It is estimated that the Republican plan to repeal and replace the Affordable Care Act would reduce federal Medicaid spending by $880 billion over the next 10 years. That would have a devastating effect, particularly in rural America.
As many as 24 million Americans could lose their health insurance over the next decade if the American Health Care Act is enacted. That's according to the nonpartisan Congressional Budget Office's staggering assessment of the Republican plan to repeal and replace the Affordable Care Act.
The CBO says most of that savings would come from reductions in federal Medicaid spending, which would amount to $880 billion over the 10-year span, in part because of a shift to a per-capita, capped entitlement. That estimate does not include the billions of dollars in state Medicaid matching funds cuts that are likely when the federal dollars disappear.
It has been widely reported that the AHCA's ill-effects would be felt mostly by older, rural Americans (ironically, a key demographic for President Donald Trump.) We can well imagine what will happen to the quality of life for millions of Americans who may find themselves without healthcare coverage if the ACA's Medicaid expansion is repealed and alternative coverage becomes unaffordable.
Beyond that debacle, imagine how a $880 billion funding loss in the public healthcare safety net is going to be absorbed by thousands of hospitals across the United States, many of which are already under financial duress.
The demand for healthcare services doesn't evaporate when the funding dries up. These tens of millions of newly uninsured people will access care through the emergency department, just as they did before Obamacare.
Unintended Consequences
As bad debt and uncompensated care soar, how many of these hospitals will shutter, and what will the impact of those closures mean, not just on care access, but on the economic vitality of the communities these hospitals serve?
This is a major unintended consequence that American Health Care Act fails to acknowledge. Medicaid is not just a healthcare program.
It is also one of the largest infrastructure and economic development programs that the federal government has ever devised. Instead of building roads, railroad tracks, bridges and dams, Medicaid provides a vital funding stream (however paltry the reimbursement) that keeps the doors open at many hospitals in rural America.
Community Impact
Community and critical access hospitals are economic engines for the communities they serve. They are often one of the largest employers in town, and the dollars that fund those relatively steady, well-paying hospital and ancillary jobs churn through the local grocery store, the car dealership, the restaurants, the hair salon, and the furniture store, and boost local sales and property taxes.
Beyond that, a healthy hospital is a critical component in every community's business recruiting portfolio. When the local hospital closes the doctors leave, the local healthcare infrastructure withers, and prospects for attracting industry dwindle. Why would any industry locate to a town that's incapable of supporting something as fundamental and vital to community life as a hospital?
It's also possible that the CBO estimates are too rosy, because their focus is the effect on the federal budget. If federal Medicaid dollars go away, states very likely will not increase their funding match to account for the difference.
Plight of the Poor and Sick
More likely, if Medicaid is transformed into a per-capita, capped program under the ACHA, there may not be sufficient federal oversight or leverage to ensure that states maintain adequate funding levels.
As in Congress, the poor and sick don't carry much weight in state capitols.
It is no small irony that the nearly $1 trillion in proposed cuts to Medicaid mandated by the AHCA came just one week after President Trump unveiled a $1 trillion infrastructure plan that was embraced as a job-creating stimulus plan by most pols and pundits.
The nation's transportation grid needs a significant investment. Cannot the same argument be made for the nation's healthcare delivery grid, a job-creating economic engine that powers rural America?
We should debate whether the United States should continue to spend close to 20% of its gross domestic product on healthcare. There is plenty of waste in the nation's healthcare delivery system, and every dollar that is spent on healthcare is a dollar that is not spent on other vital areas, such as education.
Argue the case, but acknowledge the risk when healthcare funding is slashed.
Electronic medical records systems can provide clinicians with reams of patient information, but the management of EHR data leads the list of concerns raised by healthcare provider organizations.
Lorraine B. Possanza, program director for ECRI's Partnership for Health IT Patient Safety, says the troves of patient information now available have created a new set of challenges for providers.
"The object is still for people to have the information that they need to make the best clinical decision," Possanza said in a statement released by ECRI. "Health information needs to be clear, accurate, up-to-date, readily available, and easily accessible."
Implementation and Use of Clinical Decision Support
Test Result Reporting and Follow-Up
Antimicrobial Stewardship
Patient Identification
Opioid Administration and Monitoring in Acute Care
Behavioral Health Issues in Non-Behavioral-Health Settings
Management of New Oral Anticoagulants
Inadequate Organization Systems or Processes to Improve Safety and Quality
ECRI uses its Patient Safety Organization event data to compile the list, which is based on concerns raised by healthcare provider organizations.
"The 10 patient safety concerns listed in our report are very real," says Catherine Pusey, RN, associate director, ECRI Institute PSO. "They are causing harm—often serious harm—to real people."
No. 2 on the list, unrecognized patient deterioration, remains a top concern, despite improved clinical protocols, training and education for providers, and public awareness campaigns that have enabled speedier recognition of, and response to, stroke and ST-elevation myocardial infarction.
"People have seen how well the campaigns have worked for stroke and STEMI and how much they've improved outcomes," says Patricia N. Neumann, RN, senior patient safety analyst and consultant, ECRI Institute.
"What if those same principles could be applied to other conditions that require fast recognition and management? We could have a big impact on improving outcomes."
No. 3 on the list, implementation and use of clinical decision support systems, encompasses "tools that we use to ensure that the right information is presented at the right time within the workflow," says Robert C. Giannini, and ECRI patient safety analyst and consultant. If implementation or use is suboptimal, however, opportunities for CDS to aid decision-making may be missed, care could suffer, and patient harm could result.
The list and guidance are designed to help providers identify priorities and create corrective action plans. ECRI Institute says provider organizations should adapt relevant patient safety interventions to meet each care setting.
Bond raters believe the American Health Care Act's funding changes for Medicaid, combined with the removal of the individual mandate and other changes to insurance markets, would reduce healthcare spending for the federal government and reduce revenues for hospitals.
A House proposal that would shift Medicaid from an open-ended to a per-capita entitlement program would reduce federal spending on healthcare, but harm hospitals' margins, the bond rating agencies believe.
"Operating revenues and margins for for-profit and not-for-profit hospitals are likely to be pressured by the passage of the legislation as proposed," S&P Global Ratings said in a research brief issued Wednesday.
"The overall payer mix for providers would weaken as the number of people without insurance would most likely rise as would the hospital sector's level of bad debt and charity care expenses," S&P said.
"Under the proposed bill, minimum insurance requirements will be diluted, and coupled with the elimination of the mandate to buy coverage, we believe preventive care may decrease leading to higher costs over the longer term. In additional the further growth in high-deductible plans that is likely, combined with greater levels of uninsured people, could result in higher health care costs to consumers."
S&P says that the not-for-profit health care sector is stable but already faces operating pressures because of weaker reimbursement growth owing to the movement to value-based reimbursements and rising labor costs.
"The passage of this legislation as proposed would in our view add to the stress in the sector and could lead to a negative outlook over time, especially for safety net providers which are especially vulnerable to Medicaid reductions," S&P says.
Those concerns were mostly echoed by Moody's Investors Service in its analysis.
"Importantly, the legislation does not repeal Medicaid expansion; states would be allowed to maintain expanded Medicaid eligibility, but they would bear a greater share of the costs starting in 2020," Moody's says.
"We expect that federal payments will grow more slowly than Medicaid program costs, forcing states to make changes that would likely be credit negative for hospitals, including lowering payments to hospitals and other providers, reducing coverage or benefits and reducing targeted payments to safety-net hospitals."
Credit-negative for Hospitals
Moody's says changes in the federal allocation of subsidies in the individual insurance markets would be a credit negative for hospitals.
"We believe that the effect of older enrollees losing coverage will outweigh the positive effect of younger people gaining coverage given that older people have greater healthcare needs and as they lose coverage, hospitals would incur greater uncompensated care and bad-debt costs," Moody's says.
Ending the individual mandate won't be calamitous for hospitals because most gains in insurance coverage under the ACA came through the expansion of Medicaid, Moody's says.
"Repealing the individual mandate would be credit negative for hospitals because some individuals would drop insurance coverage if they no longer face a financial penalty for not purchasing insurance," Moody's says.
"However, the credit effect on hospitals is not material given that the current financial penalties for not purchasing insurance are too small to compel many young and relatively healthy people to buy insurance."
The American Hospital Association was one of the first in a growing number of major healthcare lobbies to pan the House GOP less than one day after the bill was made public.
"We believe that any changes to the Affordable Care Act must be guided by ensuring that we continue to provide healthcare coverage for the tens of millions of Americans who have benefitted from the law," AHA President and CEO Richard J. Pollack said in a letter to Congress.
"We believe the legislation needs to be reviewed through this lens, and carefully evaluated regarding its impact on both individuals and the ability of hospitals and health systems which are the backbone of the nation's healthcare safety net in terms of our ability to care for all of those who walk through our doors."
America's Essential Hospitals offered conditional praise for some parts of the AHCA, particularly the repeal of cuts to disproportionate share payments for safety net hospitals. However, concerns about the negative effects of the reformed funding mechanisms for Medicaid and other changes to the individual coverage market outweighed the benefits.
AMA Opposes GOP Plan
In a letter Wednesday to House leaders, Essential Hospitals CEO and President Bruce Siegel, MD, urged them to withdraw the AHCA until the Congressional Budget Office can provide a nonpartisan estimate of costs and coverage implications.
The American Medical Association has also made clear its opposition to the House plan.
"While we agree that there are problems with the ACA that must be addressed, we cannot support the AHCA as drafted because of the expected decline in health insurance coverage and the potential harm it would cause to vulnerable patient populations," AMA CEO James L. Madara, MD, said in a letter to House leaders.
An initial review shows that the American Health Care Act does little to address healthcare access woes in rural America.
House Republicans this week made public their replacement plan for the Affordable Care Act. The so-called American Health Care Act does not have much support beyond House leadership, but before it collapses under relentless blowback from all corners, let's look at what it might have done for rural health.
Maggie Elehwany, government affairs and policy vice president at the nonpartisan National Rural Health Association, is still sifting through the fine print, but she offered a few thoughts after an initial reading of the proposed law.
"Our concern is that it does nothing to address basic access issues," she says.
"We're in the midst of a rural hospital closure crisis, where at the current rate of closure we are going to lose 25% of all rural hospitals in this country in less than a decade if Congress doesn't act. One in three rural hospitals is currently at financial risk and is vulnerable to closure. That is what we need to see in any healthcare reform bill."
"Because this bill specifically reformats Medicaid, we would have liked to have seen them address Medicaid equity for rural providers," Elehwany says.
"We have concerns over the phasing out of the FMAP and introducing the per capita cap. We strongly support the federal government's maintaining its moral obligation to ensure that Medicaid funding goes to needed populations. Rural America is disproportionately dependent upon Medicaid. They are poorer, they are sicker, they are per capita older."
To be clear, the plight of rural hospitals predates the American Health Care Act, but states that refused to expand Medicaid under the ACA didn't do their rural hospitals any favors either. Elehwany says non-expansion states are still contending with high percentages of uninsured citizens.
"If you are a rural state, more likely than not you didn't expand Medicaid, but they are still showing up in hospitals sick and these small, rural hospitals are subsidizing care," she says.
"Additionally, in the exchanges we saw that rural Americans were mostly buying bronze plans, maybe not realizing how high the deductible was, but they couldn't afford their insurance. So, they're still showing up in the emergency room, still getting sick, not being able to be treated. Those bad debt cuts are really harming rural providers. We would like to see that addressed."
Improving access to healthcare in rural America isn't simply a matter of expanding health insurance, which remains a valid criticism of the ACA.
"Just because you have an insurance card doesn't mean you can access care," Elehwany says.
"And like we saw the high-deductible plans on the federal exchanges, it didn't mean you could actually afford your healthcare coverage. It didn't mean that, with the workforce shortages that are plaguing rural America, you could find a doctor in your rural community."
A Matter of Access
"Twenty percent of the U.S. population lives in a rural community, but only 9% of physicians practice there. It doesn't mean that you can access care if you live in a community where your rural hospital has closed, and now you have to drive 50 miles to the nearest emergency room," she says.
"It doesn't mean that you can access care if the plan you purchased has a narrow network created by the insurance company and you can't go to your local provider."
NRHA also has concerns about the per capita Medicaid funding scheme proposed in the House bill.
"We don't have a specific policy on a per capita cap, which looks like the movement in the House bill. We're trying to develop that rapidly and probably will have concerns that the federal government shouldn't abdicate oversight authority to ensure that federal tax dollars go to the neediest populations," Elehwany says.
"You can certainly have local and state control. We just don't want to see the federal government abdicate all its authority."
Elehwany found some positives for rural health in the House bill.
"It does look like there is safety net funding; $10 billion over five years. We strongly hope that that money is going to be targeted to help the safety net of rural America," she says.
"The bill summary says non-expansion states would receive an increased matching rate of 100% for calendar years 2018 through 2021, and then it would be reduced to 95%. So, it looks like they are trying to help states that haven't expanded Medicaid, which is a good thing."
"Is that going to do enough? We're concerned about that. We would love to see them allow safety net providers to have cost-based reimbursement in Medicaid similar to how they have cost-based reimbursement in Medicare, and have that enhancement come through the federal funding."
Let's Be Blunt
The ink is still wet on this bill, but it is DOA, even before the Congressional Budget Office has scored it. Democrats are unified in opposition, as are powerful lobbies, including the American Hospital Association, which has influential members in every Congressional district.
Republicans have majorities in the House and Senate, but intraparty support is already splintering and it's not going to coalesce in the coming weeks as the costs and other unsavory details emerge, even as leadership fast-tracks the bill.
For moderate Republicans, the bill goes too far. For conservatives, it doesn't go far enough. So far, President Trump has offered only tepid support.
However slim its chances, the American Health Care Act remains the most aggressive attempt to fundamentally revise Medicaid since its creation in 1965, so it bears watching.
The study finds gains in quality of hospital care and slower cost growth over five years, which analysts say may be a harbinger of future trends as more hospitals shift from fee-for-service payment models.
Truven Health Analytics has named its 100 Top U.S. hospitals for 2017.
The annual five-year trend analysis is based on overall organizational performance between 2011 and 2015, and uses markers such as inpatient mortality and complication rates, 30-day readmissions, and lengths of stay.
The analysis also found that cost growth was flat for most of the hospitals.
"The hospital industry's ongoing transition from fee-for-service to value-based care appears to be bearing some positive results for both patients and payers," Jean Chenoweth, senior vice president at Truven Health Analytics, said in remarks accompanying the list.
"The magnitude of improvement we've observed over the last five years is greater than any other five-year period we've tracked," she said.
"On top of that, this year's winners have reached new highs in performance in comparison to peers across the country, which suggests that improvement in value from hospitals is likely to continue."
Nationwide Benchmarks
The 100 Top Hospitals study calculates five-year changes in performance on an annual basis. This directional performance data provides a granular look at where U.S. hospitals are showing the most significant improvement, and where performance has plateaued or declined.
Some of the most noteworthy trends in overall hospital performance include:
Improved 30-Day Readmission Rates: One of the most closely watched quality metrics, 30-day readmission rates, has shown improvement in 52% of hospitals over the past five years. That rate has stayed flat in 48% of hospitals and worsened in .1% of hospitals.
Improved Mortality Index: The risk-adjusted mortality showed improvement in 21% of hospitals, remained steady in 79% of hospitals, while only 0.1% of hospitals saw an increase in mortality.
Shorter Average Length of Stay: The severity-adjusted average length of stay improved in 18% of hospitals over the same time period. That rate held steady in 76% of hospitals and worsened in 6% of hospitals.
Flat Inpatient Expenses: The average cost of treating an inpatient over five-years improved in 2% of hospitals, held flat in 79% of hospitals, and worsened in 19% of hospitals.
Top 100 Benchmarks Exceed Peers
The 100 Top Hospitals winners' performance and improvement was markedly better than that of peers, including mortality index rates that were 23% better and complications index rates that were 17% better.
This was achieved while incurring inpatient expenses that were 9% lower.
Truven estimates that if all Medicare inpatients received the same level of care as those treated in its 100 Top Hospitals:
Nearly than 89,000 additional lives could be saved;
Over 61,000 additional patients could be complication free;
Over $5.6 billion in inpatient costs could be saved;
The average patient stay would decrease by half a day;
Over 300,000 fewer discharged patients would be readmitted within 30 days;
Patients would spend nine minutes less in hospital emergency departments per visit.
Truven, a subsidiary of IBM Watson Health, evaluates clinical and operational performance in 11 areas: inpatient mortality; 30-day mortality rate; complications; core measures; 30-day risk-adjusted readmission rate; severity-adjusted average length of stay; mean emergency room throughput; inpatient expense per discharge; Medicare spend per beneficiary; adjusted operating profit margin; and Hospital Consumer Assessment of Healthcare Providers and Systems score. The study has been conducted annually since 1993.
Major Teaching Hospitals
Advocate Lutheran General Hospital – Park Ridge, IL
Baptist Medical Center Jacksonville – Jacksonville, FL
Beaumont Hospital - Royal Oak – Royal Oak, MI
Emory University Hospital – Atlanta, GA
Houston Methodist Hospital – Houston, TX
NorthShore University HealthSystem – Evanston, IL
Northwestern Memorial Hospital – Chicago, IL
Ochsner Medical Center – New Orleans, LA
OhioHealth Doctors Hospital – Columbus, OH
Providence - Providence Park Hospital – Southfield, MI
SSM Health St. Mary's Hospital – St. Louis, MO
St. Joseph Mercy Hospital – Ann Arbor, MI
St. Luke's University Hospital - Bethlehem – Bethlehem, PA
University of Colorado Hospital – Aurora, CO
University of Utah Health Care – Salt Lake City, UT
Teaching Hospitals
Adventist Medical Center Hinsdale – Hinsdale, IL
Aspirus Wausau Hospital – Wausau, WI
Beaumont Hospital - Grosse Pointe – Grosse Pointe, MI
Bethesda North Hospital – Cincinnati, OH
Billings Clinic Hospital – Billings, MT
BSA Health System – Amarillo, TX
Franciscan Health Indianapolis – Indianapolis, IN
IU Health Ball Memorial Hospital – Muncie, IN
Kendall Regional Medical Center – Miami, FL
Lancaster General Hospital – Lancaster, PA
LDS Hospital – Salt Lake City, UT
Mercy Health Saint Mary's – Grand Rapids, MI
Mercy Hospital St. Louis – St. Louis, MO
Newton-Wellesley Hospital – Newton, MA
Park Nicollet Methodist Hospital – St. Louis Park, MN
Parkview Regional Medical Center – Fort Wayne, IN
Poudre Valley Hospital – Fort Collins, CO
Riverside Medical Center – Kankakee, IL
Rose Medical Center – Denver, CO
Sentara Leigh Hospital – Norfolk, VA
St. Cloud Hospital – St. Cloud, MN
St. Luke's Boise Medical Center – Boise, ID
St. Mary's Hospital – Madison, WI
St. Vincent Healthcare – Billings, MT
The Christ Hospital Health Network – Cincinnati, OH
Large Community Hospitals
Advocate Condell Medical Center – Libertyville, IL
Asante Rogue Regional Medical Center – Medford, OR
Chandler Regional Medical Center – Chandler, AZ
Chester County Hospital – West Chester, PA
CHRISTUS Mother Frances Hospital Tyler – Tyler, TX
EvergreenHealth Kirkland – Kirkland, WA
FirstHealth Moore Regional Hospital – Pinehurst, NC
Florida Hospital Memorial Medical Center – Daytona Beach, FL
Henrico Doctors' Hospital – Richmond, VA
Logan Regional Hospital – Logan, UT
Memorial Hermann Memorial City Medical Center – Houston, TX
Mercy Hospital – Coon Rapids, MN
Mosaic Life Care – Saint Joseph, MO
North Florida Regional Medical Center – Gainesville, FL
Roper Hospital – Charleston, SC
Scripps Memorial Hospital La Jolla – La Jolla, CA
St. David's Medical Center – Austin, TX
St. Francis Downtown – Greenville, SC
WellStar West Georgia Medical Center – LaGrange, GA
West Florida Hospital – Pensacola, FL
Medium Community Hospitals
American Fork Hospital – American Fork, UT
Baptist Medical Center Beaches – Jacksonville Beach, FL
Baylor Scott & White Healthcare - Round Rock – Round Rock, TX
Blanchard Valley Hospital – Findlay, OH
Bon Secours St. Francis Hospital – Charleston, SC
Chino Valley Medical Center – Chino, CA
Clermont Hospital – Batavia, OH
Dupont Hospital – Fort Wayne, IN
Fairview Park Hospital – Dublin, GA
Holland Hospital – Holland, MI
Inova Fair Oaks Hospital – Fairfax, VA
Medical Center of the Rockies – Loveland, CO
Mercy Medical Center – Cedar Rapids, IA
Ochsner Medical Center - Baton Rouge – Baton Rouge, LA
Saint Alphonsus Medical Center - Nampa – Nampa, ID
Sherman Oaks Hospital – Sherman Oaks, CA
St. Vincent Carmel Hospital – Carmel, IN
Sycamore Medical Center – Miamisburg, OH
Texas Health Harris Methodist Hospital Southwest Fort Worth – Fort Worth, TX
West Valley Medical Center – Caldwell, ID
Small Community Hospitals
Alta View Hospital – Sandy, UT
Aurora Medical Center – Two Rivers, WI
Aurora Medical Center – Oshkosh, WI
Fairview Northland Medical Center – Princeton, MN
Franklin Woods Community Hospital – Johnson City, TN
Hawkins County Memorial Hospital – Rogersville, TN
Henry Community Health – New Castle, IN
Lakeview Hospital – Bountiful, UT
Lakeview Hospital – Stillwater, MN
Lakeview Medical Center – Rice Lake, WI
Oaklawn Hospital – Marshall, MI
OSF Saint James - John W. Albrecht Medical Center – Pontiac, IL
Parkview Huntington Hospital – Huntington, IN
Spectrum Health United Hospital – Greenville, MI
Spectrum Health Zeeland Community Hospital – Zeeland, MI
St. John Owasso Hospital – Owasso, OK
St. Joseph Mercy Livingston Hospital – Howell, MI
Texas Health Harris Methodist Hospital Alliance – Fort Worth, TX
Waynesboro Hospital – Waynesboro, PA
Yampa Valley Medical Center – Steamboat Springs, CO
Farzad Mostashari, MD, the former National Coordinator for Health IT at the Department of Health and Human Services, and Martin S. Gaynor, a professor of economics and health policy, discuss how policy helps and/or harms competition in the healthcare marketplace.
Despite the near-universal agreement that the U.S. healthcare delivery system should remain market-based, there has been surprisingly little talk amongst government policy makers and private payers about the potential for stifling competition with over-regulation.
An essay this month in JAMAcalls for a re-examination of how healthcare rules, regulations, and policies help or harm competition in the healthcare marketplace.
Farzad Mostashari, MD, the former National Coordinator for Health IT at the Department of Health and Human Services, and Martin S. Gaynor, a professor of economics and health policy at Carnegie Mellon University, two authors of the essay, spoke with HealthLeaders last week. The following is a lightly edited transcript.
HLM: When is consolidation in healthcare good?
Mostashari: Healthcare consolidation can be good when the integration leads to the larger organization taking on the work of truly integrated patient care experience.
In particular, as we are entering into this realm of moving from volume to value, when that larger organization uses those efficiencies that are often promised but rarely delivered to actually provide more value, whether it's for the taxpayer, the government, the employer or the individual.
Unfortunately, the evidence to date does not support a whole lot of that kind of good consolidation. On average those entities that have consolidated have increased prices, but not increased quality.
Gaynor: It's important to remember that consolidation is not integration. Consolidation is change of ownership. Integration is really working together and becoming a single organization working to one purpose in a coordinated way.
Simply buying another firm doesn't mean that that post-acquisition that the two entities actually become integrated and coordinated.
HLM: Is there an overarching reason that is pushing healthcare consolidation/integration?
Mostashari: There are payment policies in particular that are literally distorting the economics of healthcare such that they push small and independent practices into employment or other owned arrangements with consolidating health systems.
The shining example of this is when a private practice cardiologist is bought by a hospital so they can re-categorize it as a hospital outpatient department. All of a sudden, for the same service delivered by the same person in the same facility, Medicare and other payers following suit will pay two or three times for that echocardiogram as would have been done in a private practice office.
That is a distorting factor.
HLM: Is government policy the biggest driver of consolidation?
Mostashari: As a former regulator, I absolutely do not believe that there is a federal policy to encourage consolidation. The consolidation is an unintended consequence of some policies. And this is our whole point here.
Every policy needs to consider its implications on competition. To this point, we don't think that many well-intentioned, intelligent people who are addressing policy in their domain are not doing it with an eye toward its impact on competition, and they need to do so.
Gaynor: There is not a federal policy that is designed to promote consolidation. It's just that sometimes there are policies that are designed for a completely separate purpose that unintentionally have that result.
You don't need to consolidate to take risk-based payments. You don't need to consolidate to coordinate care. As a matter of fact, sometimes it can be done more efficiently by independent entities.
There is the possibility of virtual groups, where policy can facilitate independent practices to come together in a virtual way so that they don't have to consolidate under one ownership to take risks or comply with a certain requirement that is coming down from CMS or other payers.
HLM: Why do these administrative fiats become so burdensome?
Mostashari: One of the things I learned as national coordinator is that there are well-intentioned and dedicated policy makers for whom, through an accumulation of either wanting to be responsive to all constituents or trying to accomplish too much, every measure independently and individually is totally reasonable, but collectively when you put it all together it's insane.
When every regulator is thinking of their domain, they are not thinking about this in a more provider-centric way. Every different group that touches them has their own 'we're only asking for one or two little things. What's the big deal?' And it's not just the federal government, it's the private payers too.
In fact, a lot of the burden is on prior authorizations from private payers, it's from all the one thousand paper cuts that the practices are sustaining.
Gaynor: These burdens grow and grow and practices that would be perfectly efficient are no longer efficient because of these growing burdens, and that leads to consolidation, which then leads to less competition.
Nobody designed or planned or wanted that. But it happens. We're saying step back, take a look at that. You need to listen to people who are actually experiencing these things directly. We need better lines of communication and consideration of the holistic impact of these things, not one-by-one.
HLM: You call for the elimination of the Certificate of Need. Does that create problems, such as cherry picking?
Gaynor: There are no valid arguments. CON was established a long time ago, and we have a number of states that have repealed them. There is a lot of research evidence and it does not support the claims that CON constrains costs or reduce investments. It does not lead to more facilities located in "underserved areas."
CON is well-intended. Nobody designs these regulations thinking they are going to do something bad, but it just hasn't worked out. There is a long track record that shows CONs protect existing firms from competitions and it reifies so you don't get innovation and dynamism. If anything, it serves communities poorly.
HLM: What should state and federal regulators be asking when they examine consolidations among providers?
Gaynor: Will it harm competition? If the answer to that is 'no' then from an antitrust perspective, you don't have a problem. If it looks like there is the potential for harm then you look at the other side: Is there a potential for benefits and are the benefits substantial enough and would they be passed on to consumers so that they would overcome any harm that would flow from the merger?
HLM: Do we need another level of bureaucracy to ensure that these regulations are coordinated and not overly burdensome and counterproductive?
Mostashari: Definitely not! Every agency that cares about and relies upon the health of markets should increasingly consider the impact on competition with consolidation.
There is a formal review process for all regulations that involve the Office of Information and Regulatory Affairs that does fine work reviewing regulations and the burden on data collection, for example, or the regulatory impact.
I don't believe competition is specifically one of the regulatory impacts considered.
Gaynor: In a sense, we are just saying 'Hey, when you're formulating rules, regulations, and policies think about their impact on competition.' Just doing that can go an awful long way.
But also, there are plenty of opportunities for communication and consultation across federal agencies, between states and the federal government. And these things happen to a large extent already. What's required is for people to be thinking about these things. But I am not suggesting more bureaucracy.
HLM: Anything else you'd like to add?
Mostashari: The United States has determined that the way we are going to deliver healthcare is through markets. This is one of those issues that is truly embraced across the political spectrum, but we have had surprisingly few actionable policy recommendations around competition in healthcare.
Competition is not just the responsibility of the Federal Trade Commission. There are many actionable policy recommendations across federal, state and private sectors that can help improve the functioning of our healthcare system for everyone.
Armed with improved demographics data, the nation's safety net providers are poised to take population health initiatives beyond the hospital walls to help patients overcome economic and social barriers to health.
There were a couple of new developments in the past week on the population health front that are worth noting.
For starters, the Essential Hospitals Institute, the research arm of America's Essential Hospitals, has been awarded an 18-month grant from the Robert Wood Johnson Foundation to begin the second phase of a coordinated effort to promote community-integrated healthcare.
Bruce Siegel, MD, president and CEO of America's Essential Hospitals, says safety net hospital administrators and clinicians have long understood the linkage between patient outcomes and social-economic challenges such as poverty and the ills that come with it, but have often lacked the resources to move beyond hospital walls and into the communities they serve.
"Essential hospitals often are anchor institutions in their communities and serve patients for whom social determinants profoundly influence health," Siegel said in remarks accompanying this week's announcement.
"While this gives them a deep understanding of these nonclinical factors, applying that experience to improve community health often faces severe resource challenges."
During Phase One of the project, which was also funded by RWJF, the Essential Hospitals Institute late last year completed an assessment its members' capacity to improve population health and to find the support to deploy population health programs.
Using in-person summits, distance learning opportunities, and online resources, Phase 2 builds on those findings by
Supporting population health partnerships among safety-net providers on the state and national level
Compiling and sharing population health tools and resources designed for safety-net hospitals
Convening "learning communities" to build safety-net hospitals' internal capacity to address population health
To mitigate funding restraints, the program looks to leverage safety-net hospitals' unique and leading role in the health of their communities to broker partnerships between essential hospitals, public health departments, and community organizations.
"Our work reflects the simple reality that to succeed as partners of the population health movement, hospitals need support to apply key tools and to develop core partnerships in population health," says Kalpana Ramiah, DrPH, Essential Hospitals Institute's research director.
"Support provided now will have a lasting impact on moving our nearly 300 member hospitals toward community-integrated care."
500 Cities Project
In a similar vein, public health data broken down to the neighborhood level for the largest 500 Cities in the nation will be available on an interactive website starting this week, thanks to a collaboration between RWJF, the Centers for Disease Control and Prevention, and the CDC Foundation.
This granular data source gives anyone living in these regions—from public health stakeholders to local residents—the ability to retrieve, visualize, and explore uniformly defined city and census tract-level data on 27 chronic disease measures, health outcomes, and clinical preventive service use.
RWJF says the data will empower anyone to better see how health varies by location and plan tailored interventions.
Until now, public health officials and other policy wonks were limited by health data available at only the state or county level. This new data source brings that down to the neighborhood level, where local policy makers will be able to identify risk behaviors associated with illness and early death, and health conditions and diseases that are the most common, costly, and in many cases preventable.
The 500 Cities webpage is the latest and most detailed of a number of data sources on public health that includes the annual County Health Rankings and America's Health Rankings, a nationwide public health and state-by-state ranking system that using 34 measures of behaviors, community and environment, policies, and clinical care data; and the VCU Life Expectancy Maps, which illustrate dramatic variances in life expectancy from neighborhood to neighborhood.
Local public health advocates need all the tools they can get to understand the public health threats that pose the greatest challenges to their service areas, especially at a time when the Affordable Care Act, Medicare and Medicaid are under consideration for fundamental redesign.
Data sources such as 500 Cities won't necessarily provide the answers, but they will help policy makers assess the challenges, and where best to steer scant resources.
The proposed rules are seen as an interim measure to stabilize the Obamacare market in the short term, while Congress and the Trump administration work to repeal and replace the Affordable Care Act.
New rules proposed this month by the Department of Health & Human Services would stabilize health insurance exchanges created by the Affordable Care Act and would be credit positive for hospitals and insurers, Moody's Investors Service says.
"Hospitals benefit from functioning health insurance exchanges because they are the primary vehicle for individuals to purchase health insurance and a smaller uninsured population reduces the bad-debt expense that hospitals need to absorb," Moody's said in a Credit Outlook published this week.
"The proposal aims to improve the profitability of health plans offered on the exchanges so that insurance companies are incentivized to continue offering them," Moody's said.
"Specifically, the proposed rules aim to improve the risk pool by limiting people's ability to only sign up for insurance when they need medical treatment. The rules would shorten the annual enrollment period, enhance oversight of consumers who enroll during special enrollment periods, and would require consumers who owe premium payments from prior years to settle those debts before being permitted to renew their annual enrollment."
Good for Non-Profits
Non-profit hospitals with large insurance operations could also benefit from the rules changes. Specifically, Moody's cited these organizations: Intermountain Healthcare in Salt Lake City, UT; University of Pittsburgh Medical Center; Geisinger Health System, based in Danville, PA; and Presbyterian Healthcare Services, in Albuquerque, NM.
Moody's estimates that the health insurance industry lost $3 billion on the exchanges in 2014 and more in 2015. The losses likely continued in 2016, but they were offset somewhat because of higher premiums, redesigned plans and more selective participation.
While the proposed rules are seen mostly as a credit positive for hospitals, there is the potential for some credit negatives because they will prevent some people from obtaining health insurance, particularly people in need of medical care.
"As an isolated factor, this is credit-negative for hospitals because it will lead to an increase in bad debt and uncompensated care," Moody's said. "However, despite this negative aspect of the proposed rule changes, hospitals stand to lose more from the exchanges collapsing."
Payers Support the Rules
The proposed rules changes have the support of America's Health Insurance Plans, the insurance industry group headed by former administrator of the Centers for Medicare & Medicaid Services, Marilyn Tavenner.
"We commend the Administration for proposing these regulatory actions as Congress considers other critical actions necessary to help stabilize and improve the individual market for 2018," said Tavenner, AHIP's president and CEO.
"Our commitment is to ensure short-term stability and long-term improvements," Tavenner said. "While we are reviewing the details, we support solutions that address key challenges in the individual market, promote affordability for consumers, and give states and the private sector additional flexibility to meet the needs of consumers."
The healthcare quality rating service claims that patients treated in their Top 100 hospitals have a 27% lower risk of dying than patients treated in hospitals that did not receive the award.
Healthgrades, the online healthcare provider rating service, this week released its widely read list of America's 50 and 100 Best Hospitals for 2017, with few changes seen from the 2016 list.
As in 2016, the Top 50 hospitals, representing the top 1% of all hospitals, were located in 22 states. No hospitals cracked the Top 50 in 28 states, nor the Top 100 in 23 states. California had the most Top 50 hospitals, with 10, and 12 other California hospitals were in the Top 100. Illinois followed with all seven of its selections in the Top 50.
Massachusetts placed only one hospital on the Top 50 list: Baystate Medical Center, a 716-bed independent academic medical center in Springfield. Only three other Massachusetts hospitals made the Top 100 list, down from eight in 2016.
Healthgrades designates Top 100 hospitals as those have been in the top 2% of hospitals in the nation for exhibiting clinical excellence for at least three consecutive years. The Top 50 hospitals are those have been in the top 1% for at least six consecutive years.
Healthgrades evaluates hospital quality for conditions and procedures based solely on clinical outcomes for the most common in-hospital procedures and conditions and adjust for risk factors, such as age, gender and medical condition.
The analysis is based on more than 45 million Medicare medical claims records for the most recent three-year time period available from nearly 4,500 hospitals nationwide.
Healthgrades says the top performing hospitals also outperform their peers in treating a core group of conditions that account for more than 80% of mortalities in areas evaluated by Healthgrades, including heart attack, heart failure, pneumonia, respiratory failure, sepsis, and stroke.
Patients treated in Healthgrades' Top 100 hospitals have, on average, a 27.1% lower risk of dying than if they were treated in hospitals that did not receive this award. If all hospitals, as a group, performed similarly to the Healthgrades Top 100, on average, 179,438 lives could have been saved.
In a whitepaper released with the rankings, Healthgrades said that many Top 100 hospitals engage patients as participants in their care. For example:
Virginia Mason Medical Center in Seattle, WA implemented the Orthopedic Patient-Peer Partner program, an idea put forth by the medical center's orthopedic patients who have undergone joint replacement surgery and return as volunteers to support others who are preparing to undergo hip, knee or shoulder replacement.
HealthPartners hospitals in Minnesota works with first responders to extend care to patients in their homes. Through the Community Paramedic Program, the two largest hospitals in the HealthPartners system work with local first responders to help patients participate in their own care.
Penrose St. Francis Health Services in Colorado Springs, CO, which has been named one of America's 50 Best Hospitals for 10 consecutive years, uses multiple strategies to engage consumers, including an inter-visit communication program that provides digital health coaching.
"Hospitals that have achieved America's Best Hospitals distinction have sustained high quality outcomes for their patients over many years and often, offer programs that engage consumers and their overall communities in their care," Healthgrades CMO Brad Bowman, MD, said in remarks accompanying the study.
"Healthcare consumerism is requiring hospitals and health systems to innovate in a variety of areas, including quality, to meet growing expectations about the level of care, personalization and convenience," he said.
Fresh out of medical school and residency, Van Breeding, MD, could have gone anywhere to practice his profession. The son of a coal miner returned to his home in Eastern Kentucky.
Eastern Kentucky has acquired some dubious distinctions over the years. The rugged corner of Appalachia has some of the nation's highest rates of obesity, tobacco use, diabetes, high blood pressure, cardiovascular disease, various cancers, and respiratory illnesses such as black lung and emphysema.
Not coincidentally, the region is also one of the nation's poorest, and prospects have gotten bleaker with the demise of the coal industry. Unemployment in Letcher County, nestled on the Virginia state line, stands at 9%, nearly twice the national average, the poverty rate is above 28%, and local healthcare workers say that many of the 500 or so annual births at Whitesburg Appalachian Regional Healthcare Hospital are delivered by women addicted to opiates and other drugs.
As a newly minted physician fresh out of medical school and residency at the University of Kentucky in 1991, Van Breeding, MD, could have gone anywhere. He chose to return to his hometown of Whitesburg and a career that beckoned with an irresistible call for 16-hour work days, few vacations, scant resources, and low pay.
"Going somewhere else was never ever a thought," says Breeding, 55. "I grew up in this town. I went to high school in this town. All of my family is in this town. My patients are either family or friends of mine."
As a child, Breeding witnessed the societal costs that the coal industry exacted upon the people who worked in the mines and lived in the surrounding area. His father was a miner who was disabled and blind by age 50. At age 7, Breeding watched as his grandmother nearly died from lack of access to care after suffering a heart attack. His good friend, a former high school quarterback, has black lung.
With the coal industry in decline, Breeding, a self-described "Hillbilly Doctor," is dealing with a new set of population health problems that center around poverty and a lack of access to care, including obesity, cardiovascular disease, diabetes and malnutrition. In 2009, one of Breeding's colleagues was murdered by an addict desperate for pain medication.
Breeding practices with Mountain Comprehensive Health Corp. in Whitesburg, one of more than 1,600 government-subsidized community health centers nationwide. His patients are mostly poor and uninsured.
On an average day Breeding works 16 hours, starting with 5 AM rounds at the hospital. He sees about 40 patients a day at the clinic, and then rounds at the nursing home at night. He also makes house calls.
There were only five practitioners at MCHC when Breeding arrived more than 25 years ago. Now there are more than 40 clinicians, and the clinic has expanded from two to seven sites.
Thanks to the Affordable Care Act, Breeding says MCHC has the funding to provide dental and optometry services, and even venture into population health.
Obamacare's Impact
Proactive community outreach efforts by MCHC have created pioneering programs to address diabetes through a "Farmacy Program" that improves access to fresh fruits and vegetables. A colon cancer initiative that improved screening rates from 18% to 60% was lauded by the Centers for Disease Control and Prevention.
Breeding bristles when he hears Kentucky's political leaders vow to repeal the ACA "root and branch."
"It drives me crazy, because I feel in my heart that at Mountain Health Corporation we have the blueprint of what healthcare should be," he says. "If you can practice healthcare like this anywhere in the United States, you are going to have great outcomes."
"There are a lot of drawbacks on stopping Obamacare because these people need preventative care," he says. "If this goes away, we will have to discontinue dental and optometry and we won't be able to have extended hours because we won't have the funding."
"It is going to make a huge difference for healthcare here in an area where we have the highest rates of diabetes, heart disease and high blood pressure and local forms of cancer in the coal fields here in East Kentucky. We rank poorly but we definitely made progress on improving those numbers in the areas where we have a clinic and we have the proof."
Breeding's work has not gone unnoticed. Earlier this year he was named Country Doctor of the Year by Staff Care. Breeding says he will decline the two-weeks of time off that comes with the award, and will ask Staff Care to donate $10,000–the value of the temporary physician services that would have covered his absence–to 20 local charities.
"I don't trust my patients with anyone else," he says.
