Medicaid programs are uniquely placed to address patients’ social needs, given their central role in supporting low-income Americans, yet little evidence is available to guide Medicaid initiatives in this area. A study in Health Affairs examined how California and Oregon used Section 1115 waivers to expand Medicaid’s role in addressing patients’ social needs by supporting health and social service partnerships and providing greater flexibility to fund social interventions. Investments were made in direct services—including care coordination, housing services, food insecurity programs and legal supports—as well as capacity-building programs for healthcare and community-based organizations. Several factors influenced program implementation, including the local health system context and wider community factors.
Kaiser Permanente will soon launch a new care network that connects the system's 12 million members to community services that address their social needs such as food insecurity or housing instability, according to Modern Healthcare. The Thrive Local initiative will be integrated into Kaiser's electronic health record system and will be rolled out regionally over the next three years. In addition to community partner referrals, the network will track service outcomes to measure the degree to which participants' needs are met. Kaiser plans to eventually make Thrive Local's network of resources available to community-based organizations to help them reach out to non-Kaiser members in need.
The Integrated Healthcare Association’s third California Regional Health Care & Cost Quality Atlas found that provider risk sharing arrangements are associated with higher quality, at the same or lower cost, reports State of Reform. This free report includes two dozen measures of cost, quality and utilization from more than 30 million Californians with commercial insurance, Medicare and/or Medi-Cal.
A new Colorado law protects patients from surprise medical billing by prohibiting healthcare providers from sending consumers a bill when they’ve unknowingly received out-of-network care. According to High Plains Public Radio, the law also sets a reimbursement rate that insurers pay to out-of-network hospitals and doctors. Researchers with the Center on Health Insurance Reforms at Georgetown University have found Colorado is more protective of consumers with respect to surprise medical billing, than other states in the region.
A new Colorado law caps co-payments for insulin at $100 a month for insured patients, regardless of the supply they require. Insurance companies will have to absorb the balance. According to NPR, the law also directs the state’s attorney general to launch an investigation into how prescription insulin prices are set throughout the state and make recommendations to the legislature. The price of insulin has tripled between 2002 and 2013, according to a 2016 study in JAMA.
The District’s latest “health equity” maps show a city divided by race and income – how well you live, or sometimes whether you live at all, can depend on what side of the line you are on, reports The Washington Post. Average life expectancy in Woodley Park, a wealthy and predominantly white neighborhood, is 21 years longer than in the St. Elizabeths neighborhood, which is poor and predominantly black. The D.C. Health Department’s report recommends engaging a broad spectrum of the community in efforts to address these stressors and focusing on “changing community conditions, not on blaming individuals or groups for their disadvantaged status.”
Louisiana is finalizing a deal that would allow the state to pay a flat fee over a set number of years—in effect, a subscription—for Hepatitis C drugs. The subscription model has been deployed in Australia using drugs to fight Hepatitis C and it has saved it an estimated $4.9 billion over five years, according to a study published in the New England Journal of Medicine. Due to cost, five years after Hepatitis C drug Sovaldi’s approval, only about 15 percent of Americans with Hepatitis C have been treated, and only 384 of the 35,000 people in Louisiana with the disease who are on Medicaid or in prison received treatment in 2017, according to The Hill. Officials say the idea is to spend the same amount, or less, than the state already spends on the Hepatitis C drug to get unlimited access
Maryland’s Governor is expected to sign the Maryland Easy Enrollment Health Insurance Program (MEEHP), which will use income tax filing as an immediate onramp to health coverage. An uninsured tax filer will be able to check a box on their state income tax return asking the Maryland health insurance exchange to determine their eligibility for free or low-cost insurance and have relevant information from their tax return sent to the exchange, according to Health Affairs. It is expected that this new enrollment system will go into effect in January 2020, when returns are filed for tax year 2019, but implementation may be delayed to January 2021 if the state tax agency finds the original timeline infeasible.
Johns Hopkins Hospital has filed more than 2,400 lawsuits in Maryland courts since 2009 against patients with unpaid bills. According to The Baltimore Sun, patients being sued include many residents from distressed neighborhoods surrounding the East Baltimore medical campus. A report from the Coalition for a Humane Hopkins, National Nurses United, and AFL-CIO reveals that the number of cases has been increasing, from 20 in 2009 to a peak of 535 in 2016.
A first-in-the-nation measure in Maryland to create a prescription drug affordability board will become law without the Governor’s signature, according to The Associated Press. The law creates an independent board with the authority to evaluate expensive drugs and recommend methods for addressing high costs. The measure was scaled back significantly from an initial proposal. For one thing, it will only apply to state and local governments, not all Maryland residents. Also, the board could only set upper-payment limits with approval from a legislative panel beginning in 2022.
A Minnesota Department of Health study found that during a five-year period one in five deaths of Minnesotans younger than 75 were potentially avoidable with effective and timely healthcare treatment. According to The Austin Daily Herald, the study revealed that for Minnesotans who died before age 75, those living in higher income, majority white areas lived an average of 57 years, while those living in low-income, majority white census tracts lived 54 years. The average was just 50 years among those who were living in lower-income areas where the majority of people were people of color or American Indians.
Early results of Minnesota’s certified community paramedic programs indicate that these house calls improve patient satisfaction and patient health, and reduce spending on medical care, according to Minnesota Public Radio. A local hospital, Region Hospital, implemented a three-year pilot project that made nearly 1,000 home visits to help people manage diabetes and high blood pressure. Paramedics visit patients at home to help them transition out of the hospital and manage chronic conditions.
Montana’s Governor has signed a package of healthcare bills, including the reauthorization of Medicaid expansion and a program to lower insurance premiums on the individual market. Other legislation was aimed at lowering prescription drug prices and increasing access to medical, mental health and substance use treatment in rural and American Indian communities, according to the Governor’s Office. Other legislation would protect federally qualified health centers from discrimination in prescription drug pricing, hold accountable pharmacy benefit managers by applying protections to their billing practices and preventing surprise fees, and prohibit pharmacy benefit managers from requiring pharmacies to charge consumers more in copayments than it costs to make a drug.
Montana has seen an increase in the number of direct primary care facilities, where the billing and payment agreement made between a doctor and their patient does not involve insurance. According to KULR 8 News, these direct primary care facilities provide monthly membership plans and are now being offered in several cities in the state. One of the founders of a Montana direct primary care facility claims that they are already seeing a huge decline in emergency room visits and hospitalizations in their community, saving the healthcare system money.
A new Nevada law limits the amount insured patients can be charged for emergency services when they receive care from an out-of-network provider, according to KTVN. The law will end surprise billing practices “that can leave patients on the hook for unexpected bills for emergency care that can run up to $10,000 or more." The Governor also signed Assembly Bill 170, which codifies the Affordable Care Act’s protections for people with pre-existing conditions into Nevada state law, providing Nevadans assurance that they won’t be denied healthcare based on a pre-existing condition regardless of what happens at the federal level.
New York City has the largest homeless population in the country, an issue the city has tackled through prevention, affordable housing and healthcare initiatives, according to this article in Harvard Business Review. The safety-net health system for the city, New York City Health + Hospitals, which serves more than one million people a year, is using data science to identify homeless patients and tailor their care and match them to the right hospital or community-based supports—ultimately including housing itself.
Montefiore Health Systems worked with a startup, Valera Health, using a HIPAA-compliant app to better engage patients and give them more context about their care. According to MedCity News, Montefiore began working with Valera Health after receiving a grant from the CMS Innovation Center to develop a financially sustainable way to integrate behavioral care and primary care. Montefiore began using the Valera app during a pilot study that began in July 2016, which found that patients using the app missed fewer appointments, connected more frequently with their care teams than with phone calls, and experienced significant improvement in depression and anxiety scores, as well as remission rates.
A recent analysis of New York’s Emergency Services and Balance Billing Law five years post-enactment found that insurer, provider and consumer stakeholders generally agree that the implementation of the law went smoothly, and that consumer complaints declined dramatically. There continue to be significant gaps within the law concerning surprise balance bills due to patient misinformation about a provider’s network status and use of out-of-network facilities during emergencies, according to the Georgetown University’s Center on Health Insurance Reforms. The law protects consumers from charges for out-of-network services not paid by an insurance plan in cases of emergency of circumstances in which the patient did not have a reasonable choice between an in-network and out-of-network provider.
A new United Hospital Fund report reveals that New York accountable care organizations (ACOs) participating in CMS programs meant to reduce Medicare spending reduced spending by $11.5 million in 2017, after increasing spending by roughly $60 million in each of the two prior years. According to the United Hospital Fund, CMS still ended up about $40 million in the red after accounting for the ACOs that reported losses and distributing incentive payments to those that saved money. CMS started the Medicare Shared Savings Program six years ago to offer healthcare providers the opportunity to create an ACO that would be held accountable for the quality and cost of care of Medicare patients, in return for a share of any savings generated
Healthcare spending in Texas grew 18.5 percent between 2013 and 2017 and many factors contribute to that growth, according to Dallas News. Texas ranked 37th last year in the overall health of its residents, according to America’s Health Rankings. Texas ranked near the bottom on many measures—it has many more adults with diabetes and obesity, and far fewer primary care doctors and mental health providers for the population. Additionally, 17 percent of the population in Texas has no health insurance—the largest in the nation. The state is one of 14 not expanding Medicaid, but experts assert that coverage is the biggest determinant of health outcomes. “Once people land in the hospital, they’ll spend a lot of money,” Lynn Quincy, director of the Healthcare Value Hub at Altarum, said. “Anything that keeps them healthy often costs less at the end of the day.”
All-payer claims databases (APCDs) are a promising, high-quality tool for cancer surveillance, according to a Utah study published in Health Services Research. Medicare data has previously proven beneficial in capturing cancer treatment that is under-reported to cancer registries for the 65 and over population. Researchers looked at the Utah APCD to assess the potential of these databases to offer similar benefit to cancer surveillance, including information on comorbidities at diagnosis, recurrence and late effects of treatment. The study concluded that an APCD can act as a high-quality surveillance tool when accurate identifiers exist to support linkage to cancer registry data, if claims for the same patient can successfully be linked in the ACPD, and if the population of patients diagnosed with cancer have adequate coverage.
Washington state has a history of innovative approaches to expand health coverage and ensure affordability, according to NPR. This includes the establishment of a "public option" health insurance plan that, in theory, will be more affordable for consumers. Public option plans will be available in all 39 counties, eliminating “bare counties” where one or no private insurance carriers provide coverage. Washington is the first state to authorize a public insurance plan of this type, although other states are following suit.
A new Washington law will direct money to tribal healthcare systems and create a council focused on improving health outcomes for members of Washington’s 29 tribes, reports The Seattle Times. The program will dedicate $3-$5 million in the first year (and potentially more in subsequent years) to implement an Indian Health Improvement Advisory Plan, designed by the Governor’s Indian Health Advisory Council. The council, also established by the law, will include a representative from every tribe in the state, CEOs of the state’s two Urban Indian Health Boards, legislators from both parties and a representative from the governor’s office.
For more state news and to get alerts for your state, visit the Hub website.
Many countries use external reference pricing to help determine drug prices. However, external reference pricing has, thus far, received little attention in the U.S. A study in Health Affairs assessed the price differentials between single-source brand-name drugs sold in the U.S. and those sold in the U.K., Japan, and Canada. Medicare Part D could save an estimated $72.9 billion by adopting the average price of drugs in the reference countries. This, in turn, could improve affordability for patients.
Health insurance marketplaces have received considerable attention for their narrow network health plans. Yet, little is known about consumer tastes for network breadth and how they affect plan selection. Using 2017 individual enrollment data and provider network directories, researchers developed a geospatial measure of network breadth that reflects the physical locations of households and network providers. The study found that preference for broad networks increases with household age, income, and household size.
A substantial number (40 percent) of rural Americans struggle with routine medical bills, food and housing. Additionally, about half (49 percent) say they could not afford to pay an unexpected $1,000 expense of any type, according to a poll of rural Americans conducted by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health. In terms of access, one-quarter of respondents said they were not able to get healthcare when they needed it, despite nearly 9 in 10 reporting that they had health insurance of some sort, as described by NPR. Of those not able to get healthcare when they needed it, the poll found that 45 percent could not afford it and 23 percent said the healthcare location was too far or difficult to get to. With rural hospitals closing at an alarming rate, many are turning to telehealth. However, broadband access is a perennial issue in many parts of rural American, with 21 percent saying accessing high-speed internet is a problem for their family.
In Philadelphia in 2017, the implementation of a beverage excise tax on sugar-sweetened and artificially sweetened beverages was associated with significantly higher beverage prices and a significant and substantial decline in volume of taxed beverages sold, according to JAMA. However, this decrease in taxed beverage sales was partially offset by increases in sales in bordering areas. Additionally, researchers suggest that supermarkets may have experienced larger volume decreases than other store types because they were more likely to display signage about the tax and because there may have been a shift to purchasing sweetened beverages at mass merchandise stores instead of supermarkets.
Previous studies show that health insurance is a strong predictor of cancer screening. This study in the American Journal of Preventive Medicine examined changes in breast cancer and colorectal cancer screening patterns among low-income adults in all states to determine whether the timing of Medicaid expansion was related to improvements in screening prevalence. Like earlier studies, this study found colorectal cancer screening prevalence was greater among low-income adults aged 50–64 years residing in the six early expansion states compared with non-expansion states but these increases screening prevalence was not immediate. Reflecting this delay, colorectal cancer screening in state that had only expanded recently were comparable to non-expansion states. Breast cancer screening increased only modestly among low-income women residing in expansion states.
Hospital staff were more likely to report harmful safety events for white patients compared to patients from minority groups, a new study found. Though 39.8 percent of total patients studied were white, they accounted for 47 percent of the reported safety events. However, while black patients made up 52 percent of the patient population studied, they accounted for 46 percent of the reported safety events. Researchers studied 10 hospital systems located in the District of Columbia and Maryland between 2015 and 2017. Authors theorized that factors such as implicit bias could potentially influence the likelihood of reporting harmful adverse patient safety events. Moreover, race differences in adverse events may exist for many reasons, including phenotype, health literacy, communication, cultural differences, unequal healthcare access, and differences in illness complexity and healthcare utilization. Patient safety has been a prominent concern ever since a 1999 Institute of Medicine report revealed that 44,000 to 98,000 patients die from preventable errors in hospitals each year, according to Modern Healthcare. More recent studies have estimated that 161,250 preventable deaths occur each year in hospitals.
The prices paid to hospitals for privately insured patients was 2.4 times higher than rates Medicare paid in 2017, according to a new study from the RAND corporation. The study, which looked at the prices paid by private health plans to 1,600 hospitals across 25 states, also found prices varied widely between different states. While hospitals in Kentucky, Michigan, New York and Pennsylvania had average prices that were 150 to 200 percent of what Medicare paid, hospitals in Colorado, Indiana, Maine, Montana, Wisconsin and Wyoming had average relative prices that were closer to 250 to 300 percent of what Medicare paid, according to FierceHealthcare. RAND also found that 21 percent of higher-priced hospitals received a 5-star rating on Medicare’s Hospital Compare, compared to 9 percent for lower-priced hospitals.
In response to a study released by the RAND Corporation that found that private insurance pays hospitals more than twice what Medicare does, the American Hospital Association (AHA) stated that they had a number of concerns about the report. For one, the study featured a small sample size, constituting less than 5 percent of all covered persons in about half of all states and just 2 percent of Americans with employer-sponsored insurance. Moreover, Medicare payment rates, which reimburse below the cost of care, should not be held as a standard benchmark for hospital prices.
Using 2014 commercial claims data from Colorado, Massachusetts, Oregon and Utah, researchers demonstrated the feasibility of using state-based claims data sets and standardized processes to develop comparable healthcare performance measures to inform state, regional and organizational healthcare policy, according to a study in AJMC. Researchers standardized calculations from each state for a set of cost and quality measures, resulting in a Uniform Data Structure file format that can be scaled across populations, measures and research dimensions. This new format provides a consistent method to produce comparable findings.
Between 2010 and 2018, mean prices per fill for anticancer medications (covered by Medicare Part D) rose from $7,438 to $13,922, according to a study published in JAMA. Moreover, mean 12-month out-of-pocket spending rose from $8,794 in 2010 to an expected $10,470 in 2019, despite efforts to close the coverage gap. Researchers state that because Part D beneficiaries pay a percentage of the drug’s price and have no out-of-pocket spending limits, even large price decreases may not provide sufficient financial relief to patients requiring long-term anticancer drug use. Efforts to reduce drug prices and limit beneficiary out-of-pocket spending are needed to improve access to high-cost drugs.
The Source on Healthcare Price & Competition and Catalyst for Payment Reform have introduced a database of state laws impacting cost and quality. The database is an interactive tool that catalogues ongoing state legislative efforts to implement healthcare reform. Users can use the database to search state healthcare laws in five main categories: health insurance benefit design laws; provider network laws; price transparency laws; provider payment laws; and healthcare market power laws.
Five action steps would push implementation science towards equitable implementation, according to a blog post by Academy Health. An expert working group of practitioners, researchers, and funders recommended: shift implementation science’s terminology to place different perspectives on equal footing; employ strategies and build structures that elevate equity concerns; cultivate relationships and trust; shift funding incentives to value practice expertise and questions; and to promote exchanges between researchers and community members.
Visit the Hub website for more on drug spending, healthcare cost drivers, reference pricing, narrow networks, rural healthcare, sin taxes, medical harm and more!
High and rising prescription drug prices force consumers to take unacceptable risks with their health—nearly three in 10 people report not taking their medicines as directed due to high costs. To leverage federal purchasing power effectively to obtain affordable and fair prices for prescription drugs, the Coalition for Fair Drug Prices has highlighted key reforms that should be included in drug pricing legislation. Two such reforms include: allowing the federal government to negotiate with drug manufacturers coupled with an effective enforcement mechanism and using independent assessments to guide fair price determinations. The report addresses the role of pharmacy benefit managers (PBMs), stating that though policymakers should address questionable PBM practices, prescription drug manufacturers still capture two-thirds of all U.S. revenues and should remain Congress’s focus.
High maternal death rates are only one of many race and ethnicity-related health disparities that exist in the U.S. Others include higher rates of chronic illness, premature death and failure to receive appropriate care for pneumonia, heart attacks, pain and preventive measures for post-operative complications. Some estimates indicate that these disparities cost the economy $230 billion a year in direct medical expenditures and more than $1 trillion in indirect costs. Earlier studies have shown that ethnic diversity in the healthcare workforce is directly linked to health outcomes for people of color and the lack of workforce diversity is the result of institutional racism. An important step in diversifying the healthcare workforce will involve pipeline programs, or ones that facilitate the entry of students of color into undergraduate programs and professional schools such as medicine, nursing and social work, according to commentary published in The Hill.
Healthcare reforms to improve value in surgical care have focused almost entirely on inpatient and postoperative care but have ignored the value and efficiency of services provided prior to surgery. To tackle the problem of low-value care, we must appropriately evaluate care provided during the presurgical period, according an article in AJMC. The proposed expansion of episode-based measurement models of quality and efficiency, the authors argue, has the potential to facilitate improved care coordination and value.
The Food and Drug Administration (FDA) has announced that it is ending its controversial “alternative summary reporting” program, which allowed medical device companies to conceal millions of reports of harm and malfunctions from the general public, according to Kaiser Health News. The agency plans to open past records to the public. KHN revealed that the program has collected 1.1 million reports since 2016. Moving forward, device manufacturers will be required to file individual reports describing each case of patient harm related to a medical device.
The Congressional Budget Office (CBO) released a report highlighting policymaker considerations for shifting to a single-payer healthcare system the U.S. Some key takeaways highlighted by FierceHealthcare include: commercial plans could play one of three roles in a single-payer system; other government programs like TRICARE and the Veterans Affairs health system could stick around; global budgets would most likely evolve as the primary method of paying providers; and premiums and cost-sharing would still be in play.
Visit the Hub website for background on medical devices, single-payer systems, surprise medical bills and more!