

Trump health chief 'looking closely' at thousands who lost Medicaid from work requirements

A top Trump administration health-care official on Tuesday said she is “looking closely” at why thousands of people have lost Medicaid coverage in Arkansas due to the state’s new work requirements, but indicated the administration would not slow down in implementing the new rules.

The Hill

Wednesday, November 28, 2018

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.

Too Much Stupid Stuff

by Kim Bellard, November 16, 2018

Melinda Ashton, M.D., has a great article in NEJM: Getting Rid of Stupid Stuff. It describes a program her health system (Hawaii Pacific Health) undertook to do exactly that, with some promising results.

The impetus of their program was to address the issue of burnout, specifically around documentation burdens. Their EHR had been in place for 10 years, and they reasoned that some tasks might no longer be necessary or appropriate. So, starting October 2017, they asked all employees to nominate anything in their EHR that was “poorly designed, unnecessary, or just plain stupid.”

Dr. Ashton and her team reminded employees that: “Stupid is in the eye of the beholder. Everything that we might now call stupid was thought to be a good idea at some point.” Fair enough. They expected nominations to be in three categories:

• unintended documentation that could easily be eliminated;
• documentation that was needed but that could be collected more efficiently;
• documentation that needed better training to accomplish.

They ended up getting nominations in all three categories, and have already implemented a number of changes, as well as eliminating 10 of the most frequent 12 physicians alerts. The program has now been extended beyond just documentation and beyond just the EHR because, as Dr. Ashton writes: “It appears that there is stupid stuff all around us.”

It would be easy but short-sighted to take healthcare’s collective frustration out on EHRs. But let’s not kid ourselves: EHRs are not the stupidest thing we have in healthcare. EHRs may, in fact, be the smartest stupid thing healthcare has done, because at least there are significant upsides to having EHRs, even if we’re not achieving them yet. There are plenty of things we do in healthcare that are just plain stupid.

Admit it: if you work in healthcare, you see stupid stuff every day. Some are things imposed on you from external sources, and some are things required by your own organization. As Dr. Ashton cautioned, some may have been a good idea at some point. Some may never have been a good idea. Some are things that just keep getting done simply because of habit/ tradition/rules. Some are stupid things that someone, somewhere, still thinks is a good idea but, when push comes to shoving patient care, aren’t. They’re still stupid, and should be stopped.

The program at Hawaii Pacific Health as aimed primarily at reducing daily frustrations for its employees, but we need to go much further. These kinds of programs need to attack daily frustrations for all stakeholders, and especially for patients.

If you are a healthcare leader, start a program like this. If you work in a healthcare organization, advocate for one until your leadership puts one in. If you are a patient or family member of one, don’t wait for a formal program from the healthcare organizations you interact with; speak up about the stupid stuff you see and have to deal with, and make sure your thoughts get to those organizations’ leadership.

It’s stupid to accept stupid stuff, especially with something as valuable as our health at stake.

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:

As states race to expand Medicaid, AHIP study reaffirms the program's value

The effectiveness of Medicaid, as compared to private insurance, has long been a matter of debate, but in recent years conservative critics have not-so-quietly suggested that the program provides no improvement to beneficiaries' health whatsoever.

Fierce Healthcare

Thursday, November 15, 2018

More leeway for states to expand inpatient mental health

The Trump administration Tuesday allowed states to provide more inpatient treatment for people with serious mental illness by tapping Medicaid, a potentially far-reaching move to address issues from homelessness to violence.

AP News

Wednesday, November 14, 2018

With Hospitalization Losing Favor, Judges Order Outpatient Mental Health Treatment

When mental illness hijacks Margaret Rodgers’ mind, she acts out. Rodgers, 35, lives with depression and bipolar disorder. When left unchecked, the conditions drive the Alabama woman to excessive spending, crying and mania.

Kaiser Health News

Tuesday, November 13, 2018

Cigna app targets reduction of risks for expecting moms

Health insurer Cigna is launching a mobile app to connect members to its Healthy Pregnancies and Healthy Babies prenatal program.

Health Data Management

Tuesday, November 13, 2018

Veritas Capital, Elliott to buy Athenahealth for $5.7 billion

Private equity firm Veritas Capital and hedge fund Elliott Management are buying Athenahealth Inc (ATHN.O) for about $5.7 billion, the U.S. healthcare software maker said on Monday.

Reuters

Tuesday, November 13, 2018

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.

He/She Said | Doctor Said

by Clive Riddle, November 9, 2018

The AAFP (American Academy of Family Physicians) has highlighted a new Harris Poll survey - commissioned by the Samueli Integrative Health Programs  - that shows "there are considerable gaps between what primary care physicians (PCPs) discuss with their patients and what patients would like to discuss with their physician." In particular, the concern raised from the survey seems to be that this communication gap is an impediment to SDOH (social determinants of health) goals.

AAFP reports that "although 74 percent of adults said they typically had discussions about physical health with their physician -- and more than 50 percent had discussions about test results, medications and exercise -- discussions about other key factors, including issues related to social determinants of health, were reported by less than half of respondents."

AAFP elaborates that "Fifty-two percent of adults said they and their physician didn't discuss much more than medical needs, such as physical symptoms, test results, medications and surgical history. Conversely, 53 percent of adults wished their physician would talk to them about nonmedical therapies such as nutrition, acupuncture, massage therapy and meditation, and 45 percent of adults said they wished they and their physician talked more about why they want to be healthy."

Here's some more details:

• 42% had discussions about the patient's diet
• 40% had discussions on sleep
• 36% had discussions about the patient's mental health
• 20% discussed why it is personally important to the patient to be healthy
• 13% discussed the patient's personal environment
• 11% discussed what brings the patient joy and happiness
• 10% had discussions about the patient's spiritual health

Wayne Jonas, M.D., the executive director of Samueli Integrative Health Programs, comments on the communication gap, stating "Part of the disconnect stems from how doctors are trained. Medical training sharply limits the ability of physicians to make healing their primary mission, and the current model of care does not allow for much time to capture the personal, social, behavioral and environmental factors that contribute to most chronic diseases. Unfortunately, patients will often defer to their doctor about what is discussed during their appointment, so if it's not brought up by their doctor, they may not be likely to mention it."

Another study published this month in JMIR mHealth and uHealth might offer hope for improvement in patient-physician communication in the form of mHealth.  The study: Simulated Clinical Encounters Using Patient-Operated mHealth: Experimental Study to Investigate Patient-Provider Communication was designed to examine “how personal mobile technology, under patient control, can be used to improve patient-provider communication about the patient’s health care during their first visit to a provider.”

The study found that “Overall, encounter and task times averaged slightly faster in almost every instance for the treatment group than that in the control group. Common ground clearly was better in the treatment group, indicating that the idea of designing for the secondary UX to improve provider outcomes has merit.”

But the age of technology advancing mHealth also has brought the avalanche of available medical information to patients. Combined with increased availability of direct-to-consumer medical products and services that empower patients to have greater autonomy in their healthcare, resulting challenges emerge in patient-physician communication.

The challenges are addressed in a JAMA article published last month: The New Age of Patient Autonomy - Implications for the Patient-Physician Relationship. The authors state that “expanded access to information and to a variety of health-related products and services will bring new opportunities for patients to direct their own health care. It will also bring new challenges for physicians who must manage the downstream consequences of tests and screens they did not order. Most important, the new age of patient autonomy will necessitate that physicians reconceptualize their role in the patient-physician relationship.

The authors conclude that in this new age of autonomy, physicians may need to act in the following three capacities: 

1. "Physicians will serve as consultants or advisors to patients who will increasingly direct their own care."
2. "Physicians will continue to perform diagnostic and therapeutic procedures that patients are not able to carry out."
3. "Although physicians will still be the gatekeepers of many medical resources, the function of gatekeeping will change. The availability of DTC products and services has pushed physicians gatekeeping back a level."

Searching for the Key to the New Front Door to Healthcare

By Clive Riddle, November 2, 2018

Oliver Wyman’s just released 2018 consumer healthcare survey report: Waiting for Consumers, appropriately includes a picture of a door on its cover, as the headline on the second page of narrative reads “The New Front Door, Try It, You’ll Like It.” The report concludes that “those who have tried alternative forms of healthcare delivery are happy with them” and “despite that finding, there hasn’t been much change in the number of consumers – about 10 percent – who have actually used the new front door, though the number who say they are willing to try is rising sharply.”

A very meaningful insight, no doubt – but I got stuck at the new front door. What rock have I been hiding under (a large one evidently) that I haven’t been fully immersed in discussion of healthcare’s new front door? I like doors. I like new things. I would very much would have liked to have been in on hearing all about healthcare’s new front door back when discussing the door was still new, and not evidently, when everyone who is anyone has been talking about the new front door for some time.

So I set out to find out all about healthcare’s new front door, and what awaits behind it. The Oliver Wyman report enlightened me that the door is constructed of retail clinics and telehealth, but not enough people are walking through it yet, although many are thinking about taking the plunge. They state “what has changed since our last survey is consumer willingness to try new kinds of health services. For example as shown in Exhibit 3, almost 40 percent of consumers in our 2018 survey said they would be comfortable receiving treatment for minor medical issues through a retail clinic, and 35 percent of consumers would receive that care through telehealth – in both casesan increase of 12 percentage points since 2015 when we asked consumers this same question.”

So clearly Oliver Wyman has been working with this door for several years. I wanted to find out more. Two seconds later, my first google search yielded their March 2016 report entitled The New Front Door to Healthcare is Here, which tells us: “over the past few years, there has been much discussion about the need for a ‘new front door to healthcare.’ In general, this refers to moving certain types of care out of the emergency room and doctor’s office and delivering it through more convenient means, such as a retail clinic, urgent care center, or telehealth.” 

So now we know about the old front door being replaced. In particular, the emergency room has borne that label for considerable time. That old front door can be expensive, and take a heck of a lot of time to get through.

The 2016 Oliver Wyman report goes on to say that “The ‘new front door’ is not about replicating today’s healthcare system in a more convenient setting. Instead, the new front door is about bolstering today’s healthcare system with a variety of consumer-friendly access points. The new front door is multi-dimensional (urgent care centers, retail health clinics, telehealth consultations, mobile apps). It is very clear that individually, none of these can deliver the full promise of the new front door. In fact, if offered as individual point solutions, consumer experience, health outcomes, and cost could suffer. An integrated new front door strategy, however, holds tremendous promise for consumers, payers, providers, and retailers alike.” Oliver Wyman had knocked on the door in previous years as well, such as this July 2015 piece: How Healthcare's New Front Door is Opening Up Opportunities.

But after leaving their thoughtful reports, I encountered a number of doors, like a contestant on the old Let’s Make a Deal Show:

1. CEOs of CVS Health, Aetna say merger will offer new front door to healthcare
2. Could Alexa Become the New Front Door to Healthcare?
3. By Opening a Front Door to Care, Telehealth Will Finally (Finally) Take Off

Then as I pondered which door to choose, I learned the front door might be from those sci-fi or paranormal films, where it shifts all around while you attempt to enter it, as I was told How Healthcare Leaders Adapt to the Evolving Front Door to Care.

Which finally led me to read that Patients might need map to find 'front door' to health care, as the story asks “what and where is the real "new front door to health care in America?"

I will continue my quest searching for the key.

Two Reports on Cost Driven Deferred Medical Care

By Clive Riddle

Two reports were published this week on deferred medical care driven by cost considerations, based on survey findings. Earnin’s report: Waiting to Feel Better: Survey Reveals Cost Delays Timely Care is based on two surveys – a commissioned online Harris Poll among over 2,000 U.S. adults and an Earnin poll of their users, “many of which live paycheck to paycheck.” AccessOne’s report: AccessOne Patient Finance Survey- Analysis on how healthcare costs impact is based on a survey conducted by ORC International of 693 people with at least $35,000 in annual household income, weighted by age, sex, geographic region, race and education.

Earnin tells that 54% of Americans “have delayed medical care for themselves in the past 12 months because they could not afford it, “ with the top three most delayed types of care being dental/orthodontic work (55%), eye care (43%), and annual exams (30%.) Earnin reports that “23 percen) have put off getting medical care for more than one year because they could not afford it. Among those whose household is living paycheck to paycheck or not making enough to get by, the rate of this extremely delayed care averages 36 percent. Nearly half of Americans (49 percent) say their health tends to take a back seat to other financial obligations.”

AccessOne reports that “Twenty-seven percent of households with children are likely to delay care because they can’t afford to pay for it.” Focusing on the dollar amounts involved and financing issues, they tell us that

• 21% of families who had trouble paying their medical bill reported that their accounts had been sent to collections.
• More than half of respondents were concerned about their ability to pay a medical bill of less than $1,000; with 35 percent being concerned about paying a bill that totals less than $500 – 20 times less than the average healthcare balance of a person in the U.S.
• Only 21 percent of respondents said their healthcare providers have spoken to them about available patient financing options in the past two years.
• Fifty-five percent of those surveyed said they prefer to discuss healthcare costs and financing options before care of service is delivered.
• Fifty-four percent of those surveyed said they would use a no-interest financing option for a balance of $1,000 or less, and 57 percent said availability of a no-interest finance option is important or very important in evaluating a provider.

So if the AccessOne report implications bear out that improving financing options up front will reduce deferred medical care, the question is, will our younger generations that have had to assume much greater overall burden of college debt, also assume a growing burden of medical debt?

Friday Five: Top 5 healtcare 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:

Health secretary warns pharma: Administration will push ahead with drug pricing reforms

Health and Human Services Secretary Alex Azar said Friday he would push ahead with drug pricing reforms despite pushback from the pharmaceutical industry.

The Hill

Friday, October 26, 2018

Trump Aims To Lower Some U.S. Drug Spending By Factoring In What Other Countries Pay

The Trump administration says it plans to change how Medicare pays for some expensive drugs for cancer and arthritis in a move to bring the costs more in line with the prices paid in European countries.

NPR

Thursday, October 25, 2018

U.S. 'turning the tide' on the opioid crisis, health secretary says

The U.S. is "beginning to turn the tide" on the opioid epidemic, HHS Secretary Alex Azar said Tuesday, pointing to new federal data showing a slight dip in overdose deaths last year.

Politico

Wednesday, October 24, 2018

CMS Broadens ACA Waiver Scope for State Insurance Programs

CMS has issued federal guidance intended to expand the scope and availability of state-level waiver programs.

HealthPayer Intelligence

Tuesday, October 23, 2018

Medicaid expansion becomes key issue in GOP-leaning states

It’s helped them win every statewide office, control the Legislature and hold all the state’s congressional seats. So it was something of a surprise for Bob Tatum when he set out to ask his fellow Nebraskans if they would back a ballot initiative to expand Medicaid, one of the pillars of Obama’s health overhaul.

Associated Press

Monday, October 22, 2018

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.

Three Questions for Gary Word, Ph.D., Vice President, Network and Payment Solutions, Change Healthcare: Post-Webinar Interview

Recently, Gary Word, Ph.D., Vice President, Network and Payment Solutions, Change Healthcare, participated in a Healthcare Web Summit webinar discussion on Ways to Leverage Financial Tools to Optimize Digital Member Engagement. If you missed this informative webinar presentation, watch the On-Demand version here. After the webinar, we interviewed Gary on key takeaways from the webinar:

1. How is the paradigm shifting for consumer healthcare payments?

Gary Word: Several factors are contributing to this shift. First, adoption of high-deductible health plans has increased for both sponsored plans and especially for individual health plans. This means that consumers, more than ever, bear a higher financial responsibility for their healthcare – both in terms of paying higher insurance premiums, as well as paying a larger share of their healthcare costs. Because of these factors, there is an increase in people becoming active consumers and shoppers. In this way, healthcare payers and providers have entered an era of consumerism. Payers and providers need to attract and retain consumers, partly by providing tools that facilitate a smooth healthcare payment experience. In the digital consumer era, this means that payers that offer digital tools are more likely to retain a member.  Providers are also expected to improve the consumer user experience to ease the historically complex exercise of understanding healthcare finances.

2. How is the change in consumer payment responsibility having an impact on provider financials?

Gary Word: With the increase in high-deductible health plans, consumers are responsible for a much larger portion of healthcare expenses. The collection of these obligations is of increasing importance for providers. The billing process has also become more complex, with a single hospital visit sometimes resulting in the consumer receiving many bills, some from providers they didn’t even know provided them with healthcare services. We know there is a direct correlation between satisfaction in the billing process and whether or not the consumer will pay his or her bill in full and in a timely manner, or even return to the provider for future service. Conversely, a consumer that is satisfied with their healthcare billing experience is more likely pay their obligation in full and more likely to return to the provider.

3. Tell us more about how the Change Healthcare solution is supporting Aetna’s mission to improve member engagement and experience?

Gary Word: The payer is in a unique position to facilitate payment across all providers a member sees from a centralized location. Our consumer surveys indicate that payers are typically a trusted resource to verify financial obligations because the information the payer includes in the explanation of benefits is what the consumer trusts to be the correct patient responsibility. By offering a centralized payment option for the consumer, a payer enhances relations and satisfaction with both providers and consumers by facilitating collections and payments, while also earning additional opportunities to engage with their membership. It’s a win-win-win situation. 

Aetna has partnered with Change Healthcare to enable processed claims to effectively serve as a patient statement proxy and allow the member to easily pay their providers for their patient responsibility within the Aetna member application. Upon reviewing the claim detail and seeing the patient responsibility, the consumer is offered the ability to make a payment right then and there. Aetna and Change Healthcare then work together to process the payment and send the funds to the provider. The ease of payments increases the likelihood that the member will turn again to Aetna to make future payments.  Aetna will then be able to engage with the member and provide targeted messages – such as for wellness initiatives or broader communications. Additionally, these digital tools are easing the member’s burden and stress associated with healthcare financial management by providing insights into expenditures to aid consumers with planning and management of costs, allowing Aetna to focus on the total healthcare of their membership. 

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:

Health Care Tops Guns, Economy As Voters’ Top Issue

Health care has emerged as the top issue for voters headed into the midterm elections, but fewer than half of them say they are hearing a lot from candidates on the issue, according to a new poll released Thursday.

Kaiser Health News

Thursday, October 18, 2018

Trump: All Republicans will support people with pre-existing conditions 'after I speak to them'

President Trump tweeted Thursday that “all Republicans support people with pre-existing conditions, and if they don’t, they will after I speak to them.”

The Hill

Thursday, October 18, 2018

What will CVS-Aetna mega-merger mean for consumer choice

It's the latest merger between two major healthcare players that could affect tens of millions of Americans. Last week, CVS and insurance giant Aetna finalized a nearly $70 billion merger. The deal could impact where people get their care, how they get their drugs and how much choice they have. Judy Woodruff discusses with Larry Merlo, CEO of CVS Health.

PBS News

Tuesday, October 16, 2018

Insurer Anthem will pay record $16M for massive data breach

The nation’s second-largest health insurer has agreed to pay the government a record $16 million to settle potential privacy violations in the biggest known health care hack in U.S. history, officials said Monday.

AP News

Tuesday, October 16, 2018

Medicare Advantage Riding High As New Insurers Flock To Sell To Seniors

Health care experts widely expected the Affordable Care Act to hobble Medicare Advantage, the government-funded private health plans that millions of seniors have chosen as an alternative to original Medicare.

KFF

Monday, October 15, 2018

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.

Imagining the Future Us

By Kim Bellard, October 17, 2018

One of the most thought-provoking articles I've read lately is Tom Vanderbilt's Why Futurism Has a Cultural Blindspot in Nautilus.   In it, he discusses how our technological visions of the future seem to do much better on predicting the technology of that future than they do the culture in which they will be used. 

As he says, “But when it comes to culture we tend to believe not that the future will be very different than the present day, but that it will be roughly the same. Try to imagine yourself at some future date.... Chances are, that person resembles you now.” We need to keep this in mind when thinking about the future of healthcare: not just the nifty new technologies we'll have, but who and how we expect to use them. 

All too often, especially in healthcare, we develop technology to solve incremental issues, not foundational ones.  All too often, especially in healthcare, we develop technology and then try to fit it into our existing culture, rather than imagining the culture we want and developing technologies to help achieve it.

It's not so hard to imagine how technology will change what health care is likely to look like in the not-so-distant future. But, like imagining that "office of the future" in the 1960's, what will the healthcare system in which they are used look like? 

Here are some open questions about the culture in which all these cool technologies will be used. Will we live in a culture:

• that accepts health problems becoming financial disasters for some people?
• in which poor people can expect to get less care, to be less healthy, and to live less long?
• in which where you live dictates how well and how long you live, and the quality and quantity of care you receive?
• that treats social determinants of health and public health as secondary considerations?
• that treats health as primarily a medical concern, with too many people delegating responsibility for their health to their healthcare professionals and expecting some kind of medical interventions to deal with any health problems?
• that expects "treatment at any cost for any chance," especially for terminal issues? 
• that treats services like dental, vision, or "custodial" care as step-children?
• with an ever-growing array of medical experts? 
• that treats medical expertise as primarily a local/state-level issue, rather than a   national/international  one?  

If the healthcare system of the future looks pretty much like the healthcare system of today, just with more and better tech, we will have failed.  And probably be broke. 

We need a different culture for health, and that culture needs new designs.  Marcus Engman, the former head of design for Ikea, told FastCompany:  “I want to show there’s an alternative to marketing, which is actually design.  And if you work with design and communications in the right way, that would be the best kind of marketing, without buying media.”

I read that and I think "healthcare."  Substitute "health care" for "marketing" in Mr. Engman's quote and we start to get to what Steve Downs calls Building Health into the OS -- that is, designing to make health an integral part of our daily lives.  That's design.  That's a culture change.

We have a culture of health care -- or, more accurately, of medical care -- rather than a culture of health.  Technology can exacerbate this, or help change it.  It's up to us to imagine the future in which we're most likely to be healthy.

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

The State of BPCI

by Clive Riddle, October 12, 2018

CMS announced that “1,299 entities have signed agreements with the agency to participate in the Administration’s Bundled Payments for Care Improvement – Advanced (BPCI Advanced) Model.  The participating entities will receive bundled payments for certain episodes of care as an alternative to fee-for-service payments that reward only the volume of care delivered. The Model participants include 832 Acute Care Hospitals and 715 Physician Group Practices – a total of 1,547 Medicare providers and suppliers, located in 49 states plus Washington, D.C. and Puerto Rico.”

CMS also reminds us that “BPCI Advanced qualifies as an Advanced Alternative Payment Model (Advanced APM) under MACRA, so participating providers can be exempted from the reporting requirements associated with the Merit-Based Incentive Payment System (MIPS).”

CMS further explains these three differences between the new BPCI Advanced Model and the original BPCI Initiative that ended September 30, 2018:

1. BPCI Advanced offers bundled payments for additional clinical episodes beyond those that were included in BPCI, including – for the first time – outpatient episodes.
2. BPCI Advanced provides participants with preliminary target prices before the start of each model year to allow for more effective planning. The target prices are the amount CMS will pay for episodes of care under the model.
3. BPCI Advanced qualifies as an Advanced APM.  Participating clinicians assume risk for patients’ healthcare costs and also meet other requirements including meeting quality thresholds, potentially qualifying them for incentive payments and exempting them from the MIPS program.

CMS has released results of its evaluation of the original BPCI Initiative, Models 2-4 for Years 1 -3 (through 12/31/2016.) CMS notes that “Model 2 episodes begin with a hospital admission and extend for up to 90 days; Model 3 episodes begin with the initiation of post acute care following a hospital admission and extend for up to 90 days; and Model 4 episodes begin with a hospital admission and continue for 30 days. The BPCI initiative rewards participants in Models 2 and 3 financially through reconciliation payments for reducing Medicare payments for an episode of care relative to a target price. Alternatively, when episode payments are higher than the target price, Awardees may have to pay amounts to CMS. Under Model 4, Medicare makes a prospective payment for the episode, so Awardees keep the difference if their costs are below the prospective payment.”

Of all participants, 22% of Model 2, 33% of Model 3, and 78% of Model 4 participants withdrew from the initiative.

CMS evaluation is based on the 169-page study just released by the Lewin Group: CMS Bundled Payments for Care Improvement Initiative Models 2­4: Year 5 Evaluation &  Monitoring Annual Report. Their findings included:

• While BPCI was associated with a decline in episode payments, after considering the reconciliation payments made to participants, BPCI did not result in savings to the Medicare program.
• Across the 67 Model- participant- and clinical episode-combinations analyzed in this report, payments declined for 50 and the change was statistically significant for 27.
• The average Model 2 episode initiator (EI) participated in eight clinical episodes, and the most commonly selected clinical episode was MJRLE. BPCI Model 2 accounted for nearly 90% of the approximately 796,000 episodes initiated during the first 13 quarters of the initiative.
• Episode volume was lower than in Model 2. Skilled nursing facility (SNF) EIs were most likely to participate in MJRLE, where they initiated over 9,600 episodes during the first 13 quarters of the initiative. Congestive heart failure (CHF) had the greatest enrollment of home health agency (HHA) EIs and the largest patient volume, exceeding 4,800 episodes during the same period.
• Participation in Model 4 continued to wane in the third year of the initiative. Only five hospitals participated in Model 4 in 2017 and another three Model 4 hospitals transitioned to Model 2 rather than withdraw entirely from the initiative. At the peak of enrollment, 23 episode-initiating hospitals participated in Model 4. A total of 13,551 episodes, primarily for MJRLE, were initiated under the Model through December 2016.