In addition, 20 more health insurance companies will participate in the Federal Health Insurance Exchange in 2020, bringing to 175 the total number of issuers, up from 132 in 2018, CMS said.
Health and Human Services Secretary Alex Azar said the coming year's drop in premium prices follows a 1% decrease from 2018 to 2019.
"I said last year that President Trump, the president who was supposedly trying to sabotage this law, has been better at running it than the guy who wrote the law and that has remained the case this year," Azar told reporters during telephone conference call.
"In total, 27 out of the 38 states on the federal exchange are seeing decreases in the benchmark premium. There will be 175 issuers offering plans on the federal exchange and an increase of 20 issuers from 2019."
Azar said only two states will have a single health insurance plan in 2020, down from five states last year.
"The average enrollee will have 3.5 issuers available in 2020, compared with 2.8 issuers in 2019," he said.
Even with the expanded number of health plans, Azar said, ACA plans are largely unaffordable for most people without a subsidy.
"For instance, a 27-year-old single person buying the second-lowest cost Silver plan in Nebraska is going to pay $583 a month for coverage, down from $687 in 2019," he said. "Now that's real savings. But she's still going to be spending almost $7,000 a year on insurance premiums when she could be making as little as $48,000 in income, and she will still have a sizable deductible to spend through."
Six states will see double-digit percentage declines in benchmark silver plan premiums for 27 year olds including, Delaware (20%), Nebraska (15%), North Dakota (15%), Montana (14%), Oklahoma (14%), and Utah (10%).
CMS Administrator Seema Verma said that in recent years people who aren't eligible for tax credits "have been hit particularly hard and have found they simply cannot afford to keep their plan."
"Between 2016 and 2018 unsubsidized enrollment across the country declined by 2.5 million people, a 40% drop in just two years," she said. "It was inevitable that Obamacare's affordability crisis would eventually increase the number of uninsured, and that is exactly what the latest census data show."
"The fact is, 85% of the 1.9 million additions to the uninsured in 2018 occurred among people with income higher than 300% of the federal poverty line," she said. "These are people who do not qualify for large ACA subsidies and who now represent a new class of uninsured who can't afford Obamacare premiums."
Verma said a 55-year-old couple making $70,000 in Quincy, Florida would have to pay $31,000 a year for a Silver plan that comes with a $12,000 deductible.
"These are not affordable premiums," she said.
"In addition to increasing premiums," Verma said, "Americans had fewer choices. In 2016 to 2017, the number of issuers and states using Healthcare.gov declined from 237 to 167, and in 2018, the number dropped 132, a 44% drop during these last two years."
"These were the conditions the Trump administration inherited, and this is what people too often forget."
(To view the 2020 Health Insurance Exchange Premium Landscape Issue Brief, click here. To view the 2020 Plan Landscape Data, click here. To see the 2020 Health Insurance Exchange Public Use Files, click here.)
Here's a tip for providers who want their hospital patients to experience less pain. Be nice!
Research presented at the ANESTHESIOLOGY® 2019 annual meeting this week in Orlando analyzed responses from 4,740 adults who were asked about pain management for a variety of illnesses and surgeries during their hospital stay, which averaged 5.3 days with 3.8 blood draws.
Researchers found that 3,882 of the 4,740 patients (82%) answered "always" when asked how often the staff did everything they could to help them with their pain and 3,112 (65%) answered "always" when asked how often their pain was well-controlled.
Patients were also asked to rate from "very poor" to "very good" the courtesy of the person who drew their blood. Those patients who answered "very good" were 390% more likely to have rated their pain management as very good, than those who rated their provider less courteous.
"It's not surprising that a courteous health care provider can improve the patient experience, but we were shocked at just how powerful that factor was," said Mario Moric, MS, lead author of the study and a biostatistician at Rush University Medical Center, Chicago. "We thought the more needle sticks the higher the pain perception, but we found that effect was small. It turns out the experience of pain is much more significantly affected by the attitude of the people treating you."
Patient feedback has shown that blood draws are a major cause of fear and anxiety. Study co-author Asokumar Buvanendran, MD, said the results suggest that if the person drawing blood is empathetic and courteous, the patient's overall pain experience can be improved.
"It's important to continue to improve health care procedures by making them less invasive, but listening to patients and letting them know you are trying to minimize their discomfort also is really powerful and should be a focus for all health care training programs," said Buvanendran, chair of the American Society of Anesthesiologists Committee on Pain Medicine and vice chair of research at Rush University Medical Center.
"Being kind makes a big difference in the patient experience, and that's good for everyone," he said.
The 30-day mortality rate for these high-risk patients was 15.9% at major teaching hospitals, compared with 18.2% at non-teaching hospitals.
High-risk general surgery patients have higher survival rates at major teaching hospitals than at non-teaching hospitals, new research shows.
The 30-day mortality rate for these high-risk patients was 15.9% at major teaching hospitals, compared with 18.2% at non-teaching hospitals, according to researchers at Penn Medicine, who examined the medical records of 350,000 Medicare beneficiaries who underwent general, vascular or orthopedic surgery at 2,780 hospitals across the country, including 340 major teaching hospitals.
The findings were published this month in Annals of Surgery. The study was funded in part by the Association of American Medical Colleges.
Major teaching hospitals were defined by the researchers as having a resident-to-bed ratio of greater than .25.
"Academic medical centers are often recognized for their ability to deliver advanced clinical and surgical care, but there has been limited data on which specific patient groups benefit the most—when factoring costs and outcomes—from receiving care at the hospitals," senior author Lee A. Fleisher, MD, said in comments accompanying the study.
"Our study showed that as the severity of a patient’s medical condition worsened and the complexity of the surgery increased, the benefit of undergoing general or vascular surgery at a teaching hospital also increased," said Fleisher, chair of Anesthesiology and Critical Care at Penn.
The study examined costs and patient outcomes—including 30-day mortality rates—for dozens of procedures, such as mastectomy, appendectomy, gastric bypass, blood vessel repair and total knee replacement.
The researchers calculated the cost of care within 30 days of admission, including office visits and readmissions. Researchers matched pairs of individuals based on the procedure, risk profile and factors related to their medical history, including comorbidities such as diabetes and high blood pressure.
The mortality rate of high-risk vascular surgery patients was 15.5% at teaching hospitals compared to 16.4% at non-teaching hospitals. The mortality rate for orthopedic surgery procedures was significantly lower across the board than the rates for vascular and general surgery.
To calculate the cost for a 1% reduction in mortality rates, the researchers divided the variations in resource costs at major teaching and non-teaching hospitals by the difference in 30-day mortality rates. Under that equation, the value for general surgery was $965 for a 1% reduction in mortality, while the estimate for vascular surgery was $3,567.
"Our study provides new data that can help inform patient decisions and influence hospital referral patterns, ultimately moving us closer to a system that ensures patients have access to the treatment they need," Fleisher said.
The analysis projects that the costs for the opioid crisis in 2019 will range anywhere from $172 billion to $214 billion.
The opioid crisis has cost the nation at least $631 billion over the past four years, and nearly one-third of that estimate is attributable to excess healthcare spending, according to an analysis by the Society of Actuaries.
The $205 billion attributable to excess healthcare spending between 2015 and 2018 included providing medical care for opioid addicts and infants born with neonatal opioid-related conditions, and other family members bearing costs associated with those diagnoses.
“As stakeholders seek to understand and address the opioid epidemic, this analysis provides insight into the tremendous impact across all areas of our economy,” says Dale Hall, managing director of research at SOA.
"Our goal is really to help our member actuaries, insurers and other stakeholders better understand the implications of the opioid crisis," Hall says. "A lot of our members can use this information to build into pricing exercises, healthcare evaluation exercises, and understand the impact of premature mortality."
The analysis projects that the costs for the opioid crisis in 2019 will range anywhere from $172 billion to $214 billion, depending on key metrics, such as the prevalence of opioid use disorder and the number of opioid overdose deaths this year.
"We'll have a better idea when we get final, premature mortality deaths due to the opiate crisis," Hall says. "It's been trending up, about 45,000 per year and most recent years. We will also want to see what those premature death counts end up being in 2019. Those two categories, healthcare costs and mortality costs, are 70% of the total, and so those are the things that we want to watch out for."
The largest financial burden imposed by the opioid crisis was attributed to premature mortality, which accounted for $253 billion – 40% – of excess spending between 2015 and 2018, mostly measured in lost lifetime earnings for people who died prematurely due to opioid overdoses.
The SOA analysis is based several data sources, including administrative claims, federal surveys, and databases, and prior peer-reviewed literature to determine the total economic burden.
Here's a further breakdown of the financial burden of the opioid epidemic across the economy between 2015 and 2018:
Costs associated with criminal justice activities, including police protection and legal adjudication activities, lost property due to crime, and correctional facility expenditures, totaled $39 billion, about 6% of the total cost.
Government-funded child and family assistance programs and education program costs contributed another $39 billion.
Lost productivity costs comprised the remaining 15% of total costs, totaling $96 billion, and include the cost of absenteeism, reduced labor force participation, incarceration for opioid-related crimes, and employer costs for disability and workers' comp for opioid-addicted workers.
SOA said the economic burden could be higher than its estimates, because the analysis does not include economic impacts for which there is a lack of adequate data, such as reductions in non-paid household productivity, reductions in on-the-job productivity, or reductions in quality of life for people impacted directly or indirectly by opioid use disorder.
New contract provides annual 3% raises in each of the next four years, invests $130M for workforce development.
Kaiser Permanente workers in California have "overwhelmingly" ratified a new four-year contract with the health system, the Service Employees International Union said.
The new contract runs through September 30, 2023.
"Our new contract recognizes the skill and dedication we bring to our work, and the guaranteed raises and protected benefits give us the peace of mind to focus on caring for our patients," Jessica Rodriguez, an emergency department technician at Kaiser Permanente in Oakland, said in an SEIU media release.
"We are also proud to have negotiated an agreement that is focused on the future and making sure patients have access to highly skilled and trained caregivers in the years to come," she said.
Kaiser Permanente, in a brief statement, called the ratification of the new contract "encouraging" and said it would have more comments after the Coalition of Kaiser Permanente Unions announces final results later this week.
The ratified contract:
Revitalizes the worker-management partnership, which promotes cooperation between frontline workers and managers to improve care delivery and job conditions, and lower costs;
Invests $130 million in workforce development to recruit, train and place thousands of clinicians in licensed healthcare positions, and addresses workforce shortages.
Focuses on recruiting and retaining caregivers with annual 3% raises in each of the next four years;
Bans subcontracting and limits outsourcing of current positions.
In addition to the 57,000 KP employees in California, another 26,000 KP workers in Colorado, Washington, Oregon, Hawaii, Virginia, Maryland and Washington, D.C. either voted to ratify – or are in the process of voting to ratify – similar contracts. The combined 83,000 workers comprise the Coalition of Kaiser Permanente Unions.
Health center directors believe the declines may be owing to confusion over the Trump administration's public charge rule.
Community health centers across the nation are reporting that many immigrant patients are not enrolling in Medicaid, possibly because of fears and confusion surrounding recent immigration policy changes that could jeopardize their status as legal residents, a new survey shows.
The Kaiser Family Foundation survey found that 47% of community health centers said that many or some immigrant patients didn't sign up for in Medicaid in the past year, and that 32% of CHCs said patients dropped or didn't renew their coverage.
The enrollment declines come as the Trump administration has attempted to tighten eligibility requirements for Medicaid under the public charge rules, leading some health center staff respondents to the survey to suggest that fear and confusion over the policy shift may be the reason, KFF said.
Late last week, federal judges in California, New York, and Washington State issued temporary injunctions against the policy shift, which would have allowed the federal government to withhold green cards and for immigrants who enroll in Medicaid or seek other public assistance, such as food stamps and housing subsidies.
The survey and interviews also found some changes in healthcare utilization, with 28% of health centers reporting drops among adult immigrant patients in seeking healthcare in the past year, including pregnant women and people with chronic illness, KFF said.
In addition, 22% of centers reported reductions in healthcare use among children in immigrant families.
Health center directors told KFF they're training clinical staff to answer questions about the public charge rule.
There are 1,362 health centers across the United States, providing care for about 28 million patients in medically underserved rural and urban areas.
The survey of community health centers and phone interviews with health center directors and senior staff was conducted from May to July 2019 by researchers at KFF and the Geiger Gibson Program in Community Health Policy at the George Washington University.
Experts on healthcare law say the proposed revisions to the Stark Law and Anti-Kickback Statute will create more opportunities for providers, and challenges.
What can we anticipate with the Stark Law and Anti-kickback Statute proposed revisions put forward this month by the Trump administration?
We asked four healthcare attorneys for their initial assessments of the proposed revisions and how it may change the landscape for healthcare delivery.
Here's what they said. Their responses have been slightly edited for length.
HLM: Will these proposed revisions deliver the promise of reducing regulatory burdens on providers?
The proposed changes add flexibility and some important clarifications. For example, the newly proposed value-based exceptions and safe harbors are generally broad and flexible, which will stimulate innovation with respect to value-based payment models. Moreover, several of the changes will help facilitate greater patient engagement in value-based programs.
There are also a number of valuable Stark regulatory clarifications and changes that will alleviate some of the regulatory burdens. For example, CMS clarified its aim to interpret the Stark statutory prohibitions narrowly and the exceptions broadly; and in doing so, broadened the applicability of several exceptions. Also, the industry likely breathed a collective sigh of relief upon seeing CMS's proposed definition of "commercial reasonability," which clearly states that profitability is not determinative of commercial reasonability.
At first blush the proposals do not lessen the complexity overall; nor, could the agencies really have achieved that absent statutory changes. The length of the proposals alone is evidence of the continuing complexity. At the end of the day, these laws contain a maze of definitions, exceptions or safe harbors, special rules and thousands of pages of preamble guidance; and, the risk of any missteps remains high.
For healthcare systems and physician providers, these changes provide welcome clarification to key concepts of the Stark Law, and provide some clarity on the types of features that the government expects to see in permissible value-based arrangements. Other providers, including certain manufacturers and suppliers, may want to provide comments in response to the proposed rules in order to carve out a place for themselves at the value-based table.
William Maruca, a partner at Fox Rothschild LLC
Most of these changes don't address regulatory burdens as much as uncertainty about whether different kinds of relationships among providers, payors and Medicare are legal. Given that the Stark Law is a strict-liability law, anything that didn't fit squarely within an exception before was considered too risky. These changes will have minimal impact on most current arrangements but may encourage the growth of new minimally-integrated networks of providers sharing risk and coordinating care in ways we haven't seen. The goal is to break the stranglehold of fee-for-service on the economics of healthcare so that delivering quality outcomes is more important and more lucrative than churning visits, procedures and RVUs.
HLM: What real-world impact will we see if these proposals are approved?
Sloane: The proposals, if finalized, are likely to spur expansion of value-based models used by healthcare organizations. Given, however, the sophisticated data analysis necessary to implement these programs and the continuing regulatory complexities, consolidation across the industry is likely to continue, if not accelerate. We are likely to see new start-ups emerge that aim to help start, facilitate and manage value-based payment models. Hopefully, the proposals will result in fewer frivolous whistleblower lawsuits or, at least, make them easier to defend. Also, the revised EMR and new cybersecurity safe harbors and exceptions should help effectuate cybersecurity improvements across the industry that will better protect all of our personal data.
Thallner and Aiken-Shaban: For healthcare systems and providers, like hospitals and physicians, if finalized, these proposals will bring greater certainty to the compliance of the value-based enterprises such providers engage in currently, or seek to develop. Furthermore, the Stark Law clarifications will allow providers greater certainty on how to structure arrangements within existing exceptions that rely on key concepts of fair market value, commercial reasonableness, and that the remuneration not vary with the volume or value of referrals between the parties. This and other changes should reduce the need for self-disclosures of non-compliant arrangements to CMS, and enhance defenses in related False Claims Act litigation based on alleged non-compliance with those exceptions.
Maruca: The Medicare ACO program is only one form of value-based reimbursement, but its results suggest many other approaches to care coordination and risk-bearing will be developed in the coming years. It is likely to take some time for the results to appear. The value-based models promoted under these new rules will primarily benefit larger organizations and health systems who have the infrastructure to monitor costs and outcomes. Independent medical practices have survived many premature obituaries but this is another pressure point that may encourage some of the survivors to sell or at a minimum to contract with the organizations who are better positioned to participate in these models.
HLM: Are there any unforeseen consequences of these actions?
Sloane: There is some risk people will take the relaxation of certain regulations too far. Healthcare companies should not use these proposals (assuming finalized) as a reason to reduce their compliance efforts. Many of the changes, particularly with respect to Stark, seem like defensive safeguards against a violation of Stark in the event existing policies and procedures (e.g., contracting procedures) unintentionally break down. For example, we would not recommend any hospital stop or carve back its physician contracting procedures because certain inpatient hospital services are no longer DHS.
It is clear that the OIG is on the lookout for any unintended consequences of the new value-based payment safe harbors. The OIG notes that value-based arrangements come with their own risks of things like inappropriately reducing care, cherry picking lucrative or adherent patients, lemon dropping expensive or noncompliant patients, and manipulating performance data. In part for these reasons, the OIG's value-based safe harbors are more restrictive than the Stark exceptions.
Thallner and Aiken-Shaban: For those categories of healthcare manufacturers and suppliers proposed to be excluded from the value-based exceptions, it draws into question their continued ability to rely on existing exceptions and safe harbors that they have historically used to protect or assess the risk posed by value-based and shared savings arrangements.
Maruca: People and organizations can be expected to react to financial incentives, so there may be issues where unscrupulous players try to game the new system by fudging outcomes, screening out the sickest patients, or just undertreating patients to generate savings they can then share in. Both CMS and OIG are anticipating these concerns in their preambles and both acknowledge that there may be more risks that cannot be foreseen. This is one reason proposed rulemaking is published for comment. Watching the comments come in will be one way to identify potential consequences unanticipated by the regulators. Another challenge will be measuring quality of outcomes, adjusting for severity of illnesses across populations to minimize any ill effects of financial rewards that are designed to discourage unnecessary care and end up reducing necessary care.
HLM: Are there any icebergs looming for this proposal that may jeopardize implementation?
Sloane: These laws impact every healthcare provider, supplier and practitioner. A lot of discussion and many viewpoints will emerge in the coming months. CMS and OIG will get a lot of comments, which will likely slow the release of the final rule. But in the end, a lot of these proposals will be finalized.
Thallner and Aiken-Shaban: The manufacturer and supplier community may not have seen the types of changes it had hoped to see with regard to value-based pricing, and therefore may oppose the proposals strongly. Additionally, in their proposals, OIG and CMS offered a large number of alternative structures, elements, and definitions on which they solicited comments, which leaves stakeholders uncertain as to the likely contours of the final regulations, and which might give OIG and CMS more challenges in finalizing the proposed value-based rules in a timely fashion.
Maruca: Fortunately for the agencies, no vote is needed in Congress, since there is little chance for any consensus there. There will be a 75-day comment period where stakeholders can provide input, then CMS and OIG will need to react to those comments. One area of controversy is that the OIG has decided to exclude certain players from participating in Safe Harbor-approved "Value Based Enterprises", specifically pharmaceutical manufacturers; manufacturers, distributors, or suppliers of durable medical equipment, prosthetics, orthotics or supplies; and laboratories. They are also considering excluding pharmacies, specifically compounding pharmacies, and pharmacy benefit managers and have requested input.
While still reading the fine print, stakeholders say they're pleased that CMS has taken steps to update the 30-year-old laws.
Key stakeholders are offering praise in their early reviews of proposals to update the Stark Law and Anti-kickback Statute unveiled Wednesday by the Centers for Medicare & Medicaid Services.
American Medical Association President Patrice A. Harris, MD, said the nation's largest physicians association "is still assessing the full scope of (Wednesday's) proposal," but was "pleased to see that the administration has acknowledged a need for policy revisions in response to potential barriers that impede the delivery of patient-centric care."
"The AMA has previously called on the administration to modify the regulations in order to facilitate the move to value-based care," Harris said in prepared remarks.
"Currently, the Stark Law and anti-kickback statute can have a negative impact on the ability of physicians to assist with coordination because they inhibit collaborative partnerships, care continuity, and the engagement of patients in their care," he said.
Rick Pollack, president and CEO of the American Hospital Association applauded CMS "for putting patients first and taking action to modernize the rules so they support, rather than hinder, the teamwork among healthcare providers."
"When health care providers are able to work together to coordinate care, it is patients that benefit the most," Pollack said. "For far too long, a group of out-of-date regulations has created unnecessary roadblocks to the kind of collaboration and coordination that enables caregivers to meet all of their patients’ health care needs, whether in the hospital, the doctor’s office or their own homes."
The CMS proposal would create new and permanent exceptions to the 30-year-old Stark Law for value-based arrangements, permitting physicians and other providers to try innovating solutions without fear that their legitimate efforts to coordinate care might violate the law, according to an agency fact sheet. Those new exceptions would apply for Medicare and non-Medicare populations alike.
"The proposed rules provide greater certainty for healthcare providers participating in value-based arrangements and providing coordinated care for patients," Health and Human Services Secretary Alex Azar said in a media release. "The proposals would ease the compliance burden for healthcare providers across the industry, while maintaining strong safeguards to protect patients and programs from fraud and abuse."
The HHS Office of Inspector General proposal would create three new safe harbors for certain forms of remuneration among eligible participants in value-based arrangements and make other changes, according to an OIG fact sheet.
Both CMS and OIG are soliciting public comments on the details of their proposals and related matters.
Ted Okon, executive director of the Community Oncology Alliance called the proposed reforms "an important first step towards making the dream of paying for cancer care based on value a reality."
However, he also warned that the proposed reforms could "accelerate the trend toward hospital acquisitions of community oncology practices and providers."
"COA is very concerned about hospitals taking advantage of changes to Stark Law and Anti-Kickback Statute to further monopolize cancer care and referrals," Okon said. "COA is hopeful that CMS and HHS will continue efforts to combat this, including site neutral payments and addressing misguided public policies that have driven the growth of hospital-based cancer care, such as the 340B Drug Pricing Program."
Clif Gaus, president and CEO of the National Association of ACOs, said the nation's ACOs "strongly support the administration’s efforts to enhance value-based care, giving ACOs and other models tools needed to succeed, improving regulatory certainty, and reducing administrative burden."
Gaus said administration officials on Wednesday confirmed that the new proposals do not supersede or override current HHS waivers for ACOs participating in the Medicare Shared Savings Program.
"NAACOS would encourage HHS to underscore this positive news and clarify that these new proposals build upon and give additional flexibility for today's ACOs," Gaus said.
NAACOS has asked HHS for additional clarity on patient sharing data, and how waivers apply to other models is welcomed.
Farzad Mostashari, MD, CEO and founder of the Aledade physician-led ACO network, and the former national coordinator for health information technology at HHS, said he was "glad to see the clarification of existing waivers to encourage more providers to adopt value-based and advanced payment models."
"Cooperation between providers to better coordinate and manage patient care is critical to the success of value-based arrangements for patients and providers alike," Mostashari said. "That said, it’s important that these rules safeguard against misuse by clinically integrated networks and provider groups who seek to control referral patterns and ultimately increase costs."
Researchers suggest that a cap on per-resident funding could rechannel money toward community-based physician training.
Capping Medicare Graduate Medical Education funding at $150,000 per resident could free nearly $1.3 billion that could be used to alleviate physician shortages in underserved areas, a new study in JAMA Internal Medicinesuggests.
"Our study suggests Medicare GME may be overpaying some hospitals up to $1.28 billion annually," study lead author Candice Chen, MD, MPH, said in comments accompanying the study.
"Those funds could be redirected and used to strengthen the physician workforce, especially in underserved areas," said Chen, an associate professor of health policy and management at the George Washington University Milken Institute School of Public Health.
The researchers looked at cost reports to calculate GME payments to hospitals from 2000 through 2015. They found that GME annual funding rates for teaching hospitals can vary by more than $75,000 per resident. In 2015, for example, 25% of hospitals receiving less than $105,761 while 25% received more than $182,233 per resident.
The researchers then calculated the savings if Medicare capped GME payments at $150,000 per year, which is the rate used for the Teaching Health Center Graduate Medical Education (THC) program, which trains residents in community health centers, and other community-based settings in underserved areas.
Chen said residents trained under the THC GME program are more likely to enter primary care, and practice in rural and underserved areas. Funding for the program dries up in mid-November unless Congress appropriates more money.
Medicare's current funding mechanisms for GME have resulted in some teaching hospitals – often located in urban areas – receiving a disproportionate share of the money. Residents who train at these big city hospitals tend to remain in urban settings, Chen said.
"Our study suggests that the savings produced by capping all hospitals at the THC GME rate would add up enough to expand the THC program by tenfold," Chen said.
Atul Grover, MD, PhD, executive vice president of the Association of American Medical Colleges, said his organization has "several concerns about this recommendation."
"The most critical being that the authors fail to adequately distinguish between the purposes of Medicare Direct Graduate Medical Education (DGME) and Indirect Medical Education (IME) payments and fail to recognize the impact of $1 billion in annual Medicare reductions," Grover said in an email exchange with HealthLeaders.
"These cuts would have a devastating impact on patients and communities, reducing access to the critical services teaching hospitals provide, such as trauma centers, burn units, neonatal intensive care units, and other specialized and standby services," Grover said.
"Additionally, while we agree that the Teaching Hospital Center (THC) GME program is an important, targeted tool for training physicians, HRSA estimates that the GME rate used for the THC GME program covers the full costs incurred by THCs when training residents," Grover said.
"Medicare DGME payments to teaching hospitals only cover 21% of the training costs. At a time when our growing and aging population is driving a physician shortage of up to 46,900 to 121,900 by 2032, it makes little sense to slash funding for vital care and services available almost exclusively at teaching hospitals and destabilize a system that has produced high-quality doctors and other health professionals for more than 50 years and is widely regarded as the best in the world," he said.
Chen acknowledged that the study does not look at how much it actually costs to train residents at particular hospitals, or if some hospitals have characteristics that make it costlier to provide GME.
She called capping the Medicare GME payment rate "a limited reform."
"More comprehensive approaches to GME reform would involve restructuring payment and increasing accountability for these publicly funded training programs," she said.
The study found that 90% of hospitals with palliative care are in urban areas, and 17% of rural hospitals with fifty or more beds provide palliative care.
Access to and quality of hospital-based palliative care in the United States has more to do with geography than need, a new state-by-state report card finds.
The report – America's Care of Serious Illness: 2019 State-by-State Report Card on Access to Palliative Care in Our Nation's Hospitals – found "persistent gaps in access" across the nation for the estimated 12 million adults and more than 400,000 children living with chronic illnesses such as cancer, dementia, heart disease and kidney disease.
The study found that 90% of hospitals with palliative care are in urban areas, and only 17% of rural hospitals with fifty or more beds report palliative care programs.
"As is true for many aspects of healthcare, geography is destiny. Where you live determines your access to the best quality of life and highest quality of care during a serious illness," said Diane E. Meier, MD, director of the Center to Advance Palliative Care, which compiled the report.
"The aging of the baby boomer generation is contributing to a growing population of patients in need who live for years with serious and chronic illness. The need to improve the quality of their health care is therefore urgent," Meier said.
The report card found robust growth in palliative care teams at hospitals, with 72% of U.S. hospitals with 50 or more beds having palliative care teams. That's up from 53% in 2008 and just 7% in 2001. These hospitals 87% of the nation's inpatients.
Meier credited many of the advances in palliative care access and quality to a growing palliative care workforce, changes in reimbursements, evidence-based quality initiatives, and enhanced clinical training.
"We want to acknowledge that progress does not happen in a vacuum," she said. "Over the last few years, we have seen growing support from federal and state officials and private sector leaders, as well as continued work from organizations in the field."
"These efforts have contributed to an environment in which more stakeholders recognize the value of palliative care and have the tools to implement it," she said.
Despite this overall growth, the 2019 grade for the nation is a B, just as it was in 2015, owing to the large swaths of the country that still have limited access to palliative care, the report said.
"Many gaps remain in access," Meier said. "Access to palliative care in U.S. hospitals depends on where you live and the type of hospital to which you are admitted."
The report found that larger, not-for-profit hospitals were more likely to provide palliative services than were for-profit hospitals.
"Larger hospitals are probably more likely to provide palliative care programs because the size of the hospital and volume of patients can support a full interdisciplinary team," she said.
As for why for-profit hospitals are less likely to offer palliative care services, Meier said "the reasons are unknown."
"However, there are studies that have shown that for-profit hospitals have a higher emphasis on providing services that are immediately profitable to the hospital," she said, pointing to a study that CAPC published in Health Affairs which found that for-profit hospitals were also less likely to provide other high-value, but low-revenue services to patients.
"Palliative care provides significant cost savings to a hospital, but that's not the same as bringing in revenue," she said.
As for what could entice for-profit hospitals to take up palliative care, Meier said changes to Medicare's Conditions of Participation for hospitals that "would require accountability for access to high-quality care for patients with serious illness across all types of hospitals."
In addition, Meier recommended "payment reform recognizing and rewarding quality of care and outcomes important to patients, instead of the current fee for service financial incentives driving volume and procedures."
Meier was asked to identify a "common thread" among the states that scored well on the report card.
"There are some differences in the makeup of the hospitals within states or regions, although these differences may not fully explain the differential prevalence rates," she said.
"For example, the three regions that received A grades (New England, East North Central, and Mid-Atlantic) all have the highest proportions of non-profit hospitals in the United States and subsequently, the lowest rates of for-profit hospitals," she said. "More than 85% of the hospitals in those regions are non-profit compared to 71% nationally."
Meier said the two regions that scored the lowest and received C grades (East South Central and West South Central) have disproportionately more for-profit hospitals than other regions.
"More than one-quarter of the hospitals in East South Central and more than one-third in West South Central are for-profit, compared to only 16% of hospitals nationally," she said. "Rural hospitals are also less likely to provide palliative care and in East South Central, rural hospitals account for 13% of the hospitals with 50 or more beds compared to only 4% nationally."
