WEEKLY E-BULLETIN


NBC News: Surgery Is Big Business, Prices Continue Steady Climb

Surgery has bloomed into a $500 billion industry in the United States, where 80 to 100 million procedures are performed annually — a per-capita rate that’s some 50 percent higher than in the European Union, according to researchers, and the cost of surgery is increasing every year. Click here for this NBC News report that takes a closer look at surgery prices.

Judge Rules In Favor of 340B – Again

A Washington, D.C., federal judge has rejected requests from Pharmaceutical Research and Manufacturers of America to invalidate a new interpretive rule involving so-called orphan drugs in the 340B drug discount program, saying the trade group must bring a new lawsuit to proceed. The ruling was the latest development in a fast-evolving dispute over the Obama administration’s position that drugmakers must provide discounts to certain hospitals and clinics for rare-disease products known as orphan drugs when those drugs are used for nonrare conditions. It’s a setback for Pharma, but the debate is far from over as HRSA continues to develop a new regulatory framework for the 340B program. Click here for the judge’s ruling.

CMS Offers Deal to Hospitals on RAC Appeals; Conference Call Tomorrow

CMS has announced it is offering an administrative agreement to any hospital willing to withdraw its pending RAC appeals in exchange for timely partial payment (68% of the net allowable amount). CMS encourages hospitals with inpatient status claims currently in the appeals process to make use of this administrative agreement mechanism to alleviate the administrative burden of current appeals on both the hospital and Medicare system. Only acute hospitals and CAHs are eligible. Psych, IRFs, LTCHs, Cancer and Children’s hospitals are not eligible. Click here for more information from CMS. Click here to register for a special CMS conference call tomorrow, Sept. 9 at 1 p.m. EDT.

Report Shows Benefits to Hospitals in Medicaid Expansion States; Moody’s Says NFP Hospitals Challenged

A new report from PwC found that hospitals in states that expanded Medicaid had an average 47 percent drop in uninsured patients. Hospitals in states that sat out expansion saw only tiny reductions. For one major chain, Tenet Healthcare, this translated to $78 million less in uncompensated care during the first half of 2014, compared to the same period last year. Click here for this interesting report. However, a new Moody’s report says not-for-profit hospital revenue growth is at an all time low. Click here for the announcement from Moody’s. Click here for the NYTimes report.

New Plan Would Expand Accountable Care to States

There’s a new accountable care plan on the table that would expand the idea to entire states. The Center for American Progress is proposing a multi-payer “Accountable Care States” model under which CMS would offer broad payment reform flexibility to states limiting per-capita spending and in turn share with states the resulting health care savings, which the group estimates could reach $1.7 trillion over 10 years. Click here for the complete proposal.

FDA OKs New $150,000 Drug

The debate over expensive pharmaceutical regimens will likely intensify with the FDA last week approving a new kind of cancer drug from Merck that is designed to unleash the body’s immune system against tumors. The drug is part of a long-anticipated wave of medicines that could transform cancer treatment and forge a large new market for pharmaceutical companies. The FDA cleared the drug, pembrolizumab, for the treatment of a deadly form of skin cancer, melanoma. Merck plans to sell the drug under the brand name Keytruda. Merck said the cost to payers for many patients will be $12,500 per patient monthly, or $150,000 for a year’s worth of treatment. Click here for the FDA announcement and here for the WSJ story.

New Drug Prolongs Lives of People with Heart Failure

An experimental drug has shown a striking efficacy in prolonging the lives of people with heart failure and could replace what has been the bedrock treatment for more than 20 years, according to researchers. The drug, which is being developed by Novartis, reduced both the risk of dying from cardiovascular causes and the risk of being hospitalized for worsening heart failure by about 20 percent in a large clinical trial. Click here for the story.

Seniors with Higher Co-Pays for Brand Name Drugs Buy Less Rx

Seniors enrolled in Medicare plans that charge higher co-pays for brand name or non-preferred medications fill almost 15 percent fewer prescriptions than their peers who have a flat co-pay for all prescription medications, a new study released last week finds. The data highlights a tough decision for older Americans: Spend more or skip some of their medicines, including those for chronic diseases such as diabetes and high blood pressure. Click here for details.

HHS Formally Delays Meaningful Use, Allows More EHR Flexibility

HHS has published a final rule that allows health care providers more flexibility in how they use certified electronic health record technology (CEHRT) to meet meaningful use for an EHR Incentive Program reporting period for 2014. The rule officially delays stage 2 of meaningful use for another year to 2016 and stage 3 to 2017. Click here for the HHS details, including an updated Meaningful Use timeline. CHIME expressed disappointment with a key part of the rule. Click here.

CMS Actuary Says Uninsured Will Decline Significantly, Spending Growth Will Increase

The number of uninsured is expected to decline by nearly half from 45 million in 2012 to 23 million by 2023 as a result of the coverage expansions associated with the Affordable Care Act, according to a CMS actuary report released last week. Health spending growth for 2013 is projected to remain slow at 3.6 percent, which would mark the fifth consecutive year of spending growth under 4.0 percent. National health expenditures (NHE) are projected to grow at an average rate of 5.7 percent for 2013 through 2023, about 1.1 percentage points faster than the expected average annual growth rate for the Gross Domestic Product. Click here for the CMS report. Medicare spending is actually falling, according to a NYTimes report. Click here. Key Senate Republicans are mounting a spirited counter to the claims of Obamacare successes. Click here for their new report.

Osteopathic Medicine Is On the Rise

The number of osteopathic physicians is surging and some believe it is due in part to the transformation of health care and the Affordable Care Act. Click here for the story.

5 States Will Get SHOP Launch Early

HHS is planning a soft launch for the small business health option program (SHOP) exchange, allowing companies in just five states–Delaware, Illinois, Ohio, Missouri and New Jersey–to start accessing the marketplace next month. HHS is opening the SHOP marketplace to the five states early to hopefully work out any kinks and glitches before the exchange goes live Nov. 15 for the full open enrollment period. Click here for more.

Health Insurance Premiums on Exchanges Have Remained Steady

Health insurance premiums for health plans participating in state health exchanges over its first year have remained fairly steady, according to a Kaiser analysis of 2015 premium changes. The newly released survey of health plans across 15 cities is one of the “first tangible tests of how well the ACA is working,” according to the report. Premiums for some plans actually dipped, the study found. For example, the premium for the second-lowest-cost silver plan in the marketplaces decreased by an average of -0.8 percent, before taking any income-related tax credits into account. Click here for the analysis and a state-by-state review.

Highmark Files Suit Against UPMC on Pricing of Cancer Drugs

Health insurer Highmark filed a lawsuit last week against University of Pittsburgh Medical Center (UPMC) for allegedly overbilling the insurer by $300 million for cancer drugs. If Highmark wins, the case could be a “landmark and precedent-setting event” for insurers seeking to block providers from overcharging on procedures, according to a report in the Pittsburgh Post-Gazette. Highmark claims that UPMC has been engaging in “pricing manipulation” by charging overly expensive prices for oncology and cancer-related treatments. Click here for the story. Click here for a report on how insurers in New Jersey are dealing with certain hospital pricing tactics.

Blue Cross CEOs See Big Salary Increases

Thirty-two Blues plan CEOs who served that role for part or all of 2013 collectively earned nearly $25 million in salary and about $103 million in total compensation, which includes bonuses and incentives, according to a report published last week. While some top executives saw substantial compensation increases, salary levels were relatively flat in 2013 compared with prior years. Between 2011 and 2013, many Blues plans offered their top executives “very significant” increases in the size of their long-term, performance-based financial incentives, but modest increases to their target annual incentives, according to one analyst. Click here for the story that includes specific compensation information on each plan.

HHS Releases $65 Million to Reduce Infant Mortality

HHS has released $65 million in grants to help 87 organizations in 33 states reduce high infant mortality rates and other health problems related to pregnancy and mothers’ health. Click here for a list of awardees.

Legislators Urge CMS Not to Cut Payments for Certain Cancer Procedure

Bipartisan groups of lawmakers in both chambers are urging CMS not to go through with proposed cuts in reimbursement for a procedure that kills cancer with targeted radiation. The lawmakers and radiation oncologists take issue with CMS’ justification for one technical element of the proposal: that the vaults housing linear accelerators are indistinguishable from the medical-office buildings to which they join and therefore are not a direct practice expense. CMS’ decision in the proposed Physician Fee Schedule to remove radiation treatment vaults as a direct cost for radiation treatment codes would cut average Medicare reimbursement for radiation oncology services by 4 percent, and that’s on top of the 20 percent in pay cuts to radiation oncology services over the past five years. Click here for the letter led by Sens. Debbie Stabenow (D-MI) and Richard Burr (R-NC).

Newspaper Examines Financial Moves of For-Profit Hospital Group

How do for-profit hospital operators make money with their enterprises? That’s the question pursued by a newspaper in New Jersey where Prime Healthcare Services may soon own as many as four hospitals. Click here for the report.

Urgent Care Centers Taking Business from Hospitals

Promoting themselves as cheaper and quicker alternatives to hospital emergency rooms, urgent care centers cater to patients who need stitches, X-rays of broken bones or treatment of allergic reactions. Some clinics have been around for years, and about 300 open each year across the country and hospitals say they are losing insured patients to them. Click here for this story from Texas.

Mental Health Services Expanding Across the Country

The Affordable Care Act has paved the way for a vast expansion of mental health coverage in America, providing access for millions of people who were previously uninsured or whose policies did not include such coverage before. Under the law, mental health treatment is an “essential” benefit that must be covered by Medicaid and every private plan sold through the new online insurance marketplaces. Click here for the NYTimes story on how this change is impacting people across the country.

Obesity Rates Continue to Increase

All 50 states failed to bring down their adult obesity rates last year, and in six states, rates inched up, according to an analysis released last week. The annual obesity progress report found that while there are some bright spots, not enough progress has been made fighting the epidemic in the United States, even with unprecedented national attention on the importance of healthy eating. Alaska, Delaware, Idaho, New Jersey, Tennessee and Wyoming all saw obesity levels increase. Mississippi and West Virginia are tied for the highest obesity rates with just over 35 percent. Arkansas, Tennessee and Kentucky are next highest by just a couple percentage points. Colorado still has the lowest obesity rate with just over 21 percent. Click here for the obesity report with a state-by-state review.

SAMHSA Report Details Illicit Drug Use

In 2013, 24.6 million Americans aged 12 or older were current illicit drug users — 9.4 percent of this age group, according to a report released last week by the Substance Abuse and Mental Health Administration. That is a slight increase from the 9.2 percent in 2012. Marijuana was the most commonly used illicit drug, with about 19.8 million users — nearly a million more than the 18.9 million users in 2012. The data are only through 2013 and may not reflect increases due to states legalizing marijuana. Click here for the SAMHSA report.

Doctor Details His Fight with a Hospital Over a Bill

How to fight an outrageous hospital bill? A doctor/lawyer writes a compelling piece for the NYTimes. Click here.