Providers are urging UHC for a "full and permanent reversal" of the policy.
UnitedHealthcare has temporarily shelved its decision to retroactively deny emergency care claims after acknowledging withering blowback from major provider associations.
The American Hospital Association, the Federation of American Hospitals, and the American College of Emergency Physicians had blasted UHC's decision to retroactive review claims. The policy was supposed to take effect next month, but UHC said it would delay implementation until at least the end of the COVID-19 pandemic.
"Based on feedback from our provider partners and discussions with medical societies, we have decided to delay the implementation of our emergency department policy until at least the end of the national public health emergency period," UHC said in a statement.
In a letter to UHC's CEO Brian Thompson, urging him to reverse the decision, AHA President and CEO Richard J. Pollack said "patients are not medical experts and should not be expected to self-diagnose during what they believe is a medical emergency."
"Threatening patients with a financial penalty for making the wrong decision could have a chilling effect on seeking emergency care," Pollack said.
Pollack issued a statement after UHC announced the delay. He applauded the "temporary reprieve for patients" and pressed UHC for a "full and permanent reversal."
"If enacted, this policy would have a chilling effect on patients seeking emergency services, with potentially dire consequences for their health," Pollack said, adding that the policy "is also part of an unfortunate pattern of commercial health insurers denying care for needed services."
"Patients should have the confidence to seek the emergency care they need without worrying about coverage being denied," he said. "There is no justification for these restrictions now or after the public health emergency."
Like ACEP, the AHA points to the "prudent layperson standard," which requires health insurance plans to base reimbursement on a patient's presenting complaint rather than the final diagnosis, according to the American Academy of Emergency Medicine.
AHA is also asking United Healthcare to "confirm in writing that if the facility attests that a case met the prudent layperson standard that the services will be covered."
AHA says United Healthcare "acknowledges that this policy change is financially-motivated" and is skeptical of United Healthcare's argument that it would pass those cost savings onto consumers.
It says United Healthcare premiums and profits continue to rise even as it restricts coverage, noting that United Healthcare's parent company UnitedHealth Group posted a 35% year-over-year increase in operating profits in the first quarter of 2021.
"Despite earning $6.7 billion in a single quarter, UHC enrollees are being asked to pay more for their coverage," Pollack writes.
In addition to calling on United Healthcare to reverse its policy, the AHA also questions some of United Healthcare's other policies and guidance that appear to contradict its plan to retroactively deny emergency care claims.
For instance:
AHA cites United Healthcare's own online guidance for its members to that seems to contradict the new policy, which says: "Do not ignore an emergency. Take action if a situation seems life-threatening. Head to your nearest emergency room or call 9-1-1 or your local emergency number right away."
AHA says the new policy "raises significant questions about the criteria UHC will use to determine emergency services coverage."
AHA questions how United Healthcare is addressing the kinds of healthcare barriers that might push patients toward emergency care, such whether its enrollees have enough providers available during non-traditional hours; whether they help connect their enrollees with a primary care provider; whether its networks offer sufficient access to alternate sites of care, and whether it will cover the care provided at those sites without excessive administrative barriers.
AHA suggests other United Healthcare policies also restrict access—and therefore push patients to emergency departments even more. For instance, AHA cites a policy that "would reduce or eliminate coverage for certain hospital-based surgeries, laboratory and other diagnostic services, specialty pharmacy therapies, and evaluation and management services, including those provided in the emergency department, as well as those that constitute primary care."
HealthLeaders' Alexandra Wilson Pecci contributed to this report.
A Mayo Clinic program used in-home technology to monitor oxygen levels, vital signs and COVID-19 symptoms, and relied on a centralized virtual care team to manage patients.
Cancer patients with COVID-19 were less likely to need hospitalization if they received care from home using remote patient monitoring, than were cancer patients with COVID-19 who did not, a new Mayo Clinic study finds.
"We evaluated 224 Mayo Clinic patients with cancer who were found to have COVID-19 through standardized screening prior to receiving cancer treatment, or due to symptoms or close exposure," said study senior author Tufia Haddad, MD, a Mayo Clinic medical oncologist.
Researchers followed the patients March 18–July 31, 2020. The study results were presented on Friday at the American Society of Clinical Oncology Annual Meeting and published in the Journal of Clinical Oncology.
Mayo at the outset of the COVID-19 pandemic built a remote patient monitoring program for its COVID-19 patients who were at risk for severe illness.
The program used in-home technology to monitor oxygen levels, vital signs and COVID-19 symptoms, and relied on a centralized virtual care team to manage patients. Haddad said the program had served more than 8,000 patients in rural and urban locations across 41 states by November 2020.
Among cancer / COVID patients who did not need hospitalization, those monitored remotely were significantly less likely to require hospitalization, compared with those who were not monitored, the study found.
"After balancing the two groups of patients who were or were not managed by the remote monitoring program for factors known to impact COVID-19 outcomes, such as old age, male gender and obesity, there was a 78% reduction in the risk of hospitalization (a 2.8% risk for patients on the remote monitoring program, compared to 13% for patients not on the program) attributed to the remote monitoring program," Haddad said.
In addition, cancer patients in the remote care program who subsequently were hospitalized saw fewer hospitalizations of more than one week, and fewer ICU admissions and deaths.
"It is possible that our results were due to early detection of adverse symptoms and vital sign trends that enabled earlier care interventions to alter the trajectory of disease," Haddad said, adding that further research is needed to confirm the study's results.
Slipkovich had served as interim CEO since September 2020, shortly after the for-profit health system emerged from bankruptcy.
Quorum Health announced this week that "interim" has been removed from CEO Daniel Slipkovich's title.
Slipkovich, a veteran healthcare executive, has served as a board manager for the Brentwood, Tennessee-based for-profit health system since July 2020, as the company was emerging from bankruptcy. He was named interim CEO in September.
"Dan stepped up at a challenging time and impressed us with his strategic vision and execution," Board Chair Catherine Klema said in a media release. "He's focused the company on its core operations and mission and established a commitment to excellence that will serve both Quorum Health and its affiliated hospitals – clinically, operationally and financially – for years to come."
Quorum operates 22 general acute care hospitals and outpatient services in 13 states, primarily in rural and mid-sized markets. That's almost half as many as the 38 hospitals it owned when it spun off from Community Health Systems in early 2016. The company sold 16 hospitals since then as part of an effort to reduce about $500 million in debt.
Quorum on May 28 sold its QHR Health consulting and management company to private equity firms Grant Avenue Capital, Nashville Capital Network and Brentwood Capital Advisors, with Grant Avenue holding a majority stake. Financial terms were not disclosed.
"This transaction positions QHC to refocus on our core operations," Slipkovich said. "The capital generated by the transaction will allow us to accelerate certain high priority projects and capital investment to expand health services in our existing markets and invest in new market opportunities."
In 2005, Slipkovich founded and led Capella Healthcare until its 2016 merger with RegionalCare Hospital Partners. He was also president and COO of Providence Healthcare, a senior vice president and founding executive of LifePoint Hospitals, and served in several leadership roles at HCA Healthcare.
Quorum also announced that President and COO Martin D. Smith, an executive with the company since it was formed in 2016, will retire at the end of summer.
"Marty has served as a cornerstone of this company from our formative days more than five years ago through the most difficult moments during the height of the pandemic," Slipkovich said. "We understand and respect his desire to make a change and are grateful for his dedication and stewardship."
Scott Raplee, who joined Quorum Health this year after more than 20 years in leadership at LifePoint Health, was named executive vice president and COO.
"Scott will now lead the corporate operations team as we enhance services in our existing locations and pursue opportunities in new markets," Slipkovich said. "The continued refinement of our strategic focus, coupled with our strengthened capital position and commitment to performance excellence, makes us a partner of choice for community hospitals and physicians."
Ambulatory services accounted for 22,000 job gains while nursing homes reported 2,400 job losses.
The healthcare sector grew 22,000 jobs in May, nearly triple the 8,100 jobs the sector recorded in April, preliminary federal data show.
Hospitals created 2,900 new jobs, while ambulatory services accounted for 22,000 jobs. Nursing and residential care recorded 2,400 job losses, the Bureau of Labor Statistics reported on Friday.
The healthcare sector has shed 476,000 jobs since the start of the pandemic in January 2020, with hospitals accounting for 84,000 axed jobs, and nursing homes accounting for 339,000 job losses. There were 15.9 million people attached to the healthcare sector workforce in May, BLS said.
The BLS report accounts for employment in mid-May and can be subject to considerable revision.
The larger economy saw healthy but unspectacular job growth in May, with 559,000 new jobs created. More than half of those jobs (292,000) were in the leisure and hospitality sector. State and local government hirings rebounded as well, with 53,000 new jobs reported, as school systems across the nation rehire teachers.
The nation's unemployment rate inched down by 0.3 percentage point in May to 5.8%, and the number of jobless people fell by 496,000 to 9.3 million.
BLS noted that the numbers are "down considerably" from April, but "remain well above their levels prior to the coronavirus (COVID-19) pandemic (3.5% and 5.7 million, respectively, in February 2020)."
Despite the upheaval caused by COVID-19, MGMA's annual compensation report reveals surprising findings.
Physician compensation during the COVID-19 pandemic remained largely unchanged, even as just about everything else across the healthcare landscape shifted, a new report shows.
The Medical Group Management Association's 2021 MGMA Provider Compensation and Productionreport examined data from more than 185,000 providers across more than 6,700 physician- and hospital-owned care venues and found that primary care physician compensation saw modest growth in 2020, and other physician specialties saw slight increases or met previous year compensation amid the pandemic.
That relative stability occurred despite patient volumes falling off a cliff, caps in elective and nonemergency procedures, and the shuttering of thousands of physician practices.
"MGMA's modest compensation findings belie the turmoil of 2020," said Halee Fischer-Wright, MD, president and CEO of Englewood, Colorado-based MGMA. "Our numbers tell a story of a year of unprecedented challenges that could have potentially led to a serious decline in compensation across every category we track."
According to MGMA, total compensation for primary care physicians rose by 2.6% between 2019 and 2020, compared to the three- and five-year cumulative increases of 5.27% and 10.15% respectively.
Other physician specialties also held stable, and decreases in compensation for some specialists were not as bad as anticipated, despite patient access challenges during the pandemic.
"Surgical physicians, for example, whose patient volumes were significantly limited because of regional lockdowns and overwhelmed hospitals, experienced a compensation decrease of 0.89% in 2020," MGMA said. "Nonsurgical specialists also reported a decrease of 1.29% despite the significant challenges faced by those specialists last year."
Advanced practice providers also saw a slight bump in compensation in 2020.
Federal government subsidies, most notably the Paycheck Protection Program and the Provider Relief Act, were credited with stabilizing many medical practices in 2020, and a rebound in patient volumes at the end of the year also helped to contend with the pandemic's fallout.
Fisher-Wright said the quick action by physicians to recognize the threat posed by the pandemic also helped soften the blow.
"Practices acted quickly to leverage government programs to cover staff costs and expenses during the early part of the 2020," she said. "They adapted to new delivery models such as telemedicine and were able to quickly ramp up when patient volumes returned later in the year. It is a testament to the resiliency of physician groups that weathering the challenges of a year that tested us all in so many ways."
Anthem disputed the findings and rejected the recommendations in its rebuttal of the report.
Federal auditors are calling for Anthem Community Insurance Company, Inc., to refund nearly $3.5 million in alleged upcoded overpayments submitted to and paid for by Medicare Advantage.
The audit, conducted by the Office of the Inspector General at the Department of Health and Human Services, examined 203 unique enrollee-years with the high-risk diagnosis codes for which Anthem received more money from 2015 to 2016.
"For 123 of the 203 enrollee-years, the diagnosis codes that Anthem submitted to CMS were not supported in the medical records and resulted in $354,016 of net overpayments for the 203 enrollee-years," OIG said.
"These errors occurred because the policies and procedures that Anthem had to detect and correct noncompliance with CMS's program requirements, as mandated by Federal regulations, were not always effective," the audit said. "On the basis of our sample results, we estimated that Anthem received at least $3.47 million of net overpayments for these high-risk diagnosis codes in 2015 and 2016."
In addition to the refund, OIG recommended that Anthem similar instances of noncompliance that occurred before or after the audit period and refund any additional payments and enhance its compliance procedures to focus on diagnostic codes that are at high risk of being misused.
Anthem disputed the findings and recommendations in its rebuttal of the report, asked OIG to withdraw the demand for an extrapolated $3.47 million payment, and instead conduct more audits beyond the 203 samples and make any repayments based on those findings.
Anthem Responds
In a statement emailed Wednesday to HealthLeaders, Anthem said it "complied with applicable Medicare Advantage regulations, including those set forth by CMS and reviewed in this audit by the OIG for HHS."
"The OIG report acknowledges that Anthem and CIC had compliance procedures in place to determine whether submitted diagnosis codes to calculate risk-adjusted payments were supported by medical record documentation," Anthem said.
"The OIG also acknowledged that Anthem had procedures to compare diagnosis codes from specific claims to the diagnoses that were documented on the associated medical records, make corrections as appropriate, and provide guidance on how its reviewers should address certain high-risk diagnoses. It further found that Anthem's compliance procedures included outreach to help educate our providers. The OIG did not identify any specific deficiencies in our programs through its audit."
Brooks-LaSure will face the immediate tasks of implementing President Biden's plan to expand the ACA and overturning policies put forward by former President Trump.
On a 55-44 mostly partisan vote, the U.S. Senate on Tuesday approved the nomination of veteran Democratic healthcare policy expert Chiquita Brooks-LaSure to become the first Black woman to lead the Centers for Medicare & Medicaid Services.
Five Republicans crossed the aisle to vote for Brooks-LaSure.
As administrator of the $1 trillion agency, Brooks-LaSure will face the immediate and simultaneous tasks of leading a massive federal bureaucracy as the COVID-19 pandemic winds down, implementing President Joe Biden's plan to expand the Affordable Care Act, and overturning policies put forward by former CMS Administrator Seema Verma under President Donald J. Trump.
Brooks-LaSure's nomination eked by the Senate Finance Committee in April on a partisan 14-14 vote. At the time, she told the committee that focusing on healthcare access and inequity would be a key priority for her.
"During my career, I’ve seen how communities of color too often experience worse health outcomes, which we’ve seen so acutely during this pandemic," she told the committee.
Brooks-LaSure has a long tenure in health policy, having worked as a Medicaid analyst for the Office of Management and Budget, a Democratic staffer on the U.S. House Ways and Means Committee, and from 2010 to 2014 as a policy maker in the Obama Administration with the Center for Consumer Information and Insurance Oversight at CMS, which played a role in formulating policy for the Affordable Care Act.
Most recently, Brooks-LaSure was managing director of the Health Division of Manatt, Phelps & Phillips.
This is not the first time that the nomination of CMS administrator has proven contentious. In March 2017, Seema Verma, Brook-LaSure's predessor, was appointed on a partisan 55-43 vote, with two Senators abstaining.
In July 2010, President Obama appointed Donald Berwick, MD, to lead CMS, where he served as acting administration for five months. He was forced to resign in December 2010 because of Republican opposition to his nomination.
Stakeholders had asked the California governor for an additional $200 million annually in ongoing funding to bolster a depleted and understaffed public health infrastructure.
Public health officials in California are panning Gov. Gavin Newsom's newly revised $268.7 billion budget, noting that it fails – for a second straight year – to provide new money for vital healthcare services, despite a record-breaking $76 billion surplus.
A coalition of 61 local health departments and other stakeholders from across the state had asked the governor for an additional $200 million annually in ongoing funding from the state's $197 billion general fund to bolster a depleted and understaffed public health infrastructure that has been battered to the breaking point during the ongoing pandemic.
"This is a missed opportunity for investment in public health," said Kat DeBurgh, executive director of the Health Officers Association of California.
"California's local health departments have been losing staff since the great recession, and funds are needed now to make sure California is protected from disease going into the future," she said.
Newsom on May 14 unveiled his $100 billion California Comeback Plan that features about $12 billion in stimulus payments for California families, along with financial assistance to small businesses, and additional money to fund universal Pre-K and address homelessness, affordable housing, wildfire containment and infrastructure improvements.
"California’s economic recovery will leave nobody behind," Newsom said. "That's why we're implementing the nation's largest state tax rebate and small business relief programs in history, on top of unprecedented investments we're making to address California's most persistent challenges. This is a jumpstart for our local economies, and it’s how we’ll bring California roaring back."
State legislators will begin their review of the budget this week and must pass something by the June 15 deadline mandated by the state constitution. California's Fiscal Year 2021-22 begins July 1.
In 2020, Newsom also provided no additional funding for public health, as the state struggled to cover a $54 billion budget deficit.
Michelle Gibbons, executive director of the County Health Executives Association of California, said the pandemic "exploited the cracks in public health readiness caused by a decade of disinvestment in our public health infrastructure and workforce."
"The biggest lesson of COVID-19 is that waiting until a crisis to invest in public health costs lives," she said. "Astoundingly, this budget would repeat the same mistakes California made before COVID-19, leaving local public health departments too under-resourced and understaffed to address day-to-day public health threats such as the high rates of STDs, increasing rates of tuberculosis cases and chronic diseases -much less facing down a threat like COVID-19."
Twenty-three state attorneys general say the Trump administration's 2019 changes to Title X "harmed our states by, among other things, reducing the availability of family planning services and accessible reproductive healthcare in our communities."
California Attorney General Rob Bonta is among a coalition of 23 state attorneys general applauding the U.S. Department of Health and Human Services' proposal to eliminate the Trump-era "domestic gag rule" that prohibits Title X providers from making abortion referrals.
In a 15-page letter on May 17 to HHS Secretary Xavier Becerra, the AGs said the Trump administration's 2019 changes to Title X "harmed our states by, among other things, reducing the availability of family planning services and accessible reproductive healthcare in our communities."
"These harms have been compounded by the COVID-19 pandemic," the AGs wrote. "Moreover, the 2019 Rule has caused significant harm to women and to populations that have faced difficulties accessing essential healthcare services, such as patients in rural areas, people of color, and lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals; doctors and other healthcare providers; and numerous entities in our states that receive federal healthcare funding."
The AGs noted that Title X funding also covers access to contraceptive methods, critical screenings for high blood pressure, anemia, diabetes, sexually transmitted diseases, and cervical and breast cancer. The restrictions in the 2019 rule resulted in a dramatic loss of Title X providers, the AGs said, which in turn resulted in a 60% decline in the numbers of people served by the program between 2018 and 2020.
HHS announced the proposed rule in mid-April and said the 2019 rules "have undermined the public health of the population the program is meant to serve."
HHS said it plans to "revise the 2019 rules by readopting the 2000 regulations (65 FR 41270), with several modifications needed to strengthen the program and ensure access to equitable, affordable, client-centered, quality family planning services for all clients, especially for low-income clients," HHS said.
The announcement came just days after the CDC loosened restrictions on mask usage for fully vaccinated people.
State health officials announced this week that they will extend a mask mandate through June 15, despite Centers for Disease Control and Prevention guidelines that lifted many of the restrictions for fully vaccinated people.
"Until June 15, when California plans to fully reopen the economy, California will keep our existing guidance around masks in place," California Health and Human Services Secretary Mark Ghaly, MD, said in a media release.
"On June 15, California plans to implement the CDC's guidelines around masking to allow fully vaccinated Californians to go without a mask in most indoor settings," Ghaly said. "This four-week period will give Californians time to prepare for this change while we continue our relentless focus on delivering vaccines, particularly in underserved communities."
The announcement came just days after the CDC loosened restrictions on mask usage for fully vaccinated people. The announcement got mixed reactions from across the political and healthcare spectrums, with some complaining that the new guidelines were confusing, and others complaining that they were long overdue.
CDC Director Rochelle Walensky has defended the decision to loosen restrictions, telling CNN's State of the Union that the move was based on "evolving data."
"I'm delivering the science as the science is delivered to the medical journals. And it evolved," she said. "I deliver it as soon as I can when we have that information available."
The California Nurses Association -- noting that the United States is still recording more than 600 COVID-19-related deaths each day -- had vigorously opposed the CDC guidance and had asked Gov. Gavin Newsom to ignore it.
CNA President Zenei Triunfo-Cortez, RN, said the state's decision to delay any changes to the current guidance "a prudent one that we applaud."
"We encourage our state officials to continue to look to the data and the science when making these critical public health decisions and not cave to political pressure or arbitrary timelines," Triunfo-Cortez said.
California, with 39.5 million residents, has recorded nearly 63,000 COVID-19 deaths, the most of any state. However, the state is ranked 29th overall in per-capital deaths, recording 159 deaths per 100,000 people.
Ghaly said the state "has made amazing progress" in the pandemic fight with more than 34 million vaccines administered and one of the lowest case and positivity rates in the nation.
