Less-invasive surgeries and new drugs have stanched demand, but more government oversight is needed to safeguard the supply of blood to hospitals.
The nation's blood collection system may require more rigorous government oversight to protect the blood supply from shortages and health risks, a new RAND Corporation study says.
"The U.S. blood system operates effectively, but it is in a state of flux and uncertainty," Andrew Mulcahy, lead author of the study and a policy researcher at RAND, said in comments accompanying the study.
"Financial pressures, changes in healthcare practice and technology, and the emergence of external threats such as the Zika virus are pressuring the system and may potentially threaten the available supply of blood," Mulcahy said. "We need a better, more-efficient and more-sustainable system."
Medical advances such as less-invasive surgeries and new drugs have decreased the demand for blood during the past decade. However, the size of the blood collection and distribution system has decreased only slightly, according to the RAND study.
At the same time, hospital consolidation has given larger hospitals a leg up in negotiating for lower blood prices. The result has been increased competition among blood centers that has led to falling prices for blood, which slices into blood centers' already thin margins and revenue.
In addition, blood suppliers are grappling with technological innovations and the emergence of pathogens, such as the Zika virus, which add new production and testing costs. A dwindling pool of active donors poses an additional challenge.
To address these issues, the RAND study recommends:
Collecting data on blood use and financial arrangements: Stakeholders have access to statistics on blood use and transactions tied to their individual organizations, but the U.S. government does not have access to comprehensive data describing the performance of the blood system.
Developing a vision for appropriate levels of surge capacity: Describing a desired level of surge capacity from a public health and preparedness perspective will help stakeholders and policymakers plan and estimate the costs associated with maintaining surge capacity.
Subsidizing blood centers' ability to maintain surge capacity: Surge capacity to respond to serious events and emergencies falls outside the typical financial arrangements between hospitals and blood centers, so there is an argument that the government should separately finance this surge capacity.
Building relationships with brokers and other entities to form a blood "safety net": A well-established set of relationships can reduce emergency response times.
Building a value framework for new technology: We recommend that HHS invest in health technology assessment research for existing technologies with low adoption rates and for technologies on the horizon.
Paying directly for new technologies in which there is no private business case for adoption: Technologies often have clear public health and preparedness benefits. In these cases, U.S. government financing of technology acquisition costs might be appropriate.
Implementing emergency use authorization and contingency planning for key supplies and inputs: The FDA could implement emergency use authorizations for replacement supplies and other inputs in the event of a shortage.
Mulcahy said in the long term the blood supply market may need to consolidate. In the shorter term, however, the abrupt closure of multiple blood centers owing to these market pressure could affect the availability of safe blood products.
Recent deals will boost credit ratings for large statewide systems, but will squeeze smaller, independent hospitals.
When it comes to credit ratings, the wave of mergers and acquisitions of not-for-profit hospitals in New Jersey is creating two classes of hospitals in the eyes of Moody's Investors Service.
"Increased competition will remain a credit challenge for independent hospitals and smaller health systems as large systems within the state have formed, increasing in-state competitive pressures," Moody's Associate Analyst Jennifer Barr said.
"The ability to adjust quickly to change will be an important determinant of New Jersey hospitals' credit quality."
M&As have been taking place across the nation in the past few years, but New Jersey mergers play a more significant role in credit quality, given the statewide presence of multiple health systems, competition from neighboring states New York and Pennsylvania, and continued state fiscal pressures, Barr said.
In addition, providers from Philadelphia and New York City look to expand in New Jersey through out-of-state mergers and clinical affiliations.
In April, for example, the merger of statewide systems RWJ Barnabas Health and Hackensack Meridian Health was credit-positive for these organizations because it brought them new size, scale and geographic coverage.
For smaller hospitals in the state, however, the merger brought intensifying market competition.
New Jersey hospitals will experience additional funding pressure in 2017 owing to a $200 million reduction in state subsidies for charity care, states the report, Not-for-Profit and Public Healthcare—New Jersey: Large-Scale Mergers are Credit Positive; Challenges Ahead for Small Independent Hospitals.
Reliance on these lower funds varies by hospital, with safety net hospitals most exposed. These include Trinitas Regional Medical Center in Elizabeth, St. Joseph's Healthcare System in Paterson, and Cooper Health Systems in Camden.
"Following Medicaid expansion in 2014, the state began reducing charity care subsidies as more state residents gained health insurance under expanded Medicaid eligibility criteria. However, the cuts have accelerated in recent years, exacerbated by the state's own fiscal concerns," Barr said.
New Jersey's safety net hospitals have benefitted from the Medicaid expansion with reductions in bad debt and unfunded care. This has resulted in improved operations and rating upgrades for Trinitas, St. Joseph's, and Cooper Health, she said.
The American College of Emergency Physicians takes insurers to task for lack of insurance coverage for emergency care.
The American College of Emergency Physicians responded to Cigna Health Insurance Company's national ad campaign featuring famous TV doctors—from Patrick Dempsey to Noah Wiley—with a satirical video of its own starring real emergency physicians.
"We are poking fun at Cigna to highlight a serious issue: the lack of fair coverage for value in emergency medical care," ACEP's president, Rebecca Parker, MD, FACEP, said in a release.
"Many people don't realize how little insurance coverage they have until they visit the ER, and then they are shocked at how little their insurance company pays."
The $9 million Cigna spent on the ad, in which famous actors play physicians, could have been better spent on patients. "Emergency physicians fight hard for their patients who are bearing an increasingly large share of the burden for their medical care," Parker said.
The ACEP video, which has been viewed more than 24,000 times since it was posted on November 15, closely parodies Cigna's commercial. However, it focuses on the life-saving care ED doctors provide to nearly 140 million patients each year, much of which is uncompensated.
ACEP's video claims the insurance industry has enacted measures that increase its profits, while shifting the cost burden to patients and the physicians who treat them.
"Cigna, and others like them, are exploiting federal law [EMTALA] to reduce coverage for emergency care, knowing emergency departments have a federal mandate to care for all patients, regardless of their ability to pay," Parker stated.
In the ACEP statement, Parker encourages patients to investigate what their health insurance covers and demand fair and reasonable coverage for emergency care.
"Emergency physicians are there for their patients 24 hours a day, every day of the year. We can't say the same for the insurance industry."
The video stars Sudip Bose, MD, of Chicago; Alison Haddock, MD, of Houston; Jay Kaplan, MD, ACEP's immediate past president, of New Orleans; Ryan Stanton, MD, of Lexington, KY; and Jose Torradas, MD, of Stockton, CA. They were not compensated for appearing in the video.
This year, the fundraising effort helped hospitals by prompting charitable donations via shopping, radiothon, and email blast.
Giving Tuesday (often rendered by its Twitter hashtag, #GivingTuesday), an initiative that encourages consumers to give back after spending on Black Friday and Cyber Monday, has been around since 2012. Here are three ways healthcare organizations participated in Giving Tuesday this year.
Charitable Shopping
Kmart, which has been a corporate sponsor of St. Jude Children's Research Hospital for 10 years, decided to up the ante this #GivingTuesday and raise $100 million for the organization.
Kmart shoppers could contribute to this goal by purchasing a suite of St. Jude gifts in stores or on Kmart.com.
"St. Jude is so grateful for the generosity and support of our friends at Kmart, who have fully embraced our lifesaving mission unlike any other," Richard Shadyac, Jr., president and CEO of ALSAC, the fundraising and awareness organization for St. Jude, said in a release.
"Kmart and their incredibly compassionate shoppers and associates have reached a remarkable milestone—raising $100 million—more funds than any other St. Jude partner," Shadyac stated.
"Kmart's contributions have helped fund the St. Jude mission for the past decade, and the company's dedication to the patients and families of St. Jude is unsurpassed."
Radiothon
The Valley Hospital Foundation—the fundraising organization for The Valley Hospital in Ridgewood, NJ—participated in its second-annual Giving Tuesday with a radiothon.
This year, the foundation decided to focus its Giving Tuesday efforts on Valley's Urologic Oncology Program and prostate cancer, because November is National Men's Health Month.
The foundation partnered with a local radio station to help spread the word. On Tuesday, Q104.3FM's "Rock and Roll Morning Show" were scheduled to air interviews with Valley clinicians speaking about Valley's prostate cancer services from 5 a.m. to 9 a.m.
The Valley Hospital Foundation also included a "Donate Now" link on its website's homepage.
Email Blast Munson Healthcare in Traverse City, MI, encouraged its patients, staff, and community members to donate to the hospital on Giving Tuesday in order to give back to those around them in a meaningful way.
"We are so thankful for the generosity of northern Michigan residents and our staff over the years," said Munson's Chief Development Officer Desiree Worthington, in a Boyne City Gazettereport. "#GivingTuesday is about ordinary people coming together to accomplish extraordinary things. Munson Healthcare hospitals offer several different ways to give that promote quality health care and a positive patient experience."
On Tuesday, Munson Healthcare Foundations emailed supporters to encourage those who have not yet considered a gift to the organization to remember local health needs in the season of giving.
"We're encouraging people to use the hashtag #GivingTuesday to talk about how important it is to support your local hospital," Worthington said.
Regulators claim the deal presents "substantial risk" of higher healthcare costs, lower quality, and reduced access to care.
If consummated, the proposed merger of Wellmont Health System and Mountain States Health Alliance would lead to significantly less competition for healthcare services in southwest Virginia and northeast Tennessee, the Federal Trade Commission declared.
In a comment to the Tennessee Department of Health, FTC staff expressed concerns that the deal would "eliminate this beneficial competition" that now exists between the two neighboring health systems.
"It is clear that the new health system would have a dominant share of the market, making it a near-monopoly and allowing it to exercise significant market power," FTC staff said, adding that any state oversight likely would not mitigate the harm created by the merger.
In September, FTC regulators expressed similar concerns in comments submitted to the Southwest Virginia Health Authority, which is reviewing a cooperative agreement request.
Earlier this month, Alexis Gilman, assistant director for the Mergers IV Division of the FTC, spoke at a public hearing before the Tennessee Department of Health in Johnson City, TN, and recommended the Certificate of Public Advantage (COPA) be denied.
"The hospitals have not sufficiently justified why this highly anticompetitive merger is necessary and the only way to achieve their claimed benefits," Gilman said.
If the merger is approved by Virginia and Tennessee, the deal is exempt from FTC antitrust challenges.
"It's in the state's hands and all FTC can do is try to persuade them to see things the way they do and not issue the COPA," says Jay L. Levine, a disinterested observer and anti-trust litigator with PorterWright.
"If the COPA isn't issued, then the merger may be DOA unless the hospitals want to try and beat the FTC in court, which may be doubtful."
Leaders from Mountain States Health Alliance and Wellmont Health System have said their proposed merger would invest nearly $500 million in regional health initiatives over the next decade while holding healthcare cost growth below national averages in their two-state service area.
The proposed merger would place limits on negotiated rates with insurers, and tie healthcare cost growth for their operations in Tennessee and Virginia to the previous year's growth as measured by the federal Hospital Consumer Price Index and Medical Consumer Price Index.
In his public remarks, Gilman said the proposed rate caps may not fully control prices. "Even if they did fully control prices, the rate caps would do nothing at all to prevent harm to quality of care, and would in fact make that quality harm more likely," he said.
"Ultimately, the commitments being offered will be difficult to construct in a way that prevents the likely harm to consumers, will be difficult to monitor, and will be difficult to enforce."
In a joint response sent to HealthLeaders Media News last week, Mountain States Health Alliance and Wellmont Health System stated the proposed merger "represents the best opportunity to sustain access to high quality care while also investing in research, physician training, and new, needed services."
"The FTC has made similar arguments against other mergers, and their arguments were rejected. For example, in a recent such case in West Virginia, the FTC's arguments were rejected by the West Virginia Health Authority and the Attorney General of West Virginia."
Further, the Southwest Virginia Health Authority unanimously voted to recommend the proposed merger of Mountain States and Wellmont after considering the FTC's testimony and comments, according to the statement.
The merged system will be subject to a cap on rate increases to reduce the pace of healthcare cost growth and other commitments to protect payers and physicians. "The new system will be actively supervised by state officials to ensure these conditions are met," the statement claimed.
Trainees reported more satisfaction with patient safety and continuity of care, but their wellbeing took a hit, according to FIRST Trial analysis.
Not only do general surgery residents strongly prefer flexible policies that allow them to work longer when needed, but such policies also didn't negatively affect patient care, according to new analysis of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial.
The trial included 3,700 surgeons and compared 59 general surgery residency programs with standard Accreditation Council for Graduate Medical Education surgical resident duty hour requirements to 58 programs that tested a policy waiving certain ACGME rules about maximum shift lengths and mandatory time off between shifts.
Eighty-six percent of the FIRST Trial participants preferred flexible duty (work) hour policies over standard duty hours, or had no preference, according to an analysis of the trial published on the Journal of the American College of Surgeons website.
The surgeons in training preferred policies that allow them the flexibility to work longer when needed to provide patient care, rather than standard, more restrictive work schedules. That preference only grows as they move through their training, according to the study.
Waiving the rules allowed residents to stay longer when they needed to provided patient care or participate in education. Both groups were limited to an 80-hour workweek averaged over four weeks.
An earlier analysis published in the New England Journal of Medicine in March showed that flexible duty hours didn't worsen outcomes or adversely affect overall resident well-being.
The more recent analysis gauged interns, junior residents, and senior residents' perceptions of patient safety, continuity of care, resident education and clinical training, and resident well-being.
Researchers found that trainees at all levels preferred the flexible hours. Almost 89% of senior residents preferred the flexible hours, compared to almost 85% of interns and 84% of junior residents.
"The vast majority of residents at all levels preferred to work under flexible duty hour policies," wrote FIRST Trial principal investigator Karl Y. Bilimoria, MD, MS, FACS, Director of the Surgical Outcomes and Quality Improvement Center at Northwestern University Feinberg School of Medicine, in Chicago.
Residents in the flexible study cohort appreciated flexible duty hours even more and expressed an even stronger preference for flexible duty hour policies, Bilimoria wrote. Residents in the flexible-hours group were less likely to be dissatisfied with patient safety and continuity of care.
However, residents in programs with flexible duty hours were more likely to report that duty hour policies had a negative effect in areas such as their rest and leisure time.
"We already know that flexible training hours do not harm patients and improve residents' educational experience," said David B. Hoyt, MD, FACS, executive director of the American College of Surgeons, stated in the JACS online analysis.
"The next step is for residency programs to achieve a proper balance between safely caring for patients and training residents to an optimal level, while considering the well-being of the resident physicians who provide that care."
A 45-day public comment period is underway for recommended changes to standards for ACGME-accredited U.S. residency and fellowship programs.
Among the recommendations is greater flexibility in resident work hours, including allowing first-year residents to work 24-hour shifts within an 80-hour workweek, rather than limiting their shifts to 16 hours, as is current practice.
Patients receiving palliative care report improved quality of life and symptom burden and higher satisfaction with their healthcare, a data meta-analysis shows. For caregivers, the evidence of improvement is mixed.
People coping with serious illness who are under palliative care have a better quality of life and suffer fewer symptoms than those who don't receive palliative care, a new study from the University of Pittsburgh School of Medicine shows.
The study, which appears this week in the Journal of the American Medical Association, is the first meta-analysis of palliative care's effect on patients' quality of life, symptoms and survival.
The researchers reviewed 43 trials of palliative care interventions, including 12,731 adults with serious illness and 2,479 of their family caregivers. Researchers also performed a meta-analysis on the association between palliative care and three outcomes linked with palliative care—patients' quality of life, symptom burden, and survival.
"Taken all together, this is a very compelling message," said study lead author Dio Kavalieratos, assistant professor of medicine in the Section of Palliative Care and Medical Ethics in Pitt's Division of General Internal Medicine.
"People's quality of life and symptoms improved; their satisfaction with their healthcare improved—all during what is likely one of the most difficult periods of their lives."
Kavalieratos' team found that palliative care was associated with improvements in advance care planning, patient and caregiver satisfaction with care, and lower healthcare utilization. There was mixed evidence of improvement, however, with site of death, patient mood, healthcare expenditures, and caregiver quality of life, mood or burden.
Beyond Cancer
"Historically, palliative care has overwhelmingly focused on individuals with cancer, but anyone with a serious illness, be it cancer, heart failure, multiple sclerosis, or cystic fibrosis, deserves high-quality, individualized care that focuses on reducing their suffering and improving their quality of life," Kavalieratos said.
"We need to find ways of integrating palliative care concepts in patients' usual care experiences so it isn't a luxury, but a standard part of healthcare for those living with serious illness."
Over the past five years, much attention has been paid to the idea that palliative care improves patients' survival, Kavalieratos added. Although some individual studies had shown that, the association didn't play out when multiple studies were pooled together in the meta-analysis.
"As a field, we need to develop new methods of studying how palliative care impacts people with serious illness and their caregivers," Kavalieratos added.
"These methods should not burden patients and caregivers who participate in this research, but also need to be rigorous enough to capture what's going on at this critical point in people's lives."
The financial terms offered are marginally less attractive than its 2014 settlement pact for disputed claims.
Hospitals that have appealed Medicare billing denials for inpatient services have a new federal settlement offer to consider.
Details of the settlement deal are available on a Centers for Medicare & Medicaid Services (CMS) webpage and on slides that CMS officials released last week.
Under an administrative process set to begin December 1, the settlement deal offers payment at a rate of 66 cents on the dollar for disputed billing claims in exchange for hospitals dropping their appeals.
The offer applies to acute-care hospitals and Critical Access Hospitals (CAHs) that have appeals at the Administrative Law Judge (ALJ) and Departmental Appeals Board (DAB) levels.
In 2014, CMS offered a slightly sweeter settlement deal aimed at alleviating a massive appeals backlog.
Despite settling about 346,000 claims with 2,022 hospitals in the 2014 settlement offer, more than 884,000 Medicare claims were awaiting adjudication at the ALJ level for the federal fiscal year ending September 2015.
Under the 2014 settlement deal, hospitals received payments totaling about $1.47 billion, according to CMS.
The deal on the table now is designed to convince more acute-care hospitals and CAHs to drop their appeals, according to the 2016 settlement process webpage. "CMS has decided to once again allow eligible providers to settle their inpatient status claims currently under appeal," the webpage states.
Whether a patient was appropriately designated for inpatient status is a key requirement for a disputed billing claim to be eligible for the settlement deal.
"Eligible claims are those denied by a Medicare contractor on the basis that services may have been reasonable and necessary but treatment on an inpatient basis was not," the webpage says.
The so-called two-midnight rule that went into effect in October 2013 is linked to many of the disputed billing claims eligible for settlement.
Under the rule, which CMS is using to draw a line in the sand on patient status, medical care is deemed appropriate for inpatient status and reimbursement at Medicare A rates based mainly on two factors:
If a patient is expected to be in a hospital for a period of time spanning at least two midnights or
If a patient actually received care for a period spanning at least two midnights.
Otherwise, hospital care provided for less than two midnights is reimbursed at the lower outpatient rate under Medicare Part B.
Physician judgment is a crucial factor in the determination of medical necessity for hospital care under the two-midnight rule, and physicians are urged to document why treatment in an outpatient setting would be unsafe.
Hospitals have until January 31, 2017 to file an "expression of interest" to start the settlement administration process.
For-profit chain will use $425 million from Rockwood Health System deal to pare down its $15B debt burden.
Community Health Systems, Inc. continued its efforts to trim $15 billion in red ink with the sale of Rockwood Health System, a two-hospital system in Spokane, WA, to MultiCare Health System, in a deal valued at $425 million.
Facilities included in the deal include 388-bed Deaconess Hospital in Spokane, 123-bed Valley Hospital in Spokane Valley, and the multi-specialty Rockwood Clinic, all in Washington. The deal is expected to be finalized in the first quarter of 2017, CHS said in a news release.
The sale is the latest in a series of divestments that CHS CEO Wayne T. Smith announced in a conference call earlier this month with analysts.
"As we look to the future, we want to make sure we are in sustainable markets where we have good opportunities to deploy our resources and capital so that we can expand in those markets going forward," Smith told analysts.
"We will continue to evaluate our properties, in terms of ones that are beneficial."
The acquisition of Rockwood Health would help to expand access and build a stronger network of care in a service area that includes 1.5 million people in Eastern Washington, Northern Idaho, and Western Montana, said MultiCare CEO and President Bill Robertson.
"This is an important step for MultiCare, which will become the largest community-based, locally governed health system in the state when the transaction is complete," Robertson said.
"This acquisition will help the organization advance on our vision of becoming a Pacific Northwest system of care."
Rockwood Health System will become part of Tacoma, WA-based MultiCare's integrated not-for-profit healthcare system, which includes four acute-care adult hospitals, one acute-care children's hospital, and a robust network of community-based primary, specialty, and urgent care facilities.
Franklin, TN-based CHS, one of the largest publicly traded hospital companies in the nation, owns, leases or operates 158 hospitals in 22 states.
Policyholders have higher approval of their plans in most areas—but there is plenty of room for improvement, two industry reports show.
Consumers have a more favorable view of health plans than they once did, according to the most recent American Customer Satisfaction Index report.
The ACSI report covers finance and insurance, which includes health insurance along with property and casualty insurance, life insurance, retail banks, credit unions, and internet investment services.
ACSI researchers estimated customer sentiment based on email interviews with 9,608 policyholders between July 11 and September 23. These interviews showed the health insurance industry's overall favorability improved by 4.3%, to an average of 72 on a 100-point scale.
All major providers posted gains over the previous year. Aetna and Anthem both saw significant gains to tie for first place at 75. Kaiser Permanente is up 4% to 74, followed by the group of smaller insurers at 73. Humana gained 1% to reach 72, the industry average.
Blue Cross and Blue Shield, however, fell short of the average at 71. Other underperformers included UnitedHealth, although it gained 6% to reach 70. Cigna had the largest gain, but was last at 67.
Policyholders believe many aspects of the health insurance industry have improved, including access to primary care and specialty care doctors. Coverage of medical services is slightly better than it was a year ago, and it is easier to submit a claim, according to the report.
There's still room for improvement. "As with last year, consumers do not find insurance statements easy to understand. While call centers are doing a better job, this contact channel still scores low (73)."
The least satisfying aspect of health coverage is the choice of available plans with differing levels of coverage, premiums, deductibles, and copays, indicating that consumers are looking for more choice, the report found.
The ACSI findings are similar to those of a J.D. Power Member Health Plan Study released in March. On a nationwide basis, member satisfaction with their health plans improved nine index points in 2016, scoring a total of 688 on a 1,000-point scale. That followed a 10-point improvement in 2015, the J.D. Power study found.
Member satisfaction with health plans reached a low point in 2014 after the introduction of the health insurance marketplace as part of the Affordable Care Act (ACA).
The Member Health Plan Study concluded that policyholder satisfaction is highest in areas of the country that have more competition among health plans.
Member satisfaction in cost and information and communication was significantly lower in areas where one carrier holds more than 50% of market share, the study found.
However, in markets with less competition, members were more satisfied with the choices within their plan. J.D. Power theorized that some customers might be happier with fewer options because too many choices can be overwhelming.