Data suggests that minorities continue to seek inpatient care at safety net hospitals, even as access options at other hospitals expand under Massachusetts' universal healthcare reforms.
Assumptions that newly insured minorities under the Patient Protection and Affordable Care Act would expand their traditional inpatient care options beyond the nearest safety-net hospital are being challenged by a report published in the journal Medical Care.
Boston University researchers found that the proportion of discharges among minority patients receiving inpatient care at minority-serving safety net hospitals in Massachusetts increased, even after the reforms expanded access to non-safety net hospitals.
They used 2004 –2009 data reflecting Massachusetts' expanded health insurance coverage under its sweeping healthcare reforms.
Study lead author Karen Lasser, MD, a primary care internist at Boston Medical Center, a 496-bed academic medical center and the largest safety net hospital in New England, says the findings bolster the claim that minority-serving hospitals remain a vital component of healthcare delivery that could be helped by raising or restoring Medicaid reimbursements.
"We made a hypothesis that some minorities would move," Lasser says.
"Was I surprised? Not so much. I've been working in the safety nets in Massachusetts for many years and the feeling is that things haven't changed that much. There hasn't been that migration."
According to the study, funded by the National Institutes of Health, researchers compared inpatient discharge data from Massachusetts, New York, and New Jersey between 2004 and 2009 and identified minority-serving hospitals and safety-net hospitals in each state.
Researchers examined the change in concentrations of minority discharges at minority-serving hospitals and tracked the movement of safety-net hospital users, or patients with at least four hospitalizations within the study period.
The results showed that Massachusetts' minority-serving hospitals saw an increase of 5.8% in minority discharges compared to New Jersey, and a non-significant 2.1% increase compared to New York.
Of those patients identified as "safety-net hospital users" in all three states, 62% continued to receive care at safety-net hospitals in the post-reform period.
Patient movement from safety-net to non-safety-net hospitals was slightly greater in Massachusetts than New York and New Jersey.
"We do need to compensate these hospitals that are doing disproportionate care for poor and minority patients," Lasser says.
"We have another study we are working on right now looking at segregation of hospitals by payer and race and there are certain hospitals that are taking care of less-affluent patients who may have more psycho-social needs and we may need to fund social workers at those hospitals."
Lasser offered several potential explanations for the findings, including the brand loyalty of minority patients to hospitals that are close by and have served them before they had insurance.
Other reasons could include interpretation services for non-English-speaking patients, intensive case management, and a lack of primary care physicians in Massachusetts.
"There are also some providers who aren't accepting new patients or patients with these public forms of insurance that don't reimburse well," she says.
The data is limited to the three-state area, but the Affordable Care Act is modelled on Massachusetts' healthcare reforms, so it would be reasonable to assume that these findings are playing out in other parts of the country since 2014.
"As we expand health insurance, there is this idea that patients can now go anywhere, that they aren't necessarily going to go to safety net hospitals, so those safety net hospitals don't need additional funding for uncompensated care or for all of the special programs the safety nets hospitals take on," Lasser says.
"Safety net hospitals still need those added resources."
If Pioneer Community Hospital of Scott follows through on its closure notice, it will be the sixth rural hospital in the Volunteer State to close in the past sixteen months.
In what is becoming a disturbingly common event, another rural hospital in Tennessee has filed notice with the state that it will close.
If Pioneer Community Hospital of Scott follows through on its 30-day notice with the state, it will be the sixth rural hospital to close in Tennessee in the past 16 months. The list of shuttered hospitals includes Gibson General Hospital in Trenton; Humboldt General Hospital; Haywood Park Community Hospital in Brownsville; Methodist Fayette in Somerville; and McNairy Regional Hospital in Selmer.
(Since 2010, Tennessee has also lost Parkridge West Hospital in Jasper, Starr Regional Medical Center-Etawah, and United Regional Medical Center in Manchester.)
The specific details of the closings vary somewhat for each hospital.
In most cases the hospitals were old and in need of significant capital upgrades. Their patient mixes were largely uninsured or Medicare-/Medicaid-dependent.
When Gibson and Humboldt closed, parent company West Tennessee Healthcare kept outpatient clinics open to assure continued access to care. In most cases, the communities were left to fend for themselves.
The closure of Pioneer Community Hospital of Scott, which is owned by Magee, MS-based Pioneer Health Services, provides a dire example of all the bad things that happen when a hospital shuts down in rural America.
Pioneer is a critical access hospital serving a poor and isolated region. When it closes, residents of Scott County, which borders Kentucky, will have to travel 40 miles on twisting roads to access care at the nearest hospital: Jamestown Regional Medical Center.
'You Can't Get There from Here'
On the economic side, Scott County is one of the poorest counties in Tennessee. The mean annual household income is $30,206, and 26% of families live below the federal poverty line.
The loss of about 100 relatively well-paying hospital-related jobs is sure to have a negative effect on the local economy, and the lack of a hospital will make it that much harder to recruit new businesses to an already struggling area.
"Scott County is one of those places where you can't get there from here," says Tennessee Hospital Association President Craig Becker.
"It is up in the mountains and it's a long haul down to Knoxville for sick patients. That was one of those hospitals that is very much isolated and one where it's going to be a devastating economic impact on that community as well."
The common thread for this spate of closings is that Tennessee remains one of 19 states that continue to reject Medicaid expansion under the Affordable Care Act.
That means that hospitals across Tennessee have to provide charity care for about 350,000 people who otherwise would have been eligible for Medicaid. Becker says 24 rural hospitals in the state have been identified as "vulnerable" to closing and he says the refusal to expand Medicaid is taking its toll.
"All you have to do is look at what is going on in other states (that have expanded Medicaid) to realize that it does make a positive difference for rural hospitals," he says. "We have seen what it can do in other states and we think the same thing would happen here."
Feeling the growing public pressure, the Republican-controlled Tennessee General Assembly has called for a task force to consider a gradual approach to Medicaid expansion.
"We're hopeful on that, but right now there are not a whole lot of details," says Becker.
"Because hospitals are going to be expected to pay for it, until we see the details we are holding back."
Hospital and physician associations warn that the governor's Medicaid privatization scheme has failed to deliver and threatens the program's existence.
Kansas Gov. Sam Brownback's $56 million cut to the privatized KanCare Medicaid program is facing blowback from healthcare providers.
In a media release detailing the cuts, Brownback said KanCare's 4% reductions to providers, which take effect on July 1, would exempt home- and community-based services and almost 100 hospitals defined as rural, densely settled rural, frontier and critical access hospitals.
After identifying KanCare as one of "the three main drivers of budget growth," Brownback said "we are working to slow the growth of government spending and our projected FY 2017 expenditures are less than FY 2015 actuals. Kansans cannot afford the explosive growth of state government spending that occurred in the past."
In a sharply worded open letter last week, however, Kansas Hospital Association President and CEO Tom Bell threw the baloney flag and accused the governor of attempting to obfuscate the scope of the cuts, which were part of more than $80 million in reductions to the overall state budget.
"There has been a flurry of inaccurate or incomplete information, and we need to set the record straight. Despite comments to the contrary, there simply is no 'rural' exemption from the proposed cuts," Bell said.
"Every part of the state will feel the effect of the cuts through reductions in payments to physicians, nursing facilities, home health agencies, hospitals or other caregivers."
More than 30 of the state's 107 rural hospitals are in danger of closing, and Bell said the ongoing effect of the KanCare cuts has become "obvious."
"Almost every comment made about this new proposed policy warns that KanCare reimbursement cuts will seriously jeopardize access to care," he said. "We've now seen concrete examples of hospitals in different parts of the state struggling under the current system, and these cuts will only exacerbate those struggles for all providers."
Kansas remains one of 19 holdout states that reject Medicaid expansion and the money that comes with it under the Affordable Care Act. As a result, Kansas has lost an estimated $1.2 billion in federal matching funds.
Brownback privatized KanCare in 2013 with assurances that the leaner and more efficient program would improve access to care.
So far, those promises have not materialized. Providers and patient advocates hate it, and commercial payers aren't happy with it either. The Witchita Eagle reported last week that KanCare's health plans, Sunflower, UnitedHealthcare and Amerigroup, reported losing $52 million in Kansas in 2014.
Bell accused the governor of reneging on promises made to providers.
"When KanCare was announced, the Administration repeatedly stated that the program would improve access to healthcare and allow the state to avoid cutting provider rates," Bell said.
"And encouraged by these promises, healthcare providers have been good partners regarding KanCare. This despite the fact that the program pays them less than the cost of providing care; despite the growing financial pressure facing those providers; and despite increasing evidence that KanCare isn't working as promised."
The Kansas Medical Society has also weighed in on the cuts, warning that physicians are already providing KanCare services for about half the payment of commercial plans, and that further reductions "are likely to adversely impact access to care, and will inevitably result in higher overall costs to the program."
"If the cuts cause physicians to drop out of the program, or place strict limits on the number of Medicaid patients they are able to see in their offices, more care will be delivered in hospital emergency departments, which are considerably more expensive settings than a physician clinic," KMS said in a statement.
KMS said that the cuts would exacerbate the very problems that the privatization was supposed to resolve: "They represent a reversal of one of the administration's key principles upon which KanCare was founded a few years ago: improved patient care outcomes and lower costs, all to be achieved without cutting provider payments."
Bell said the KanCare cuts are "simply bad public policy" that do not account for the ripple effect that the funding loss will have in communities across the state.
"In Kansas, the healthcare sector is the fourth-largest employer statewide and generates approximately $1.5 billion in state and local tax revenue annually," he said. "The Kansas Industry and Occupational Outlook created by the Kansas Department of Labor puts healthcare among the top 10 job creators, showing more job growth than any other industry in the state with over 33,000 new jobs added over the next decade."
Brownback was elected in 2010 with nearly 70% of the vote on a promise to slash income and business taxes. (He was reelected in 2014 with 49% of the vote.)
Taking a page from the trickle-down economics playbook, Brownback said the lower taxes would spur investment and job growth. So far, that investment and job growth has not kept pace with the cuts, which has led even one-time supporters to concede that Brownback's "real, live experiment" is a failure.
For obvious reasons, state healthcare provider professional associations tend to be very cautious when wording displeasure with elected officials. Perhaps the KHA and KMS are feeling a bit more emboldened because of growing public discontent at the direction of state government.
At least one poll shows that Brownback's 26% approval rating makes him the least-popular governor in the nation.
Or, perhaps the KHA and KMS are just tired of seeing their provider members and the poor and vulnerable patients they serve used as guinea pigs for a radical experiment that isn't working.
The Salt Lake City, UT-based health system wants to tear down silos that often isolate telemedicine visits from the patient's continuum of care.
Over the past several months, Intermountain Healthcare has quietly rolled out its Connect Care telehealth platform for patients in Utah and Idaho.
Program Medical Director William Daines, MD, says Connect Care clinicians will have access to Intermountain patients' medical files as part of a greater effort to include telehealth in the continuum of care. Daines spoke with HealthLeaders Media. The following is a lightly edited transcript.
HLM: Was Connect Care a soft launch?
Daines: We started a launch with Intermountain employees only. That was February 8. It was a great chance for us to solve a few technology problems, to gauge was general interest would be, and also to make sure that our medical protocols and safety mechanisms were working the way we wanted them to.
Sometime in the middle of March we went live with SelectHealth members, our allied insurance partner. In April we started with our public marketing campaign, which included lots of different advertising channels; print, outdoor, television, radio, digital.
There was also a soft digital campaign that launched at the end of March that was on a few patient-facing websites. We've been slowly over the course of February into April increasing our publicity.
HLM: How did you determine the need for Connect Care?
Daines: We've seen direct-to-consumer telehealth has become a growing part of medicine across the country. Utah and Idaho have been a little bit late to the game. When we gauged public awareness of telehealth with surveys in 2015, we only saw that about 10% of people were even aware of telehealth as a concept.
I would venture that if you went to California or New York or bigger cities you would see that telehealth is already a much more publicly known way of getting medical care.
HLM: Were there specific challenges for telehealth in Utah or Idaho?
Daines: There were a few legislative changes that needed to happen in Idaho to give us the legal groundwork to do telehealth. New developments tend to happen on the East or the West Coast and they make their way to Utah a little bit later. It's not that there was any major obstacle. It's just that none of the major healthcare organizations in Utah and Idaho had taken this step into telehealth yet.
HLM: Does Connect Care have a dedicated staff?
Daines: Currently we have two providers and we have two more in the credentialing process. They are going to be on board quickly. We don't know exactly how big our staff will be when we are 100% operational. A lot of it will depend upon patient demand. Our goal is to have 24/7/365 access with wait times of under five minutes.
Currently, our internal staff sees patients from 8AM to 8PM Monday through Sunday. We have a backup group of physicians called the Online Care Group. From 8PM to 8AM or if our daytime call volumes exceed what one provider can handle, they're there for backup.
Our goal is as soon as possible to be staffed 100% internally and have all the medical care being provided by Intermountain providers.
We feel strongly about that. We feel Intermountain has strong brand recognition and a long and prestigious dedication to high-quality care.
HLM: Are their special challenges that come with telehealth?
Daines: One of the things we have seen with telehealth is that for the past five or 10 years it's emerged as a new way of accessing care, but it is operating separately from people's normal care providers.
They might have a normal primary care doctor who they see on a regular basis. But when they access a telehealth provider, the primary care provider is not aware of it, the medical records don't get transferred, the telehealth provider can't see what medications the patient is already on. The primary care doctor can't see what medications the telehealth provider prescribes.
I am a big believer in continuity of medical care, but it's impossible to ask one doctor to be available for every patient 24/7/365.
Systems such as Intermountain Health Connect develop channels of communications and shared treatment standards so that if you happen to see one of our providers in urgent care or in one of our emergency rooms or one of our primary care practices there is shared communication between all the providers involved in the patient's care and they are all operating according to shared treatment standards.
HLM: How does the Connect Care platform work?
Daines: All of our visits are video-based. We partner with America Well that has a video based platform. It's like Skype except it is secure, (Health Insurance Portability and Accountability Act-) compliant, and has a high-resolution video feed. We also have the ability to accept photographs or PDF medical records.
HLM: Do you have any expectations for telehealth patient volume?
Daines: That number is in flux. I can't provide solid numbers right now because we are rolling out our marketing campaign. We haven't reached a point that I would consider static or a representative sample. Maybe by later this summer we will have a better sense of what we are seeing.
HLM: Is telemedicine different from an in-patient visit?
Daines: It reinforces and amplifies the things I should be doing during my general patient visits. Unfortunately, it's become a little bit of a cliché that the doctor is off in the corner during the exam looking at the computer and barely paying attention to the patient.
With telehealth you have to fight that urge even more. You have to make sure you are looking into the webcam so the patient gets a sense that you are looking at them and not looking at some screen.
You have to really listen. We know that about 80% of medical diagnoses can be made just from what the patient tells you. The physical exam is important for some medical conditions but there are many things we diagnose just by listening. A video visit really reinforces how important listening is in the doctor/patient relationship.
HLM: How did you settle on $49 as the fee for telemedicine visits?
Daines: If you look at other organizations that are doing this around the country that is a pretty standard rate. It is much less expensive than an urgent care visit, much less expensive than an ER visit.
We are partnered with some insurance plans so that even that $49 can be reduced if you're covered. Insurance companies understand how important it is to do the right thing for the right patient in the right place at the right time.
If someone calls with a medical complaint that is clearly not fit for telehealth, for example chest pains or stroke-like systems, what is best for them is to go to the ER and not to be charged for what is essentially a triage phone call.
We are not looking to extract $49 from a patient when they are already going to have to go to the ER and get a higher level of care.
HLM: What metrics will you use to determine if Connect Care is working?
Daines: There are a couple of things. When somebody's finished a visit we ask them a few questions about their experience, what they thought of the provider and the total platform experience.
With some patients we follow up later on to make sure they actually get better. One of the most important things with any medical treatment is are we helping the patients feel better, stay healthy, be healthy.
We also want to be part of the solution to the healthcare expenditure problem, not part of the problem. We want to help lower the cost of care by helping patients get the care they need in the appropriate setting at the appropriate time.
The Helping Hospitals Improve Patient Care Act has bipartisan support in the House, addresses key reimbursement issues created with the passage of the Bipartisan Budget Act of 2015, and has the support of the AHA and other hospital groups.
Hospital lobbyists are backing a bipartisan bill in Congress that would ease payment restrictions for some outpatient services and adjust 30-day readmissions penalties to account for socioeconomic disparities.
The Helping Hospitals Improve Patient Care Act (H.R. 5273) has bipartisan sponsors in the House Ways and Means Health Subcommittee, is paid for with offsetting budget cuts, and addresses what its backers say are Medicare reimbursement problems created with the passage of the Bipartisan Budget Act of 2015.
In a letter this week to senior committee members on the House Ways & Means Committee, the American Hospital Association urged the lawmakers to pass the bill, after spelling out the problems created by the BBA.
"Under current law, facilities operating before Nov. 2, 2015 are 'grandfathered' and
can continue to be paid at the hospital outpatient department (HOPD) rate, while new facilities
opening after Nov. 2, 2015 are capped at the lower Physician Fee Schedule rate," AHA Executive Vice President Tom Nickels said in the letter.
"The BBA did not provide for HOPDs that had already begun construction and spent millions of dollars and countless man hours to build facilities based on the prior reimbursement amounts."
"In addition, the way BBA was developed, with no hearings or Committee consideration, with legislative text released approximately one week before it was signed into law, put those HOPDs in an unfair and untenable situation," the AHA continued.
Calendar Adjustment
The bill moves the grandfather date from Nov. 2, 2015 to Dec. 31, 2016, or 60 days after enactment, whichever is later.
While the adjustment creates "significant relief" for hospital HOPDs caught in that time period, Nickels noted that "some HOPDs that were underway on Nov. 2, 2015 will not be completed by Dec. 31, 2016 in order to qualify for the grandfather. We would like to continue to work with the Committee to find additional ways to address the issue."
Safety Nets React
America's Essential Hospitals praised a provision in the bill that amends and adjusts the Medicare Hospital Readmissions Reduction Program "to level the playing field for hospitals that are disproportionately penalized by the program: those that care for large numbers of low-income and other disadvantaged patients."
The adjustment would act as a "bridge" while data is being compiled under the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT).
Until then, the bill allows the Secretary of Health and Human Services to compare performance of hospitals that service similar proportions of Medicare/Medicaid dual eligible patients when applying readmissions adjustments.
When IMPACT data is obtained, HHS would adjust performance payments based on that research.
Community and Rural Hospitals React
The Federation of American Hospitals also backs the bill, which federation President Chip Kahn said "recognizes the importance of access to hospital care for millions of Americans. That is why I am pleased to offer the support of the FAH for this targeted, thoughtful measure that would, among other provisions, allow community hospitals to finalize essential outpatient arrangements in order to better serve patients in their communities."
"At the same time," he said, "while the reduction might be viewed as minor, the effects of cumulative cuts on hospitals are taking a toll, and further cuts must be avoided."
The bill also extends for five years the Rural Community Hospital Demonstration Project, which Nickels told lawmakers "has become vital to participating hospitals and is providing valuable data on potential new models for these vulnerable hospitals."
Other provisions include:
A "mid-build" exception to the current law on increasing the number of beds for long-term care hospitals;
Modification of the treatment of ambulatory surgery center patient encounters for the meaningful use program;
A delay in CMS authority to terminate contracts for Medicare Advantage plans failing to achieve minimum quality ratings while CMS conducts research and reports on socioeconomic status and quality ratings;
A requirement that CMS report Medicare enrollment data by Congressional district.
A "cross walk" of 10 inpatient surgical codes that will be linked to outpatient surgical codes.
The bill is sponsored by Reps. Pat Tiberi (R-OH), House Ways and Means Health Subcommittee chairman, and Jim McDermott (D-WA), the subcommittee's ranking member.
Pediatrician and senior executive Marc Harrison, MD, will take over in October, with the retirement of Intermountain CEO Charles W. Sorenson, MD.
Marc Harrison, MD, a pediatrician and senior executive at Cleveland Clinic, has been named president and CEO of Intermountain Healthcare, the health system announced.
Harrison will take over at the Salt Lake City, UT-based not-for-profit health system on Oct. 15 with the retirement of Intermountain's current CEO Charles W. Sorenson, MD. Sorenson will stay at Intermountain as founding director of the health system's leadership institute, which opens in 2018.
Harrison, 52, most recently chief of International Business Development for Cleveland Clinic, and CEO of the Cleveland Clinic Abu Dhabi.
He led a 3,500-member multi-national workforce and oversaw clinical and business operations for the new medical campus, which cared for patients from 31 countries in its first 10 months of operations. He has also served as chief medical office for Cleveland Clinic, and chairman of pediatric critical care.
"Dr. Harrison has impressive experience and a proven track record of leading health organizations and is immensely qualified to build on Intermountain's legacy and oversee the organization as we continue the work of transforming healthcare to meet the challenges ahead," Intermountain Board Chair Scott Anderson said in prepared remarks.
Harrison earned an undergraduate degree at Haverford College and a medical degree at Dartmouth Medical School. He completed a residency and an internship in pediatric critical care through the University of Utah School of Medicine, working primarily in the critical care units of Intermountain's Primary Children's Hospital.
His wife, Mary Carole Harrison, MD, served as the chief resident in the same program. Marc Harrison later received a masters of Medical Management from Carnegie Mellon University and studied management at Harvard Business School.
Intermountain Healthcare includes 22 hospitals, 185 clinics, a Medical Group with about 1,300 employed physicians, a health plans division called SelectHealth.
The announcement came days after plans were unveiled for the construction of a 45,000-square-foot Memorial Hermann Convenient Care Center in Kingwood, Texas.
"Families in the greater Lake Houston area are vitally important to Memorial Hermann," MHHS President and CEO Benjamin K. Chu said in remarks accompanying the announcement.
"This transaction is a testament to the long-standing commitment made to this community nearly a decade ago," Chu said.
"I look forward to meeting the business, community and civic leaders in the Lake Houston area and hearing their thoughts on how Memorial Hermann can continue to serve as their healthcare provider of choice for years to come."
An 11-member community board appointed by the Humble City Council has served as the governing body of the Northeast Hospital Authority Hospital since 1977.
"The purchase of the hospital further strengthens the ties so many of our staff and affiliated physicians have established in the area over the last decade," Memorial Hermann Northeast President and CEO Heath Rushing said in prepared remarks.
"We are thankful for the great relationships we've forged with the Northeast Hospital Authority and all of our partners in helping provide quality care to our community."
Memorial Hermann will build a five-story, 123,000-square foot patient tower with 90 updated patient rooms, and the flexibility to add an additional 30 inpatient beds. The patient tower will also house patient and staff dining services. Construction is expected to be completed in 2018.
Memorial Hermann is the largest integrated health system in the Houston area, with 14 hospitals and a medical staff of more than 24,000 employees. It operates laboratories, a chemical dependency treatment center, a home health agency, a retirement community.
ACEP claims new rules allow health insurers to arbitrarily set low out-of-network reimbursements for emergency care, putting payment responsibility on patients.
The federal government is being sued over new rules that plaintiffs claim allow health insurance companies to unfairly and arbitrarily set low out-of-network reimbursements for emergency care.
The American College of Emergency Physicians is asking the U.S. District Court in Washington D.C. to overturn a rule adopted by the Department of Health and Human Services which ACEP says violates the government's rulemaking procedures.
The plaintiffs allege that the rule does not meet the standards required by the Affordable Care Act for transparency of data and fair insurance coverage for emergency patients who are "out of network" because of a medical emergency.
"Patients can't choose where and when they will need emergency care and should not be punished financially for having emergencies," ACEP President Jay Kaplan, MD, said in remarks accompanying the suit.
ACEP claims that insurance companies have forced providers out of their health plans with low reimbursements that barely cover the cost of care, creating narrow networks that offer scant coverage for emergency care in many parts of the country.
'A History of Data Manipulation'
"Health insurance companies need to be transparent about the data they are using to pay for services provided by out-of-network providers," Kaplan said. "They have a history of data manipulation and not paying for emergency care. They are shifting their responsibility to our patients, and that is just wrong."
"The federal government has done an injustice to emergency patients and emergency physicians by giving carte blanche to insurance companies to pay whatever they want. Historically we know that amounts to as little as possible," he said.
HHS has said that the Affordable Care Act requires that a reasonable amount be paid based on an objective standard when patients receive emergency care from providers who are not in the plan's network. ACEP says the regulation adopted does not hold insurance companies accountable to do what the ACA requires. They also want the federal court to clarify the "usual and customary" standard.
Kaplan says emergency physicians worked with the Centers for Medicare & Medicaid Services for four years to address the out-of-network issue, and were shocked and disappointed when the final rule was published last November.
'Ridiculously Low Rates of Reimbursement'
ACEP says the final rule allows insurance companies to arbitrarily set their own rates and shift costs to patients. The new rule says "minimum standards of payment are not necessary" in states that have banned balance billing.
The practical effect of this, ACEP claims, is that insurance companies can set whatever prices they want without regard to the consequences to patients, providers, or the nation's safety net of emergency care.
"Health insurance companies have taken gross advantage of patients and emergency medical providers since the ACA, arbitrarily slashing payments by as much as 70%," Kaplan said.
"They are forcing many providers out of their networks by imposing ridiculously low rates of reimbursement. In addition, health insurance companies are misleading patients by offering so-called 'affordable' premiums for these policies that cover very little because of the narrow networks, high co-pays and astronomical deductibles. It is insurance in name only because there is hardly any real coverage for the patient."
Hospital and health system mergers and acquisitions have grown by 70% since 2010. That means "vigorous enforcement of the antitrust laws is more important than ever," says the chair of the Federal Trade Commission.
Federal Trade Commission Chairwoman Edith Ramirez has reaffirmed that regulators will continue to take a "very active" look at consolidations in the healthcare sector, including efforts to skirt antitrust laws through state interventions that she said still have the potential to limit competition and drive up costs for consumers.
In a recent speech before the American Health Lawyers Association, Ramirez left little doubt about where the FTC stands on hospital consolidation, noting that hospital and health system mergers and acquisitions across the nation have grown by 70% since 2010.
"In the midst of these ongoing changes, vigorous enforcement of the antitrust laws is more important than ever," she told the lawyers. "That is the key message I want to leave with you today."
"The latest empirical research continues to consistently show that provider competition results in the greatest price and quality benefits for consumers, justifying the FTC's continued vigilance in healthcare provider markets. And we have been very active," she said, noting that the commission is currently challenging at least three high-profile hospital mergers.
A Troubling Tactic
A particularly troubling trend, she said, involves the efforts of some healthcare systems to bypass federal antitrust review by obtaining state-issued Certificate of Public Advantage waivers. She specifically cited the Cabell Huntington Hospital's proposed acquisition of nearby St. Mary's Hospital in Huntington, WV, and the proposed Mountain States/Wellmont merger in Tennessee and Virginia.
"Proponents of these legislative measures claim that FTC enforcement efforts undermine the policy aims of the Affordable Care Act to improve the quality of healthcare and lower costs by encouraging more coordination between healthcare providers in local communities," Ramirez said.
"In my view, these legislative efforts to immunize combinations from the antitrust laws are misguided and risk harming consumers. We understand that coordination of care has the potential to further key goals of healthcare reform, including encouraging provider collaboration, avoiding duplicative testing, increasing preventive care, and encouraging greater patient follow-up. But procompetitive collaborations are already permissible under the antitrust laws."
As a result, Ramirez said the primary effect of COPA laws "may very well be to immunize mergers that will not generate substantial efficiencies and therefore would not pass muster under the antitrust laws, likely leading to increased healthcare costs and lower quality and decreased access to care."
Hospitals' Response
Reached this week, Wellmont and Mountain States issued a joint statement in response.
"The policy and laws of Tennessee and Virginia permit the very type of collaboration our systems have proposed. We are following the law and decades of precedent that have been set by the courts and other states, which support the legal foundation and rationale for proposed mergers like ours," the statement read.
"We respect the important work the FTC and our state attorneys general do, and we remain committed to cooperating with them. The enormous value of our proposed merger is evident through the support that has been expressed by the business community, which pays a large share of the costs of health care, and the leaders throughout the region, who see the evidence of the value created by our proposed merger for the people of our region. We sincerely appreciate the hard work the FTC does and we believe our proposed COPA addresses the very issues the chairwoman discussed."
"We agree some hospital mergers lead to higher costs without demonstrable benefit for their communities, and we believe the COPA we have proposed provides a clear alternative to those types of mergers. We have held more than 40 public meetings throughout the region, and the process for approval by the states has been more transparent than the types of mergers the chairwoman has referenced. In fact, the FTC has participated in those public meetings and has provided comments we believe have been important in the process."
Ramirez said most merging hospitals have "largely failed to present us with even a close case on efficiencies, often providing little substance to back-up their claims. In particular, parties have failed to make their case when trying to demonstrate that a merger is necessary to achieve the claimed efficiencies."
"Parties often claim that their merger will provide the necessary patient volume to allow them to engage in risk-based contracting and population health management," she said. "We recognize that healthcare is increasingly moving in this direction, and we continue to assess, on a case-by-case basis, whether a merger that enables parties to engage in these and other activities could benefit consumers. Yet there is strong evidence that scale, at least over a certain threshold, is not necessary to engage in those practices. Greater scale can also be achieved through another combination that is not a merger with a close rival."
Telemedicine has grown tremendously in the past five years in some rural areas. Yet barriers remain, and only a fraction of the population has access.
"Soccer is America's sport of the future," so that old joke goes, "and it always will be."
I am reminded that of that chestnut every four years as I follow the World Cup misfortunes of the U.S. men's team, and whenever the subject turns to telemedicine.
For so many years we've been talking about the potential of telemedicine, how it can improve population health and access and contain costs, particularly in rural America. Still, we've yet to achieve the sort of widespread utilization and population health benefits that many advocates have envisioned.
For example, a new study in JAMA examined claims data and found that telemedicine visits among Medicare beneficiaries increased by 28% each year from 2004 to 2013, and that 107,000 telemedicine visits were provided in 2013.
More than 40,000 rural Medicare beneficiaries received one telemedicine visit that year, with a mean of 2.6 visits each. That's pretty impressive growth.
Still, 107,000 telemedicine visits represent a fraction of 1% of the nation's 55 million or so Medicare beneficiaries.
There is a human face behind each of those 107,000 visits in 2013. The study found that the most likely users of telemedicine services were disabled beneficiaries with mental illness who were generally sicker and poorer than the average Medicare beneficiary.
It also found that that the "vast majority" of these visits were for behavioral health services. The numbers aren't overwhelming, but for many of these vulnerable people telemedicine is a lifeline.
In tribal communities, such as the Fort Peck Indian Reservation in Montana, "initial internal reviews and anecdotal evidence suggest that the physical distance [of psychiatric consultations by videoconference] helps patients open up about difficult experiences more quickly than if they received therapy in-person, potentially speeding up treatment progress," according to the Billings Gazette.
Is the Glass Half Empty? Or Half Full?
JAMA study lead researcher Ateev Mehrotra, MD, an internist, pediatrician, and associate professor of Medicine and Health Policy at Harvard Medical School, takes the half-empty/half-full approach to telemedicine.
"The glass half full perspective is that after all these years of conversation and interest in telemedicine, we see very steady and fast growth in the number of telemedicine visits that are provided for Medicare beneficiaries, despite all the restrictions and complaints about how the Medicare rules are outdated." Mehrotra says.
"The fact that there have been more than 100,000 of these telemedicine visits provided in the Medicare population is a big number if you compare it to things like bypass operations and other things in the Medicare population. From that perspective it is relatively big numbers."
"The glass half empty aspect is pretty much the opposite. Less than 1% of the Medicare population rural beneficiaries are being affected," he says.
"Yes, it is growing fast but it hasn't had a big population-level effect. It does take a while for things to take off and the numbers might be even higher in 2014 and 2015."
Mehrotra says some of the blame goes to Medicare for its conservative approach to expanding telemedicine. The Centers for Medicare & Medicaid Services limits payments for telemedicine care to patients living in rural areas who receive a live-video visit at a clinic or other facility.
"The reimbursement to the provider of a telemedicine visit is the same as an in-person visit, and on top of that there is a small additional fee that is given to the hosting site," he says. "The concern is that it is very limited in terms of who can get a telemedicine visit. The debate is often about why we are limiting this only to rural beneficiaries."
At the state level, the response has been uneven, with turf wars erupting over licensing requirements, regulation, efficacy, and scope of practice.
Even with that foot-dragging, progress creeps forward. More than half of the 50 states have passed parity laws mandating that telemedicine visits be reimbursed as the same level as in-person visits.
"Telemedicine is very geographically varied," Mehrotra says.
Barriers to Telemedicine Expansion
"In some states there are very high rates of usage, and in other states there are very few telemedicine visits. The question is why isn't it growing even faster? I don't know the answer to that question."
He says some explanations include the "crazy reimbursement structure" for telemedicine. "This plan may be covering it, and this plan may not," Mehrotra says. "So, as a physician, it is hard to go all in on telemedicine because you're not sure."
There are also issues around the quality of the technology. "In many of these rural communities they may not have the level of high-speed internet necessary to support a video teleconference," Mehrotra says.
Another reason is the ambivalence of physicians. Mehrotra says many physicians aren't sold on the efficacy of telemedicine, and that even when they support it, they may not have time to put it into practice.
"There is not a huge pool of doctors who are willing to do this," Mehrotra says.
"The average doctor it is not sitting in the office with lots of extra time on their hands to expand their business with telemedicine. Providers are busy enough, so when you already have a demand for in-person visits in your office you may not see a huge call for telemedicine visits in another county or state."
That has led to speculation that a growing number of physicians will dedicate themselves to telemedicine, rather than dedicating one or two days a week to remote care.
"I don't even know what the word would be. 'Telemedicinist?'" Mehrotra says.
"You are seeing a number of companies that are focused only on telemedicine care. They feel that the skill set necessary to provide telemedicine visits is different, and that you have to be fully committed to it as opposed to doing it here and there on the side like a hobby."
Of course, there's another huge problem with telemedicine. Nobody knows if it works. Anecdotal evidence suggests that it does, it passes the common sense test, and some smaller clinical tests have shown that telemedicine is just as effective as in-person visits in treating or monitoring conditions such as depression and diabetes.
However, there is no evidence that telemedicine has improved the health of rural Medicare beneficiaries, in large part because there aren't enough rural Medicare beneficiaries using it. "The whole point is not that we are replacing in-person visits but that we are providing a complement for those rural beneficiaries who can't get in to see a provider," Mehrotra says. "We don't know if that has led to an improvement in health."
Despite all the stutter steps, Mehrotra has big hopes for telemedicine.
"When we think about telehealth to improve care, it doesn't always have to be a video visit. It could be text or email, or you answer a series of questions and do an e-visit," he says.
"It is a broad umbrella for telehealth and there is a lot of potential to improve access and improve the quality of care that we provide in rural communities and everywhere else in the nation. We are still figuring this out."
