Friday Fve: 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:

Premiums for popular ACA health insurance dip for the first time

The average price tag for the most popular level of insurance sold in the Affordable Care Act’s federal marketplaces is dropping slightly, the first time the rates have stopped going up since the health plans were created a half-dozen years ago.

Washington Post

Friday, October 12, 2018

Prescriptions for Millions of Opioid Pills Lead to Charges Against 5 Doctors

It was not hard to tell when the doctor was in at the Staten Island office of Carl Anderson. Noisy crowds of people, some with visible signs of drug addiction, stood in long lines at all hours of the night, seeking prescriptions for oxycodone pills, the authorities said Thursday.

The New York Times

Thursday, October 11, 2018

CVS Health and Aetna $69 Billion Merger Is Approved With Conditions

The Justice Department’s approval of the $69 billion merger between CVS Health and Aetna on Wednesday caps a wave of consolidation among giant health care players that could leave American consumers with less control over their medical care and prescription drugs.

The New York Times

Wednesday, October 10, 2018

Trapped by the ‘Walmart of Heroin’

The first time Mark shot up “Philly dope” was in the summer of 2017, with his girlfriend, Sarah. They had been on their way from Massachusetts to South Carolina, hoping to get clean there and find someplace cheap to live. The plan was to detox slowly on the way. In New Jersey, they needed to buy more drugs, just enough to make it to Myrtle Beach.

The New York Times

Wednesday, October 10, 2018

Cross-market hospital mergers continue despite rising regulatory scrutiny

The proposed tie-up between Dallas-based Baylor Scott & White Health and Houston-based Memorial Hermann Health System poses an increasingly important antitrust question given the prevalence of cross-market hospital mergers, regulatory experts said.

Modern healthcare

Monday, October 8, 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.

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

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

Congress OKs opioid legislation in show of bipartisanship

Setting aside the Supreme Court fight, members of Congress this week approved bipartisan legislation aimed at curbing the devastating opioid addiction across the country.

The Associated Press

Thursday, October 4, 2018

GOP senators scrutinize CBO's new health insurance simulation model

Republicans on the Senate Budget Committee have pressed the Congressional Budget Office to release details of the forthcoming new health insurance simulation model.

Modern Healthcare

Thursday, October 4, 2018

Premiums see moderate increase in 2018 for employer plans

Premiums for individuals and families enrolled in employer plans increased moderately in 2018, but more workers are paying higher deductibles, according to a new survey released Wednesday.

The Hill

Wednesday, October 3, 2018

Despite Patient Privacy Risks, More People Use Wearables for Health

Despite the patient privacy risks that collecting health data on insecure wearable devices could pose, the number of US consumers tracking their health data with wearables has more than doubled since 2013, according to the Deloitte 2018 Survey of US Health Care Consumers.

Health IT Security

Wednesday, October 3, 2018

Pfizer CEO to step down at end of year

Pfizer CEO Ian Read will step down at the end of the year after eight years of leading the pharmaceutical giant. Albert Bourla, Pfizer's current chief operating officer, will succeed Read on Jan. 1.

The Hill

Monday, October 1, 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.

Eighteen Things to Know from the 2018 KFF Employer Benefits Survey

By Clive Riddle, October 4, 2018

The Kaiser Family Foundation 2018 Employer Benefit Survey, an annual 200+ page definitive report of the state of employer health benefits since 1999, includes these eighteen things to know that KFF highlights:

1.  On average, employees are contributing $5,547 toward the cost of family coverage, with employers paying the rest.
2. Annual premiums for single coverage increased 3 percent to $6,896 this year, with employees contributing an average of $1,186.
3. This year’s premium increases are comparable to the rise in employees’ wages (2.6%) and inflation (2.5%) during the same period. 
4. Since 2008, average family premiums have increased 55 percent, twice as fast as employees’ earnings (26%) and three times as fast as inflation (17%).
5. Currently 85% of covered employees have a deductible in their plan, up from 81% last year and 59% a decade ago. 
6. The average single deductible now stands at $1,573 for those employees who have one, similar to last year’s $1,505 average but up sharply from $735 in 2008. 
7. 26% of covered employees are now in plans with a deductible of at least $2,000, up from 22% last year and 15% five years ago. 
8. Among covered employees at small firms (fewer than 200 employees), 42 percent face a deductible of at least $2,000.
9. 57% of employers offer health benefits, the same as five years ago. 
10. Some employers that offer health benefits provide financial incentives to employees who don’t enroll – either for enrolling in a spouse’s plan (13%) or otherwise opting out (16%).
11. Overall 10% of all offering firms – and 24% of large ones – expect fewer employees and dependents to enroll because of the elimination of the ACA tax penalty.
12. 21% of large firms report they collect some information from employees’ mobile apps or wearable devices as part of their wellness or health promotion programs (14% last year.)
13. Most large offering employers (70%) provide employees with opportunities to complete health risk assessments.
14. 38% of large offering firms provide incentives for employees to participate in wellness programs.
15. 29% of firms that offer health benefits offer a high-deductible health plan with a savings option. 
16. 61% of firms offering HDHPs only this type of plan to at least some of their employees. Overall, 29% of covered employees are enrolled in such plans.
17. 74% of large firms (200+ employees) cover services provided through telemedicine, up from 63% last year and 27% in 2015. 
18. 76% of large firms cover services received in retail clinics.

NCQA Health Plan Ratings: What About the 25% With No Rating?

By Clive Riddle, September 28, 2018

NCQA has released its 2018-2019 Health Insurance Plan Ratings. The ratings are a key tool used by stakeholders in evaluating health plans. NCQA tells us they “studied nearly 1,500 health plans and rated 1,040: 445 private (commercial), 418 Medicare and 177 Medicaid” and that “of the 1,040 rated plans, 85 (8%) received a top rating of 4.5 or 5.0 out of 5. Twenty-five (2%) earned the ratings of 1.0 to 2.0.”

The ratings website is searchable by plan type, state, or plan name and can be sorted by ratings (rated on a scale of 1.0 to 5.0). What isn’t readily available is a summary of the number of plans by each rating category, so we compiled one:

What struck us was the 25% of plans studied that aren’t rated. If you’re a plan that likely would get a rating below 3.0, wouldn’t you be motivated to avoid being rated at all? So let’s look at the ratings methodology.  Here’s a summary of NCQA health plan rating methodology, provided by NCQA: 

“Health plans are rated in three categories: private plans in which people enroll through work or on their own; plans that serve Medicare beneficiaries in the Medicare Advantage program (not supplemental plans); and plans that serve Medicaid beneficiaries. This year’s ratings do not include Marketplace plans because they have not developed sufficient data for analysis. NCQA ratings are based on three types of quality measures: measures of clinical quality from NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS®2); measures of consumer satisfaction using Consumer Assessment of Healthcare Providers and Systems (CAHPS®3); and results from NCQA’s review of a health plan’s health quality processes (performance on NCQA Accreditation standards). NCQA rates health plans that report quality information publicly.”

NCQA provides this explanation of plans listed as having partial data:

“Plans with partial data do not receive a rating, but NCQA lists them in the ratings and shows their scores on the measures they report. A plan is considered to have partial data if it: Submits HEDIS and CAHPS measure data for public reporting, but has “missing values” (i.e., NA or NB) in more than 50 percent of the weight of measures used in the methodology. Plans that fall into this category receive an overall rating status of “Partial Data Reported” and their measure rates are displayed as “NC” (No Credit). Refer to HEDIS Volume 2: Technical Specifications for information about missing values. Submits HEDIS data for public reporting but does not submit CAHPS data, or vice versa. Plans that fall into this category receive an overall rating status of “Partial Data Reported” and their measure rates for the dataset they did not submit are displayed as “NC” (No Credit).  Earned NCQA Accreditation without HEDIS data (health plan accreditation standards only) and did not submit HEDIS or CAHPS data for public reporting. Plans that fall into this category receive an overall rating status of “Partial Data Reported” and their measure rates are displayed as “NC” (No Credit).”

NCQA provides this explanation of plans listed as having no data reported:

“Plans that submit results but do not report data publicly, or plans that report no HEDIS, CAHPS or accreditation information to NCQA, are given a rating status of “No Data Reported” and their measure rates are displayed as “NC” (No Credit). Plans that fall into this category and have fewer than 8,000 members are omitted—they are not rated and are not listed in displays related to ratings.”

Based on these explanations, there are plans that legitimately should not be rated. But some of these aren’t included in the above numbers of plans with partial or no data, such as plans with fewer than 8,000 members with no data reported, or Marketplace plans with not enough data history.

But what about the rest? Could there be plans that avoid full data reporting to avoid potentially low ratings? Certainly the small numbers of plans publicly singled out with 2.0 or lower ratings come across looking far worse that the large number of plans listed with partial data or no data reported.

Perhaps NCQA should come up with a way to make the listings of applicable partial or no data reported plans perceived in a more negative manner?

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

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

Trump health chief: Premiums to drop for popular ACA plan

Premiums for a popular type of “silver” health plan under the Affordable Care Act will edge downward next year in most states, the Trump administration’s health chief announced Thursday.

AP News

Friday, September 28, 2018

Aetna sells Medicare drug business, clearing way for $69 billion CVS merger

Health insurer Aetna Inc. said Thursday that it plans to sell its Medicare prescription drug plan business to WellCare Health Plans Inc., according to a filing with the Securities and Exchange Commission (SEC).

The Hill

Thursday, September 27, 2018

Trump administration defends Medicaid work requirements

A top health official in the Trump administration defended Medicaid work requirements Thursday, arguing that its intent isn't to expel people from the program.

The Hill

Thursday, September 27, 2018

31% of Beneficiaries Face Social Isolation, More Health Risks

A new survey of Humana’s commercial population has found that almost one-third of members over 65 years old experience social isolation. The survey reveals that payers could benefit by addressing social isolation among their elderly members because reducing loneliness enhances member satisfaction as well as overall health.

HealthPayer Intelligence

Tuesday, September 25, 2018

Major healthcare groups question Medicare ACO proposal

MSSP has been under a spotlight lately with the proposed changes. Reports have shown savings, but not necessarily as much as initially expected. The regulatory push toward more risk reflects a desire for providers to commit to value-based contracting despite the potential for financial loss.

Healthcare Dive

Monday, September 24, 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.

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 Try To Rein In Drug Spending, Feds Slap Down One Bold Medicaid Move

States serve as “laboratories of democracy,” as U.S. Supreme Court Justice Louis Brandeis famously said. And states are also labs for health policy, launching all kinds of experiments lately to temper spending on pharmaceuticals.

Kaiser Health News

Friday, September 21, 2018

Despite Red Flags At Surgery Centers, Overseers Award Gold Seals

At his surgery center near San Diego, Rodney Davis wore scrubs, was referred to as “Dr. Rod” and carried the title of director of surgery. But he was a physician assistant, not a doctor, who anesthetized patients and performed liposuction with little input from his supervising doctor, court records show.

Kaiser Health News

Thursday, September 20, 2018

Time Helps Accountable Care Organizations Realize Savings in MSSP

Experience is a key factor to realizing greater cost savings in the Medicare Shared Savings Program (MSSP), a new Avalere analysis found.

RevCycle Intelligence

Thursday, September 20, 2018

Does investing in pop health and social determinants work? New study finds link to lower Medicare spending

Proponents and skeptics not convinced that investing in population-level interventions and social determinants of health, take note: New research finds that the overall well-being of a population on a county level is associated with lower healthcare spending for each Medicare fee-for-service beneficiary.

Healthcare Finance News

Wednesday, September 19, 2018

Cigna deal gets antitrust nod, positive sign for CVS/Aetna

Health insurer Cigna Corp’s (CI.N) $52 billion acquisition of pharmacy benefits manager Express Scripts Holding Co has passed U.S. antitrust scrutiny, the companies said on Monday, allowing them to proceed with a combination they say will lead to lower costs by better coordinating pharmacy and medical benefits.

Reuters

Tuesday, September 18, 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.

In China, It’s the 21st Century

by Kim Bellard, September 21, 2018

It is 2018 everywhere, but not every country is treating being in the 21st century equally. China is rushing into it, even in healthcare, while the United States is tip-toeing its way towards the future. Especially in healthcare: Let’s look at a few examples:

5G: You may just be getting used to 4G, but 5G is right around the corner, with U.S. carriers expected to start offering networks in a few cities by the end of this year. Meanwhile, China has committed to having national 5G coverage by 2020, and the government is working closely with its private sector to spur development. U.S. wireless trade association CTIA believes China is leading the 5G race. Deloitte agrees; in a recent report, they cite reasons why China is leading, and warn that countries that adopt 5G first “are expected to experience disproportionate and compounding gains in macroeconomic benefits caused by “network effect.”’

Artificial Intelligence: Yes, the U.S. has been the leader in A.I., with some of the leading universities and tech companies working on it. That may not be enough. A year ago China announced that it intended to be the world leader in A.I. by 2025. China is far outspending the U.S. on A.I. research and infrastructure, coordinating efforts between government, research institutes, universities, and private companies. Dr. Steven White, a professor at China’s Tsinghua University, “likens the country’s succeed at all costs AI program to Russia’s Sputnik moment.” We have yet to have that wake-up call.

Quantum computing: Don’t worry if you don’t understand quantum computing; no one does. What matters is that quantum computing is literally a quantum leap above what current computing, so the first to deploy it will have unimaginable advantages. Take a guess what country is leading. Paul Stimers, the founder of the U.S. Quantum Industry Coalition, told CNN: “They [China] have a quantum satellite no one else has done, a communications network no one else has done, and workforce development program to bring new Chinese quantum engineers online. You start to say, that’s worrisome.”

Genetic research: The U.S. has been the leader in genetic research, but — you guessed it — that lead has been rapidly diminishing. Earlier this year, Eric Green, the head of the National Human Genome Research Institute told Asia Times: I do know that if you look in the last 15 years, the investment in genomics, in particular, have been more substantial in countries like China, South Korea, Singapore, and even places like Brazil. For example, the U.S. is still doing research on techniques like CRISPR, but The Wall Street Journal found that China is “racing ahead” in gene editing trials, in large part due to a more relaxed attitude towards regulation and possible ethical considerations.

When it comes to healthcare, China recognizes shortcomings of its existing system, and is rapidly trying to deploy 21st century solutions to it. China adopted a universal healthcare system in 2011 (about the same time the U.S. adopted ACA.)

Last year Fortune reported on China’s healthcare “boom,” spurred in part due to direct government investments and favorable regulatory processes. Similarly, earlier this year The New York Times noted U.S. tech companies’ interest in healthcare, but pointed out that their Chinese counterparts had already jumped in.

I don’t want to live in China, nor would I want to get my health care there. Yet. But if we don’t soon have our own “Sputnik moment” (or moments), we’re going to see the 21st century of healthcare happen in China, not here.

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

Post ACA Operating Margins: Health Systems and Health Plans

By Clive Riddle, September 14, 2018

Navigant this week released an eight-page report: Stiffening Headwinds Challenge Health Systems to Grow Smarter, that provides “an analysis of a three-year sample of the financial disclosures of 104 prominent health systems operating 47% of U.S. hospitals,” in which Navigant  “found broad-based and significant deterioration of operating earnings.”

Navigant reports that from 2015 to 2017:

• The average operating margin decline for analyzed systems was 38.7%. Not-for-profit system margins fell 34%, while for-profit margins fell 39%.
• 65% of systems experienced operating income declines totaling $6.8 billion, with the most significant reductions occurring in the U.S.’s fastest-growing regions: West/Southwest and South Central.
• At the root of these declines were multiyear reductions in the rate of topline operating revenue growth, which fell from 7% (2015 to 2016) to only 5.5% (2016 to 2017), and a failure to contain expenses in line with revenue deterioration. 

Navigant cites these drivers of earnings deterioration:

1. Weakening demand for such core hospital services as surgery and inpatient admissions, due in part to rising patient cost exposure from high-deductible health plans;
2. Deteriorating collection rates for private accounts in non-ACA expansion states;
3. Steady erosion in Medicare payment rates due to the ACA and the 2012 federal budget sequester; and
4. Failure of health system value-based insurance contracts to deliver sufficient patient volume to offset steep upfront payer discounts and significant hospital population health investments.

Meanwhile on the other side of the post-ACA equation, Mark Farrah Associates this week “released an analysis brief providing insights into mid-year profitability for commercial and government lines of health insurance business. MFA compared second quarter, year-over-year profitability for the Individual, Employer-Group, Medicare and managed Medicaid segments.”

They found that:

• At the end of second quarter 2018, the average medical expense ratio for the Individual segment was 70.8%, as compared to 77.2% the previous year.
• Growth in premiums pushed the average medical expense ratio for the Employer-Group segment down to 80.9% for 2Q18 from 81.8% in 2Q17.
• For Medicare Advantage, premium growth outpaced increases in medical expenses pushing the medical expense ratio down to 85.3% from 86.1% in 2Q17.
• 2.9% increase in premiums per member per month pushed the medical expense ratio for Managed Medicaid down to 88.6% from 91.0% in 2Q17.

Mark Farrah Associates concludes the current outlook is better than the one Navigant finds for health systems: “At the mid-year point, all four health care segments are signifying improved profitability for health insurers over 2017.  The most significant change is once again in the Individual segment showing improvement over 2017, which ended up being a profitable year for the segment overall.  While this analysis of mid-year segment performance sheds light upon profitability trends for 2018, it’s a wait and see proposition until final financial results are revealed in spring of 2019.”

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

By Claire Thayer, September 14, 2018

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:

New Medicare Advantage Tool To Control Drug Prices Could Narrow Choices

Starting next year, Medicare Advantage plans will be able to add restrictions on expensive, injectable drugs administered by doctors to treat cancer, rheumatoid arthritis, macular degeneration and other serious diseases.

NPR

Friday, September 14, 2018

Here’s the data behind the new Apple Watch EKG app

When the new Apple Watch heart monitoring app can get a reading, it can accurately detect that a person has an irregular heart rhythm known as atrial fibrillation 99 percent of the time, according to a study of the new device that Apple submitted to the Food and Drug Administration.

Stat News

Friday, September 14, 2018

Calling teen vaping 'epidemic,' officials weigh flavor ban

U.S. health officials are sounding the alarm about teenage use of e-cigarettes, calling the problem an "epidemic" and ordering manufacturers to reverse the trend or risk having their flavored vaping products pulled from the market.

ABC News

Thursday, September 13, 2018

Hospital Operating Margins Slide 39% After ACA Expansion

The three-year stretch between 2015 to 2017 saw widespread income deterioration along with declining operating margins, according to a new study.

HealthLeaders

Wednesday, September 12, 2018

ACA about-face: Insurers keeping premium increases lower than last year, RWJF and AP studies find

The Affordable Care Act market has turned around for 2019, according to two studies, and that means premiums are not increasing as much as they did in 2018.

Healthcare Finance News

Tuesday, September 11, 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.

20 Interesting Takeaways From the CMS NORC Next Generation ACO First Annual Report

By Clive Riddle, September 7, 2018

The recently released 111-page Next Generation Accountable Care Organization (NGACO) Model Evaluation First Annual Report prepared by NORC on behalf of CMS provides a treasure trove of ACO tidbits, as CMS uses the report to tout emphasizing higher risk sharing arrangements. Here’s the NGACOs examined in the report, followed by twenty selected interesting takeaways:

1. There were 18 active NGACOs in 2016, with 15 having prior Medicare ACO experience
2. These 18 NGACOs served 477,197 beneficiaries, with 31,070 network providers and 775 network facilities
3. In aggregate, NGACOs served three percent of total Medicare beneficiaries in all markets
4. On average, a 2016 NGACO served about 26,500 aligned beneficiaries (median of 24,219 beneficiaries)
5. NGACOs are associated with a 1.7% reduction in Medicare spending for aligned beneficiaries totaling $100.08 million (1.1% reduction after shared savings payment went to NGACOs)
6. The estimated gross reduction in Medicare spending with $18.20 per beneficiary per month ($11.20 reduction after $7.00 in shared savings went to NGACOs)
7. NGACOs experienced 1.7/1,000 fewer IP Hospital Days (1.3% reduction) and 20.4/1,000 more wellness visits per year (11.9% increase)
8. Standardized risk-adjusted, per capita Medicare spending in NGACO markets ($9,638) is comparable to that of non-NGACO markets ($9,519)
9. Considered geographically, many NGACOs have contiguous or overlapping markets and are concentrated in the Midwest (11 ACOs), with pockets in the Southeast (7 ACOs) and Northeast (4 ACOs)
10. Nine NGACOs are in highly concentrated markets, dominated by one or a few hospital systems 
11. NGACOs operate in markets with high Medicare Advantage and Shared Savings Program penetration rates
12. Commercial and Medicaid ACO initiatives are more likely to be located in NGACO markets
13. Eleven of the 18 2016 NGACOs were integrated delivery systems 
14. On average, physicians represented more than half of each NGACO’s governing board membership
15. Most 2016 NGACOs chose to assume 80 percent risk and the fee-for-service (FFS) payment mechanism
16. Twenty-four percent of the 2016 NGACO participating providers’ Medicare FFS revenue from paid QEM visits was generated from care provided to NGACO-aligned beneficiaries.
17. Seventy-one percent of aligned beneficiaries’ paid QEM visits were within their respective NGACO provider networks, compared with forty percent of the comparison group’s
18. All but two NGACOs had preferred providers in their networks
19. All NGACOs address end-of-life care
20. The SNF waiver was the most commonly implemented of the three NGACO model benefit enhancements

Provider Directories – What’s Next for Provider Data Exchange?

By Claire Thayer, September 5, 2018

The U.S. spends a staggering $2.1B annually across the healthcare industry chasing and maintaining provider data – and as much as 75% of this cost is duplicative. Maintaining and facilitating exchange of accurate provider data is a critical component to payers being able to operate effectively and ensure their members have access to the care they need. But a key challenge remains: inaccurate provider data.

This recent edition of the MCOL infoGraphoid, co-sponsored by LexisNexis Risk Solutions, features key concepts impacting the provider information paradigm and core elements essential for provider data exchange.

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.

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

By Claire Thayer, August 31, 2018

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:

How Modern Medicine Has Changed the Supreme Court

Two related health trends mean that each Supreme Court nomination now has the potential to shape the nation’s highest court for far longer than in the past.

The New York Times

Friday, August 31, 2018

The $109K Heart Attack Bill Is Down To $332. What About Other Surprise Bills?

A Texas hospital that charged a teacher $108,951 for care after a heart attack slashed the bill to $332.29 Thursday — but not before the huge charge sparked a national conversation over what should be done to combat surprise medical bills that afflict a growing number of Americans.

Kaiser Health News

Friday, August 31, 2018

Trade deal between U.S. and Mexico is criticized for allowing high drug prices to continue

Although details of the new trade deal between the U.S. and Mexico have not yet been released, a fight is already brewing among some drug makers and consumer advocates over one provision.

Stat News

Thursday, August 30, 2018

CFOs Expect Higher Hospital Labor Costs As Staffing Shortages Loom

About 78 percent of healthcare finance leaders expect hospital labor costs to grow in the next 12 months as the industry faces a worsening shortage of healthcare professionals, a new survey shows.

RevCycle Intelligence

Wednesday, August 29, 2018

Healthcare Ridesharing Makes Inroads in Lost Revenue

Nearly 4 million patients per year miss out on care due to lack of available transportation options related to cost or geographic barriers, according to the 2017 American Hospital Association study, "Transportation and the Role of Hospitals."

Health Leaders Media

Monday, August 27, 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.

First, Let’s Blow Up All the Hospitals

By Kim Bellard, August 27, 2018 

A few recent stories are, I believe, reaffirming one of the big problems about healthcare: hospitals are 19th century institutions operating under 20th century business models in the 21st century. It’s time to rethink what we want a “hospital” to be.

The Boston Globe reported on Stanford’s new Lucile Packard Children’s Hospital, which cost a cool $1.3 billion and is touted as, of course, the “hospital of the future.” As they describe it, it doesn’t look like a hospital at all, but rather: “It is some hybrid of hotel, museum, and high-tech laboratory.” The Globe notes a similarly ambitious, $1.2 billion renovation at Boston Children’s, along with big hospital projects in numerous other cities.

The problem is that hospitals are big and getting bigger, going from building to buildings to campuses. They are expensive and getting more expensive. At some point, we have to ask: is this really how we want to spend our healthcare dollar?

Some hospitals are figuring other ways to spend their — I mean, “our” — money on our health. Take Nationwide Children’s Hospital. Located in a somewhat blighted neighborhood of Columbus (OH), its Healthy Neighborhoods Healthy Families (HNHF) program “treats the neighborhood as the patient,” as their summary in Pediatrics put it.

The hospital is leading a partnership that has built 58 affordable housing units, renovated 71 homes, given out 158 home improvement projects, and helped spur a 58 unit housing/office development. They’ve also hired 800 local residents and instituted a jobs training program. They’re already seeing lower murder rates, higher high school graduation rates, and are studying impacts on emergency room visits, inpatient days, and rates of specific conditions such as asthma.

“This is a national trend,” Jason Corburn, professor of city and regional planning at the University of California, Berkeley, told NPR. “It’s happening in cities across the country,” citing similar efforts in Atlanta, Boston, New York, and Seattle.

It is true that hospitals (excuse me, “health systems”) are diversifying — building/buying satellite locations, free-standing emergency rooms, urgent care centers, and physician practices — but those big buildings remain the locus, and their sunk costs weigh on hospitals’ finances.

There’s a great quote from Philip Betbeze of HealthLeaders: “the future of the hospital is not a hospital.” The future requires, as Richard Darch, CEO of Archus, more recently wrote, “radically and fundamentally rethinking the hospital, and even discarding the term ‘hospital’ to the history books.”

I’d go further: not a building, not even a campus, but as a dispersed array of services — some medical, many not — that are delivered as close to our homes as possible (and, preferably, in our homes).

It requires us blowing up our concept of a “hospital.”

Don’t donate money for hospital expansion/renovation plans. Don’t buy bonds for them either. Don’t sit passively on hospital boards that push for them or expensive new equipment.Instead, we should be questioning: how can a “hospital” most impact our communities’ health? What kinds of investments in our communities’ health can they be making? How we do push healthcare and health down as close to where and how people live as possible?

The argument will always be, well, payors won’t pay for those kinds of things. The business models don’t support them. To that I say: it’s time not just for new kinds of “hospitals,” but also new kinds of business models.

Let’s get to it.

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

By Claire Thayer,  August 24, 2018

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:

CIGNA Shareholders Approve $52B Express Scripts Merger

Cigna shareholders overwhelmingly approved the merger agreement with Express Scripts on Friday morning, the health insurer announced. Early results show that 90% of shareholders favored the proposal.

HealthLeaders

Friday, August 24, 2018

Your Office Doctor Is Getting a Big Push From Private Investors

A group of investors is putting up $165 million to fuel an expansion of Paladina Health, bringing a recent surge of private funds flowing into companies that run primary-care clinics to more than a half-billion dollars.

Bloomberg

Thursday, August 23, 2018

Senate backs $854B bill to fund health, education, military

The Senate approved an $854 billion measure Thursday that funds much of the government, including $675 billion for the Defense Department. The bill combines military spending with disbursements for Health and Human Services, Education, Labor and other agencies.

The Associated Press

Thursday, August 23, 2018

The Man Who Used To Run Medicaid Has A New Idea To Make It Better

Andy Slavitt was working as an executive at Optum in 2013 when he was called in to be part of the team tasked with repairing Healthcare.gov’s disastrous rollout, kicking off a two-year stint as acting administrator of the Centers for Medicare and Medicaid Services.

Forbes

Thursday, August 23, 2018

Why Are Black And Latino Kids More Likely To Die Of Certain Cancers?

When it comes to cancer survival, the United States is sharply divided by race. According to the Centers for Disease Control and Prevention, the cancer death rate for African-Americans is 25 percent higher than whites, and Hispanics and Latinos are more likely to be diagnosed with cancer at a late, and more dangerous, stage of the disease.

NPR

Tuesday, August 21, 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.

Out of Network Services: Not Just Surprise Medical Bills, They Also Erode Care Coordination and Patient Retention

by Clive Riddle, August 23, 2018

Last week, Kaiser Family Foundation released a study of medical bills in large employer plans that found "a significant share of inpatient hospital admissions includes bills from providers not in the health plan’s networks, generally leaving patients subject to higher cost-sharing and potential additional bills from providers." The report stated "almost 18 percent of inpatient admissions result in non-network claims for patients with large employer coverage. Even when enrollees choose in-network facilities, 15 percent of admissions include a bill from an out-of-network provider, such as from a surgeon or an anesthesiologist."

 

The focus of the KFF study of course was surprise medical bills. This week, Kyruus released their 12-page 2018 Referral Trends Report: Positioning for Patient Retention which examines out of network services from a different perspective – when referred by an in-network physician, with the issue focus being on care coordination and patient retention.

The report presents physician survey findings that indicate “one-third of out-of-network referrals would be avoidable with more robust information about in-network colleagues," and "while 77 percent of providers surveyed recognize the importance of keeping patients in-network for care coordination, a notable 79 percent say they refer patients out of network."

The report tells us:

• Among those who refer out of network, 45 percent say that it’s difficult to determine who is in the network
• On average, providers that refer out of network send almost 1/4 of patients out-of-network
• 42 percent of patients leave a provider’s office without a necessary referral appointment booked, despite over 60 percent of providers considering point-of-service scheduling extremely or very important.        
• Personal networks drive current referral behaviors: 72 percent of providers say they or their staff usually refer to the same provider for a given specialty
• 40 percent of providers report always knowing whether or not their referral was appropriate for the patient or whether the patient needed to be re-referred, hindering care coordination.       

The report concludes that "providers understand the importance of keeping patients in network to improve care. However, without the right tools to facilitate clinically appropriate and in-network referrals, providers will not necessarily break from familiar patterns."

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

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:

Purdue Pharma’s Sales Pitch Downplayed Risks Of Opioid Addiction

Two decades ago, Purdue Pharma produced thousands of brochures and videos that urged patients with chronic pain to ask their physicians for opioids such as OxyContin, arguing that concerns over addiction and other dangers from the drugs were overblown, company records reveal.

Kaiser Health News

Friday, August 17, 2018

Best Buy to buy a provider of health devices for the aging

Consumer electronics retailer Best Buy is pushing more into the health field, acquiring a company that provides emergency response devices for the aging.

ABC News

Thursday, August 16, 2018

Google parent invests $375M in ObamaCare startup Oscar

Google’s parent company, Alphabet, is investing $375 million in Oscar Health, a startup health insurance company seeking to redefine the industry by using technology and data.

The Hill

Wednesday, August 15, 2018

Icahn Drops Fight to Block Cigna's Express Scripts Takeover

Activist investor Carl Icahn has dropped his fight to block Cigna Corp.’s $54 billion acquisition of Express Scripts Holding Co. after two prominent shareholder advisory firms came out in support of the deal.

Bloomberg

Tuesday, August 14, 2018

Employers drive healthcare change through direct contracting, ACOs, combatting opioid epidemic

With the cost of ensuring employees sharply on the rise, employers are innovating now and planning for the future because they are frustrated with the pace at which the industry itself is driving change.

Healthcare Finance News

Monday, August 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.

Healthcare costs – not grandchildren gone wild – the top retiree concern

By Clive Riddle, August 17, 2018

What’s the top concern about retirement years voiced by retirees as well as retirement plan sponsors? Its not grandchildren gone wild, keeping up with new technology, staying ahead of future inflation, or even staying in good health. Instead, its paying for that health.

Results just released from the 2018 TIAA Plan Sponsor Survey of 1,001 plans sponsors from nonprofit and for-profit organizations found that 91% of plan sponsors believe that healthcare costs are the most significant retirement security issue today. 54% answered very significant and 26% said somewhat significant, while 2% were neutral and – the plan sponsors I’m curious about: 3% said not at all significant.) After health care at 91%, the next highest concern of the top six: Ensuring employees are prepared to retire on a timely basis total 81% saying it was very or somewhat significant.

Meanwhile, another new survey tells us even affluent retirees are plenty scared about those retirement costs. A new Nationwide Retirement Institute survey of adults age 50+ with household income exceeding $150k, conducted by the Harris Poll indicates that 73% of affluent, older adults “list out-of-control health care costs as one of their top fears in retirement and 64 percent of future retirees say they are ‘terrified’ of what health care costs may do to their retirement plans.”

Here’s more of Nationwide’s survey findings:

•  72% wish they better understood Medicare coverage
•  42% admit they would give away all their money to their children so they could be eligible for Medicaid-funded long-term care.
•  53% do not know that Medicare Part B is not free even if you have worked and paid Social Security taxes for at least 10 years
•  23% do not know you cannot enroll in Medicare at any time
•  29% do not know Medicare does not cost the same for everyone
•  62% do not know that future changes will impact the ability to sign up for Medigap/Medicare supplement   plans
•  53% are unsure or can't estimate what their annual health care will be
•  65% are unsure what their long-term care costs will be
•  27% of even these affluent, older adults say they couldn't cover more than $1,000 in unplanned expenses:   44% couldn't cover more than $4,000 and 60%couldn't cover more than $5,000 of unplanned expenses
•  50 % have access to a Health Savings Account (HSA) through their employer, with 30% participating in or   contributing to the HSA

25 Things to Know About The CMS Medicare ACO Proposed Rule: Pathways to Success

By Clive Riddle, August 10, 2018

Here are 25 major points to note in the CMS Pathways to Success Proposed Rule introduced on August 9th:

1. The redesigned Medicare Shared Savings program is called “Pathways to Success.
2. There are five stated goals Pathways to Success is intended to advance: Accountability, Competition, Engagement, Integrity, and Quality.
3. The CMS projected financial impact of the proposal would be savings to Medicare of $2.2 billion over ten years.
4. CMS notes that 460 of the 561 or 82% of all ACOs in the Shared Savings Program in 2018 – are not taking on risk for increases in costs.
5. The amount of time that an ACO can remain in the program with upside-only risk  would be limited to two years (or one year for ACOs identified as having previously participated in MSSP under upside-only risk) instead of the current timetable of up to six years.
6. A 6-month extension would be provided for current ACOs whose agreements expire at the end of 2018, along with a special one-time July 1, 2019 start date that will have a spring 2019 application period for the new participation options.
7. The number of tracks would be reduced to two, the “BASIC” track and the “ENHANCED” track, and would allow providers to pick between these two tracks. 
8. The length of ACO participation agreements would expand from three years to five years.
9. The BASIC track would feature a glide path for taking risk.  It would begin with up to two years of upside-only risk and then gradually transition in years three, four, and five to increasing levels of performance risk, concluding in year five at a level of risk that meets the standard to qualify as an Advanced Alternative Payment Model (APM) under MACRA. 
10. Current upside-only ACOs would be limited to one year without risk before being required to transition to the risk level in year three of the glide path.
11. The ENHANCED track would allow providers to take on risk and qualify as an Advanced APM immediately.  This track would offer the same amount of risk for each of the five years of the agreement period, at a level of risk sharing higher than the maximum amount reached in the BASIC track.
12. Eligible ACOs (ACOs that are inexperienced with two-sided risk in Medicare) would be able to enter at any level of risk in the BASIC track’s glide path or go straight to the ENHANCED track.
13. After completing a five-year agreement under the BASIC track, low revenue ACOs would be able to renew for a second agreement period at the highest level of risk in the BASIC track, while high revenue ACOs would be required to move to the ENHANCED track and take on additional risk.
14. Each ACO would provide a standardized written notice to its Medicare beneficiaries, informing them at their first primary care visit of a performance year that they are in an ACO and what that means for their care.
15. CMS would allow certain two-sided ACOs to provide an incentive payment of up to $20 to each assigned beneficiary for each qualifying primary care service that the beneficiary receives, as an incentive for taking steps to achieve and maintain good health. 
16. CMS is seeking comment on an approach that would allow beneficiaries to opt in to an ACO as an alternative to assignment. 
17. CMS would streamline the measures that ACOs are required to report, to ensure that all measures have a meaningful impact on patient care.
18. CMS would require a specified percentage of the eligible clinicians participating in an ACO to adopt the 2015 edition of Certified EHR Technology (CEHRT) as part of the Administration’s MyHealthEData initiative promoting interoperability of medical data and patient control of their data.
19. Physicians in ACOs that take on risk could receive payment for telehealth services provided to patients regardless of the patient’s location.
20. Regional (county-level) spending would be incorporated into ACO benchmarks starting in their first agreement period.
21. Methodology for risk adjustment would more accurately account for changes in beneficiaries’ health status.
22. When calculating and updating benchmarks, CMS would factor in national spending growth rates in addition to regional rates, so ACOs that constitute a large fraction of their local market would not be penalized if they reduce the market growth rate.
23. ACOs in two-sided models would be accountable for losses even if they exit mid-way through a performance year.
24. Termination of ACOs with multiple years of poor financial performance would be authorized.
25. The detailed Medicare Shared Savings Program Notice of Proposed Rulemaking (CMS-1701-P), “Accountable Care Organizations‑‑Pathways to Success,” is available at https://www.federalregister.gov/public-inspection/  and https://www.cms.gov/newsroom/fact-sheets/proposed-pathways-success-medicare-shared-savings-program.

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

By Claire Thayer, August 3, 2018

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:

Express Scripts hits back at criticisms of PBMs, says it 'would do just fine' without drug price rebates

Express Scripts, the country's largest pharmacy benefits manager, is challenging the rhetoric that paints PBMs as the villain behind the rising cost of drugs.

FierceHealthcare

Friday, August 3, 2018

Hospitals see $4.8B lift in final CMS payment rule that focuses on price transparency, interoperability

The Centers for Medicare & Medicaid Services (CMS) has finalized a hospital payment rule that includes an additional $4.8 billion for inpatient services as well as several new requirements around price transparency and data sharing.

FierceHealthcare

Thursday, August 2, 2018

How Rival Opioid Makers Sought To Cash In On Alarm Over OxyContin’s Dangers

As Purdue Pharma faced mounting criticism over deaths linked to OxyContin, rival drugmakers saw a chance to boost sales by stepping up marketing of similarly dangerous painkillers, such as fentanyl, morphine and methadone, Purdue internal documents reveal.

Kaiser Health News

Thursday, August 2, 2018

‘Short Term’ Health Insurance? Up to 3 Years Under New Trump Policy

The Trump administration issued a final rule on Wednesday that clears the way for the sale of many more health insurance policies that do not comply with the Affordable Care Act and do not have to cover prescription drugs, maternity care or people with pre-existing medical conditions.

NY Times

Thursday, August 2, 2018

Individual market enrollment dropping amid premium increases

Enrollment in the individual health insurance market — the market for people who don't get coverage through work — has declined 12 percent in the first quarter of 2018, compared to the same period last year, according to a new analysis released Tuesday.

The Hill

Wednesday, August 1, 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.

Medicare Part D Premiums and Enrollment by the Numbers

By Clive Riddle, August 9, 2018

CMS this week announced that Part D premiums are expected to fall from $33.59 this year to $32.50 in 2019. Of course it’s not that simple. First of all, $32.50 is the “basic” premium rate. What Medicare beneficiaries actually pay is income adjusted on a sliding scale. Here are the 2019 “income-related monthly adjustment amounts” just released by CMS:

 

CMS informs us that:

• “the base beneficiary premium is equal to the product of the beneficiary premium percentage and the national average monthly bid amount”
• "the national average monthly bid amount is a weighted average of the standardized bid amounts for each stand-alone prescription drug plan and MA-PD plan.. The weights are based on the number of enrollees in each plan."
• “The national average monthly bid amount for 2019 is $51.28.”
• “The beneficiary premium percentage (“applicable percentage”) is a fraction, with a numerator of 25.5 percent and a denominator equal to 100 percent minus a percentage equal to (i) the total reinsurance payments that CMS estimates will be paid for the coverage year, divided by (ii) that amount plus the total payments that CMS estimates will be paid to Part D plans based on the standardized bid amount during the year, taking into account amounts paid by both CMS and plan enrollees.”
• Using the above calculations “the Part D base beneficiary premium for 2019 is $33.19”
• Then the Income-Related Monthly Adjustment Amounts “are determined by multiplying the standard base beneficiary premium by the following ratios: (35% − 25.5%)/25.5%, (50% − 25.5%)/25.5%, (65% − 25.5%)/25.5%, (80% − 25.5%)/25.5%, or (85 – 25.5%)/25.5%.

Clear as mud?

On the enrollment side of PDP world, here’s a look compiled from July 2018 CMS data:

Here are Medicare national drug plan enrollment totals:

• Total PDP Contracts: 63
• PDP Drug Plan Enrollment: 25,459,900
• MA Drug Plan Enrollment: 18,004,980
• PACE/Cost/Dual Drug Plan Enrollment: 689,113
• Total Drug Plan Enrollment: 44,153,993

The top five states for PDP enrollment penetration are:

• North Dakota – 63.9%
• Vermont – 62.6%
• Delaware – 62.6%
• Iowa – 60.5%
• Wyoming – 58.9%

This compares to a national average of 41.2% penetration. As one might expect, the high PDP penetration states have correspondingly lower Medicare Advantage penetration. For example, North Dakota has 2.7% MA penetration. Conversely, Puerto Rico has only 2.1% PDP penetration, but has the highest MA penetration at 71.1%. (national average MA penetration is 33.8%)

There are 114 counties with PDP penetration rates above 70.0%, mostly concentrated in the above states. Leading the pack is Dubuque County, Iowa at 72.3%. The bottom 77 of the 3,218 counties listed are all in Puerto Rico, as mentioned above. The first mainland county just above them is Clackamas County, Oregon with 17.6% penetration.