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California passed a law in 2016 to protect many people with insurance from surprise billing, but the law didn’t cover the type of PPO plan that 250,000 CalPERS members have, according to The Sacramento Bee. House Bill 1611, which passed the House and is now under consideration by the Senate, would increase protections for these (and other) patients by limiting how much an out-of-network hospital can charge an insurance company in emergencies. The Assembly Health Committee projects that the bill would increase premiums for PPO policyholders by a total of about $1.3 million, but reduce their medical spending by about $22 million.
State regulators approved two major hospital mergers and acquisitions under the condition that the organizations agreed to healthcare cost price caps tied to the Consumer Price Index, reports the Hartford Business Journal. This type of agreement is a first for Connecticut and one of the most stringent cost controls ever placed on hospital combinations in the state. Compared to states like Massachusetts and Rhode Island, Connecticut’s caps are relatively modest. Nevertheless, they are an important protection against rising healthcare costs, which have historically increased with consolidation
The Colorado legislature passed numerous bills in the healthcare space that primarily focused on reducing the cost of care for consumers and improving accountability for quality care, according to the National Law Review. Some of these laws include HB 19-1174, which requires insurance carriers, providers and facilities to begin providing patients with information on the potential impact of receiving services from an out-of-network provider, prohibits “balance billing” patients who receive covered services from out-of-network providers at an in-network facility or emergency services from out-of-network providers or facilities, and establishes the reimbursement amount insurance carriers must pay to out-of-network providers that provide health care services to covered persons at an in-network facility or out-of-network providers for emergency services. HB 19-1131 requires that manufacturers and their representatives provide information about the wholesale acquisition cost of a prescription drug when providing information to a health care provider licensed to prescribe controlled substances or prescription drugs, and that when providing wholesale prescription drug price information, the manufacturer and representatives must also provide a list of at least three generic prescription drugs from the same therapeutic class and their wholesale acquisition costs. HB 19-1320 requires certain hospitals to complete an annual community health needs assessment and annual community benefit implementation plan.
A resolution, passed in 2017, directed the Cabinet Secretary for Health and Social Services to develop a strategy to reduce healthcare cost growth and improve health outcomes in Delaware, according to a Health Affairs blog. Delaware was the first state to set both a healthcare spending growth target and implement a suite of associated quality and population health measures. This article describes the evolution and implementation of the cost and quality benchmarks and the use of transparency (rather than incentives, penalties or regulatory levers) as the primary strategy for meeting the initiative’s goals. It is currently unclear whether transparency alone will help stakeholders lower cost growth and seek strategies to improve primary prevention and better manage care for high-risk patients.
Florida has passed legislation authorizing the state to import prescription drugs from Canada and other countries, potentially lowering the cost of lifesaving medicines that millions of people take every day, according to AARP. The law creates two prescription drug importation programs: The Canadian Drug Importation Program focuses on bringing down the cost of drugs to state-funded programs, such as Medicaid and the state prison system; and The International Prescription Drug Importation Program allows medicines to be imported from Canada and other countries, and then purchased by consumers through wholesale distributors and pharmacies. In order to implement these programs, states need approval from the U.S. Department of Health and Human Services (HHS) to begin their programs.
LifeBridge and Johns Hopkins are among the local health systems partnering with ride-hailing service firms to provide on-demand transportation to patients in need and reduce overall care costs, according to the Baltimore Business Journal. The program targets specific patient populations who demonstrate the most need, and do not have easy access to reliable transportation options, namely patients residing in areas of West Baltimore who need access to services at LifeBridge's Sinai and Levindale Hebrew hospitals. The goal is to ensure community members are able to get to preventative care appointments more easily, reducing the costs associated with missed healthcare appointments and helping community members remain healthy.
Twenty percent of Massachusetts residents have experienced a recent medical error and most of them said they “feel abandoned or betrayed by their doctor,’’ according to a survey summarized in the Boston Globe. Researchers estimated that 61,982 errors occurred in a single year, costing $617 million in follow-up care patients needed as a result of the mistakes. Despite a law that requires healthcare providers to disclose medical errors that cause significant harm and encourages them to apologize, only 19 percent of residents who reported an error said they received an apology. The survey, conducted by the Betsy Lehman Center for Patient Safety – a state agency – is one of the most comprehensive statewide examinations of medical errors to date
Drug benefit managers are increasingly profiting off pharmacies and insurers, driving up Massachusetts’s spending on healthcare, according to the Boston Business Journal. A new state report, issued by the Health Policy Commission, shows that pharmacy benefit managers have bolstered their own profits through a practice of “spread pricing” - negotiating a far lower price than what it passes on to the insurer. In 2017, total prescription drug spending at pharmacies grew 4.1 percent in Massachusetts – one of the highest healthcare spending increases in the state.
Minnesota lawmakers have extended to 2023 a moratorium that blocks the state’s nonprofit HMOs from being sold to for-profit companies, according to The Star Tribune. The measure was first adopted two years ago as a temporary measure to block conversion transactions, as lawmakers were concerned that nonprofit assets could wrongly be shifted to investor-owned carriers in a merger or acquisition.
Gaps in local health partners’ knowledge of available Medicaid services for homeless individuals and underuse of Medicaid reimbursements by qualified homeless individuals exhibit opportunities to reduce the healthcare costs associated with homelessness, according to KTVQ News. The Montana Healthcare Foundation report highlights that by targeting individuals in need of supportive housing intervention and aligning Medicaid funding for critical housing services, communities can realize cost savings and better health outcomes.
Nevada passed a law creating a Patient Protection Commission (PPC) that will examine healthcare costs and the primary factors that are driving those costs, reports KTV News. The PPC will also review the roots of disparities in care among different communities, including the adequacy of healthcare providers and availability of health insurance plans. The PPC will have 11 members appointed by the governor with recommendations from legislative leadership. Membership will include representation from across the industry – health plans, providers, hospitals, and pharmaceuticals – an academic experienced in healthcare policy and patient advocates to represent healthcare consumers.
A study that examined the network adequacy in New York State provides an overview of hospital network size and quality in the commercial, Medicaid, and NY State of Health markets, according to the New York State Health Foundation. The report found that some New York State regions offer residents access to primarily low-quality hospital networks, that differences exist in network size both within and across plan-product lines and there is a weak correlation between network quality and size. This project demonstrated that it is possible to measure health plan hospital network quality using publicly available sources.
An analysis of New Jersey data on Medicare’s mandatory bundling program shows that, while there are noticeable changes in discharge status trends correlated to types of bundled payment programs, more research is needed, according to Yahoo Finance. The recent report by NJHA’s Center for Health Analytics, Research & Transformation compared data for hospitals participating in the Comprehensive Care for Joint Replacement (CJR) bundle, hospitals participating in the Bundled Payment Care for Improvement “Classis” program (BPCI) and hospitals that participated in neither initiative. Results show that since CJR was mandated for 38 New Jersey hospitals in 2016, length of stay for joint replacement patients declined for all the hospital groups; CJR hospitals saw a 19-percentage point decrease in patients discharged to skilled nursing facilities and a 26-percentage point increase in patients discharged to home with home health assistance. Meanwhile, BPCI hospitals saw a large uptick in discharge to home with self-care and a large decrease in discharge to home with health assistance. Hospitals not participating in a bundling initiative, however, saw the greatest change in the increase of patients discharged to home with self-care, from 28 to 46 percent. Though the findings show that CJR bundles worked to reduce length of stay, there is a need for more investigation of whether complex patients who would have previously gone to inpatient rehabilitation are receiving the required services at skilled nursing facilities or outpatient care.
Pennsylvania is moving to take over the online health insurance exchange that has been operated by the federal government since 2014, saying it can cut health insurance costs for the hundreds of thousands who buy individual Affordable Care Act policies, according to the Lexington Herald Leader. Currently, the federal government takes 3.5 percent of the premium paid on plans sold through the exchange, or an estimated $94 million in 2019, though the state can operate the exchange for $30 million to $35 million and use the difference to draw down extra federal dollars for a reinsurance program that reimburses insurers for certain high-cost claims. The state's share would be about one-quarter of the reinsurance program cost, according to estimates. Those reimbursements will allow insurers to lower premiums within the state's insurance marketplace, as demonstrated by the experience with reinsurance programs in other states.
Texas has passed a law shielding patients from getting a huge bill when their insurance company and medical provider can’t agree on payment, according to Kaiser Health News. Under the new law, insurance companies and medical providers can enter into arbitration to negotiate a payment, removing patients from the middle of payment negotiations. Last year, a Kaiser Family Foundation poll found that 67 percent of people worry about unexpected medical bills — a larger share than those who say they worry about prescription drug costs or basic necessities such as rent, food and gas. Commonwealth Fund’s most recent report on the issue found about half of states offer some legal protections from surprise bills, but only six states had laws that provide “comprehensive” consumer protections similar to those just passed in Texas.
Vermont is eyeing birth control, insulin and pricey medications for HIV and multiple sclerosis as possible candidates for the state's landmark program to import cheaper drugs from Canada, reports Politico. State officials determined that the importation program could save insurers up to $5 million annually, based on this list of drugs, which the state has yet to finalize. A potential barrier is that Vermont must prove that the importation program wouldn’t pose additional risks to patient safety and that consumers will pay less for drugs under the new model in order to receive approval from HHS. HHS set up a working group last summer to study importation, but many of the details have been kept secret.
A new West Virginia will enable residents to access life-saving medicines when their supply runs out, the prescription is expired and the doctor can’t be reached to 'OK' it, according to WV Metro News. HB 2524 grants pharmacists the discretion to fill those prescriptions under specified conditions and certain circumstances. This bill allows pharmacists, under specified conditions, to extend 30-day prescriptions to 90 day and requires payers to cover the cost if it is consistent with the patient's benefit plan.
A 10-year project of the University of Wisconsin-Madison Population Health Institute and the Robert Wood Johnson Foundation shows the health disparities among populations in Wisconsin, according to The Milwaukee Independent. The interactive tool displays different health measures for the different counties in Wisconsin, from air pollution-particular matter to income inequality to ratio of population to primary care physicians.
Hospitals in Wyoming charged private insurance plans more than three times what Medicare would pay for the same care in 2017, according to a national study that looked at 14 hospitals in the state and nearly 1,600 facilities statewide, according to the Casper Star Tribune. Of the 25 states studied, Wyoming had the second-highest disparity between Medicare and private insurance for outpatient services: Private plans were charged 302 percent more than Medicare, a difference of $8 million. Only Indiana had a higher disparity. SageWest Health Care in Fremont County had the highest relative price in the state: The hospital charged private insurance more than eight times what the facility was paid by Medicare. Representatives of the Wyoming Hospital Association responded to the report suggesting that Medicare “doesn’t pay the actual cost of delivering care,” and therefore should not be used as the “measuring stick.”
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The use of Nurse Practitioners (NPs) and Physicians Assistants (PAs) as primary care providers for complex patients with diabetes was associated with less use of acute care services and lower total costs, according to a study published in Health Affairs. Case-mix-adjusted total care costs were 6–7 percent lower for NP and PA patients than for patients primarily cared for by physicians. The savings were driven by less frequent use of emergency and inpatient services.
Looking between the years of 2014 and 2016, researchers from the Research Consortium for Health Care Value Assessment found that spending on 5 high-value services increased by 17 percent. Meanwhile, spending on the 5 low-value services grew by 2 percent. The report analyzed spending from a commercial payer covering 10 million lives. These findings suggests that though there has been significant discussion around reducing low-value care services, improvements are not taking place. Low-value services included in the study were: vitamin D screening tests; prostate-specific antigen screening in men over 75; unneeded testing and laboratory work prior to low-risk surgery; imaging for uncomplicated low-back pain within the first 6 weeks of diagnosis; and use of more expensive brand name medications when generics are available. Low-back pain screening experienced the most significant increase during the study period, while there were decreases in spending on vitamin D testing and pre-operation testing, according to analysis from AJMC. Of the high-value services studied, healthy behavioral counseling and HIV ART experienced the most rapid growth (61 percent and 36 percent, respectively). Annual flu shots increased by 19 percent, retinopathy for diabetes increased by 9 percent, and vaginal deliveries increased slightly by 1 percent.
Studies have found that primary care physicians (PCPs) play a role in increasing low-value care (LVC) expenditures, indicating that payers, policymakers, and healthcare organizations should incentivize and enable wise spending on the primary care level, a slate of researchers have concluded, according to commentary published by Health Payer Intelligence. This piece highlights three recent studies that focus on how policymakers can cut low-value care expenditures, claiming that by concentrating on PCP education and empowerment in appropriate healthcare spending, payers, policymakers, and healthcare organizations may achieve greater success in lowering LVC expenditures.
Eighteen percent of all emergency visits and 16 percent of in-network hospital stays resulted in at least one out-of-network charge, leaving patients at risk for surprise medical bills, according to an analysis of 2017 claims data from large employer plans conducted by the Kaiser Family Foundation. The analysis also found that the incidence of such charges varied greatly by state, for both emergency visits and hospital stays. For instance, emergency care visits were more likely to result in at least one out-of-network charge in Texas, New Mexico, New York, California and Kansas, and less likely in Minnesota, South Dakota, Nebraska, Alabama and Mississippi. KFF polling also showed that nearly two-thirds of Americans are worried about being able to afford their own or a family member’s unexpected medical bills. The findings come at a time when policymakers of both major political parties in Washington have vowed to pass legislation to protect consumers against surprise medical bills. At the same time, more than a dozen states have enacted or implemented laws to combat the problem for people enrolled in state-regulated plans.
High-cost patients and high-cost doctors were much more likely to exit accountable care organizations (ACOs) than low-cost patients and doctors, according to HealthLeaders. A recent study published in Annals of Internal Medicine concluded that ACOs in the Medicare Shared Savings Program (MSSP) did not show improvement in spending or quality between 2008 and 2014 even after selective dropping of clinicians and their patients from the program. These results are concerning with respect to discrimination against high-cost patients. The National Association of ACOs (NAACOs) pushed back on the new paper, pointing to a guest post in the Incidental Economist blog that noted "several problems" in the study's methodology. "This paper is not an indictment of the real savings ACOs have generated, but further evidence of how the model is unfolding," NAACOS said in a statement.
Though quality measures play an essential role in driving improvement, measurement is fraught with challenges that make consistent application difficult, according to a recent study in the American Journal of Managed Care. The study reviewed how the approval of a heart failure drug introduced complexities in the measure life cycle for two value-based payment heart failure measures. The authors noted that for quality measures to be effective, they must communicate clear, evidence-based standards of quality care so that those providers being measured can understand what they must do to meet those standards.
A new issue brief from the Employee Benefit Research Institute (EBRI) found that, over time, as people build up more money in Health Savings Accounts (HSAs), they also tend to spend more; moreover, these savings accounts are more beneficial to higher income people. For every $1,000 in HSA balances, spending was nearly $500 higher. This contradicts assertions that HSAs encourage people to shop more smartly for healthcare services, bringing down spending, according to the Association for Health Care Journalists.
Researchers at the Urban Institute found that rolling out reforms, like adopting additional tax credits and provider payment caps, could reduce overall federal government spending by $12 billion in 2020 while also decreasing overall household spending by $9.2 billion and average premiums by $200 per month for those making 400 percent or more of the poverty level. Introducing capped rates or a public option on its own would reduce federal spending by $19.4 billion in 2020, a 5 percent decline from current spending on Medicaid, the Children’s Health Insurance Program and ACA subsidies, according to analysis from FierceHealthcare.
Counties in states that expanded Medicaid experienced an average of four fewer deaths from heart disease per 100,000 people than states that didn't expand their Medicaid programs, according to a new study. This amounts to about 2,000 fewer deaths per year, according to analysis from HealthDay News. Researchers found that deaths from heart disease remained stable in states with expanded Medicaid. In states without added Medicaid, however, heart disease deaths climbed from 176 per 100,000 to nearly 181.
Patients' out-of-pocket costs for inpatient services increased by 14 percent, on average, between 2017 and 2018, according to a new report from TransUnion Healthcare, which included self-pay, commercially insured and Medicare patient data. Patients' deductibles and co-pays averaged $4,659 for an inpatient visit in 2018, compared with $4,086 in 2017. In 2018, the average out-of-pocket bill for a trip to the emergency room was $617, up 7 percent from $577 in 2017. The study also found 59 percent of patients last year had an average out-of-pocket expense of $501 to $1,000 for a healthcare visit, up from 39 percent in 2017. Health systems are attempting to improve their patients’ financial experiences by instituting payment plans and planning to implement pre-service estimates, according to Modern Healthcare.
Researchers wanted to explore whether family medicine residents are learning the procedural skills they need to care for the nation’s fastest growing patient population -- adults age 65 and older, according to the American Academy of Family Physicians News. Researchers queried billing records and CPT coding data for both the control (Medicare patients who completed appointments with clinicians at a large multiregional healthcare system) and treatment (all Medicare patients who visited the family medicine residency clinic in Kasson, Minn.) groups over the three-year study, and found that large joint injection was the only clinical procedure performed with similar frequency between the control group and the residency clinic, while procedure rates were significantly different for the nine other studied procedures. Researchers also noted the rapidly changing medical landscape where residents are being trained to work in care teams with members working at the tops of their licensure, and the more recent spectrum of practice patterns in primary care where family physicians follow either the traditional path of providing comprehensive care themselves or serve as the coordinator of medical serviced on a team of healthcare professionals.
Visit these pages for more on scope-of-practice, health savings accounts, quality measures, surprise medical bills, the linkages between coverage and outcomes and more!
In a column in JAMA Network, authors argue that healthcare systems need to take a much more proactive role in building and earning the trust of communities experiencing high levels of disparities. Forging these trusted relationships will help to overcome decades of eroded confidence, and make progress toward eliminating those disparities. The authors explain that this “mistrust stems from historical events, structural racism, disparities in care and personal experiences of discrimination.” They acknowledge the necessity of strong community and consumer partnerships in order to truly begin addressing all the drivers of health, focusing on the vital role of trust in these relationships.
The demand for post-acute care—medical care required after a patient is discharged from the hospital—is on the rise as the population ages. However, patients and their families rarely have the expertise and support needed to navigate websites, identify higher-quality providers, assess their options, and make the best possible choice for post-acute care, according to STAT. Federal regulations restrict hospitals from recommending specific providers for post-acute care to avoid financial conflicts of interest, leaving consumers to select care based on location or word-of-mouth rather than the quality of care. Proposed regulations would require hospitals to share with patients and families quality information about rehabilitation centers and other post-acute care providers that is relevant to their treatment goals and preferences. Experts also suggest that integrating patient shared decision-making into discharge planning would help patients and their families make more informed decisions.
Each year an estimated 1 in 20 U.S. adults experience missed, delayed, or incorrect diagnoses. Of the estimated 12 million Americans impacted, 4 million are believed to suffer serious harm, with diagnostic errors contributing to about 10 percent of patient deaths. An AHRQ blog post discusses potential solutions, including improving diagnostic safety with the application of proven patient safety strategies, thoughtful integration of predictive analytics with clinician workflow, personalized and precision medicine, and new technologies like artificial intelligence. Congress has already authorized $2 million in FY 2019 for AHRQ to initiate a research agenda to understand and solve the problem. In addition, the recently released AHRQ QuestionBuilder App helps patients prepare and organize questions before a medical visit to help ensure a more accurate and timely diagnosis.
The Center for Medicare and Medicaid Innovation (CMMI) has released a new primary care payment model, called Primary Care First (PCF), which consists of three components: a risk-adjusted per-person capitation payment; a flat fee of $50 per visit; and a performance incentive based on inpatient utilization rates. The success of this program depends, in part, on how much assistance primary care physicians need in efforts to rebalance the delivery system, according to a Milbank blog post. Based on CMMI’s revenue calculations, there is only a financial gain for practices if they save money on administration or collect incentive money. The main question remains: What is the right balance between upfront resources that allow practices to build capacity and payments based on the achievement of desirable outcomes? CMMI could learn from other programs implemented by health plans that offered enhanced up-front payments and technical assistance to improve primary care, as well as performance-based payments at the back end. The author asserts that not all primary care practices can or will be part of a larger risk-bearing entity and creating stronger financial incentives for them is necessary but not sufficient.
A recent Centers for Disease Control and Prevention study found that of the estimated 700 annual maternal deaths in the U.S., 3 in 5 could be prevented with greater access to care, earlier and more accurate diagnoses, and greater recognition of warning signs. A large contributor to problems in maternal healthcare has been the lack of continuity of care, according to Modern Healthcare. Andria Cornell, associate director of women’s and infant health at the Association of Maternal & Child Health Programs, stated that “There’s a fragmentation in how we understand birth outcomes, how we measure and evaluate the quality of care and the support that a person receives based on these various time points.” Many mothers experience severe complications after they are discharged and are forced to go to the ED. A 2015 study found that 73 percent of patients going to the ED postpartum had obstetrical complications. States are taking action—California cut its maternal mortality rate by 50 percent from 16.9 deaths for every 100,000 live births through its Maternal Quality Care Collaborative.
Healthcare systems and policymakers in the United States increasingly use language related to social determinants of health in their strategies to improve health and control costs, but the terms used are often misunderstood, conflated and confused. This Milbank Quarterly publication highlights key terms in an effort to provide clarity.
Visit these pages for more on glossaries to navigate the healthcare value space, solutions to address disparities, medical harm, price and quality transparency, social determinants of health and more!