Trump Eyes Executive Order to Cripple Individual Mandate

Originally published on Healthcare Dive.

President Donald Trump’s administration has reportedly prepared an executive order to end the Affordable Care Act’s (ACA) individual mandate. Trump may direct his departments to not enforce the mandate and could allow for more hardship exemptions that let people avoid fines for not having coverage.

Trump is reportedly not following through until he sees whether an individual mandate repeal winds up in major tax legislation. Republicans are trying to pass a tax bill by the end of the year, but they need to find ways to fund the $1.4 trillion tax cut over 10 years. One way is by repealing the individual mandate, which could save $416 billion over a decade.


House Speaker Paul Ryan (R-Wis.) said the individual mandate repeal isn’t part of the current tax bill, but leaders could add it to the legislation.

The Congressional Budget Office predicted earlier this year that about 15 million Americans would lose coverage over 10 years and premiums would increase 20% for individual plans without the individual mandate.

Scrapping the individual mandate would result in fewer people seeking health insurance and fewer government subsidies to help people buy coverage.

Repealing or seriously weakening the mandate would also result in healthier people leaving the insurance markets. Healthier members help offset the sickest members. Without that offset, the health insurance markets will become unbalanced, which would likely result in higher premiums and out-of-pocket costs for those who maintain coverage. Ending the individual mandate would also cause more payers to flee the ACA exchanges.

Increasingly frustrated by the Republican-led Congress not passing ACA repeal legislation this year, the president has taken other ways to chip away at the ACA law. One of his first executive orders in January requested the HHS “exercise all authority and discretion” to delay ACA provisions that impact members and states financially.

That order led to the CMS’ recent proposed rule that would allow states to bypass the ACA’s essential health benefits (EHBs) and let them decide on their own EHBs. It would also remove regulations that require payers in the ACA exchanges to pay a certain amount of premium dollars on claims. Right now, the ACA requires payers in the exchanges to uphold at least an 80% medical loss ratio. In the proposed rule, states would also have more influence over deciding what’s considered a qualifying health plan.

Trump additionally signed an executive order to allow small businesses and groups of people to come together to buy insurance as an association health plan. That order also expands short-term catastrophic plans, which offer barebones insurance coverage with high deductibles. Currently, only young people and those who meet hardship requirements can buy catastrophic plans in the exchanges. Trump’s order could open catastrophic plans for everyone.

In addition to the executive orders, the Trump administration has slashed the ACA advertising budget by 90% and cut the open enrollment period in half this year.

ACA opponent on Capitol Hill haven’t been as successful as the president in weakening the law. The House could add an individual mandate repeal to its tax bill, but the legislation may face impenetrable obstacles in the Senate. The Senate has already failed to pass ACA repeal legislation multiple times this year. Trying to wipe out a key plank to the ACA in the Senate likely won’t happen.

If Congress fails to repeal the individual mandate, the president may once again take aim at the ACA. The president’s previous executive orders and policies have wounded the ACA, but harming the individual mandate could be the final trump card that topples the ACA exchanges.



What Will be the Fallout from Anthem’s New Imaging Policy?

Originally published on Healthcare Dive.

A movement health systems have been dreading is gaining speed, as commercial and government payers are implementing more and more policies that restrict reimbursements for services that can be performed outside a hospital. Anthem’s recent announcement that it will no longer pay for MRIs and CT scans performed at a hospital in an outpatient basis could be a harbinger for what’s to come.

Several hospitals and health systems have already taken steps to recapture revenue lost to these demands for pushing patients outside their walls whenever possible. But with the industry already suffering from reduced patient volumes and lower reimbursements in general, policies restricting the services hospitals count on for steady cash flow could be a major disruption.

Anthem’s new rule

Anthem plans to implement the policy in 13 of its 14 states by March 2018, with only New Hampshire exempt from the new policy. The payer has already implemented it in nine states.

Hospital officials are predictably concerned about what this could mean to their margins. Higher in-hospital reimbursement for MRIs and CT scans made them profitable, even though they’re not a major service for hospitals. One estimate said some health systems collect more than half of their profit from imaging services.

Anthem’s new policy is part of a payer movement to reduce healthcare costs by pushing patients to get care at locations less expensive than hospitals. That’s also true for another controversial Anthem policy to stop paying for Emergency Department (ED) care it deems unnecessary.

Trying to cut healthcare costs is nothing new for insurance companies, or the industry in general. For many years, payers and employers have created health plans that reward members for getting care at less expensive locations. That benefit design has resulted in patients paying more to go to specialists rather than primary care physicians and going to EDs rather than places like urgent care centers. Payers have also nudged members to get more services as an outpatient and avoid being admitted to a hospital.

Those cost-cutting efforts seem to be working. Altarum’s Center for Sustainable Health Spending’s recent Health Sector Economic Indicators reported overall national health spending growth decreased in the second quarter. A major reason for the slower spending growth was connected to hospital spending growth, which was only 1.3% rather than the expected 4% growth rate. Hospital spending growth was the slowest major healthcare category over the past year. Hospital spending increased in June by 0.8%, which was the slowest growth rate year-over-year since January 1989.

While payers have looked for passive ways to re-direct patient care in the past, Anthem’s two new policies extend beyond benefit design and go to the heart of hospital funding. In recent years, hospitals overcame lower Medicare reimbursements by making more on imaging and ED services, which have been steady profit centers. Now, hospitals in 13 states will see that funding dry up.

Anthem said its new Imaging Clinical Site of Care program dovetails with the Institute for Healthcare Improvement Triple Aim Initiative, which seeks to improve the patient experience, improve population health and reduce per capita cost of healthcare.

Anthem subsidiary AIM Specialty Health is administering the program to identify when hospital outpatient services for services like MRIs and CT scans are medically necessary. Lori McLaughlin, Anthem communications director, told Healthcare Dive getting services in a “clinically appropriate setting” like a freestanding outpatient clinic or imaging center is less expensive and clinical research shows those locations are safe.

Anthem said the policy will result in lower healthcare costs for members and the healthcare industry overall. Imaging services in a hospital can cost $1,000 more than a freestanding clinic, and that cost could fall to the patient if they haven’t met their plan’s deductible.

Anthem said AIM Speciality Health will only review the level of care if there are at least two alternate freestanding imaging centers nearby. So, imaging would be approved in rural areas that might not have more than one option for an MRI or CT scan, according to the payer.

McLaughlin said Anthem doesn’t know how much it has saved or how many hospital scans it has reduced because the plan is still so new. With the imaging policy set, McLaughlin said Anthem will continue to look for more ways to save healthcare costs.

“Anthem’s primary concern is to provide access to quality, safe and affordable healthcare for our affiliated health plan members. We’re always looking at new approaches to ensure clinical quality and improve affordability and we are committed to reducing overall medical cost where possible when the safety of the member is not put at risk,” she said.

Will other payers follow suit?

Anthem is a major insurer in more than a dozen states, so any decision will have a ripple effect in those areas and beyond.

Lea Halim, senior research consultant at Advisory Board, told Healthcare Dive other payers will likely watch how Anthem’s policy plays out.

“Will Anthem get a lot of pushback from patients and employers? Will hospital lobbies succeed in getting state governments to force Anthem to roll back the policy? If Anthem does not face, or successfully overcomes these types of challenges, other payers may very well follow suit,” Halim said.

Payers are working to bring down costs in other ways, too. One example is insurance companies buying surgical centers, said Gregory Hagood, senior managing director at SOLIC Capital Advisors, which works with hospitals on mergers and acquisitions. Another example is payers creating networks that encourage members to use alternative (i.e., less expensive) services.

Hagood expects payers will continue to look for more ways to cut costs, including reviewing elective services performed in hospitals. “We’re seeing all insurance companies trying to create an alternative network where, theoretically, the quality of these centers are what you get in the hospital, but at a lower rate because you don’t have all the overhead of hospitals,” he told Healthcare Dive.

Private companies like Anthem aren’t the only payers creating policies that cut costs and affect hospital finances. The CMS also recently announced a proposal to make costs more site neutral. With this change, CMS would pay services at off-campus hospital outpatient departments by 25% of regular outpatient rates (while increasing outpatient payments overall by 1.75%). The CMS expects the proposal would save about $500 million this year. The American Hospital Association has spoken out vociferously against the proposal.

Medicare is also proposing hip surgeries in surgery centers in addition to just hospitals. Knee and hip surgeries have the highest margins for hospitals, but Medicare is pushing more volume to outpatient services.

“Those are huge dollars you’re talking about there,” Hagood said. “It’s another where a hospital’s lucrative services like joint replacement and imaging are starting to get squeezed from both sides — from CMS and private payers.”

Impact to hospitals

Anthem’s size and importance in the 13 states where it is active means its imaging policy will affect hospital finances. However, Paul Keckley, healthcare researcher and managing editor of The Keckley Report, told Healthcare Dive many hospitals are already competing with freestanding and physician-owned facilities. So, though Anthem’s policy will affect hospitals, Keckley said those facilities are already “accustomed to the downward pressure on their margins.”

Hagood estimates that MRIs and CT scans make up only 5%-10% of a hospital’s business, but those services are profitable and have huge profit margins for hospitals.

Hagood said an MRI for a knee or shoulder would cost about $500 on average in a physician’s office, but that would swell to somewhere between $1,000 and $2,000 at hospitals in many markets. This means hospitals are making an average of $1,000 more on each procedure, he said.

Spread over a year, that’s about $800,000 more profit for hospitals, which these facilities stand to lose with Anthem’s new imaging policy.

Halim said hospitals stand to lose the reimbursements from Anthem, but those with their own freestanding imaging facilities that bill at a lower rate already should be able to capture a portion of the lost revenue.

Beyond hospital finances, the policy change would impact patients both positively and negatively. Anthem patients in a high-deductible plan will pay less out-of-pocket for an MRI or CT scan at freestanding facilities. However, patients not in a high-deductible plan and who may not pay much out-of-pocket anyway, may feel inconvenienced if they’re told they can’t get the services at their local hospital. Plus, if the ordering physician doesn’t direct the patient to a freestanding facility and the person gets the services at a hospital, Anthem could deny the claim and the patient will get stuck with the bill, said Halim.

What will hospitals do?

Hagood doesn’t think hospitals will make up the lost funding in other areas. Instead, he expects staffing cuts and hospitals squeezing vendor contracts for supplies and maintenance.

One way hospitals could respond is by working with the payer to get a little more money for imaging than a freestanding imaging center, but much less than what Anthem has been paying hospitals. Hagood said hospitals may get a “modest premium,” such as maybe get another $100 or $200 for a scan instead of the extra $1,000 Anthem has been paying them.

Halim said hospitals may accept the outpatient payment rate for hospital-based facilities in exchange for a policy waiver. Plus, they may invest more in their own freestanding imaging centers.

“If Anthem represents a significant portion of their revenue — and if the new policy sticks — that may lead some hospitals to consider investing in freestanding facilities so that they can still capture Anthem’s outpatient imaging business,” Halim said.

Healthcare, Insurance

CareSource Will Cover Final County Without an ACA Option in 2018

Originally published on Healthcare Dive.

CareSoure announced Thursday it will cover the last county at risk of having no Affordable Care Act (ACA) plans in 2018. CareSource will offer health insurance plans in Paulding County, Ohio, which the Kaiser Family Foundation (KFF) said was the only “bare county” left.

The Dayton, Ohio-based payer was also one of five insurers that recently announced they will cover 19 other bare counties in Ohio. Altogether, more than 11,000 Ohioans have ACA coverage in those counties.

All U.S. counties are now expected to have at least one ACA plan option. However, nearly one-quarter of ACA plan enrollees will only have one option, which means there is no competition in those areas.

In a statement from CareSource, the company said its decision to offer plans in bare counties “speaks to our mission and commitment to the marketplace and serving those who are in need of healthcare coverage.”

Ohio Department of Insurance Director Jillian Froment said filling the bare counties has been a priority for her department. “There is a lot of uncertainty facing consumers when it comes to health insurance and these announcements will provide important relief,” she said.

The Ohio Department of Insurance said it is working with payers to finalize products and rates in the ACA exchanges next year. The department expects to complete review of insurer filings by early September, before payers must sign contracts with the federal government by late September to offer ACA plans.

Although she is pleased to have the bare counties filled for 2018, Froment said the move is only a “temporary solution and one that only applies to 2018.” She called on Congress to pass legislation to stabilize the individual insurance market. Congress is expected to take up the issue when it returns from break.

One area that is causing much unease is whether President Donald Trump will continue to pay cost-sharing reduction (CSR) subsidies to insurers. The CSR payments help ACA insurers cover lower income Americans. Trump has threatened multiple times to stop CSR payments to insurers, but so far he has ultimately paid the subsidies. Without those subsidies, the Congressional Budget Office predicted ACA premiums would skyrocket another 20%.

“Insurers are still looking for predictability in the health insurance market. Now is the time for Congress to work on reforms that will strengthen our health insurance markets in ways that improve access and affordability,” said Froment.

There was a time not too long ago when healthcare and state officials fretted about dozens of potential bare counties in 2018. That included nearly all Nevada counties. However, Nevada Gov. Brian Sandoval announced last week that Centene agreed to sell ACA plans in the 14 bare counties in Nevada. Centene also recently filled the final county in Indiana.

The St. Louis-based insurer has been expanding its ACA footprint this summer, while other major payers are pulling back or completely out of the exchanges. Centene is also entering Kansas and Missouri and expanding its footprints in Florida, Georgia, Indiana, Ohio, Texas and Washington.

Filling in all of the counties is good news, but there is still the issue of competition. Nearly one-quarter of members in ACA plans will have only one choice and another one-quarter will have just two choices. There is also concern about large premium increases. Early rate filings have already shown the negative effects of uncertainty.

Opponents of the ACA plans say the market is in a “death spiral.” However, the KFF found in a recent report the individual health insurance market is actually stabilizing, and insurers are regaining profitability. KFF warned there are “more fragile” parts of the country and uncertainty coming from Washington could destabilize the market.

So, the question remains: Is 2018 a year of transition for the ACA market that is stabilizing? Or will political fighting continue to cause unease and ultimately topple the exchanges in some parts of the country? Congress could go a long way to stabilize the market by agreeing to fund the CSR subsidies long-term and take that decision out of the hands of the president.


Health Reform Driving Payer-Provider Partnerships

Originally published on Healthcare Dive.

Payers and providers have for decades stayed in their silos, leading to a more fractured and adversarial healthcare system. That relationship, however, is starting to soften for many in the industry. Payer-provider partnerships put the two groups on the same team in hopes of reducing costs and improving care and outcomes through sharing data and better communication.

A major driver of these partnerships is the move away from fee-for-service payments and toward valued-based payments and population health management.

“We’ve been tracking these partnerships for many years now and of the approximately 200 that have launched in the last five years, 92% are emphasizing value-based compensation in some shape,” Thomas Robinson, partner at Oliver Wyman, told Healthcare Dive.

The payer-provider partnerships popping up across healthcare vary in type, size, location and model. There are 50/50 joint ventures with co-branding, and less intensive partnerships like accountable care organizations (ACO), patient-centered medical homes (PCMH), pay for performance and bundled payments. Oliver Wyman found the partnerships can be broken down depending on providers’ appetite for risk.

The differences are endless, but they all focus on improving care for the individual patient. They do this through close communication between stakeholders, better interoperability and data-sharing, using data analytics to track patients and reducing administrative burdens.

Keys to partnerships: Trust, communication and a focus on the patient

The first step in these partnerships is building trust between payers and providers. Robinson said that can be difficult, as payers and providers may have an fractured relationship. Payers and providers can overcome differences by aligning around the big issues as early as possible, and establishing the right governance model.

Chuck Lehn, president of Banner Health Network, told Healthcare Dive a successful joint venture allows each organization to offer its administrative strengths and have a clear understanding of its roles and accountabilities.

“In our experience, we have found that streamlining the administrative pieces of our product can lead to better efficiency and a great member experience,” said Lehn.

Brigitte Nettesheim, president of transformative markets for Aetna, told Healthcare Dive partnerships necessitate a culture change, and participants need to understand they’re both in it for the long run. This requires aligning responsibilities and carefully crafting, negotiating and planning down to the most minute detail before the partnership is signed and executed.

Another key is communication. Lehn acknowledged that communicating across systems and platforms between two organizations and healthcare providers requires time, attention and resources. In a successful partnership, both sides need to communicate regularly and invest in technology, such as portals, so the two sides can share data seamlessly.

Caring for the whole patient works best when payers and providers share data, so there is improved care management, better interventions and better analytics around population health. This requires a capital commitment, so there is communication between not only payers and providers, but also between those two groups and patients, said Robinson.

The two sides can go much deeper into care for patients by going beyond claims. In partnerships, payers shouldn’t have to wait for claims to see how their members are doing and doctors shouldn’t have to hope that their patients tell them when they have received care elsewhere. All of that data should be shared freely and promptly.

“Most communication has been traditionally centered around transactions. That’s just not sufficient anymore, ” James Leatherwood, marketing communications manager at Availity, told Healthcare Dive.

In addition to regular back and forth, payers and providers need regular meetings, whether monthly or quarterly, that focus on strategic issues about the partnership, said Leatherwood.

The third part of a successful partnership is aligning incentives that focus on keeping people healthy and creating a positive healthcare experience, said Robinson.

Partnerships must provide patients the right incentives, integration, investment, insight and innovation to work with the plan to deliver improvements across cost, quality, outcomes and experience, said Robinson.

“The point of these partnerships is to create something new, rather than just building the same old offerings with a narrow network. Successful partnerships will take the opportunity to innovate around the product and experience now that the incentives, insight, investment and integration are all for it,” said Robinson.

Partnerships to watch

Payers that are involved in partnerships vary from new players in the payer space like Oscar Health and Bright Health to large, established insurers like Aetna, various Blues and Cigna.

Here is a handful of the closely watched partnerships:

Aetna is one payer to watch in the partnership arena. Nettesheim said the company has committed to moving 75% of its contracts to value-based arrangements by 2020. Aetna is currently at 48%.

Aetna and Banner Health agreed on the partnership in October 2016 and have been laying out the groundwork before its launch this month in Maricopa and Pinal counties in Arizona. The two companies hope to expand the program statewide ultimately.

To prepare for the partnership, Tom Grote, who became CEO of Banner | Aetna joint venture in May, told Healthcare Dive that Banner Health and Aetna have developed joint operating committees, including marketing/sales and population health, that include members from both organizations.

The partnership looks to improve consumer experience by fully integrating providers, Aetna and administrative services, while eliminating redundancies in care and administrative problems. Aetna and Banner Health expect streamlining care and services will lead to savings for patients and employers.

Nettersheim said the partnerships are about “each side playing to its strengths, aligning incentives and driving scale.”

The two companies have worked together for more than five years on a separate ACO. The ACO has resulted in nearly $10 million in savings, a 24% drop in avoidable surgical admissions and increased generic drug prescribing rates by 4%, according to Aetna.

Grote said the key to partnerships is a common vision between the entities and leadership that healthcare needs to move to a value-based system.

“If we keep the customer — the end user — in mind and build partnerships with that as our North Star, we believe we will have a more successful, efficient and collaborative health system,” said Grote.

Nettersheim said most provider-sponsored health plans formed since 2010 haven’t shown a profit yet. In some cases, this is because they aren’t yet able to scale up to what is needed to create profits.

Aetna’s partnerships with Banner, Allina and Sutter Health are still too new to find results, but Nettersheim is confident that Aetna’s partnerships will achieve scale by offering stability, expertise, volume and market power.

Another partnership to watch is Blue Cross Blue Shield of Michigan’s (BCBSM) PCMH, which is the largest medical home project in the country. The model is part of BCBSM’s Value Partnerships, which works with physician organizations and hospitals to improve patient care and provide value to members and customers.

The PCMH program isn’t a 50/50 co-branded joint venture like Banner | Aetna, but is an example of a less intensive partnership looking to have a similar result. The PCMH started nine years ago and includes 4,692 physicians in 1,709 practices. There are PCMH practices in 81 of Michigan’s 83 counties.

The idea of a PCMH began a decade ago as a way to improve care and outcomes while cutting costs. The model has primary care physicians leading care teams, which include specialists, that focus on each patient by tracking conditions and making sure patients get care “at the appropriate time and in the most appropriate setting,” according to BCBSM.

The payer said they have seen success. This year, PCMH practices are performing better than other practices. Blue Cross Blue Shield of Michigan said PCMH practices have seen 19% lower rate of emergency room (ER) visits for adults; 23% lower rate for primary care sensitive ER visits for adults; 25% lower rate of ambulatory care sensitive inpatient stays for adults and 15% lower rate of pediatric ER visits.

“If we keep the customer — the end user — in mind and build partnerships with that as our North Star, we believe we will have a more successful, efficient and collaborative health system, ” Tom Grote, CEO of Banner | Aetna joint venture, told Healthcare Dive.

A recent Health Services Research report also found that hospital per-member per-month cost was reduced by 17.2% and emergency department per-member per-month cost was reduced by 9.4% for Blue Cross PCMH patients with asthma, angina, diabetes, chronic obstructive pulmonary disease, high blood pressure and congestive heart failure.
Tom Leyden, director II of the Value Partnerships Program at BCBSM, told Healthcare Dive members actively engaged with their primary care physicians are seeing better outcomes. What’s made the BCBSM program a success is “strong relationships that have been cultivated within the Michigan healthcare community,” he said.

Leyden said providers want to be active participants in system transformation.

“This requires ongoing support from the payer and demonstrated evidence of practice transformation and clinic results from the provider community,” said Leyden. “Administration of these programs is an integral aspect of measuring performance.”

Leyden said the payer strives to make the programs as manageable as possible because physicians need to perform many administrative tasks on an ongoing basis. BCBSM regularly solicits feedback from providers during quarterly meetings and phone calls, emails, webinars and in-person meetings on what’s working, what’s not and what needs to be changed.

Barriers to overcome

One barrier that still needs resolution in partnerships is moving providers away from phone communication. Availity recently published a survey of 40 health plans and more than 400 practice- and facility-based providers that found respondents said phone communication is the preferred way for providers to communicate with payers.

Leatherwood said a more efficient way is a queue system. In this system, a provider could check the status of all claims and get alerts when they need to provide more information. The system would allow providers to look in one queue, update the claims information and then move on with their day. Payers would have their own queue and would get alerts when providers have questions. This would reduce phone calls and create immediacy.

Leatherwood said the healthcare system is stuck in a “chart chase” between providers and payers, and moving to an automated queue system would be a gamechanger.

Another big question is whether partnerships can scale. Expanding these partnerships beyond local or state boundaries may be difficult. Grote said partnerships are intensive and require close relationships, so joint ventures work best on a regional or state level.

It’s still too early in the process to say how partnerships will morph down the road. There are many different types of partnerships and more are likely to develop depending on locations, providers, payers and needs.

“I think in the near-term what we’re going to see is larger healthcare providers are going to be more strategic, working directly with payers. The health plans are going to be more interested not just in working with the staff level, but executive levels,” said Leatherwood.


Alzheimer’s patients need special care, but providers aren’t ready to give it

Originally published on Healthcare Dive.

Diagnoses of Alzheimer’s disease have been increasing and are expected to skyrocket, but the health system has been slow to respond. Death rates are going up and there are still no prevention methods or long-term treatments.

The neurological disease is the leading cause of dementia and is one of the most feared conditions. It also leads to twice as many hospital stays and has an overall high cost of treatment.

“I think America, in general, is waking up to the fact that we haven’t done enough,” Rob Egge, chief public policy officer at the Alzheimer’s Association, told Healthcare Dive.

People are living longer and there is better recognition of the disease. Now, 1 in 10 Americans 65 and older has Alzheimer’s disease. Diagnoses will increase as more Baby Boomers reach their elderly years. Alzheimer’s is now the sixth leading cause of death in the U.S. and kills more than breast cancer and prostate cancer combined.

Alzheimer’s disease diagnoses and deaths have increased over the past 20 years —  and those numbers are expected to skyrocket over the next 30 years.

The Centers for Disease Control and Prevention recently released a study showing death rates from Alzheimer’s increased 55% from 1999 to 2014. About 5.5 million Americans are living with Alzheimer’s and that’s expected to reach 16 million by 2050.

It’s not just the elderly. About 200,000 Americans under 65 have younger-onset Alzheimer’s. “That alone would be a major health problem,” Egge said.

There doesn’t appear to be much immediate help either. While fatality rates have decreased for other diseases thanks to medical breakthroughs and treatments, there is still no prevention, cure or even a way to slow Alzheimer’s. Healthcare can only offer Alzheimer’s and dementia patients short-term symptom relief. Egge said that might help for six months, but much more is needed to improve patients’ lives.

Some health systems are taking steps toward better preparation, however. Experts recommend using staff training and interdisciplinary physician teams as well as simpler measures like adjusting patient visiting hours.

Alzheimer’s and healthcare costs

Healthcare costs skyrocket when someone has dementia. More than 85% of people with Alzheimer’s have one or more other chronic conditions, which increases healthcare costs. People with Alzheimer’s often can’t manage their co-morbidities, which leads to more health problems, hospitalizations and costs.

Alzheimer’s is expected to cost $259 billion in 2017 with $175 billion directly from Medicare and Medicaid. That’s expected to reach $1.1 trillion by 2050. Twenty-four states will see Medicaid spending for people with Alzheimer’s disease increase at least 40% before inflation by 2025, according to the Alzheimer’s Association.

Nearly one dollar of every five Medicare dollars is spent on dementia care. Within 20 years, that’s expected to rise to one in three.

Hospitalizing Alzheimer’s patients

People with Alzheimer’s and other dementias are more likely to have co-morbidities and staff may not even know about other health issues because of a patient’s communication limitations.

Older people with Alzheimer’s have twice as many hospital stays per year as other older Americans. They also have four times longer hospital stays and nearly three times more emergency department visits.

Caring for someone with Alzheimer’s is complicated and can take more nurse and doctor resources, which can put a strain on staff. Hospitalization can often raise anxiety and confuse people with Alzheimer’s. They’re in a different environment and might not know what’s happening. That anxiety is increased and is often coupled with pain. Often they’re hospitalized for issues not related to the disease, such as heart disease or a hip fracture.

“People with Alzheimer’s really need a lot of care,” Dr. Kostas Lyketsos, professor of psychiatry and behavioral sciences at Johns Hopkins Medicine, told Healthcare Dive.

The Alzheimer’s Association suggests avoiding unnecessary hospitalizations and says doctors should perform procedures, tests and treatments in an outpatient client whenever possible.

How hospitals are facing the crisis

Demands will increase on doctors, hospitals, payers, Medicare and Medicaid as the number of people with Alzheimer’s increases.

Hospitals and health systems do have options for improving their ability to care for people with Alzheimer’s.

Lyketsos said an important first step is to make sure hospitals are evaluating patients with the disease. Johns Hopkins started the Memory and Alzheimer’s Treatment Center, which is a partnership between the departments of psychiatry, neurology and geriatric medicine, and sees close to 1,000 new patients annually. The center performs a patient assessment, diagnosis and comprehensive treatment that includes counseling, education and guidance for family caregivers.

The center developed a program called Maximizing Independence (MIND) at Home, which is a home-based coordination program for people with Alzheimer’s and other dementias. The program lets people stay in their homes, while receiving care through care coordination with community-based agencies, medical and mental healthcare providers and community resources.

The interdisciplinary team uses six basic care strategies: resource referrals, attention to environmental safety, dementia care education, behavior management skills training, informal counseling and problem-solving.

The program’s main tenets are to assist family caregivers and allow people to live safely and with dignity in the community.

Johns Hopkins is in the research phase of the program and is testing whether MIND at Home is an “effective and cost-efficient approval to providing community-based dementia care to a diverse population.”

So far, program leaders have found that MIND at Home reduces a caregiver’s burden and that Alzheimer’s patients need a whole package of services to meet their myriad needs, including making sure they’re complying with medications and setting up a proper home environment for the Alzheimer’s patients.

Lyketsos said the program can delay Alzheimer’s patients from being forced out of their home and into a nursing home. Lyketsos said Johns Hopkins hopes to expand the program to a larger audience after the project’s research phase.

What hospitals can do better

Egge said the most important thing hospitals and health systems can do to tackle the influx of Alzheimer’s patients is to track the patient’s cognitive impairments from admissions to post-discharge. Hospital staff should be aware of a patient’s Alzheimer’s and deliver care accordingly.

Lyketsos said hospitals need to improve Alzheimer’s detection. Treating someone with Alzheimer’s in the hospital and post-discharge is more complicated than other patients.

Only 30-40% of Alzheimer’s patients are recognized by hospitals. So, knowing at the time of admission of a person’s Alzheimer’s diagnosis is key to the rest of the patient’s hospital stay and post-discharge.

Another issue is that doctors and nurses might not recognize symptoms of younger people with early onset Alzheimer’s. “That, too often, is a fumble,” said Egge.

In addition to better detection, hospitals need to plan carefully for a patient’s post-discharge care to reduce rehospitalizations. Transitioning a patient back to the home with caregiver support can help keep an Alzheimer’s patient from returning to the hospital.

Beyond care, Egge said hospitals should create policies that help Alzheimer’s patients. For instance, don’t enforce visiting hours strictly for caregivers. Sundowning is a time of confusion and restlessness for patients. Having a caregiver there during those times can calm the patient, but strictly enforcing visiting hours may limit when a caregiver is with the patient.

Lyketsos said the CMS also needs to do a better job reimbursing doctors who are caring for Medicare patients. Paying doctors for half-hour visits for older people, especially those with complicated conditions like Alzheimer’s, is often not enough.

CMS recently took a positive step by implementing a Medicare billing code G0505 that is for cognitive assessment and care planning for patients with cognitive impairment. The services can include cognition-focused evaluation, functional assessment, review of high-risk medications, evaluating neuropsychiatric and behavioral symptoms, safety evaluations and creating a care plan.

Egge said G0505 will lead to “more holistic reimbursements for care planning services.” He said he hopes the CMS will apply the code broadly to include other offerings, such as Medicare Advantage.

Looking ahead, Egge said the explosion of Alzheimer’s patients over the next 30 years is going to cause serious issues in healthcare. “It’s going to be tremendously profound and difficult for the healthcare system,” said Egge.


Children’s Hospitals — And Their Patients — Caught in the Crosshairs with Planned Federal Cuts

Originally published on Healthcare Dive.

Republican plans targeting federal funding for health coverage have drawn ire from Americans in all corners of the country, but some of the loudest voices are coming from parents. They have cornered members of Congress at town halls to ask how the slashed budgets will affect some of society’s most vulnerable.

Suggested cuts to Medicaid and the Children’s Health Insurance Plans (CHIP) would throw millions of Americans off insurance and leave hospitals that are already teetering financially facing more uncompensated care. Children’s hospitals, safety net hospitals and rural hospitals will be most affected, and disabled children will face devastating cuts in coverage.

The funding decreases have been proposed in bills making their way through Congress and separately by President Donald Trump. They would shift the cost burden further onto states, many of which have seen success in expanding Medicaid, which is also on the chopping block.

“Children, the elderly, the disabled, and others from our most vulnerable populations would all be affected by these deep budget cuts,” Joanna Hiatt Kim, vice president of policy at the American Hospital Association, told Healthcare Dive. “For hospitals, this could mean more uncompensated care as millions continue to seek needed healthcare without any coverage. For the patient, this could mean delayed care or foregoing care altogether.”

Impact on children’s healthcare

More cuts to Medicaid and CHIP would reverse the trend of fewer uninsured Americans, including children.

Congress created CHIP 20 years ago when 15% of children were uninsured. CHIP, the Affordable Care Act and Medicaid expansion provided more insurance offerings and now only about 5% of children are uninsured. CHIP, which is a federal/state partnership, includes free well-child visits in many states and also provides prescription coverage, inpatient and outpatient care and emergency services.

While suggesting a two-year CHIP extension in his budget plan, Trump proposed a 20% CHIP cut over the next two years. His budget also seeks a $610 billion cut from Medicaid over 10 years, despite early promises to leave the program alone.

Studies have shown that CHIP helps reduce hospitalizations and child mortality, and improves quality of care. The program has bipartisan support. However, HHS Secretary Tom Price voted twice against expansion when he was a congressman.

CHIP is up for reauthorization by Sept. 30 and governors recently spoke out in favor of expanding it. In his budget proposal, Trump proposes a two-year extension of CHIP, but also suggests program cuts, including the matching rate for states.

Jim Kaufman, vice president of public policy at Children’s Hospital Association (CHA), told Healthcare Dive that CHIP helps children’s hospitals.

“CHIP is good for kids, and that makes it good for children’s hospitals and children’s providers,” Kaufman said.

Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities, told Healthcare Dive that the cuts would shift costs to states and reduce benefits. He said Trump’s budget would eliminate a 23-percentage-point increase in each state’s federal CHIP matching rate, which is in effect until 2019. That would mean $3.5 billion cut from the program.

The budget would also cut CHIP funding for children with families that have incomes above 250% of the federal poverty line, which would affect 28 states and Washington, D.C. that provide CHIP coverage to children above the income threshold, according to Park.

This will mean states will need to pick up more of the CHIP program costs if they want to maintain the current coverage level. Park said he believes Congress will reauthorize the program, but questions remain about CHIP’s funding and benefits.

Children are about half of Medicaid’s enrollment

The CHA released a report in May that said changes to Medicaid will hurt children, who are the largest group covered under Medicaid. Disabled children will feel the brunt of the pain.

Park said Trump’s proposed budget goes well beyond the Medicaid cuts included in the American Health Care Act (AHCA). The House plan would cut Medicaid by 24% over 10 years. Trump’s budget would reduce the Medicaid budget by 45% in that period.

Park said children make up about half of Medicaid enrollment, but cause very little in costs. Seniors and people with disabilities make up about one-fifth of enrollment, but about half of costs.

Forty-five percent of children with special healthcare needs are on Medicaid. If those children don’t get insurance elsewhere, hospitals would feel the financial burden of caring for those higher cost children without getting reimbursed by Medicaid.

The House approved the AHCA in May, which proposed Medicaid per capita caps starting in 2020 that would be based on 2016 federal Medicaid spending. In a study earlier this year, KFF said that creating a Medicaid block grant or per capita cap “would shift risks and costs to states, enrollees, and providers and could result in reductions in coverage for children.”

Children’s hospitals would be affected more than many other hospitals. The average children’s hospital pay mix is about 54% Medicaid, so children’s hospitals are especially vulnerable if there are large cuts to Medicaid and CHIP at the federal and state levels. Uncompensated care has dropped since CHIP and Medicaid expansion. Kaufman estimated that uncompensated care is an average of about 2% now.

“Since Medicaid is the largest payer of children’s healthcare services and the largest payer for children’s hospitals, the proposed Medicaid cuts included in the AHCA would have a significant impact on the more than 30 million children covered by Medicaid,” said Kaufman. “The states would cut coverage, benefits and access to care. Cuts of this magnitude will have a negative impact on all children’s healthcare.”

The Congressional Budget Office predicts 23 million Americans would lose their health insurance by 2026 under the newest version of the AHCA.

Park said the CBO score confirms the House bill isn’t fixable. “It’s clear just from the cost shift that kids would certainly be facing cuts if the House bill was enacted,” he said. “And that would be particularly problematic for kids who need Medicaid coverage that isn’t provided by private insurance.”


Healthcare, Insurance

DOJ sends warning shots on Medicare Advantage overpayments

Originally published on Healthcare Dive.

The Medicare Advantage (MA) program seems to be hitting the sweet spot, with more interest from beneficiaries as well as insurers. It now includes one-third of all Medicare beneficiaries, and a large chunk of payer profits.

With more money, however, comes greater scrutiny. And the federal government is finding reason to ramp up efforts as it issues more allegations of insurers changing diagnoses to bring in higher MA payments and covering up the actions.

Congress created Medicare Advantage as a risk adjustment payment program that pays insurers more for sicker beneficiaries. Payers in Medicare Advantage now receive a yearly fee for each enrolled member and monthly risk adjustment payments for each enrolled beneficiary, based partly on the person’s health status. This means a person with diabetes and other chronic health conditions will bring a larger monthly reimbursement than someone who needs few services.

Such a program is open to fraud. CMS estimated that it overpaid $14.1 billion in 2013 to MA organizations. Medicare Advantage payers received about $160 billion in 2014 for approximately 16 million beneficiaries. CMS estimated about 9.5% of those payments were improper.

Intensive coding

Kip Piper, an expert on Medicaid, Medicare and health reform, told Healthcare Dive plans differ in their internal capabilities and data quality. “Each insurer is incentivized to make sure their data supports the highest risk score — as high as can be justified but of course no higher,” he said, adding, “Sometimes insurers will ‘leave money on the table’ because they are unable to show that their risk score really ought to be higher.”

Timothy Layton, an assistant professor at Harvard Medical School who researches the health insurance markets, told Healthcare Dive Medicare Advantage overpayments are driven partly by fraud, but mostly by “legal intensive coding.”

“CMS has a fairly broad definition of an acceptable diagnosis. Each diagnosis just needs to be justified by some record from a face-to-face encounter with a physician. This allows insurers significant ability to maximize their risk scores without resorting to fraud,” he said.

Layton said there is fraud, but that’s “small potatoes” compared to excessive payments because of intensive coding. “It’s also small relative to the massively inefficient expenditures insurers are investing in coding that has basically no social benefit whatsoever,” he said.

UnitedHealth cases

The U.S. Department of Justice (DOJ) is involved in two high-profile False Claims Act cases involving one of the largest health insurers. The DOJ joined two lawsuits involving UnitedHealth Group (UHG), which is the largest Medicare Advantage payer with more than 50 Medicare Advantage and drug prescription plans.

The lawsuits allege UHG overcharged the federal government for Medicare Advantage. In 2016, CMS reportedly paid UnitedHealth $56 billion for covering 3.6 million Medicare Advantage beneficiaries.

Two whistleblowers have said UnitedHealth changed diagnosis codes to make patients seem sicker. These “data-mining projects” can raise Medicare reimbursements by nearly $3,000 for every diagnosis. The suit alleges that employees collected bonuses for making these changes.

The lawsuit said UHG didn’t notify the CMS of at least 100,000 invalid diagnoses that caused it to overpay. Those incidents alone led to $190 million in overpayments, according to the lawsuit.

UnitedHealth Group denies the claims. “We are confident our company and our employees complied with the government’s Medicare Advantage program rules, and we have been transparent with CMS about our approach under its unclear policies. The complaint shows the Department of Justice fundamentally misunderstands or is deliberately ignoring how the Medicare Advantage program works. We reject these claims and will contest them vigorously,” Matt Burns, UnitedHealth spokesman, told Healthcare Dive in a statement.

Piper said he expects a “long, protracted and expensive battle” involving these cases. The case is complex because the payments are from years ago and federal policies were “particularly muddy back then.”

If United were to lose, Piper expects a multi-billion dollar payment and a corporate integrity agreement with the HHS Office of Inspector General that would include oversight and imposed processes to make sure it doesn’t happen again.

Piper doesn’t think the cases would hurt UnitedHealth financially because the large payer is “well-capitalized and in a position to cover the loss if it comes to that.”

Piper doesn’t expect the CMS would restrict UnitedHealth’s participation in Medicare Advantage or Part D because of its market size. Such restrictions would affect millions of beneficiaries.

“It will, and likely already has, resulted in greater scrutiny of United’s practices in regards to risk adjustment. But federal policies have tightened. All Medicare Advantage plans are now on guard to be extra cautious and take steps to support risk scores with data, analyses and independent verification or audits,” said Piper.

DOJ investigating other MA insurers

Investigators will follow the money, and with billions of dollars at stake, Medicare Advantage plans now get extra attention, undesired by payers. False Claims Act cases and settlements have become relatively common.

Chief Counsel to the Inspector General Gregory Demske of the HHS Office of Inspector General said his office will continue to make sure “Medicare Advantage insurers . . . play by the rules and provide Medicare with accurate information about their provider networks and their patients’ health.”

Being the largest Medicare Advantage payer puts a large bull’s-eye on UHG’s back, but investigations into overpayment to Medicare Advantage payers aren’t just connected to UHG. Investigators are also checking into other Medicare Advantage payers, including Aetna, Cigna, Health Net and Bravo Health.

Also, Freedom Health, another Medicare Advantage payer, agreed to pay $31.7 million to settle a False Claims Act case after the Tampa, Fla.-based insurer submitted or caused others to submit “unsupported diagnosis codes to CMS,” which led to larger than owed reimbursements from 2008 to 2013. The company reportedly made “material misrepresentations to CMS regarding the scope and content of its network of providers” in applications in 2008 and 2009, said the DOJ.

Congress is also interested in the overpayment issue. Sen. Charles Grassley, chairman of the Senate Judiciary Committee, sent a letter to CMS Administrator Seema Verma in April questioning what CMS is doing to “implement safeguards to reduce score fraud, waste and abuse.”

Grassley said there was about $70 billion in improper Medicare Advantage payments between 2008 and 2013 because of “risk score gaming.”

“CMS must aggressively use the tools at its disposal to ensure that it is efficiently identifying fraud and subsequently implementing timely and fair remedies,” Grassley wrote.

What should MA payers do now?

Layton said payers need to be more careful about submitting only justified codes. This will mean more payer oversight, which will lead to more costs for them and healthcare in general.

“They’ll just switch from trying to derive codes out of thin air to trying even harder to get docs to write things down. Given that the fraud was likely for cases that could have been justified with a written record with a bit more effort, they’ll likely just exert that extra effort. Unfortunately, the cost of that extra effort will represent additional socially wasteful spending on top of an already enormous amount of waste,” he said.

Anand Shroff, founder and chief development officer at Health Fidelity, told Healthcare Dive that health plans need to focus on risk adjustment coding accuracy to ensure they submit information to the CMS that’s substantiated by documented clinical evidence.

“Medicare Advantage insurers use outdated risk adjustment coding methods, including archaic data acquisition and document review systems. They should invest in the latest risk adjustment technology solutions that pull together patient risk factors and clinical evidence for accurate results using advanced technology, such as natural language processing and clinical analytics,” said Shroff.

Piper said some payers have already adapted its systems and staffing to improve risk adjustment payment compliance.

“Financially, risk adjustment plays a critical role in how plans are paid. This will only increase if CMS moves forward to improve the risk adjustment methodology to increase its accuracy and to better adjust for socioeconomic factors that heavily influence patient complexity and utilization,” he said.

Piper offers a few suggestions to payers involved in Medicare Advantage. Payers need to work closely with the CMS to work out technical issues and have the federal government agency understand how the plans operate and how federal guidance impacts the plans.

Piper said payers need to collaborate with providers to improve “the completeness and accuracy of their claims and encounter data and underlying medical records, including full use of electronic health records.”

MA plans should also consider using “red teams” to test their management and controls, look for compliance weaknesses and identify policies, systems, incentives and even cultural factors that may unintentionally encourage gaming or create risks, said Piper.

“Part of this, frankly, is having a multi-disciplinary team of in-house and outside experts — white hats — thinking about risks and vulnerabilities and then closing them,” he said.

Improving education and training and removing corporate silos, as well as hiring regulatory experts can also help payers, said Piper.

“A surprising number of companies that do business with Medicare or Medicaid have few, if any, board members with real-world government experience or policy expertise. Companies need to bring that talent in at the board level, just as they do at management levels,” he said.

Healthcare, Insurance

Uneasy Payers Seek More Guidance as ACA Exchange Deadline Nears

Originally published on Healthcare Dive.

As the June deadline for payers to decide whether to continue in the Affordable Care Act (ACA) exchanges and set their rates is approaching, insurance companies are running the numbers, reviewing their member populations and analyzing how they’ve made out on the exchanges market over the past year. But it’s not just their numbers that are influencing the decision.

What’s happening in Washington is also playing a major role — specifically, whether Republicans will pay cost-sharing reduction (CSR) payments to insurers. The payments help insurers cover lower income Americans.

Last week Trump reportedly told staff he was still considering withholding payments to push the hands of those reluctant to support the AHCA, so payers and patients advocates are quite leery of what would happen to the exchanges market if CSR subsidies stop.

Without those payments, insurance companies warn of higher rates and more payers dropping out of the exchanges market.

Beth Fritchen, partner at Oliver Wyman Actuarial Consulting, told Healthcare Dive that the best way to describe payers in the exchange market is “hesitant.”

“CSR is definitely something people are looking at and watching for,” Fritchen said.

Payers are also waiting to see the Senate’s healthcare reform, which will likely look quite different than the House bill.

ACA exchanges market stabilizing

You wouldn’t know it from the drumbeat from Washington, but one recent study found that the ACA exchanges market is stabilizing after years of losses.

A Kaiser Family Foundation study found that the individual market insurers’ medical loss ratio, which is the percentage of premium dollars that an insurer spends on medical claims, dropped 7 percentage points between 2015 and 2016 to 96%. That’s the best number since the ACA created exchanges, but is still higher than the 85%-90% figure needed to make the individual market profitable.

Despite those improved numbers, payers are still uncertain about the exchanges. Insurance companies usually don’t like the unknown, but that’s what they’re facing in the healthcare industry and specifically the individual market.

Brian Wright, senior financial professional at communications and advisory firm ICR, told Healthcare Dive that the unease comes because payers need a risk pool that doesn’t change dramatically from one year to the next.

The Center on Budget and Policy Priorities said the uncertainty will lead to higher rates and fewer insurers willing to continue in the exchanges. To stabilize the market, the group suggested Congress stop talking about repealing the ACA and focus on improving the current law.

Stopping short of agreeing not to repeal the ACA, there are other ways that Congress can help stabilize the market. America’s Health Insurance Plans President and CEO Marilyn Tavenner spoke before the Senate Committee on Health, Education, Labor and Pensions in February about the need to stabilize the individual health insurance market. Tavenner gave short-term and long-term solutions that she said would create “lower costs, more choices and better quality care.”

For this year, AHIP suggests continuing the CSR payments, creating premium tax credits, which help make coverage more affordable, and fully pay federal reinsurance payments for 2016. The reinsurance program helps cover high-need people, including those with chronic conditions.

Who’s in, who’s out for 2018?

As some payers have announced they are cutting back on the ACA exchanges or even pulling out completely in 2018, those who support repealing the ACA have stoked that instability to their advantage. ACA foes say payers pulling out shows that the exchanges are in a “death spiral,” but others point to the ACA foes as the ones promoting the fears, which lead to uneasiness.

So, where are we at this point in the ACA exchanges market? Aetna announced it is leaving the exchanges in its remaining states — Delaware, Nebraska, Iowa and Virginia. The payer said it could lose $200 million this year for its individual insurance after losing nearly $700 million between 2014 and 2016.

Wellmark Blue Cross Blue Shield is another payer that’s completely dropping out. The company will drop the exchanges plans for next year after reportedly losing $90 million from them over the past three years. Wellmark already dropped out of South Dakota’s exchanges last year.

A former big player in the exchanges market, UnitedHealth, scaled back from 34 states to three this year. For 2018, the company said it will remain “in only a handful of states.”

Not all payers are leaving the exchanges. CareFirst BlueCross Blue Shield plans to stay in the Maryland, Virginia and D.C. exchanges despite losing $500 million on the exchanges so far and another $100 million expected this year. Though the payer is staying, CEO Chet Burrell said the insurer plans a 58% increase for individual insurance plans next year.

BlueCross BlueShield of Tennessee announced last week that it planned on moving back into 16 counties in eastern Tennessee that would not have had any insurers in the exchanges after Humana announced it was pulling out in 2018. Humana is down to fewer than 200,000 members in the individual market in 11 states this year and plans to stop offering all ACA exchanges plans in 2018. Instead, it will redouble efforts on Medicare offerings.

Anthem is also expecting to stay in the exchanges. The company, which has 1.1 million members in ACA exchanges, is working on 2018 rates.

Kaiser Permanente is also staying onboard. Though acknowledging the market instability, Chief Executive Bernard Tyson recently said the market isn’t in a “death spiral.”

Will more drop out? Oliver Wyman conducted a survey in early April and asked insurers about the 2018 ACA exchanges markets. Of all the payers surveyed, a “vast majority” said they are committed to the exchanges, though they are still cautious. Only one survey respondent said it plans to leave the exchanges.

The survey also found that 70% of respondents expect to stay in the exchanges without any major strategy shift in 2018. The remaining 30% said they are looking for ways to stabilize their ACA lines of business, including modifying plan offerings, such as eliminating gold-level plans, and changing to plans with tighter benefit design, such as HMOs or narrower network plans, according to the survey results.

Nearly half of respondents said early April was too early to determine rate increases. However, for those that were ready to set rates, half of respondents said they plan to increase rates by 10% to 20%. One-quarter said they planned to increase rates by less than 10% and the other one-quarter said they expect to raise rates more than 20%. The average rate increase was 22% in 2017.

Fritchen says that disparity isn’t surprising given the exchange market’s fluidity. That said, Fritchen says payers are cautiously moving forward and some states have even said they will allow insurers to set rates and then change them if there is a new development, such as no CSR payments.

“Their number one goal is solvency,” she says.

The survey results found that payers plan to wait as long as possible before setting 2018 rates in hopes of getting more guidance from the government.

One important thing to remember about the survey is that it was conducted in early April. The longer payers don’t get reassurances that CSR payments are on their way, the more instability for the market and the greater likelihood that some payers may decide to drop out.

How much will rates increase? Cori Uccello, senior health fellow at American Academy of Actuaries, told Healthcare Dive “premium rate changes for 2018 will vary by state, and will reflect cost trends and changes in expected enrollment and composition of the risk pool.”

Uccello says factors that will affect decisions include the CSR payments, “whether the individual mandate is enforced, and the effects of new regulations that shorten the open enrollment period and tighten special enrollment rules.”

Payers will also soon know what risk-transfer payments they’re getting from the federal government. These numbers traditionally come at the end of June. The payments pay insurers for coverage, which keeps premiums and out-of-pocket costs lower than if there were no payments. You can expect rates to jump if the federal government decreases those payments.

Payers to watch

There are insurance companies whose decisions will greatly influence the ACA exchanges debate. Here are three payer decisions to watch, whose decisions could cause people with no option in the exchanges:

  • Anthem — The only payer in 59 counties in Kentucky.
  • Centene — The only option for all exchanges in Mississippi.
  • Cigna — The only insurer in 14 counties in Tennessee.

If any of these three pull out of those markets, there could be counties with no insurer option in the exchanges market, which could cause panic and send states scrambling. An insurer pulling out of those counties could lead to more uninsured or people going onto Medicaid, which will affect payments to hospitals and doctors.

What do unease and fluctuations mean for healthcare industry as a whole?

CSR payments don’t directly affect hospitals and doctors. These payments help payers cover lower income Americans. However, cuts to the CSR payments would lead to rate increases for individuals.

It could even cause payers to leave the exchanges. If rates skyrocket or if payers pull out, more Americans could be uninsured or go onto Medicaid, which has lower reimbursement rates than private payers. At that point, hospitals and doctors would feel the pain of uncompensated care and lower payments.

How does location affect payer decisions about whether to stay in exchanges?

Before the ACA, there was wide variety in regard to state regulations. Some states required certain types of coverage, while others had fewer mandates. The ACA leveled out a lot of those regulations and created a single risk pool.

However, states do vary in terms of population, cost, competition and provider networks. Payers with experience already in particular states know the market, the competition and how to price rates adequately. Highly competitive exchanges markets actually bring in more payers.

A recent Robert Wood Johnson Foundation study found that more competitors lead to lower premiums. Regions with only one or two insurers “tended to be sparsely populated and heavily concentrated in southern states.”

States with fewer rate fluctuations bring in more payers, said Fritchen.

Payers look at pricing, network strength and their relationships with provider networks when deciding whether to stay in a market or expand into another one.

“For the most part, they’re going to look at their block of experience to date and can they sustain any losses or can they fix it,” said Fritchen.

The future of the individual market

No one knows what plan the Senate will bring forward. There is only a two-vote swing in favor of the Republicans so the Senate will need to create a plan that doesn’t lose more than two Republican votes unless they get Democrats to support their plan.

Centralist Republicans will push for a similar ACA system or maybe even tweaks to the current system. They will also want to avoid Medicaid cuts. Conservatives, on the other hand, will want Medicaid cuts and will look to completely repeal the ACA.

Threading that needle will likely mean an even more difficult process than the onein the House, which narrowly passed the AHCA earlier this month.

What they decide and whether the government will continue to fund CSR payments will be major factors as to whether payers continue in the ACA exchanges or flee the market.


Nurse Burnout: 3 Low-Cost Ways Hospitals Can Help

Originally published on Healthcare Dive.Originally published on Healthcare Dive.

Nurses across the country are stressed, burnt out and thinking of leaving the profession. Surveys, polls and studies of all kinds point to nurses with longer hours, more work and less time to care for patients and unwind from the intense stress of the job.

A University of Phoenix College of Health Professionals 2016 poll found that four out of five nurses are playing a larger role in patient care management than two years ago and 84% of registered nurses believe non-doctors will play an even larger role in patient care management in the next five years. That means more work for nurses.

A recent Kronos Incorporated survey showed that 90% of nurses are thinking about leaving their hospital for another job because of a poor work/life balance. Also, most of the surveyed nurses (83%) said hospitals are losing good nurses because other employers offer a better work/life balance. “Nurse burnout is real, although some like to avoid or downplay it,” Elizabeth Scala, author of Stop Nurse Burnout, told Healthcare Dive. “In fact, there is often a stigma related to nurse burnout. Nurses fear that if they speak up, they will not be heard or worse . . . will be retaliated against in some way.”

 In addition to worsening the wellbeing of nurses themselves, burnout can lead to problems with patient safety and hospitals finances. However, there are steps hospitals can take to help ease burnout and some are relatively simple and inexpensive.

What’s causing burnout among nurses

A nurse’s workload, work/life balance and a nursing shortage are all contributing to stressed nurses. An RNnetwork study earlier this year found that 70% of nurses feel burnt out and half of the nurses have considered leaving the profession. Also, nearly half of nurses surveyed said their workload has increased.

Kronos Incorporated’s survey found that many nurses said they skipped breaks and didn’t get enough sleep in between shifts. One-quarter of those surveyed said a change from eight- to 12-hour shifts exasperated burnout.

Half of the nurses in a new CareerBuilder study said they feel “tired all the time.” Staffing isn’t expected to improve anytime soon. CareerBuilder said nursing job vacancies are “increasing at an accelerated rate.”

But hospitals and health systems are struggling to find enough qualified nurses to fill the jobs. CareerBuilder reported that hospitals posted a job listing for registered nurses an average of 10 times on different sites in the first quarter of this year, which points to a “highly competitive hiring environment” for hospitals and health systems.

This employment crunch can lead to larger workloads and longer hours for nurses.

But it’s not just more work and longer hours that is causing stress. Technology can also create a barrier between a nurse and a patient. Scala argued technology like electronic health records (EHRs) systems can make a nurse feel disconnected from patients.

EHRs can help improve care coordination. However, nurses may worry that they are simply inputting information and not making a difference for their patients, Scala said. “While the nurse went into the profession of nursing to provide relationship-based care and impact patients, the computers and charting can make it difficult for the nurse to feel as though they have the time to spend with the patient and family in front of them,” Scala said.

Nurses used pen and paper when Lisa Radesi started in the profession 38 years ago. Now, they have to spend a lot of their time on computers and using other technologies. Radesi, who currently serves as the academic dean at the School of Nursing at the University of Phoenix, told Healthcare Dive that computer and technology literacy are a relatively new skill set in nursing. “They have to be computer savvy and electronically savvy. Fifteen or 20 years ago, you didn’t have to be,” she said. “That’s a big role change for them.”

Nurses are also playing a larger role in the overall management of patient care. They are providing more care coordination, post-discharge management and pre-discharge work. Many nurses are taking on more leadership roles in health systems. Nurses have a great influence in patient care and often take on more roles, which can lead to overwork, according to Radesi.

How burnout impacts nurses, patient safety and a hospital’s finances

Studies have found that nurse burnout can impact patient infections, patient satisfaction and quality of care.

“Nurse burnout affects patient care negatively,” Scala said. “If a nurse shows up to work and is feeling tired, disengaged and unappreciated, then they are not going to provide their best care. They may make a mistake, such as forgetting to check in on a PRN medication or overlook a crucial lab value.”

Patients and families can pick up when a nurse is burned out, which leads to lower satisfaction, Scala added.

Burnt out nurses can also have a financial implication on hospitals. Nurses leaving the job means hospitals have to recruit, hire, train and orient new nurses. That costs a lot of money — not to mention what constant turnover can do to staff morale.

“In today’s healthcare environment, organizations are finding that nurses are leaving clinical roles in less than two years’ time,” Scala said. “The constant turnover can be costly to the organization’s bottom line.”

What hospitals can do to help nurses

An increasing number of surveys and studies point to a nurse burnout problem. But what can a hospital or health system do to help nurses who feel stressed out?

Lower nurse-to-patient ratios are one way to help. Implementing those types of levels can reduce stress levels while improving patient care, according to Radesi.

“A lower nurse-to-patient ratio “gives nurses the opportunity to take good care of patients from head to toe,” she said.

 Another idea is to implement hourly or purposeful rounding. A study on hourly rounding looked at how it affected patient satisfaction with nursing care. The report found that hourly rounding in inpatient care can “improve patients’ perceptions of nursing staff responsiveness in units where this may have been a problem, reduces patient falls and call light use, and improves patient satisfaction scores.”
The authors of the report recommended that nurse administrators implement an hourly rounding program to test out the idea and find “the most cost-effective approach.”Seun Ross, director of nursing practice and work environment at the American Nurses Association, told Healthcare Dive that she supports the idea. Frequent unit rounding can maintain awareness of the “pulse of the unit,” she said.
Seun Ross, director of nursing practice and work environment at the American Nurses Association, told Healthcare Dive that she supports the idea. Frequent unit rounding can maintain awareness of the “pulse of the unit,” she said.

One the two approaches has a cost connected to it, while the other may require making changes to the way nurses perform their work.

What does a health system or hospital do if it can’t afford to add more nurses or doesn’t have buy-in for hourly rounding? Here are three low-cost tips:

Watch for signs of stress

Spotting burnout isn’t easy, Scala noted. Nurses may come to work trying to hide their stress because they’re afraid of a reprimand.

A clear sign of burnout is less enthusiasm for the job. Other examples are a usually social nurse, who starts avoiding colleagues, and a team player who withdraws from team activities, such as projects and committees, according to Scala.

Ross argued hospitals monitoring changes in engagement and attendance can get a view on nurses’ stress levels. Nurses who miss shifts, leave early, complain more or disagree more with co-workers might need help.

Claudia Douglas, administrative director of the Institute for Evidence-Based Practice and Nursing Research at Hackensack University Medical Center, told Healthcare Dive that her facility conducts anonymous surveys to get feedback from staff and specifically runs a nurse satisfaction survey to get feedback from nurses. “The results are benchmarked against a national database,” Douglas said. “For areas indicating opportunity for improvement, leaders are required to complete an action plan.”

Stephen Young, research scientist of leadership insights and analytics at the Center for Creative Leadership, who co-authored “How Nurse Leaders Can Reduce Burnout: Focus on Mental Energy!” told Healthcare Dive that hospitals need to measure employees’ “mental energy levels and adopt initiatives that will most effectively enhance where energy is low within the organization.”

Staff with low mental energy may need a work shift scheduling change, while low emotional energy may “indicate a harmful interpersonal environment,” Young said.

Annual surveys aren’t enough, Young added. Instead, give employees game-based apps to use daily to examine their energy. That kind of energy assessment tool “can help you to objectively measure your organization’s human energy crisis and determine how severe it is,” according to Young’s report.

Teach self-care strategies

Scala, who teaches self-care strategies in her Burnout Proof Live training, argued it’s important for nurses to learn how to separate work from home life. Nurses need to learn how to leave work at home.

“Teaching individual nurses burnout prevention tools is one piece of this complex puzzle,” she said.

Young said engaging workers on their energy levels on a daily basis raises their self-awareness. With that data, a hospital could teach individualized strategies, such as coping and break scheduling.

“Nurses, like any human beings, are a diverse group,” Scala said. “Each nurse needs to find the self-care technique that works best for them. A variety of tools must be offered. The best thing an organization can do is to assess what the nurses want/need to cope and prevent burnout. And then to listen to the feedback, implementing a variety of strategies to support their nursing staff.”

Make wellness a priority

Surveys have found that nurses often work through their breaks. Nurses not having any time off during a shift can lead to higher stress levels.

Hospital leaders need to make sure their nurses are taking enough time off during their shift so they are alert.

One way to show the importance of wellness is to create wellness teams. Radesi believes having wellness teams can keep health front of mind for nurses and staff. Some ideas could be offering nurses massages during a shift, holding departmental group sessions to talk about health and creating a reward program connected to wellness, such as giving a prize to the staff member who walks the most.

Another example is setting aside space for wellness. Douglas Hackensack University Medical Center has respite areas with comfortable seating and soothing lighting. The areas promote mental, emotional, spiritual and social opportunities, Douglas said.

Employees often follow their leader — and wellness is no exception. Nurse leaders should model behaviors that can reduce burnout, such as practicing mindfulness, Young said.

By putting each employee’s wellness in the forefront, hospitals can improve morale and lower stress levels.

“In today’s healthcare environment, organizations are finding that nurses are leaving clinical roles in less than two years’ time. The constant turnover can be costly to the organization’s bottom line,” said Scala.

Understand your nurses

All of these tips go back to the same thing — get to know your nurses. Hospitals should look to improve communication with nurses and involve them in the decision-making process. Also, explain changes when they’re made. Nurses crave professional development, Radesi argued.

“The more they know, the easier it is for them to do their job,” Radesi said.

Hackensack University Medical Center’s leadership team holds Town Hall meetings on various shifts to help foster better communication, according to Douglas. “Hospital leadership must be engaged with their team members,” Douglas said. “They must be attuned to the challenges team members may face. Collaboration, partnership, active listening, and open and continuous lines of communication are essential.”



How Hospitals Can Prepare for an Influenza Pandemic

Originally published on Healthcare Dive.

Public health officials agree that the next major pandemic will be influenza. Are U.S. hospitals ready for it?

The U.S. Department of Health and Human Resources (HHS) estimates that an infectious disease pandemic could infect 90 million Americans and kill as many as 1.9 million people. This kind of pandemic would put a strain on the country’s healthcare system, sicken hospital staff and stretch hospital resources to their limits and beyond.

An influenza pandemic would go well beyond the normal seasonal flu virus. Patients’ immune systems won’t be able to cope with a pandemic flu, and it will spread quickly across the globe.

This isn’t just the stuff of science fiction. There have been multiple pandemics over the past century.

The Spanish Flu of 1918 caused more than 50 million deaths. Between 20% and 40% of the world became infected. The late-1950s saw the Asian flu, which killed about 2 million people, including 70,000 in the U.S. In recent years, the H1N1 virus in 2019 killed 17,000 people worldwide.

Billionaire Bill Gates spoke about the pandemic threat earlier this year during a security conference in Munich.

“Imagine if I told you somewhere in this world, there’s a weapon that exists — or that could emerge — capable of killing tens of thousands, or millions of people, bringing economies to a standstill and throwing nations into chaos,” Gates said. “Whether it occurs by a quirk of nature or at the hand of a terrorist, epidemiologists say a fast-moving airborne pathogen could kill more than 30 million people in less than a year.”

Hospitals across the country are now planning and testing models to implement when an infectious disease pandemic eventually hits the U.S.

Are we prepared?

A 2015 report “The Next Pandemic: Hospital Management” examined how a pandemic could impact the healthcare system, the state of preparedness of hospitals and special considerations for them during a pandemic.

The authors of the report, Robert E. Falcone, vice president of clinical policy and population health at the Ohio Hospital Association and clinical professor of surgery at Ohio State University, and Andrew Detty, quality and population health analyst at the Ohio Hospital Association, warned that a severe pandemic like the 1918 flu could: infect 90 million Americans, hospitalize 9.9 million and kill 1.9 million.

To put that into perspective, the H1N1 virus in that impacted the country from 2009 to 2010 increased emergency department (ED) visits by 18% over the baseline in from 2005 through 2008 with individual hospitals and health systems seeing much higher rates.

Part of the issue with H1N1 was not so much that people were infected, but that they were afraid that they or their children had the H1N1 virus and rushed to EDs, according to the 2015 report. That caused a major drain on the healthcare system.

Preparing for a pandemic

The National Strategy for Pandemic Influenza involves three parts: preparedness and communication; surveillance and detection; and response and containment.

Over the past decade, the federal government has sounded the alarm about a potential pandemic. The Centers for Disease Control and Prevention (CDC) created a free program for hospitals called FluSurge 2.0 to figure out the number of hospitalizations, intensive care unit (ICU) admissions, ventilators needed and deaths caused by an influenza pandemic.

Hospitals and health systems, in turn, have employed full-time incident coordinators, created pandemic preparedness committees with clinical, support and senior administrative representatives and participated in regional hospital planning.

Colin Bucks, medical director for the office of emergency medicine at Stanford Health Care in Stanford, CA, tells Healthcare Dive Stanford has a standing committee of 20 people that includes specialists in disease prevention, infection control and infectious diseases. The group meets quarterly to review plans, monitor infectious disease and bioterrorism updates, look for potential outbreaks, implement infection control procedures and decide when to start screening methods to prevent infections from spreading.

They also promote patient education, such as communicating with at-risk populations, informing patients about when to go to the hospital and educating people about proper disease-prevention hygiene so that they take the proper precautions to prevent infectious diseases.

Bucks says the health system also learns by reviewing how other health officials respond to crises, such as the SARS outbreak in Toronto in 2003 and the Ebola pandemic in 2014 and 2015, which he saw firsthand.

“It’s good to take the path that’s been tread before,” Bucks says of learning how healthcare facilities have tackled other emergencies. “Let’s learn from folks who have gone through major events.”

Preparing for a pandemic isn’t cheap. A 2006 report called “Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science” estimated a 164-bed hospital would need to spend $1 million to prepare for a pandemic, including $200,000 for a pandemic plan, $160,000 for staff education and training, $400,000 for stockpiling minimal personal protective equipment (PPE) and $240,000 to stockpile basic supplies.

Joan Ivaska, senior director of infection prevention at Banner Health, based in Phoenix, Ariz., tells Healthcare Dive she’s not able to put a dollar amount on how much the large health system has spent on influenza pandemic preparation. Banner, which has 28 acute care facilities in six states, has committed resources to emergency management and infection prevention programs for any emergencies.

“Banner Health takes an all-hazards approach to preparedness for an influx of infectious disease patients,” Ivaska says. “We maintain plans for responding to an influx of infectious patients, whether from influenza or some other disease,” she adds.

Staff education and drills

It’s one thing to put down a plan on paper. It’s quite another thing to put it into action. Education and training drills help hospital staff, and administrators get more comfortable with a plan before there’s an influenza pandemic.

The Occupational Safety & Health Administration recommends that staff education and training include infection control precautions, how to report pandemic influenza to hospital and public health officials, proper PPE usage, hand hygiene, training of infection control monitors and tabletop simulation exercises.

Banner Health reviews emergency response plans on a routine basis and conducts staff training and drill exercises every year, says Ivaska.

“We have staff with expertise in infection prevention and control and emergency management who coordinate these activities as part of their ongoing responsibilities,” she says.

Stanford Health Care tested an ED “drive-through” a few years ago to rapidly evaluate patients outside of the hospital environment to prevent cross-infection during a pandemic. In the test, hospital staff evaluated patients still in their vehicles or next to their vehicles.

The hospital tested the feasibility of the external influenza clinic and measured throughput times of simulated patients. Stanford Hospital used 38 patient charts from people treated during the H1N1 outbreak in 2009 to simulate the scenarios. It found that the medical length of stay was 26 minutes and physicians were able to identify the patients admitted and discharged during the real ED visit with 100% accuracy.

The ED drive-through and other programs that look to limit the spread of infectious disease focus on patient screening. They also seek to protect staff who meet patients first, including administrative staff, clerks, greeters, and security, as well as doctors, nurses and housekeeping staff. Stanford Health Care makes sure there are hand-washing supplies, masks, and other PPEs to protect them from infectious illnesses.

Stanford Hospital officials said the drive-through model is a “feasible alternative to a traditional walk-in ED or clinic and is associated with rapid throughput times. It provides a social distancing strategy, using the patient’s vehicle as an isolation compartment to mitigate person-to-person spread of infectious diseases.”

Bucks says Stanford hasn’t needed to test or implement the ED drive-through model again, but it’s in the emergency plan when needed. However, Stanford has needed to readapt the model because of changes to buildings or new facilities in the system, such as the new Stanford Hospital, which is slated to open in 2018.

“We haven’t had to activate that in anger, but it’s still a standing part of our response procedures,” says Bucks.

Bucks says the ED drive-through works for Stanford Health Care and other hospitals can start a similar program with proper planning and testing. “I think others can look at this and implement it, but I wouldn’t be under the illusion it could happen as a just in time,” says Bucks about the need for planning and testing the plan.

Stanford’s model is one of many that tried to limit potential exposure. Another example is triage telephone lines. The Minnesota Department of Health collaborated with health plans and hospital systems to establish MN FluLine.

MN FluLine uses standardized triage protocol and registered nurses talk to patients about their symptoms, when to seek medical care, and offers prescriptions to high-risk patients who are advised to stay home. MN FluLine believes the program has prevented about 11,000 face-to-face healthcare encounters. The CDC is looking at similar triage phone lines to see if it can reduce the spread of infectious diseases.


An influenza pandemic would quickly fill EDs and ICU beds and could cause staffing, ventilator and PPE shortages if hospitals aren’t prepared.

A 2010 study found that there were a little more than 62,000 full-feature mechanical ventilators in U.S. acute care hospitals. That’s about one for each ICU bed.

The SARS outbreak of 2003 in Canada is an example of what happens to supplies when hospitals are overwhelmed with an infectious disease. In Toronto, one 1,300-bed hospital used 3,000 disposable isolation gowns, 14,000 pairs of gloves, 18,000 N95 respirator masks, 9,500 ear loop masks and 500 pairs of goggles daily during the peak of the outbreak. The HHS recommends that hospitals stockpile disposable N95 respirators and surgical masks, face shields, gowns and gloves in case there’s a pandemic.

Banner maintains an inventory of essential supplies and equipment in the event of an influx of infectious patients, according to Ivaska. The health system would also partner with public health partners for specific needs if there’s a pandemic.

In terms of staffing, hospitals may need to bring in more staff to help with patient care and hospital upkeep to minimize the spread of the virus.

Hospital staff would also likely become sick themselves. One estimate suggests 40% of hospital staff would be absent during a pandemic because they’re sick, caring for a sick family member or they may even refuse to come to work for fear of getting sick.

Hospitals may need to call in volunteers, medical students, nursing students and retired healthcare workers to help hospital staffing during a crisis.

There is also the issue of staff, patient and community well-being. In “The Next Pandemic: Hospital Management,” the authors pointed to the 2003 SARS outbreak as an example of what happens to staff during a health crisis.

Quarantine during the SARS outbreak “caused fear, anger, loneliness, and boredom among isolated patients, and the fear of becoming infected and restrictions on activity caused discomfort for uninfected patients,” the authors wrote. “Healthcare workers expressed fear and resentment in the face of the danger of infection and constantly changing information; social isolation exacerbated their anxiety, as did concern about infecting loved ones.”

There is also the issue of hospitals needing to segregate flu patients to reduce spreading the disease. In case of a pandemic, a hospital may need to move patients to specific parts of a hospital or even to off-site locations.

Bucks says Stanford Health Care has used external facilities at times and the system would likely need to implement a similar plan if there is a flu pandemic.

Banner Health takes a whole system approach if there’s an influx of infectious patients or other healthcare emergencies, Ivaska says. How specifically the system would respond to a specific emergency depends on a number of factors, including a facility’s location, infrastructure, capabilities and staffing, she adds.

Planning for a pandemic in the current political climate

The federal government helps hospitals and health systems prepare for a possible health crisis through training and grants, such as $850 million in Hospital Preparedness grants.

But there is concern that federal money may soon dry up. In his budget outline in March, President Donald Trump proposed cutting nearly 18% from the Department of Health and Human Services budget. The president also proposed cutting almost $6 billion from the National Institutes of Health and another $400 million from training programs for nurses and other health professionals.

The Obama administration spent $1 billion on the Global Health Security Agenda, which focused on global health security, including preventing pandemics. That funding ends in fiscal year 2019, and the Trump administration hasn’t said whether it will continue.

Congress will ultimately decide on the actual budget, and will likely ignore many of Trump’s proposed health services cuts. In response to the president’s proposed cuts, Rep. Tom Cole (R-OK), who chairs the House Appropriations subcommittee on labor, health and human services, education and related agencies, called the health agencies “the front lines of defense for the American people for some pretty awful things.”

“If the idea of a government is to protect the United States and its people, then these people contribute as much as another wing on an F-35, and actually do more to save tens of thousands of lives,” he said, referring to Trump’s plan to increase military spending while decreasing money for health services.