March 25, 2019

Battle Lines Forming Over Surprise Billing
Battle lines are being drawn over a growing number of spruprise billing proposals now under discussion in Congress. Insurance and business groups sent a proposal to leaders in the House and Senate last week that would peg reimbursements to contracted market rates insurers pay physicians in a similar geographic area or tying payments to a percentage of Medicare reimbursements. Hospital associations were quick to criticize the proposal saying, “it is essential that insurers and providers of care retain the ability to negotiate appropriate payment rates.” Hospitals are concerned about the government having the ability to set rates as “it could also create unintended consequences for patients by disrupting incentives for health plans to create comprehensive networks.” Click here for the proposal, and here for the hospital response.  Congress is holding its first hearing on this issue the first week of April, while a bipartisan group of senators is expected to produce its first legislative draft later in the month.

  • Click here for last week’s Time Magazine story of a woman who received $227,000 in ‘surprise’ medical bills.  These are they types of stories that are driving Congress to take action.

CMS’ Advanced Bundled Payment Model Drops Participants by 16-Percent in First Five Months
CMS’ Bundled Payments for Care Improvement Advanced model participation dropped 16% in 5 months — 1,547 providers originally, now has dropped to 1,295 in just the first five months. Providers had until March 1, 2019 to drop without financial penalty. The BPCI Advanced model, that goes through Dec. 31, 2023, is a single retrospective bundled payment model that combines payments to the physician, hospital and other healthcare provider services. Those who participate may get an additional payment if all the costs for an episode of care are less than a benchmark price, discounted by 3%. Exceeding the benchmark would require a repayment of up to 20% of the excessive costs to Medicare. CMS intends to open the application period for Model Year 3 in April 2019. For more on the model and the list of participants, click here.

EHRs: A Healthcare Solution Gone Wrong
For providers, the shortcomings of EHRs are nothing new. Unintentional changes to data in conversions, poorly conceived drop down menus, generic and sometimes needless alerts, and perhaps the most common complaint: the number of clicks. The “how” of EHRs that have gone wrong vary greatly, but the “why” was what Kaiser Health News wanted to know.  “This is something the government mandated,” one ER doctor told KHN. “There really wasn’t the time to let the cream rise to the top; everyone had to jump in and pick something that worked and spend tens of millions of dollars on a system that is slowly killing us.” According to KHN, it’s not just the doctors, but more scarily, it’s killing patients. For the full joint investigation by Kaiser Health news and Forbes click here.

Medical Transportation Cuts Targeted in President’s Proposed Budget
In an effort to curb spending, the President’s budget has identified $143 billion in projected cuts, one of which includes non-emergency rides to doctors visits for beneficiaries. The latest addendum to the budget puts the choice in states’ hands. Federal health officials plan to specify that non-emergency medical transportation services are “strictly optional.” In the current language there are no protected groups or differentiation for those beneficiaries who are unable to take public transit or alternative means of transportation. The white House has indicated that the current transportation benefit rules will be reexamined in May. To read the budget details click here.

  • A new GAO report on the cost of air ambulances shows 69% of the time the transport was outside of the patient’s network, with an average cost of $36,000 and patient out of pocket costs over $10,000, click here.

Patients are Turning to Alternatives as Prescriptions Become More Expensive
More Americans are turning to alternative treatments and skipping doses to curb medication costs. In a report released by the CDC, 60% of Americans received a prescription in 2017, 20% of those requested an alternative treatment and 11% skipped or otherwise altered their medication schedule to cut down on costs. This comes as a new poll from the Kaiser Family Foundation found that almost a quarter of Americans find it difficult to pay for their medication. Not surprisingly, it is lower income and older Americans who find it the most difficult. Click here for the CDC report, and here for the KFF poll.

  • A new Congressional Budget Office presentation shows that spending on specialty drugs in Medicare has tripled and in Medicaid it has doubled, click here.

Price of Drugs in TV Commercials May Be Required Soon
The Trump administration is reportedly moving ahead with its proposal to require drug companies to disclose the prices of their products in television commercials, despite strenuous objections and the threat of legal challenges by drug makers and TV broadcasters. The White House is reviewing the text of a final rule to impose the requirement, contending that the disclosures “will provide manufacturers with an incentive to reduce their list prices by exposing overly costly drugs to public scrutiny.” Click here for the NYTimes report.

States Looking to Medicare Rates to Keep Costs Down for State Employees
States including North Carolina, Oregon, and Montana plan to use Medicare reimbursement rates to recalibrate how their state employee health plans pay hospitals. Private insurance is typically paid out at higher rates than Medicare, so hospitals can cover their losses incurred in government programs. Restructuring state government workers health insurance like this would severely affect hospital reimbursement. Hospitals fear it will affect them similarly to how Disproportionate Share Hospitals, that have high Medicare and Medicaid populations, often struggle financially.  See the report from Kaiser Health News here.

New Analysis Underscores Impact of Social Determinants on Health
Across the U.S., more than 1 in 10 households (11%) spend more than half of their income on housing costs. Among those who own their home, housing cost burden has decreased in the past decade. At the same time, there has been no improvement in the rates among renters. Housing cost burden remains substantially higher among renters than owners, particularly for households with low incomes. The severe housing cost burden affects health and is linked to barriers to living long and well. Across counties, increases in the share of households severely cost burdened are associated with more food insecurity, more child poverty, and more people in fair or poor health. The Robert Wood Johnson Foundation released its annual County Health Rankings last week showing that meaningful gaps still persist in health outcomes among counties across the U.S., driven in large part by the social determinants of health. Click here.

Zulresso: The First FDA Approved Postpartum Depression Drug
With Postpartum Depression Disorder gaining increasing attention in the news and media, Zulresso has come at an ideal time as the first FDA approved drug for PPD. The drug has a great turn around on effectiveness, just 48 hours. There is a caveat — it requires an IV for 60 hours and, therefore, a medical stay. Available for  $34,000 before insurance or any other discount, it may not be the most affordable option. For the FDA press release click here, and here for more information on the pill form of the drug being developed by Sage Therapeutics.

$102 Million Awarded in Healthy Start Grants
HRSA announced awardees of the 2019 Healthy Start Grants that target communities with infant mortality rates that are at least one and a half times the U.S. national average with the aim to reduce negative birth outcomes such as maternal mortality, poverty, education, access to care, and other socioeconomic factors.  For a state-by-state list of awardees, click here.

FDA Will Continue to Curb Youth E-Cigarette Usage
In an joint op-ed in the Washington Post last week by HHS Secretary, Alex Azar, and out-going FDA Administrator, Scott Gottlieb, the two officials declared that the Administration will continue to crack down on teen usage of vaping products even after Gottlieb departs. He had made it a high priority during his FDA tenure. This follows a recent speech by Gottlieb when he declared that the FDA is likely to consider pulling all pod and cartridge e-cigarettes from the market if the next survey on youth tobacco use shows an increase in young Americans using the products. Click here for the op-ed, and here for Gottlieb’s speech.

Millennials Forcing Change to the U.S. Healthcare System
Millennials are forcing a change in the American health care landscape. In general the trend has been wanting more connectivity, more convenience, and more consistent primary care.  Now the type of care young patients are receiving in the ER is changing too. New research published in Pediatrics indicates that there was a 28% spike in patients aged 6 to 24 receiving emergency room psychiatric care. Within this spike, teenagers increased by 53% and minorities by 91%. The Pediatrics study can be found in its entirety here.

Health Care Has Dominated Federal Spending for Over a Decade 
From 2008 to 2018, federal payments are up 42% to states from where they were in 2008 during the recession. Of those payments, a whopping 73% is healthcare related. Currently, federal policy allows up to 90% of the cost of ACA to be covered by federal funding, prior to 2017, it was 100%.  Also contributing to a significant portion of federal spending in states is Medicaid expansion, of which began in 2015. For the full fact sheet click here.

Fentanyl Drug Overdose Deaths Rising Among African Africans
According to new analysis from the CDC, overdoses related to fentanyl have been increasing, with the greatest rise among African Americans. From 2011-2016, the death rate among African Americans from fentanyl drug overdoses rose by 141% each year. Between 2015 and 2016, the overall death rate involving fentanyl overdoses more than doubled, increasing exponentially among both sexes, but more rapidly for males than females. To read the report, click here.

Psychosis Linked to Daily Use and High Potency of Marijuana
Consuming pot on a daily basis and especially using high-potency cannabis increases the odds of having a psychotic episode later, according to a recent study published in The Lancet Psychiatry. The researchers considered high-potency cannabis to be products with more than 10 percent tetrahydrocannabinol or THC, the psychoactive part of the drug. The study examined over 900 people between the ages of 18 and 64 with diagnosed psychosis and then asked about their habits, including marijuana use and showed that people that use the drug daily are 3 times more likely to have a psychotic episode compared to non-users. Click here to read the study.

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