The list of potentially inappropriate medications includes antidepressants, barbiturates, androgens, estrogens, nonsteroidal anti-inflammatory drugs, first-generation antihistamines, and antipsychotics.
One-in-three older Americans is prescribed inappropriate medications and that leads to increased hospitalizations and an additional $458 a year in per-patient healthcare spending, according to new research.
"Although efforts to de-prescribe have increased significantly over the last decade, potentially inappropriate medications continue to be prescribed at a high rate among older adults in the United States," lead investigator David Jacobs, PharmD, PhD, an assistant professor of pharmacy practice in the UB School of Pharmacy and Pharmaceutical Sciences, said in a media release.
The study, published in the Journal of the American Geriatrics Society, used the 2011–2015 Medical Expenditure Panel Survey to examine the prescription of 33 potentially inappropriate medications or classes of medications to adults 65 and older.
The list of potentially inappropriate medications includes antidepressants, barbiturates, androgens, estrogens, nonsteroidal anti-inflammatory drugs, first-generation antihistamines, and antipsychotics.
Of the more than 218 million older adults surveyed, more than 34% were prescribed at least one potentially inappropriate medication, and also spent an additional $458 on healthcare, including an extra $128 on prescription drugs.
On average, those 34% of patients were prescribed twice as many drugs, were nearly twice as likely to be hospitalized or visit the emergency department, and were more likely to visit a primary care physician compared to older adults who were not prescribed potentially inappropriate medication, the study found.
"De-prescribing is currently at an early stage in the United States," Jacobs said. "Further work is needed to implement interventions that target unnecessary and inappropriate medications in older adults."
Marcus Whitney, CEO and co-founder of Nashville-based Health:Further, talks about the winding path that led him to healthcare entrepreneurship and his commitment "to make my life's work about this."
How does one transition from an aspiring hip-hop artist to an established healthcare entrepreneur and investor?
"That's a 20-plus-year story, and I don't think you'll have enough words for that," says Marcus Whitney, CEO and co-founder of Nashville-based Health:Further consulting.
"The simple way to put it is I've been an entrepreneur in Nashville for the last 10 years and, during that time, I entered into the venture capital space and quickly learned that Nashville's superpower was healthcare. And so, in 2015, my partner and I started a healthcare-only early-stage venture fund," he says.
Part of that "20-plus-year story" included two years at the University of Virginia, where Whitney dropped out during his junior year to pursue a career in hip-hop and to wait tables.
"I don't see it as it wasn't a good decision, but it was certainly part of my story, that's for sure," the East Flatbush, Brooklyn native says. After a few years in Atlanta, where Whitney says, "We just didn't quite feel like we had the community around us that we needed," he and his family moved to Nashville.
Nashville prides itself as the Music City, but Whitney quickly learned that healthcare was king. Nashville and its donut counties are home to some of the nation's largest healthcare companies, including HCA Health, Inc., and Community Health Systems, Inc. The city's healthcare sector generates about $92 billion in revenue globally and accounts for about 570,000 jobs.
"Healthcare was the market where we were most likely to be successful as venture capitalists in Nashville," Whitney says. "It has since changed from just that to become an incredible market globally and also a fulfilling market to do work in."
With little experience in healthcare, Whitney knew the learning curve would be steep.
"I had a lot of help. Nashville is a great community and, fortunately, I was relatively well known when we started," he says. "I was able to get access to leaders in the community quickly. You get to skip grades quickly when you're talking to the people who actually run everything, and they can explain to you exactly how things work."
Over the past decade, Whitney says he's come to embrace the healthcare sector "because you can work on it for your entire life; you can pick an area and you can say, 'I'm going to make my life's work about this.' "
"It's going to be meaningful because it touches each one of us, and there's also enough money there to meet your financial needs. It's an amazing industry to be involved in," he says.
Following are highlights from Whitney's conversation with HealthLeaders.
"This is the moment. No one is looking for scared thinking right now. Be bold and think about ways within your locus of control and within your realm of power to effect meaningful change that is going to stick for the next 50 years. The changes we're making right now are going to be multigenerational changes. So, it's a unique window and a unique opportunity."
"The healthcare industry is counterintuitive insofar as it's not a normal economic model. The patient is not the payer. The "aha!" moment for me was understanding the incredible role of CMS and the relationship between CMS and all the commercial payers and how all of that played into the providers. Learning that dynamic is the foundation for everything that you need to know."
"It's critical to have people of color in leadership roles in healthcare, and it's also not happening; not in any way that would be reasonable and measurable. It's important because it's the largest segment of the United States economy, and it also is an essential service that touches every life in America."
"For a person of color, for Black people, that's 18% of the total population of the country, they're all completely affected by it. When you don't have representation, then there's a lack of understanding or lack of perspective. It's not intentional, but there's a lack of empathy for those people. There's also exclusion from the wealth generation that occurs in the lucrative healthcare industry."
"Correcting this will require a lot of work. It starts with commitment from leaders to first acknowledge that such an issue exists. We're still working on that. There hasn't been any meaningful acknowledgment that I can point to from the leaders of the largest healthcare companies in the country to this fact. You have to start with an acknowledgment and once you have an acknowledgment, then you can start the long process."
"We're here to help leaders get inspired about what innovation could do within their organizations and then what their organizations could then do for the communities that they serve. We've done that many times through both our strategic advisory engagements as well as through our conferences over the years. The connections and the inspiration that we were able to create is collectively the success that we're going for."
"Innovation is an understanding that you can always make something better. It starts with the perspective that what we have today can be improved, and then it's the resolve to improve it."
"There are tons of problems in healthcare today. It costs too much and it's inefficient. There are access problems and quality issues, and data rights issues. So, there are opportunities for innovation everywhere."
"The pandemic has exposed a lot of weaknesses in the nation's care delivery."
"We should be honest about the areas where we fell short. We can listen to healthcare workers about where we failed them. We can listen to patient advocates about areas where we should have been more prepared. We can think about re-domesticating our medical manufacturing."
"In five years, I expect to see a lot of changes around technology, telemedicine, and medical manufacturing and stockpiling. We're going to see a lot more competition. There seems to be some important stuff that's going to make its way through CMS right now to change requirements around physician oversight of many reimbursable procedures."
"It's going to be a different looking healthcare system in five years. It was already headed that way with venture capital, private equity, and the digital health revolution, per se and now with COVID-19. That was a real accelerant for change, and it doesn't seem to me that we're going to go back to business as usual."
HHS also is expanding provider eligibility for $20 billion in emergency funding under its Phase 3 distribution of PRF money.
Acknowledging negative feedback from stakeholders, the Department of Health and Human Services announced Thursday that it is revising reporting requirements for $175 billion in pandemic emergency aid under the Provider Relief Fund.
"In response to concerns raised, HHS is amending the reporting instructions to increase flexibility around how providers can apply PRF money toward lost revenues attributable to coronavirus," HHS said.
"After reimbursing healthcare related expenses attributable to coronavirus that were unreimbursed by other sources, providers may use remaining PRF funds to cover any lost revenue, measured as a negative change in year-over-year actual revenue from patient care related sources," HHS said.
HHS revised the rules on September 19 to address concerns that some providers were profiting from the PRF funding while other providers were struggling financially.
Essentially, the revised rules prohibited providers from being more profitable in 2020 than they were in pre-pandemic 2019, so that funding could be given to less-profitable providers.
That revision drew the ire of providers, who urged HHS to allow providers to use PRF payments for all lost revenues.
In a letter this week to HHS Secretary Alex Azar, American Medical Group Association CEO Jerry Pesno said comparing operating income in 2020 and 2019 "would inadvertently deny PRF aid to clinicians and group practices that would otherwise qualify because of an accounting requirement."
"Under the (Sept. 19) proposed formula, when additional providers join a medical group, it may appear that revenue grew for the group," he said. "However, the increase in volume is a result of the new clinicians joining and not due to growth in volume of services delivered."
"COVID-19 continues to decrease patient volume, and in fact, the average revenue per clinician is well below last year's," he said.
The revision also extends by six months – until mid-June 2021 – the allotted time for providers to spend all of their remaining PRF funds for COVID-19 related expenses that are not reimbursed by other sources, or to apply the funds for lost revenues up to an amount not above the difference between 2020 and 2019 actual revenue.
Phase 3 Distribution
HHS on Thursday also announced that it was expanding provider eligibility for $20 billion in emergency funding under its Phase 3 general distribution of PRF money.
"Today, we are expanding the pool of eligible providers to include a broader array of practices, such as residential treatment facilities, chiropractors, and vision care providers that may not have already received payments," Azar said.
Under Phase 3, providers that had already received PRF money may apply for additional funding that considers changes in patient care operating revenue and expenses caused by the coronavirus, HHS said.
Report credits rapid technological advances and improved access and availability for exponential growth.
The global telemedicine market will see an exponential compounded annual growth rate of 23.5% over the next six years, reaching $185.5 billion by 2026, according to an analysis from Fortune Business Insights.
The report credits rapid advances in technology, and the expansion of remote care venues for subspecialities such as cardiology, radiology, and behavioral health with transforming the sector, especially by improving accessibility and availability, both in developed and developing nations.
"This will further give rise to new healthcare business models in telemedicine," the analysis said. "People around the world prefer virtual consultation as it reduces the cost of other healthcare services such as hospital stays."
The projected growth over the next six years marks a five-fold increase from the $34.5 billion global market in 2018, Fortune Business Insights said.
Teleradiology, teledermatology, telepathology, and telepsychiatry services are projected to lead the market over the forecast period, fueled by favorable reimbursement policies. In addition, the entry of new players and the increased adoption of real-time communication are driving the sector, Fortune Business Insights said.
The analysis notes that healthcare providers are increasingly adopting the Picture Archiving and Communication System to securely store and transmit electronic images from anywhere in the world with the help of electronic medical records.
The United States is expected to play a dominant role in the growth of telehealth, thanks to government and commercial payer reimbursement policies, a growing and aging patient pool, and improving practice standards for telehealth and e-health, the analysis said.
"As the aging population is increasing and preference towards telemedicine is rising, the number of e-health visits are increasing exponentially. This will further increase the telemedicine market share in North America," the analysis said.
Editor's note: This story was updated on October 22, 2020.
The settlement does not release from further criminal charges the Sackler family, owners of Purdue, nor any of company's executives or employees.
OxyContin maker Purdue Pharma will pay $8 billion and dissolve as a company in a deal to settle civil and criminal charges for its decade-long leading role in fueling the nation's opioid crisis that has claimed hundreds of thousands of lives, the Department of Justice announced Wednesday.
Under a deal reached with federal prosecutors in New Jersey, and subject to the approval of a bankruptcy court, Purdue will plead to a three-count felony information charging it with one count of dual-object conspiracy to defraud the United States and to violate the Food, Drug, and Cosmetic Act, and two counts of conspiracy to violate the Federal Anti-Kickback Statute, for violations that occurred between 2007 and "at least March, 2017," DOJ said.
"It is important to note that this resolution does not prohibit future criminal or civil penalties against Purdue Pharma's executives or employees," Deputy U.S. Attorney General Jeffrey Rosen said in remarks accompanying the announcement.
The settlement includes a criminal fine of $3.5 billion and $2 billion in criminal forfeiture, and a civil settlement of $2.8 billion to resolve its civil liability under the False Claims Act. Separately, the Sackler family has agreed to pay $225 million in damages to resolve its civil False Claims Act liability, DOJ said.
Federal prosecutors hailed the settlement the largest penalty ever levied against a drug maker. However, the $8 billion forfeiture is dwarfed by the societal costs of the opioid epidemic, which has claimed hundreds of thousands of lives over the past 20 years.
The Centers for Disease Control and Preventionhas estimated that the "economic burden" of opioid epidemic is $78.5 billion a year, which includes the costs of healthcare, lost productivity, addiction treatment, and criminal prosecutions.
"Purdue deeply regrets and accepts responsibility for the misconduct detailed by the Department of Justice in the agreed statement of facts," Steve Miller, who joined Purdue's Board as Chairman in July 2018, said in prepared remarks.
Purdue said new company will emerge from bankruptcy as a "public benefit company, created and operated "for the benefit of claimants and the American people" under a new owner, with new trustees "to provide for free or at cost millions of doses of lifesaving opioid addiction treatment and overdose reversal medicines."
"Resolving the DOJ investigations is an essential step in our bankruptcy process," Miller said. "The settlement agreement will pave the way for Purdue to submit a plan of reorganization to the bankruptcy court that will transfer all of Purdue’s assets to a public benefit company, and ultimately deliver more than $10 billion in value to claimants and communities."
A KFF analysis finds that admissions cratered in March and April but were at 95% of predicted admissions by mid-summer.
Hospital admissions have rebounded somewhat since volumes tanked during the first months of the coronavirus pandemic, but they haven't returned to pre-pandemic levels and likely will be 10% lower than initial projections for 2020, according to an analysis released Monday by the Kaiser Family Foundation.
Using electronic medical record data gleaned from Epic Health Research Network, the KFF researchers looked at total hospital admissions and non-COVID-19 admissions by patient sex, age, and region to calculate the actual admissions as a share of total predicted admissions for 2020 based on past trends.
Researchers say the new data will provide a better understanding of the magnitude of the drop in hospital admissions, its effect on hospitals, insurers and other healthcare stakeholders, and which patients are delaying or foregoing healthcare.
"The data show which areas of the country experienced the steepest declines and where admissions came back to nearly pre-pandemic levels," said study co-author Sam Butler, MD, Epic's vice president of clinical informatics. "In the future, we'll be able to compare this data with patient outcomes to better understand which non-emergency care is most critical."
Among the key findings:
Total hospital admissions dropped to as low as 68% of predicted admissions on April 11, and then increased to a high of 94.3% of predicted levels by July 11, 2020.
As of August 8, admission volume has dropped to 91% of predicted levels.
The number of hospitalizations lost due to admissions drops between March and August represent 6.9% of the total expected admissions for 2020.
With non-COVID-19 admissions, people age 65 and older had half as many admissions in late March and April compared to what was predicted.
Admissions for seniors have stabilized at 80%-85% of their predicted level in early August.
Admissions for people under age 65 were at about 90% of predicted levels during the same seven-month period.
Epic's EMR data ncludes all inpatient hospital admission volume from Dec 31, 2017 to August 8, 2020, for patients who either were discharged or died, as of September 13, 2020.
The data are aggregated weekly and pooled from 27 health systems representing 162 hospitals in 21 states that cover 22 million patients.
The 21 states had 67% of COVID-19 cases as of mid-September and represent 66.5% of the U.S. population.
A Robert Wood Johnson study estimates that 21 million people would lose health insurance coverage if the U.S. Supreme Court overturns the ACA.
A U.S. Supreme Court ruling nullifying the Affordable Care Act would result in the uninsurance rate for nonelderly people climbing nearly 70%, with 21 million Americans losing coverage, according to a new study commissioned by the Robert Wood Johnson Foundation.
"Invalidating the ACA would be devastating to millions, especially people who gained access to affordable health coverage in the past decade," said Avenel Joseph, vice president for policy at the Robert Wood Johnson Foundation.
"Nearly overnight, America's health care system could become more expensive and less accessible and perpetuate health and financial insecurity. Unfortunately, those who have the least stand to lose the most," Joseph said.
The Supreme Court has scheduled oral arguments for November 10 on the constitutionality of the ACA in the consolidated California v. Azar and Texas v. Azar lawsuits, but a ruling is not expected until mid-2021 at the earliest.
The plaintiffs in both cases are asking the justices to rule on the constitutionality of the individual mandate without a tax mandate, and whether the mandate is severable, and the rest of the law can remain in place.
The study suggested that if the high court nullifies the ACA, the lost coverage would disproportionately hurt "certain racial and ethnic groups" For both non-Hispanic Black and white people, the uninsurance rate is expected to increase nearly 85% (to 20% of Blacks and 15% of whites). Among Hispanics, the increase would be nearly 40% (to 30%).
Poor people in states that expanded Medicaid access would also be disproportionately affected, with Maine, Kentucky, and West Virginia seeing their uninsurance rates nearly triple.
If the ACA is overturned, the study also estimated that federal health care spending would fall $152 billion annually and the amount of uncompensated care sought by the uninsured would rise 74%.
To get their estimates, the researchers tapped the Urban Institute's Health Insurance Policy Simulation Model, a microsimulation model of the health insurance system that allows researchers to estimate cost and coverage implications of health policy decisions.
The analysis takes into account projections that the United States will have partially recovered from the COVID recession as of 2022.
Utah-based MSSI for more than six years allegedly paid millions of dollars in kickbacks to healthcare providers in the form of free advertising, practice development, practice support, and purported unrestricted "educational" grants.
Medical device maker Merit Medical Systems Inc. will pay $18 million to settle whistleblower allegations that it paid kickbacks to hospitals and physicians to use their products, the Department of Justice said.
According to federal prosecutors in New Jersey, South Jordan, Utah-based MSSI used a scheme known as the Local Advertising Program that for more than six years paid millions of dollars in kickbacks to healthcare providers in the form of free advertising, practice development, practice support, and purported unrestricted "educational" grants to induce them to purchase MMSI products, which the providers used on procedures for Medicare, Medicaid and TRICARE beneficiaries.
"Paying kickbacks to doctors in exchange for referrals undermines the integrity of federal healthcare programs," said Acting Assistant Attorney General Jeffrey Bossert Clark of DOJ's Civil Division.
"When medical devices are used in surgical procedures, patients deserve to know that their device was selected based on quality of care considerations and not because of improper payments from manufacturers," Clark said.
MMSI issued a statement saying it agreed to the settlement "in order to avoid distraction from its core mission, and the cost of litigating the matter to success."
"The settlement agreement does not constitute a finding of wrongdoing by Merit or its management, and it expressly recognizes that Merit denies the allegations," the company said in a media release.
The products included MMSI's EmboSphere devices, used for uterine fibroid embolization procedures, and its QuadraSphere devices, used for other types of embolization procedures.
MSSI claimed that its financial assistance was designed to "increase the awareness" of medical treatments, but DOJ alleged that the device maker provided the aid only to some healthcare providers to reward past sales, induce future sales, and steer business to MMSI and away from MMSI's competitors.
DOJ also alleged that MMSI ignored numerous warnings that its conduct violated the Anti-Kickback Statute, including warnings from MMSI's own chief compliance officer.
Under the settlement, MMSI will pay $15.21 million to the federal government, and $2.79 million to states that funded Medicaid claims involving MMSI devices.
The whistleblower, Charles J. Wolf MD, the former chief compliance officer of MMSI, will receive $2.65 million from the federal share of the settlement.
Along with the civil settlement, MMSI entered into a five-year Corporate Integrity Agreement with the Department of Health and Human Services-Office of Inspector General.
Medicaid and CHIP have seen the number of services delivered via telehealth increased by more than 2,600%.
The Centers for Medicare & Medicaid Services on Wednesday added 11 new telehealth services that Medicare fee-for-service will pay for during the coronavirus pandemic Public Health Emergency.
The new telehealth services include some neurostimulator analysis and programming services, and cardiac and pulmonary rehabilitation services. Medicare will begin paying for the new telehealth services immediately and for the duration of the PHE.
Since the beginning of the PHE last spring, CMS has used an expedited process to add 144 services to the Medicare telehealth services list – such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services.
Between mid-March and mid-August more than 12 million Medicare beneficiaries – representing 36% of people with Medicare FFS – have used telemedicine services.
The data shows that there have been more than 34.5 million services delivered via telehealth to Medicaid and Children's Health Insurance Program beneficiaries between March and June, an increase of more than 2,600% when compared to the same time last year.
"Medicaid patients should not be forgotten, and today's announcement promotes telehealth for them as well," CMS Administrator Seema Verma said. "This revolutionary method of improving access to care is transforming healthcare delivery in America."
The data also shows that adults ages 19-64 received the most services delivered via telehealth, although there was substantial variance across both age groups and states, CMS said.
The share of markets between 2014 and 2019 that were highly concentrated increased from 71% to 74%, the analysis found, with more than half (52%) of the markets that were highly concentrated in 2014 even more concentrated by 2019.
"For many of the 70 million Americans who live in highly concentrated health insurance markets, a lack of competition is a problem that keeps getting worse as consumers have more limited health insurance options to choose," AMA President Susan R. Bailey, MD, said in a media release.
"The AMA strongly encourages a dialogue among regulators, policymakers, lawmakers, and others about the need for a better, more open and competitive marketplace to benefit patients and the physicians who care for them," Bailey said.
The 2020 Competition in Health Insurance: A Comprehensive Study of U.S. Markets examined 384 metropolitan statistical areas across the nation using the Herfindahl-Hirschman Index. Markets with an HHI of 2500 points or higher are "highly concentrated."
AMA singled out Elizabethtown-Fort Knox, Kentucky as a glaring example. In 2014, this MSA-level market had an HHI of 3534 – exceeding the federal threshold for a highly concentrated market by more than 1000 points. In 2019, the HHI rose to 5159.
Anthem, the dominant provider in that region, saw its market share grow from 45% in 2014 to 70% in 2019.
Across the nation, AMA said, the average MSA-level market had an HHI of 3473 – exceeding the federal threshold for a highly concentrated market by nearly 1000 points. Market concentration levels increased on net between 2014 and 2019 with the average market HHI rising by 151 points. More than half (56%) of markets experienced an increase in the HHI, and in 17% of markets the HHI increased by at least 500 points. In markets with a rise in the HHI, the average increase was 481 points.
The HHI scores illustrate that 92% of MSA-level markets had a single insurer with a market share of 30% or greater, while 48% of MSA-level markets had a single insurer with a market share of 50% or greater, AMA said.
The study found that:
The 10 states with the least competitive commercial health insurance markets were: 1. Alabama, 2. Hawaii, 3. Michigan, 4. Delaware, 5. South Carolina, 6. Kentucky, 7. Alaska, 8. Louisiana, 9. Illinois, 10. North Carolina. See the 10 states with the least competitive PPO, or exchange markets.
Fifteen states had a single health insurer with a state-wide market share of 50% or greater: 1. Alabama (86%), 2. Michigan (67%), 3. Hawaii (66%), 4. South Carolina (64%), 5. Delaware (64%), 6. Kentucky (64%), 7. Louisiana (62%), 8. Illinois (59%), 9. Indiana (56%), 10. Mississippi (55%), 11. North Carolina (55%), 12. Oklahoma (55%), 13. North Dakota (54%), 14. Vermont (53%), and 15. Alaska (51%).
The five health insurers with the highest market share in the most MSA-level markets were: 1. Anthem (75 MSAs), 2. Health Care Service Corp. (43 MSAs), 3. UnitedHealth Group (28 MSAs), 4. Florida Blue (22 MSAs), and 5. Highmark (21 MSAs).
AHIP Responds
David Allen, an AHIP spokesperson, responded on Thursday to HealthLeaders' request for comment on the AMA report.
"The key to negotiating lower prices is competition among doctors and hospitals – not health insurance providers," Allen said in an email. "That means hospital market consolidation is a key concern. Unfortunately, the AMA study failed to include this major factor in its analysis (in fact, the word "hospital" is only used once in the study’s 67 pages). But facts matter.
"The fact is highly concentrated hospital markets result in health care costs above and beyond what Medicare pays for the same services. This leads to higher health care costs and increased premiums for patients and communities.
"What's more, hospital market consolidation continues to trend upward. According to the Health Care Cost Institute's Healthy Marketplace Index, almost 75% of U.S. hospital markets are now designated as 'highly concentrated.' And it's not just hospital mergers and acquisitions that drive up prices; hospitals are also purchasing physician practices too.
"We agree doctors and hospitals should be fairly compensated for the value of care they offer. But we all have a role to play in reducing healthcare prices and improving quality of care for America's patients. And as the facts show, provider consolidation drives up prices and fails to address healthcare costs."
