A House committee hears suggestions from policymakers and patient advocates to address surprise billing.
This article was first published on Tuesday, April 2, 2019 in MedPage Today.
By Joyce Frieden,News Editor, MedPage Today April 02, 2019
WASHINGTON -- Patients aren't the only ones who have problems with surprise billing issues, Rep. Phil Roe, MD (R-Tenn.), said Tuesday at a hearing on the topic.
"I've been negotiated out of healthcare networks," said Roe, an ob/gyn and a member of the House Education and Labor Subcommittee on Health, Employment, Labor, and Pensions. "There are no innocents in this, when you look at insurers, at hospitals; everybody's culpable here."
Roe also said he had been falsely listed in some cases as an in-network provider. "Many of those unscrupulous networks will use that to get people to sign up, because 'My doctor is in there' when they're really not, and you get a surprise bill."
Surprise billing refers to bills that patients receive for services that they thought were in-network but turned out not to be -- for example, a bill from an out-of-network anesthesiologist who is practicing at an in-network hospital.
"Despite people paying their premiums, doing their homework, and trying to work within the system, they are being left with unanticipated and sometimes financially devastating bills," said Frederick Isasi, JD, MPH executive director of Families USA, a left-leaning healthcare consumer organization here. "This is happening in part because hospitals, doctors, and insurers are washing their hands of the patient's interest."
States are looking at these issues, noted Jack Hoadley, PhD, research professor emeritus at Georgetown University here.
"Our research shows that 25 states have acted to protect consumers from surprise bills; nine offer what we consider to be comprehensive protection -- they apply in both emergency settings and in-hospital settings, they apply to HMOs, PPOs, and all [other] insurers, they hold consumers harmless from balance billing, and they adopt some kind of payment standard, such as an arbitration process."
However, state laws can't offer complete protection because large, self-insured employers in every state are exempt from state law by the federal Employee Retirement Income Security Act (ERISA).
"Although states are making progress, they are looking to the federal government to address [ERISA plans] they cannot regulate," said Hoadley. "In addition, state officials have noted federal law can help when a state resident receives care across the border in another state."
One impetus for surprise billing is the movement of hospitals to offload their requirements for staffing their emergency departments to third-party management companies, often without requiring the staffing of the department to fit within the networks that the hospital has agreed to, Isasi said. He gave the example of Nicole Briggs of Morrison, Colorado, who awoke one night with intense stomach pain and went to a freestanding ED; doctors there told her that she needed an appendectomy, so she went to a local hospital.
"She did her due diligence, confirmed repeatedly that the hospital and its providers were in-network," he said. "However, months later she received a surprise bill from the surgeon who, it ended up, was out of network. The bill to Nicole was $5,000."
Briggs tried negotiating with her insurer, to no avail. "Within 2 years, a collection agency representing the surgeon took her to court and won the full amount, including interest. As a result, a lien was placed on her home and the collection agency garnished her wages each month," Isasi continued.
"This is inexcusable behavior on the part of doctors, hospitals, and health insurers," he said. "They each know, or should know, that patients have no way of understanding the financial trap they just walked into. It is the providers and insurers, not the patients, who should bear the burden of settling on a fair payment."
Several witnesses at the hearing criticized providers who took advantage of surprise billing.
"Because volume doesn't depend on the prices set by providers, going out of network frees them to bill patients at any rate they choose," said Christen Young, JD, a fellow at the USC-Brookings Schaeffer Initiative on Health Policy here.
"Physician specialties who can bill out-of-network have extraordinarily high charges compared to other doctors." For instance, "for most physician types, median out-of-network charges are about double what Medicare pays for the same service, but for anesthesiologists and ED physicians, charges are about five times greater than the equivalent Medicare payment," Young said.
There are many providers who still go in-network, she added, but even then, "they appear to receive some of the highest in-network rates in the healthcare industry ... One way to understand the high in-network rates is these physician [specialties] exploit the fact that they could remain out-of-network to demand very high payment rates when they do go in-network."
Young had two suggestions to solve the problem: one would be to establish an amount that these doctors will be paid when they deliver care out-of-network. The price could be established directly or through arbitration, and in addition, "[lawmakers could] prohibit balance billing by the provider above this amount, and require that the insurer treat it as in-network. The goal is not to establish the exactly correct payment rate for the service, but rather to establish conditions that diminish the attractiveness of the out-of-network option, and leave these providers to go in-network or work with hospitals to get paid a fair rate for the service."
A second idea is to get these physicians out of the business of billing directly to patients and instead have them be paid by the hospital, she said.
Committee members all seemed to agree that surprise billing was a problem they would like to fix, although how to do it remained elusive. "I'm struck by the fact that we all seem to be wanting a solution to this problem, but the solutions I'm hearing don't sound really workable in the context of our present medical system, and that's where I struggle to understand how we're going to fix this," said Rep. Susan Wild (D-Pa.).
A Senate committee examines two proposed rules issued by CMS to make healthcare records more interoperable, including banning information blocking by health IT vendors or healthcare providers.
This article first appeared on Tuesday, March 26, 2019 inMedPage Today.
WASHINGTON -- The Trump administration should make its interoperability rules more clear and encourage increased use of technologies to improve patient matching in electronic health records, witnesses told a Senate committee Tuesday.
The Senate Health, Education, Labor & Pensions Committee hearing was aimed at discussing two proposed rules issued by the Centers for Medicare & Medicaid Services (CMS) as part of implementing the 21st Century Cures Act.
The rules address ways to make healthcare records more interoperable, including banning information blocking by health IT vendors or healthcare providers.
Committee chairman Lamar Alexander (R-Tenn.) pleaded in his opening statement for advice on enforcing these rules. "I also want to be aware of unintended consequences from these rules: Are we moving too fast?" he asked. "In 2015, I urged the Obama Administration to slow down the Meaningful Use program, which they did not do, and looking back, the results would have been better if it had."
Alexander also wondered whether the rules' standards for data elements were too rigid, and asked, "Is the door still open for bad actors to game the system and continue to information block?"
"I want to ensure these rules will make the problem of information blocking better, not worse," he said.
Christopher Rehm, MD, chief medical informatics officer at Lifepoint Health, a healthcare provider based in Brentwood, Tennessee, noted that one proposed rule "would require hospitals to send electronic notifications when a patient was admitted, discharged, or transferred" as part of the conditions of participation in Medicare and Medicaid.
"In order to comply with conditions of participation, providers must clearly understand the requirement and the objective compliance measure. This proposal lacks both of those elements, which is concerning given the tremendous penalties hospitals face for failing to comply with conditions of participation," he said.
Ben Moscovitch, Project Director for Health Information Technology at The Pew Charitable Trusts here, noted that "interoperability also requires health organizations to know they're communicating about the same person, [what's called] patient matching. When data are exchanged, records may not be matched up to half the time."
A studythat Pew did with Indiana University in Indianapolis "revealed that the use of the Postal Service standard for addresses would increase match rates by approximately 3%, a significant improvement," he continued. "One technology developer said it would help their system match an additional tens of thousands of records per day."
"To improve matching, the ONC [Office of the National Coordinator for Health Information Technology] should specify use of the Postal Service standard for addresses and include other routinely collected elements like email addresses, which is already in half of [the] records but not used for matching," Moscovitch said.
Alexander asked the witnesses about data's role in interoperability, specifically, the data collected by medical devices. "The CMS rule focuses on getting patients' claims data, and claims today, for the millions of patients with implants, lack key information -- and that's the device identifier of the implant they have in their body," said Moscovitch. "CMS can close that gap by adding device identifiers to claims."
Mary Grealy, JD, president of the Healthcare Leadership Council, a broad industry coalition, focused on the rule's privacy aspects. "I would note that both proposed rules include changes to how patient health information is used and shared," she said. "These rules incorporate new, innovative products such as third party applications not currently covered by HIPAA [the Health Insurance Portability and Accountability Act]."
"We need to ensure a thoughtful approach on how entities currently subject to HIPAA share information with these new entities to ensure safeguarding of sensitive and valuable personal health information," said Grealy. "Any future legislation or rulemaking that addresses the electronic flow of identifiable health information should engender the same trust that HIPAA has done for these past 20 years."
Grealy also made another request: "Given the significant impact of these rules ... we're requesting ONC and CMS grant a 30-day extension of the comment period for the proposed rules." Alexander seemed sympathetic to that idea. "Your concern -- and it's a concern we share -- is allowing [time] for the implementation of standards," he said. "I think we'll hear from everyone that they'll want a bit more time."
Sen. Mitt Romney (R-Utah) wanted to know the practical effect of making healthcare information more interoperable. "Is the data being used to allow the patient to inform their life choices, so if a record indicates someone looks like they're at risk for developing diabetes, is this flagged by someone; are they seeing that?" he asked. "Are they given instruction on what type of foods they should be eating or what things they should be avoiding?"
Lucia Savage, JD, chief privacy and regulatory officer at Omada Health in San Francisco, said that one diabetes prevention program her company offers through the health plans it contracts with allows patients to use their smartphones to see their weight record, and food intake at any point in order to help them meet their health goals. "So in fact, when you can figure out the business relationship and the data relationships, that magic alchemy occurs," she said.
Sen. Patty Murray (D-Wash.), the committee's ranking member, emphasized the importance of focusing on patients' needs. "As we continue to improve our health IT system, we need to make sure health information is provided in a way that works for patients as well," she said, citing the example of a woman who took a pregnancy test but got her results back in the form of a hormone level, which wasn't helpful to her.
"Our objective should be to make sure technology companies are putting patients in the driver's seat, not the other way around."
PHILADELPHIA -- Medical students have a little secret: many of them don't think very highly of the training they're getting, said a professor at the soon-to-openKaiser Permanente School of Medicine.
"A major contributor to [medical student] burnout -- but also a subtler contributor -- is that students are much more aware that what they're being trained to do is not particularly helpful," said Paul Chung, MD, speaking here at the Population Health Colloquiumsponsored by Thomas Jefferson University.
"They are finding less and less obvious intrinsic justification for becoming a doctor, because when they look out at the health of the population they don't see it getting better," said Chung, who is professor and chair of Health Systems Science at Kaiser's new medical school in Pasadena, California. "So part of [our effort] is to help students recapture a sense of purpose and lead a purpose-driven life."
Three Unusual Schools
Chung spoke during a panel discussion featuring officials from three unique medical schools. At Kaiser -- slated to open in August 2020 -- the curriculum is based on "flipped" classrooms featuring case-based small group and team-based learning; the emphasis will be on preparing students for careers in primary care and specialty medicine in diverse settings. There will also be longitudinal experiences with patients -- and those don't involve just shadowing physicians -- starting from the first year at the school, which will begin with 48 students in each class.
Those aren't the only unusual features of the school, according to Chung: one entire floor of the building will be dedicated to student wellness, and patient data will be incorporated into classwork routinely. "There will be opportunities for population-level exercises ... so we have a good sense that students will be swimming in this stuff, which I think is actually wonderful. It's one of the things that excites me most about the school." One other thing: the first five cohorts at the school will be able to attend tuition-free.
And, just in case anyone was wondering, the school "is not a training ground for Kaiser Permanente," Chung said. "Kaiser Permanente has 22,000 physicians, and 48 students means nothing to them ... What's the point of keeping it all internal? There are so many other kinds of health systems our students need exposure to; the diversity of U.S. healthcare is amazing and impressive -- and troubling, all at the same time."
Another school still in the works is the University of Houston College of Medicine, where the goal is to have 50% of the students coming from underrepresented minorities, and also to have 50% enter primary care or much-needed specialties such as general surgery and psychiatry, explained Stephen Spann, MD, MBA, the school's founding dean and vice president for medical affairs. Students will provide care to the Houston community through interprofessional teams. "There is a big focus on interprofessional care ... and finding ways to engage with and partner with communities, particularly those with major health disparities."
As part of their experience, "students will spend half a day every week for the entire 4 years of medical school as part of a primary care team, either in a federally qualified health center or a practice providing value-based care," Spann said. "They will also spend one half-day a month as part of an interprofessional student team who will each be assigned a family with complex medical and social problems to follow that family monthly over 4 years." Like Kaiser, the school is scheduled to start its first class in the summer of 2020.
"We hope that our graduates will have a deep understanding of the social determinants of health, and of health disparities," said Spann. "Our four departments are medical sciences, clinical sciences, behavioral and social sciences, and health systems and population health sciences: there is a lot of emphasis on population and health sciences."
Improving Care in the Community
Steve Scheinman, MD, president and dean of the Geisinger Commonwealth School of Medicine, in Scranton, Pennsylvania, said one of the unusual things about his 10-year-old institution is that "we were founded by the community, not by a university or a medical system ... The community wanted to improve care in the community and replenish the [healthcare] workforce. We were the first school to implement a longitudinal integrated clerkship for the entire class."
Scheinman said his school, along with Kaiser's and Houston's, "are all moving away from the model where somebody stands at a podium and talks at you." He said his schools weaves together clinical and basic science across the 4 years, with emphasis on subjects such as population health, genomics, social determinants, value-based care, wellness, health economics, and health policy.
The type of student the three schools are recruiting is different from more traditional schools, the speakers said. "We're not looking for a class full of people from 'The Big Bang Theory,'" Scheinman said, referring to the geek-centric TV show. "We want people who can make good eye contact and have a demonstrated commitment to service that goes back more than just a couple of years before they applied to medical school. We require 100 hours of community service and over half of our students do well more than that. I think we've gotten good at telling applicants who have what we're looking for."
At Kaiser, "we're placing a premium on a commitment to social justice," Chung said. "We want students who are humble and curious [so they want to] acknowledge [the] system we're in and work to change it ... Those are the students that we're looking for. [We want] an intentionally diverse community of students representative of the community that medical students are going to have to practice in."
Houston's ideal student is similar, said Spann. "We're looking for students that have done something between college and medical school, who have evidence of grit and resilience," he said, noting that the standard grade point averages and medical school entrance exam "will set a floor but not be the ultimate factor" in admissions decisions.
Changing the Admissions Process
Session moderator Billy Oglesby, PhD, associate dean for academic and student affairs at the Jefferson College of Population Health, noted that "some schools, like ours, are threatening to eliminate the Medical College Admission Test as a requirement for admission. We are experimenting with a new initiative where intentionally seeking undergraduate students with no experience in the sciences ... who would come to us a few months ahead of time to get the science pieces."
Scheinman said Geisinger actually addresses that issue in its materials, although students do have to demonstrate that they're capable of doing well in the sciences. "Students know we're looking for somebody committed to service, and academics are a small part of what we're looking for," he said.
Scheinman added that Mount Sinai's medical school in New York City is a model in this area because it actually reserves 25 seats in each medical school class for humanities majors. In spite of these efforts, however, "premed students are gun-shy of majoring in anything but biology or chemistry because they're afraid they won't get in."
As for getting faculty to teach at these types of schools, that doesn't appear to be a problem. "We put out a call for applicants for clinical faculty leadership positions," said Chung. "That was a mistake because hundreds and hundreds of people were applying. [But] it's incredibly gratifying to know there are people who want to help and who believe in this mission."
Study examined incidence of immune-related adverse events after flu vaccination.
This article first appeared on Tuesday, March 19, 2019 onMedPage Today.
By Molly Walker, Staff Writer, MedPage Today
For cancer patients receiving treatment with immune checkpoint inhibitors for cancer, there was no increase in incidence of immune-related adverse events after receiving the flu shot, researchers found.
No increase in incidence or severity of immune-related adverse events occurred in these advanced stage cancer patients, mostly with lung cancer and melanoma, within 2 months after receiving the inactivated influenza vaccine (IIV), reported Mini Kamboj, MD, of Memorial Sloan-Kettering Cancer Center in New York City, and colleagues.
Importantly, there were no fatal adverse events (such as encephalitis or myocarditis) among this population, and the portion of patients who developed immune-related adverse events was lower than previous reports, the authors wrote in Clinical Infectious Diseases.
They noted that patients with underlying cancer are at higher risk for influenza-related complications, but a recent study from Switzerland found a 52% incidence of immune-related adverse events among vaccinated patients on PD-1 inhibitors, which was characterized as "unexpectedly high."
"If [the] flu vaccine poses an exaggerated risk of [immune-related adverse events] in patients on [immune checkpoint inhibitors], larger studies are needed to clarify a possible association," the authors wrote, adding that "many clinicians defer seasonal influenza vaccination" for patients on this therapy, despite the CDC Advisory Committee on Immunization Practices' (ACIP) recommendations for annual influenza vaccination.
Researchers examined data from patients with advanced cancer at a tertiary care center in New York City who received the influenza vaccine within 65 days of therapy with immune checkpoint inhibitors. These agents included CTLA4 inhibitor ipilimumab (Yervoy), and anti PD-1 agents, pembrolizumab (Keytruda) or nivolumab (Opdivo).
Types of influenza vaccine included standard and high dose, as well as trivalent and quadrivalent, but adjuvanted vaccines were not used. Immune-related adverse events were classified according to the Common Terminology Criteria for Adverse Events five-point grading system. Data were collected for the 2014-2015, 2015-2016, and 2016-2017 influenza seasons.
Overall, 370 patients received a flu shot within 65 days of receiving therapy with immune checkpoint inhibitors. Almost half of examined patients had advanced stage lung cancer, while almost 20% had melanoma. About 60% of patients received therapy with anti PD-1 agents only, while about 20% received combination treatment (ipilimumab plus nivolumab).
There were 75 patients who experienced immune-related adverse events, the most common being grade 3 (36%) and grade 2 (53%). There were no grade 5 adverse events (i.e., those leading to death). The authors found that a little over a quarter of immune-related adverse events were endocrine, 25% were pneumonitis, and colitis or transaminitis were 13% and 12%, respectively. A little under half were managed by steroid or immunosuppressive treatment, while 35% were managed with treatment interruption.
A higher portion of immune-related adverse events occurred among patients treated with ipilimumab plus nivolumab (30%), though the authors noted the incidence was lower than other published reports of 50%-55%. The overall rate of immune-related adverse events for patients on anti PD-1 therapies was 17%, they said.
When comparing this to prior trials, the authors noted the 17% overall rate of immune-related adverse events and the 6.6% rate of grade 3/4 adverse events was "comparable or better than published studies in lung cancer with grade 3/4 IRAE rates typically <20%."
There were only two cases of laboratory-confirmed influenza during the study period, both during the 2016-2017 season, and both influenza A (H3N2), though 36 patients presented with 46 episodes of influenza-like illness >2 weeks after vaccination. This incidence of 3.5% for confirmed influenza among the study cohort was lower than the 10.7% institution-wide incidence, the authors said, and no post-vaccination events or "exaggerated local site reactions" related to influenza vaccine were observed in the study cohort.
Limitations to the data include its retrospective nature, and that the authors were unable to compare risk of immune-related adverse events in vaccinated versus unvaccinated patients, which could introduce both selection bias and "healthy user bias." Poor clinical documentation may not have captured all immune-related adverse events in the cohort, the authors noted.
The study was partly funded by the NIH/NCI Cancer Center.
Kamboj disclosed no relevant relationships with industry. Co-authors disclosed support from Lippincott, Foundation Medicine, Bristol-Myers Squibb, Merck, Aduro, Array BioPharma, Novartis, Incyte, NewLink Genetics, Adaptive biotech, Advaxis, Amgen, Apricity, Array BioPharma, Ascentage Pharma, Astellas, Bayer, BeiGene, Celgene, Chugai, Elucida, Eli Lilly, F Star, Genentech, Janssen, Kleo Pharma, Linnaeus, MedImmune, Neon Therapeutics, Ono Pharmaceuticals, Polaris Pharma, Polynoma, PsiOxus, PureTech, Recepta, Sellas Life, Serametrix, Surface Oncology, Syndax and Esanex. One co-author disclosed a patent Xenogeneic DNA Vaccines with royalties paid to Merial, and several other patents.
Healthcare organizations cannot afford to ignore consumers in 2019, as a number of major trends shape the future of care delivery (and a number of other trends warrant more critical thinking).
This article was first published March 18, 2019, by MedPage Today.
PHILADELPHIA — The consumer will be where it's at for population health in 2019, David Nash, MD, MBA, said here Monday at a Population Health Colloquium sponsored by Thomas Jefferson University.
"Whatever business model empowers the consumer, wherever she is," including at home, will spell success, according to Nash, who is dean of Jefferson's School of Population Health. "That's where population health must go."
Nash noted that back in 1990, Kodak, Sears, and General Electric were the most important companies in the Dow Jones Industrial Average; all those companies have disappeared or almost disappeared today.
"If we ignore the consumer, it will be at our peril," Nash said, citing home healthcare, telehealth, and the use of wearables among the trends to watch in the coming year.
Nash, who is a columnist for MedPage Today, also cited these other trends to watch:
The growth of Medicare Advantage and managed Medicaid. "These are two programs that are working," he said. "They're working because they deliver value -- high-quality care with fewer errors -- and they follow our mantra: no outcome, no income."
Tax reform. "Whatever your politics are [on this issue], park it at the door," he said. "The sugar high is over, and now we're in a carbohydrate coma. We've got the biggest deficits in American history; if we continue to spend money we don't have, what will that do to healthcare? I think it will bite us in the butt when [it] comes to the Medicare trust fund."
Precision medicine and population health. "[There is a notion] that precision medicine and population health are actually kissing cousins," said Nash. "They are inexorably linked."
Continued deal-making. The CVS/Aetna, UnitedHealth Group/DaVita, and Humana's deals with Kindred Healthcare and Curo Health Services are just some of the more recent examples, he said. And he noted, the healthcare company formed by Amazon, Berkshire Hathaway, and JPMorgan Chase now has a name: Haven. "It's a place where they're going to figure it all out and they'll let us know when they do."
Continued delivery system consolidation. "Big surprise there," he said sarcastically. "The real question is will they deliver value? Will they deliver synergies?" Nash noted that his own institution is a good example of this trend, having gone from one or two hospitals 5 years ago to 16 today with another two in the works.
Population health technology. "The gravy train of public money into this sector will [soon] be over; now the real challenge is for the IT [information technology] systems on top of those legacy companies; can they create the patient registry information and close the feedback loop, and give doctors, nurses, and pharmacists the information they need to improve care?"
The rise of "population health intelligence." "That's our term for predictive analytics, big data, artificial intelligence, and augmented intelligence ... It says we don't want to create software writers -- we want doctors, nurses, pharmacists, and others who can glean the usable information from the terabyte of information coming our way, to [know how to interpret it]."
Pharmaceutical industry disruption. "This is really under the thumb of consumers ... It's all about price, price, price," Nash said. "We've got to find a way to rationalize the pricing system. If we don't, we're going to end up with price controls, and as everybody in this room with a background in this area knows, those don't work either."
More venture capital money. Nash described his recent experience at the JPMorgan Chase annual healthcare conference, where people were paying $1,000 a night for hotel rooms that would normally cost $250, and being charged $20 just to sit in the lobby of one hotel. "What was going on there? It was more private-sector venture money coming into our industry than ever before. [These investors] know that when there's $1 trillion of waste in an industry, it's ripe for disruption."
Workforce development. This is needed for the entire industry, said Nash. "More folks know a lot more [now] about population health, quality measurement and management, Lean 6 Sigma, and improving processes and reducing waste. The only way we're going to reduce that waste of $1 trillion is to have the right kind of workforce ready to go."
Lawton Burns, PhD, MBA, director of the Wharton Center of Health Management and Economics at the University of Pennsylvania here, urged the audience to look critically at some of these possible trends.
"You need to look for evidence for everything you hear," said Burns, who coauthored an article with his colleague Mark Pauly, PhD, about the need to question some of the commonly accepted principles of the healthcare business.
Some of the ideas that merit more critical thinking, said Burns and Pauly, are as follows:
Economies of scale
Synergy
Consolidation
Big data
Platforms
One-stop shops
Disruption
Killer apps
Consumer engagement
"I'm not saying there's anything wrong with those 10 things, but we ought to seriously consider" whether they're real trends, Burns said. As for moving "from volume to value" in healthcare reimbursement, that idea "is more aspiration than reality" at this point, he said. "This is a slow-moving train."
Burns also questioned the motives behind some recent healthcare consolidations. In reality, "most providers are positioning themselves to dominate local markets and stick it to the payers — let's be honest," he said. "You have to think when you hear about providers doing a merger, you have to think what's the public rationale and what's the private rationale? The private one is [often] more sinister than you realize."
WASHINGTON -- All the healthcare data being collected on patients won't do any good unless it's funneled to doctors and other clinicians who can act on it, Dan Mendelson, founder of consulting firm Avalere Health, told health insurance executives gathered here.
"We have the [patient] data; we can look at cohorts, do predictive analytics ... to predict where patients are likely to get in trouble and how to engage [them] in a cost-effective way," Mendelson said Wednesday at a health policy conference sponsored by America's Health Insurance Plans. "But it's not enough to have the information; you have to have a connection to physicians who are actually touching the patients ... That targeted intervention is really necessary to reap the benefits of the data. Data without intervention is a science experiment."
A relationship with physicians "is very, very important and underlies a lot of the better work that's being done right now ... it's about interaction, where the clinician -- physician, nurse, or phone operator calling the patient for a low-cost intervention -- is engaging in a way that improves patient health."
Having that link with doctors is one reason "why you see plans so engaged in the healthcare delivery system -- buying delivery systems, partnering with them, contracting with them, and the like," he said. "It's also why you see so much interest in value-based purchasing. When you bring value into the equation and compensate your providers ... that's where you can have that targeted intervention, achieve cost savings, and improve patient care."
Payers have become increasingly interested in value-based purchasing contracts, especially for cost-saving reasons, Mendelson said, citing a survey his firm conducted which found that 74% of respondents listed cost savings as an advantage with value-based contracts. Other advantages lagged well behind -- improved patient outcomes was cited by 44%, followed by the contracts' assurance that the product performs as advertised (41%), and improved relations between payers and manufacturers (24%).
But not everyone understands the need for cost savings, he added. "I've had many conversations with pharmaceutical executives where they have an idea for a value-based [purchasing] program, but it won't save the plan any money." And yet, there are plenty of places where a value-based contract could produce a win for both sides -- "cholesterol management is a great one; reducing infections in the hospital [is another]," Mendelson said.
In the meantime, technology companies are investing in healthcare, but so far without much effect, he continued. "I've lived through the last 25 years of seeing great comments from different large IT [information technology] companies saying they're going to revolutionize healthcare, and it hasn't happened. [Instead], a lot of the innovation I see is coming from really small companies with tangible and practical solutions."
Mendelson said he recently looked at a company that had a great compliance module for Crohn's disease and colitis. "They improved the quality of care, reduced exacerbations, improved compliance with medication, and saved the plan a significant amount of money. They're selling this tool and it's very attractive. It was developed by a group of Crohn's physicians -- not Amazon and not Google; it's just a practical solution that works. And I think it's really what the plans need right now."
One big tech investment that Mendelson said he found interesting wasGoogle's investment in Oscar, a small health insurer that's betting on using big data to disrupt the industry. "[These large] companies are getting into the consumer revenue stream, and health plans are ultimately the consumer revenue stream in healthcare," he said. "You think about Apple and Google and Amazon with market capitalizations of over $1 trillion and health plans don't have that much value, even the largest ones. The idea that a tech company will start to make an acquisition in plan space -- that I find interesting."
Investing in improvements in patients' social determinants of health -- non-medical areas such as housing, transportation, and food insecurity -- is another potentially big area, he said. "It's a major opportunity for plans to position around this and make it real. The more plans can address social determinants of health, [the more] plans can become truly organizations dedicated to health as opposed to organizations dedicated to incurring medical costs, and that to me is a bright future and a bright way to position the industry."
Democrats rip the Trump administration for 'taking a hatchet to every part of the healthcare system,' undermining the ACA, slashing spending for Medicare, and pushing work requirements on Medicaid.
This article was first published on Wednesday, March 13 in MedPage Today.
By Shannon Firth, Washington Correspondent, MedPage Today
WASHINGTON -- Health and Human Services Secretary Alex Azar fielded sharp criticism from Democrats over the Trump administration's fiscal year 2020 budget proposal during a House Energy & Commerce Health Subcommittee hearing this week.
"The Trump administration has taken a hatchet to every part of the healthcare system, undermining the Affordable Care Act, proposing a fundamental restructure of Medicaid, and slashing Medicare," Chairwoman Anna Eshoo (D-Calif.) said in her opening remarks at Tuesday's hearing. "This budget proposes to continue that sabotage."
Rep. Frank Pallone (D-N.J.), chairman of the full committee, said the "sham" of a budget proposal, along with efforts to restrict contraception access and squeeze Medicaid funding, amounted to a "devastating record for an agency whose mission is to advance the health and well-being of all Americans."
Republicans for the most part praised the secretary's work, though a few raised questions over the administration's efforts on containing drug prices.
Lead Republican for the subcommittee, Rep. Michael Burgess, MD (R-Texas), called Azar the "most transparent and accessible" HHS secretary he's ever known. Burgess went on to commend the agency's work in expanding programs aimed at preventing or treating opioid abuse, or for helping those in recovery, and also highlighted proposals to curb childhood cancer and eliminate HIV.
The Trump administration's $4.7 trillion budget includes $1.29 trillion for HHS. "Program level" allocations include $6.1 billion for the FDA, $12 billion for the CDC, $34.4 billion for the National Institutes of Health, and $6.3 billion for the Centers for Medicare and Medicaid Services. Each of these, with the exception of the FDA, is less than what was pledged for fiscal year 2019.
Overhauling Medicaid
One of the most radical provisions in the proposal centers around mandating work requirements for Medicaid recipients.
Rep. Joe Kennedy (D-Mass.) noted that in less than a year, nearly 20,000 Americans lost healthcare coverage in Arkansas -- the first state to implement work requirements. At the same time, the state's unemployment rate has increased.
Azar said the agency did not have data yet on why people had dropped off the program. It's possible some Medicaid recipients found work and received coverage from their employer, he said. "We just don't know."
At this, Kennedy pounced: "So your agency's budget proposes implementing mandatory work requirements for Medicaid beneficiaries, not knowing what the impact will be?" he said. "You want to extend that to every single state. What's the logic in that?"
Azar underscored that only "able-bodied adults" receiving "free healthcare" on the backs of taxpayers would be required to work or take part in community-engagement activities, including job-training.
"Can you point me to one study that says work requirements make people healthier?" Kennedy asked.
Rep. G.K. Butterfield (D-N.C.) also zeroed in on changes to the Medicaid program in the budget proposal, including a transformation to a per-capita cap block grant and cuts of $1.4 trillion.
He noted that one in five Americans rely on the program. "Just wait for the firestorm that this will create," Butterfield said.
Transparency at HHS
Pallone questioned Azar about his inaction in sharing documents related to the agency's involvement in the Texas v. The United States case, which aims to repeal the ACA on grounds that it's unconstitutional. (A federal judge ruled in December that the law was unconstitutional, but soon afterwards, agreed to stay all proceedings while the case is appealed, according to Health Affairs.)
Pallone said he hadn't received a single document from the secretary in 9 months.
Azar said he aims to send him as much material as he can "as soon as possible," but he added that laws related to executive privilege also need to be reviewed.
A second round of questioning involved another oversight issue, that of family separations at the border, after Azar declined an invitation to be a witness for a House hearing in February (the agency sent a career public health staffer formerly at the Office of Refugee Resettlement instead).
Another Perspective
Rep. Greg Walden (R-Ore.), ranking member for the full committee, lauded the 2020 budget proposal as a plan that promotes "fiscal responsibility" and maintained protections for pre-existing conditions.
He noted that it "strengthened" the Medicare program by extending its solvency for 8 more years, tackled overpayment to post-acute care providers, and targeting the drug companies.
Democrats, meanwhile, argued that by promoting short-term limited duration plans, the proposal does not protect those with pre-existing conditions. The proposal also resurrects the Graham-Cassidy ACA repeal bill first offered in 2017, and cuts $460 billion from Medicare, Eshoo noted.
Amid his praise, Walden did express some concern over HHS making changes that would affect "protected classes."
He said patients are not happy about new step therapy requirements that force them to re-try drugs they know will not work for them, before they can access more effective options.
Azar said he was aware of such concerns and would take such feedback "very seriously."
Rep. Gus Bilirakis (R-Fla.) also questioned the secretary about access to prescription drugs through Medicare.
He asked whether the government could negotiate better deals for the Medicare program than the plans do.
Azar responded that the only way to negotiate better deals would be if the government restricted the formulary and told seniors which drugs they could and couldn't get. "You may have Humira; you may not have Enbrel," he said as an example.
Given the pushback that's already been seen around step therapy, Azar suggested that such a tactic might not be very popular.
After adjusting for proximity to a home healthcare agency versus an SNF, the difference was a 5.6-percentage point greater rate of readmission at 30 days with discharge home.
This article was first published on Monday, March 11 in MedPage Today.
By Ashley Lyles, Staff Writer, MedPage Today
Discharge to home healthcare may have yielded more readmissions than discharge to a skilled nursing facility (SNF) but was associated with similar functional and survival outcomes, a retrospective Medicare cohort study found.
Heading home after the hospital was associated with a 15.8% readmission rate at 30 days compared with 17.8% with SNF patients, which persisted after adjustment for initial hospitalization type and comorbidities (1.6 percentage points, P<.001).
However, after adjusting for the association with proximity to a home healthcare agency versus an SNF, the difference was a 5.6-percentage point greater rate of readmission at 30 days with discharge home (P=0.02), reported Rachel Werner, MD, PhD, of the University of Pennsylvania in Philadelphia, and colleagues in JAMA Internal Medicine.
There were no significant differences in improvement in functional status (absolute difference 1.9%, P=0.71) or 30-day mortality (absolute difference 2.0%, P =0.12).
Among patients discharged to home, Medicare payments were significantly lower than those of patients discharged to an SNF (absolute difference $5,384, P<0.001), and so were total payments within the initial 60 days following admission (absolute difference $4,514, P<0.001).
The use of postacute care has increased considerably over the last few decades.
"There is a tradeoff between how much we spend on health care and what we get out of it. While patients at SNFs were less likely to be readmitted to the hospital, caring for patients in SNFs is expensive. There are likely alternative approaches such as providing more intensive treatment at home, that could balance these tradeoffs," Werner told MedPage Today.
Prior investigations yielded inconsistent results and have been small and assessed few conditions, and the majority inadequately controlled for the considerable differences in patient characteristics across settings, the study authors noted.
"Combine the ease and standardization of transferring a patient to another medical facility with the administrative complexity and effort required to coordinate simultaneous delivery of medications, equipment, and multiple staff to a Medicare beneficiary's home and it becomes clear why there is a structural preference for discharge to an SNF," wrote Vincent Mor, PhD, of Brown University in Providence, Rhode Island, in an accompanying editorial.
Werner's group assessed over 17 million hospitalizations using Medicare claims information collected from SNF and short-term acute care hospitals in the U.S. Participants had an average age of 80.5 years and were 62.2% female. There were over 6.5 million patients in the home healthcare group and over 10.5 million patients in the SNF group.
Patients were included if they were discharged from a hospital to SNF or from a hospital to home with home agency care. Exclusion criteria included: being discharged to hospice, having a hospital length of stay under 3 days, being in a nursing home in the 30 days leading up to hospitalization, and being younger than 66 years.
The researchers acknowledged the limitations of their study as the findings are only applicable to Medicare beneficiaries. "While our instrumental variable approach provides a higher level of evidence than most prior studies of how outcomes differ between home and SNF settings, this approach may not fully address unobserved confounding."
"These results warrant further investigation of these postacute care settings and others given the common use and high costs associated with postacute care," the researchers concluded.
Werner disclosed relationships with the Agency for Healthcare Research and Quality (AHRQ), the National Institute on Aging (NIA), CarePort Health, and National Quality.
Mor disclosed relationships with HCR ManorCare, naviHealth, Sanofi, Seqirus, and National Institutes of Health.
Complication rates are lower for white patients when compared with black patients.
This story was first published Thursday, March 7, 2019, byMedPage Today.
By Kristen Monaco, Staff Writer
After bariatric surgery, black patients may face worse outcomes than white patients, according to a new study.
In a retrospective analysis of over 7,100 bariatric surgery patients from Michigan, black patients had a significantly higher chance of having complications compared with white patients (adjusted OR 1.33, 95% CI 1.17-1.51, P=0.02), reported Jonathan Finks, MD, of the University of Michigan Health Systems in Ann Arbor, and colleagues.
However, serious complications (2.5% for blacks vs 1.9% for whites) and rates of mortality (0.10% vs 0.10%) were similar among black and white patients, the researchers wrote online inJAMA Surgery.
As for healthcare utilization measures, black patients had significantly higher rates of the following outcomes versus white patients:
Readmissions: 5.8% (black patients) vs 3.5% (white patients) (aOR 1.73, 95% CI 1.47-2.03)
Emergency department visits: 11.6% vs 7.6% (aOR 1.60, 95% CI 1.43-1.79)
Longer length of hospital stay: mean 2.2 days vs 1.9 days
A year after surgery, black patients also reported significantly less weight loss overall -- an average of 32.0 kg (70.5 lb) compared with an average loss of 38.3 kg (84.4 lb) for white patients. Black patients had less weight loss after a year for all three bariatric procedures included in the study: Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding. A higher proportion of black patients underwent gastric bypass or sleeve gastrectomy, while more white patients opted for the adjustable gastric band.
Interestingly, the researchers said, the remission rates for comorbidities varied between black and white patients: Although the remission rates of hypertension were significantly lower for black patients (40.0% vs 56.0%), black patients had higher rates of remission for gastroesophageal reflux disease (78.6% vs 75.4%) and sleep apnea (62.6% vs 56.1%). However, remission rates for diabetes with or without insulin dependence and hyperlipidemia did not differ between races.
"We found that both adverse events and resource utilization declined across the board with rising income status, and racial differences were most pronounced at the lower income levels," Finks and co-authors explained, adding that "other potential contributing factors include unmeasured differences in the severity of underlying comorbid diseases and/or functional status between black and white patients."
The team also suggested that racial difference in pain threshold and tolerance may account for some of the variability seen in length of stay and emergency department visits.
"Finally, racial differences in the quality of patient-clinician communication may also contribute to higher resource use by black patients in the perioperative period," Finks and colleagues speculated.
One year after bariatric surgery, the majority of both patient groups reported being satisfied with their surgery, although black patients were slightly less likely to indicate that compared with white patients (78.4% vs 84.2%). Similarly, although the large majority of both patient races reported good or very good quality of life a year after surgery, black patients were slightly less likely to report this (87.2% vs 90.4%).
In an invited commentary, Brian Hodgens, MD, and Kenric M. Murayama, MD, both of the University of Hawaii at Manoa in Honolulu, pointed out that patient-reported satisfaction and quality-of-life differences were relatively small between the groups. This then also brings up another topic for discussion, Hodgens and Murayama said: "cultural attitudes toward medicine and weight loss."
"Interestingly, in this study, the authors report that 'black patients were more likely than white patients to report good or very good quality of life at baseline ... but were less likely to do so at 1 year after surgery.' This difference in perceptions of obesity by black patients may lead to pursuing treatment later and possibly not as enthusiastically," Hodgens and Murayama explained.
The commentators said that until future research on this topic is conducted, bariatric surgeons can use the study to help manage individual patient expectations after surgery.
The study was funded by Blue Cross Blue Shield Michigan/Blue Care Network. Several study authors reported relationships with the Blue Cross Blue Shield Michigan/Blue Care Network.
Commentator Murayama reported a financial relationship with Medtronic.
If one person's choices on vaccines threaten other people's health, whose liberty is infringed?
This story was first published Tuesday, March 5, 2019, byMedPage Today.
By Shannon Firth, Washington Correspondent, MedPage Today
WASHINGTON -- Two Republican senators, both physicians, clashed Tuesday over whether the government should make vaccinations mandatory.
When Sen. (and ophthalmologist) Rand Paul, MD (R-Ky.), known for his libertarian views, said some vaccine mandates had "run amok," that drew the attention of Sen. (and gastroenterologist) Bill Cassidy, MD (R-La.).
"If you are such a believer in liberty that you do not wish to be vaccinated, then there should be a consequence and that is that you cannot infect other people," Cassidy said in defending school vaccination requirements.
Senators on the Health, Education, Labor, and Pensions (HELP) Committee met Tuesday to gain insight from stakeholders regarding what Congress can do to boost vaccination rates and reduce "vaccine hesitancy."
Measles, as witnesses and senators testified, was thought to have been eradicated in the U.S. in 2000.
Six measles outbreaks are underway now in the U.S., noted Washington state's health secretary, John Wiesman, DrPH, MPH, in written testimony.
"[O]ne in Washington, three in New York, one in Texas and one in Illinois," Wiesman noted. "The current outbreak is larger and infecting people faster than those in recent history."
Last year, there were 17 outbreaks nationwide, primarily concentrated in three states, according to the CDC, The Washington Post reported.
The problem, said HELP Committee Chair Lamar Alexander (R-Tenn.), is the "pockets" in the U.S. where vaccination rates have fallen.
While most senators agreed on the need for vaccination, Paul disputed the need to make it mandatory.
He noted that, in the past, a government-mandated vaccine for rotavirus was reversed when it was discovered that the vaccine caused intestinal blockages in children. Paul also pointed out that flu vaccines are sometimes "completely wrong" when scientists choose the wrong strain of vaccine.
"[I]t is wrong to say that there are no risk to vaccines," he said, noting that the government's Vaccine Injury Compensation program has paid $4 billion since 1988.
And still, Paul said, no informed consent is required for a vaccine.
Paul also appeared ambivalent over concerns about individuals who choose not to be immunized for non-medical reasons, spreading diseases to people with compromised immune systems.
"There doesn't seem to be enough evidence of this happening, to be reported as a statistic, but it could happen," he said.
"I'm not here to say don't vaccinate your kids. If this hearing is for persuasion, I'm all for persuasion. I vaccinated myself, I vaccinated my kids. For myself and my children, I believe that the benefits of vaccine greatly outweigh the risk, but I still do not favor giving up on liberty for a false sense of security," Paul concluded, garnering applause from anti-vaccine advocates in the room.
Choosing his words carefully, Cassidy said he'd like to "give some color to what Senator Paul said."
He pointed out that there currently is a federal statute requiring that vaccine information statements be shared with patients, and that most states "typically do require informed consent." He noted that in years when scientists choose the wrong strain of flu vaccine, "there is a cross benefit that will decrease the severity."
And Cassidy stressed the matter of "herd immunity" to counter Paul's' skepticism, by noting that hospitals often require employees to be immunized.
"[I]f the nurse's aide is not immunized she can be a 'Typhoid Mary,' if you will, bringing disease to many who are immunocompromised," Cassidy said.
"In terms of a requirement," Cassidy continued, "the requirement is just that you cannot enter school unless you're vaccinated. ... If you believe in liberty, that's fine, don't get immunized but I don't think you need to necessarily expose others to disease."
Cassidy noted and confirmed with one of the witnesses that in Washington state, several years ago, an immunocompromised child with cancer died after another child brought measles to school.
Witnesses were asked what more Congress can do to prevent future outbreaks of diseases for which there are vaccines.
Sen. Tammy Baldwin (D-Wis.) asked specifically how Congress can help state health departments in particular.
Wiesman noted that resources for prevention at all levels -- state, local, tribal, and territorial -- have been declining. He recalled a few months ago being on a call with CDC staff who encouraged a "proactive vaccination campaign" targeting homeless individuals and injection drug users.
"I asked my staff, 'What would a plan look like?'" he said. "It would probably cost us $5 million dollars. I don't have those resources. I don't have the staff. ... That's very, very concerning to me."
At the same hearing, a now-famous high school student from Norwalk, Ohio, explained why he defied his mother, and chose to get immunized in December 2018, once he was of legal age to do so. His story was already well known thanks to national media coverage in the weeks leading up to Tuesday's hearing.
Ethan Lindenberger said his decision was based out of concern for his own health and safety as well as for others. Throughout his life, he grew up understanding his mother's belief that vaccines were dangerous. Yet "seeds of doubt" grew from conversations his mother had, either in person or online, with critics of her views.
While he was pulled from class and told every year he could not attend school without his vaccines, every year he was "opted out" of immunizations and, because of current legislation, allowed to stay in school, Lindenberger's written testimony noted.
"And so my school viewed me as a health threat ... that for me also pushed into getting my vaccines, despite my mother's beliefs," Lindenberger told the committee.