A HealthCare.com analysis of federal data examines emergency department statistics related to diagnoses, payer types, costs, and income level.
Health insurance type plays a role in the reason for an emergency department visit, according to analysis by HealthCare.com.
The researchtakes a look at federal dataon emergency department visits in 2018 and finds the four payer types—private, Medicare, Medicaid, and self-pay—are differentiators for trips to the ER.
Among the top 15 treat-and-release diagnoses, the four payer types have in common just six conditions: nonspecific chest pain, abdominal pain/diarrhea, superficial injury, musculoskeletal pain, urinary tract infections, and sprains and strains.
Meanwhile, five conditions behind treat-and-release emergency department visits are among the top 15 for only one payer type. Headaches are among the top 15 for private insurance, whereas teeth and gum disorders are among the top 15 for self-payers, chronic obstructive pulmonary disease is among the top 15 for Medicare, and pregnancy nausea and ear infections are among the top 15 for Medicaid.
The most common treat-and-release ER visits for all payers were for abdominal pain, respiratory infection, and chest pain.
Hospitals in the U.S. saw 143.5 million emergency department visits in 2018, with 14% of visits resulting in hospital admission and 86% resulting in treatment and release. However, emergency department visits by privately insured and self-pay patients declined from 2009-2018, while visits by those insured by Medicare and Medicaid increased, according to HealthCare.com.
Part of the reason for the changes in number of ER visits could be due to the differing costs of a trip based on insurance type.
Additional analysis by HealthCare.com of 2017 federal datafinds Medicare patients have an average cost of $660 per visit, followed by private insurance at $560, self-pay at $460, and Medicaid at $420.
Income level is also a factor, with the research uncovering that patients in the lowest income quartile visit ERs at a rate of 641 per 1,000 people, compared to 281 per 1,000 people for the highest income quartile.
When it comes to outcomes, it's clear that having insurance allows individuals to be more willing to seek out necessary care and make a trip to the emergency department.
"We know that expanding health insurance leads to better health and financial security for families," Ben Sommers, HHS deputy assistant secretary Ben Sommers told HealthCare.com.
"The emergency department is one area where disparities can show up prominently. That's why the department's focus has been making sure that we have as good coverage and access as we can, and we've seen that in near historic lows in the uninsured rate in the past year, and the record high of people enrolled in Affordable Care Act coverage and Medicaid. If you don't have coverage you'll face big bills and risk not getting the care you need."
The company co-founder and president will step into the role vacated by founder Vivek Garipalli as part of a succession plan.
Changes are ahead for Clover Health, which announced president and co-founder Andrew Toy will be the new CEO from the start of next year.
Toy will transition into the role while current CEO and founder Vivek Garipalli continues his responsibilities as executive chairperson and works closely with Toy in what the company is calling an "inherently symbiotic" relationship.
Garipalli revealed the move is the culmination of a succession plan Clover has had in place since Toy joined as CTO and led the development of Clover Assistant.
"Andrew is a unique technologist and business strategist," Garipalli said in a statement. "He's a true founder in every sense of the word — having built companies from scratch, he has an abundance of grit needed to solve the hardest problems in healthcare. He has the fastest learning speed of anyone I've ever met, and I believe his transition to CEO will give Clover a strategic edge overnight that will only continue to pay dividends for our mission moving forward."
Toy stated Garipalli will continue at the company in a more strategic fashion.
"While Vivek would no doubt continue to be an incredibly successful CEO of Clover for years to come, I know that his true passion is big picture strategy and the rapid, scrappy uncertainty that exists in the building stages of a company," Toy said. "In this more strategic role, he can continue to lean into his strengths and bring outsized value to Clover and to me as CEO."
Clover announced the executive move on the same day it released its second quarter financial report, which showed a significant rise in year-over-year revenue dampened by skyrocketing operating expenses.
Second quarter revenue was $846.70 million, compared to $412.47 million over the same period in 2021, but total operating expenses also shot up from $594.33 million in Q2 of last year to $949.25 million for this year.
The result was a net loss of $104.18 million, which is down from the $317.61 million lost in the second quarter of 2021.
"Our focus on building a sustainable, intelligent growth engine has led to a reduction in MCRs and improvement in operational efficiencies which we believe is the foundation of our progress toward profitability." Toy said in a statement.
He added: "Our technology platform is moving from strength to strength as Clover Assistant penetration continues to show significant growth. We believe there is tremendous opportunity and potential to continue iterating and advancing Clover Assistant's clinical capabilities. We believe each improvement supports physicians in catching and treating conditions earlier to increase the health and well-being of their patients while simultaneously reducing costs for the healthcare system."
The group is asking CMS to provide an appropriate timeline for layering new surprise billing requirements, which have created administrative burden for providers.
The Medical Group Management Association (MGMA) is pushing HHS and CMS to give providers at least six months' notice before enforcing any additional requirements for the No Surprises Act.
Several aspects of the surprise billing mandate went into effect on January 1 of this year, including federal protections against balance billing, uninsured and self-pay good faith estimate (GFE) requirements, continuity of care protections, and provider directory requirements. While the policies have been beneficial for patients, MGMA says the requirements have created administrative burden for providers as the interim final rules were published with minimal time before implementation.
With HHS and CMS indicating additional rulemaking will be published related to the advanced explanation of benefits (AEOB) requirements, continuity of care protections, and provider directory requirements, MGMA recommends an appropriate timeline for implementation and enforcement.
"MGMA recognizes the statutory requirements and the urgency to prevent any further delays in patient access to this information, however, we believe that existing cost estimate information provided by both insurers and practices can adequately ensure patients are aware of cost estimate information prior to the implementation of the AEOB requirements," the group writes in a letter to HHS secretary Xavier Becerra and CMS administrator Chiquita Brooks-LaSure.
"Similarly, group practices have been complying with the continuity of care protections and provider directory requirements in a good faith, reasonable effort according to the statute since January 1, 2022."
MGMA cites a recent member educational webinar in which 58.2% of respondents said additional guidance on state vs. federal surprise billing requirements is necessary, while 54.2% wanted additional guidance on the uninsured and self-pay GFE requirements, and 41.2% wanted additional guidance on the prohibition on balance billing.
Additionally, MGMA is asking HHS and CMS to delay the implementation of the convening and co-provider requirements related to the uninsured and self-pay GFE requirements, set to take effect on January 1, 2023.
Over 60% of MGMA members need more guidance on the convening and co-provider requirements before they go into effect to properly implement the policy, the group states.
"These new mandates require significant time to understand and implement," MGMA writes. "Group practices are currently facing significant staffing shortages, record-breaking inflation, and significant reductions in Medicare payment."
The health solutions company reported net income of $2.95 billion, a significant increase from the $2.78 billion posted in the second quarter of 2021, while revenue rose to $80.64 billion, compared to $72.62 billion over the same period last year.
For the year, CVS Health has brought in $157.5 billion in total revenue, up 11% from 2021, illustrating that the company's strategy of adding more health services is delivering results.
"Despite a challenging economic environment, our differentiated business model helped drive strong results this quarter, with significant revenue growth across all of our business segments," CVS Health president and CEO Karen Lynch said in a statement. "The continued success of our foundational businesses accelerated our strategy to expand access to health services and help consumers navigate to the best site of care."
CVS Health also revealed its plans of expanding individual coverage under the Affordable Care Act to four new states in 2023.
The news was delivered in the company's earnings call, in which Lynch announced the company's Medicare Advantage membership hit the 2 million milestone in the second quarter, including dual eligibles.
"As we continue to build our individual exchange business, we're on track to expand coverage where we currently have individual exchange offerings and are obtaining final approval to add four new states to our portfolio, bringing our total to 12 states," Lynch said.
Both hospital groups stressed the importance of the waivers for providing care to patients during the COVID-19 pandemic, as well as allowing providers the necessary flexibility during a difficult climate rife with challenges such as the labor shortage.
In the letter to HHS secretary Xavier Becerra, FAH urged for the PHE to be renewed another 90 days when it expires in October, with another 90 day-day extension in the works if necessary. AHA, meanwhile, asked for the PHE to be continued without specifying a renewal length in their penned response.
Pointing to the waivers specifically, AHA outlined several benefits for patients and providers, including hospital-bed flexibilities and relief from administrative burdens.
"Additionally, the PHE declaration has allowed for several critical coverage and hospital payment policies, including a 20% DRG add-on payment for COVID-19 patients, new technology add-on payments for new COVID-19 therapeutics, an enhanced Federal Medical Assistance Percentage (FMAP) rate of 6.2% for states," AHA wrote. "Ending the PHE prematurely would place our hospitals in an extremely challenging position and would directly affect our ability to care for our patients and communities."
AHA cited responses from hospitals and health systems to their survey, which showed that 93% of respondents said their hospitals would be impacted if the waivers were rolled back, with 60% indicating it would be significant. Another 89% said they still depend on the flexibilities provided by the waivers to deliver needed care.
FAH argued that the waivers have transformed the healthcare system by encouraging new technologies to modernize delivery of care and accelerating adoption of alternative care models.
In the letter, FAH also listed key waivers and policies that it wants made permanent, spanning remote services, clinical services, lab services, discharge planning, behavioral health, physician self-referral, workforce, and increased capacity.
"Indeed, the PHE has already served as a bridge to CMS' efforts, which we strongly endorse, to transform certain temporary waivers into permanent Medicare policy, some of which may require Congressional action to avoid any disruptions," FAH stated.
Several groups have backed the Seniors' Timely Access to Care Act, which will now head to the House floor.
The Seniors' Timely Access to Care Act continues to receive support as it moves to the full House after the House Ways and Means Committee unanimously voted to advance the bill.
The voice vote now tees up the legislation for a floor vote in the fall, with the bill receiving over 300 co-sponsors and the endorsement of over 500 organizations.
If passed, the bill would establish requirements and regulations for prior authorization under Medicare Advantage plans, such as establishing an electronic prior authorization program that includes the ability to provide real-time decisions in response to requests for items and services.
Several groups, from providers and payers alike, have advocated for the bill to improve the streamlining of the administrative process.
"These policies to streamline MA prior authorization requirements by eliminating complexity and promoting uniformity would reduce the wide variation in prior authorizations methods that frustrate both patients and providers. Thank you for your support to improve the prior authorization process to increase patient access to care and reduce burden for providers."
"Most importantly, the additional sections of the legislation mandating MA plans to issue faster prior authorization decisions are crucial policy improvements that will ensure more timely access to care and, as a result, improved patient health care outcomes and better stewardship of scarce Medicare resources. The AMA supports the requirements for health plans to provide real-time prior authorization decisions for routinely approved services, as defined in implementing regulations."
“MGMA strongly supports the Improving Seniors’ Timely Access to Care Act of 2022," said Anders Gilberg, senior vice president of Government Affairs at MGMA. "If enacted, this legislation would significantly improve a prior authorization process that is overused, costly, onerous, inefficient, opaque, and, most critically, responsible for dangerous delays in the delivery of necessary patient care. By establishing an electronic prior authorization program for Medicare Advantage (MA) plans, medical groups will have less administrative burden and can appropriately focus attention back on the patient."
“H.R. 8487 will build on the work the Medicare Advantage community has already undertaken to modernize prior authorization while protecting its essential function in facilitating highvalue, clinically appropriate care," said Mary Beth Donahue, president and CEO of the Better Medicare Alliance. "We urge members of the Ways and Means Committee to vote ‘yes’ and look forward to continuing to partner with our bipartisan champions in Congress to secure passage of this bill on the House floor in short order.”
The company suffered a rough second quarter with decreases across the board year over year.
"Challenging operating dynamics" between lower than anticipated volume and significant contract labor costs resulted in a difficult second quarter of the year for Community Health Systems.
The Franklin, Tennessee-based company reported a net loss of $326 million in its Q2 earnings report, which marks a sizeable decline from the $6 million in net income over the same period in 2021.
Operating revenue, meanwhile, was $2.93 billion, representing a 2.4% decrease compared to $3 billion last year.
Expenses increased year over year from $2.69 billion to $2.82 billion, and Community Health Systems CEO Tim Hingtgen attributed much of that to contract labor costs driven by the labor market and inflationary pressures.
He also pointed to lower volume, as admissions decreased 3.5% from 111,543 to 107,805 year over year, while adjusted admissions dropped by 0.5% from 248,013 to 247,119.
Hingtgen expressed optimism for a bounce back in admission volume, as well as in strategies to combat the labor issue.
"We have initiatives underway intended to actively address these pressures by accelerating strategic growth opportunities in key markets, aggressively working to recruit and retain permanent staff to replace contract labor, achieving incremental expense reductions, and leveraging our centralized resources to achieve improved results," Hingtgen said in a statement.
"Over the past several quarters, we have made strategic investments in our markets, and we continue to believe we are well-positioned to meet healthcare demand and take market share as patient volumes return. We are committed to intense operational execution, and we remain confident that our strategies will deliver long-term growth and value."
The 83-hospital system did complete the divestiture of one hospital in July, but received the proceeds at a preliminary closing for the second quarter.
The proposed rule will prohibit discrimination on the basis of race, color, national origin, sex, age, and disability in healthcare programs and activities.
The Biden administration is seeking to reinstate nondiscrimination protections for individuals under Section 1557 of the Affordable Care Act, which would strengthen civil rights limited during the Trump era.
HHS announced the proposed rule will prohibit discrimination on the basis of race, color, national origin, sex, age, and disability for certain health programs and activities. It will also interpret Medicare Part B as federal financial assistance for the first time, ensuring the protections are applied more broadly.
The 2020 version of the rule under the Trump administration limited its scope and power and rolled back nondiscrimination protections from the Obama era, specifically on gender identity and the termination of a pregnancy. It received major pushback at the time from individuals and groups, such as the American Hospital Association and the American Medical Association.
The newly proposed rule makes clear that discrimination on the basis of sex includes discrimination on the basis of pregnancy or related conditions, including pregnancy termination, HHS stated.
"Everyone in America should be able to get the care that they need from any health provider in the country, especially if that provider is receiving funding from HHS," secretary Xavier Becerra said on a call with reporters.
“We want to make sure that Americans are free from discrimination when they try to access the care that they need."
The proposed rule also addresses requirements for providers and health plans:
Clarifies the application of Section 1557 nondiscrimination requirements to health insurance issuers that receive federal financial assistance.
Requires entities to provide a notice of nondiscrimination along with an notice of the availability of language assistance services and auxiliary ads and services.
Explicitly prohibits discrimination in the use of clinical algorithms to support decision-making in covered health programs and activities.
Refines and strengthens the process for raising conscience and religious freedom objections.
Comments on the proposed rule are due 60 days after publication.
Critical access hospitals (CAHs) have not had to abide by the rule in recent years due to financial strains and COVID, but there is concern of future enforcement.
In a letter to HHS, a bipartisan group of 25 House members has asked for clarification on the enforcement of Medicare's 96-hour payment rule for CAHs after the COVID-19 public health emergency (PHE).
The members, in their written remarks to HHS secretary Xavier Becerra, conveyed the potential ramifications of the rule if it is not continued to be waived as it has during the PHE to help CAHs survive the impact of the pandemic.
Established through the Balanced Budged Act of 1997, the rule requires CAHs to certify inpatients will be discharged or transferred to another hospital within 96 hours of admission to receive payment. CAHs are also required to ensure inpatient stays are below 96 hours on an annual average basis.
After COVID surged, the rule became nearly untenable as many patients required long hospital stays. However, even before the pandemic, the members argue that the rule put CAHs in difficult positions which resulted in patients not receiving care or being forced into unnecessary transfers to other facilities, while the hospitals often had to forego payment.
"Even after the PHE formally ends, COVID and other respiratory diseases are likely to cause some patients to need hospitalizations lasting longer than 96 hours," the representatives wrote. "These and other patients who can safely and effectively be treated in their local hospital deserve the option of receiving care closer to their homes, families, and usual doctors."
Though the 96-hour rule has not been enforced in the last several years, the members express concern that the end of the PHE will mark a return.
Specifically, they seek answers to the following five questions by September 9:
Upon termination of the COVID-19 PHE, do you intend to reinstate enforcement of the 96-hour conditions of participation or payment?
What rationale was employed in determining whether the condition(s) would be enforced following the PHE?
If either condition will be enforced after the end of the PHE, will there be a grace or phase-in period before penalties will be applied to CAHs that fail to meet the condition(s)?
What impact do you believe enforcement would have on the outcomes of patients hospitalized for treatment of COVID-19, pneumonia, and other acute respiratory infections?
Do you support legislative efforts to repeal either or both of the 96-hour conditions?
With the PHE set to end on October 13, governing bodies of healthcare need to consider what a post-COVID landscape looks like and how the enforcement of a rule like the 96-hour stipulation would impact providers and patients.
The health system survived a bumpy start to the year dealing with contract labor and other expenses.
Profits were down for HCA Healthcare in the second quarter of the year as compared to Q2 of 2021, but the health system pointed to declining costs as reason for optimism for the remainder of the year.
The Nashville, Tennessee-based facility operator announced net income of $1.15 billion in its Q2 earnings report, a fall from the $1.45 billion it raked in during the same period last year.
Revenue, however, was up year over year, with $14.82 billion earned over the past three months, compared to $14.43 billion in 2021.
Meanwhile, same facility admissions declined 1.2% and same facility equivalent admissions increased 0.5% in Q2, compared to last year.
"Many aspects of our business were positive considering the challenges we faced with the labor market and other inflationary pressures on costs," said Sam Hazen, CEO of HCA Healthcare. "Our teams executed well as they have in the past through other difficult environments."
In the earnings call, HCA Healthcare leaders said operating costs were flattening from the highs during earlier stages of the COVID-19 pandemic.
Labor contracts usage, in particular, fell in Q2 and is expected to continue declining through the rest of the year, alleviating some of the expenses on the bottom line.
HCA Healthcare CFO Bill Rutherford said in the call: "[Contract labor] was at a peak high in the first quarter really due to the COVID services, and we anticipated to be able to see sequential improvement. And indeed, that's what we saw. We thought it would first start with being able to modify the rates that we were seeing in the market in terms of the average early rate. And indeed, we saw that and we were able to execute on that as the quarter went through.
"We finished with June at rates we were anticipating when we reset our guidance after quarter. And I think over the course of the year, we'll continue to see hopefully a reduction in the utilization of that contract labor."
