Research Roundup - April 2019


New Billing Practices at San Francisco's Largest Public Hospital Could Help Low-Income Patients Save Money

By Jamie Ducharme | TIME | April 16, 2019

New billing practices at Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) could ease the financial burdens of patients seeking care at the community hospital — 94 percent of whom are uninsured or covered by Medicare or Medi-Cal, according to TIME. The new policies would create income-based, out-of-pocket maximum costs for patients; make more patients eligible for financial assistance; ensure that out-of-network patients are billed the same amount as in-network patients; and end the practice of balance billing, through which patients are charged for costs their insurer declines to cover. The recommended changes were developed by San Francisco’s public health department at the request of the Mayor and Supervisor.

Los Angeles County will Join State’s Prescription Drug Single-Purchaser System

By Office of Governor Gavin Newsom | April 17, 2019

Governor Gavin Newsom announced that Los Angeles county, one of the largest public purchasers of prescription drugs in California, will partner with the state to use their combined market power in an attempt to lower the cost of prescription drugs, reports The State Network. This announcement follows an executive order the governor signed directing California agencies to consolidate pharmacy purchasing authorities. The state Legislative Analyst’s Office reported that the Medi-Cal component of the executive order could potentially save the state hundreds of millions of dollars annually by increasing Medi-Cal’s bargaining power.


Unique Collective Has Ambitious Plan to Lower Healthcare Costs

By Tara Bannow | Modern Healthcare | April 13, 2019

A collective in Summit County, home to 30,000 people in Colorado, is implementing a novel strategy to address high healthcare costs, according to Modern Healthcare. A knee replacement in the county costs 89 percent more, on average, than in the Denver metro area, while a craniotomy can cost a patient 163 percent more, on average. Peak Health Alliance, a collective of small and large businesses and individuals, representing roughly 6,000 people, has launched a unique model to negotiate discounted rates for medical services directly with the county’s main health system and only hospital provider, Centura Health. Following this negotiation process, Peak sends those contracted rates to health insurers to see who can craft the best plans. The effort was strengthened by a wealth of claims data that revealed that the county’s providers collected more than 500 percent of Medicare rates for outpatient hospital services in 2015 and 2016, driving many residents out of the county for care. Some of Peak’s success will depend on how well the selected insurer is able to manage the small population of members that drive 50 percent of the spending.


As Health Insurance Prices Soared, ‘The State Was Powerless to Stop It.’ State Legislation Aims to Change That

By Lisa Schnecker | Chicago Tribune | April 22, 2019

Consumers in Illinois have been bogged down with steep price increases when buying health insurance on the Affordable Care Act (ACA) marketplace. According to the Chicago Tribune, new proposed legislation would give the Illinois Department of Insurance the power to say “no” to certain sky-high price increases proposed by insurance companies for plans sold to individuals and small businesses. The bill wouldn’t apply to plans offered by large employers. Opponents of the bill say it does nothing to address the rising prices of healthcare that can lead to higher insurance prices, and it could limit the types of plans insurers are able to offer.


Maryland Legislature Passes Laws to Make Health Insurance Enrollment Easier and Create Drug Price Board

By Meredith Cohn and Pamela Wood | The Baltimore Sun | April 11, 2019

The Maryland General Assembly passed a slate of related measures to make health coverage easier to secure for uninsured Marylanders and prescription drugs cheaper for government workers, reports The Baltimore Sun. One law would require uninsured people to check a box on their state tax returns to report whether they’re interested in obtaining health coverage through the state. Another would establish a board to study the controversial idea of capping prescription costs for state and municipal employees. The legislature also enacted a patient’s bill of rights and approved sustained funding for a reinsurance program that helps insurers offset costs for the biggest healthcare users. Collectively, these measures are expected to make a significantly improve healthcare access and affordability for consumers.

Maryland’s Experiment with Capitated Payments for Rural Hospitals: Large Reductions in Hospital-Based Care

By Jesse M. Pines, et al. | Health Affairs | April 2019

In 2010 Maryland, for some rural hospitals, replaced fee-for-service payment with a global budget approach called Total Patient Revenue (TPR) to incentivize hospitals to manage resources more efficiently. A study in Health Affairs found evidence consistent with both the incentive to provide care more efficiently and the incentive to provide less care during the 2010-2013 study period. For TPR hospitals, service use fell sharply – ED admissions declined 12 percent, direct (non-ED) admissions fell 23 percent, ambulatory surgery center visits fell 45 percent and outpatient clinic visits/services fell 40 percent. The authors conclude that most of the drop in inpatient admissions at TPR hospitals was offset by higher admissions at Maryland hospitals outside the global budget or moved to neighboring states.  Since hospital revenues are maintained under TPR, if care that is no longer provided within budget moves off budget, total healthcare costs could rise. The authors found evidence of higher overall healthcare spending for the FFS Medicare population. Unfortunately, no published studies have examined the effect of TPR on population health or on overall healthcare costs. In 2014, Maryland replaced the limited TPR program with Global Budget Revenue (GBR) for all Maryland Hospitals. The authors conclude that capitation models require strong oversight to ensure that hospitals do not respond by shifting costs to other providers.


How Grand Rapids, Michigan, is Using Data to Advance Health Equity and Economic Opportunity

By Rosalynn Bliss | Health Affairs Blog | April 16, 2019  

Policymakers in Grand Rapids, Michigan worked with Invest Health, a project of the Robert Wood Johnson Foundation and Reinvestment Fund, used data from the NYU School of Medicine’s City Health Dashboard (CHDB) to compare Grand Rapids’ data to the national average for many social and economic factors, physical environment, health outcomes, health behavior and clinical care, according to a blog post. The project’s Economic Opportunity Dashboard shows economic inequities and brings together historical data on city investments, citywide and by neighborhood. Based on findings from the Dashboard, academics and policymakers developed strategies to address the social and economic barriers identified as leading to disparate health outcomes in the Neighborhoods of Focus (the city’s first and third wards).

New Jersey

Building a Culture of Health: A Policy Roadmap to Help All New Jerseyans Live Their Healthiest Lives

By Margaret Koller, et al. | Robert Wood Johnson Foundation | April 2019  

Creating health equity through public policies is the focus of a new report. The report identifies 13 policy priorities for improving health and well-being in the state, and recommends a comprehensive series of actions to close health gaps, broaden opportunity and ensure that everyone in New Jersey—no matter who they are, where they live or how much money they make—can live the healthiest life possible.


OSDH Awarded Grant to Aid Access to Healthcare

By The Oklahoman | April 7, 2019

The Oklahoma State Department of Health was awarded a five-year grant from the U.S. Health Resources and Services Administration totaling more than $890,000 to improve access to healthcare services for people who are uninsured, isolated or medically vulnerable, reports The Oklahoman. The health department will work with the federal agency to produce a statewide primary care needs assessment, identify unmet healthcare needs and barriers to care (like workforce shortages) and advance strategies which improve access to comprehensive primary healthcare services in Oklahoma.

Bill Would Give Doctors in Rural Areas $25,000 Tax Credit

By Steve Matzer | The Journal Record | April 9, 2019

Proposed legislation in Oklahoma would establish a pilot program to attract physicians to rural parts of the state, according to The Journal Record. If signed into law, the bill would provide an income tax credit of up to $25,000 annually for up to five years for doctors who set up practices in communities of less than 25,000 people. To qualify for the income tax credit, doctors would have to have completed their medical training or medical residency in Oklahoma and would have to live in the same rural counties where they practice.

South Carolina

A Loophole Lets SC Hospitals Take Millions from Residents’ Tax Refunds for Unpaid Bills

By Mary Katherine Wildeman | The Post and Courier | April 20, 2019

In South Carolina, a law originally written to help state and local governments collect debts is being used by private companies to seize tax refunds from people with past-due medical bills, according to The Post and Courier. In 2017 alone, healthcare organizations took approximately $92.9 million in more than 172,000 seizures to pay off medical debt. The program makes big money for the state—the Department of Revenue earned $12.6 million in 2017 through the fees for its collection programs. Tragically, about a third of the state’s population under 65 has past-due medical bills. This debt collection program is especially harmful for low-income individuals who rely on their tax refund. This program is also troublesome because a review of five years of Medicare’s investigations of hospitals showed 30 percent of claims have errors. It is often difficult for consumers to get their money back even if they were billed incorrectly.


Six Provider Organizations to Use Data to Trim Low-Value Care in Virginia

By Diana Manos | Health Data Management | April 9, 2019

Using a $2.2 million grant from Arnold Ventures, the Virginia Center for Health Innovation (VCHI) is launching a statewide pilot to reduce the use of low-value services, according to Health Data Management. In 2012, the American Board for Internal Medicine identified 550 tests and procedures as having a low value. Accessing insurance claims data, VHCI looked at 42 measures for 5 million patients using a health-waste calculator and found more than 2 million unnecessary services, costing approximately $747 million. The pilot will be implemented across 900 clinical sites in Virginia and will involve an employer task force on low-value healthcare.  VCHI will initially focus on providers and seven sources of low-value care and then will expand to include a set of consumer-driven measures.

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Recent Reports

Surprise Out-of-Network Medical Bills During In-Network Hospital Admissions Varied by State and Medical Specialty, 2016

By Kevin Kennedy, Bill Johnson and Jean Fuglesten Biniek | Health Care Cost Institute | March 2019

A new study from the Health Care Cost Institute (HCCI) exploring the prevalence of surprise bills associated with in-network hospital admissions among the privately-insured showed that in-network hospital admissions associated with at least one out-of-network professional claim ranged from 1.7 percent of admissions (Minnesota) to 26.3 percent (Florida). Researchers examined which medical specialties represented the largest share of out-of-network claims during an in-network hospital admission and found that anesthesiology took the lead at 16.5 percent. When looking at which medical specialties most often billed out-of-network as part of an in-network hospital admission, the largest share was made up by independent labs at 22.1 percent. The analyses used HCCI's large database of commercial claims from 2016 that spans 37 states and the District of Columbia. Part of the problem may be that insurance designs are becoming more complicated with tiered or narrow networks, more restrictive coverage policies and new reimbursement models, according to analysis from Modern Healthcare. Legislators are currently exploring different approaches to mitigate surprise medical bills, including capping out-of-network charges to a regional average or resolving out-of-network disputes between insurers and providers through arbitration.

KFF Health Tracking Poll – April 2019: Surprise Medical Bills and Public’s View of the Supreme Court and Continuing Protections for People with Pre-Existing Conditions

By Ashley Kirzinger, Bryan Wu and Mollyann Brodie | Kaiser Family Foundation | April 24, 2019

An April Kaiser Family Foundation tracking poll found that most Americans support targeted actions on prescription drug costs (68 percent), protections for pre-existing conditions (64 percent) and surprise medical bills (50 percent), while fewer support broader reforms like Medicare-for-all (31 percent) and repealing and replacing the Affordable Care Act (27 percent). Support for broader reforms was split across party lines—nearly half of Republicans said repealing and replacing the Affordable Care Act (ACA) is a top priority while a similar share of Democrats said implementing a national Medicare-for-all plan is a top priority. The poll also revealed significant support across political affiliation for the federal government to act to shield patients from surprise medical bills.

Medicare’s Bundled Payments for Care Improvement Initiative Maintained Quality of Care for Vulnerable Patients

By Brandon Maughan, et al. | Health Affairs | April 2019

CMS’s Bundled Payments for Care Improvement (BPCI) initiative established four models to test whether linking payments for an episode of care could reduce Medicare payments while maintaining or improving quality. Prior evaluations concluded that model 2, the largest, generally lowered payments without reducing quality for the average beneficiary, but concerns lingered that these results could mask adverse findings among vulnerable subpopulations. A study in Health Affairs analyzed changes in emergency department (ED) visits, unplanned hospital readmissions, and all-cause mortality within 90 days of hospital discharge among beneficiaries with one or more of three vulnerable characteristics — dementia, dual eligibility for Medicare and Medicaid and recent institutional care – for twelve types of medical and surgical episodes. The findings suggest that BPCI model 2 did not adversely affect care quality for beneficiaries with the above-mentioned vulnerabilities. 

Cross-Agency Strategies to Curb Healthcare Costs: Leveraging State Purchasing Power

By Trish Riley, et al. | NASHP | April 15, 2019

Rising healthcare costs are a challenging problem nationally, but states, faced with balanced budget requirements and growing voter concern, aren’t waiting for a federal solution. When acting together, state agencies exert considerable buying power in an increasingly consolidated healthcare system. This recent NASHP report highlights the new wave of state initiatives that leverage collective purchasing clout to lower the healthcare cost trajectory.

Value-Based Care in America: State-by-State

By Change Healthcare | April 2019

Value-based care (VBC) is being delivered across the U.S. New care and payment models designed to improve quality and reduce costs are changing the way providers practice medicine and how they are compensated for their services. A study conducted by Change Healthcare provides an overview of value-based care models and payment reforms and state-based efforts to implement VBC and reimbursement models. The study found that over the past 5 years, 48 VBC programs have been implemented nationwide, and 34 states are two years or more into implementation. The study provides an in-depth discussion of state efforts.

Why High Rents Are a Healthcare Problem

By Patrick Sisson | Curbed | April 3, 2019

A new survey commissioned by Enterprise Community Partners found that more than half of renters surveyed delayed healthcare because they couldn’t afford it, and 100 percent of medical professionals surveyed said they had dealt with patients in the past who expressed concerns and anxiety about affordable housing. Of severely rent-burdened respondents--those who spent half or more of their monthly on housing--45 percent said they weren’t able to follow a medical treatment plan because they couldn’t afford it. The survey data explores the intertwined nature of health and housing outcomes, according to Curbed. A 2016 study in Portland conducted by Enterprise and the Center for Outcomes Research and Education (CORE) found that after Medicaid beneficiaries with unstable living situations moved into stable and affordable housing, their Medicaid costs declined by $48 per resident per month. Medicaid programs in Oregon, New York, and Massachusetts have partnered with local and regional healthcare systems to invest in housing services and even housing stock, while other large healthcare systems have invested in community benefit funds to build new affordable housing developments.

States Guide the Governance of Accountable Health Entities to Promote Community Health and Engagement

By Amy Clary | National Academy for State Health Policy | March 29, 2019

At least 12 states are developing accountable health models to improve health and control costs by addressing health-related community needs, such as transportation, recreation and housing, with the goal of building healthy communities and improving health equity through cross-sector partnerships.  In a new brief, the National Academy for State Health Policy (NASHP) examines the overall goals and functions of each governing body and their required representation to create a table of accountable entity governance structures. NASHP also examined the language states used to ensure that the local community was meaningfully engaged in the operations of the accountable entity.

Most Hospitals Provide Electronic Access to Records, but Patients Slow to Engage, ONC Says

By Meg Bryant | Healthcare Dive | April 9, 2019

A new briefing paper from the Office of the National Coordinator for Health IT (ONC) shows that 90 percent of U.S. nonfederal acute care hospitals allow patients to view and download their hospital records electronically. Critical access hospitals lagged significantly behind other facilities at just 60 percent. However, among all hospital types, only 8 percent said half or more of their patients activated access to the patient portal, while roughly two-thirds of hospitals said fewer than 25 percent of patients activated their access to the portal. Access to these portals was lower in rural hospitals compared to urban ones, according to Healthcare Dive. Hospitals are continuing to offer more capabilities to patients like paying bills online, requesting amendments to health records, receiving and sending secure messages and requesting prescription refills. Contrasting a desire for access, a Kaiser Family Foundation survey found that approximately 60 percent of consumers between 50 and 64 worry about unauthorized access to their records, highlighting the need for robust cybersecurity.

Impact! How Consumers Have Shaped Health System Delivery Reform

By The Center for Consumer Engagement in Health Innovation | April 2019

In a new report, Community Catalyst’s Center for Consumer Engagement in Health Innovation highlights case studies of how consumers with complex health and social needs have shaped policy and practice in delivery reform initiatives. The six states featured in the report found that consumers having a positive impact on the health system tend to fall into one of three categories: process impacts, communications impacts and policy impacts. For example, though Alabama scrapped their Regional Care Organization (RCO) structure, consumer input through the fledgling RCO Consumer Advisory Board in 2016 resulted in changes that are likely to remain in effect as the state implements its new reform program, the Alabama Coordinated Health Network (ACHN). The report includes additional examples from Maryland, Massachusetts, Pennsylvania, Rhode Island and Tennessee. Report authors emphasizes the importance of credibility, funding, technical assistance, time, continuity and collaboration to support meaningful consumer engagement.

Consumer-Centric Evaluation of Healthcare Price and Quality Transparency Tools

By Lynn Quincy, Christine Stanik and Dakota Staren | Altarum | April 2019

A new study from Altarum employs a unique approach to evaluating healthcare price and quality transparency tools, designed to emulate consumers’ real-world experience of trying to schedule needed healthcare. The findings reveal a deep divide between the information that consumers would typically seek and the information provided by transparency tools. While a few of the tested tools received high marks from the consumers, for the most part, the tools did not emphasize the type of information that patients most desired. Information on physician attributes was of key importance when seeking care whereas cost was not typically a key attribute for insured participants. The diversity of design approaches to price and quality transparency tools, low consumer uptake and the lack of commonality when it comes to evaluating such tools suggests there is still much to learn about successful design of, and role for, these tools.

Workplace Wellness Programs Barely Move the Needle, Study Finds

By Julie Appleby | Kaiser Health News | April 16, 2019

A study published in JAMA found that workplace wellness programs, which have become an $8 billion industry in the U.S., do not cut costs for employers, reduce absenteeism or improve workers’ health. Though other studies have shown positive results, many of them encountered limitations like failing to have a comparison group, or having difficulties figuring out whether people who sign up for such wellness programs are somehow healthier or more motivated that those who do not, according to Kaiser Health News. A new University of Chicago and Harvard study randomly assigned 20 BJ’s Wholesale Club outlets to offer a wellness program to all employees and compared results with 140 stores that did not. Though workers enrolled in wellness programs self-reported healthier behavior, efforts did not result in differences in health measures. However, wellness program company executives noted that incentives offered in the BJ’s study, as well as the one published in JAMA, may not have offered large enough incentives to spur changes needed to affect health outcomes.

New SHADAC Issue Brief Highlights Lessons Learned from SIM States Working to Align Quality Measures

By Colin Planalp | SHADAC | March 21, 2019

States are increasingly moving away from fee-for-service reimbursement models that reward quantity toward alternative payment models that reward value. A new issue brief from the State Health Access Data Assistance Center (SHADAC) examines the work of five State Innovation Model (SIM) states to develop common measure sets that align quality measures across private and public payers—a strategy aimed at reducing administrative burdens on providers and giving focus to quality improvement efforts. Conversations with states revealed a common set of lessons that can be utilized by other states planning to undertake quality measure alignment moving forward. 

Visit these pages on the Hub website for more on consumer views on healthcare affordability, drug spending, consumer harm from high costs, healthcare cost drivers, health information technology, surprise medical bills, bundled payments, value-based insurance design, wellness initiatives and more!


Providing Useful Hospital Pricing Information to Patients: Lessons from Voluntary Price Disclosure

By Ge Bai, et al. | Health Affairs Blog | April 19, 2019

To address the problem of nontransparent markets in healthcare, the Department of Health and Human Services (HHS) required all hospitals to post online their “standard charges” for all available services, starting on Jan. 1, 2019. The HHS mandate was intended to improve price transparency and enable patients to engage in comparative shopping. However, many hospitals responded by posting their chargemasters—bookkeeping tools that were not designed for price comparison purposes. In many cases, chargemasters are virtually impossible for patients to interpret, constraining the potential for the HHS mandate to achieve its goals. This blog post identifies strategies for regulatory improvement, including identifying and adopting best practices for price disclosure design.

The Promise—and Politics—of State Innovation for Health

By Joshua M. Sharfstein | The Milbank Quarterly | April 2019

States are especially well positioned to manage the local politics of health reform and can draw on a number of policy tools including: the ability to collect data necessary for systemic reform; the authority to regulate the content and sale of health insurance; and the responsibility for determining the scope of practice and licensing of health professionals, including nurse practitioners and other primary care clinicians, according to The Milbank Quarterly. For example, Delaware and Rhode Island established benchmarks for total healthcare spending growth. Pennsylvania has created global budgets for rural hospitals. The authors caution: federal support is still important for state experimentation and innovation. CMS has allowed states to bring forward compelling reforms with substantial local support and then share in the risk and potential savings from their implementation and also plays the critical role of a fair and independent judge of reform ideas.

Skimpy Health Plans Touted by Trump Bring Back Familiar Woes for Consumers

By Noam N. Levey | The Los Angeles Times | April 2, 2019

Many of the consumer protections included in the Affordable Care Act (ACA) are being relaxed by the Trump administration through the use of skimpier short-term health plans that are not subject to the ACA’s consumer protections. For example, many of these plans do not include protections for people with pre-existing conditions. Despite warnings from patient advocates, physician groups and state regulators, the administration last year took a major step to promote short-term plans, issuing rules that allow consumers to renew them for up to three years, according to The Los Angeles Times. Charley Bulter, a Montana truck driver who was unaware of his short-term plan’s shortcomings, was diagnosed with testicular cancer in 2016. His insurer moved to cancel his coverage over a preexisting medical condition uncovered during a “rescission review,” a practice that insurance companies once undertook to avoid paying customers’ medical claims by unearthing evidence of preexisting medical conditions that consumers failed to disclose when they bought the policy. Though this practice was effectively eliminated by the ACA, customers with certain short-term plans are still subject to it. 

U.S. Health Officials Unveil Experiment to Overhaul Primary Care

By Casey Ross | STAT | April 22, 2019

Federal health officials have unveiled a new primary care experiment that seeks to pay doctors for providing stepped-up services that keep patients healthy and out of the hospital, according to STAT. The initiative, called CMS Primary Cares, includes five new payment options for small and large providers, allowing them to take varying levels of financial responsibility for improving care and lowering costs. Though primary care only accounts for about 3 percent of costs, primary care providers influence the trajectory of illnesses that account for a much greater percentage of expenses. The new payment programs will create two basic pathways: Primary Care First and Direct Contracting. Primary Care First, designed for small practices, will include a monthly per-patient payment to providers to cover the total cost of caring for patients. These providers would also receive a bonus for keeping patients healthy, but they could lose revenue if their patients get sicker. Direct Contracting is intended for larger provider organizations and would include three payment options with varying levels of financial risk.

Moving Health "Upstream": Getting More from Return-on-Investment Evidence

By Edward L. Hunter | AcademyHealth | April 11, 2019

A recent AcademyHealth study concluded that higher total public health spending is associated with better health outcomes – often with returns to society that exceed initial financial investments. Experts conducted a literature review of how ROI-related evidence is used in “real world” public and private decision-making. They found that common characteristics, like having existing legal and administrative authority, access to investment capital and in-house expertise, were associated with groups making direct use of ROI-related evidence. The blog post also goes on to highlight barriers to using such evidence, including: reluctance from advocates who believe that public health should not be monetized; the “wrong pocket” problem whereby stakeholders who make investments don’t benefit from savings; and mismatches between the specificity of evidence generated by ROI researchers and the real-world decisions faced by public agencies.

Visit these pages on the Hub website for background on price transparency, social determinants of health, public health, provider scope of practice, all-payer claims datasets, financing silos and more!