Beyond the fears that public disclosure of negotiated rates could harm payers and providers, a reason why price transparency is lagging in healthcare is because "it's hard to do," says Suzanne Delbanco, PhD, executive director of Catalyst for Payment Reform.
"There are some logistical challenes to getting the information to people in a way that is accurate, understandable, and relevant," she says. "While health insurance companies themselves have gotten much better with the tools that they offer, there's still a lot of missing data; the functionality is still clunkier than it should be. We still have a way to go in terms of figuring out how to do it."
Kari Cornicelli, CFO at Phoenix Children's Hospital, says the pediatric provider works closely with patients' families to give them as accurate a cost estimate as possible, but challenges remain.
"If you're paying the bill, you want to understand what you're paying for, but when there are complexities related to a very difficult diagnosis, the care is going to change depending on how the patient reacts to each phase of care," Cornicelli says. "So, it's really hard to give solid out-of-pocket costs to the family."
"Many times, the family doesn't really fully understand the complexities of their care," she says. "Therefore, when they ask for pricing, and we give it for what we think they're getting, and then their services are actually different, that's where it becomes more challenging."
"We're really focused in on what is the difference between what they're going to be responsible for," she says. "We don't want to go into the whole complexity of their insurance product. We want to get back down to identifying what their copay or their deductible is going to be."
Price transparency has become a major flashpoint in healthcare as the industry's payers and providers point blame at one another for the industry's runaway costs. But there's no reason to think this kerfuffle will fade.
The public is stressed over rising healthcare costs and looking for answers. That anxiety has been noticed by Congress and the U.S. Department of Health and Human Services, which are each pursuing transparency initiatives vigorously.
When the Centers for Medicare & Medicaid Services proposed in July to require hospitals to disclose the rates they negotiate with payers, the proposed rule was panned immediately. American Hospital Association President and CEO Rick Pollack said it "misses the mark, exceeds the administration's legal authority and should be abandoned."
Hospitals were widely expected to mount a legal challenge. It's unclear whether the courts would allow the Trump administration to force disclosure of information that is generally considered to be confidential.
But even if the rule were vacated or the administration were to decide not to finalize it, the core issue is too big to go away. The push for price transparency will continue. Ultimately, the debate will not be about whether price transparency is needed. Rather, the debate will center on how much and what kind of price transparency.
With that in mind, payers and providers have a choice to make. They can continue to obscure prices from consumers and risk an even heavier government intervention. Or, they can acknowledge that demands for price transparency are not going away and accept a version that provides consumers with fast, simple-to-understand, and accurate estimates for how much their care will cost.
In this issue, HealthLeaders spoke with payers, providers, and policy experts who understand the need for price transparency, the challenges ahead, and what it will take to get there.
It's all about out-of-pocket costs
Richard Miller, chief business strategy officer at Northwell Health, says the Long Island–based health system has been working on improving price transparency for a decade, and he believes he knows what healthcare consumers want.
"We've actually just completed some consumer research that backed up our assumption that what consumers are most interested in is what their out-of-pocket costs will be when they get various healthcare services," Miller says.
"If someone is going in for a joint replacement, they want to know, 'What is the amount that I'm going to have to write a check for in order to pay for the services that I'm going to receive?' "he says.
Those out-of-pocket costs, he says, are not controlled by hospitals, but are driven by the cost-sharing provisions in their insurance coverage.
"It's going to vary not only as a function of the provider they choose, but it varies more significantly as a result of the insurance that they've chosen and where they're at during the course of the year with meeting their deductibles," he says.
"Whether it's a bundled payment or any other type of value-based payment mechanism, or just old vanilla fee-for-service, we reach out to the insurer via a phone call and we work with them to identify what those cost-sharing amounts will be for the patient," Miller says.
Northwell is in the process of implementing new technologies that will allow it to specify patient cost-sharing provisions electronically "so that we can give them a really good estimate up front before they have their procedure," Miller says.
Northwell's research also found that cost takes a back seat to quality for many healthcare consumers deciding where to receive care.
"To have the cost discussion in the absence of any quality information is really not getting complete information," he says.
Because healthcare consumers are driven primarily by out-of-pocket costs and quality, Miller says, they probably won't care about accessing a provider's payer-specific negotiated rates, as CMS proposes.
"They're most interested in how the cost will affect them," he says.
Payers, providers pan disclosing negotiated rates
There is a growing acceptance among payers and providers about disclosing out-of-pocket and other consumer-borne costs. But those stakeholders also share an opposition to HHS' call for disclosing negotiated rates between payers and providers. Such transparency wouldn't help patients, who likely aren't interested anyway, and it could actually raise healthcare costs, they argue.
Whether or not the theory is true, it's become a key talking point for both the AHA and America's Health Insurance Plans (AHIP).
"Mandating the disclosure of negotiated rates between insurers and hospitals is the wrong approach," the AHA's Rick Pollack says. "Instead, it could seriously limit the choices available to patients in the private market and fuel anticompetitive behavior among commercial health insurers in an already highly concentrated insurance industry."
AHIP president and CEO Matt Eyles says the mandate is not needed because "virtually all plans (nearly 95%) empower consumers to comparison shop for a doctor."
"And the vast majority of plans (about 90%) can show consumers their likely out-of-pocket costs—like copays, coinsurance, and deductibles—for specific procedures and services," Eyles says.
Eyles raises a concern frequently noted by both hospitals and insurers that "disclosing privately negotiated rates will make it harder to bargain for lower rates, creating a floor—not a ceiling—for the prices that hospitals would be willing to accept."
"Publicly disclosing competitively negotiated, proprietary rates will push prices and premiums higher—not lower—for consumers, patients, and taxpayers," he says.
John Baackes, CEO of L.A. Care Health Plan, says that's what happened a decade ago in Massachusetts when then–Attorney General Martha Coakley acquired and published the reimbursement codes for every hospital in the state.
"For certain codes, the most expensive hospitals were getting twice the reimbursement from insurers than the least-costly hospital," Baackes recalls. "Coakley's thinking was they'll go to the hospitals and get them to reduce the cost so that there'll be a more-level playing field. All that happened is the hospitals that were at the low end came to the payers and said, 'Hey, give us what those guys are getting.' "
For that reason, Baackes says, insurers have been "reluctant to share what they're paying the providers because many insurers believe it is a competitive advantage."
Hospitals feel the same way, he adds.
"They honor the proprietary nature of the reimbursements from the insurer because if that particular insurer is paying them more, they're not going to want to jeopardize their relationship with the insurer by advertising that," Baackes says.
"And when the insurer figures out that maybe they're paying more than everybody else, or particularly if the insurer is paying less than the average of other insurers, they don't want that out there because then the other insurers will come to the hospital and say, 'Well, if you're charging them less, I want to pay less too,' " Baackes says.
This penchant for secrecy between payers and providers won't change, Baackes says, "until we get the notion out there that the reimbursement relationship is not proprietary, but it is based on some sort of cost-plus system, where the hospital can then be transparent about what its real costs are to provide the services."
Besides, he says, the difference in the reimbursements among insurers is immaterial.
"It's very small, because the providers will look for consistency with reimbursements, and there aren't too many favored-nation arrangements," he says.
Baackes says the price transparency movement could be greatly enhanced by dumping the chargemaster and transitioning to a cost-based system.
"The chargemaster is total fiction," he says. "Yet that's what's used when some poor sucker walks in the door who doesn't have an insurance card in their wallet. And that's what they hound them for and drive people into bankruptcy over."
When hospitals try to fashion reimbursements from insurers around the chargemaster, Baackes says "we avoid those like the plague."
"The chargemaster is in the control of the hospital, and they could tomorrow raise everything 10% and then our costs go up 10% as well," he says. "We like to have more specificity. We're going to pay them a fee based on a Medicare reimbursement, which is more of a standard, but that is not transparent. It's between us and the hospital."
Under a cost-based reimbursement system, Baackes says, charges would be transparent because they're the same for everybody.
"If we went to a cost-based system, where the hospital or the doctor says, 'It cost me this much to provide the service, and I have this much markup so that I can make a living or keep the doors open,' then everybody has a better idea of what the real value of it is," he says, "because the chargemaster rate at a hospital has nothing to do with the underlying costs. It's sort of, 'What can we get away with?' "
"Now, there could be some arrangement where there is a slight discount because the insurer pays faster, or you could go to an arrangement where the insurer pre-pays the provider and that results in some sort of discount," Baackes says.
"But again, until we get over this idea that what the insurance paid the providers is proprietary information, you're never really going to crack the transparency thing," he says.
What about value transparency?
Suzanne Delbanco, PhD, executive director of Catalyst for Payment Reform, says the healthcare sector historically has had poor transparency not just with prices, but with quality, too.
"If you're a patient, and you are trying to choose a hospital for X procedure, the chances that you can actually find the information that you want to compare hospitals on that particular procedure and get your out-of-pocket costs … and come up with some overall value choice is still largely impractical," she says.
"So, as consumers want to assess their options, it can be pretty challenging, and not just for the individual patient-consumer, but also for the employer-purchaser, trying to decide which health plan offerings to make available to their population," she says.
Delbanco says narrow networks pose their own challenges because patients want to be reassured that they're not compromising on quality for the sake of lower cost.
"If [employers] have a narrow network, are they going to be providing something that is a good value to their members or could they, without realizing it, be sending people to poor-quality providers?" she says.
A pushback for obscurity?
Even with the growing public support behind the price transparency movement, there are no guarantees that it's going to happen, Delbanco says.
In fact, she says, it could get muddier "as providers continue to consolidate and amass more market power, and therefore put more terms into their contracts that are favorable for them. We're going to see a resurgence of gag clauses that prohibit this information from being shared."
She says she sees a scenario where "must-have" providers with major market power for payer network adequacy or competitive purposes are able not just to dictate higher prices, but also prohibit information sharing on negotiated rates.
"I'm putting it out there," she says, playing devil's advocate.
"There's obviously a much bigger cry for transparency than there has been, but we're also seeing provider consolidation continue," she says. "As much as we could all say what the right thing is, I don't know that it will happen."
There are also concerns among providers of losing patient volume if they have to be transparent on their quality and prices.
"Will people know how to interpret that correctly and make the right decision?" Delbanco says. "There is the risk, for example, that a provider who charges a higher price for a given procedure might actually ultimately take care of that patient at lower expense than another system whose price was lower."
"For example, if the higher-price hospital does a better job at getting things right the first time and there are no complications and no readmissions," she says, "that could be cheaper, but that kind of stuff is challenging to convey."
Intervention is coming
With all the interest around price transparency, Delbanco foresees there being more state and federal intervention to make it happen.
"At the state level, we will see a handful more states pass laws that address these issues, and there are so many different ways to do it," she says. "I don't think we're going to see rate setting, where states try to say this is how much hospitals can get paid for X. We're more likely to see something like what Rhode Island has in place, putting a cap on how much prices can increase over time."
That legislative intervention could take the form of reference pricing, which Delbanco says has seen growing interest in recent years.
"In other words, if you tell the members of a health plan, that if you go to a provider that's higher than a reference price that we've set for something, then you have to pay the difference out of pocket," Delbanco says. "You can't do that, without transparency."
Whatever the method, Delbanco says, we're going to see more policy intervention for sure.
Medicaid insurers offered the lowest-priced silver plan 72% of the time when competing with an MMCO.
Commercial insurers would likely lower premiums if they had to compete with a public health plan option, a new Urban Institute analysis shows.
That's because setting provider payment rates close to Medicare's would lower marketplace premiums, particularly in high-priced markets," the analysis found.
"As we have suggested elsewhere, a public option could catalyze competition in less competitive markets, leading other marketplace insurers to lower their premiums," the analysis said.
In 2019, areas with an MMCO selling coverage in ACA marketplaces had benchmark premiums about $30 per month lower than comparable areas without a participating Medicaid insurer, controlling for other market differences. Those Medicaid insurers offered the lowest-priced silver plan 72% of the time.
Researchers estimate the potential savings from a public option would have a particularly significant effect in areas with only one commercial insurer.
"Competition can encourage insurers to negotiate lower prices with healthcare providers," said Linda Blumberg, Institute Fellow at the Urban Institute. "A public option may deliver the catalyst that insurers and providers need to make coverage more efficient and affordable."
Using Medicaid Managed Care Organizations that existed before the Affordable Care Act as a stand-in for a public plan, the Urban Institute analysis attempted to understand how commercial insurers would respond to a public competitor with lower expenses.
Rather than fearing that they couldn't compete, Blumberg said the lower rates paid by a public option could give compete insurers more bargaining power over providers with market control, and that bargaining power would be critical to private insurers retaining significant market share.
"Providers could therefore accept lower payment rates, given the threat that a public option would dominate, and insurers could then offer lower premiums," the analysis said.
"A public option paying rates similar to traditional Medicare rates could offer coverage with premiums lower than those of insurers who pay commercial rates. Thus, many commercial insurers resist this reform, believing they cannot compete," the analysis said. "Evidence showing insurers would respond with somewhat lower rates and continue to compete with a Medicaid insurer could inform the conversation about the implications of introducing a public option."
MMCOs are not purely public options, but were used in the analysis because their coverage on ACA marketplaces resemble existing Medicaid networks, which allows MMCOs to pay providers lower rates than commercial insurers, Blumberg said.
The analysis was funded in part by the Robert Wood Johnson Foundation.
In addition, 20 more health insurance companies will participate in the Federal Health Insurance Exchange in 2020, bringing to 175 the total number of issuers, up from 132 in 2018, CMS said.
Health and Human Services Secretary Alex Azar said the coming year's drop in premium prices follows a 1% decrease from 2018 to 2019.
"I said last year that President Trump, the president who was supposedly trying to sabotage this law, has been better at running it than the guy who wrote the law and that has remained the case this year," Azar told reporters during telephone conference call.
"In total, 27 out of the 38 states on the federal exchange are seeing decreases in the benchmark premium. There will be 175 issuers offering plans on the federal exchange and an increase of 20 issuers from 2019."
Azar said only two states will have a single health insurance plan in 2020, down from five states last year.
"The average enrollee will have 3.5 issuers available in 2020, compared with 2.8 issuers in 2019," he said.
Even with the expanded number of health plans, Azar said, ACA plans are largely unaffordable for most people without a subsidy.
"For instance, a 27-year-old single person buying the second-lowest cost Silver plan in Nebraska is going to pay $583 a month for coverage, down from $687 in 2019," he said. "Now that's real savings. But she's still going to be spending almost $7,000 a year on insurance premiums when she could be making as little as $48,000 in income, and she will still have a sizable deductible to spend through."
Six states will see double-digit percentage declines in benchmark silver plan premiums for 27 year olds including, Delaware (20%), Nebraska (15%), North Dakota (15%), Montana (14%), Oklahoma (14%), and Utah (10%).
CMS Administrator Seema Verma said that in recent years people who aren't eligible for tax credits "have been hit particularly hard and have found they simply cannot afford to keep their plan."
"Between 2016 and 2018 unsubsidized enrollment across the country declined by 2.5 million people, a 40% drop in just two years," she said. "It was inevitable that Obamacare's affordability crisis would eventually increase the number of uninsured, and that is exactly what the latest census data show."
"The fact is, 85% of the 1.9 million additions to the uninsured in 2018 occurred among people with income higher than 300% of the federal poverty line," she said. "These are people who do not qualify for large ACA subsidies and who now represent a new class of uninsured who can't afford Obamacare premiums."
Verma said a 55-year-old couple making $70,000 in Quincy, Florida would have to pay $31,000 a year for a Silver plan that comes with a $12,000 deductible.
"These are not affordable premiums," she said.
"In addition to increasing premiums," Verma said, "Americans had fewer choices. In 2016 to 2017, the number of issuers and states using Healthcare.gov declined from 237 to 167, and in 2018, the number dropped 132, a 44% drop during these last two years."
"These were the conditions the Trump administration inherited, and this is what people too often forget."
(To view the 2020 Health Insurance Exchange Premium Landscape Issue Brief, click here. To view the 2020 Plan Landscape Data, click here. To see the 2020 Health Insurance Exchange Public Use Files, click here.)
Here's a tip for providers who want their hospital patients to experience less pain. Be nice!
Research presented at the ANESTHESIOLOGY® 2019 annual meeting this week in Orlando analyzed responses from 4,740 adults who were asked about pain management for a variety of illnesses and surgeries during their hospital stay, which averaged 5.3 days with 3.8 blood draws.
Researchers found that 3,882 of the 4,740 patients (82%) answered "always" when asked how often the staff did everything they could to help them with their pain and 3,112 (65%) answered "always" when asked how often their pain was well-controlled.
Patients were also asked to rate from "very poor" to "very good" the courtesy of the person who drew their blood. Those patients who answered "very good" were 390% more likely to have rated their pain management as very good, than those who rated their provider less courteous.
"It's not surprising that a courteous health care provider can improve the patient experience, but we were shocked at just how powerful that factor was," said Mario Moric, MS, lead author of the study and a biostatistician at Rush University Medical Center, Chicago. "We thought the more needle sticks the higher the pain perception, but we found that effect was small. It turns out the experience of pain is much more significantly affected by the attitude of the people treating you."
Patient feedback has shown that blood draws are a major cause of fear and anxiety. Study co-author Asokumar Buvanendran, MD, said the results suggest that if the person drawing blood is empathetic and courteous, the patient's overall pain experience can be improved.
"It's important to continue to improve health care procedures by making them less invasive, but listening to patients and letting them know you are trying to minimize their discomfort also is really powerful and should be a focus for all health care training programs," said Buvanendran, chair of the American Society of Anesthesiologists Committee on Pain Medicine and vice chair of research at Rush University Medical Center.
"Being kind makes a big difference in the patient experience, and that's good for everyone," he said.
The 30-day mortality rate for these high-risk patients was 15.9% at major teaching hospitals, compared with 18.2% at non-teaching hospitals.
High-risk general surgery patients have higher survival rates at major teaching hospitals than at non-teaching hospitals, new research shows.
The 30-day mortality rate for these high-risk patients was 15.9% at major teaching hospitals, compared with 18.2% at non-teaching hospitals, according to researchers at Penn Medicine, who examined the medical records of 350,000 Medicare beneficiaries who underwent general, vascular or orthopedic surgery at 2,780 hospitals across the country, including 340 major teaching hospitals.
The findings were published this month in Annals of Surgery. The study was funded in part by the Association of American Medical Colleges.
Major teaching hospitals were defined by the researchers as having a resident-to-bed ratio of greater than .25.
"Academic medical centers are often recognized for their ability to deliver advanced clinical and surgical care, but there has been limited data on which specific patient groups benefit the most—when factoring costs and outcomes—from receiving care at the hospitals," senior author Lee A. Fleisher, MD, said in comments accompanying the study.
"Our study showed that as the severity of a patient’s medical condition worsened and the complexity of the surgery increased, the benefit of undergoing general or vascular surgery at a teaching hospital also increased," said Fleisher, chair of Anesthesiology and Critical Care at Penn.
The study examined costs and patient outcomes—including 30-day mortality rates—for dozens of procedures, such as mastectomy, appendectomy, gastric bypass, blood vessel repair and total knee replacement.
The researchers calculated the cost of care within 30 days of admission, including office visits and readmissions. Researchers matched pairs of individuals based on the procedure, risk profile and factors related to their medical history, including comorbidities such as diabetes and high blood pressure.
The mortality rate of high-risk vascular surgery patients was 15.5% at teaching hospitals compared to 16.4% at non-teaching hospitals. The mortality rate for orthopedic surgery procedures was significantly lower across the board than the rates for vascular and general surgery.
To calculate the cost for a 1% reduction in mortality rates, the researchers divided the variations in resource costs at major teaching and non-teaching hospitals by the difference in 30-day mortality rates. Under that equation, the value for general surgery was $965 for a 1% reduction in mortality, while the estimate for vascular surgery was $3,567.
"Our study provides new data that can help inform patient decisions and influence hospital referral patterns, ultimately moving us closer to a system that ensures patients have access to the treatment they need," Fleisher said.
The analysis projects that the costs for the opioid crisis in 2019 will range anywhere from $172 billion to $214 billion.
The opioid crisis has cost the nation at least $631 billion over the past four years, and nearly one-third of that estimate is attributable to excess healthcare spending, according to an analysis by the Society of Actuaries.
The $205 billion attributable to excess healthcare spending between 2015 and 2018 included providing medical care for opioid addicts and infants born with neonatal opioid-related conditions, and other family members bearing costs associated with those diagnoses.
“As stakeholders seek to understand and address the opioid epidemic, this analysis provides insight into the tremendous impact across all areas of our economy,” says Dale Hall, managing director of research at SOA.
"Our goal is really to help our member actuaries, insurers and other stakeholders better understand the implications of the opioid crisis," Hall says. "A lot of our members can use this information to build into pricing exercises, healthcare evaluation exercises, and understand the impact of premature mortality."
The analysis projects that the costs for the opioid crisis in 2019 will range anywhere from $172 billion to $214 billion, depending on key metrics, such as the prevalence of opioid use disorder and the number of opioid overdose deaths this year.
"We'll have a better idea when we get final, premature mortality deaths due to the opiate crisis," Hall says. "It's been trending up, about 45,000 per year and most recent years. We will also want to see what those premature death counts end up being in 2019. Those two categories, healthcare costs and mortality costs, are 70% of the total, and so those are the things that we want to watch out for."
The largest financial burden imposed by the opioid crisis was attributed to premature mortality, which accounted for $253 billion – 40% – of excess spending between 2015 and 2018, mostly measured in lost lifetime earnings for people who died prematurely due to opioid overdoses.
The SOA analysis is based several data sources, including administrative claims, federal surveys, and databases, and prior peer-reviewed literature to determine the total economic burden.
Here's a further breakdown of the financial burden of the opioid epidemic across the economy between 2015 and 2018:
Costs associated with criminal justice activities, including police protection and legal adjudication activities, lost property due to crime, and correctional facility expenditures, totaled $39 billion, about 6% of the total cost.
Government-funded child and family assistance programs and education program costs contributed another $39 billion.
Lost productivity costs comprised the remaining 15% of total costs, totaling $96 billion, and include the cost of absenteeism, reduced labor force participation, incarceration for opioid-related crimes, and employer costs for disability and workers' comp for opioid-addicted workers.
SOA said the economic burden could be higher than its estimates, because the analysis does not include economic impacts for which there is a lack of adequate data, such as reductions in non-paid household productivity, reductions in on-the-job productivity, or reductions in quality of life for people impacted directly or indirectly by opioid use disorder.
New contract provides annual 3% raises in each of the next four years, invests $130M for workforce development.
Kaiser Permanente workers in California have "overwhelmingly" ratified a new four-year contract with the health system, the Service Employees International Union said.
The new contract runs through September 30, 2023.
"Our new contract recognizes the skill and dedication we bring to our work, and the guaranteed raises and protected benefits give us the peace of mind to focus on caring for our patients," Jessica Rodriguez, an emergency department technician at Kaiser Permanente in Oakland, said in an SEIU media release.
"We are also proud to have negotiated an agreement that is focused on the future and making sure patients have access to highly skilled and trained caregivers in the years to come," she said.
Kaiser Permanente, in a brief statement, called the ratification of the new contract "encouraging" and said it would have more comments after the Coalition of Kaiser Permanente Unions announces final results later this week.
The ratified contract:
Revitalizes the worker-management partnership, which promotes cooperation between frontline workers and managers to improve care delivery and job conditions, and lower costs;
Invests $130 million in workforce development to recruit, train and place thousands of clinicians in licensed healthcare positions, and addresses workforce shortages.
Focuses on recruiting and retaining caregivers with annual 3% raises in each of the next four years;
Bans subcontracting and limits outsourcing of current positions.
In addition to the 57,000 KP employees in California, another 26,000 KP workers in Colorado, Washington, Oregon, Hawaii, Virginia, Maryland and Washington, D.C. either voted to ratify – or are in the process of voting to ratify – similar contracts. The combined 83,000 workers comprise the Coalition of Kaiser Permanente Unions.
Health center directors believe the declines may be owing to confusion over the Trump administration's public charge rule.
Community health centers across the nation are reporting that many immigrant patients are not enrolling in Medicaid, possibly because of fears and confusion surrounding recent immigration policy changes that could jeopardize their status as legal residents, a new survey shows.
The Kaiser Family Foundation survey found that 47% of community health centers said that many or some immigrant patients didn't sign up for in Medicaid in the past year, and that 32% of CHCs said patients dropped or didn't renew their coverage.
The enrollment declines come as the Trump administration has attempted to tighten eligibility requirements for Medicaid under the public charge rules, leading some health center staff respondents to the survey to suggest that fear and confusion over the policy shift may be the reason, KFF said.
Late last week, federal judges in California, New York, and Washington State issued temporary injunctions against the policy shift, which would have allowed the federal government to withhold green cards and for immigrants who enroll in Medicaid or seek other public assistance, such as food stamps and housing subsidies.
The survey and interviews also found some changes in healthcare utilization, with 28% of health centers reporting drops among adult immigrant patients in seeking healthcare in the past year, including pregnant women and people with chronic illness, KFF said.
In addition, 22% of centers reported reductions in healthcare use among children in immigrant families.
Health center directors told KFF they're training clinical staff to answer questions about the public charge rule.
There are 1,362 health centers across the United States, providing care for about 28 million patients in medically underserved rural and urban areas.
The survey of community health centers and phone interviews with health center directors and senior staff was conducted from May to July 2019 by researchers at KFF and the Geiger Gibson Program in Community Health Policy at the George Washington University.
Experts on healthcare law say the proposed revisions to the Stark Law and Anti-Kickback Statute will create more opportunities for providers, and challenges.
What can we anticipate with the Stark Law and Anti-kickback Statute proposed revisions put forward this month by the Trump administration?
We asked four healthcare attorneys for their initial assessments of the proposed revisions and how it may change the landscape for healthcare delivery.
Here's what they said. Their responses have been slightly edited for length.
HLM: Will these proposed revisions deliver the promise of reducing regulatory burdens on providers?
The proposed changes add flexibility and some important clarifications. For example, the newly proposed value-based exceptions and safe harbors are generally broad and flexible, which will stimulate innovation with respect to value-based payment models. Moreover, several of the changes will help facilitate greater patient engagement in value-based programs.
There are also a number of valuable Stark regulatory clarifications and changes that will alleviate some of the regulatory burdens. For example, CMS clarified its aim to interpret the Stark statutory prohibitions narrowly and the exceptions broadly; and in doing so, broadened the applicability of several exceptions. Also, the industry likely breathed a collective sigh of relief upon seeing CMS's proposed definition of "commercial reasonability," which clearly states that profitability is not determinative of commercial reasonability.
At first blush the proposals do not lessen the complexity overall; nor, could the agencies really have achieved that absent statutory changes. The length of the proposals alone is evidence of the continuing complexity. At the end of the day, these laws contain a maze of definitions, exceptions or safe harbors, special rules and thousands of pages of preamble guidance; and, the risk of any missteps remains high.
For healthcare systems and physician providers, these changes provide welcome clarification to key concepts of the Stark Law, and provide some clarity on the types of features that the government expects to see in permissible value-based arrangements. Other providers, including certain manufacturers and suppliers, may want to provide comments in response to the proposed rules in order to carve out a place for themselves at the value-based table.
William Maruca, a partner at Fox Rothschild LLC
Most of these changes don't address regulatory burdens as much as uncertainty about whether different kinds of relationships among providers, payors and Medicare are legal. Given that the Stark Law is a strict-liability law, anything that didn't fit squarely within an exception before was considered too risky. These changes will have minimal impact on most current arrangements but may encourage the growth of new minimally-integrated networks of providers sharing risk and coordinating care in ways we haven't seen. The goal is to break the stranglehold of fee-for-service on the economics of healthcare so that delivering quality outcomes is more important and more lucrative than churning visits, procedures and RVUs.
HLM: What real-world impact will we see if these proposals are approved?
Sloane: The proposals, if finalized, are likely to spur expansion of value-based models used by healthcare organizations. Given, however, the sophisticated data analysis necessary to implement these programs and the continuing regulatory complexities, consolidation across the industry is likely to continue, if not accelerate. We are likely to see new start-ups emerge that aim to help start, facilitate and manage value-based payment models. Hopefully, the proposals will result in fewer frivolous whistleblower lawsuits or, at least, make them easier to defend. Also, the revised EMR and new cybersecurity safe harbors and exceptions should help effectuate cybersecurity improvements across the industry that will better protect all of our personal data.
Thallner and Aiken-Shaban: For healthcare systems and providers, like hospitals and physicians, if finalized, these proposals will bring greater certainty to the compliance of the value-based enterprises such providers engage in currently, or seek to develop. Furthermore, the Stark Law clarifications will allow providers greater certainty on how to structure arrangements within existing exceptions that rely on key concepts of fair market value, commercial reasonableness, and that the remuneration not vary with the volume or value of referrals between the parties. This and other changes should reduce the need for self-disclosures of non-compliant arrangements to CMS, and enhance defenses in related False Claims Act litigation based on alleged non-compliance with those exceptions.
Maruca: The Medicare ACO program is only one form of value-based reimbursement, but its results suggest many other approaches to care coordination and risk-bearing will be developed in the coming years. It is likely to take some time for the results to appear. The value-based models promoted under these new rules will primarily benefit larger organizations and health systems who have the infrastructure to monitor costs and outcomes. Independent medical practices have survived many premature obituaries but this is another pressure point that may encourage some of the survivors to sell or at a minimum to contract with the organizations who are better positioned to participate in these models.
HLM: Are there any unforeseen consequences of these actions?
Sloane: There is some risk people will take the relaxation of certain regulations too far. Healthcare companies should not use these proposals (assuming finalized) as a reason to reduce their compliance efforts. Many of the changes, particularly with respect to Stark, seem like defensive safeguards against a violation of Stark in the event existing policies and procedures (e.g., contracting procedures) unintentionally break down. For example, we would not recommend any hospital stop or carve back its physician contracting procedures because certain inpatient hospital services are no longer DHS.
It is clear that the OIG is on the lookout for any unintended consequences of the new value-based payment safe harbors. The OIG notes that value-based arrangements come with their own risks of things like inappropriately reducing care, cherry picking lucrative or adherent patients, lemon dropping expensive or noncompliant patients, and manipulating performance data. In part for these reasons, the OIG's value-based safe harbors are more restrictive than the Stark exceptions.
Thallner and Aiken-Shaban: For those categories of healthcare manufacturers and suppliers proposed to be excluded from the value-based exceptions, it draws into question their continued ability to rely on existing exceptions and safe harbors that they have historically used to protect or assess the risk posed by value-based and shared savings arrangements.
Maruca: People and organizations can be expected to react to financial incentives, so there may be issues where unscrupulous players try to game the new system by fudging outcomes, screening out the sickest patients, or just undertreating patients to generate savings they can then share in. Both CMS and OIG are anticipating these concerns in their preambles and both acknowledge that there may be more risks that cannot be foreseen. This is one reason proposed rulemaking is published for comment. Watching the comments come in will be one way to identify potential consequences unanticipated by the regulators. Another challenge will be measuring quality of outcomes, adjusting for severity of illnesses across populations to minimize any ill effects of financial rewards that are designed to discourage unnecessary care and end up reducing necessary care.
HLM: Are there any icebergs looming for this proposal that may jeopardize implementation?
Sloane: These laws impact every healthcare provider, supplier and practitioner. A lot of discussion and many viewpoints will emerge in the coming months. CMS and OIG will get a lot of comments, which will likely slow the release of the final rule. But in the end, a lot of these proposals will be finalized.
Thallner and Aiken-Shaban: The manufacturer and supplier community may not have seen the types of changes it had hoped to see with regard to value-based pricing, and therefore may oppose the proposals strongly. Additionally, in their proposals, OIG and CMS offered a large number of alternative structures, elements, and definitions on which they solicited comments, which leaves stakeholders uncertain as to the likely contours of the final regulations, and which might give OIG and CMS more challenges in finalizing the proposed value-based rules in a timely fashion.
Maruca: Fortunately for the agencies, no vote is needed in Congress, since there is little chance for any consensus there. There will be a 75-day comment period where stakeholders can provide input, then CMS and OIG will need to react to those comments. One area of controversy is that the OIG has decided to exclude certain players from participating in Safe Harbor-approved "Value Based Enterprises", specifically pharmaceutical manufacturers; manufacturers, distributors, or suppliers of durable medical equipment, prosthetics, orthotics or supplies; and laboratories. They are also considering excluding pharmacies, specifically compounding pharmacies, and pharmacy benefit managers and have requested input.
