A study examines 'subjective workload' among NICU nurses, and finds a number of perceived stressors that take time away from essential care and could lead to sub-optimal outcomes.
Patient volume and acuity play a role in a nurse's ability to provide optimal care, but they aren't the only factors, a new study shows.
Researchers at The Ohio State University found that a nurse's "subjective workload"—which could include everything from the mental pressures of the job to relentless time constraints—affects her or his ability to provide optimal care, no matter how many patients they're attending.
The study, in the journal JAMA Pediatrics, calls for developing broader workload strategies to ease nurses' stress and improve care quality.
"We were surprised to discover how important subjective workload is to care quality, and it's something we typically don't measure in healthcare. This is really the nurse's voice telling us how intense things were," said study lead author Heather L. Tubbs-Cooley, RN, an associate professor of nursing at Ohio State.
The study examined data collected during 332 12-hour shifts from 136 neonatal intensive care nurses caring for 418 infants. Researchers during each shift collected objective measures of infant-to-nurse staffing ratios and infant acuity.
The NICU nurses were asked to fill out the NASA Task Load Index to measure perceived workload based on mental demand, physical demand, time constraints, and overall effort needed to accomplish patient care.
The nurses also gave the researchers reports on "essential care" that they missed during shifts—including hourly assessments of the patients' intravenous sites, oral feedings, collection of laboratory results and safety checks of equipment and alarms.
The researchers used the data to create multiple statistical models to evaluate the relationships between objective and subjective workload measures and quality of care. They found that, regardless of the model, the nurses' perceived workloads had a consistently strong influence on missed essential care.
Some of the models showed that higher patient ratios contributed to missed care, which has been demonstrated in other studies. However, the researchers saw little connection in this study between the severity of patients' health status and missed care.
"Subjective workload was the one variable that was consistently and strongly associated with missed care," Tubbs-Cooley said. "Staffing ratios get a lot of attention—and they’re important—but nurses' in-the-moment workload judgments matter as much or more."
While NICU nurses are under tremendous stress while caring for the sickest, most-fragile patients, Tubbs-Cooley says her study's implications suggest "a universal phenomenon among front-line caregivers in hospitals and even those in outpatient and community settings."
With repealing the ACA off the table, Democrats and Republicans might find common ground on issues such as drug pricing.
For healthcare economist Gail Wilensky, the big message that voters sent to their elected officials during Tuesday's midterm elections was straightforward and simple.
"Don't mess with my healthcare," says Wilensky, a senior fellow at Project HOPE and a former MedPAC chair.
"It's as clear as that. There were no subtleties involved here," she says. "That includes protections for preexisting conditions and added coverage under Medicaid."
Consider what happened on Tuesday:
Overall, Democrats wrested control of the House from Republicans in an election where healthcare was seen as the single biggest issue. Democrats ceaselessly hammered Republicans with the claim that the GOP would eliminate protections for preexisting conditions.
Ballot initiatives in three bright-red Republican states all passed with healthy margins. A similar ballot initiative in Montana failed, but observers blamed the failure on an unpopular $2-per-pack tax on cigarettes that would have paid for the expansion.
Wisconsin Attorney General Brad Schimel, a plaintiff in a Texas v. Azar, was ousted by Democrat Josh Kaul, who promised to withdraw Wisconsin from the suit.
Three-term Wisconsin Gov. Scott Walker lost a reelection bid to Democrat Tony Evers, likely scuttling that state's recent waiver approval for Medicaid work requirements. Evers also pledged to expand Medicaid.
Phil Weiser, Colorado's Democratic Attorney General-elect, and a former Obama administration staffer, told Colorado Public Radio that one of his first actions would be to join the 17 Democratic attorneys general intervening to defend the ACA in Texas v. Azar.
Wilensky says the midterm results reinforce one of the oldest truisms in politics: Once an entitlement is proffered, there's no going back.
"There is no precedent that I'm aware of in American political history where a benefit can be taken away," she says. "Once granted, it can be modified, it can be increased, it can be augmented in some way, but there's no taking it away after it's been in place."
When Democrats took control of the House, Wilensky says, they drove a stake through the heart of the "repeal and replace" movement.
"Republicans couldn’t even get that done when they control both houses of Congress, she says. "It's a non-issue, in part because a lot of Republicans support major provisions of the Affordable Care Act."
With repealing the ACA off the table, Democrats and Republicans might find common ground on issues such as drug pricing.
"That's clearly is the most obvious, in general, but the specifics of what you want to do become much more challenging," Wilensky says. "Typically, Democrats want to use administered pricing the way that we use administer pricing in parts of Medicare. I don't know how much Republican support there is for that."
The two parties could reach some sort of bipartisan agreement on Medicare Part B drugs, Wilensky says, because it's a smaller program and the drugs are generally much more expensive.
"Most members of Congress are not talking about messing around with Part D, the ambulatory prescription drug coverage," Wilensky says. "So it really has to do either with the expensive infusion drugs that are administered in the physician's office or maybe something about drug advertising. Even then, it's going to be hard lift when you actually get down to the specifics."
Besides, Wilensky says, it's not the cost of drugs that's at the heart of voter agitation.
"You have to unpack what they're saying to figure out what they're actually pushing for," she says. "People couldn't care less about drug prices. They only care about what it costs them. So when they talk about drug prices they mean, 'I want to spend less for the drugs I want, and I don't want any constraints about what I can order.'
More likely, she says, common ground could be found in arcane areas such as mandating greater transparency for pharmacy benefits managers, and changing PBMs' rebate structure.
Wilensky warns that giddy Democrats should learn from the mistakes of Republicans in the midterms and not attempt to force a Medicare-for-All solution on a wary public.
"First of all, they're going to have to define what it means," she says. "But, you have to be very careful because historically there's not been warm and fuzzy response to taking away people's employer-sponsored insurance."
"Again, historically, when candidates mess around with employer-sponsored insurance they have gotten themselves into trouble," she says. "Most people would like to keep what they have, because keeping what you have is much safer than going with something as yet to be defined."
In a sharp departure from Trump Administration policy, HHS Secretary Alex Azar pushes mandatory payment models.
The Centers for Medicare & Medicaid Services in the coming weeks will roll out mandatory Medicare payment models for cancer and "revisit" voluntary cardiac care models, Health and Human Services Secretary Alex Azar said Thursday.
"Bundled Payments for Care Improvement is a voluntary model, where potential participants can select whether they want to join. But we're not going to stick to voluntary models," Azar said in a speech Thursday before the Patient-Centered Primary Care Collaborative Conference.
"BPCI Real experimentation with episodic bundles requires a willingness to try mandatory models. We know they are the most effective way to know whether these bundles can successfully save money and improve quality," Azar said.
The mandatory payment models would be a sharp departure for the Trump administration, which in the past has steered away from forcing providers into downside risk models.
Azar on Thursday said the HHS has "reexamined" last year's decision to reduce the size of the Comprehensive Care for Joint Replacement Model, and its decision to pull back on cardiac care episode payment models before they were even launched.
"We intend to revisit some of the episodic cardiac models that we pulled back, and are actively exploring new and improved episode-based models in other areas, including radiation oncology," he said.
"We're not going to stop there: We will use all avenues available to us—including mandatory and voluntary episode-based payment models," he said.
Azar's comments will likely irritate physicians who generally support voluntary alternative payment models, but who've warned that there's not enough evidence to show that at-risk models work.
American Society for Radiation Oncology CEO Lauran Thevenot said her association has "aggressively pursued" adoption of CMS's proposed radiation oncology APM, but she stopped short of endorsing mandatory participation.
"While ASTRO is enthusiastic about the prospects for a RO-APM, we have concerns about the possibility of launching a model that requires mandatory participation from all radiation oncology practices at the outset," Thevenot said.
"ASTRO believes it is important to acknowledge that any radiation oncology payment model will represent a significant departure from the status quo," Thevenot said. "Care must be taken to protect access to treatments for all radiation oncology patients and not disadvantage certain types of practices, particularly given the very high fixed costs of running a radiation oncology clinic."
Azar warned that anyone who "doubts our ambitions in this area" should look at HHS's proposed mandatory International Pricing Index for drugs that was rolled out last month.
"We want to advance models like these in a collaborative manner. That has been a key priority for this administration since day one," Azar said. "But there is nothing virtuous about maintaining outdated systems within Medicare fee-for-service—effectively a mandatory system for so long—when we know we could be exploring better alternatives."
"We need results, American patients need change, and when we need mandatory models to deliver it, mandatory models are going to see a comeback," he said.
Mandatory alternative payment models have never been popular with physicians. A Medical Group Management Association poll in March found that 72% of medical group practices oppose the idea.
"Despite support for APMs, a large majority of physician practices oppose government mandated participation, citing lack of evidence, diversity among medical practices, and the negative impact on practice innovation," Anders Gilberg, MGMA's senior vice president of government affairs said at the time.
Azar's reversal of Trump administration policy on mandatory payment models should not come as a complete surprise. Azar has always been more receptive to the idea than his predecessor Tom Price, MD.
During his confirmation hearing in January Azar told the Senate Finance Committeethat "we need to be able to test hypotheses."
"I want to be a collaborative in doing this. I want to be transparent and follow appropriate procedures. But if to test a hypothesis around changing our healthcare system it needs to be mandatory as opposed to voluntary to get adequate data, then so be it," Azar told the committee.
Democratic Attorney General-elect Josh Kaul vows to withdraw Wisconsin from a multistate suit that challenges the constitutionality of the Affordable Care Act.
A lead plaintiff among the 20 Republican attorneys general suing to dismantle the Affordable Care Act has lost his re-election bid, and the man who defeated him says the state will withdraw from the suit.
Wisconsin Attorney General Brad Schimel narrowly lost to Democrat Josh Kaul by about 22,000 votes in Tuesday's statewide election that also saw the defeat of embattled three-term Republican Gov. Scott Walker to Democrat Tony Evers.
Schimel is a lead plaintiff in a suit brought by 20 Republican attorneys general who argue that the ACA is unconstitutional.
Led by Texas Attorney General Ken Paxton, who won re-election on Tuesday, the Texas v. Azar plaintiffs claim that the ACA became unconstitutional when Congress zeroed-out the tax penalty for the individual mandate, thus invalidating the sweeping legislation in its entirety.
The case was argued before U.S. District Judge Reed O'Connor in early September, but O'Connor has yet to issue a ruling.
When the suit was filed in February, Schimel said the ACA's "irrational design wreaks havoc on health insurance markets."
"Obamacare causes premiums to rise and coverage to fall, forcing Wisconsin and other states to take extreme, costly measures to protect their citizens' health and pocketbooks," he said.
"I bring this challenge to Obamacare because, as Wisconsin's attorney general, I swore to uphold the rule of law and protect our state from overreaching and harmful actions from the federal government."
It's not clear if Schimel's vocal role in the ACA suit was a factor in his narrow defeat, but the state's AG-elect made it clear Wednesday that he would reverse course.
In his acceptance speech, Kaul, a former federal prosecutor, pledged to work with Evers to withdraw Wisconsin from Texas v. Azar.
Kaul also pledged to expand Medicaid coverage to about 80,000 people under Wisconsin's Badgercare program, which he said would save the state about $190 million a year.
Paxton, a conservative Republican in deep red Texas, won re-election after defeating Democrat Justin Nelson by four percentage points.
During the campaign, Nelson accused Paxton of filing the suit to distract voters away from his felony indictments for securities fraud, for which he is awaiting trial.
"I will withdraw Texas from the lawsuit on my first day on the job," Nelson told POLITICO.
"Texas has one of the worst rates of uninsured people and one of the highest rates of pre-existing conditions in the country," he said. "We should be the leader in fighting to protect people from insurance companies, but instead we're the face of the lawsuit to end coverage of pre-existing conditions."
Nationwide, Republican attorneys general in Wisconsin, Nevada, Colorado and Michigan lost to Democrats, but no Democrats lost to Republicans, according toBallotpedia.
Colorado's Democratic AG-elect Phil Weiser, a former Obama administration staffer, told Colorado Public Radio that one of his first actions would be to join the 17 Democratic attorneys general intervening to defend the ACA in Texas v. Azar.
"I'm not prepared to tell you which is the first lawsuit Colorado will join when I become AG, but I will tell you one of the first is standing up for the protection of the ACA against the action by the Texas AG and others to undermine this critical protection," Weiser told CPR.
The other Republican states that joined the Texas v. Azar lawsuit are Alabama, Arkansas, Arizona, Florida, Georgia, Indiana, Kansas, Louisiana, Maine, Mississippi, Missouri, Nebraska, North Dakota, South Carolina, South Dakota, Tennessee, Utah and West Virginia.
Led by California, Democratic attorneys general from 17 states and the District of Columbia have filed a motion to intervene. Those states are Connecticut, Delaware, Hawaii, Illinois, Kentucky, Massachusetts, Minnesota, North Carolina, New Jersey, New York, Oregon, Rhode Island, Virginia, Vermont, Washington, and the District of Columbia.
Healthcare-related initiatives were on the ballot in several states on Tuesday, with mixed results.
California voters on Tuesday voted to approve a ballot initiative that authorizes $1.5 billion in bonds to fund capital improvements at the state's 13 children's hospitals.
Proposition 4, the Children’s Hospital Bond Act of 2018, passed with more than 60% of the vote. It will cost California taxpayers $80 million a year for the next 35 years, for a total of $2.9 billion, according to the state's Legislative Analyst's Office.
California Children’s Hospital Association President and CEO Ann-Louise Kuhns said the state's pediatric hospitals were "grateful to voters."
"These funds will allow our hospitals to upgrade their facilities to meet new seismic safety requirements, update technology and expand capacity so that we can continue to provide the best care and save more lives," Kuhns said.
Some observers questioned whether a ballot initiative was the proper way to secure a bond offering. California voters approved a $750 million bond in 2004 and a $980 million bond in 2008.
"I think it's a misuse of the initiative process for private groups to sponsor ballot measures that are intended to benefit them exclusively," Elizabeth Ralston, a former president of the League of Women Voters of Los Angeles, told Kaiser Health News.
The league had recommended a "no" vote on the measure.
Another healthcare-related California ballot initiative did not fare so well. Proposition 8 would have capped the profits of kidney dialysis providers at 15% above direct patient costs, but it was roundly defeated 62% to 38%.
"Yes of Prop. 8" leader Emanuel Gonzales said dialysis corporations used scare tactics in a $111 million campaign to defeat the initiative, but Gonzales said he hopes to have it back on the ballot in 2020.
"We're proud to have exposed the unacceptable conditions in many clinics caused by understaffing, including reports from patients about cockroaches and unclean facilities," said Gonzales, a dialysis technician whose father is a dialysis patient.
"We exposed the massive profits this industry makes off people who literally can't live without this treatment," he said.
Nevada Nixes Sales Tax on Medical Equipment
Voters in Nevada approved a ballot initiative to remove the sales tax from medical equipment.
Local media in Nevadaare reporting that more than 67% of voters in state voted for Question 4, which amends the Nevada Constitution to require the state legislature to exempt some durable medical goods, including oxygen delivery equipment and prescription mobility-enhancing equipment, from sales tax.
The proposal passed a first time in 2016 and would become law if it passes again. Proponents of the initiative argued that it would but Nevada in line with other states, but critics said the measure is vaguely worded, as the Reno Gazette Journal reported.
OK Not OK with Optometrists in Walmart
Oklahoma voters rejected the Walmart-backed Question 793, which would have amended the Oklahoma Constitution to give optometrists and opticians the right to practice in retail stores.
Walmart gave nearly $1 million in the third quarter alone to proponents of the initiative, which was narrowly defeated by less than 6,000 votes. Those opposing the measure consist primarily of individual optometrists, as NewsOK.com reported.
The Oklahoma Council of Public Affairs, which backed the initiative, accused opponents of mounting "a scare campaign that worked."
"To protect their profits, a special interest convinced Oklahomans that a few more choices for eye care would be dangerous," the council said.
The ad hoc group "Yes on 793" said it was "disappointed" with the outcome, but would seek "legislative remedy" to resolve the impasse.
University of Michigan Health executive Paul King will become CEO of Lucile Packard Children's Hospital in early 2019.
Veteran pediatric healthcare executive Paul King has been named president and CEO of Lucile Packard Children's Hospital Stanford and Stanford Children's Health, effective in early 2019, the California-based health system announced.
"The possibilities that are within reach for the world-class Stanford Medicine academic medical institutions are truly limitless," King said in a media release.
"I look forward to working with the board and executive leadership, the physicians and staff, as well as with partners at the School of Medicine and Stanford Health Care, to continue to advance pediatric care and research and raise the bar for patient experience and outcomes not just for our patients, but for children and expectant mothers everywhere," he said.
King succeeds Interim CEO Dennis Lund, MD, who took over following the retirement of long-serving CEO Chris Dawes, in March 2018.
"As a physician leader it is vital to have executive and board leadership who embrace the voices of our physicians and care teams, as front line providers, researchers and innovators," said Mary Leonard, MD, Lucile Packard's physician in chief.
"Paul's experience and understanding of how to nurture growth within academic medical institutions make him a wonderful leader and ally to pursue our goals in science, education and patient care," Leonard said.
King has more than 30 years of experience as an executive at pediatric health providers and has been executive director at University of Michigan Health System's C.S. Mott Children's Hospital and Von Voigtlander Women's Hospital since 2013.
Before that, King was president and CEO for the Pediatric Management Group, a 550-physician academic pediatric subspecialty group practice affiliated with Children's Hospital Los Angeles.
"With more than 35 years in healthcare, including 22 years in executive roles leading pediatric healthcare enterprises, Paul brings a wealth of experiences and leadership expertise to Stanford Children’s Health," said Lucile Packard Board Chair Jeff Chambers.
An injuction against the Affordable Care Act would create chaos for the statute's Marketplace plans, which begin enrollment on November 1. If such a ruling were handed down before the midterms, it would be a welcome gift for Democrats.
It's been nearly two months since a U.S. District Judge in Fort Worth, Texas, heard oral arguments in Texas v. Azar challenging the constitutionality of the Affordable Care Act.
But court watchers hoping for a ruling soon probably shouldn’t expect anything from Judge Reed O'Connor until after the midterm elections next week, says Timothy S. Jost, professor emeritus at Washington and Lee University School of Law, and coauthor of the casebook Health Law.
"I'm sure Judge O'Connor is going to wait until after the election to rule," Jost says. "He's keeping his ear to the political news."
Healthcare has emerged as a top issue in the midterm elections, with 58% of voters in a recent Reuters/Ipsos poll saying they want to keep the ACA intact.
Jost says a ruling in favor of Texas Attorney General Ken Paxton and Republican officials from 19 other states who want to slap an injunction on the ACA would provide a pre-election gift to Democrats, as well as create upheaval for Marketplace plans, which begin open enrollment on November 1.
That was not lost on Department of Justice attorneys, who during oral arguments last month urged O'Connor to delay any injunction until 2019 to avoid "chaos."
The Republican attorneys general argued that the ACA became unconstitutional when Congress zeroed-out the tax penalty for the individual mandate, thus invalidating the sweeping legislation in its entirety.
A secondary argument by the plaintiffs focuses on the language in the 2010 statute, which says that the individual mandate is essential to creating a market in which guaranteed issued and preexisting condition exclusion bans are possible.
"The real question is what did the 2017 Congress intend to do when they zeroed out the tax?" Jost says. "Did they intend to get rid of the preexisting condition exclusions or not? You ask anyone in the Senate right now whether they think preexisting conditions should be excluded or not, they'll say, 'Oh no that's not what we did!'"
"So, the important question is when Congress repealed the tax in 2017 did they mean to get rid of the rest of the ACA?" Jost says. "Obviously they didn’t. They tried to amend parts of it in 2017 and they failed. To argue otherwise is just ridiculous."
Plaintiffs win likely
"When O'Connor does rule," Jost says, "he will probably hold that the individual mandate is unconstitutional and throw out the guaranteed issued community rating and the pre-existing condition ban."
"He might also throw out all of Title I, the exchanges, premium tax credits, and the premium stabilization programs, maybe even insurance reforms such as the age rating," Jost says.
"It's very unlikely he is going to throw out the Medicare donut hole closing, and the generic biologics provisions and the reforms to the Indian Health Service and all the other things that are inconceivably, not related to the individual mandate," Jost says.
Appeal is Certain
If O'Connor rules in favor of the Republican plaintiffs, that will most assuredly prompt an appeal to the 5th Circuit Court by the Democratic attorneys general from 17 states, who intervened when the DOJ said it would not fully defend the ACA.
"The 5th Circuit, last time I checked, had as many Trump appointees as from prior Democratic presidents," Jost says. "Although frankly I think the argument is ridiculous, there is some chance the 5th Circuit would uphold it."
"Then it goes to the Supreme Court. I think the Supreme Court would very likely reverse," he says, "but we do have a fairly conservative court at this point. I am not absolutely sure if they would."
Gail Wilensky, a former director of Medicare and Medicaid and a former chair of the Medicare Payment Advisory Commission, previously told HealthLeaders that she's skeptical this case will make it all the way to the Supreme Court. If it does, though, she would expect the justices to side against the plaintiffs, rejecting their approach to severability.
A president who rails against the ACA and champions free markets now calls for expanding Obamacare's marketplace coverage and government controls on drug prices. Go figure!
With midterm elections looming, the Trump administration has provided another interesting week for healthcare policy.
Consider this:
On Tuesday, the same administration that has done as much as it could to undermine the individual health insurance markets created under the Affordable Care Act unveiled a new proposal that could send 7.5 million people into those plans.
On Thursday, President Donald Trump floated an idea to link Medicare Part B prescription drug prices to the prices paid by other developed nations, most of which have some sort of single-payer, government-run, national health plan.
The proposals have left observers and stakeholders either scratching their heads or dismissing the initiatives as a pre-election stunt to provide cover for Republicans who polls show are getting pummeled on healthcare.
"For decades, other countries have rigged the system so that American patients are charged much more—and in some cases much, much more—for the exact same drug," Trump said Thursday, after floating the Part B pricing initiative, which would not take effect until 2020.
"In other words, Americans pay more so that others can pay less. It's wrong. It's unfair," said Trump, sounding more like Sen. Bernie Sanders, I-VT than a conservative Republican.
Trump launched the proposal just as Health and Human Servicesissued a report showing that the price of 27 of the most expensive physician-administered drugs is 80% higher in the U.S. than it is in other wealthy nations.
PhRMA was not amused.
"The administration is imposing foreign price controls from countries with socialized healthcare systems that deny their citizens access and discourage innovation," PhRMA President and CEO Stephen J. Ubl said in a media release.
"Americans have access to cancer medicines on average about two years earlier than in developed countries like in the United Kingdom, Germany and France," Ubl said.
Republican leaders in Congress mostly said nothing. Senate Minority Leader Chuck Schumer, D-NY, dismissed the proposal and said it stands in stark contrast to the administration's efforts to kneecap the Affordable Care Act.
"It's hard to take the Trump administration and Republicans seriously about reducing healthcare costs for seniors two weeks before the election when they have repeatedly advocated for and implemented policies that strip away protections for people with pre-existing conditions and lead to increased health care costs for millions of Americans, Schumer told The New York Times.
HRA Proposal Protects Workers
Trump's HRA expansion proposal—which has been months in the making—didn't generate much attention in the media, even though the proposal could send about 7.5 million people away from employer-sponsored coverage and into individual Marketplace plans.
When the president announced earlier this year that the HRAs program would get an overhaul, critics had raised concerns that employers would send their sickest employees to the marketplace, undermining them with adverse selection.
It appears that robust protections for workers were baked into the proposed rule.
"I'm having a hard time understanding it," John Barkett, who served in the Obama administration's Office of Health Reform, says of the Trump administration's proposal to expand Health Reimbursement Arrangements.
"What leapt off the page for me after reading the proposal was how much they cared about protecting the individual market from adverse selection," he says. "They were very concerned about putting this rule out in a way that wouldn't let employers send their sickest workers into the individual marketplace."
Barkett notes that the proposal requires employers to offer HRAs or traditional group coverage.
"You can't do both," says Barkett, now senior director of policy affairs at Willis Towers Watson. "If they wanted to create a way for employers to keep their sickest people on their own plan and send other employees out to the individual market, they wouldn't have put that requirement."
The Treasury Department's estimates that average premiums will change by less than 1% as a result of the projected 7.5 million people transition to the individual market under the new HRA.
"Adding 7.5 million people and having no change effectively in premiums shows that they don't necessarily agree with the idea that the sickest people only are going to be the ones who are going into it," Barkett says.
The Prospects
Trump's Part B proposal got a lot of attention in the mainstream media, but it's not clear how much enthusiasm it will generate after the elections. The silent response to the proposal from Republicans was deafening. Efforts by the Obama administration to lower drug prices were quashed in 2016.
Even if the proposal goes nowhere, Rick Weissenstein of Cowen Washington Research Group in a note to clients called it "politically shrewd."
"The timing, less than two weeks before the mid-term elections clearly gives him the high ground on a topic that is as populist as they come," Weissenstein said, according to Politico. "It also puts the Dems on the defensive on an issue they have used to hammer Republicans for years."
Barkett says the HRA proposal may not be see the sort of blistering partisan opposition that other Trump Administration healthcare reforms have faced, in part because there are components of the proposal that appeal to Democrats and Republicans.
"This is not an issue that falls neatly into ideological storylines," he says. "It would give the Affordable Care Act side of the House more lives the individual market and not necessarily just sick people. It would give the conservative healthcare side policies that they've been pushing for a long time, like flexibility, portability, and competition."
The provider allegedly billed Medicare for non-reimbursable procedures, and offered improper remuneration to physician investors and medical directors.
Philadelphia-based Vascular Access Centers L.P. and its 23 subsidiaries in eight states will pay at least $3.8 million to resolve False Claims Act allegations involving kickbacks for referrals, the Department of Justice said.
Federal prosecutors alleged that VAC violated the False Claims Act by billing Medicare for non-reimbursable vascular access procedures performed on end stage renal disease beneficiaries and that the company used kickbacks to entice referrals for the procedures.
"Medicare patients with end stage renal disease, like other beneficiaries, are entitled to receive care in accordance with their clinical needs and not based on the financial interests of healthcare providers," DOJ Civil Division Assistant Attorney General Joseph H. Hunt said.
HealthLeaders' calls to VAC were not returned.
VAC allegedly billed Medicare for vascular access surgical procedures performed on ESRD beneficiaries, including fistulagrams and percutaneous transluminal angioplasties, without all of the required supporting medical documentation.
The settlement also resolves Anti-Kickback Statute allegations that VAC submitted false claims to Medicare for services from referrals that VAC had induced through improper remuneration to physician investors and medical directors.
VAC agreed to pay a minimum of $3.8 million in a series of fixed payments over five years, and could pay up to $18.3 million if contingencies in the settlement are triggered.
VAC has also entered into a five-year Corporate Integrity Agreement with the Department of Health and Human Services Office of Inspector General that will focus on VAC's arrangements with physicians and other providers.
The settlement resolves whistleblower allegations brought in two lawsuits. The whistleblowers will collectively receive at least $612,000 as their share of the settlement.
While the president has undermined the ACA's individual marketplace, his HRA expansion proposal would transition a projected 10.7 million people into these plans in the next decade.
A proposed expansionof the health reimbursement arrangements (HRA) program announced this week by the Trump administration provides surprisingly robust protections against adverse selection, according to a former Obama administration policy wonk.
"What leapt off the page for me after reading the proposal was how much they cared about protecting the individual market from adverse selection," says John Barkett, who served in the Obama administration's Office of Health Reform.
"They were very concerned about putting this rule out in a way that wouldn't let employers send their sickest workers into the individual marketplace," he says.
"For example, they require employers to only offer this or to offer their traditional group coverage. You can't do both," says Barkett, now senior director of policy affairs at Willis Towers Watson. "If they wanted to create a way for employers to keep their sickest people on their own plan and send other employees out to the individual market, they wouldn't have put that requirement."
Barkett says he was also struck by the Treasury Department's estimates that average premiums will change by less than 1% as a result of the projected 7.5 million people transition to the individual market under the new HRA.
"Adding 7.5 million people and having no change effectively in premiums shows that they don't necessarily agree with the idea that the sickest people only are going to be the ones who are going into it," he says.
The administration's efforts to expand the individual market appear at odds with its simultaneous efforts to undermine the individual markets. That effort includes draconian funding cuts to the "navigator" enrollment program, virtually no budget for advertising, and the introduction of cheaper, less-comprehensive short-term insurance plans.
"I know. I know. I'm having a hard time understanding it," Barkett says.
Undermining the Marketplace
Critics have contended that the proposal could allow employers to push their sickest employees into Marketplace plans. Barkett says those fears are "simplistic."
"It's not a slam dunk to just say the only people moving are the ones who have the sickest people," he says. "There are some countervailing forces that will prevent a lot of employers who do have, on average, sicker populations from taking on this model."
"Employers are not monolithic," he says. "Some have employees that remained at their company for a long time, and those employers invest heavily in the health and well-being with generous benefit plans that cost a lot of money. Other companies employ people for not that long and there aren't great returns to justify heavily investing in their employees' health and well-being."
Payers and Providers
"Treasury estimates that by 2028, 10.7 million people would be getting individual coverage," Barkett says, which could reinvigorate interest in the marketplace plans among payers and providers.
Those estimates include 6.8 million people shifting from group coverage to individual coverage, 800,000 uninsured people who now have access to coverage, and 3.8 million who were in the individual market already but now they have the employer option.
"That's a lot of people," Barkett says. "That's another 7 million customers that insurance companies could pursue. That's a lot of premium dollars, if you think about the typical person maybe spending $7,000—$10,000 a year on healthcare. Multiply that by seven-and-a-half million new customers and that markets growing by tens of billions of dollars. Does United Healthcare or Humana look to get back into that market?"
Individual plans usually have narrow networks, and Barkett says many providers have stayed away because of low reimbursements. That may have to change, he says, if the individual market hits the growth numbers projected by Treasury.
"They might feel more compelled to contract with insurers who provide individual coverage," he says.
Own your Plan
Barkett praised the proposal's call to let employees "own" their coverage.
"If an employee who get his coverage through the individual market with an HRA leaves the job, your HRA goes away but your health care coverage doesn't. If you want to keep paying your premium out of pocket you can," he says. "That's a that's a sea change in U.S. healthcare, where normally leaving your job means disrupting your coverage."
"Let's go a step further," he says. "What if you move from one job that offered this type of benefit to another job that offered this type of benefit? Then you really could stay in your plan, replaced one HRA way with the other, and you're not having to change doctors."
"Your insurance company doesn't have to write off the investments they're making in you because they know you're going to change jobs in a couple of years," he says. "They can realistically look at you as someone they're trying to keep as a customer for life. That's a different approach than insurers have taken in the past."
Partisan appeal
Barkett says the HRA proposal may not be see the sort of blistering partisan opposition that other Trump Administration healthcare reforms have faced, in part because there are components of the proposal that appeal to Democrats and Republicans.
"This is not an issue that falls neatly into ideological storylines," he says. "It would give the Affordable Care Act side of the House more lives the individual market and not necessarily just sick people. It would give the conservative healthcare side policies that they've been pushing for a long time, like flexibility, portability, and competition.
