President-elect Donald Trump has promised to repeal and replace Obamacare with "something terrific." His pick to lead HHS has called for radical overhauls of Medicare and Medicaid, and the Republican-controlled Congress has the votes to get it done, or not.
For better or worse, the next 12 months could be the most unsettled period for the healthcare sector in decades. Or, not much could happen.
The only thing that's certain is uncertainty.
We could see the complete unravelling of the Affordable Care Act, or not. President-elect Donald Trump vowed throughout his campaign to repeal and replace it with "something terrific" on his first day in office.
Now that the election is over, however, there are mumblings that the repeal could go forward, on a delayed track, while the "replace" component could take years to craft, and most certainly won't occur before the mid-term elections in two years.
In large part, that's because the ACA is mind-bogglingly complex, entrenched and expansive, and Republicans have so far provided only a vague outline of a potential replacement, and they don't want to do anything to anger voters.
It's not clear what any of this will mean for the approximately 20 million people that HHS says have gained health insurance in some form through the ACA, or how trimming the ranks of the insured would affect hospital operations.
The presumption is that it would not be a good thing for hospital bottom lines.
Medicare's Fate Uncertain
Trump's pick to lead the Department of Health and Human Services, Rep. Tom Price, MD, (R-GA), an orthopedic surgeon, has called for radical transformations of Medicare and Medicaid.
Republicans control both chambers of Congress, but any such reforms are dynamite, especially with Medicare, and Democrats have promised a bruising fight to defend these safety net programs.
At this point, there's no way to project how much the Republicans will do, or if it's all just empty campaign rhetoric.
On other fronts, the American Hospital Association wasted no time and twice last week presented the president-elect with an aggressive and expansive wish list.
It's not clear how receptive the Trump administration will be to these ideas, but even if only a handful of reforms are adopted, such as RAC reforms, ditching Stage 3 Meaningful Use, factoring socio-demographics in readmissions, and protecting DSH payments, they could have a significant effect on hospital operations.
Look to the Financial Indicators
It is in these times of flux that we look to the sober analyses of the bond rating agencies. With all the potential for massive disruption, Moody's Investors Service this week projected a stable outlook in 2017 for the nation's not-for-profit and public healthcare sector, which was based on a "modestly positive pace of operating cash flow growth" in the next 12 to 18 months.
"Following two years of extraordinary growth associated with expansion under the Affordable Care Act, hospital operating cash flow has moderated to 0% to 1%," Moody's Senior Analyst Eva Bogaty writes. "Top-line revenue growth continues to be strong, but constrained increases in reimbursement rates and rising expenses will counteract that growth."
Here are some other key projections from Moody's:
Patient volume growth is stable at about 1%. Utilization will be more modest in 2017 as the uninsured population stabilizes, but revenue growth will remain favorable with hospitals pursing outpatient growth strategies.
Expenses are on the rise, compressing margins. Soaring pharmaceutical costs, employment growth and rising pension pressures are driving thinner bottom lines.
Bad debt is rising as expected. Hospitals in non-Medicaid expansion states will see continued growth in bad debt as exchange enrollment likely contracts. In Medicaid expansion states, strong declines in bad debt will moderate because the benefits of expansion have largely been realized. High deductibles and rising co-pays will also drive bad debt.
Bogaty believes the outlook could be revised to positive if operating cash flow growth rises above 4% over the next 12 to 18 months, or revised to negative if the economy flattens or there is "any major regulatory changes or disruption of current policy."
Those are a handful of big "ifs," but there's not much else we can hold on to right now.
The Association of American Physicians and Surgeons counts Tom Price, MD, the nominee for HHS Secretary, as a member. The group's agenda calls for a phase-out of Medicare.
When President-elect Donald Trump last week nominated U.S. Rep Tom Price, (R-GA,) an orthopedic surgeon, to serve as secretary of Health and Human Services, media focus turned to the Association of American Physicians and Surgeons, a self-described non-partisan group that espouses the merits of " individual liberty, personal responsibility, limited government" and calls for the phase out of Medicare and greater autonomy for physicians.
HealthLeaders Media spoke this week with Jane M. Orient, MD, executive director of Tucson, AZ-based AAPS and a general internist. The following is a lightly edited transcript.
Orient: We were founded in 1943 and we promote independent private medicine. We are opposed to socialized medicine, which means a government takeover or government intrusion into medical care dictating what you can and cannot have, what you must pay for and what you can't pay for, and that sort of thing.
We believe physicians should be working for the patients and not the government or a third party because they have the control over their paycheck.
We really believe in freedom of expression and thought. We don't believe in setting up a scientific dogma that this is what you have to believe.
You are not allowed to raise questions about certain areas, because there are so many uncertainties and so many unknowns if we try to gag people and say if you raise a suggestion that is not in the mainstream you deserve to be gagged or ostracized. We need freedom of thought.
HLM: What is your membership?
Orient: Approximately 5,000, all over the country, all specialties.
HLM: Is Dr. Price a member of AAPS?
Orient: He's a member. He's spoken at our meeting. We in general agree with his philosophy, although not with every detail he has proposed.
HLM: Why do you support Dr. Price's nomination?
Orient: We think he is a good man. He's certainly well qualified. He has a first-hand understanding of the impact that government regulation has out in the real world. He generally has a philosophy of freedom and supports the right to practice independent medicine.
HLM: In what areas do you disagree with Dr. Price?
Orient: Republican plans have this idea of refundable tax credits, which in our opinion is the same thing as a subsidy and being deprived of a credit is the same thing as a penalty or a mandate.
It gives the federal government the power to define what constitutes an acceptable or qualified insurance plan to enable you to get the tax credit.
We can have some discussions about the details, but we would agree with him that Obamacare needs to be repealed. We don't even know yet what all is in it, but it has created a real maze of complexity and interactions and taxes and mandates and so on.
HLM: Is AAPS libertarian-leaning?
Orient: We've been called conservative. We've been called libertarian. Generally, we believe in constitutionally limited government; interpreting the constitution the way it was written, which means that Congress has certain enumerated powers and other things should be left to the states. That would include the regulation of insurance and the practice of medicine.
HLLM: Would AAPS like to see Medicare and Medicaid abolished?
Orient: We would like to see them phased out. There is no way you can abolish them suddenly because you have so many people utterly dependent upon them. But we need to rethink the whole structure of the program, which was enacted under false pretenses to fund Social Security.
Seniors believe they have paid for their care through these "contributions" they had to make while they were working, but in fact it's not a right all. There is no contractual right to get anything out of it. It's an entitlement. It's a privilege.
And all of the money we put into it is gone immediately to pay for other people's medical care or if there is a surplus to pay for whatever else the government wants to spend it on.
The Social Security trust fund is a fiction. It's just indebtedness for what the government has taken from the payroll tax to buy other things, from aircraft carriers to food stamps, or anything to reduce the size of the deficit.
HLM: Without Medicare, how could healthcare be affordable for senior citizens?
Orient: First of all, we ought to allow people who want to get out to get out. Like me, I want to get out. But, if I claim my Social Security, I have to be on Medicare Part A, so I haven't claimed it yet.
These two things should not be tied together. We need to allow people to do that without paying back any Social Security they've ever gotten or renouncing it in the future. That way, a private market for catastrophic insurance could develop.
You can turn down Medicare Part B, although there is a penalty if you want to re-enroll. My mother just got a bill. Her premium has practically doubled, it's gone up by $199 per month this year, and that is a consequence of the Affordable Care Act that people aren't aware of.
That is $6,000 a year. You [could] buy a whole lot of physician care, which is what Part B covers, if you had that $6,000.
Whereas if it is under Medicare Part B, you get only what the government decides is necessary and prudent and you can only get it at the price the government agrees to pay, which is often not enough to get you some real time with your doctor.
HLM: How would you address concerns that premiums would be unaffordable without subsidies for many seniors, who would otherwise face catastrophic medical bills?
Orient: First of all, we have to look at why that bill is that high. That bill is escalating. It doubled or tripled immediately after Medicare went into effect in 1965. Before 1965 maybe half of seniors didn't have health insurance, and medical care was maybe half as expensive.
Funneling all this through a third party introduces tremendous fraud and waste and increases prices because checks and balances are dismantled. You no longer have customers deciding whether to part with their own money.
They will take what you give them as long as it's free, but if they have to pay $20 for it they might not think it's worth it.
HLM: How long would it take to phase out Medicare?
Orient: I don't know. We need to let people get out as quickly as they want to. What is going to happen, it's just kind of the handwriting on the wall, is that Medicare truly is bankrupt. It is already spending a lot more than it is taking in, and the demographics are terrible.
We are going to have fewer than three working people supporting one retiree. How can three people who are struggling to support their own families and whose wages have been really frozen for quite a long time, or who can't get a good fulltime job, how are they supposed to support all these retired people?
Already we are curtailing what we pay to doctors and hospitals and the value-based system is really a system for rationing care. You spend too much and we aren't going to pay you. The system is like any Ponzi scheme. When you run out of new subscribers something bad is going to happen.
HLM: What other issues are important to AAPS members?
Orient: A lot of it has to do with Medicare and managed care and trying to undo the effect of Medicare on escalating costs, which is imposing a lot of practice guidelines that are intended to control costs but which dictate what physicians can and cannot do.
Of course, the guideline writers have huge conflicts of interest with the pharmaceutical industry and others. The market is so distorted by government rules and mandates and price controls that it is hard for people to imagine what freedom looks like. They don't have a memory extending back to 1950.
HLM: Do you take an issue on abortion?
Orient: We have a resolution on the record from quite a few years ago supporting the sanctity of human life from conception to natural death. We have not been active in deciding what the government should do about abortion, but the oath of Hippocrates is quite clear on that point: Doctors are healers not killers. They do not give women means to procure abortion.
That doesn't say what our members may or may not believe on whether women have the right to get an abortion. But it's clear that the Hippocratic physician doesn't do abortion.
HLM: Is it a fair criticism to say that AAPS is not in the mainstream?
Orient: I guess it depends partly on what you mean by the mainstream. The majority of people in this country are in a state of deep denial about the fiscal realities of our situation.
HLM: Will Dr. Price's membership in your group be a liability for him in the nomination process?
Orient: It's going to be a liability for him on some fronts because a lot of people don't agree with us about limited government or the desirability of independent private practice.
But it should help on other fronts. The people who do agree with us might think it's a point of pride.
A Merritt Hawkins poll suggests physicians believe Tom Price, MD, President-elect Trump's pick to lead HHS, will improve physician autonomy and reduce federal intrusions, but also hurt patient access to care.
President-elect Donald Trump's nomination of Rep. Tom Price, MD, (R-GA), as secretary of the Department of Health and Human Services received lavish and universal praise from physicians' associations that curry favor with the federal government.
Support, however, is not as widespread among practicing physicians for Price, an orthopedic surgeon, according to a small sampling released this week by Merritt Hawkins.
An online survey of 1,094 physicians by the Dallas-based physician recruiting firm found the attitude of physicians is more ambiguous and reflective of the general population, with 46% of physicians generally positive about Price, 42% generally negative, and 12% neutral.
"It's a plurality. It's not a majority. The split down the middle reflects the mood of the country right now," says Kurt Mosley, vice president of strategic alliances at Merritt Hawkins.
"We had a divisive election, so no matter who gets nominated, you are going to have people who are positive about it and an equal amount who are negative. We are more divided than ever and the survey reflects that."
The survey also asked physicians if they thought Price would improve medical practice conditions for physicians if his nomination for HHS secretary is confirmed. The plurality of respondents (46%) believe Price will improve practice conditions, 34% said he will worsen them, and 20% are neutral.
"Physicians have told us that the least satisfying part of their work is the regulatory paperwork burdens and erosion of autonomy," Mosley says. "When the American Medical Association endorsed his nomination they talked about his preference for market-based solutions and the need to reduce excessive regulatory burdens."
Mosley said that Price has also been a huge proponent of redoing MACRA, which he feels is onerous and complicated and confusing. Last May, Price came out with the Empowering Patients First Act, which calls for repealing of the Affordable Care Act and replacing it with "patient-centered solutions."
A Colleague
Price's biggest attribute among physicians is that he is a colleague. "He was a doctor for more than 20 years before he entered Congress. He's been in the trenches. He's billed Medicare. He knows the issues," Mosley says.
"Of the last eight HHS secretaries, only three have been physicians, and that's if Price is approved. He's also the chairman of the House Budget Committee, and a lot of physicians said he knows the inner workings of Congress and seems like he can get stuff through."
When asked about care access, however, the returns are less favorable. A plurality (47%) said Price will detract from patients' access to care if his nomination is confirmed, 42% said he will improve access to care, and 11% remain neutral.
"The big concern is figuring out what to do with the 20 million people who became insured under Obamacare," Mosley says. "This repeal and replace, which Price has been a huge proponent of, has a lot of people scared that he is going to come in and whack the thing off at the knees, and then what do we do with those 20 million people? There are also concerns that he is going to reduce CHIP funding."
Pleading that the nation's hospitals face a "substantial and unsustainable" regulatory burden, the American Hospital Association presented an eight-page list of remedies to the president-elect.
For the second time in three days, on Friday the American Hospital Association has provided President-elect Donald Trump with a lengthy list of requests for regulatory reforms to scale back bureaucratic red tape.
"Reducing administrative complexity in healthcare would save billions of dollars annually and allow providers to spend more time on patients, not paperwork," AHA CEO and President Rick Pollack said in letter dated December 2nd.
"The Centers for Medicare & Medicaid Services and other agencies of the Department of Health and Human Services released 43 proposed and final rules affecting hospitals and health systems in the first 10 months of this year alone, comprising almost 21,000 pages of text," Pollack wrote. "In addition to the sheer volume, the scope of changes required by the new regulations is beginning to outstrip the field's ability to absorb them."
Because the rules are promulgated by CMS and other agencies within HHS, Pollack said the president-elect could take immediate action administratively.
Among the 33 reform actions listed in the letter, the AHA wants the Trump administration to:
Suspend hospitalstar ratings: Despite objections from a majority of the Congress, CMS published a set of deeply flawed hospital star ratings on its website this fall. The ratings were broadly criticized by quality experts and Congress as being inaccurate and misleading to consumers seeking to know which hospitals were more likely to provide safer, higher quality care.
Cancel Stage 3 of "meaningful use" program: Hospitals face extensive, burdensome and unnecessary "meaningful use" regulations from CMS that require significant reporting on the use of electronic health records (EHRs) with no clear benefit to patient care.
These excessive requirements are set to become even more onerous when Stage 3 begins in 2018. They also will raise costs by forcing hospitals to spend large sums upgrading their EHRs solely for the purpose of meeting regulatory requirements.
Suspend electronic clinical quality measure reporting requirements: Hospitals have spent significant time and resources to revise certified EHRs to meet CMS electronic clinical quality measure requirements for 2016, with no benefit for patient care. Moreover, CMS acknowledges that the electronic test submissions by hospitals and physicians do not accurately measure the quality of care provided.
Despite these facts, CMS regulations double the electronic clinical quality measure reporting requirements for hospitals for 2017, creating additional burden without an expectation that the data generated by EHRs will be accurate.
Remove faulty hospital quality measures: Improvements in quality and patient safety are accelerating, but the ever increasing number of conflicting, overlapping measures in CMS programs take time and resources away from what matters the most, improving care.
Most recent measure additions to the inpatient quality reporting and outpatient quality ;reporting programs provide inaccurate data, and do not focus on the most important opportunities to improve care.
Eliminate unfair Long-term Care Hospital regulation: With the implementation of site-neutral payments for LTCHs, which began in October 2015 (as mandated by the Bipartisan Budget Act of 2013), the LTCH "25% Rule" has become outdated, excessive and unnecessary. CMS should rescind the 25% Rule and instead rely on the site-neutral payment policy to bring transformative change to the LTCH field.
End onerous home health agency pre-claim review: CMS's mandatory Medicare demonstration to test pre-claim review is causing patient care and payment delays in the first of five states under the program.
Restore compliant codes for inpatient rehabilitation facility 60% Rule: During the transition to ICD-10-CM, CMS reduced the number conditions that qualify toward compliance under the IRF "60% Rule," which is a criterion that must be met for a hospital or unit to maintain its payment classification as an IRF. Yet certain codes that qualified under ICD-9-CM were inadvertently omitted as a result of the conversion to ICD-10-CM.
Withdraw proposed mandatory Part B drug demonstration: CMS has proposed a mandatory Medicare demonstration program that would unfairly hold hospitals financially accountable for the high prices charged by drug manufacturers.
Protect Medicaid DSH hospital payments: CMS's proposed rule that addresses how third-party payments are treated for purposes of calculating the hospital-specific limitation on Medicaid disproportionate share hospital payments could deny hospitals access to needed Medicaid DSH funds.
Undo agency overreach on "information blocking": Hospitals want to share health information to support care and do so when they can. But technology companies and the federal government have so far failed to create the infrastructure to make sharing information electronically easy and efficient.
Hold Medicare RACs accountable: Medicare RACs are paid a contingency fee that financially rewards them for denying payments to hospitals, even when their denials are found to be in error. The AHA urges the Administration to revise the RAC contracts to incorporate a financial penalty for poor performance by RACs, as measured by administrative law judge appeal overturn rates.
Adjust readmission measures to reflect socio-demographics: Hospital readmission measures and other outcome measures lack appropriate adjustment for the impact of the community and other factors, so those hospitals serving certain communities sustain larger penalties.
Make future bundled payment programs voluntary:The Center for Medicare and Medicaid Innovation has engaged in regulatory overreach by making bundled payments mandatory. Hospitals should not be forced to bear the expense of participation in complicated new programs if they do not believe they will benefit patients.
Expand Medicarecoverage oftelehealthservices: Coverage and payment for telemedicine services remain major obstacles for providers seeking to improve patient care. Medicare, in particular, lags far behind other payers due to its restrictive statutes and regulations.
Researchers urge the Trump administration to consider stroke-of-the-pen changes to federal tax policy that would encourage non-profit hospitals to invest in community health initiatives.
Non-profit hospitals shy from investing in community health initiatives for fear that the murky verbiage in the tax code could bring down an audit, a research report suggests.
Because of that, researchers at the George Washington University's Milken Institute School of Public Health want the Trump administration to revise Internal Revenue Service policies governing community benefit spending to encourage greater hospital involvement in community-wide health initiatives.
About 60% of non-profit hospitals community spending goes toward financial assistance to patients who have difficulty paying for their care, says report lead author Rosenbaum, a professor of health law and policy at Milken.
"There is room to reprogram or expand one's horizons regarding how you are spending that other chunk of funding, which may be going into research or something called community health improvements," Rosenbaum says.
"Those activities as the IRS defines them are relatively narrow right now. We are suggesting that it makes great sense to broaden the definition of what is community health improvement to include activities that today are excluded from the definition and instead called community building."
Rosenbaum says the definitions could be broadened administratively, and would not require any additional funding or action by Congress.
Burden is on Hospitals
"The snag is that under Schedule H there are certain activities that are called community building," she says. "They are not community benefit. The IRS says that if you think your community building activity would meet the community benefit definition you can provide us with an explanation."
"The problem is it puts the burden on the hospital to justify what it's doing," she says. "If you're a hospital and concerned about running in a compliant and prudent fashion with IRS policy, you don't want to push the envelope, because you're probably already pushing the envelope on other matters."
The report analyzed the most-recent community health needs assessments compiled by non-profit hospitals and found that 72% of hospitals identified obesity, 68% identified mental health and 62% identified diabetes as the top health challenges of their communities.
However specific programs, such as sponsoring farmers' markets or working to improve access to affordable and safe housing, would likely not fall under the current definition of community benefit.
3 Recommendations
"The better part of discretion is to just stay on the straight and narrow and continue to do financial assistance or free immunizations clinics," Rosenbaum says. "That is all very good, but it's these community building activities that really are a form of community health improvement, but they fall outside the definition."
Specifically, Rosenbaum's report recommends that the IRS:
Issue guidance to hospitals stating that activities now designated as community building efforts but that promote population health on a community-wide basis will be treated as community benefit spending.
Bring greater transparency to community benefit reporting by creating a link between community health priorities documented through the community health needs assessment process and their community-benefit spending allocations.
Issue tax guidance on effective community-wide health improvement activities, not only in health, but in areas such as nutrition, education, the environment, transportation, the work force, and housing.
A blog by Rosenbaum and colleagues on this topic appears in Health Affairs.
Republican President-elect Donald Trump has promised to repeal and replace Obamacare with 'something better.' Amid this upheaval, rural health advocates see opportunity.
More than any other demographic, rural American voters contributed to the unexpected election of Donald Trump. Alan Morgan, CEO of the National Rural Health Association, says Trump's election has put the issues facing rural America on the front burner after years as an afterthought. The following is a lightly edited transcript.
HLM: What was the message rural America sent in this election?
Morgan: It is the result of a lack of focus on a substantial population in America that's seen declining health, declining life expectancy, a rural hospital closure crisis that we are engaged in right now, and yet a lack of focus on how to bring access to high-quality healthcare services to 60 million Americans.
We are hopeful, recognizing the importance that health and especially hospitals play in rural communities from an economic standpoint too, that we can start looking at what we can change and modify to ensure that we maintain access in rural communities.
HLM: How big of an effect will this election have on rural health?
Morgan: We are hopeful it will have a substantial beneficial impact on rural health because of the national focus on what is happening in rural now.
We have been beating the bushes for the past 10 years about workforce problems and the declining life expectancy of rural populations and we just haven't been getting a lot of traction on that among policy makers.
So, I am hopeful that now that this refocuses attention on the population that has been largely forgotten at the national level.
HLM: President-elect Trump and Republicans controlling Congress have called for radical overhauls of healthcare. Are you concerned that proposals to eliminate Obamacare, block grant Medicaid, and privatize Medicare could harm rural America?
Morgan: It's always a concern when you're proposing significant changes in the healthcare system. You always run the risk of making things worse. We've always communicated that the rural safety net is like arctic tundra; you step on it and trample it and it may never come back.
You can look at this two ways: Things are already not well and we are looking to roll back some of these insurance coverage issues and what that will mean to rural. Or you can look at it from a more positive standpoint that you can't go ahead with reforming the healthcare system and having rural as an afterthought. There has to be a rural focus as we move ahead.
Our organization would oppose any Medicaid block grant proposals. We are concerned what that would mean for rural populations. We are concerned that if they do any major modifications to Medicaid, we don't make the situation worse. And the rural hospitals have closed in states that have not expanded Medicaid, so rolling back Medicaid isn't going to help things.
We are looking at trying to make the health exchanges work better in the rural context; what marketplace revisions need to be made. It is true that more people have health insurance now in rural America because of the exchanges.
But it's also been well documented that we haven't had the uptick sign on of the exchanges from rural populations that we expected, and with the high deductibles and high copays the future of the health exchange, even if Hillary Clinton had won, would've been problematic. That needs to be addressed.
HLM: Was there anything that Trump said in the campaign that shows he "gets it" with rural health?
Morgan: We are going to run with his pledge to invest in infrastructure. Obviously, if he maintains his commitment to the economy, to infrastructure, not leaving people behind that have been forgotten in the past, we can build on that, and how can we have a federal-local partnership in investing and transforming our healthcare system.
In the debates he referenced the need to invest in healthcare and hospitals. I know a lot of my peers question what the investment would be.
Certainly, from a rural standpoint, these old Hill-Burton hospitals that are designed for a large inpatient volume need to be restructured for 24/7 emergency services and an outpatient delivery system. If he maintains that focus on putting America first and investing in infrastructure there is a lot we can work with.
HLM: What signals will you look for in the first few months of the Trump administration?
Morgan: First and foremost, will this new administration be talking about the rural hospital closure crisis? I'll be honest, that is one thing we haven't seen the current administration acknowledge, that we have a rural hospital closure crisis on our hands.
We are hoping that they acknowledge that we are heading in the wrong direction when it comes to healthcare access in rural communities.
Second, as they talk about innovation and transformation of the healthcare system, are they going to include rural? A lot of the transformation efforts by the current administration have exempted critical access hospitals and rural health clinics from the reporting process and really put them over to the side. Are we going to embrace rural facilities as we move forward? That is something we will be looking for in public statements and signs from CMS, what directions are they going to head on.
If they go ahead with the ACA repeal and replace, I want to hear how they are going to replace these high deductibles and the problems with the insurance market in rural underserved locations.
This is putting a lot of emphasis on the Trump administration, and Republicans will control Congress, but I am optimistic that Democrats recognize that this is a tremendous opportunity for them as well. They too have a focus about ensuring that rural is not left behind. How do we change this perception that DC simply doesn't get it from a rural standpoint?
HLM: NRHA is apolitical, but at some point are you going to have to get political to advance your agenda?
Morgan: I hope not. We have worked really hard to keep rural health a nonpartisan issue. That is going to be difficult.
Looking at how strongly rural America supported a certain political party makes it more difficult to do that. At the end of the day, when you are talking about low-income populations with high health disparities and a large senior population, you have to have Republicans and Democrats find some common ground.
HLM: What are you telling your members in the "flyover" states?
Morgan: The key message is now's the time to strike while the iron is hot. We are pushing an optimistic message that this is a great opportunity now to focus finally on rural.
The medical establishment is praising the appointment of Tom Price, MD, to lead the Department of Health and Human Services. That enthusiasm is not shared by women's health advocates and some Democrats in Congress.
President-elect Donald Trump's nomination of Rep. Tom Price, (R-GA), an orthopedic surgeon and avowed opponent of Obamacare, was greeted with high praise by the major professional lobbies in the healthcare sector.
"As healthcare continues to evolve and as care becomes more patient centered, Dr. Price's experience both as a surgeon, along with practicing at Emory University and Grady Memorial Hospital, makes him uniquely qualified to lead the Department of Health and Human Services," said American Hospital Association CEO Rick Pollack.
"He has spent most of his career working in hospitals as an orthopedic surgeon, and his experience as a provider of care will serve patients well in this new role. We have worked with him as a member of the House Ways and Means Committee and as Chairman of the House Budget Committee. His clinical knowledge along with his congressional experience make him an impressively qualified candidate for HHS secretary."
Patrice A. Harris, MD, chair of the American Medical Association Board of Trustees, urged the Senate to "promptly consider and confirm Dr. Price for this important role."
"The American Medical Association strongly supports the nomination of Dr. Tom Price to become the next Secretary of Health and Human Services. His service as a physician, state legislator and member of the U.S. Congress provides a depth of experience to lead HHS," Harris said.
"Dr. Price has been a leader in the development of health policies to advance patient choice and market-based solutions as well as reduce excessive regulatory burdens that diminish time devoted to patient care and increase costs."
AHIP
Marilyn Tavenner, president and CEO of America's Health Insurance Plans, said that Price has for years "been committed to ensuring that patients and consumers are well-served. He will bring a balanced and thoughtful perspective to his role as Secretary of HHS. We look forward to working with him to promote competition, increase choice, and lower costs for every consumer."
Likewise, Tavenner praised Seema Verma, who was picked to serve as Administrator for the Centers for Medicare & Medicaid Services, a position Tavenner once held.
"We look forward to working with Seema Verma to strengthen our nation's healthcare system and empower Americans to improve their health and financial well-being," Tavenner said, "particularly those who depend on the valuable support and services provided through Medicare and Medicaid."
AAFP
John Meigs, Jr., MD, president of the American Academy of Family Physicians, noted Price would be the first physician to serve as secretary of HHS since 1989.
"With his background as a former practicing physician and as a legislator on both state and national levels, he will provide a much needed medical perspective to U.S. health policy at a time of health reform and global outbreaks of new health threats," Meigs said.
Association of American Medical Colleges President and CEO Darrell G. Kirch, MD, cited Price's academic career as a former assistant professor at Emory University School of Medicine and medical director of the Orthopedic Clinic at Grady Memorial Hospital in Atlanta.
"Rep. Price understands firsthand the work and challenges faced by our nation's medical schools and teaching hospitals, and has long been a proponent of academic medicine," Kirch said.
"We are confident that Rep. Price will bring a thoughtful, measured approach to tackling the wide range of issues affecting the nation's health—from funding for biomedical research to training the next generation of physicians to transforming the nation's healthcare system in order to provide all Americans with the care they need when they need it."
America's Essential Hospitals
Bruce Siegel, MD, president and CEO of America's Essential Hospitals said the selection of Price as HHS secretary demonstrates that President-elect Trump "has made experience a priority in his choices" of both Price and Verma.
"Rep. Tom Price has an extensive clinical, administrative, and academic background in healthcare and long experience in the legislative process," Siegel said. "Seema Verma, MPH, offers a deep understanding of healthcare delivery and policymaking and can contribute an important state-level perspective on Medicaid, insurance, and public health. We are especially proud of her accomplishments as a graduate of the association's Fellows Program.
"Particularly noteworthy about both nominees is their experience caring for low-income and other vulnerable people, shaped by their work at hospitals with a safety net role—essential hospitals," Siegel said.
AAOS
Gerald R. Williams, Jr., MD, president of the American Association of Orthopaedic Surgeons, was delighted that a AAOS member was picked to lead HHS.
"Dr. Price has decades of leadership on health care policy issues and firsthand experience caring for patients for nearly 20 years," Williams said.
"He has worked closely with AAOS on issues including repeal of the Medicare sustainable growth rate formula, oversight of mandatory bundled payment models, increasing flexibility within electronic health record programs, defending important in-office ancillary services, and protecting the patient-physician relationship. He has been an indispensable voice within the House Republican Doctors Caucus, making significant contributions to health policy reform and furthering the interests of patients. And he has been one of the most important champions in improving the care of patients in the specialty, rural, and small or solo practice settings."
CHIME
CHIME President and CEO Russell Branzell said Price "has been at the forefront of advancing important reforms to the nation's health IT policy landscape."
"He was a leader in pushing for greater flexibility in the Meaningful Use program, including the 90-day reporting period," Branzell said. "The shorter reporting period is a more realistic timeframe and will help hospitals stay focused on optimizing electronic health record systems for improved patient care. Dr. Price was also instrumental in 2015 in extending the timeline for providers to apply for hardship exemptions under the Meaningful Use program."
Concerns Over Access
Not everyone was pleased with Price's nomination. NARAL Pro-Choice America Senior Vice President Sasha Bruce said that with the nomination "Trump is sending a clear signal that he intends to punish women who seek abortion care."
"Tom Price is someone who has made clear throughout his career that he does not trust women to make our own decisions about our healthcare. Instead, he wants to punish us for the choices we make for our bodies, our futures, and our families," Bruce said.
"In Congress, Tom Price cosponsored some of the most offensive anti-choice legislation on record, legislation that could ban abortion for almost any reason. Not only has Tom Price tried to outlaw abortion nationwide, including in cases of rape, incest, and health of the woman, he has worked to put an outright ban on the most common forms of contraception. As chair of the Budget Committee, he has been on the front lines of the efforts to dismantle the lifesaving Affordable Care Act, as well as the dangerous attempts to defund Planned Parenthood. For the seven in 10 Americans who support legal access to abortion, this is an incredibly alarming pick."
Sen. Chuck Schumer, D-NY, who will lead the Senate minority next year, aired his disdain for Price's nomination on Twitter. "Nominating Rep Price @HHSGov Sec like asking a fox to guard the hen house; risks seniors, women, people w/ disabilities' healthcare access," Schumer wrote.
Contrary to researchers' expectations, data shows that for low-acuity ailments, the proliferation of retail healthcare clinics across the United States does not reduce patient volumes at hospital emergency departments.
Retail medical clinics located near hospital emergency departments do not reduce visits to the emergency departments for minor health ailments, a RAND Corporation study shows.
The study, published online this week in Annals of Emergency Medicine, examined five years of data from 2,000 emergency departments in 23 states for 11 low-acuity ailments such as respiratory infections and ear aches.
"One hope for retail clinics was that they might divert patients from making expensive visits to the emergency department for minor conditions such as bronchitis or urinary tract infections, but we found no evidence that this has been happening," said Grant Martsolf, lead author of the study and a policy researcher at RAND.
"Instead of lowering costs, retail clinics may be substituting for care in other settings such as primary care practices or spur some patients to seek care for problems they previously would have treated on their own," Martsolf said.
There are nearly 2,000 retail clinics across the United States now, and they receive more than 6 million patient visits annually. These clinics are often staffed by nurse practitioners, with prices that are often considerably lower than at a physician's office or an emergency department, often because fewer tests are performed.
Methodology
RAND used information from the federal Healthcare Cost and Utilization Project State Emergency Department Databases from 2006 to 2012 to combine emergency department use with information about the opening of retail clinics obtained from Merchant Medicine, a research firm that tracks trends in walk-in medicine.
Retail clinical penetration was measured as the percentage of an emergency department's catchment area that overlapped with a 10-minute drive of a retail clinic. The 11 low-acuity conditions studied are commonly seen in both retail clinics and hospital emergency departments.
According to the study, the number of retail clinics grew from 130 in 2006 to nearly 1,400 in 2012. The proportion of the emergency department catchment area that overlaps with a 10-minute drive radius of a retail clinic more than doubled between 2007 and 2012 among states in the study sample. One-third of the urban population in the United States now lives within a 10-minute drive of a retail clinic.
During the period studied, there were only about 17 fewer low-acuity trips to the emergency department in one year for privately insured patients living in areas where the retail clinic penetration rate increased by 40% in that year, which is less than a 1% reduction, the study found.
"Retail clinics may emerge as an important location for medical care to meet increasing demand as more people become insured under the Affordable Care Act," said study co-author Ateev Mehrotra, MD, an associate professor at the Harvard Medical School and an adjunct researcher at RAND.
"But contrary to our expectations, we found retail clinics do not appear to be leading to meaningful reductions in low-urgency visits to hospital emergency departments."
Walk-in Clinics Boost Utilization
An editorial accompanying the study suggested that the primary effect of opening retail clinics is to increase healthcare use, not substitute for emergency department visits.
"Given that convenience settings don't prevent ER visits, what can be done in an era where looming government reforms may soon restrict the very payments that support them?" said editorial author Jesse Pines, MD, of the George Washington University School of Medicine and Health Sciences. "The answer is not to build more convenience settings, but to improve the value of existing settings by increasing the connectivity among providers and with longitudinal care."
Retail Health Industry Reaction
In response to the RAND findings, the Convenient Care Association, the national trade association for the retail health industry, issued a statement.
"Retail clinics provide accessible, affordable high-quality healthcare in locations that are convenient for patients and consumers and today there are approximately 2,300 clinics in 41 states and the District of Columbia," said Tine Hansen-Turton, Executive Director of the CCA.
"The RAND Study relied upon old data from when there were only about 1,200 clinics in operation." Hansen-Turton explained that "with the growing number of retail clinics today and in the future, clinics will have a bigger effect on the reduction of low-acuity visits to emergency rooms."
She further noted that "the study did not take into account the more than 9,000 urgent care centers in the areas of the study, thereby leaving an opportunity to for additional research to better understand the complete picture of where low-acuity visits are taking place."
For the most part, the nation's major healthcare payer and provider associations are serving up predictable good-faith pledges to the president-elect, who has promised to upend the healthcare landscape.
One of the most contentious and shocking presidential elections in U.S. history has been greeted with safely worded platitudes by the nation's major healthcare provider and payer associations.
Republican President-elect Donald J. Trump has promised to repeal Obamacare and replace it with "something better," which could create chaos for the healthcare sector.
Nonetheless, it is hard to detect a sense of urgency or alarm based on the comments made so far by major players in the nearly $3 trillion healthcare sector, who greeted the new administration with business-as-usual bromides.
Hospitals
American Hospital Association President and CEO Rick Pollack issued a statement that could have been drafted before the votes were counted. He did not refer to Trump by name, but said the nearly 5,000 hospitals in his organization would continue to "work in a bipartisan manner advancing our agenda."
"We look forward to working with the new Administration and Congress on the nation's healthcare challenges and will continue to do everything we can to meet our commitment to the people and communities we serve," Pollack said in prepared remarks.
Bruce Siegel, MD, president and CEO of America's Essential Hospitals, congratulated Trump and urged him to make good on his "commitment to serve as a president for all Americans."
"By ensuring the best possible care for the least fortunate, our hospitals provide the best care to all people," Siegel said. "We must sustain federal support for this mission, reject policy changes that reduce spending at the expense of coverage and access, and continue progress toward transformative approaches to better quality and value."
Payers
America's Health Insurance Plans concedes that there "is still a lot to be learned about what policy changes will be proposed," but pledged to "work across the aisle - with every policymaker and the new administration - to find solutions that deliver affordable coverage and high-quality care for everyone."
Kristine Grow, AHIP's senior vice president for communications says the nation's commercial health plans maintain "a commitment to continuous coverage.
Consumers should be covered and patients should be protected – and sudden disruptions would jeopardize both. Consumers, patients, and plans should be given enough time, flexibility and support so that any changes ensure safe and stable coverage."
Blue Cross Blue Shield Association CEO Scott Serota said the "health insurers for one-in-three Americans look forward to working the new president and Congress.
"In particular, we are sharing ideas for improving the individual market, so that consumers have more choices, better prices and a robust private marketplace that is predictable and stable," Serota said.
BCBSA also posted a Tweet recommending that people who are feeling stressed "hug your pet." (#stressed, #stress )
Providers
AMA President Andrew W. Gurman, MD, said his organization "has a history of working in a bipartisan manner as we pursue policies," and that he looks "forward to working with President-elect Trump and a new Congress to improve the health of the nation."
"One of our long-standing policy objectives has been to reduce the number of Americans who lack health insurance coverage, because research demonstrates that those without insurance experience greater suffering and premature deaths," Gurman said.
"A key factor in our evaluation of future proposals is whether the result is more or fewer Americans with insurance and the extent of the coverage compared to existing policies."
American Academy of Family Physicians President John Meigs, MD, sent the president-elect a list of priorities for primary care that included: expanding access to care, ensuring delivery and payment reform, improving affordability, building the primary care workforce, and promoting wellness and prevention.
Even though Trump has supported the expansion of high-deductible health plans as an alternative to Obamacare, the American College of Emergency Physicians is urging him to close insurance coverage gaps that are leaving emergency patients with crippling debts.
"Many people don't realize how little insurance coverage they have until they need emergency care, and then they are shocked at how little their insurance companies pay," ACEP President Rebecca Parker, MD, said in prepared remarks.
"Health insurance companies mislead patients by selling so-called 'affordable' policies that cover very little, until large deductibles are met—and then blame medical providers for charges. State and federal policymakers need to ensure that health insurance plans provide adequate rosters of physicians, affordable deductibles and co-pays and fair payment for emergency services," Parker said.
American Nurses Association President Pamela F. Cipriano, RN, said her organization also looks forward to working with the new Administration that "has an opportunity to unite the country around a shared vision that puts protecting and promoting quality healthcare for all Americans above partisan politics."
Cipriano also noted that 83% of the 52 candidates endorsed by ANA's Political Action Committee won their election and will serve in the 115th Congress.
NNU Battles On
National Nurses United, which had fervently embraced the grassroots candidacy of Sen. Bernie Sanders, (I-VT), made it clear that it would not strike a conciliatory pose with President-elect Trump in a statement that read more like a political manifesto.
"The challenge to all of us now is to fight with every breath to expand, and coalesce that progressive, social change movement to resist the coming assault by the right, and reinvigorate our work for real change," NNU said.
"The agenda for real transformative change of our broken political and economic system is the only way to protect our nation and our planet."
IHI Acknowledges Angst
Institute for Healthcare Improvement CEO and President Derek Feeley was one of the few healthcare leaders to publicly acknowledge the angst that has fallen over large swaths of the population since Trump's victory.
"We share the sense of uncertainty and anxiety about the future that we are hearing from many of our friends and partners across the world," Feeley said. "At the same time, we are reminded that IHI's mission to improve health and healthcare worldwide can act as a beacon for us, and we trust for others, during unsettled times."
"Although health reform may now face some major challenges, IHI feels more determined than ever to work with partners, old and new, to demonstrate that change is necessary and that improvement is achievable."
More than 90% of the patients at a small Memphis clinic are on Medicaid. The physicians there were stunned to learn that federal auditors wanted a $400,000 refund for Medicaid overpayments.
"We are the dream team," says William Rodney, MD, founder of the clinic, and board certified in obstetrics, geriatrics, emergency, and family medicine.
The physicians at Medicos Para La Familia were stunned to learn that federal auditors wanted a $400,000 refund for Medicaid overpayments that were made under an initiative to expand primary care services in underserved areas–which is exactly what Medicos did.
The private clinic's bilingual staff provides healthcare for poor people in Memphis and Northern Mississippi. It's a full-service clinic with many of the same services as an emergency department, including imaging, and at a fraction of the cost.
More than 90% of the 40,000 patients that Medicos' five physicians and staff see each year are on Medicaid.
"We deliver babies. We provide prenatal care," Rodney says. "You can walk in seven days a week and if you are sick, you do not need an appointment. And I especially mean pregnant women. We lowered the rate of babies dying in Memphis because of this system."
When the Medicaid Enhanced Payments came along in 2013 and 2014, Rodney says, Medicos welcomed the windfall.
Unfortunately for Medicos, and the patients it serves, the Centers for Medicare & Medicaid Services added requirements that called for physicians receiving the enhanced payments to be board certified in primary care.
"We got caught in a trap because one of our older physicians was no longer board certified, even though he had practiced family medicine for 35 years," Rodney says. "His name is Rickey Carson. If you wanted a poster child for what a family doctor looks like you would see Rickey Carson's face. He is in the office every day, sees 30 to 35 patients a day. Patients love him."
"Ricky was down on the books for about 4,000 to 5,000 patients in both 2013 and 2014, but he gets a letter saying we want our money back," Rodney says.
"In the meantime, this primary care bonus has been spent for enrichments for poor people; more staff, more hours, some equipment we needed for pregnant patients. Now we are looking at a payback bill of $400,000 over two years. We don't have $400,000. We are going to close the practice if we don't get some relief."
With their appeals to common sense falling on deaf ears, Carson and 20 other primary care physicians from across Tennessee have filed suit in U.S. District Court in Nashville, asking a judge to halt efforts to reclaim more than $2.3 million that was paid out during the two-year enhancement period. [View the complaint.]
CMS 'Overreach'
The plaintiffs argue that the CMS rules change was arbitrary, runs counter to the intent of the law passed by Congress, and has the potential to greatly disrupt care access to thousands of poor people with few other options beyond the nearest emergency department.
The plaintiffs have the support of the Tennessee Medical Association, which has accused CMS of "blatantly overreaching its authority and misinterpreting the intent of Congress."
"These arbitrary actions by CMS punish doctors trying to do the right thing and put some of Tennessee's most underserved populations and communities at even greater risk," TMA general counsel Yarnell Beatty said.
Let's recap: The Medicaid Enhanced Payment Statute, which was designed to expand healthcare access to underserved areas by paying physicians more money, now threatens to do exactly the opposite; take money away from physicians and threaten the solvency of their practices, which would worsen care access in underserved areas.
How did such a well-meaning piece of legislation mutate into its evil twin? This is what happens, Rodney says, when policy makers and politicians working at the 30,000 feet don't understand how medicine is practiced in the fly-over.
"The road to hell is paved with good intentions," he says.
"Legislators really wanted to help and they did, kind of, but most legislators really don't understand medicine as it is practice outside of Boston or Washington or New York City. You have a policy elite running things, and once you get out of the Beltway, we have a saying down here, Massachusetts is a lot different from Mississippi."
