Research Roundup - November 2016


California Releases Latest ‘Report Cards’ on Health Plans, Doctor Groups

By Ana B. Ibarra | California Healthline | Oct. 24, 2016

California’s Office of the Patient Advocate released its annual report cards on health plans and medical groups. The report cards assign ratings to the largest HMOs and PPOs in the state, as well as over 200 physician groups, based on quality of care and patient experience.

Mobile Healthcare Teams Prevent ER Visits

Elizabeth Whitman | Modern Healthcare | Nov. 19, 2016

At-risk patients may experience better health outcomes and fewer emergency department visits when supported by a mobile healthcare team, according to Modern Healthcare. A preliminary study of such a program in Florida found a 19 percent decrease in monthly emergency room costs per patient. A similar program called Community Paramedics launched in California with a focus on patients requiring mental health services and is expecting to evaluate the success early next year, according to California Healthline


Starling Physicians Partners with Aetna on Oncology Medical Home Model

Connecticut | Oct. 28, 2016

Starling Physicians will partner with Aetna to participate in an oncology medical home model designed to improve patient experience by enhancing delivery of quality and value in cancer care. The model will be centered around the whole person, with evidence-based, integrated and personalized medical care, with a focus on quality and safety; and enhanced access to care.

SNOMED CT Code Framework Will Aid EHR Reporting, Interoperability

By Jennifer Bresnick | HealthIT Analytics | Nov. 1, 2016

A coalition of pharmacy societies has released a new framework for mapping medication therapy management services to the SNOMED CT codes used for EHR documentation, interoperability efforts, and quality reporting. Unlike ICD-10, which is primarily geared toward recording diagnoses and procedures, SNOMED CT attempts to capture a more holistic view of the patient and his or her experiences, including socioeconomic data, medication use, lifestyle behaviors and family history. 


Patient-Centered Healthcare Program Proving Successful

By Mary Mayle | SavannahNow | Nov. 19, 2016

Primary care physicians have been participating in Blue Cross Blue Shield of Georgia’s value-based, patient-centered program for three years and have delivered significant successes, according to SavannahNow. BCBS of Georgia’s data identified a 2 percent higher rate of care for diabetic patients, a 3.5-percent better rate of cervical and breast cancer screenings, and a 4.5-percent increase in patients taking their cholesterol, blood pressure and diabetes medications as prescribed.

New Jersey

What New Jersey’s Proposed Out-of-Network Cap Would Do to Hospital Margins

By Shelby Livingston | Modern Healthcare | Nov. 22, 2016

New Jersey hospitals are pushing back against efforts to pass legislation capping the amount that they can charge for involuntary out-of-network services, according to Modern Healthcare. A study commissioned by for-profit hospital operator CarePoint Health estimated that the law would lead to operating losses at 48 percent to 70 percent of hospitals, depending on how high the cap was set. “Hospitals live off the margins from these out-of-network payments,” said the lead author of the study. But other analyses have found that New Jersey has some of the highest hospital rates in the nation. Several states, including California, Connecticut, Florida and New York, have passed legislation to protect patients from surprise bills and require health plans and hospitals to set up an arbitration process to work out any billing issues.


Pfizer Sues Texas Agency Over Drug Price Disclosure

By Erica Teichert | Modern Healthcare | Nov. 18, 2016

The Texas Health and Human Services Commission is being sued after providing drug pricing data to two Texas Senate committee heads, according to Modern Healthcare. The Texas Attorney General claims the disclosure was required under Texas law, yet Pfizer insists the action violated federal law.


FTC Opposes Proposed Merger of Mountain States, Wellmont Health

By Maria Castellucci | Modern Healthcare | Oct. 4, 2016

The Federal Trade Commission (FTC) recommended Virginia regulators reject the proposed merger of two large regional health systems. according to Modern Healthcare. FTC official Mark Seidman said the deal would cause an anticompetitive healthcare climate in the state, leading to higher prices and lower quality of care for patients. 

For more state news, please visit

Recent Reports

2015 Health Care Cost and Utilization Report

Health Care Cost Institute | November 2016

Price increases far outpaced utilization increases for the third straight year, according HCCI’s annual Cost and Utilization Report. For example, in 2015, healthcare prices rose 9 percent for prescription drugs, 6.6 percent for inpatient services, and 3.5 percent for outpatient services and professional services. In contrast, utilization decreased by 0.3 percent for prescriptions and 3.8 percent for inpatient services, and grew by 1.0 percent for outpatient services and 0.2 percent for professional services. Out-of-pocket spending also grew by 3 percent in 2015. 

Costly, Deadly -- and Avoidable, Central-Line Infections Reduced Across the Country

By Hallie Levine | Consumer Reports | Nov. 21, 2016

Consumer Reports created a list of the highest and lowest-performing U.S. teaching hospitals with respect to preventing central-line infections in intensive care units. The analysis also identified four top-performing states, including Oregon, Kansas, Minnesota and Wisconsin that had 71 percent or more of hospitals meeting the national target for central-line infections. Comparatively, the worst -- including New Mexico, Arkansas, Louisiana, Mississippi, and Alabama -- had no more than 43 percent of hospitals meeting the national target.

Out-of-Network Emergency-Physician Bills -- An Unwelcome Surprise

By Zack Cooper and Fiona Scott Morton | NEJM | Nov. 17, 2016

Patients are often treated by out-of-network physicians in emergency departments, according to a study published in the New England Journal of Medicine. The nationwide study found that 22 percent of patients who went to in-network hospitals in 2014 and 2015 were treated by out-of-network physicians, which potentially exposed them to significantly larger medical bills than if they had received in-network care.

Fewer Americans Say Cost is a Barrier To Getting Healthcare

Dana O. Sarnak, et al. | The Commonwealth Fund | Nov. 16, 2016

Fewer Americans are skipping doctor visits, recommended care and prescription doses due to cost of care; however, the percent that continue to struggle is more than double that of U.K., Germany and eight other developed countries. The other countries included in the study provide universal coverage to residents, have strong financial consumer protections and typically have lower prices for healthcare services. 

CMS Offers First Peek Into Medicaid Drug Pricing Trend

Centers for Medicare & Medicaid Services | Nov. 14, 2016

Newly released data on Medicaid and Medicare drug costs found that the cost of twenty drugs in the Medicaid program more than doubled in 2015, totaling an additional $340 million. The drugs associated with the highest total spending for Medicaid include Harvoni and Abilify. However, brand and generic drugs both experienced high year-over-year price increases. 

BEA Releases New Batch of Healthcare Statistics

BEA Blog | Nov. 2, 2016

Average healthcare expenses per person grew more slowly in 2013 than previous years, according to the new data released by the Bureau of Economic Analysis (BEA).  The newly released data comes from various sources and is part of BEA’s Health Care Satellite Account. The program allows the public to breakout healthcare spending by disease instead of the location of services provided, such as a physician’s office.

Retail Clinics Don’t Reduce ED Use for Low-Acuity Conditions

By Maria Castellucci | Modern Healthcare | Nov. 14, 2016

Despite rapid adoption of retail clinics across the United States in recent years, a new Annals of Emergency Medicine study suggests the presence of these clinics near a hospital emergency department (ED) does not reduce ED visits from patients with low-acuity illnesses (like influenza, urinary tract infections and ear aches). In part, this may be due to the fact that only 60 percent of retail clinics were found to accept Medicaid and this group is the most likely to seek care at an ED for low-acuity conditions. About 13.7 percent of all emergency department visits are for low-acuity conditions, the study notes. [Link]

Study Examines Causes of Emergency Department Visits for Adverse Drug Events

Nadine Shehab, et. al | JAMA | Nov. 22, 2016

Anticoagulants, antibiotics and diabetes agents were implicated in just short of half of emergency department visits for adverse drug events, according to research featured in JAMA. Three drug classes were implicated in sixty percent of ED visits for adverse drug events among older adults, the group accounting for 35 percent of ED visits for adverse drug events and the highest hospitalization rates.

2015 Risk Corridor Payments Released: No Winners, Many Losers

U.S. Department of Health & Human Services | Nov. 18, 2016

Risk corridor payments help stabilize premiums in the small and non-group markets by redistributing money from plans with very healthy risks to those with unexpectedly costly enrollees. A new report from Department of Health & Human Services finds that, similar to 2014, risk corridor payments are outpacing collections. As a result, 2015 risk corridor collections will be used to pay a portion of the outstanding risk corridor payments from 2014. The report lists, by state and insurer, the 2015 risk corridor amount in the individual and small group market and the expected payments toward 2014 amounts.

For more background on transparency, medical harm, surprise medical bills, prescription drug costs and more, please visit


5 More Locations Pass Soda Taxes: What’s Next for Big Soda?

By Bruce Y Lee | Forbes | Nov 14, 2016

Boulder, Colorado; San Francisco, Oakland and Albany California; and Cook County, Illinois join the U.S. cities that levy taxes on sugar-sweetened beverages, according to Forbes. Research has found these taxes reduced consumption and acted as a great source of revenue. Similar initiatives are expected to hit other California cities; Baltimore, Md.; Sante Fe, N.M.; and the entire state of Illinois. A fun infographic can be found at Modern Healthcare.

A Portfolio Strategy for Affordable Coverage: Disaggregating Problems, Aggregating Solutions

By John Rother and Mark Goldberg | Health Affairs Blog | Nov. 18, 2016

At the heart of the new post-election healthcare debate is affordability of insurance for employer-sponsored plans and marketplace plans, according to this commentary in the Health Affairs Blog. Policy analysts and policymakers should first identify the cost drivers in the healthcare system, then identify the opportunities to address each one. These solutions, tackling growing healthcare costs at various stages has a greater potential to bend the cost curve compared to a strategy tackling just a few stages.

What the Trump Administration Needs to Do About Health Care

By Leemore S. Dafny and Thomas H. Lee | Harvard Business Review | Nov. 10, 2016

The uncertainty that the Trump administration brings raises the risk providers will pursue mergers in an effort to sustain profits. As a result, the administration should commit to promoting and protecting competition at every level of healthcare, according to the Harvard Business Review. The Trump administration can do this by increasing funding to the Federal Trade Commission and the Department of Justice, accelerating the Medicare and Medicaid reforms rewarding quality over quantity and encourage transparency on outcomes.

The Real Drivers of Healthcare Aren’t Being Addressed

By Andy Lazris | Real Clear Health | Nov. 2, 2016

Only five percent of Medicare’s non-HMO funding is spent on primary care. The remaining funding is excessive spending for aggressive procedure-based medical care, unhelpful to consumers and a contributor to rising premiums, according to Real Clear Health. This problem can be addressed by eliminating the Relative Value Scale Update Committee and normalizing doctor pay, encouraging insurers to start paying equally for home care and hospital care and to stop encouraging unnecessary procedures and hospitalizations.

HealthEngine Releases Value Marketplace

By Melissa Eckl | PR Web | Oct. 27, 2016

HealthEngine, LLC, a healthcare technology company, released its Value Marketplace, which claims to incorporate the profiles of every medical professional and medical facilities in the U.S. and provide information on cost, quality, and patient satisfaction metrics across a range of medical services. The Value Marketplace seeks to have healthcare facilities compete for patients and physicians by competing on prices and showcasing validated clinical quality data. 

A Brief History of Price Controls by Annoyed Republican Administrations

By Uwe Reinhardt | The Healthcare Blog | Nov. 21, 2016

Drug companies, among other entities, may not be getting the free pass many are expecting from the Trump administration, according to Uwe Reinhardt in The Healthcare Blog. Republican administrations have a history of “fearsome, regulation-prone, price-controlling” policies typically associated with Democrats. For example, the healthcare price controls implemented under Nixon, centrally administered Medicare prices for the entire country under Reagan and the Medicare Fee Schedule and global budgets under George Bush. 

U.S. Charges in Generic-Drug Probe to Be Filed by Year-End

By David McLaughlin and Caroline Chen | Bloomberg Markets | Nov. 3, 2016

An antitrust investigation by the Justice Department over suspected price collusion involving two dozen drug products may announce charges by the end of the year, according to Bloomberg Markets. Once hitting the news, companies named in the investigation experienced a tumble in stock prices. Although pharmaceutical prices have garnered a lot of scrutiny this year, this investigation is unique in that it targets generic drugs.

Mega Insurance Merger Proposals Get Their Time in Court

By Shannon Muchmore | Modern Healthcare | Nov. 21, 2016

The case against Anthem and Cigna started in court this month with the government arguing that the merger would result in higher prices for consumers, reduced quality, fewer consumer choices and less innovation, according to Modern Healthcare. The Aetna and Humana deal will start their trial in December. The health insurers in both cases have pushed for rulings by the end of 2016. 

AMA, LexisNexis Partner on New Provider Directory Tool

By Henry Powderly | Healthcare Finance | Nov. 21, 2016

The new tool will streamline physician network directories to ensure the most up-to-date data is available to insurers, providers and patients, according to Healthcare Finance.  Accurate provider directories better protect consumers from high out-of-network bills. 

American Diabetes Association Calls on Congress to Hold Hearings on Insulin Prices

By Carolyn Y. Johnson | The Washington Post | Nov. 18, 2016

The American Diabetes Association wants Congress to hold hearings and pass legislation that would ensure people have affordable access to insulin, according to The Washington Post. The group also has a petition, “Stand up for affordable insulin” calling for transparency, affordability and access in the wake of a 48 percent increase in the annual cost of diabetes, gestational diabetes, and prediabetes in the United States over five years. A similar campaign was announced by the National Multiple Sclerosis Society in September.