Research Roundup - November 2019


California AG Rejects Adventist—St. Joseph Merger
By Harris Myer | Modern Healthcare | Oct. 31, 2019

California regulators rejected a proposed merger between Adventist Health System/West and St. Joseph Health System, citing concerns that the transaction could increase healthcare costs and limit access to healthcare services, according to Modern Healthcare. Consumer advocates support the decision, despite the systems’ claims that the merger would boost access to quality care for vulnerable and underserved populations throughout Northern California

Sutter to Pay $46 Million over Improper Payment Allegations
By Harris Myer | Modern Healthcare | Nov. 18, 2019

Sutter Health and a group of physicians will pay the federal government $46 million to settle allegations that they violated the Stark law by billing Medicare for services provided by professionals with whom the entities had improper financial relationships, reports Modern Healthcare. This is the second federal settlement by Sutter this year – In April, Sutter and several of its affiliated medical foundations agreed to pay $30 million to resolve allegations that the foundations submitted inaccurate information about the health status of Medicare Advantage enrollees, resulting in plans and providers being overpaid.


Colorado has 71 Census Tracts Where High Rates of Mental Health Issues and High housing Costs Overlap
By Forest Wilson | The Colorado Independent | Nov. 18, 2019

A recent report from the University of Colorado Denver revealed that there are 71 census tracts in Colorado where a high rate of housing insecurity and mental health needs overlap, according to The Colorado Independent. The interactive map included in the report will be used by officials and lawmakers to more efficiently target services and funding. These preliminary findings support a 2019 study by the Robert Wood Johnson Foundation that found households that struggle with greater housing cost burdens also see poorer health outcomes. Experts hope this map will allow policymakers to locate the best areas to provide additional support to produce better outcomes.


Healthcare Affordability Standard Tool to Influence Policy Debates
By Matt Pilon | Hartford Business | Nov. 15, 2019

Connecticut’s state comptroller and Office of Health Strategy are developing a “healthcare affordability standard” to calculate how much money individuals and families in the state must earn in order to afford healthcare without compromising other basic needs, like food and housing, reports Hartford Business. According to officials, understanding the threshold at which healthcare becomes unaffordable is vital to creating sound policies. The tool is anticipated to launch in Spring of 2020.

Researcher IDs Connecticut's Most Litigious Hospital; Thousands of Patients Sued Annually
By Matt Pilon | Hartford Business | Nov. 12, 2019

Connecticut’s state comptroller and Office of Health Strategy are developing a “healthcare affordability standard” to calculate how much money individuals and families in the state must earn in order to afford healthcare without compromising other basic needs, like food and housing, reports Hartford Business. According to officials, understanding the threshold at which healthcare becomes unaffordable is vital to creating sound policies. The tool is anticipated to launch in Spring of 2020.


New Health Indicators Added to My Healthy Community Data Portal 
Delaware Health and Social Services | Nov. 14, 2019

The Delaware Division of Public Health announced updates to its My Healthy Community data portal, which delivers neighborhood-focused population health, environmental and social determinant of health data to state residents. Data indicators in areas like community safety, maternal and child health, healthy lifestyles and health services utilization help users understand and explore the factors that influence community health. Additionally, the data collected aids Delaware's efforts to bring transparency to healthcare spending and to set targets for improving the health of Delawareans.

District of Columbia

CMS Approves D.C. Waiver of Medicaid Exclusion Rule
By Steven Ross Johnson | Modern Healthcare | Nov. 6, 2019

D.C.’s Medicaid program is the first in the country to receive approval for a demonstration project that will use federal Medicaid money to pay for patients with severe mental illness to be treated in large residential psychiatric institutions and treatment centers, according to Modern Healthcare. Medicaid currently prohibits payments to institutions with more than 16 beds, which behavioral health advocates claim has contributed to the high unmet need for the treatment of both mental health and substance use disorders.


The Cost of Not Expanding Medicaid in Florida? Nearly 2,800 Deaths, A New Report Estimates
By Ben Conarck and Elizabeth Koh | Miami Herald | Nov. 14, 2019

Florida likely suffered the second-highest total of deaths attributed to not expanding Medicaid—2,776 between 2014 and 2017—trailing only Texas, which has an estimated 2,920 deaths, according to a report from the Center on Budget and Policy Priorities. A bill to expand Medicaid with work requirements is making its way through the legislature, but advocates fear its chances are slim, an analysis from the Miami Herald states. Legislators in the state have already shortened the time period Medicaid can retroactively pay for hospital bills and criticized the costs of Medicaid for people with disabilities. 

New Florida Website Providing Healthcare Cost Transparency
By Rick Adams | ABC News | Nov. 4, 2019

Florida has launched the Florida Health Price Finder website, which gives residents the ability to search for prices on non-emergency medical procedures in the state, according to ABC News. Some healthcare advocates are critical because the website only provides average numbers from a few years ago, which may be out of date. Moreover, the tool does not take Medicare and negotiated rates into account. The Florida Hospital Association has also called the validity of the data into question.


Health Education and Advocacy Unit Saved Nearly $2.5 Million for Patients, Maryland Consumers
The Southern Maryland Chronicle | Nov. 17, 2019

Maryland legislators announced that the Health Education and Advocacy Unit within the Consumer Protection Division of the Office of the Attorney General closed 1,974 cases in Fiscal Year 2019 and assisted consumers in saving or recovering almost $2.5 million. The Annual Report on the Health Insurance Carrier Appeals and Grievances Process estimates that when consumers seek assistance from the Health Education and Advocacy Unit, carrier denials are overturned or modified over 50 percent of the time.


Years After the State Mandated Health Cost Transparency, Few Massachusetts Residents Taking Advantage of It
By Kelly Gooch | Becker's Hospital Review | Nov. 6, 2019

Few Massachusetts consumers know how to get price information before a procedure, despite the state’s 5-year old transparency provisions, according to a Becker’s Hospital Review analysis of a poll by the Pioneer Institute and DAPA Research. Indeed, seventy percent of respondents said they want to know the price of a medical service before obtaining it, though thirty-two percent of respondents said they don’t know whether their insurance company has a website or cost estimator tool that would allow them to compare out-of-pocket costs. Researchers believe this shows that though the public wants transparency in their healthcare prices, easy access is not yet a reality.

Alternative Payment Models Fail to Control Costs in MA
By Samantha McGrail | RevCycleIntelligence | Oct. 24, 2019

A report from Massachusetts’ Attorney General finds that alternative payment models did not shift care to lower cost providers, as frequent plan-switching by patients and the administrative complexity of the arrangements limited the effectiveness of the models, according to RevCycleIntelligence.


Hospital-Acquired Condition Reduction Program is Not Associated with Additional Patient Safety Improvement
By Kyle Sheetz, et al. | Health Affairs | November 2019

The Hospital-Acquired Condition Reduction Program did not improve patient safety in Michigan beyond existing trends, according to an independent evaluation published in Health Affairs. While rates of all hospital-acquired conditions declined from 133 per 1,000 discharges in the pre-program period to 122 in the post-program period, greater improvements were observed for non-targeted measures.  


Missouri's Refusal to Treat Mental Health like a Physical Condition Means Patients Wait Months
By Alex Smith | KCUR | Nov. 13, 2019

As the need for mental health treatment in Missouri grows, patient advocates say the state’s refusal to enforce mental health parity may worsen barriers to access, according to KCUR. Missouri remains one of the last holdouts in the battle against the federal Mental Health Parity and Addiction Equity Act, which requires insurers to cover mental healthcare no differently than treatment for physical conditions. The federal government intended for states to enforce the law, passed in 2008, but Missouri officials insist they lack the authority. Every other state, except for Oklahoma, actively upholds the law.

New York

Statewide Network for Clinical Data Sharing Reduces Healthcare Costs by an Estimated $160-195 Million Annually
New York eHealth Collaborative | Nov. 12, 2019

Using methodology developed by HHS’ Office of the National Coordinator, a New York eHealth Collaborative (NYec) analysis revealed that the use of the Statewide Health Information Network for New York is reducing unnecessary healthcare spending in the state by $160-$195 million annually. The analysis estimates that were the network to be fully leveraged across all current participants, the state could save almost $1 billion annually by avoiding duplicative testing, avoidable hospitalizations and readmissions and preventable ED visits if current participants alone were to continue using the system’s full capabilities.

Maps Illustrate "Hotspots' Where Poor Housing Quality, Childhood Asthma and High Medicaid Enrollment Converge in New York City
United Hospital Fund | Oct. 22, 2019

Hot spot maps identify key areas in New York City where Medicaid intervention and social determinants of health ( programming have the potential to help improve the health of individuals, according to a report from the United Hospital Fund. Several current initiatives offer promising strategies to tackle social determinants that could benefit from the use of these hot spot maps, including New York Medicaid’s reform initiative, the Delivery System Reform Incentive payment (DSRIP) program, the Healthy Homes value-based payment pilot and others.

North Carolina

Hot-Spotting North Carolina's Big Medicaid Transformation
By Kadakia Kishal, et al. | Health Affairs Blog | Nov. 5, 2019

Researchers looking into North Carolina’s Medicaid program released a case study detailing the poor health outcomes and high-cost Medicaid beneficiaries in Graham County, North Carolina, and paired these stories with policy recommendations to reorient the Medicaid program around patient needs, according to a Health Affairs blog post. Graham County has seen a gradual decay of outpatient care delivery infrastructure, and patients suffer from a lack of providers and lack of transportation, often forcing them to use emergency medical services as primary care or for transportation. Policy recommendations include investing in telehealth, deploying the existing workforce more efficiently, and empowering local officials by providing them with adequate funding for the increased responsibilities they shoulder.  


Surprise Medical Bills Hit Many Oklahomans
By Trevor Brown | Oklahoma Watch | Oct. 26, 2019

Oklahoma ranks in the top ten for states with the highest rates of surprise medical bills, reports Oklahoma Watch. A study by the Peterson Center on Healthcare and the Kaiser Family Foundation found that one in five emergency room visits in Oklahoma resulted in at least one out-of-network charge for patients with employer-sponsored health plans in 2017. Despite several legislative attempts, Oklahoma remains one of 25 states without laws protecting patients against out-of-network surprise bills as of 2019.  

South Carolina

South Carolina Ranks Near Bottom in National Mental Health Study
By Heath Ellison | Charleston City Paper | Oct. 31, 2019

According to a new report by Mental Health America, South Carolina ranks 44th overall in the nation for mental health problems and access to proper care, explains the Charleston City Paper. In the past five years, South Carolina has dropped 11 places in the ranking.  

School-Based Telehealth Program Reduces ED Visits by Pediatric Asthma Patients
By Jeff Lagasse | Healthcare Finance | Nov. 8, 2019

Researchers at the Medical University of South Carolina released a report in JAMA Pediatrics that associates a school-based telehealth program with reduced emergency department visits for children with asthma in a rural and underserved region of South Carolina, reports Healthcare Finance. Children with access to school-based telehealth were 21 percent less likely to visit the emergency department for asthma than those without access, but the three-year study showed no association between school-based telehealth and all-cause emergency department visits.


The Rural Healthcare Crisis, Mapped
By Ronaldo Hernandez | Texas Observer | Nov. 20, 2019

In 2018, Texas had about 54 primary care physicians per 100,000 people—one of the lowest ratios in the country, far below the national ratio of 76 per 100,000. More than a quarter of Texans live in an underserved county, according to the Texas Observer. As a result, Texans often have to travel for hours to get care, which ultimately leads to poorer outcomes and higher mortality. 


Washington Health Alliance Report Finds Downward Trend in Wasteful Healthcare Spending
By Emily Boerger | State of Reform | Nov. 6, 2019

A 2019 analysis by the Washington Health Alliance found a 10 percent decrease in wasteful spending in the state’s commercially insured population and a 24 percent decrease in wasteful spending in the Medicaid population from 2014-2017, reports State of Reform. Despite significant progress, wasteful spending continues to be an issue, as 51 percent of the 9.5 million services examined were deemed “low-value” and likely representing unnecessary spending. 


Lawmakers Vote to Continue Database That Previously Showed Wyoming Has Among Highest Healthcare Costs 
By Seth Klamann | Casper Star Tribune | Nov. 6, 2019

Lawmakers in Wyoming have voted to extend the state’s multi-payer claims database which revealed that the costs of healthcare are the highest in the region and among the highest in the nation, according to the Casper Star Tribune. For example, an appendectomy costs a Wyoming resident and their insurer is $21,287—nearly $7,000 more than the median national cost. In response to the data, the Labor, Health and Social Services Committee has also approved a bundled pricing bill that may reduce healthcare spending.
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Recent Reports

Changes in Physician Consolidation with the Spread of Accountable Care Organizations
By Genevieve P. Kanter, et al. | Health Affairs | November 2019

Accountable Care Organizations (ACOs) may increase county-level concentration of physician practices, according to a study in Health Affairs. Researchers found a 4 percentage-point increase in large physician practices and 2.7 percentage-point decrease in small physician practices in counties with high ACO penetration (compared to those with no ACO penetration) from 2010 to 2015. Similar trends were seen in counties with moderate ACO penetration, though the magnitude of the effect was smaller. These patterns suggest that gains from care coordination facilitated by ACOs will have to be balanced against higher prices that could result from consolidation.   

Medicaid Expansion Reduced Preventable Hospitalizations
By Harris Meyer | Modern Healthcare| Nov. 4, 2019

States that expanded coverage to low-income adults under the Affordable Care Act saw a 3.5 percent reduction in annual "ambulatory-care sensitive" condition discharge rates, and a 3.1 percent drop in inpatient days in 2014 and 2015, according to the study published in Health Affairs. Hospital costs dipped by nearly 3 percent. The findings suggest Medicaid expansion could save money and lower preventable hospitalizations, an analysis in Modern Healthcare states.

Drug Discount Cards End Up Costing Insurers More Compared to Generics
By Michael R. Law, et al. | CMAJ | Nov. 11, 2019

Pharmaceutical companies often offer drug discount cards to help cover out-of-pocket costs for patients' prescription drugs, but a new study out of Canada revealed that such discounts end up costing private insurers. Looking at nearly 3 million prescriptions for 89 different medications, researchers found that discount cards cost private insurance companies 46 percent more in healthcare costs compared to similar generic prescriptions. At the same time, spending on brand name drugs by public insurance—which Canada offers to all its citizens—was only 1.3 percent higher than for generic drugs, and patients saved about 7 percent per brand name, or CAD $3.49, per prescription by using the discount cards. Although nearly every public drug plan in Canada will pay only the generic price when a generic is available (even when a brand version is dispensed), this is not the case for many private drug plans.

Pharma Execs: Thirst for Profit Drives High Drug Prices
By Fedor Darkhin | The Oregonian | Nov. 25, 2019

Anonymous interviews with four pharmaceutical executives found that thirsts for profits have driven companies to regularly hike prescription drug prices. The four executives who spoke confidentially to Oregon State University researchers cited a need for ever-increasing revenue and an unfettered ability to raise prices as two of the core reasons their companies kept hiking costs, The Oregonian reports. This contradicts pharmaceutical industry assertions that they need to charge high prices to pay for the research and development associated with new medications.

Public Sector Financial Support for Late Stage Discovery of New Drugs in the United States
By Rahul K. Nayak, et al. | The BMJ | Oct. 23 ,2019

A review of the patents associated with new drugs approved over the past decade indicates that publicly supported research had a major role in the late stage development of at least one in four new drugs. In order words, taxpayers are not only contributing to basic research, but also late stage drug development. Drug companies have often used their investment in drug discovery and development to justify high drug prices, asserting that public institutions only contribute to basic research—an assertion this new data contradicts.

Comprehensive Health Management Pharmacist-Delivered Model: Impact on Healthcare Utilization and Costs
By Leticia Moczygembra, et al. | American Journal of Managed Care | Nov. 12, 2019

Reference pricing could help lower drug prices, but is not a cure-all on its own, according to a new report from the Bipartisan Policy Center (BPC). The report delineated two types of reference pricing: external pricing, which uses international prices as a benchmark to set or negotiate the price of drugs; and internal reference pricing, which could be used in various scenarios to ensure that therapeutically equivalent drugs are priced similarly, and encourages the use of the least costly alternative therapy. Experts stated that existing evidence demonstrates that external reference pricing can lead to lower prices in the short-term, but this effect may diminish over time. The report recommends that HHS form an advisory group to compare new drugs and biologics to either existing therapeutically equivalent drugs or the standard of care as a way to help with internal reference pricing, MedPage Today reports.

Surprise Billing Services Had Higher-than-Average Markups By Shannon Muchmore | HealthCare Dive | Nov. 11, 2019

Services most frequently cited in surprise medical bills had substantially increasing markups in recent years that far exceeded inflation, according to a research letter published in JAMA Internal Medicine, reports Healthcare Dive. Markups for emergency medicine increased 28 percent from 2012 to 2016 while anesthesiology services grew 32 percent in that time period, according to the analysis of Medicare Part B claims from more than 2,000 hospitals. That compares to a 7 percent growth for the internal medicine markup ratio. The annual increases were greatest at for-profit hospitals, those that served more uninsured patients (for emergency medicine services) and facilities in the Southeast. The authors noted that these findings are particularly worrisome given that the incidence of emergency department surprise medical bills increased from 32 percent to 43 percent between 2010 and 2016, leading to greater patient financial liability.

Medicare Spending Trends 2010-2016: Increase in Prescription Drug Spending More Than Offsets Lower Beneficiary Costs for Other Services
By Cathy Schoen, Amber Willink and Karen Davis | The Commonwealth Fund | Nov. 6, 2019

Out-of-pocket spending on drugs increased by 16 percent between 2010 and 2016, according to the Commonwealth Fund. This increased spending was only partially offset by a 22 percent decrease spending on hospital services and a 30 percent decrease on skilled nursing home care. By 2016, beneficiaries spent more out-of- pocket for retail prescription drugs than for the combined cost of physician and inpatient care, underscoring the need for policies to address both payments and benefits to ensure Medicare can help protect the health and financial independence of its beneficiaries.

Millions in U.S. Lost Someone Who Couldn't Afford Treatment
By Dan Witters | Gallup | Nov. 12, 2019

More than 13 percent of American adults, or about 34 million people, reported having at least one friend or family member in the past five years who died after not receiving needed medical treatment because they were unable to pay for it, based on a new study by Gallup and West Health. Additionally, the percentage of people who reported not having enough money to cover medical care or drugs rose significantly, from 18.9 percent in January to 22.9 percent in September. Authors note the level of medication insecurity is high and rising and is doing so against a backdrop of overwhelming public sentiment regarding the inappropriately high prices of prescription drugs.

State Efforts to Standardize Consumer Affordability
By Liz Hagan | United States of Care | November 2019

United States of Care has released a report highlighting state efforts to state and advocacy efforts to define healthcare affordability, develop affordability standards, and suggest key elements to consider when creating such a definition or standard. Case studies include an overview of action in Colorado, Connecticut, Massachusetts, Rhode Island and Vermont.   

Leapfrog Releases Fall 2019 Leapfrog Hospital Safety Grades
By Martina Dolan | AboutHealthTransparency.org | Nov. 7, 2019

The Leapfrog Group has released its Fall 2019 Hospital Safety Grades as part of its a bi-annual grading assigning letter grades to general acute-care hospitals in the U.S., reports AboutHealthTransparency.org. It is the nation’s only rating focused entirely on patient safety—preventable errors, accidents, injuries and infections. More than 2,600 hospitals were graded with the breakdown as follows: 33 percent earned an “A,” 25 percent earned a “B,” 34 percent earned a “C,” 8 percent a “D” and just under 1 percent an “F.” The five states with the highest percentages of “A” hospitals were: Maine (59 percent), Utah (56 percent), Virginia (56 percent), Oregon (48 percent) and North Carolina (47 percent). There were no “A” hospitals in three states: Wyoming, Alaska and North Dakota.

U.S. Lags Behind Other Countries in Care Quality
By Gabrielle Masson | Becker's Hospital Review | Nov. 7, 2019

Though the U.S. spends the most on healthcare globally, its quality performance doesn't necessarily reflect this when compared to other countries, according to a report from the Organization for Economic Co-operation and Development (OCED), reports Becker’s Hospital Review. Takeaways include: the U.S. had the second highest rate of obstetric trauma for vaginal deliveries between 2012-17, reporting a rate of 11.1 obstetric traumas per 100 instrument-assisted vaginal deliveries; the U.S. reported the fourth lowest percentage of hospitalized patients with one or more healthcare-associated infections in 2015-17; and in 2017, the U.S. had the 10th highest admission rate for avoidable asthma and chronic obstructive pulmonary disease out of 37 countries. 

20 Years After 'To Err Is Human,' Hospital Care Quality Measures are Still of Little Use
By Maria Castellucci | Modern Healthcare | Nov. 9, 2019

In the years following the two-decades-old report To Err is Human: Building a Safer Health System, much has changed, but these moves have not done much to protect patients, reports Modern Healthcare. The CMS now requires hospitals, outpatient settings and nursing homes to track quality. And with the 2010 passage of the Affordable Care Act, the agency now penalizes hospitals for performance on some measures such as readmissions and infections. But those moves have done little to protect patients. In fact, some research suggests one of the more successful metrics, lowering the rate of readmissions, may have led to unintended deaths. A recent report from the U.S. Government Accountability Office found the CMS has different approaches to decide which quality measures it will develop and use. The agency also doesn’t have a way to assess whether the measures under consideration will achieve strategic objectives.

Treating Substance Abuse: Toolkit for State Medicaid Leaders
By Patricia Boozang, Jocelyn Guyer and Jessica Nysenbaum | Manatt | November 2019

Manatt Health, with support from Arnold Ventures, has developed Using Medicaid to Advance Evidence-Based Treatment of Substance Use Disorders: A Toolkit for State Medicaid Leaders. The Toolkit is designed to help state leaders identify Medicaid strategies from around the nation to expand treatment and recovery supports to those with opioid use disorder (OUD), implement in their respective states, and then evaluate and expand what works.

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Healthcare Has a Bias Problem: Here's How to Fix It
By Shanoor Seervai | The Commonwealth Fund | Nov. 16, 2019

In a Commonwealth Fund podcast, host Shanoor Seervai discusses ways to tackle bias in healthcare with Ann-Gel Palermo, who works on diversity and inclusion at New York’s Icahn School of Medicine at Mount Sinai, and Joia Crear-Perry, who founded the National Birth Equity Collaborative to address racial disparities in healthcare. They explain that bias is not just a concern at the individual provider level; it’s actually baked into the system, starting in medical school.  

Doctors Should Know What Meds Cost
By Mathew Perrone | The Beacon | Nov. 5, 2019

While the price of almost any good or service can be found online, most Americans don’t know what they’ll owe for a prescription medication until they get it, according to The Beacon. Doctors often have no idea what a medication might cost a patient and consumers may not understand things like copays, coinsurance and deductibles.

Patients Feel the Pain of Hospital-Physician Consolidation
By Michael Brady | Modern Healthcare | Nov. 7, 2019

Hospital-physician integration has increased cost-sharing for Medicare beneficiaries and prices for commercial insurers, according to Modern Healthcare. Despite this, the share of physicians employed by hospitals increased from 26 percent in 2012 to 44 percent in 2018. Experts assert that site-neutral payments, which pay doctors the same amount for a medical service no matter where it's delivered, could lessen the incentives for providers to merge if the deal isn't going to improve quality or efficiency.  

Google Sparks New Privacy Fears Over Healthcare Data
By Chris Mills Rodrigo | The Hill | Nov. 13, 2019

Google’s work to help Ascension, the nation’s largest nonprofit health system, collect and analyze data on millions of patients is coming under intense scrutiny from lawmakers, privacy advocates and regulators, according to The Hill. The data includes doctors’ diagnoses, medical records and medical test results along with names and other vital statistics, and that some Google employees may have had access to the data. The Office for Civil Rights in the Department of Health and Human Services will investigate whether the project "fully implemented" HIPPA protections.

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