DOJ says the deal will prevent Geisinger from exerting control over Evangelical and "restore the defendants' incentives to compete with each other on both quality and price."
Provisions of the settlement are designed to prevent Geisinger from exerting control over Evangelical "and to restore the defendants' incentives to compete with each other on both quality and price," DOJ said.
In addition, the settlement would prohibit Geisinger from increasing its ownership stake in Evangelical, loaning or providing a line of credit to Evangelical, or exerting control over Evangelical expenditures, and requires Evangelical to use money from Geisinger for projects that benefit patients and the community. The two providers must also implement antitrust compliance programs.
However, the settlement allows Evangelical to get an electronic health records system and tech support from Geisinger.
The settlement was filed Wednesday in U.S. District Court in Harrisburg and awaits review by a federal judge, and a deal could be completed some time this year.
Richard A. Powers, acting assistant attorney general of DOJ's Antitrust Division said the initial partial-acquisition deal put forward by the rival providers would have "reduced their incentives to compete on the price, quality, and availability of high-quality healthcare services, which would have harmed patients in central Pennsylvania."
"Today's settlement ensures that those patients will continue to benefit from robust competition between Geisinger and Evangelical," Powers said.
Geisinger COO Matthew Walsh said the Danville, PA-based health system was "pleased to have worked with the Department of Justice to develop a resolution that allows us to maintain our investment in the health of this community."
"We are grateful that the Department of Justice acknowledges the investments Geisinger has made to Evangelical to date and we look forward to our continued work on projects that will benefit patients and the community at large," Walsh said.
In a civil action filed last August, DOJ claimed that Geisinger and Evangelical "are close competitors for inpatient general acute-care hospital services for patients in a six-county area in central Pennsylvania, where the two hospital systems together account for approximately 70% of the market."
DOJ had alleged that the partial-acquisition agreement created "significant entanglements between the hospitals, reducing their incentives to compete against each other and increasing the likelihood of harmful coordination."
Specifically, DOJ said that Geisinger would pay $100 million for a 30% stake in Evangelical, with the money used for upgrades approved by Geisinger.
"These terms would have set Geisinger up as a critical source of funding for Evangelical for the foreseeable future and provided opportunities for Geisinger to influence strategic decisions of its competitor," DOJ said.
The deal also gave Geisinger rights of first offer and first refusal for joint ventures and other projects, which would have hamstrung Evangelical's attempts to partner with other providers.
Combined, DOJ said, the provisions of the partial acquisition "functioned together to substantially lessen competition and unreasonably restrain trade in the market for inpatient hospital services in central Pennsylvania."
Geisinger, with annual revenues of $7.1 billion in 2019, owns 12 hospitals, urgent-care centers, outpatient facilities, and physician practices throughout Pennsylvania, with the flagship 574-bed Geisinger Medical Center.
Lewisburg-based Evangelical Community Hospital is a 132-bed independent community hospital that operates an urgent-care center, outpatient venues, and physician practices in central Pennsylvania. The hospital had annual revenues of $259 million in 2019.
Evangelical Responds
Kendra Aucker, president and CEO at Evangelical Community Hospital, cheered the settlement and stressed that it allows her hospital to remain independent.
"Evangelical can best continue to meet the needs of our community by remaining an independent, community hospital and by using Geisinger's financial support to strengthen our facilities, technology, and services," she said.
Aucker said Geisinger's investment supports Evangelical's expansion project known as PRIME, the Patient Room Improvement, Modernization, and Enhancement project, and a renovated intensive care unit.
The first two weeks of the special enrollment saw an especially enthusiastic response from consumers in states that are hostile to the Affordable Care Act.
More than 200,000 people signed up for health insurance during the first two weeks of the 2021 Marketplace Special Enrollment Period, with more than 75% of them living in states that are still fighting to eliminate the Affordable Care Act, numbers released Wednesday by the Centers for Medicare & Medicaid Services show.
Overall, the federal marketplace enrolled 206,000 people between February 15 and February 28 from 36 states that rely on the Marketplace, 155,879 of whom live in the 18 states that are challenging the constitutionality of the ACA before the U.S. Supreme Court in California v. Texas.
Texas – the lead plaintiff in the fight to nullify the ACA -- and Florida accounted for nearly half of the newly insured, with Florida enrolling 61,737 people and Texas enrolling 34,682 people.
Georgia accounted for another 16,636 people, while South Carolina added 6,104, and Tennessee added 5,623 people.
CMS said the first two weeks of the SEP saw an increase from 76,000 and 60,000 people signing up for health insurance during the same period in 2020 and 2019, respectively.
Under normal circumstances, SEPs are available only for qualifying life events. However, President Joseph R. Biden opened an SEP this year as part of his administration's response to the COVID-19 Public Health Emergency.
The Humana subsidiary will also add 49 affiliate practices to its network through downstream participation arrangements.
Humana Inc. subsidiary and geriatric care provider Convivais buying a South Florida primary care physician network that will add 12 healthcare centers to its network.
Financial terms were not disclosed for the deal, which includes the acquisition Health Promoters Limited Liability Company; Jupiter Medical Group, Inc.; Primary Care Associates, Inc.; and Richard M. Hays, M.D., P.A., all of which are owned by Rajendra Bansal, M.D.
"I am so proud of what we have built in our centers and practices where our team does such an outstanding job, every day, of looking after the health of the senior population we serve," Bansal said.
"It is clear to me that Conviva also has a great approach to serving this population, and I want all of our patients to know that they will be in good hands in the years ahead," he said. "Conviva takes the time to treat their patients right."
The four practices will expand Conviva's footprint in Florida with 12 new centers and more than 200 new Conviva employees, including more than 40 physicians, physician assistants and advanced practice registered nurses.
Conviva will also add 49 affiliate practices to its network through downstream participation arrangements.
The Florida care centers in the deal are in Ft. Pierce, Jupiter, Lake Park, Port St. Lucie, Royal Palm Beach, Stuart and Wellington.
Kevin Meriwether, Care Delivery Organization Divisional Leader for Florida, said the acquisition meshes with Conviva's holistic, value-based, managed care model.
"We're excited to grow Conviva's presence in South Florida – especially as we'll now serve more seniors who live in Treasure Coast region," Meriwether said. "Under Dr. Bansal's leadership, his network has earned a reputation for providing high-quality care for seniors throughout the region, and we look forward to continuing that tradition."
The deal brings the total of geriatric primary care centers Humana owns to more than 170 – including its Conviva, Partners in Primary Care, and Family Physicians Group facilities across the nation.
Illinois House Bill 3498 aligns telehealth coverage and reimbursements with in-person care.
Illinois' Coalition to Protect Telehealth is backing a bill to protect and make permanent consumer access to telehealth services post-COVID-19 pandemic.
Illinois House Bill 3498 aligns telehealth coverage and reimbursements with in-person care.
"Over the last year, we’ve seen significant, rapid development in telehealth technology," said the bill's sponsor, State Rep. Deb Conroy (46th House District).
"Initially spurred by the COVID-19 pandemic, both state and federal government enacted policy changes to make telehealth services easier to access and, as a result, healthcare providers, professionals and patients have seen that virtual care preserves quality and safety, while also accommodating patients’ individual needs," Conroy said.
"Illinois should support this continued investment in telehealth and the important role it will play in modernizing healthcare delivery and empowering patients," she said.
Before the COVID-19 public health emergency, 36 states had coverage parity policies and 16 states had payment parity for commercial health plans. Illinois required neither. For Medicaid, 21 states had coverage parity policies and 28 states had payment parity. Illinois offers limited Medicaid coverage for telehealth services but has no laws that direct Medicaid to treat telehealth and in-person services the same for these purposes.
A September 2020 survey by the Illinois State Medical Society found that three-out-of-four physicians had not used telehealth before the public health emergency, many citing cost and lousy reimbursements. Half of the surveyed physicians said telehealth was particularly helpful for vulnerable patients who have trouble accessing in-person visits.
The provisions of House Bill 3498 ban geographic or facility restrictions on telehealth services and allow patients to be treated virtually in their homes. The bill also mandates that patients not be required to use a separate panel of providers for telehealth services, nor would they be required to prove a hardship or access barrier to receive telehealth services.
Conversely, the bill mandates that patients cannot be required to use telehealth services and gives providers latitude to determine the appropriateness care venues and technology platforms for telehealth services.
However, hospitals, physicians and other providers would bear the brunt of the cuts.
The nation's $3.8 trillion healthcare sector could reduce costs by as much as $350 billion a year if private health insurance payments to providers were capped at the same rates as Medicare, according to a new study by Kaiser Family Foundation.
However, the study concedes that hospitals, physicians and other providers would bear the brunt of the reimbursement reductions, and it's not clear how that would affect patient care.
Relying on data from MarketScan and FAIR Health, the researchers estimated the total annual reduction in healthcare spending by employers and privately insured people that would result with a Medicare reimbursement cap on private insurance.
"A variety of policy levers could be used to move the health system in this direction, including Medicare for all, a public option, or regulatory controls over private prices," KFF said.
The KFF study said smaller reductions could be reached if private plans were reduced "to some multiple of current Medicare rates or if lower rates were phased in gradually."
"We discuss but do not model the potential effects of price reductions on the supply of services, utilization of healthcare services, or quality of healthcare," KFF said. "We also do not estimate the effects on tax obligations for individuals or employers, nor quantify the impact of this change on the federal budget or the Medicare program."
The study found that:
Healthcare spending for privately insured people would be $352 billion lower in if employers and other insurers reimbursed healthcare providers at Medicare rates. This represents a 41% decrease from the $859 billion that is projected to be spent in 2021.
Employer contributions toward employee premiums would drop by $194 billion, assuming employers' share of premiums stays constant after private rates drop to Medicare levels.
Employees and their dependents would spend at least $116 billion less for healthcare, through a combination of lower premiums and out-of-pocket spending.
The reduction in federal and individual spending on healthcare for an estimated 19 million people in the non-group market would total $42 billion.
Nearly half of the spending cuts (45%) would be for outpatient hospital services, due in part to high private rates relative to Medicare rates for outpatient care, compared to most other services. Inpatient services account for 27% of the decrease in spending, and physician office visits account for 14% of the decrease.
Healthcare spending for privately insured adults ages 55 to 64 would be $115 billion lower if private insurers used Medicare rates—this is one third of the estimated total reduction in spending. The proportion of the decrease in spending attributable to adults 55 to 64 is roughly equivalent to their share of current spending.
The two Philadelphia health systems declare victory, say their merger has cleared its "final hurdle."
The Federal Trade Commission has dropped its opposition to the proposed merger of Philadelphia rivals Jefferson Health and Einstein Healthcare Network, clearing a final hurdle for the deal that could be finalized within six months.
"The Commission vote to voluntarily dismiss its appeal to the Third Circuit of the district court decision declining to preliminarily enjoin the merger of Thomas Jefferson University and Albert Einstein Healthcare Network was 4-0," the FTC said in a case summary.
A spokesperson for the FTC said the commission would have no further comments.
The merger, first announced in March 2018, will expand Jefferson from 14 to 18 hospitals and create a health system that generates about $6 billion in revenues annually.
Jefferson Health CEO Stephen K. Klasko called the FTC's decision to drop its opposition "a milestone victory for the city of Philadelphia and for those patients and families we proudly serve."
"Two non-profit, anchor institutions coming together to preserve access to care and do the right thing by the residents of Philadelphia is a creative solution to ensure Einstein doesn't face the same fate as Hahnemann University Hospital," said Klasko, MD, MBA, who is also president of Thomas Jefferson University.
When the FTC initially blocked the proposed merger on a 4-0-1 vote, it noted that Jefferson and Einstein were "the two leading providers of inpatient general acute care hospital services and acute rehabilitation services in both Philadelphia County and Montgomery County, Pennsylvania."
"The proposed merger would eliminate the robust competition between Jefferson and Einstein for inclusion in health insurance companies’ hospital networks to the detriment of patients," the commission wrote.
In December, a federal judge called the FTC's case against the merger "not credible," and based on biased testimony from health insurers. The FTC had appealed the ruling with the U.S. Third Circuit Court of Appeals, but filed a notice to voluntarily dismiss the complaint with the appeals court on January 6.
Pennsylvania Attorney General Josh Shapiro dropped his opposition to the merger in January after he secured a commitment from Jefferson to invest $200 million for capital improvements at Einstein facilities.
"We are excited to have Einstein and Jefferson come together, as our shared vision will enable us to improve the lives of patients, the health of our communities and enhance our health education and research capabilities," said Einstein CEO Ken Levitan.
"By bringing our resources together, we can offer those we care for - particularly the historically underserved populations in Philadelphia and Montgomery County – even greater access to high-quality care," Levitan said.
Tim Wentworth, CEO of Bloomfield, Connecticut-based Evernorth, said the acquisition comes as the COVID-19 pandemic is rapidly accelerating the need for consumer-friendly, convenient care venues.
"We see an immediate opportunity to build a new model of care delivery, one that delivers a connected experience with greater affordability, predictability and simplicity," he said. "With the opportunity to serve millions more people, and with more personalized ways to deliver care, we will have an even greater impact on our customers, clients and partners."
MDLIVE specializes in providing 24/7, on-demand, online telehealth services for patients, hospitals, physician groups, employers and payers.
"Combining MDLIVE's platform and strong network for virtual providers with our comprehensive care solutions, we will be better positioned to optimize the care journey to improve affordability and accessibility, and to deliver superior support to health plans as they advance their own care delivery models for the future," Wentworth said.
MDLIVE CEO and Chairman Charles Jones said the sale is an opportunity for the Miramar, Florida-based telehealth provider "to join an organization that complements our work, and has been a long-time partner and investor in our business."
"Together, we can accelerate MDLIVE's growth strategy and ability to serve more customers, while also building new services that will benefit our existing stakeholders, including employees, partners, patients, customers, health plans and providers," Jones said.
"With this transaction, Evernorth will gain an industry-leading platform, and a passionate and pioneering workforce that made virtual care a reality, and an essential and life-saving service during the COVID-19 pandemic."
The unfavorable ratings for the programs come just as most employers say they're needed most.
Less than one-third of employers in a new survey say their wellbeing and caregiving programs meet the needs of employees.
The Willis Towers Watson survey of 494 business -- with a combined 6.4 million workers -- found that a significant minority of employers say their wellbeing (29%) and caregiving (27%) programs have helped employees during the pandemic.
The unfavorable ratings for the programs come just as most employers say they're needed most.
A majority of survey respondents (54%) say that employee stress and burnout are top wellbeing and mental health concerns, exacerbated by the need to provide caregiving for loved ones and done in social isolation.
Another 40% of employers cite higher mental health-related claims as a top challenge.
"The pandemic has taken its toll on employees especially in the areas of emotional and social wellbeing," say Regina Ihrke, senior wellbeing leader at WTW. "In fact, the impact is so great that many employers expect these effects will continue in a post-vaccine environment."
"Therefore, many employers are now acting with urgency as they look to take their wellbeing programs to the next level," Ihrke say. "To achieve this transformation, they will ramp up listening to their employee needs, communication efforts and realignment of benefit programs with a focus on mental health and caregiving."
To address these challenges, 62% of employers say enhancing mental health services and stress/resilience management is a top priority over the next six months, compared with just 47% six months ago.
Twice as many employers report developing a strategy for benefits post-COVID-19 as a top priority over the next six months (33%) compared with six months ago (15%), which Ihrke says signals a shift from crisis management to future planning.
More than two-thirds (68%) cite communicating benefits and wellbeing programs as a top benefits priority over the next six months. Another two-thirds (67%) cite increased caregiving demands as the top driver of employee mental health concerns. Caregiving issues for employees with young and school-age children (56%) and decreased use of paid time off (43%) are the top workforce challenges due to the pandemic.
Modifying Benefits
Many employers have jiggered benefits to address workers' needs.
Half (50%) changed the features of paid time off or vacation/sick day benefits, and 23% changed their annual carryover limits.
"Employers have assessed their caregiving support was not as effective as hoped, and as a result the mental health of their workforce is suffering," says Rachael McCann, senior director at WTW. "Many solutions were short term in nature, which contributed to their ineffectiveness."
"With the stakes so high, employers need a revamped approach to caregiving support that includes a holistic view of benefits, paid time off and flexible work policies," she says.
Prepping for the Vaccine
Employers are looking to increase employees' access to vaccines. Nearly two-thirds (65%) are considering contracting with vendors to provide vaccines. While virtually no employers have vaccine mandates, 45% are planning or considering proof of vaccination as a condition to return to in-person work, and 34% are planning or considering mandating vaccines as a condition of employment.
The survey also found that:
67% of employers expect the pandemic to recede enough so they can reach a "new normal" to return to the workplace and bringing to an end pandemic-related policies and programs during the second half of 2021. 26% say they expect that to happen by the first quarter of 2022 or later.
Nearly two in five employees will still be working remotely at the end of 2021, compared with 57% who work remotely now, although that varies by industry.
61% of employers say their medical and pharmacy benefit costs came in under budget in 2020, and 37% of those report actual costs 8% or more below budget. Despite this, employers remain cautious and are budgeting a 4.2% median increase for 2021 before making plan design changes and 3.0% after plan changes.
A new forecast suggests that pandemic-related financial stressors will continue well into the new year and could threaten patient care access.
Hospital revenues in 2021 are projected to fall between $53 billion and $122 billion from pre-pandemic levels as COVID-19 continues to wreak havoc with higher costs, lower volumes and tighter margins.
That's according to a new forecast released Wednesday by the American Hospital Association and prepared by Kaufman, Hall & Associates, LLC, which projects that the pandemic-caused financial pressures on hospitals could slow vaccine administration, further fatigue exhausted front-line caregivers, and reduce care access, particularly in rural areas.
Rick Pollack, AHA president and CEO, said the report shows that "hospitals need additional support to continue to provide access to care and to help get as many vaccine shots into arms quickly."
"When we talk about the historic financial challenges hospitals face, it's about more than dollars and cents," Pollack said. "It's really about making sure hospitals and health systems have the resources needed to provide essential services for their patients and communities."
The KH report offers best case / worse case scenarios for hospital revenues.
Under the "optimistic scenario" hospitals will lose $53 billion in 2021 with an assumption that patient volumes recover completely, vaccine administration goes smoothly, and the nation sees a decline in the number of COVID-19 cases.
Under the "pessimistic scenario" hospitals will bleed $122 billion in revenues if there is only a partial recovery in patient volumes, the vaccine rollout is bungled or delayed, and COVID-19 cycles through additional surges.
In addition to falling revenues, hospitals in 2021 will also likely bear additional costs for medicines and supplies, KH projects.
The report notes that, when compared with 2019, drug expenses per adjusted discharge are up 17% as patients being admitted to hospitals and health systems increased in severity and required more therapeutics, including COVID-19 patients.
In addition, purchased service expenses per adjusted discharge are up 16% when compared with 2019, as hospitals required specialized functions such as environmental services and sterilizing facilities for COVID-19 patients.
Labor expenses per adjusted discharge are also up 14% because of the increased use in contract labor, hazard pay and other expenses for maintaining a workforce.
Supply expenses per adjusted discharge also is up 13% as hospitals scaled up their purchasing of PPE and other equipment to safely treat their patients. Shortages in 2020 increased the price for many of these items.
"During the pandemic, people have put off needed care, in some cases to the detriment of their health," Pollack said. "In addition, the costs of labor and supplies have increased, adding to financial stress."
On Monday, KH released a separate report noting that even as COVID-19 cases and deaths declined in January, the pandemic continued to dampen volumes, margins, and outpatient revenues of hospitals during the first month of 2021.
The median hospital operating margin for January was –0.6%, not including federal Coronavirus Aid, Relief, and Economic Security (CARES) Act funding. With CARES funding, it was –0.1%, according to KH's National Hospital Flash Report for February, which examines data from more than 900 hospitals.
Year-over-year volumes fell across most metrics as many healthcare consumers continued to avoid or delay care.
Even as COVID-19 cases and deaths declined in January, the pandemic continued to dampen volumes, margins, and outpatient revenues of hospitals during the first month of 2021, Kaufman Hall reports.
The median hospital operating margin for January was –0.6%, not including federal Coronavirus Aid, Relief, and Economic Security (CARES) Act funding. With CARES funding, it was –0.1%, according to KH's National Hospital Flash Report for February, which examines data from more than 900 hospitals.
Median operating Earnings Before Interest, Taxes, Depreciation, and Amortization (EBITDA) margin was 4% without CARES and 4.8% with CARES. Not including CARES, operating margin fell 46.1% (4.6 percentage points) and operating EBITDA margin fell 34.1% (4.2 percentage points) compared to January 2020, KH said.
"January marked a potential turning point in the pandemic, as we saw federal coronavirus statistics start to wane later in the month," Jim Blake, a managing director at Kaufman Hall and publisher of the National Hospital Flash Report, said in a media release.
"While declining COVID-19 cases and hospitalizations are a very welcome sign, the pandemic continues to create a challenging situation for hospitals and health systems. We must remain vigilant in our fight against the virus, and in providing these vital institutions the support they need to move toward recovery," Blake said.
KH also found that:
Year-over-year volumes fell across most metrics as many healthcare consumers continued to avoid or delay care. Year-over-year, adjusted discharges fell 17.6%, adjusted patient days fell 8.3%, and operating room minutes fell 16.6%.
Emergency department visits had the biggest drop compared to other volume metrics at 24.7%. ED volumes have seen double-digit year-over-year declines each month since the pandemic began in March 2020.
Inpatient volumes fell 2.3% year-over-year following two months of increases from rising COVID-19 hospitalizations, although hospitals continue to see higher average length of stay due to higher acuity patients.
Outpatient revenue fell 10.4% compared to January 2020, the ninth decline for the metric in the past 10 months. Lower outpatient revenues pushed gross operating revenue without CARES down 4.8% year-over-year, while total inpatient revenue increased 1.3% year-over-year.
Total expenses continued to rise as hospitals bore the high costs of labor, drugs, personal protective gear, and other equipment needed to treat sicker patients, including COVID-19 cases. Year-over-year, total expense per adjusted discharge rose 25.4%, labor expense per adjusted discharge rose 30.1%, and non-labor expense per adjusted discharge rose 24.4%.
