Research Roundup - October 2018


Suit Against Sutter Spawns Fight with Bay Area Hospitals Over Trade Secrets 

By Catherine Ho | San Francisco Chronicle | Oct. 14, 2018

Defense attorneys for Sutter Health—Northern California’s largest health system—which stands accused of abusing its market power and charging higher prices, have subpoenaed 50 other California hospitals to hand over pricing information the hospitals consider proprietary, such as the terms of their contracts with insurers, reports the San Francisco Chronicle. Sutter says it needs the information to show that its pricing and contracting practices are no different than that of other hospitals. But some rival hospitals argue that handing over confidential information to their competitor could allow Sutter to use it to its advantage later—for example, by undercutting the rates that other hospitals charge insurance companies for certain services.

As Opioid Death Toll Worsens, California Doctors Will Soon be Required to Perform Database Checks 

By Kristina Davis | Los Angeles Times | Sept. 16, 2018 

Beginning Oct. 2, California doctors are required to consult the state’s prescription drug database—known informally as CURES—before prescribing opioids and other potentially addictive drugs, reports the Los Angeles Times. CURES enables physicians to view patients’ prescriptions, the doctors who prescribed them and the pharmacies that filled them to help spot signs of “doctor shopping” and identify potentially dangerous medication combinations. Theoretically, this will improve quality by enabling doctors to provide drug safety warnings, deny a patient’s request for prescriptions and even offer help when drug abuse is suspected. But some have expressed concerns over the tool’s design, which may not be user-friendly to providers. States such as New York, Kentucky and Tennessee have passed similar legislation.


Survey: CT Residents Burdened by Healthcare Costs, Complexity; Want Reforms 

By Matt Pilon | | Oct. 11, 2018 

A survey conducted Altarum’s Healthcare Value Hub for the Universal Health Care Foundation of Connecticut revealed that residents across the political spectrum want state laws that require healthcare pricing transparency and make it easier to navigate the complex system, reports The survey found that half of survey respondents had experienced healthcare affordability burdens in the previous 12 months. Of that group, four in five said they had delayed or skipped a doctor visit, medical procedure or test, cut pills in half or skipped doses, or had trouble accessing mental healthcare due to cost. Though lower-income households had the highest reported affordability burdens, 42 percent of households making more than the state's median income reported experiencing cost burdens. Respondents supported a number of steps to remedy affordability problems, such as showing patients a "fair cost" for specific procedures, requiring medical providers and insurers to give up-front cost estimates and giving the state Attorney General the authority to prevent price gouging on prescription drugs.

In a State of Great Wealth, All the Healthcare Some Can Afford 

By Keith M. Phaneuf | The Connecticut Mirror | Oct. 15, 2018 

Tens of thousands of Connecticut residents lack access to adequate healthcare, despite the state’s tremendous wealth and strong embrace of the Affordable Care Act, according to The Connecticut Mirror. While Connecticut once had a generous social safety net that elevated its poorest residents above their counterparts in most other states, it has since been eroded by massive budget deficits, which could get worse in the near future. Advocates worry that changes on the horizon could mean greater barriers to healthcare access for many Connecticut residents, including low-income individuals and families, those who rely on safety net clinics for care, middle-class earners whose income has been squeezed by healthcare costs, and those with insurance plans that increasingly require them to pay more for care.

District of Columbia 

Nurses in D.C.’s 911 Center are Helping Cut Some Unnecessary Ambulance Runs, but Not Most 

By Clarence Williams | The Washington Post | Sept. 23, 2018
A 90-day evaluation of a nursing triage line at D.C.’s 9-1-1 call center revealed that the program has yet to meet one of its intended goals: reducing ambulance trips for patients who don’t need them, according to The Washington Post. The program, known as “Right Care, Right Now,” aims to avoid unnecessary and costly trips to the ED by diagnosing callers who have non-life-threatening conditions and ordering quick, private transportation to clinics through a ride-share service. While the goal is to deploy ambulances, medics and fire crews more wisely, the evaluation showed that nearly half of all calls routed from a 9-1-1 dispatcher to triage nurses still resulted in a fire unit being sent out after the nurses heard a caller describe their medical need. Early evidence suggests that the nurses have become more comfortable with referring callers to clinics over time, although similar efforts in Philadelphia and Richmond have failed due to lack of return on investment.


The Maryland Health Enterprise Zone Initiative Reduced Hospital Cost and Utilization in Underserved Communities 

By Darrell Gaskin, et al. | Health Affairs | October 2018 

Maryland implemented the Health Enterprise Zone in 2013 to reduce health disparities by improving health outcomes and access to healthcare in underserved communities, according to an article in Health Affairs. Similar to Accountable Communities of Health, the Health Enterprise Zone provided support to coalitions of health departments, healthcare providers, and community based social service organizations to work together to address the healthcare needs of underserved communities. The primary focus of the initiative was to recruit providers to work in underserved communities and link patients to community organizations to address health-related social service needs. Each Health Enterprise Zone was designed to meet its community’s unique combinations of barriers in access to care, health problems and availability of community-based services. Researchers examined the impact of the initiative on avoidable hospital admissions and readmissions, finding significant reduction in both but an increase emergency department visits over the course of the three-year study period. The increase in ED visits was unexpected and authors postulated two reasons for the increase, while noting that on net the cost savings of the initiative far outweighed its cost for Maryland to implement.

New Hampshire 

Governor Sununu Proposes $24 Million to Boost N.H.’s Healthcare Workforce 

By Sarah Gibson | New Hampshire Public Radio | Oct. 16, 2018 

According to New Hampshire Public Radio, Governor Sununu announced $24 million dollars to help address the state’s nursing shortage. The one-time investment will help expand nursing programs at schools across the state including Plymouth State University and the University of New Hampshire. There are currently 1300 open positions to be filled in the state, and the hope is that increasing the number of trained nurses will help fill these and future openings in the state.

North Carolina 

CMS Approves North Carolina’s Innovative Medicaid Demonstration to Help Improve Health Outcomes

By Seema Verma | Health Affairs Blog | Oct. 24, 2018 

CMS has approved a North Carolina Medicaid reform demonstration to move from traditional fee-for-service payments to a managed care delivery system. The reform model is an attempt to increase quality of service as well as create a more predictable budget, according to Health Affairs Blog. North Carolina will partner with health plans in an effort to target high-need Medicaid patients and better coordinate care. Among other innovations, the state will pilot an intervention in select regions that addresses social determinants of health including food security, housing instability, reliable transportation, toxic stress and interpersonal violence. 

South Carolina 

Clemson, USC Receive Grants to Help with Healthcare Workforce Development  

By Liv Osby | The Greenville News | Oct.16, 2018 

The University of South Carolina and Clemson University each received $25,000 from the South Carolina Hospital Association to help develop the state’s healthcare workforce in response to the shortage of workers. According to The Greenville News, the schools will use the grant to support inter-professional development for nursing students and students in the masters of health administration program.


Report Highlights Significant Variation in Healthcare Costs 

By Augusta Free Press | Sept. 30, 2018 

According to a report by Virginia Health Information (VHI), healthcare costs vary dramatically depending on where consumers live, highlighting the need for local cost of care information. For example, a colonoscopy in 2016 averaged as little as $1,075 in Southwest Virginia physician offices and as much as $2,940 in Central Virginia hospitals, according to Augusta Free Press. In a 2017 national report card published by Altarum, Virginia was just one of six states earning a passing grade in pricing transparency.
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Recent Reports

Market Power: Price Variation Among Commercial Insurers for Hospital Services

By Ge Bai and Gerard F. Anderson | Health Affairs | October 2018

new study looking at variation in hospital prices paid by commercial insurers in Florida found that health maintenance organizations (HMOs) and preferred provider organizations (PPOs) have considerably more negotiating power with hospitals than other payers. The median hospital price for other payers – such as casualty (automobile), workers’ compensation and travel insurers – rose from 2.8 to 3.8 times the Medicare price from 2010-2016. The median price paid by HMOs/PPOs rose from 1.9 to 2.5 times the Medicare price over the same period. Additionally, commercial HMO/PPO insurers’ prices were similar across major hospital systems, regardless of ownership, while other insurers’ prices differed substantially across systems.

Effect of Community Health Worker Support on Clinical Outcomes of Low-Income Patients 

By Shreya Kangovi, et al. | JAMA Network | October 2018

A multi-center, randomized clinical trial assessing the impact of individual management for patients delivered by community health workers (CHWs) to address social determinants of health demonstrated that a standardized intervention did not improve patient’s self-rated health but did improve patient-perceived quality of care. Additionally, the intervention reduced total hospitalizations as well as total days spent in the hospitals, according to a study in JAMA. Thus, the program was effective in reducing the health systems costs as well as improving patient perception of their care.

Percent of Plans with Out-of-Network Benefits

By Katherine Hempstead | Robert Wood Johnson Foundation | Oct. 4, 2018

The number of insurers offering out-of-network (OON) coverage is on the decline with only 29 percent of individual market insurers offering such coverage in 2018, compared to 58 percent in 2015, according to an analysis from the Robert Wood Johnson Foundation. This may be due, in part, to the departure of many national commercial carriers from the individual market in 2016 and 2017, which left the market dominated by Blues and Medicaid managed care organizations. OON bills are a source of concern to consumers, and a recent study showed that approximately 20 percent of hospital visits among patients with large group coverage resulted in an OON bill. In about 95 percent of individual and small group plans with OON benefits, the deductible must be met before there is any cost-sharing. Median deductibles for OON coverage are approximately $12,000 and benefits generally do not have a maximum out-of-pocket limit.

High-Deductible Employer Plans Contribute to Financial Burden for Low-Income Patients

By Tina Reed | FierceHealthcare | Oct. 9, 2018

A recent study has revealed that nearly 47 percent of low-income people with multiple chronic conditions and a high-deductible plan were paying more than 20 percent of their family income on out-of-pocket healthcare expenses. This is especially pertinent considering an increasing number of employers are turning to high deductibles to stem the growth of health premiums, according to FierceHealthcare. The article notes that these individuals are likely ineligible for Medicaid or ACA cost-sharing subsidies due to the offer of employer-sponsored coverage, yet the high out-of-pocket costs associated with their employer plan may create a barrier to effectively managing their chronic conditions.

1,495 Americans Describe the Financial Reality of Being Really Sick

By Margot Sanger-Katz | New York Times | Oct. 17, 2018

A survey, conducted by the Commonwealth Fund and the Harvard T.H. Chang School of Public Health, of some of the country’s most seriously ill people found that, even with health insurance, more than a third of the respondents had spent all or most of their savings while sick. Experts believe that because the estimated 40 million people in this population visit doctors, hospitals, nursing homes and pharmacies the most, they are the most likely to see the weak points in the healthcare system, according to the New York Times. One of these “weak points,” may be financial insecurity, both for patients and their family members. Among people with health insurance, more than 20 percent had trouble paying for basic necessities and 53 percent said their work had been interrupted by illness, causing financial difficulties. Additionally, patients could not anticipate what medical bills they are responsible for, with 31 percent of respondents saying they were unsure what their health insurance would pay for and two-thirds revealing that their doctors had never discussed the cost of their care.\

Prescription Drug Spending, Prices Moderate in Q2 

By Les Masterson | Biopharma Dive | Oct. 8, 2018

After Gilead Sciences’ infamous drug Sovaldi contributed to a spike in prescription drug spending in 2014, prescription spending growth dropped to a 10-year low 1.3 percent in 2016 before rebounding to 4.7 percent in 2017, according to Biopharma Dive. An Altarum reportdetailing Q2 healthcare spending in 2018 revealed that U.S. health spending was 5 percent higher than in Q2 2017, bringing the growth rate for the first half of 2018 to 4.8 percent. Experts also noted that the share of the population with health coverage has plateaued, health spending by private payers has grown faster than public payers since 2016, and that –reflecting recent growth in wages and general inflation -- healthcare price growth is below economy-wide inflation.

The Unfinished Business of Health Reform

By Josh Bivens | Economic Policy Institute | Oct. 10, 2018

report from the Economic Policy Institute has found that healthcare cost growth does not correlate with high-quality care, noting that though U.S. spending on healthcare is higher than peer countries, quality is lower. One key finding was that the total annual cost of an employer-sponsored plan for a family rose from $5,791 to $18,142 between 1999 and 2016. The author emphasized that efforts to contain healthcare costs by controlling use are not only economically inefficient but also dangerous—leading to decreases in medically indicated and preventive care that would improve health outcomes for Americans. Instead, policymakers should focus on controlling prices, encouraging plans to incorporate a “public option,” adopting “all-payer rates,” pursuing policies that diminish intellectual property rights and increasing antitrust scrutiny of provider consolidation.

Avoidable Hospital-Acquired Conditions Spark $2 Billion in Extra Costs

By Harris Meyer | Modern Healthcare | Oct. 22, 2018

A set of 14 hospital-acquired conditions (HACs) that CMS considers avoidable accounted for 48,771 adverse patient outcomes, 3,219 deaths and more than $2 billion in excess hospital costs in 2016, according to a new IBM Watson study. Patients experiencing HACs were in the hospital, on average, 8 days longer and had an increased mortality risk of 72 percent, according to an analysis from Modern Healthcare. The report did note that HACs have been declining since 2010, which could be attributed to providers increasingly using evidence-based practices and root-cause analysis to improve clinical care processes.

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High-Deductible Health Plans Fall from Grace in Employer-Based Coverage

By Jay Hancock| Kaiser Health News | Oct. 3, 2018

A survey conducted by National Business Group on Health found that 30 percent of large, corporate employers plan to offer high-deductible health plans in 2019, compared to 39 percent this year. Kaiser Family Foundation data also revealed that the proportion of workers in high-deductible plans peaked at 29 percent two years ago and have remained unchanged for this year, according to an article in Kaiser Health News. Employer motivation for offering high-deductible plans was to encourage patients to become smarter medical consumers by bearing a greater expense at the point of care. However, because many medical treatments are unplanned, hospitals and doctors proved to be much less “shoppable” than experts predicted. Employers’ latest cost-control efforts include managing expenses for the most expensive diseases, getting workers to use nurse video-chat services and other types of “telemedicine,” and paying for primary care clinics at work or nearby.

Medical Device Makers Shut Out of Value-Based Care Without Kickback Rule Change

By Bruce Japsen | Forbes | Oct. 26, 2018

The medical device industry is pushing for a change in the federal anti-kickback law to allow companies to fully participate in the shift away from fee-for-service medicine to value-based care, according to this Forbes article. Data has revealed that large insurance companies pay nearly 50 percent of their medical claims via value-based payment models. Current federal rules prevent device makers from entering into value-based partnerships by inhibiting them from providing incentives unless they fall within safe harbor. The industry has submitted suggestions to HHS, which is seeking input on rule changes related to value-based payments. AdvaMed, the medical device industry’s trade association, has proposed three “value-based safe harbors.”

Journalism Shouldn’t be a Safeguard Against Unreasonably High Healthcare Bills

By Nisarg Patel | Slate | Oct. 18, 2018

A recent viral story focusing on an Austin teacher’s exorbitant hospital bill drove the hospital in question to reduce his bill by more than $108,000. While journalists are doing incredible work investigating these bills and holding health systems accountable for inflated billing practices, it is the responsibility of policymakers and health systems to effectively prevent unethical billing for everyone, according to an article in Slate. New York state has implemented a process to address high out-of-network bills in which insurers and hospitals each develop reasonable payment rates for a given service, explain how it was calculated and describe how they compare to usual and customary rates. After which, a neutral third party determines which payment amount should be paid. Yale researchers found that the New York law lowered the incidence of out-of-network billing by 34 percent and reduced out-of-network rates by 6.8 percentage points relative to other New England states. However, many private insurance plans are not under the jurisdiction of state insurance laws, making it difficult for other states to implement similar legislation. Alternative proposed solutions include a federal ban on any balance billing by healthcare providers for emergency and ambulance services (Brookings) and requiring hospitals to sell a package of emergency medical care, which includes both hospital and physician services, to insurers (Yale).

To Help Fix American Mental Healthcare, Reform Certificate-of-Need Laws

By Mark Flatten | National Review | Oct. 8, 2018

Certificate-of-Need (CON) laws, which generally require providers of health-related services to get approval from a state regulatory board before building or expanding a facility or service, may be contributing to the dearth of mental health treatment options. The idea behind CON laws is that medical costs can be controlled by limiting the supply of services and facilities to only what is needed, as determined by a state board or agency, according to an article in National Review. However, by eliminating competition, CON laws drive up costs, decrease quality, and limit the availability of needed services, according to a series of assessments from the U.S. Federal Trade Commission and Department of Justice. A Goldwater Institute report also found that the primary beneficiaries of CON laws are existing providers of health services, who use them to block or delay construction of new facilities by would-be competitors.

Reducing Racial Disparities in Healthcare by Confronting Racism 

By Martha Hostetter and Sarah Klein | Commonwealth Fund | Sept. 27, 2018

A new issue of “Transforming Healthcare” from the Commonwealth Fund offers examples of health systems that are making efforts to identify implicit bias and structural racism in their organizations, and developing customized approaches to engaging and supporting patients to ameliorate their effects. Compared with whites, members of racial and ethnic minorities are less likely to receive preventive health services and often receive lower-quality care. They also have worse health outcomes for certain conditions. A study conducted by the University of North Carolina School of Public Health found that at two cancer centers, black men and women with early-stage breast or lung cancer were less likely to complete treatment than white patients (81 percent of black patients completed treatment, compared with 87 percent of white patients), even after taking into account patients’ age, comorbid illnesses, health insurance, income, and marital status. After interventions that trained nurse navigators to work with patients to ensure that they understood treatment options and financial and social supports were put in place, treatment completion rates increased among all patients, but they increased more among the intervention group. The publication also offers recommendations on how to eliminate disparities. 
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