More than 100,000 employed Alabamians can’t afford healthcare, reports the Alabama Political Reporter. These employees tend to work in food services, grocery stores, schools, childcare, the auto industry, construction, home centers, food services and animal processing and can’t afford the healthcare provided by their employers or through private insurance they purchased themselves, according to a report by Alabama Arise. Alabama is one of 14 states that have yet to expand Medicaid. The report cites a study published in January 2019 by the University of Alabama at Birmingham, which found that expanding Medicaid would increase healthcare access to 340,000 people, approximately 65 percent of whom would be newly insured. The Alabama Hospital Association claims the move would provide critical revenue for rural hospitals and provide care to employed Alabamians who still cannot afford care.
California passed a measure to require Kaiser Permanente to join other insurers in providing more detailed information on expenses and revenue, reports The Sacramento Bee. Moving forward, Kaiser must report expenses and revenue for each of its facilities; break down revenue by type of payer (Medicare, Medi-Cal or private insurance) at each facility; and break down rate increases by type of service (hospital, physician services, pharmacy, radiology and laboratory). Consumer advocates support the increased transparency, citing that Kaiser has had a fairly broad exemption from much of the state’s rate review processes that other insurers have to follow. This bill ensures that Kaiser will provide the same types of information justifying their rates as other health insurers.
Blue Shield of California launched a 12-month pilot program that will allow more than 1,300 Sacramento-area residents to get free Lyft rides to primary care appointments; X-ray or lab visits; and to pick up prescriptions at the pharmacy, reports The Sacramento Bee. Blue Shield will pay for eligible members’ rides directly and will allow members to bring a caregiver to help with walkers and other aspects of their medical care. The program, called RideQ, will be evaluated on its ability to improve health outcomes and care experience, reduce costs and increase physicians’ job satisfaction. RideQ is part of a larger initiative to identify and eliminate the non-medical barriers that keep people from receiving needed care.
Health systems and physician groups have dominated the Denver healthcare market in recent years, but employers and health plans are poised to disrupt that dynamic, reports HealthLeaders. Four major health systems accounted for 85 percent of patient admissions in 2017, according to a report by Catalyst for Payment Reform and the Colorado Business Group on Health, which may be enough to stifle price competition. Indeed, the study revealed that Coloradans face 13 percent higher prices compared to the national average and 5 percent higher utilization rates. Authors of the report indicate that a statewide purchaser cooperative may be an effective method to change the market dynamics in Denver.
Connecticut is using certificate of need (CON) regulations to hold hospitals accountable for making meaningful investments in their communities’ health, according to the National Academy for State Health Policy. In a recent CON agreement, the Connecticut Office of Health Strategy mandated that merging hospitals: adopt evidence-based interventions to address community needs; explain how patient outcomes will be measured and reported to the community; and increase the total dollars spent on community benefit activities by at least one percent each year for the next five years. These activities must directly address the health and health-related social needs identified by the hospital’s Community Health Needs Assessment. While the CON conditions are time-limited, they demonstrate what is possible when states use their policy levers to maximize community benefits investments.
The District’s largest Medicaid managed care organization and a nonprofit law firm are teaming up to reduce healthcare costs by going after mold and infestations, according to the Washington Business Journal. AmeriHealth Caritas D.C, a local insurance provider with more than 100,000 members, has formed a partnership with Children’s Law Center (CLC), a network of lawyers who serve more than 5,000 families each year, to reduce asthma-related hospital visits by targeting unsafe housing conditions. Under the collaboration, AmeriHealth care managers refer members to the CLC team, which speaks with those families to understand their living environments and what needs to change. The attorneys then work to get landlords to fix poor housing conditions or relocate the residents to safer homes. The goal is to reduce the number of medical interventions needed by children with asthma in the District over time.
Washington D.C.’s Department of Health Care Finance (DHCF), the District’s Medicaid agency, announced that it will transition nearly 22,000 individuals currently in the Medicaid fee-for-service program to a Medicaid managed care program in addition to launching two major changes that will improve equity and value for the Medicaid, Alliance and Immigrant Children’s Programs. First, DHCF will expand value-based purchasing requirements in the managed care program to promote an enhanced focus on health outcomes for Medicaid enrollees. Second, DHCF will implement universal contracting for critical providers in the city’s healthcare market to even the playing field and improve access to needed healthcare providers for all Medicaid enrollees. Given DHCF’s role as the payer for 40 percent of the District’s population, these changes are expected to have a broader positive impact for the District’s healthcare delivery system, as well.
More than half of Floridians delay or skip medical care, struggle to pay their medical bills or are uninsured because health care is too expensive for them, according to a new survey. These results were especially pronounced in Central Florida, where four out of five respondents said they were worried about not being able to afford healthcare. The majority, regardless of political affiliation, said the government had to solve the problem, particularly the high cost of care and prescription drugs, the Orlando Sentinel revealed.
The MercyOne ACO is a statewide organization comprised of more than 2,300 doctors and 500 practice sites organized into regional accountable care organizations (ACOs) and clinically integrated networks in Iowa. The organization is moving spending “upstream”- shifted from just looking at claims and electronic health record data to help predict individual patient risk to a broader view of the patient experience, including social determinants, reports Healthcare Innovation. In an August 27 webinar, MercyOne ACO executives described their efforts to engage patients in discussions about food, transportation, and housing issues and the addition of community health workers to help them navigate the relationship between health systems and social service agencies.
Air ambulance companies have begun advertising memberships to rural Kansans in the wake of recent hospital closures, prompting concerns that the companies are exploiting vulnerable patients, reports KCUR. Although the membership programs promise to protect customers from out-of-pocket expenses, the contractual fine print often undermines the advertised intent. For example, privately insured patients who purchase memberships would still receive a bill and must work through their insurance company’s claims, denial and appeal processes. Additionally, air ambulance companies can end memberships at any time without obligation to notify the customer. North Dakota and Montana ban or heavily regulate the memberships in attempt to better protect consumers.
Marketwide price information at the insurer-provider-service levels could help target policy interventions to reduce healthcare spending, according to a simulation reported in Health Affairs. Researchers examined variation in fee-for-service commercial prices in Massachusetts for 291 predominantly outpatient medical services and found that prices varied considerably across hospital service areas. Prices for medical services at acute hospitals were, on average, 76 percent higher than at all other providers. The service categories with the widest price variation were ambulance/transportation services, physical/occupational therapy and laboratory/pathology testing. In this market, simulations suggested that steering patients toward lower-price providers or setting price ceilings could generate potential savings of 9–12.8 percent.
Commercial inpatient healthcare spending has increased in Massachusetts despite declining volumes, according to Modern Healthcare. Commercial inpatient spending across the state grew 10.7 percent from 2013 to 2018, while service use decreased by 12.8 percent, according to a report from the Massachusetts Health Policy Commission. In addition, the average commercially insured patient risk score increased 11.3 percent from 2013 to 2017, which theoretically should have increased intensive care unit and cardiac care unit volumes and lengths of stay. Instead, the data suggest that hospitals are maximizing coding rather than treating sicker patients.
Certificate of need (CON) laws are restricting access to innovative cancer immunotherapies in Michigan, according to Reason. Immunotherapies attempt to program the body's own immune system to attack and kill cancer cells, and have become an increasingly attractive way to combat cancer. However, under new rules adopted by the Michigan Certificate of Need Commission, hospitals will need to go through third-party accreditation processes before being able to offer these CAR T-cell therapies. Though cancer research organizations, patient advocates and pharmaceutical companies oppose the new accreditation requirements, the University of Michigan Health System, the largest in the state, argue they are necessary for patient safety. CON laws vary from state to state but require that hospitals get a state agency’s permission before offering new services, expanding facilities or installing new medical technology.
The University of Missouri is one of five institutions nationwide to receive nearly $5 million in federal funds to address the looming shortage of primary care physicians, reports the St. Louis Post Dispatch. Most of the money will go toward the expansion of programs already in progress to recruit college students from rural areas to pursue rural medicine, while also exposing more medical school students to doctors in small-town clinics instead of specialists at large teaching hospitals. A smaller portion of the money will fund the development of a new family medicine residency program at the Bothwell Regional Health Center in rural Sedalia.
Residents say the only hospital in Carlsbad, N.M., is notorious for suing its patients, adding in lots of mystery charges and refusing to give itemized bills, reports CNN. When patients can’t pay, the hospital will sometimes sue them to collect the money. An investigation of court records shows that in the past 10 years, Carlsbad Medical Center has sued more than 3,000 people to collect debts. In a statement, the hospital CEO said they sue fewer than one percent of the patients who receive care at the hospital. Still, most other hospitals in the region haven’t sued any patients for debt collection over the past 10 years.
During the 2019 legislative session, New Mexico enacted SB337, which takes effect in January 2020 and will protect New Mexico residents (who have state-regulated health plans) from surprise balance billing, reports Healthinsurance.org. Under the state’s new law, patients cannot be charged more than their regular in-network cost-sharing obligations (copays, deductible, coinsurance, up to the maximum out-of-pocket level for their plan) if they receive emergency care at an out-of-network facility or receive non-emergency care from an out-of-network provider at an in-network facility, as long as the patient either had “no ability or opportunity” to receive the care from an in-network provider instead. This includes situations in which there is no in-network provider available.
The homeless population of New York City has long used the emergency department at higher rates than the non-homeless population, but new research indicated that this may be connected to first-time shelter use, according to the Wall Street Journal. Thirty-nine percent of adult homeless shelter users visited the emergency department for treatment or were hospitalized in the year before they entered a shelter. In fact, the number of hospital visits began to increase in the months leading up to shelter entry. The study, published in Health Affairs, also shows that in the year after leaving a shelter, 43.4 percent of first-time shelter users went to the emergency department or were hospitalized. These significant spikes in visits to the emergency department just before first-time shelter use and just after leaving a shelter indicate that these may be opportunities to connect individuals with interventions and social services to prevent individuals from becoming homeless.
An integrated data system is allowing officials in Rhode Island to develop a more thorough understanding of the health needs of residents, reports HealthITAnalytics. In Rhode Island, government agencies worked together to create the Executive Office of Health and Human Services (EOHHS) Data Ecosystem. This integrated data system blends data sources from multiple organizations to help create a holistic view of Rhode Islanders. The goal of the Data Ecosystem is to help agencies improve their performance and understand the individuals they serve.
Despite efforts to increase the number of doctors in rural areas, many Oklahoma counties still lack the physicians needed to provide sufficient care for residents, reports The Oklahoman. Seventy-two of the state's 77 counties are designated as primary health-professional shortage areas by the federal government and 30 of them have 10 or fewer doctors of any type. Oklahoma has been creating incentives for doctors to practice in rural areas since the 1970s, but big-city amenities and educational and professional resources draw many physicians to other areas. Additionally, new physicians are increasingly choosing specialty practice so they can earn more and pay off sizable debt from medical school more quickly. This exacerbates the rural-urban divide because most specialty practices are located in urban areas. As a result, the state is funding a $5 million, five-year program to help pay off doctors' student debts if they agree to practice in a rural area.
Half of Ohio residents surveyed experienced healthcare affordability burdens in the prior year: they either went uninsured, struggled to pay for medical care, or avoided or delayed it, according to new Altarum Healthcare Value Hub survey data released by the Universal Health Care Action Network of Ohio. A quarter of respondents said they did not fill prescriptions, cut their medications in half or skipped doses due to cost, Statehouse News Bureau reports. Additionally, about a third of privately insured Ohioans said they'd gotten a bill they didn't anticipate, and only a third of those were solved satisfactorily.
As health plans prepare to submit rate filings, a new report from Oregon’s Division of Financial Regulation’s Prescription Drug Price Transparency Program illuminates just how much prescription drug prices impact insurance premiums. Oregon requires health plans to report on: per member, per month (PMPM) drug costs; top 25 drugs responsible for the greatest increase in planning spending; top 25 most costly prescription drugs; and the top 25 most frequently prescribed medications. Based on 2018 data, on average, drug costs represented 14 percent of premium rates in Oregon. Abbvie’s Humira, a biologic used to treat various autoimmune diseases, topped the list as both the most costly and the largest contributor to increases in plan spending.
A new rural health research center in Tennessee will focus on breaking the cycle of inter-generational behavior that contributes to poor health. The Center for Rural Health Research will be housed at the College of Public Health at East Tennessee State University in Johnson City, TN, according to Daily Yonder. The center will also work to become a source for policymakers – providing the data from which those in government and other policy making organizations can make decisions to help improve the health of those in rural and nonurban communities.
Low-income adults in Texas were much more likely to be uninsured and to experience financial barriers to care than their counterparts in the three states that expanded Medicaid, according to a new analysis from the Commonwealth Fund. Moreover, most low-income Texans support Medicaid expansion, which could extend coverage to 1.2 million uninsured individuals and increase affordability. The report includes a discussion of potential expansion effects on hospitals and the state’s economy. Studies show that Medicaid expansion reduces the share of uncompensated hospital care, which totaled $6.8 billion in Texas in 2016. Expansion has also been associated with fewer rural hospital closures (80 percent of which happen in nonexpansion states), where these entities account for 14 percent of total employment on average. Since 2013, 19 rural hospitals in Texas have closed due to financial difficulties.
Insurance premiums for Washington’s individual market are rising less than 1 percent on average in 2020, which may be due to market domination by homegrown insurance companies, according to The Seattle Times. Homegrown insurers are tied to the local community and must succeed in Washington or in the Pacific Northwest region to stay in business. Presumably, this motivates them to try harder to meet their customers’ needs. Other ways that local plans can help stabilize their state-based marketplaces include helping fill geographical market gaps, building better partnerships with local doctors and hospitals and reaching underserved populations more effectively.
A recent report by the Wisconsin Collaborative for Healthcare Quality revealed wide variation in how people in the state experience health outcomes and care, which is influenced by many factors. The report found substantial disparities across several measures. For example, the data show that Black Wisconsinites experience substantial disparities (defined as 10 percent lower than the best performing group) for childhood vaccinations, weight management, blood pressure control, tobacco use, and diabetes or heart disease prevalence. Many outcomes were stratified by race and payers or insurers. For instance, those who were uninsured or have Medicaid experienced similar and substantial disparities in nearly every measure compared to those with commercial or Medicare coverage. The Wisconsin Collaborative for Healthcare Quality hopes this data will be used to increase health equity within the state.
Comprehensive mandates for prescription drug monitoring programs (PDMPs) require state-licensed prescribers and dispensers to register with and use programs in most clinical circumstances. Such mandates have the potential to improve providers’ participation and reduce opioid-related adverse events. A study in Health Affairs found that state implementation of comprehensive PDMP mandates were associated with reductions in the opioid prescription rate, the opioid-related inpatient stay rate and the opioid-related emergency department (ED) visit rate among Medicaid enrollees from 2011-2016. Researchers estimated that annual reductions of approximately 12,000 inpatient stays and 39,000 ED visits could save over $155 million in Medicaid spending, a fact that deserves policy attention as states attempt to tackle the opioid crisis.
Although rebates for brand-name drugs in Medicare Part D substantially reduced drug spending, the rebates were not enough to offset major spikes in drug prices, according to a new study from Office of Inspector General. The OIG found that Part D spent $2 billion more for brand-name medicines in 2015 than it did in 2011, despite the total dollar amount of rebates increasing by $8 billion during that same period, Becker’s Hospital Review reports.
The Affordable Care Act’s (ACA) reductions to Medicare Advantage plan payments were not associated with declines in healthcare access or affordability for Medicare Advantage enrollees, according to a study in the American Journal of Managed Care. Researchers found that as payment cuts were phased in, Medicare Advantage plans reduced costs without diminishing healthcare access or affordability for enrollees relative to traditional Medicare beneficiaries.
Adult Medicaid beneficiaries who switched from a fee-for-service to a managed care model experienced a significant decrease in utilization -- below that of beneficiaries who had a continuous fee-for-service model and below beneficiaries who been in managed care model continuous for more than 12 months, according to a study in the American Journal of Managed Care. The beneficiaries who switched tended to be sicker, with higher adjusted average ambulatory visits at baseline than the other two groups, and the overall changes in ambulatory visits were driven by the subgroup with 5 or more chronic conditions. The results of this study support the assertion that managed care can reduce ambulatory utilization for the sickest beneficiaries.
A study of more than 1,600 U.S. hospitals revealed that value-based programs such as accountable care organizations (ACOs) appear to encourage the adoption and spread of care coordination activities by hospitals, reports Healthcare Innovation. A few key findings from the study, published in the American Journal of Managed Care, included: overall, U.S. hospitals adopted a relatively high number of care coordination activities but were less effective at spreading these activities throughout the hospital; opportunities to improve the use of care coordination activities are not evenly distributed, with hospitals reporting extensive use of some activities and minimal use of others; and hospital participation in value-based programs, especially accountable care organizations, may provide a catalyst to adopt and spread care coordination activities.
States working to coordinate care for Medicaid beneficiaries have seen inconsistent results from their efforts to reduce healthcare spending for high-cost beneficiaries, according to a report from the Government Accountability Office. About half of Medicaid spending is attributable to 5 percent of recipients. State efforts have focused on coordinating physical and mental healthcare, providing a fixed payment to managed care organizations to treat the high-cost population, providing case managers, mandating care management services and implementing home health programs, among other strategies. For example, in 2013, South Dakota implemented a health home program which paid local primary care clinics, community mental health centers, and Indian Health Service facilities to provide care management to high expenditure Medicaid beneficiaries. Medicaid officials in the state found that, for 2017, health home participants cost $204 less per month than the comparison group and experienced an 8 percent decline in emergency room visits from the prior year compared with a 10 percent increase in emergency room visits for the comparison group. However, Indiana’s Right Choices Program found relatively low cost savings. State officials have stated that the most significant barriers to care management stem from the inability to contact beneficiaries, social determinants of health and staff shortages in rural areas, Modern Healthcare reports.
Between 2013 and 2017, the share of children whose families had problems paying medical bills declined by 20 percent, but one in six children (an estimated 13 million) still lived in a family with problems paying medical bills in 2017, according to an Urban Institute report. Low-income children were more likely than higher-income children to live in families with problems paying medical bills, and four in five low-income children lived in families that were either uninsured or had health problems in the family. These findings suggest currently high levels of insurance among children are not sufficient to protect them from family financial insecurity associated with medical bills.
CMS quality measures might not indicate the actual care patients receive, according to a new Government Accountability Office report, reports Modern Healthcare. The watchdog found that CMS does not have processes in place to ensure that the indicators actually measure goals articulated by the agency’s strategic objectives. The CMS should create standard practices to assess the measures under consideration to ensure they line up with strategic quality objectives, the GAO said. The GAO recommended that CMS monitor its progress in achieving its goals by developing and using performance metrics.
Nearly three-quarters of 112 metropolitan areas across 43 states had "highly concentrated" hospital markets in 2016, according to a report by the Health Care Cost Institute. More than two-thirds of metro areas had more lopsided hospital markets in 2016 compared to 2012 and areas with concentrated hospital markets tended to see larger increases in their inpatient prices. Other studies have demonstrated a stronger link, one of which concluded that prices at monopoly hospitals are 12 percent higher than those in markets with four or more rivals. Hospital trade groups have opposed efforts to cap payments, according to analysis from Modern Healthcare.
Healthcare costs are the biggest concern for employers and many have taken steps to lower those costs, at times by passing them on to employees through higher premiums or reduced coverage, according to new poll results. The report is the result of three phases of research, funded by the Commonwealth Fund, aiming to better understand employers’ perspectives on healthcare costs. Ideologically, many employers prefer private-sector solutions to government solutions. Yet all options provided to curb costs, both market-based and regulatory options, saw support among business owners. For example, a majority of small business owners supported Medicare for All and allowing employees to buy into Medicare and Medicaid or another government-administered health plan.
Insurers will be issuing a total of at least $1.3 billion across all markets—exceeding the previous record high of $1.1 billion in 2012, according to Kaiser Family Foundation estimates. The medical loss ratio (MLR) provision requires insurance companies that cover individuals and small businesses to spend at least 80 percent of their premium income on healthcare claims and quality improvement, leaving the remaining 20 percent for administration, marketing and profit. Insurers failing to meet the applicable MLR standard are required to pay rebates to consumers. Rebates vary by state—across all markets, insurers in Virginia will pay out the highest total rebates ($149.6 million), followed by Pennsylvania ($130 million) and Florida ($107.4 million).
White Medicare patients are more likely to be transported to the closest emergency department (ED) than their black or Hispanic counterparts, according to a new study out of Boston University’s School of Medicine. Instead, the data revealed black and Hispanic Medicare patients were more likely to be transported to a safety-net ED compared to white patients living within the same zip code. Rates of transport also varied by the number of EDs within a 10-mile radius.
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America’s hospitals have managed to avoid much of the blame for rising healthcare costs, unlike pharmaceutical companies and insurers that have been targeted by politicians for years, according to The New York Times. However, data show that hospitals are by far the biggest cost in our $3.5 trillion healthcare system, where spending is growing faster than gross domestic product, inflation and wage growth. A report from Yale and other universities revealed that hospital prices increased 42 percent from 2007 to 2014 for inpatient care. Hospitals may have snuck by under the radar because every Senator and nearly every Member of Congress have a powerful hospital system in their district, often serving as the biggest employer in cities and states. Additionally, hospital trade groups, medical centers and their employees are major political donors, contributing to both political parties.
Since a shared vocabulary is the necessary first step for discussing racial equity, Generocity has put together a glossary of terms you might find useful. The terms as defined here are informed by glossaries published by Race Forward, W.K. Kellogg Foundation, The Aspen Institute and other sources.
After a Washington Post and Kaiser Health News investigation revealed that UVA Health System sues thousands of patients a year, seizing wages and home equity to collect overdue bills, the institution revealed that it would increase financial assistance and discounts to uninsured. However, the new policy still leaves numerous patients exposed to lawsuits and crippling bills, Kaiser Health News reports. The nonprofit health system has said it would grant discounts of 40 percent to the uninsured. However, experts have called for discounts to be lowered further to reflect Medicare levels. UVA Medical Center, the core of UVA Health, made an $87 million operating profit on revenue of $1.7 billion in the fiscal year ending in June and held stocks, bonds and other investments worth about $1 billion.
International perspectives on the healthcare system in the U.S., featured in Health Affairs, highlight the importance of political differences as a unique determinant of regional variations in healthcare access and performance. The healthcare system in the U.S. is a complicated and fragmented marketplace, rather than a single, coordinated and unified entity. Framing the policy debate—in other countries, there is broad consensus that healthcare is a fundamental right, rather than a privilege—unlike the U.S. Exacerbating the issue, governance is often unclear, and there is no shared understanding of what each actor in the healthcare system is accountable for (and to whom).
A new tool from the Kaiser Family Foundation combines a number of publicly available data sources to examine how much individuals and families in the United States spend on health, both directly and indirectly.