Research Roundup - July 2019


California to Pay off $10.5M in Student Debt – Giving Poor Patients Greater Access to Dentists
By Cathie Anderson | The Sacramento Bee | July 12, 2019

To improve access to care for low-income patients, California is paying off $10.5 million in student loans for 40 dentists who agree to ensure that 30 percent of their patient population is composed of Medi-Cal patients, who are among the state’s poorest and frailest residents, reports The Sacramento Bee. Currently, only one-third of California’s licensed dentists accept Medi-Cal patients due to low reimbursement rates. As a result, an estimated 13.4 million people eligible for the program struggle to obtain necessary care. This action compliments an earlier award that provided $58.6 million in student debt relief to 247 physicians.

Hospitals Block ‘Surprise Billing’ Measure In California
By Ana B. Ibarra | Kaiser Health News | July 11, 2019

California lawmakers sidelined legislation that would have prohibited out-of-network hospitals from surprise billing privately insured emergency department patients, citing fierce pushback from hospitals, according to Kaiser Health News. Instead of billing patients directly, hospitals would have to work with health plans, leaving patients responsible only for their in-network copayments, coinsurance and deductibles. Hospitals’ opposition focused on a separate provision that limited the amount they could charge insurers for each service provided. An industry spokesperson criticized the provision as an unnecessary form of rate setting, however, proponents argue that protecting patients from high costs and capping what insurers pay hospitals are inextricably linked.


CIVHC Releases Interactive Map Showing Price Variation Across Colorado
By Martina Dolan | | July 3, 2019

Using 2017 claims data available through the Colorado All-Payer Claims Database, an interactive map from the Center for Improving Value in Health Care (CIVHC) illustrates regional variation for 11 common services, according to Though no one region had consistently high or low prices, some regions stand out. For example, the West region is the highest with respect to prices for five procedures – breast biopsy, C-section, hip replacement, knee arthroscopy and tonsillectomy. 

2019 Medicaid and Commercial Access to Care Index: How Payer Type Influences Coloradans’ Access to Needed Healthcare
By Colorado Health Institute | July 3, 2019

Both Medicaid members and commercially insured Coloradans have relatively good access to healthcare, according to a new analysis by the Colorado Health Institute (CHI). CHI’s Access to Care Index scores 25 measures of access on a scale of one to 10, with 10 being the best. Overall, Medicaid members scored 7.4 and commercially insured Coloradans scored 8.2. However, the index suggests that access to care for Medicaid members has room for improvement: those with commercial insurance have a better chance of finding a provider; the logistics of getting to the doctor are harder for Medicaid members; and that regardless of payer, obtaining preventive care remains hardest.


For Smokers Trying to Quit, Chantix, Zyban Will No Longer Require A Prescription
By Shari Rudavsky | IndyStar | July 15, 2019

The Indiana State Health Commissioner and Family and Social Services Administration Secretary announced that Indiana would join 11 other states in covering tobacco cessation prescription drugs, such as Chantix and Zyban, free of charge. According to IndyStar, studies place Indiana in the top 10 states with the highest smoking rates. About 22 percent of Indiana residents smoke and 13 percent of expectant mothers. In an effort to encourage expecting and new mothers to quit smoking, state officials announced mothers on Medicaid will no longer have a co-pay for tobacco cessation products for up to a year after a child’s birth.


Hospitals Pledge $2M Toward Services for Homeless
By Brandon Weigel | Baltimore Fishbowl | July 2, 2019

A group of 10 Baltimore hospitals have pledged $2 million over two years towards a program that provides housing and medical services for people experiencing homelessness, according to the Baltimore Fishbowl. Funds from the partnership will provide homes and aid for 200 individuals and families, with medical organizations providing medical care and other services to break the cycle of homelessness. The program is designed to show that homeless individuals who receive treatment in permanent housing will ultimately see a reduction in healthcare costs.


Hospital Trade Group Wants State to Investigate Blue Cross Blue Shield of Minnesota
By Joe Carlson | The Star Tribune | July 15, 2019

The Minnesota Hospital Association claims Blue Cross Blue Shield (BCBS) of Minnesota, the state’s largest not-for-profit health insurer, may be breaking the law by imposing a slate of new policies designed to deny or delay access to routine colonoscopies and hundreds of other hospital services, according to The Star Tribune. The hospital trade group has asked state officials to investigate these practices and stop the insurer from imposing new policies that do not comply with state law and discriminate against in-network providers by limiting coverage for patients who do not receive prior authorization for services and if there are cheaper in-network service options nearby. BCBS claims that healthcare costs continue to rise to unprecedented levels and hospitals must work with payers and plan sponsors to improve the sustainability of healthcare costs.

New Minnesota Law Seeks Transparency in Medical Billing
By John Lundy | Grand Forks Herald | July 22, 2019

A new law requires clinics that are part of a larger hospital or health system to publicly disclose that patients may receive a separate charge for the facility, resulting in higher out-of-pocket costs, according to the Grand Forks Herald. The hope is that these disclosures will lower the number of Minnesotans who experience surprise medical bills. A Healthcare Value Hub survey of adult Minnesotans in 2019 revealed that nearly half experienced healthcare affordability burdens in the past year. 

Minnesota & Indiana  

Minnesota and Indiana Governors Work to Improve Social Equity and Health in Every Zip Code
By Elinor Higgins | National Academy for State Health Policy | July 22, 2019

Indiana and Minnesota offer examples of how state policymakers are using budget appropriations, executive orders and legislation to improve social equity and reduce disparities, according to NASHP. In Indiana, the governor and legislators are tackling disparities in infant mortality, aiming to reduce the state’s infant mortality across all zip codes by improving services for expecting mothers by establishing a perinatal navigator program. The program provides wraparound services and community-based, home-visiting programs, while a new law also establishes a program to provide more nurses and community health workers to help young women throughout pregnancy. In Minnesota, initiatives proposed in the budget or enacted through executive orders are designed to reduce disparities in educational attainment and employment among racial minorities in Minnesota. Though not directly tied to health, these disparities can lead to income inequality and other stressors strongly associated with poor health outcomes. The approaches taken by Minnesota’s and Indiana’s governors demonstrate how state leaders can push for social equity with targeted or broad systemic changes to improve overall social conditions


University of Montana Reaching High Marks in Retaining New Physicians in State
By Dennis Bragg | KPAX | July 17, 2019

The University of Montana Health and Medicine’s physician retention program has led to over 70 percent of residency graduates remaining in Montana as primary care rural physicians, according to KPAX. Five years ago, there was growing concern of finding enough physicians to meet demand in urban centers and rural hospitals.

New Hampshire

N.H. Is Studying Ways to Address Rural Healthcare Access
By Jordyn Haime | New Hampshire Pubic Radio | July 5, 2019

New Hampshire has created a committee to study ways to help rural hospitals cope with for-profit health centers, like urgent care facilities, according to New Hampshire Public Radio. For-profit health clinics can provide more affordable health services to patients, but some hospitals have faced financial losses due to clinics opening nearby. Current law requires new health centers opening within 15 miles of a critical access hospital to be approved by the Department of Health and Human Services to avoid having an adverse impact on the essential healthcare services provided in the service area of the critical access hospital.

Growth of Telemedicine in N.H. Has Hopes High, but Questions Remain
By Jason Moon | New Hampshire Public Radio | July 16, 2019

Telemedicine is increasing at a significant rate across New Hampshire, but some experts warn that it may not be appropriate for all patients in all cases, according to New Hampshire Public Radio. Research out of Harvard Medical School suggests that the biggest growth in telemedicine is happening in direct-to-consumer telemedicine and that most of those televisits are from new patients, meaning they are not replacing in-person doctor’s appointments, but rather adding to them. Though telemedicine would allow patients in rural areas to get help, New Hampshire’s shortage of healthcare workers remains and may hamper telemedicine’s potential.

New York

State Regulations Tied to Reduced Sepsis Mortality in New York
By Matt Kuhrt | FierceHealthcare | July 18, 2019

New York’s 2013 mandate for protocolized sepsis care produced sepsis mortality rates significantly lower than those in four states without such regulations, according to FierceHealthcare. New research published in JAMA found that the unadjusted 30-day in-hospital mortality rates in New York dropped from 26.3 percent before the regulations were implemented to 22 percent afterwards. However, these results may not be guaranteed for other states, as New York had a specific environment in which to implement the regulations. First, mortality rates in New York were already higher than most other states, and secondly, this solution came during “a perfect storm,” with an engaged department of health, active hospital associations, willing partners and grassroots advocacy. 

Local Healthcare Groups Cope with Worker Shortages
By Amy Neff Roth | Observer-Dispatch | July 22, 2019

New York is facing a shortage of healthcare workers because fewer people are choosing healthcare careers as the workforce ages and retires, according to the Observer-Dispatch. Additionally, demand has soared as the population ages and the increased turnover costs money, making it the biggest source of cost increases and including money on ads, recruitment and retention tools, lost productivity, and the cost of training employees.

New Jersey

New Jersey Fights to Keep Obamacare Alive
By Johnny Vatican | Medical Daily | July 2, 2019

New Jersey has passed a state law creating a state-based health insurance exchange to be funded by a 3.5 percent user fee on premiums, which currently goes to the federal government, according to Medical Daily. New Jersey estimates that the user fee will allow it to collect around $50 million a year to pay for marketing and enrollment fees. This action follows a 2018 law requiring all New Jersey residents to have health coverage or pay a penalty.

Heart-Attack Patients Face Worse Odds at NJ Hospitals with Lower “Care” Scores
By Caren Chesler | NJ Spotlight | July 8, 2019

Heart attack patients treated at New Jersey hospitals with low hospital performance scores have a higher chance of having another heart attack or dying of cardiovascular causes than those treated at hospitals with high performance scores, according to NJ Spotlight. The study by Rutgers University, published in the American Journal of Cardiology, found that 3 percent of heart attack patients treated at low-scoring hospitals return to the low-scoring hospitals due to a new heart attack within 30 days. Those admitted to a teaching hospital were 25 percent less likely to be readmitted after a month than those admitted to a non-teaching hospital, and their chances of suffering cardiovascular death after a year were 10 percent lower.

North Carolina

How the Eastern Cherokee Took Control of Their Healthcare
By Katja Ridderbusch | Kaiser Health News | July 22, 2019

For the North Carolina Cherokee, self-governance has meant adopting an integrated care model designed by Alaska Natives to deliver care that not only improves patients’ health, but is also tailor-made for the needs of the tribe, according to Kaiser Health News. The Cherokee have opened a 20-bed hospital and have started construction on an 18-bed mental health clinic scheduled to open in 2020. Self-governance also allows tribes to be eligible for Medicare, Medicaid, private-sector health insurance, partnerships with larger health systems, and even federal grants that are designed for underserved communities – all of which can be limited for the Indian Health Service. Half of the Indian Health Service budget is now managed by Indian tribes to various degrees, but it remains to be seen how widely the full control, which has worked out well for tribes with resources like the Eastern Cherokee, can be applied. For instance, geographic isolation, poverty and a lack of resources make new healthcare investments difficult for tribes such as the Rosebud Sioux or the Oglala Lakota on the Pine Ridge Indian Reservation.


Pharmacy Benefit Manager Reform: Lessons from Ohio
By Trevor J. Royce, Sheetal Kircher and Rena M. Conti | JAMA | June 20, 2019

After an audit revealed that a 8.8 percent spread between what pharmacy benefit managers (PBMs) charged Medicaid managed care plans and what they paid to pharmacies, Ohio Medicaid directed managed care plans to end their contracts with pharmacy benefit managers, effective January 2019. Plans were instead asked to adopt a transparent “pass-through” pricing model whereby the managed care plan would pay the PBM the exact amount paid to the pharmacy for the prescription drug, a dispensing fee, and, in lieu of spread-based revenue, an administrative fee, according to JAMA. Ohio policymakers also pursued the prohibition of gag clause by PBMs, which prevent pharmacies from sharing with patients the most cost-effective option when purchasing medications. Uniquely among states, Ohio’s approach includes assessing the potential effect of these reforms on outcomes and evaluating gains after reform implementation.


Oregon Passes Bill to Slow Cost of Healthcare and Increase Transparency
By Oregon Health Authority | The Lund Report | June 20, 2019

Oregon has passed legislation creating the Oregon Health Care Cost Growth Benchmark Program, which will set a state spending growth target that all insurance companies, hospitals and healthcare providers would have to stay within, according to The Lund Report. Oregon is the fourth state to set a spending benchmark intended to rein in the rising cost of healthcare. In Massachusetts, the policy saved $5.5 billion for consumers between 2013 and 2016. Currently, Oregon has the third highest health insurance deductibles in the country and is in the top 10 highest states for family budgets spent on out-of-pocket hospital costs.


For Value-Based Care, a Texas Health System Puts Cost and Risk Data at the Point of Care
By Bill Siwicki | Healthcare IT News | July 16, 2019

To address the health system’s need to provide cost data at the point of care, Houston Methodist is piloting a program, Smart Ribbon, that provides real-time, patient-specific cost and risk data regarding medications, labs, radiology and observational status within the clinical workflow, according to Healthcare IT News. This information automatically appears and hovers over clinicians’ screens as they work within patients’ charts in the EHR. Since the pilot, Houston Methodist Sugar Land has reported approximately $717,000 in attributable cost savings with an average incremental cost reduction of $105 per admission. This early financial success was also accompanied by clinical efficiencies because Smart Ribbon is integrated with Epic EHR and VigiLanz pharmacy surveillance and antimicrobial stewardship products, and features a Controlled Substances app, thereby reducing provider clicks and cognitive burden associated with searching for data on opioid and antibiotic use.


Survey Finds Virginia Consumers Worried About Affording Healthcare
By Robert Powell | Virginia Business | July 9, 2019

A survey of Virginia adults found that more than half of Virginia adults had problems affording healthcare during the last year, according to Virginia Business. Altarum’s Consumer Healthcare Experience State Survey also found that 78 percent of respondents worry about affording healthcare in the future. Data revealed that there was high support for government-led change crosses party lines. The top three healthcare priorities respondents want to see action on are addressing high costs (55 percent); preserving consumer protections (36 percent); and getting health insurance to those who cannot afford coverage (35 percent). The majority of respondents, regardless of political affiliation, indicated they supported government action to make it easier to switch insurance (89 percent); and requiring up-front patient cost estimates from healthcare providers (88 percent) and insurers (90 percent). Advocates agree that even with Medicaid expansion, healthcare affordability is still a top issue for all Virginians.


Compromises Made By Washington Lawmakers on Public Option Payment Rates Could Curb Potential Cost Savings for Consumers
By Sarah Kliff | The New York Times | June 27, 2019

The state of Washington is praised for creating the country’s first “public option,” but a closer look at the law reveals tradeoffs that could curb potential savings for consumers, reports The New York Times. Although the law allows the state to regulate some healthcare prices, the prices were set significantly higher than drafters originally hoped in order to gain enough support to pass. As a result, the public option may not deliver the steep premium cuts that supporters want. Estimates suggest that individual market premiums will fall 5-10 percent when the new public plan begins.


Wisconsin Medicaid Expansion Lowered Antidiabetic Drug Costs 70 Percent
By Katie Gerhards | University of Wisconsin-Madison News | June 2019

Wisconsin Medicaid’s 2014 coverage expansion had a tremendous impact on making antidiabetic drugs more affordable for childless, low-income adults, according to the University of Wisconsin-Madison News. The study, published in Health Affairs, revealed that before the expansion, this population was covered by the BadgerCare Plus Core Plan, which covered fewer medications and had higher copays for generic and brand-name drugs. The expanded coverage was also correlated with a 4 percent increase in childless adults using antidiabetic medications, such as insulin and oral medications.
For MORE newly posted state news featuring AL, CO, GA, ID, IL, MD, NJ, NC—and to get alerts for your state—visit the Hub website.  

Recent Reports

Sending the Wrong Price Signal: Why Do Some Brand-Name Drugs Cost Medicare Beneficiaries Less than Generics?
By Stacie B. Dusetzina, et al. | Health Affairs | July 2019

Medicare Part D beneficiaries who reach the catastrophic coverage phase can pay between $869 and $1,072 more out of pocket to fill prescriptions for higher-price generic drugs than brand-name counterparts, according to a study published in Health Affairs. This scenario is driven by manufacturer discounts provided in the Medicare Part D coverage gap and is common with specialty drugs (typically used to treat rare or complex conditions), when the number of generic manufacturers or clinical alternatives are limited. Policymakers should consider modifying the Part D benefit by eliminating manufacturer discounts from out-of-pocket spending calculations and extending the Part D discounts for brand-name drugs and biosimilars filled in the coverage gap to generics.

Number of Manufacturers and Generic Drug Pricing From 2005 to 2017
By Immaculada Hernandez, et al. | American Journal of Managed Care | July 2019

Increases in generic drug prices from 2005 to 2016 suggest that competition is not working in the drug market, according to a study published in the American Journal of Managed Care. Before 2010, price changes were higher for drugs supplied by fewer manufacturers, but after 2010, prices increased sharply, and drugs supplied by 4 to 7 manufacturers showed increases similar to or higher than those supplied by 1 to 3 manufacturers. The proportion of drugs supplied by 1 to 3 manufacturers that doubled in price within a year was 3.6 times higher in 2012 to 2015 than in 2005 to 2009.

Report: Growing Biosimilar Market Could Save Billions in Health Spending
By Paige Minemyer | FierceHealthcare | July 19, 2019

An increase in biosimilar market share to 25 percent would result in $2.5 billion in annual savings, according to an analysis from the Pacific Research Institute. In order to increase access to biosimilars, the FDA should make interchangeability guidelines as clear as possible and ensure prescribers have access to them when they’re selecting drugs for patients, according to analysis from FierceHealthcare. The Institute also cited Europe as an example of what a robust biosimilar market could look like.

A Look at People Who Have Persistently High Spending On Healthcare
By Gary Claxton, Matthew Rae and Larry Levitt | Kaiser Family Foundation | July 22, 2019

Though health spending is highly concentrated in high cost patients, high spenders are not a homogenous group. Those with persistently high spending between 2015 and 2017, constituted 1.3 percent of enrollees, but accounted for 19.5 percent of overall healthcare spending in 2017. People with persistently high spending averaged $87,870 in health spending in 2017, which is almost 60 percent higher than the average, according to a study from the Kaiser Family Foundation that looked at diagnostic and claims information provided by large employer plans. Persistently high spending patients spent about 40 percent more on outpatient services, while people with high spending in just one year spent more, on average, on inpatient services—likely due to the acute nature of their conditions. People with persistently high spending averaged almost $34,000 in spending on retail prescription drugs, many times more than the average for people with high spending just in the last year ($5,110) or continuously covered enrollees overall ($1,290).

What Are the Potential Savings from Steering Patients to Lower-Priced Providers?
By Sunita M. Desai, et al. | American Journal of Managed Care | July 2019

Steering patients from higher- to lower-priced providers within geographic markets in targeted service categories could generate substantial healthcare savings, according to a study published in the American Journal of Managed Care. Of the service categories researchers examined, laboratory tests had greatest within-market price variation, with about half of services (53 percent of laboratory tests, 47 percent of imaging services, and 54 percent of durable medical equipment) were billed by providers with prices above their market median. Shifting patients to median-priced providers in their markets could save significant amounts of spending on laboratory tests, imaging services, and durable medical equipment, representing savings of 11 percent of total outpatient spending and 7 percent of the sum of inpatient and outpatient spending.

Medicare’s Bundled Payment Model Did Not Change Skilled Nursing Facility Discharge Patterns
By Jane M. Zhu, et al. | American Journal of Managed Care | July 2019

Hospital participation in Medicare’s voluntary Bundled Payments for Care Improvement (BPCI) model was not associated with changes in the number of skilled nursing facilities partners or in discharge concentration relative to non-BPCI hospitals, according to a study published in the American Journal of Managed Care. Results of this study did not vary across clinical conditions and were robust across the duration of BPCI participation and with different comparison groups, but more research is needed to understand how hospitals respond to bundled payment incentives and how specific practices contribute to cost and quality improvements.

Healthcare Spending, Utilization, and Quality 8 Years into Global Payment
By Zirui Song, et al. | New England Journal of Medicine | July 18, 2019

A study examined spending, utilization and quality through eight years of the Alternative Quality Contract (AQC) of Blue Cross Blue Shield (BCBS) of Massachusetts, a population-based payment model that includes financial rewards and penalties (two-sided risk). When compared to privately insured enrollees in control states, authors found that found that annual medical spending on claims for the enrollees treated by AQC organizations was $461 lower in 2009, according to the New England Journal of Medicine. These savings were driven by lower prices in the early years and lower utilization of services in the later years. Additionally, unadjusted measures of quality under this model were higher than or similar to average regional and national quality measures. Changes in referral patterns during the early years of the contract were followed by reductions in utilization of certain services. These findings suggest that Accountable Care Organization (ACO) model featuring both financial rewards and penalties, including quality incentives, may offer a framework for slowing the growth in medical spending without sacrificing the quality of care for patients.

Prevalence, Severity, and Nature of Preventable Patient Harm Across Medical Care Settings
By Maria Panagioti, et al. | The BMJ | July 17, 2019

Roughly 1 in 20 patients experience healthcare harm that's preventable — and some of those experiences can lead to death or long-term disability, according to a new analysis published in The BMJ. Researchers reviewed studies and consistently found that about 50 percent of patient harm was preventable. The study also revealed evidence that preventable patient harm is not only a public health concern but incurs a considerable cost. The excess length of hospital stays attributable to medical errors is estimated to be 2.4 million hospital days, which accounts for $9.3 billion in excess charges in the U.S.  Nearly a quarter of the cases of preventable medical harm were related to medication or other treatments. The study also showed preventable harm is more common in intensive care units (ICUs) and surgical units.

The Secret of Healthcare Prices: Why Transparency is in the Public Interest
By Katherine L. Gudiksen, Samuel M. Chang and Jamie S. King | California Health Care Foundation | July 16, 2019

A report from the California Health Care Foundation examines the legal and economic implications of collecting and releasing data on amounts paid for healthcare services, reviews the practices of existing all-payer claims databases (APCDs), and concludes with recommendations for California’s policymakers about best practices to ensure the effective use of increased transparency to control costs and increase access to healthcare services. Authors found that while some negotiated prices may constitute trade secrets in some circumstances, no court has definitively ruled on the issue of whether negotiated healthcare rates can be protected as trade secrets. Therefore, California can allow or require such disclosures if they are in the public interest. The authors also noted that, to date, no state with an existing APCD has experienced competitive harm and that public disclosure of negotiated rates resulted in increased competition in New Hampshire. Additionally, though all states with active APCDs collect information about paid amounts and release reports of aggregated information, a few states, including Maine and New Hampshire, disclose plan- and provider-specific median paid amounts for the most commonly used healthcare services on publicly accessible websites. Based on these findings, recommendations to California include: requiring the Office of Statewide Health Planning and Development (OSHPD) to provide data submitters with clear information on policies regarding data collection; monitoring annual claims for anticompetitive behavior; creating a data release committee and declaring that all information submitted to the APCD will be released in accordance with guidelines; and establishing guidelines for data release that weigh competitive effects and public interest. 

Study: ACA, Medicaid/Medicare Expanded Insurance, Yet Hospital Use Didn’t Rise
By Yusra Murad | Morning Consult | July 22, 2019

The creation of Medicare and Medicaid, along with the expansion of Medicaid in 2014, did not result in increased hospital use according to new research published in the Annals of Internal Medicine. The study used data from the National Health Interview Survey (conducted from 1962-1970) and the Medical Expenditure Panel Survey (2008-2015) to analyze how previous health insurance expansions in the United States affected utilization of inpatient services. The research demonstrates that the effect of insurance expansions on hospital use is a matter of redistribution rather than increase, according to analysis from Morning Consult. After more people obtain health insurance, there is a slight fall in supplier-induced demand among healthier, high-income people.

Social Determinants Screenings Cut Hospital Admissions by Nearly 30 Percent
By Jessica Kent | Health IT Analytics | July 23, 2019

High-risk Medicaid enrollees who receive community-based services experienced a 26.3 percent drop in inpatient hospital admission rates, according to an analysis from AmeriHealth Caritas. Social determinants of health, such as poverty, education, and lack of social support, contribute to more than half of premature deaths in the U.S. every year. AmeriHealth Caritas found that health literacy, food insecurity, and a lack of transportation to medical facilities were significantly more prevalent among high-risk members than all other surveyed members. AmeriHealth Caritas’ uses care management teams, led by a medical director and consisting of community health navigators, to engage high- and emerging-risk members to increase their access to care and improve their health experience, according to Health IT Analytics. When high-risk patients engaged with community services alongside clinical care, high-risk members experienced a 9.7 percent reduction in emergency department visits, a 22 percent reduction in potentially preventable admissions, and a 12 percent drop in potentially avoidable emergency department visits.

Visit the Hub website for more on drug costs, biosimilars, price transparency, medical harm, coordinated care for complex patients, the linkages between coverage and outcomes and more!


Walmart Flies Employees to Top Hospitals for Surgeries in a Bid to Cut Healthcare Costs
By Dark Daily | July 10, 2019

In an effort to curb healthcare spending while ensuring workers have access to the best quality care at competitive costs, Walmart is paying the travel costs to send sick employees to out-of-state hospitals and top-ranked doctors, according to Dark Daily. Walmart and partners published a case study in Harvard Business Review, hoping that other companies would be inspired follow suit. After a local surgeon recommended spine surgery due to spinal column narrowing and disc degeneration, Walmart paid for a worker and his wife to travel to Geisinger Medical Center in Pennsylvania for a second opinion. Geisinger evaluated his condition and diagnosed Parkinson’s disease, a move that prevented an unnecessary $30,000 spinal surgery. Walmart has had its Centers of Excellence (COE) program, which allows the company to contract with leading medical centers for procedures, for six years. Until 2018, the COE program was optional for Walmart employees. Now, employees may be on the hook for the entire cost if they opt to have a covered procedure performed locally.

Price Transparency in Healthcare Is Coming — But Will It Matter?
By David Blumenthal, Lovia Gustafsson and Shanoor Seervai | Harvard Business Review | July 3, 2019

President Trump has instructed federal agencies to develop rules requiring disclosure of negotiated hospital prices in a consumer-friendly, electronic form, according to the Harvard Business Review. Additionally, legislation that passed the Senate Health Education Labor and Pensions (HELP) Committee would establish a new nonprofit entity that collects de-identified claims data with actual prices paid for services nationwide. The question remains: will price transparency lower healthcare costs? Seventy percent of hospital markets are so consolidated that they lack effective competition. New Hampshire’s experience suggests that consumers with high deductibles who consult the site choose lower priced services, but since only a tiny fraction of the state’s population participates, the overall effects on costs are negligible.

Price Controls Best Way to Cut Health Costs, Economists Say
By Joyce Frieden | MedPage Today | July 10, 2019

“On the private side, we've done a massive experiment in letting private health plans and providers negotiate without price controls, and we've seen the result: it's incredibly expensive, and it's unsustainably expensive,” Chapin White, PhD, an adjunct senior policy researcher at the RAND Corporation stated at an Altarum event sponsored by the Robert Wood Johnson Foundation. Experts pointed out that price controls already exist for the Medicare and Medicaid program, according to MedPage Today. White supports demanding that health plans pay a percentage of Medicare but added that there would be variation among states because payment rates are quite different. The current healthcare payment system is the result of the “three-legged glitch,” with the three legs being: bilateral negotiations between health plans and hospitals; an uncapped obligation for the cost of out-of-network care; and widespread “unshoppability” for hospital care due to monopolies, White said.

Insurers’ Perspectives on MA Value-Based Insurance Design Model
By Dmitry Khodyakov, et al. | American Journal of Managed Care | July 2019

Fewer than 30 percent of eligible insurers participated in the first two years of the Center for Medicare and Medicaid Innovation’s value-based insurance design (VBID) model test in Medicare Advantage, according to a study published in the American Journal of Managed Care. The main barriers to entry were a perceived lack of information on VBID in Medicare Advantage, an expectation of low return on investment, concerns over administrative and information technology hurdles, and model design parameters. To increase uptake, CMS could consider providing in-kind implementation assistance to model participants.
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