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About health insurance

CBO: Senate surprise billing legislation would save feds $7B over next decade: The Senate Health, Education, Labor and Pensions Committee asked the Congressional Budget Office for estimates on the financial impact of its proposal to address surprise medical bills and high pharmaceutical costs. The CBO reported that the law would lower federal expenses by $7 billion over the next decade. A closer look (Table 1) reveals that that savings do not start until 2025. By 2028 the net federal budget savings reaches about $4.5 billion.

Democratic chair: Medicare negotiating drug prices not moving before August: On the House side, it appears that drug price legislation will not happen before the August recess.

New CMS resources help states waive ACA requirements: The ACA has provisions to grant states waivers (Section 1332) to adopt alternative schemes to provide health insurance. “Most states have gotten or are seeking the Section 1332 waivers to establish a reinsurance program to fully or partially reimburse insurers that are covering claims for high-risk beneficiaires. This reduces the price of premiums in those states.” CMS has just issued guidelines to make the waiver process easier. The question that arises is what happens to insurance markets as the number of products increase and enrollees segment themselves among these plans by financial and health status criteria?

Trump Administration Moves to Shift Patients’ Chronic Illness Costs to Insurers: In order to have a Health Savings Accounts (HSAs), participants must also have a high deductible health plan. These plans require large out of pocket payments before the insurance becomes responsible. The Internal Revenue Service and the Treasury Department just issued a guidance for high-deductible health plans that allows insurance companies to pay for such chronic disease items as glucose monitors and blood pressure cuffs without first satisfying the deductible. This type of allowance has been discussed before with respect to total coverage of chronic medications to ensure compliance.

Insurers Running Medicare Advantage Plans Overbill Taxpayers By Billions As Feds Struggle To Stop It: Payments to Medicare Advantage plans include adjustments for the severity of illnesses of covered persons. CMS clams that over the past three years these plans have overbilled Medicare $30 billion. The controversy over this issue is whether plans are documenting better or exaggerating patient findings. We will see which is true when the government seeks to recoup the money it claims plans owe.

Early Effects of an Accountable Care Organization Model for Underserved Areas: In its first year, the Accountable Care Organization Investment Model "was associated with a differential reduction in total Medicare spending of $28.21 per beneficiary per month relative to the comparison group, which amounted to an aggregate decrease of $131.0 million…” After accounting for “$82.4 million in CMS spending, the aggregate net reduction was $48.6 million, which corresponded to a net reduction of $10.46 per beneficiary per month. Decreases in the number of hospitalizations and use of institutional post-acute care contributed to the observed reduction in overall spending.”

Health Insurance Index Report for the 2019 Open Enrollment Period: This report from eHealth found that, for unsubsidized enrollees in exchange plans, the average premiums for two-person families broke $1,000 per month for the first time and the total “combined annual premiums plus deductible for a four-person family now tops $25,000.” The good news is that for 2019 the “average individual deductible decreased 6%…” and the “average family deductible decreased 8%…”

About the public’s health

Unintentional Injury Death Rates in Rural and Urban Areas: United States, 1999–2017: We pay much attention to diagnosis and treatment of diseases such as cancers and heart attacks; however, according to the CDC, unintentional injury is a leading cause of death in the United States. In this category are traffic accidents, unintentional drug overdoses, and falls. In this July report, the CDC says that from” 1999 through 2017, the age-adjusted unintentional injury death rate increased 40%.” Clearly more attention needs to be directed at this category of deaths.

Planned Parenthood ousts leader after less than a year: Normally a job change is not big news. However, this ouster was caused by the Monday start of the rule prohibiting federally funded family planning clinics from providing referrals for abortions. Apparently former president Leana Wen, MD wanted to approach the issue as a medical one while the organization saw it as a political fight. In related stories, two Planned Parenthood clinics (in Illinois and Maine) said they would refuse federal funding so they could continue to provide abortion services.

76 billion opioid pills: Newly released federal data unmasks the epidemic: This Washington Post story details the magnitude of opioids that have been flooding the market and the role played by pharma companies and the manufacturers which supply them. This information comes from the public release of data from the Drug Enforcement Administration. The question now is not about who produced and promoted what drugs, but why the DEA was sitting on data that clearly showed an epidemic in the making.

Trump to order drive for improved flu vaccine: Now some good news. After years of questioning the safety of vaccines, President Trump “is readying an executive order that would direct HHS to overhaul the development of flu vaccine and encourage more Americans to get vaccinated.”

Incentives for smoking cessation: The best way to get people to stop smoking is to raise cigarette taxes. But does paying them to stop also work? This Cochrane Collaborative article concludes that: “Six months or more after the beginning of the trial, people receiving rewards were more likely to have stopped smoking than those in the control groups.” The amount did not matter.

New York City Hopes to Ease Strain on Its Emergency Rooms: NY City has announced an expanded primary care system called NYC Care. It is expected to serve 300,000 patients and reduce ER usage by providing a regular source of care.

About pharma

Johnson & Johnson lifts annual revenue guidance as Q2 drugs sales top estimates, led by Darzalex, Imbruvica, Tremfya: Despite the pending liability suits over opioids and asbestos in baby powder, and pressures from generics, J&J continues to be profitable. This is article provides a good look at the importance of a diversified product line.

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A look at how providers could fare in CMS' new primary care payment models: As previously reported, starting in January 2020 CMS will start a demonstration project to incentivize primary care physicians to accept risk arrangements with quality bonuses. This scheme is separate from the ACO program. This article is a nice summary of what the primary care payment models will look like.

Problems Remain for Ensuring That All High Risk Medicaid Providers Undergo Criminal Background Checks: The Office of the Inspector General of HHS surveyed states’ compliance with measures to assure “high risk” individuals were appropriately screened before being allowed to participate in the Medicaid program. The OIG “found flaws with States' implementation of fingerprint based criminal background checks for high risk Medicaid providers. Eighteen States missed the deadline for implementation that CMS had set, and 13 of those 18 States had still not implemented these checks as of January 1, 2019.” Recommendations are included in the report.

About healthcare IT

Surescripts files motion to dismiss FTC's antitrust case: Recall that in April the FTC filed suit against Surescripts for monopolizing the e-prescribing market. This article provides an update on that story.

About pharma

Advocates frustrated over pace of drug price reform: Despite all the talk in Congress (by both parties) about addressing high drug prices, nothing has been done; and the August recess is fast approaching. This article is a nice summary of what is (or is not) happening.

How pharma, under attack from all sides, keeps winning in Washington: This article provides a different spin than the one above by focusing on the role of the pharma lobby.

Limited Information Exists on the Effects of Synchronizing Medication Refills: “Medication synchronization is a process whereby a pharmacist aligns the refill dates of two or more of a patient’s medications to a single day.” The GAO was mandated to do a survey about this issue and found scant data. Some findings support increased drug adherence. But there are problems with this process. A major one is that patients stagger their filling of prescriptions because they need to spread out the costs. Perhaps the problem could be solved with a utility-like payment method that “smooths” payments rather than requiring a periodic lump sum. For example, instead of paying the out-of-pocket costs of several 90-day supplies of medications all at once, the patient could be billed equal amounts each month for 3 months.

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About health insurance

1 in 5 employers may face the ACA's 'Cadillac' tax on high-cost health plans: Health benefits are deductible expenses for employers and tax free benefits for employees. If these benefits expand in place of higher salaries (which are taxable), the government loses more money. Further, such a system discourages prudent purchasing of insurance. In this setting, the ACA mandated a so-called “Cadillac tax” ( a 40% excise tax) on an employer health plan when its cost surpasses $11,200 for an individual and $30,100 for a family. Both major political parties do not like this provision. One reason is it was not indexed to inflation or even geared to rising healthcare costs, thus causing the burden to fall on the middle class. The start date for this tax has been delayed but is now set to go into effect in 2022. If it proceeds as planned, this new study estimates that about 21% of “employers offering health plans will have at least one plan affected.” The House is expected to vote this week on a full repeal of this tax.

Biden reveals healthcare plan piggybacking on ACA: Add one more variation…Biden proposes that a Medicare-like system be offered with Medicaid benefits. This option would be offered for those who would qualify for Medicaid if their states had signed on for the expansion.

CMS Proposing Bundled Payment Model for Radiation Oncology: The title speaks for itself. This proposal has been months in the making. "Participation would be mandatory for certain geographic areas during the model's projected five-year timeline…” and prospective payments will be linked to quality metrics.

U.S. appeals court blocks Trump administration birth control exemptions: “A federal appeals court on Friday blocked the Trump administration from enforcing new rules allowing employers to obtain exemptions from an Obamacare requirement they provide health insurance that covers women’s birth control.”

About healthcare quality

Quality Payment Program Releases 2017 Physician Compare Data and Sees Increases in Clinician Participation Rates and Success for 2018: CMS Administrator Seema Verma announced that the number of Qualified Practitioners participating in the Advanced APM programs for quality reporting “nearly doubled in 2018 from the previous year, increasing from 99,076 to 183,306 clinicians…Additionally, nearly 90% of clinicians in small practices participated in 2018, which was an increase from 81% in 2017.” Any recent economic and clinical benefits still need to be assessed.

CMS to delay star ratings update pending expert panel review: This February, CMS started to look at changes in the quality assessment methodology that underpins the star reports for hospitals. After receiving more than 800 comments from a solicitation, CMS decided to delay its summer report and instead look at revisions in the program.

Serious misdiagnosis-related harms in malpractice claims: The “Big Three” – vascular events, infections, and cancers: The authors of this study looked at malpractice claims and found that '“ vascular events, infections, and cancers… account for about three-fourths of serious misdiagnosis-related harms.” They concluded that initial programs to improve diagnoses should be targeted at these conditions.

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About the public’s health

Court rules Trump administration can go ahead with Title X 'gag rule':By a 7-4 vote, the U.S. Court of Appeals for the 9th Circuit upheld the June 20 ruling by a three-judge panel that allows the government to withhold Title X funds from clinics that provide abortion referrals.

Trends in prevalence of protective levels of hepatitis B surface antibody among adults aged 18–49 years with risk factors for hepatitis B virus infection—United States, 2003–2014: Fewer than a third of high risk adults had been immunized for hepatitis B by 2014. Clearly more needs to be done to increase this coverage. (The number today is perhaps higher given the requirement for vaccine coverage under the ACA. Recall the insurance exchanges started in 2014.) This problem is the perfect example for the need for more social marketing.

Health plans ramp up new IT efforts:This article is not just about IT. The main theme is how Social Determinants of Health are being addressed by insurers. The lead example is a food market in a bus that brings healthy food into a “food desert” in Minneapolis-St. Paul.

About pharma

Failure to Launch: Patent Abuse Blocks Access to Biosimilars for America’s Patients: This Whitepaper from the trade group “Biosimilars Council” details the impediments to biosimilars getting to market. The study claims that these obstacles, including patent abuse by branded products, have cost the public $7.6 billion.

Speaking of generics, the FDA tentatively approved Mylan's generic Eliquis. As this class of drugs goes generic, prices will come down; however the number of indications have increased.

About healthcare quality

Association of residency work hour reform with long term quality and costs of care of US physicians: observational study: Work hour reforms for residents started in 2003 because of problems in care attributed to fatigue. Since then the question has been raised about the quality of care these physicians will deliver after training, viz., will the reduced hours produce less qualified practitioners? The answer, at least for internists, is “no difference.” The bottom line: “ Exposure of internists to work hour reforms during their residency was not associated with post-training differences in patient mortality, readmissions, or costs of care.”

About health insurance

CMS Proposes Elimination of RAPs, $250 Million Medicare Payment Increase: CMS is proposing a number of changes in home care payments, including a new home infusion benefit. Overall, these changes “would increase Medicare payments to home health agencies by 1.3% — or about $250 million.”

CMS proposes new approach to monitoring protections for Medicaid beneficiaries: Current Medicaid rules require states to report data on access to that program every three years. But the rule only applies to fee for service Medicaid. Since the majority of Medicaid recipients are enrolled in managed care plans. the rules need to be changed. Further, CMS plans to change the type of evaluation to more of an outcomes-driven approach.

About healthcare IT

GE anesthesia/respiratory devices have cyber vulnerabilities: This story highlights another recent example of the vulnerability of healthcare “peripherals” too hacking.

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About pharma

White House kills major drug pricing proposal: Remember the President’s proposals to lower individuals’ drug costs by re-channeling rebates? Nevermind. Now Congressional focus will be on prices pharma companies charge.

About healthcare IT

FCC approves $100M rural telehealth program: “The proposed pilot program would offer an 85 percent discount on connectivity for telehealth services powered by broadband internet access. The virtual care services would connect patients directly to their physicians through audio and video technology.” The question is whether there is adequate connectivity in places that need it.

Amazon's Alexa will now give Brits health advice: Want to ask Alexa about your symptoms or how to treat your illness? You can in the UK. It appears the concerns there are only about privacy. In this country we would also have liability concerns.

About healthcare quality

Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study: Does the threat of penalties improve care? The answer with respect to hospital acquired conditions is: “No.” In fact financially penalizing hospitals could make it more difficult to deliver care to needy populations. The research concluded: “Penalization was not associated with significant changes in rates of hospital acquired conditions, 30 day readmission, or 30 day mortality, and does not appear to drive meaningful clinical improvements.”

About the public’s health

Sugary drink consumption and risk of cancer: results from NutriNet-Santé prospective cohort:  “In this large prospective study, the consumption of sugary drinks was positively associated with the risk of overall cancer and breast cancer. 100% fruit juices were also positively associated with the risk of overall cancer. These results need replication in other large scale prospective studies. They suggest that sugary drinks, which are widely consumed in Western countries, might represent a modifiable risk factor for cancer prevention.”

About health insurance

Appeals court appears likely to call for lower court to settle unanswered questions on ACA lawsuit, experts say: More legal experts have weighed in on what might happen as the appeals court rules on the ACA. The most recent comments are that the court will send the suit back to a lower court to decide which parts of the law can exist without the individual mandate.

Rifts Emerge Over Congressional Move to Curb Surprise Medical Bills: While bipartisan support for addressing surprise medical bills still exists, the implementation details are causing some disagreements. For example, if you take the patient out of the equation, who is responsible for the difference between what the insurance company pays and what the provider is asking?

California gov signs health care bill extending coverage to some undocumented residents: “Democratic Gov. Gavin Newsom on Tuesday signed SB-104, which extends health care benefits to individuals 19 to 25 years of age, regardless of their immigration status.”



Today's News and Commentary

About the public’s health

HyperFoods: Machine intelligent mapping of cancer-beating molecules in foods: Which foods are more likely to help prevent cancers? The authors used a network-based machine learning method to find answers. The bottom line? “… plant-based foods such as tea, carrot, celery, orange, grape, coriander, cabbage and dill contain the largest number of molecules with high anti-cancer likeness through exerting influence on molecular networks in a similar fashion to existing therapeutics.” However, among the authors other cautions is the warning that “concentrations of bioactive molecules are not taken into account and it is unclear they would be present in sufficient enough concentration to exert their beneficial biological activity.”

US life expectancy has been declining. Here’s why: “A baby born in the U.S. in 2017 is expected to live to be 78.6 years old, which is down from 78.7 from the year before.” The CDC targeted three causes for this decline: rise in drug overdoses; increase in liver disease; and rise in the suicide rate.

About pharma

Novartis to sell epinephrine shot in U.S. pharmacies amid EpiPen shortage: Novartis will make its generic pre-filled epinephrine shots immediately available in local pharmacies across the United States. This announcement comes because of a shortage of Mylan’s EpiPen due to manufacturing problems. It is nice to see the market working.

Tax-Funded Drug Research Should Spell Cheaper Drugs: Advocates(Free trial available): How should we handle drug (and other) discoveries that are made using federal research funds? Should the government have an equity share in the product? Should the prices be lower? Right now there is no financial recognition. This article addresses the questions above.

Germany Joins U.S.-EU Inspection Partnership: This article is a reminder that the FDA does not have the resources to examine all foreign plants for Good Manufacturing Practices (GMPs) and is increasingly relying on other countries to police their own facilities.

Congress Seeks GAO Review of Foreign Drug Inspection Program: This article addresses the same issue as the one above.

Score! 'Good Pharma' ranking finds uptick in new drug data sharing and clinical trial transparency: Now some good news. According to findings from the Good Pharma Scorecard biennial ranking, Big Pharma is sharing more data than ever before. 95% of patient trials are “now providing public results within six months of FDA approval. If the time period is extended to 12 months, that improves to 100% for the new drugs reviewed after approval in 2015.”

About health insurance

U.S. appeals court signals sympathy to bid to strike down Obamacare: Lots of speculation on the outcome of the ACA appeals hearing yesterday. Two of the three judges were Republican appointees (which should not make a difference, but does). Observers said their questions indicated they might rule against the appellants, who are mostly attorneys general from Blue states. A decision will not be forthcoming for weeks and is likely to reach the Supreme Court regardless of outcome. This article is a nice summary of the history leading up to this trial. Here is another good source of information from the Washington Post.

Buyer beware: When religion, politics, health care and money collide:Some people are buying into what they think are insurance plans but are really faith-based medical cost sharing schemes. This article is a good example of what can (and does) go wrong when coverage is required.

Anesthesiologist indicted for alleged role in $7M telemedicine fraud case: Find an innovative healthcare technology and someone will use it to defraud payers. In this case, starting in January 2015 the anesthesiologist in the headline “and other medical providers purported to practice telemedicine pursuant to agreements with unnamed companies in exchange for kickbacks paid for each purported telemedicine encounter, according to the indictment.” The alleged fraudulent payments totaled $7 million.

Covered California says consumers will see lowest-ever premium hike for individual policies: “Covered California announced Tuesday morning that it expects an average premium increase of 0.8 percent for 2020 in the state’s individual marketplace, the lowest such rate change since the health insurance exchange started business in 2013. 
Peter V. Lee, the executive director of Covered California, attributed the low rate change to bills passed by the California Legislature and signed into law by Gov. Gavin Newsom over the past six months. 
The legislation includes a so-called individual mandate that will impose a state tax penalty on any California resident who does not maintain health insurance coverage and offers state subsidies that will help an estimated 922,000 residents pay for insurance.”

About healthcare quality

HHS Quality Summit (QS) Fact Sheet: HHS announced that it will convene a summit of “key industry stakeholders and government leaders to discuss how current quality programs administered by HHS can be further evaluated, adapted, and streamlined to deliver better outcomes for American patients.” The announcement is a bit vague but appears to be geared to streamlining all the disparate quality criteria.

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About pharma

U.S. judge strikes down Trump administration rule requiring drug prices in TV ads: This story is today’s top news. U.S. District Judge Amit Mehta in Washington ruled in favor of pharma companies Merck & Co Inc, Eli Lilly and Co and Amgen in their suit to stop the requirement for posting drug prices in ads. The judge ruled that HHS overstepped its authority in imposing this requirement and that it was up to Congress to make such a decision. Given the climate of pharma-cost bashing, Congress may pass such a measure with significant bipartisan support.

Effects of Nutritional Supplements and Dietary Interventions on Cardiovascular Outcomes: An Umbrella Review and Evidence Map: Many vitamins and dietary supplements are touted as effective preventives for cardiovascular disease. This extensive literature review, published online today, provides more insight. Other than lowering your salt intake, all other measures are, at best, unproved.

In summary:

“There was moderate-certainty evidence that reduced salt intake decreased the risk for all-cause mortality in normotensive participants… and cardiovascular mortality in hypertensive participants.”

“ Low-certainty evidence showed that omega-3 long-chain polyunsaturated fatty acid (LC-PUFA) was associated with reduced risk for myocardial infarction…and coronary heart disease…”

“Folic acid was associated with lower risk for stroke (… low certainty), whereas calcium plus vitamin D increased the risk for stroke (… moderate certainty).”

”Other nutritional supplements, such as vitamin B6, vitamin A, multivitamins, antioxidants, and iron and dietary interventions, such as reduced fat intake, had no significant effect on mortality or cardiovascular disease outcomes (very low– to moderate-certainty evidence).”

Financial Implications of 12-Month Dispensing of Oral Contraceptive Pills in the Veterans Affairs Health Care System: The arguments against dispensing a 12 month supply of oral contraceptives are financial and clinical. Less frequent renewals will require more frequent patient copays, thus reducing payer costs. Some physicians also use more frequent prescription as a way to bring patients to the office to check for side effects and deliver other preventive services. This VA study found the 12 month dispensing to be cost-effective. The one caution is that the VA population is rather stable, while the privately insured population tends to change insurance plans at a significant rate. Private insurers may be willing to pay for longer prescriptions but probably not those that exceed the contract year.

About the public’s health

Duration of Antibiotic Therapy: Shorter Is Better(Subscription required for full article): One way to reduce antibiotic resistance is to shorten the course of treatment. This article provides a review of the evidence for shorter course of therapy. For example, for community acquired pneumonia 8 randomized controlled trials “have shown that 3- to 5-day courses of antibiotic therapy are at least as effective as 7- to 14-day courses…”

2019: Vulnerabilities in Hospice Care: This site provides links to two reports by the HHS Inspector General detailing the quality of care findings for Medicare-covered hospices. In short: “the majority of U.S. hospices that participated in Medicare had one or more deficiencies in the quality of care they provided to their patients.”

About healthcare IT

Security, control of data seen as key barriers to cloud adoption by pharma: This article explains why the pharma industry does not think cloud-based data storage is safe, and therefore will not use it.

About health insurance

Trump aims to shake up kidney care market: The federal government spends more than $100 billion per year on the End Stage Renal Dialysis Program, its only disease-specific insurance. Tomorrow the Trump administration will announce plans to change payment methods to encourage more home dialysis as well as earlier detection and treatment of kidney disease.

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Welcome back after the long July 4 “weekend”

In the new format below, the article link will be in the story’s title

About pharma

Fast-Track Drug Approval, Designed for Emergencies, Is Now Routine: This article was in the print edition of the Wall Street Journal this weekend. It is a great piece about the balance between quick drug approval to help people who need treatment and the possibilities of harm from unanticipated side effects.

Only 2% of genomic material available for research comes from Africa; 54gene wants to change that: The headline is self-explanatory. The article highlights the opportunities for drug discoveries by conducting more research on highly diverse African genomes.

Exclusive: Five couples lined up for CRISPR babies to avoid deafness: Five Russian couples with hereditary deafness have applied to the country’s authorities to have children who will be genetically modified to correct the defect.

About the public’s health

Fight over vaccine exemptions hits state legislatures: This article is a nice summary of the issues around state requirements for vaccination versus personal liberties. The one key factor is that the individual risk of vaccination is negligible while the public risk of non-vaccination is considerable.

Smoke-free and tobacco-free colleges and universities in the United States: Restaurants and public places have adopted tobacco-free environments. According to this research: “In 2017, just 16.7% of accredited, degree-granting institutions in the USA had 100% smoke-free or 100% tobacco-free protections. Despite progress, more efforts can ensure that students and staff benefit from comprehensive 100% smoke-free and 100% tobacco-free protections at US colleges and universities.”

Natural history of prediabetes in older adults from a population‐based longitudinal study: One of the screens done in older adults is for pre-diabetes, i.e., an abnormal blood sugar level that doesn’t quite meet criteria for the disease. This 12 year-long Swedish research study looked at 918 individuals who had prediabetes. During that time, 22% reverted to normal, 13% developed diabetes and 23% died. The exact causes of death are not specified. The takeaway here is that prediabetes does not always progress to the disease and normal sugars can be achieved. The modifiable factors to achieve this goal are lowering systolic blood pressure and promoting weight loss. Providing this data to patients with prediabetes may give them hope so that can engage in healthy lifestyles and comply with treatment recommendations.

National and State Estimates of Lost Earnings From Cancer Deaths in the United States: “A total of 8 739 939 person-years of life were lost to cancer death in persons aged 16 to 84 years in the United States in 2015, translating to lost earnings of $94.4 billion (95% CI, $91.7 billion-$97.3 billion). For individual cancer sites, lost earnings were highest for lung cancer ($21.3 billion), followed by colorectal ($9.4 billion), female breast ($6.2 billion), and pancreatic ($6.1 billion) cancer.” Large state-by-state differences also occur.

2019 Review of Physician and Advanced Practitioner Recruiting Incentives: This recent report by physician search firm Merritt Hawkins has a number of important public health findings. Among them:

—”For the 13th consecutive year, family physicians topped the list of Merritt Hawkins’ 20 most requested recruiting assignments, underscoring the continued robust demand for primary care physicians.”

—”The use of quality/value-based physician compensation is rising. 56% of physician production bonus formulas tracked in the 2019 Review feature quality-based metrics, up from 42% the previous year.” Such figures often fail to note how much of the compensation is value-based.

—”Employment rather than independent practice remains the dominant physician recruiting model. Over 90% of Merritt Hawkins’ search assignments feature employed practice settings, while less than 10% feature independent practice.” This finding may be based on the fact that hospitals and other large employers can afford expensive search companies.

The survey also lists salary trends by specialty. Guess where the primary care physicians fall?

About healthcare IT

6 ways smaller health systems are falling behind in cybersecurity: CHIME-KLAS survey: “While large healthcare organizations are successfully adopting best practices for cybersecurity, smaller health systems and hospitals are falling behind as budget constraints and a lack of qualified talent hinder progress…” As large systems try to implement interoperability solutions, linkages with smaller organizations which are not as “cybersecure” may pose a threat. There needs to be a systemic solution to the security issue, not just an institution-by-institution implementation.

Global EHR market hits $31B but faces usability, interoperability challenges: This article summarizes a proprietary research study. “The market for EHRs, which includes revenues for EHR systems, computerized provider order entry systems, and directly related services, such as installation, training, servicing, and consulting, grew 6% from $29.7 billion the previous year…” Read the article for more details.

About health insurance

ObamaCare repeal lawsuit faces major court test: Tomorrow the 5th Circuit Court of Appeals in New Orleans “will hear arguments in a lawsuit backed by the Trump administration seeking to overturn the entire 2010 Affordable Care Act (ACA).” The article is a nice summary of the events leading up to this hearing.

Congress has ambitious agenda tackling health care costs: Now that the 4th of July holiday is over, Congress will begin to address a variety of health issues ranging from surprise medical bills to lowering out-of-pocket drug costs. This article is a nice summary of these initiatives.

Study finds 33% of ACOs took on major risk in 2018 as new program starts: This article summarizes recent research in Health Affairs (subscription only access). The survey found that “only 33% of accountable care organizations have at least one contract that takes on greater risk,” up from 28% in 2012. It will be interesting to see how many ACOs stay in the program. Starting July 1, they are allowed up to 3 years in a no-downside risk program. Previously, they could remain in that status for 6 years.

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About health insurance

CMS extends Medicare coverage for ambulatory blood pressure test: Ambulatory blood pressure monitoring (that is blood pressure readings taken outside the doctor’s office ) is the current medical recommendation for following hypertension. CMS has just approved Medicare coverage.

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Five states seek to join hearing to determine fate of CVS-Aetna merger: As previously reported, federal Judge Richard Leon is reviewing this merger, claiming it was not adequately vetted. Now attorneys general from California, Florida, Hawaii, Mississippi and Washington have repeated a request to speak before the court in favor of the deal.

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Accuracy Of The Relative Value Scale Update Committee’s Time Estimates And Physician Fee Schedule For Joint Replacement: Physicians’ time is one element that CMS uses to pay for services. This research was based on actual electronic record time stamps rather than self-reported times. The results were that “the fee schedule overestimated the operating time of original hip replacements by 18 percent and original knee replacements by 23 percent. Revision hip replacements were overestimated by 61 percent and knee replacements by 48 percent.” Keep in mind that the payment recommendations come from an AMA committee largely composed of surgical specialists, so reform in payment will be problematic.

Read the abstract

About the public’s health

Facebook to tackle content with misleading health claims: The headline is self-explanatory.

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Read another version

Exclusive: FDA enforcement actions plummet under Trump: Again, the headline is self-explanatory.

Read the report for more details

Microbiota-Driven Tonic Interferon Signals in Lung Stromal Cells Protect from Influenza Virus Infection:Despite the complex title, this research’s method is important. Because antibiotics do not help treat viral infections like influenza, physicians should avoid using them. Another reason to avoid use is fostering the emergence of drug resistance. This article provides a third reason.
Intestinal bacteria are known to have a number of beneficial effects. One benefit that this research found is that they help attack viral infections. Use of antibiotics that can kill these bacteria may make viral infections worse.

Read the abstract

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About pharma

Pharma shells out $3B to doctors and hospitals—with Roche, Sanofi leading: CMS: This story is a followup to yesterday’s post about patients not paying attention to how much their physicians are paid by pharma companies. Despite the available information, these amounts are increasing. This article provides more detail about totals and who is spending the most.

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New drug approvals in 2019 - what’s left to come…: This article is just FYI. What new drugs are likely to come to market this year.

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Study finds sizable delay in use of new antibiotics: Why did hospitals wait about a year to use five new antibiotics? A few reasons are cost (they are very expensive), stewardship (waiting to choose appropriate patients to avoid emergence of resistance), and similarity to existing drugs. Marketers should take note of these reasons.

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More states move to protect patients seeking prescribed meds: One of the most frequently used tools for controlling drug costs is “step therapy.” Patients are required to start with the cheapest and/or most proven first line treatment for their illness. If that treatment fails, a series of excepted “next steps” can be used. This article explains how some states are passing laws against insurers using such policies. It should be noted that step therapies for such conditions as asthma, hypertension and diabetes are accepted and preferred medical treatments. We need to balance government concern for patient care with its practicing medicine.

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Drug prices in 2019 are surging, with hikes at 5 times inflation: This story was all over the media today. The overall message is that for all the talk by Congress about controlling drug costs, more than “3,400 drugs have boosted their prices in the first six months of 2019, an increase of 17% in the number of drug hikes from a year earlier.”

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Another version from the Wall Street Journal

About the public’s health

10 Medical Myths We Should Stop Believing. Doctors, Too.: This is a “fun” article that is also informative.

Read the article (NY Times, may need subscription)

More states are targeting teen vaping, but health advocates say it’s not enough to curb use: Yesterday many state laws went into effect that banned teen vaping and raised the age for tobacco purchase to 21. But, as the article asks, are those measures enough to curb use of these products?

Read the article(Washington Post but appears to be open access)

Children who say hand dryers ‘hurt my ears’ are correct: A real-world study examining the loudness of automated hand dryers in public places: Maybe paper towels are healthier. “This study suggests that many hand dryers operate at levels far louder than their manufacturers claim and at levels that are clearly dangerous to children’s hearing.”

Read the research

Implications of Changing Public Charge Immigration Rules for Children Who Need Medical Care: “In October 2018, the Trump administration published a proposed rule change that would increase the chance of an immigrant being deemed a “public charge” and thereby denied legal permanent residency or entry to the United States….A total of 8.3 million children who are currently enrolled in Medicaid and CHIP or receiving SNAP benefits are potentially at risk of disenrollment.”

Read the research

Today's News and Commentary

About pharma

Cue the ‘revolving door’ criticism: Former FDA commissioner Gottlieb joins Pfizer’s board: Since retiring to spend more time with his family, former FDA director Gottlieb joined a VC firm and is now a Pfizer board member. He will also serve on the board's regulatory and compliance committee and its science and technology committee.

Read the story

American Pain Society Goes Belly Up: The Society filed for Chapter 7 bankruptcy in the wake of accusations it was a front for opioid manufacturers.

Read the story

Pfizer gains FDA approval of Zirabev as a biosimilar of Roche's Avastin: The headline is self-explanatory. Generic competition with frequently-used, expensive medications is unfortunately not as common today as once hoped.

Read the story

Evaluating Open Payments: Five years into the requirement for pharma companies to furnish lists of physicians who received payments (or in kind gifts), the program is not fulfilling its promise to make people aware of potential conflicts their physicians may have. The reason? Patients do not look up the information.

Read the study

About the public’s health

Disease Watch: What Global Travelers Should Know In Summer 2019: If you are traveling abroad, you should check the CDC website for updates on local illness and prevention. This article is a nice overview of what is going on in different countries this summer.

Read the article

Trends in Health Equity in the United States by Race/Ethnicity, Sex, and Income, 1993-2017: The summary reveals that “there has been a clear lack of progress on health equity during the past 25 years in the United States.” The research looked at illness rather than mortality rates to derive its conclusions. One finding is that the rich are staying healthy while the poorer segment of the population is is getting sicker.

Read the research

U.S. federal court delays adoption of healthcare rule on abortion: “The U.S. Department of Health and Human Services (HHS) and its opponents in a California lawsuit agreed on Friday to delay implementing a rule that would allow medical workers to decline performing abortions or other treatments on moral or religious grounds, according to a federal court filing.” This case was about the “matter of conscience” refusals that would have been allowed pending court rulings.

Read the story

Kentucky law requiring ultrasounds before abortions will stand, federal appeals court says: The courts have usually ruled against some of the more restrictive recent abortion laws. This one is an exception.

Read the story

About hospitals and health systems

Sanford Health, UnityPoint to merge: 5 things to know:These two organizations have about $11 billion in combined revenue. This article is a nice summary of the scope and impact of this latest systems merger.

Read the story

About health insurance

Individual Insurance Market Performance in Early 2019: After 3 consecutive years of 1st quarter decreases in the medical loss ratio, this year it went up to 73% from a low of 68% last year. Except for that exceptional performance last year, this quarter’s results are still lower than any in the past 8 years.

Read the report

About healthcare quality and safety

Never Events Report 2019: In 2017, the Leapfrog Group asked hospitals to add four extra commitments regarding its “Never Event” program. This year’s report (which is is for actions through 2018) shows that addition of those promises resulted in drops in compliance for every category of hospitals. The “good news” is that all hospital categories did better using the old criteria.

Read the report

AHRQ unveils new database of patient safety events reported by PSOs: “The Agency for Healthcare Research and Quality has released its new Network of Patient Safety Databases [NPSD]…, the first public, online resource listing nonidentifiable information on patient safety events gathered by AHRQ-approved Patient Safety Organizations. NPSD data will be used to create dashboards and a chartbook designed to educate providers and others about patient safety events. These resources will include information on incident distribution, near misses, unsafe conditions and ways to reduce patient safety risk and harm across health systems.”

Read the announcement

Today's News and Commentary

About pharma

European Commission Approves Opioid Dependence Implant: The headline says it all. When will it become available in the US?

Read the story

Israeli researchers discover immune mechanism that fights obesity: Fascinating research about lipid-associated macrophages and their immune mechanism role in obesity. The gene for activation of the immune mechanism is also explained. It will be a while before a medication is available that takes advantage of this pathway.

Read the article

Future is in doubt for cheaper versions of biologic drugs: “Last year, the U.S. spent $126 billion on biologic drugs, only 2% of it on biosimilars…” Why haven’t the biosimilars made more of an impact as they have in Europe and elsewhere?

Read the article for an explanation

About the public’s health

Five things found in the FDA’s hidden device database: As previously reported, the FDA recently dismantled its hidden reporting system for malfunctioning medical devices. This article explains five significant public safety issues that this system covered up.

Read the article

Health panel: Millions of US kids should get hepatitis shot: On the heels of yesterday’s HPV recommendation, the Advisory Committee on Immunization Practices recommended hepatitis A shots should be given to older children who weren’t vaccinated earlier, including 14- to 18-year-olds who turned 1 before the recommendation was made” 13 years ago.

Read the announcement

Evaluation of USPSTF Lung Cancer Screening Guidelines Among African American Adult Smokers: It took healthcare organizations many years to get lung cancer screening recommendations “right.” Early attempts did not alter mortality rates and, when more sensitive technology became available, the number of false positives was excessive. Now that the recommendations seem more reasonable, research found that they are too conservative when applied to African American smokers.

Read the research

About health insurance

Out-of-pocket costs increased across all healthcare in 2018: The article reports on a TransUnion Healthcare study reported at this year’s HFMA annual meeting. “Patients experienced out-of-pocket increases as high as 12% for their healthcare costs last year… Specifically, inpatient care costs between 2017 and 2018 went up an average of $573 per person, and outpatient costs went up an average of $119. ED costs went up an average of $40 per person.”

Read about the study

Health Care Gets Heated On Night 2 Of The Democratic Presidential Debate: On the second night of Democratic candidate debates Senators Sanders and Harris said they would abolish private insurance and all participants said they would make health insurance available to all immigrants. The arguments were over how to role out universal insurance availability.

Read a summary

About healthcare IT

The Most Googled Medical Symptoms by State: This study by eligibility.com found that nationally, 89% of patients Google their health symptoms before going to their doctor. But the subject of the search is very state specific. This article provides a map of the US and the most frequent inquiries. Yes, all healthcare is local.

Read the article

Medtronic recalls some insulin pumps as FDA warns they can be hacked: This article is a reminder about the vulnerability of “peripherals” to hacking.

Read the story

Providence St. Joseph Health acquires Epic IT solutions consultant Bluetree: Yet another case of cross-sector linkups in healthcare. “With the addition of Bluetree, the Renton, Washington-based health system now has two of the top EHR solutions companies in the country. It also owns Engage, which has grown to become one of the largest Meditech solution companies in the United States, according to the health system.”

Read the story


Today's News and Commentary

About health insurance

Democrats clash over ‘Medicare for all’ in first debate: Read about and listen to what the first 10 Democratic candidates had to say about healthcare last night. Only Warren and deBlasio favored total abolition of private health insurance.

Read and listen to the opinions

The Medical Hospital Readmission Reduction Program.Does It Do Any Good?: This editorial reviews two research papers analyzing the effect of Medicare’s Hospital Readmission Reduction Program. The “bottom line” is that the methodologies overstated the reductions attributed to the program. However, the mortality rate did decrease after implementation.

Read the paper

Appellate court raises potential new threat to ACA: “The U.S. Court of Appeals for the 5th Circuit, which is scheduled to begin hearing oral arguments about the constitutionality of the law on July 9, said it needed more information as to whether the House and Democratic states had standing to intervene in the lawsuit and whether their interventions were timely.”

Read the story

CMS approves 'Netflix' model for hepatitis C drugs in Louisiana's Medicaid program: As previously reported, Louisiana (and subsequently other states) proposed a prepaid model to cover costs for Hepatitis C drugs for which the state was responsible. The measure required CMS approval which was just granted.

Read the story

Senate Health Committee advances bipartisan package to lower health costs: The previously reported bipartisan bill to lower healthcare costs passed the Senate Health Committee. Senators Sanders, Warren and Paul voted against the measure (all for different reasons). The bill would also raise the age for tobacco use from 18 to 21.

Read the story

About the public’s health

Trump signs pandemic preparedness bill into law: The headline speaks for itself.

Read the announcement

CDC walks back pneumonia vaccine recommendation for seniors: The CDC says administration of Prevnar 13 should not be a blanket recommendation for those over 65 years old. Instead, it should be an individual decision between patient and physician.

Read the story

France loses landmark court case over air pollution: A mother and daughter successfully sued the French government over the adverse health effects of air pollution in the Paris area. I am surprised trial lawyers have not thought about this strategy in this country.

Read the story

CDC panel recommends HPV vaccine for men through age 26 and for some older adults: Citing its effectiveness, the CDC recommends extension of the ages for which HPV vaccination may be appropriate.

Read the story
Also see the Lancet research that underpins the recommendation

Overdose Deaths Likely to Fall for First Time Since 1990: The headline is self-explanatory. It appears the reason for the fall is many different types of state-initiated programs.

Read the story (Wall Street Journal. This article may require a subscription)

About healthcare IT

Google and the University of Chicago Are Sued Over Data Sharing: “On Wednesday, the University of Chicago, the medical center and Google were sued in a potential class-action lawsuit accusing the hospital of sharing hundreds of thousands of patients’ records with the technology giant without stripping identifiable date stamps or doctor’s notes.”

Read the story (NY Times but appears to be open access)

Pressure builds to secure health care data: This article reviews current Congressional efforts to protect patient data as more breeches occur and more types of devices exist as portals for hacking.

Read the story

About pharma

Drug shortages and labor costs: This study by Vizient calculates hospitals’ labor costs to deal with drug shortages as at least $359 million per year, or 8.6 million additional personnel hours.

Read the report

Today's News and Commentary

About health insurance

Policy advisers urge continued Medicare 'squeeze' of hospital pay: This brief report from a Brookings conference quotes policy experts who advocate for lower Medicare hospital payments, claiming that financial stress will result in more efficiency.

Read the story

When Patients Can’t Pay, Many Hospitals Are Suing: This Wall Street Journal article looks into the human side of a research study in JAMA that found nonprofit hospitals more aggressively go after patient balances than do for-profits.

Read the story (requires subscription)

Judge rejects effort to block suit claiming Medi-Cal discriminates against Latinos: A California judge is allowing a lawsuit to proceed that challenges the state’s low Medicaid payments. The claim is not that it hurts hospitals but creates a barrier to care for low-income people, particularly Latinos. The issue of adequacy of Medicaid payments is a national concern. At one time, the federal government had a law mandating adequacy of Medicaid payments (the “Boren Amendment”), but it was repealed long ago.

Read the story

About healthcare IT

Car-award conferrer J.D. Power sets eyes on telehealth business: The rating service famous for its auto satisfaction studies announced it will start grading telehealth businesses. While you have the freedom to buy any car (considering finances), often your telehealth service is linked to your insurer or provider organization. It would still be nice to know how “your” plan stacks up.

Read the story

UnitedHealth buys PatientsLikeMe, which faced Trump administration scrutiny over Chinese investor: “PatientsLikeMe provides an online service that helps patients find people with similar health conditions.” The company needed to find a new owner because of federal restrictions on Chinese investor ownership. This condition-based social network will also be a way for United to track its members behavior. Too much information for the payer?

Read the story

What the U.S. Medical System Can Learn From Estonia: Estonia has had leading healthcare IT systems for a while. This article briefly explains how this interoperable system works. Two key elements are a universal patient identifier and blockchain artcitecture.

Read the story

Patients with complex chronic conditions: Health care use and clinical events associated with access to a patient portal: In this study of patients with diabetes and related complications, the authors found that access “to a patient portal can increase engagement in outpatient visits, potentially addressing unmet clinical needs, and reduce downstream health events that lead to emergency and hospital care, particularly among patients with multiple complex conditions.”

Read the research

About the public’s health

Humanwide: A Comprehensive Data Base for Precision Health in Primary Care: This approach to personalized care from Stanford provides “patients with genetic screening, wearable sensors, health assessment, and wellness coaching. We synthesized patient-level biometric, genetic, social, environmental, and behavioral data into the electronic health record for primary care teams’ use in building individual care plans.”

Read the story

About pharma

Stem cell treatments are being regulated like pharmaceuticals. Their use has resulted in many complications as well as benefits. Two related articles present the downsides. Yesterday, Florida Judge Ursula Ungaro issued an injunction preventing U.S. Stem Cell Clinic “from selling a scientifically unproven procedure that uses patients’ fat to create a stem cell treatment.” Four people were blinded apparently as the result of such treatments. The other article was a research study looking at competencies of physicians who provide stem cell treatments [subscription required]. The authors found that only “13 companies (19%) that marketed stem cells for nonorthopedic indications had physicians practicing within their scope of training.”

Gov. Mills signs 4 bills to reduce medication prices, including buying from Canada: Maine has joined Florida with a state-initiated program to allow purchase of drugs from Canada. As with Florida, the state must get a federal waiver to legally carry out the program.

Read the story

Today's News and Commentary

About health insurance

Trump administration plans to require hospitals to list 'shoppable' prices: Yesterday President Trump issued an executive order to make healthcare prices more transparent. Among its provisions is for HHS to come up with a proposal for providers and insurers to let patients know what their out of pocket expenses will be before treatment. The rules would not start until, at soonest, 90 days. The real impact will not be on patients’ choice of care based on cost, there is ample evidence that such an impact is small. Instead, the “big reveal” will be differences in how much different payers pay providers; in effect, no more confidential pricing agreements.

Read the story
For a “deeper dive” read the Washington Post story

Employers’ top health care priority: offer choice and decision support tools to meet employees’ diverse benefit needs: This survey from WillisTowersWatson found that “over the next three years, three-in-four employers (75%) are prioritizing efforts to provide employees with the tools they need to make smart benefit choices and personalize a benefit package that best suits their situation. Today, just over half of employers (55%) provide benefit decision tools.” While customization is apparently good, It does add to the administrative costs. Employees should be able to make that tradeoff as well.

Read the study

About pharma

AbbVie buying Allergan for $63 billion: This purchase is today’s biggest business story.

Read the article

Today's News and Commentary

About pharma

Key Trump proposal to lower drug prices takes step forward: In October, President Trump floated the idea of linking drug prices to an international index. Last week, Senate Finance Committee Chairman Grassley (R-Iowa) expressed his oppotion to that proposal. On Friday, HHS Secretary Azar sent the White House an indexing plan. We will see if Sen. Grassley changes his mind about the scheme.

Read the story

Ingredient CBD Could One Day Become an Antibiotic: The headline speaks for itself. The article indicates promising results.

Read the article

The top 10 drug launches of 2019: This article is FYI and has details about each drug.

Read the story


About healthcare IT

Medication lists generated by EHRs lack accuracy: Although this study was for ophthalmology, it highlights the need to double check patient information.

Read the story

About healthcare quality and safety

MedPAC Seeks Changes to Medicare Advantage, Star Ratings Metrics: CMS rates Medicare Advantage plans using a star system based on the insurer’s service area. MedPAC is recommending the evaluations be based on local market measurements that are “prospectively set” in “five major, assessable domains of healthcare set on a scale from 0 to 10. Each domain contributes 20 percent to the final score…The commission offered the following as major indications of quality: avoidable hospitalizations, avoidable emergency department (ED) visits, readmissions, patient experience, and patient-reported outcomes.” It is up to CMS to accept or reject these recommendations.

Read the story

Update on FDA device reporting: As previously reported, the FDA is shutting down its Alternative Summary Reporting program that allowed manufacturers to report product malfunctions and avoid public scrutiny. It is replacing this system with “The National Evaluation System for health Technology (NEST), which uses data from patient registries, Medicare claims, and electronic health records, is meant to provide critical information for assessing the safety and effectiveness of medical devices using real-world evidence.”

Hospital Readmission Rates in Medicare Advantage and Traditional Medicare: A Retrospective Population-Based Analysis: Policy makers are always looking at difference between traditional Medicare and Medicare Advantage to promote a particular viewpoint. This study concluded that: “The HEDIS data underreported hospital admissions for 3 common medical conditions [heart attack, heart failure, and pneumonia] and readmission rates were higher among patients with underreported admissions. Medicare Advantage beneficiaries had higher risk-adjusted 30-day readmission rates than traditional Medicare beneficiaries.” The debate about which system is better will continue as “Medicare for all” proposals are still on the table.

Read the abstract

About health insurance

CMS Defines New Medicaid Integrity Guidelines:Based on a report from its Office of Inspector General (OIG), CMS is claiming that it overpaid states $1 billion because they are not accurately following Medicaid eligibility criteria. This article describes what is happening and what CMS seeks to do.

Read the article

Supreme Court agrees to hear insurers' cases seeking billions in ACA risk corridor payments: Risk corder payments were instituted to protect insurers from downside risk in the first few years of the ACA. Many lost money but the government did not pay them. The reason was that the program was legislated to be budget neutral and there weren’t enough profitable plans to come up with money for those losses. Now the Supreme Court has decided to hear a combination of 3 suits claiming $12 billion in lost payments.

Read the story

Now Trump says he meant to keep Obamacare. Say what?:In an NBC interview yesterday, President Trump says he saved the ACA despite its flaws and made it as good as it can get. Guess he forgot the failed Republican attempt at repeal in 2017 (remember how angry he got at the late Senator McCain for casting the deciding vote) and the Justice Department’s siding with the Texas court decision on appeal to declare the ACA invalid.

Read the story

Today's News and Commentary

Because of technical difficulties in sending yesterday’s blog, start here for Friday, June 21.

About the public’s health

Food Farmacy focuses on keeping patients healthy: The Presbyterian Community Health Resource Center in Albuquerque, N.M. is providing “fresh produce, dairy, dry goods and nutritious food to help patients live healthier lives.”
”’This Food Farmacy is for people who are food insecure and they're referred by a Presbyterian provider to access the Food Farmacy,’ said Leigh Caswell, Presbyterian’s vice president for community health. She says after a patient is referred to the Food Farmacy they can visit once a week for 6 months and chose up to 15 pounds of food for free. That equals about 10 to 12 meals.”
Read the story

Another cancer-causing chemical found in widely used blood-pressure pills: The blood pressure, heart failure drug valsartan was plagued by a carcinogenic contaminant (nitrosodimethylamine) earlier this year (see previous posts). Now a new contaminant, dimethylformamide, has been found.

Read the story

AHIP Launches Project Link to Address Social Determinants: The trade group for health insurers has announced its own plan, called Project Link, that will address Social Determinants of Health. Rather than duplicate local efforts it appears to be a resource for payers.

Read about the project

Appeals court lets Title X 'gag rule' go into effect, allows Trump family planning restrictions: “The final rule released in February revises regulations around the Title X family planning program to block funding to groups that provide abortion referrals.” The implementation of the rule has been on hold pending legal challenges. The 9th U.S. Circuit Court of Appeals (San Francisco) said the rule can go forth pending the litigation.

Read the story

About health insurance

Moody's: Surprise billing solutions will hurt hospitals: This report from Moody’s highlights the fact that many hospitals count on out of network (that is, higher) payments for their financial viability. If the Congressional and state-specific proposals go through, they would be paid at closer to in-network rates.

Read the story

Trump to issue executive order seeking transparency on healthcare costs: Monday may be the day the President issues an executive order requiring healthcare providers and insurers to reveal their costs.

Read the story

The Potential Implications of Texas v. United States: How Would Repeal of the ACA Change the Likelihood That People With Different Characteristics Would Be Uninsured? This study from the Urban Institute found that “increases in uninsurance would be most heavily concentrated among people with the lowest incomes (below 200 percent of the federal poverty level), young adults, families with at least one full-time worker, and residents of the South and West. These subpopulations of the United States have experienced the largest gains in insurance coverage under the ACA and consequently would be hit the hardest if the law were repealed.”

Read the research

About healthcare IT

The Patient Customer Journey: Healthcare SEO Trends from Infants to Elder Care: Where do patients get their information? Apparently there is no single site that is the “go to” source.

Read the article

BLOG FOR THURSDAY, JUNE 20

About the public’s health

Doctors increasingly use PDMPs, but opioid impact still rising: States have implemented prescription drug monitoring programs [PDMPs] to reduce opioid use and deaths. While such prescriptions decreased 33 percent between 2013 and 2018, mortality rates have not fallen. Are we targeting the wrong providers or patients?

Read the story

Trump's climate rule rollback could undermine public health: The relaxing emission standards for coal fired plants will not only harm the climate but is dangerous to the public’s health. The article references a 2015 paper by Harvard researcher Jonathan Buonocore and colleagues that “estimated 10 more premature deaths per year under an approach similar to the [new] Affordable Clean Energy rule but 3,500 fewer premature deaths annually under an approach similar to the Clean Power Plan [current plan].”

Read the article(Washington Post but open access)

About healthcare IT

FCC to vote next month on $100M telehealth pilot program:
”At its July Open Commission Meeting, the FCC will vote on a notice of proposed rulemaking seeking comment on:

  • Budgeting for $100 million in USF support for providers to offset the qualifying costs of connected care services for low-income patients, including people in medically underserved areas and veterans.

  • Targeting support for innovative pilot projects to respond to a variety of health challenges, including diabetes management, opioid dependency, high-risk pregnancies, pediatric heart disease and cancer.

  • Providing an 85 percent discount on qualifying services for a three-year period with controls in place to measure and verify the benefits costs, and savings associated with connected care technologies.

  • Collecting relevant data to enable stakeholders to better understand the impact of telehealth and consider broader reforms that can support the trend toward connected care.”

Read the story

Blockchain network looks to advance use cases in early 2020: “The Blockchain Health Utility Network was formed in January by IBM, Aetna, Anthem, Health Care Service Corp. and PNC. In February, Cigna and Sentara Healthcare joined the network.” This group is looking for case studies to illustrate how the architecture can be used in healthcare setting.

Read the article

Wellcome Global Monitor: How does the world feel about science and health?: Here is the study cited yesterday with regard to beliefs in vaccines (starts on page 106).

Read the report

About health insurance

Medicare Overpaid for Radiation Treatments, IG Reports: The HHS Inspector General “reviewed nearly $577 million in Medicare payments to three-dimensional conformal radiation therapy treatment plans between fiscal 2008 and 2017” and found more than $125 million went in unnecessary payments to hospitals for the same treatment—in part because the additional payments were billed on separate days.” The IG recommended global rates and billing for radiation therapy to avoid such problems.
The private sector has used this method for decades.

Read the story

Employers Are Steering Workers Toward Controversial Stem Cell Therapies: In order to save money on such expensive procedures as knee replacements, many employers are first sending employees to stem cell clinics to be evaluated for treatments that are largely unproven.

Read the story

Sen. Alexander Details His Plan To Fix Surprise Medical Bills: Yesterday, Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) formally announced their plan to address surprise medical bills. The crux of the proposal is that when a patient is seen by a doctor who isn’t in their network their insurance would pay the “median in-network rate.” Expect pushback from hospital- based physician groups.

Read the story

Medical cost trend: Behind the numbers 2020: This annual report from PwC says the healthcare cost trend is up slightly from the past couple years; the reason is price increases (as opposed to volume). In those price increases are increased technology, like biologics in the pharma space. To combat these costs, the paper explains a number of measures employers are using without resorting to increased cost sharing, e.g., "negotiating contract prices themselves, setting up provider networks and even building a parallel health system to take care of employees at more manageable costs.”

Read the report

Global Efforts to Cut Smoking Show Mixed Results: As the headline implies, while progress has been seen in some countries (like the US) other countries are showing increases in tobacco use. One incredible statistic: “About 2.5 million metric tons (MMT) of cigarettes were smoked in China in 2013, more than Russia (0.36 MMT), the United States (0.28 MMT), Indonesia (0.28 MMT), Japan (0.20 MMT), and the next 35 highest consuming countries combined.” The data is a bit old (as is unfortunately common in healthcare) but the trends are current.

Read the article

About heath insurance

The health plan that people recommend most: This story is FYI. The answer raised by the headline is Kaiser (for the 9th year in a row). The next question is “why?”

Read the announcement

Today's News and Commentary

About healthcare IT

From security at the perimeter to security at every interaction: This article is a great overview of security architecture and how it needs to change to keep up with the increase in apps.

Read the article

GAO: CMS needs to change its ID verification process: As previously reported, the Government Accountability Office is worried about HHS’s IT systems. A further concern is CMS’s ID verification process for healthcare.gov (for example, where ACA enrollment can be accessed). “While the agency employs a two-step email verification process to reduce the risks associated with knowledge-based verification, auditors contend that this process confirms only the email address that was used to create the account, but it does not confirm the identity of the individual who is applying for the account.”

Read the article

4 problems industry groups have with the ONC's Trusted Exchange Framework: The Trusted Exchange Framework and Common Agreement (TEFCA) is supposed to be the “onramp” for interoperability of healthcare data exchange. This article summarizes the problems industry groups have with TEFCA as it currently exists.

Read the story

About health insurance

A Targeted Affordability Improvement Proposal: The Potential Effects of Two Nongroup Insurance Reforms Designed to Increase Affordability and Reduce Costs: This paper from the Urban Institute proposes two reforms to the ACA. “The first policy would either introduce a public insurance option offering ACA compliant coverage in the nongroup market or cap private nongroup insurers’ provider payment rates at levels based on those used in the Medicare program. The second policy would extend the ACA’s premium tax credits to eligible people with incomes above 400 percent of the federal poverty level; today, no one with income above this level is eligible for those credits.” If both recommendations were implemented, the government could save $12 billion in 2020, total household spending would decrease by $9.2 billion and average premiums would be $200 per month cheaper for those at 400% or more of the poverty level. 

Read the proposal

Key Drivers Behind Continued Medicare Advantage Penetration:This thought piece from LEK consulting not only discusses the drivers behind Medicare Advantage growth but also predicts that predicts that its market penetration could grow from about 35% now to 60-70% between 2030 and 2040.

Read the analysis

About the public’s health

Maine becomes latest state to legalize physician aid-in-dying; AMA continues opposition: While the headline is self-explanatory, one interesting feature is naming this process: “physician aid-in-dying.” It used to be called physician-assisted suicide.

Read the story

About pharma

Low prices of some lifesaving drugs make them impossible to get: Sometimes very affordable off-patent drugs are not available because the profit margin is so low. If manufacturers raise prices significantly, competitors will enter the field and drive prices down again. Consider that if the government is involved in price lowering, should it also be involved in price increases to assure medication availability?

Read the story (Washington Post, but appears to be open access)

Poorer countries have more confidence in vaccines: This article is a fascinating cultural study from the Wellcome charity. The percent of populations who thought vaccines were safe are: 92% in east Africa, 95% in south Asia, 59% in western Europe, and 50 % in eastern Europe. The research names France as the most “skeptical” country, “ where only 47 per cent agreed that vaccines were safe — a level that varies little with education, age, gender, urban or rural status and even whether the respondents have children. Thirty-three per cent said they were not safe and the rest were unsure.”

Read the article(Financial Times, subscription required)

About hospitals

Pediatric powerhouse? Big hospital merger shelved between University of Minnesota, Children's Minnesota: Different names, same issues. These two institutions did not merge because of “reported differences over control, medical staffing and finances.” Recall the Stanford and UCSF merger?

Read the story

Today's News and Commentary

About health insurance

MedPAC: End 'Incident To' Billing for NPs, PAs: This article summarizes three recommendations in MedPAC’s latest report to Congress for Medicare payments. First is elimination of the “incident to” care for NPs an PAs. Currently, if they are working under direct care plans of a supervising physician, they use the MD’s provider number and can bill at 100% of Medicare eligible charges. If working independently, even if employed by a physician, they can only bill at 80% of allowable charges. Second is the recommendation to closely scrutinize ER bills, which have shown a dramatic upcoding. Finally, there would be no physician payment update for 2020, as per existing law.

Read the article

Texas hospitals applaud new bill to end surprise billing: As Congress debates what to do with surprise billing, states are taking their own actions. The latest is Texas where a new law, backed by the Texas Hospital Association (THA), " calls for an arbitration system for health plans and hospitals to come to a mutually acceptable payment amount without putting patients in the center of the dispute.”

Read the story

Performance in the Medicare Shared Savings Program [MSSP] After Accounting for Nonrandom Exit: An Instrumental Variable Analysis: Performance evaluations of the MSSP has been complicated by the variety of participants. This study “compared MSSP ACO participants versus control beneficiaries using adjusted longitudinal models that accounted for secular trends, market factors, and beneficiary characteristics.” The results are that the savings CMS claims are higher than should be reported. The researchers conclude:  “After adjustment for clinicians' nonrandom exit, the MSSP was not associated with improvements in spending or quality. Selection effects—including exit of high-cost clinicians—may drive estimates of savings in the MSSP.”

Read the abstract

Comparison of Hospitals Affiliated With PPS-Exempt Cancer Centers, Other Hospitals Affiliated With NCI-Designated Cancer Centers, and Other Hospitals That Provide Cancer Care: The Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 mandated a phasing-in of DRG payments to hospitals for Medicare inpatient services. However, certain oncology hospitals were specifically named for being exempt from the DRG methodology. The theory was that they had special expertise entitling them to higher payments. This research compares those hospitals to non-exempt institutions and finds “generally similar hospital characteristics, patient comorbidity burden, and cancer surgery outcomes.” The results raise the question “ why some cancer centers are designated as PPS-exempt and why most hospitals are not required to publicly report cancer-specific quality metrics.”

Read the abstract

Pelosi: Dems will 'fight relentlessly' against Trump's ObamaCare repeal attempts: Although we don’t yet know what the new Trump healthcare proposal looks like, Speaker Pelosi vowed to fight attempts at repealing the ACA.

Read the story


About hospitals

U.S. News & World Report Hospital Rankings & Ratings: Just FYI that the latest rankings are out.

Read the lists

About healthcare IT

Health plans to go digital with HEDIS, expert says: NCQA announced that the HEDIS quality data will be “going digital.” The article points out that large health plans who are not used to collecting data in this fashion may be at a significant disadvantage.

Read the article

Robocalls are overwhelming hospitals and patients, threatening a new kind of health crisis: Robocalls are bad enough at home. Now they are clogging phone lines at hospitals, potentially preventing important calls from getting through. For example, at “Tufts Medical Center, administrators registered more than 4,500 calls between about 9:30 and 11:30 a.m. on April 30, 2018…” Congress is considering options but the blocking technology needs to keep up with the spammers. No end in sight.

Read the story (Washington Post, but appears to be open access)

CMS rule would streamline prior authorizations for e-prescribing: One part of e-prescribing that slows down the process is getting prior authorization. Now CMS has issued a proposed rule that would add standards to expedite this task- including completion of prior authorization online as part of the prescribing process. Comments are due by August 16.

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Online mental health predictive software: Two articles look at how patterns of online entries can help healthcare professionals predict behavioral crises. The first article from the NY Times discusses a program in California whereby “state and county mental health officials, along with patient representatives, have met regularly with behavioral health companies Mindstrong and 7 Cups…to test smartphone apps for people receiving care through the state’s public mental health system.” The second article is from PLOS ONE and looks at “Evaluating the predictability of medical conditions from social media posts,” especially Facebook. In addition to behavioral health, diabetes was also accurately predicted. Both initiatives have shown success and were implemented with patient permission.

FDA Clears Smartphone-Controlled Medical Device to Treat Migraine: Smartphone apps usually take patient inputs and do something with them. This one takes input from the smartphone and uses it for “remote electrical neuromodulation for the acute treatment of migraine.”

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About the public’s health

Vaccine Injury Claims Are Few and Far Between: The National Vaccine Injury Compensation Program was established in 1988 as a no-fault system from which injured parties could obtain compensation. The Program was established because pharma companies were leaving the vaccine business due to real fears about lawsuits in, what was then, a low-margin business. The government intervened as a public health measure to ensure vaccine availability. A portion of each vaccination’s sale goes to fund the Program. This story is relevant now because of the reluctance of some to get their children vaccinated. According to the article, which pulled data from the Program, over “roughly the past dozen years in the United States, people have received about 126 million doses of vaccines against measles… and killed 400 to 500 people each year. During that period, 284 people filed claims of harm from those immunizations through a federal program created to compensate people injured by vaccines. Of those claims, about half were dismissed, while 143 were compensated.” Read the article for information about other vaccines.

Read the article (NY Times but appears to be open access)

Physician and Patient Characteristics Associated With More Intensive End-of-Life Care: Choice of medical surrogacy can influence care patterns. In this study on end of life care, terminally ill patients who delegated decisions to their physicians were more likely to receive aggressive treatments in the weeks before they died. The authors call for greater “research, clinical, and policy attention to patient treatment preferences and physician comfort with medical paternalism might lead to improvements in care of patients with advanced disease.”

Read the study
Read a summary (the original paper has abstract-only access)

Disaggregating Hispanic American cancer mortality burden by detailed ethnicity: Viewing hispanics as a single group is counterproductive in healthcare (and other fields). This article highlights that fact by looking at differences in cancer epidemiology. For example, Mexican American and Puerto Rican American males had twice the mortality rate of non-Hispanic whites from stomach and liver cancers. Cuban-Americans had the same rate of those cancers as non-Hispanic whites but a higher rate of lung cancer than other Hispanic groups.

Read the research
Read a summary (Original has abstract only without subscription)

About pharma

Pfizer bulks up in oncology with $11.4-billion deal to buy Array BioPharma: This story is FYI. It is newsworthy for the size of the deal and Pfizer’s strategy to enhance its oncology business.

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Today's News and Commentary

About pharma

U.S. drugmakers file lawsuit against requiring drug prices in TV ads: As previously reported, the federal government is requiring pharma companies to present their drugs’ prices in ads. On Friday, Amgen Inc, Merck & Co, Eli Lilly and Co and the Association Of National Advertisers filed a lawsuit against this requirement in the U.S. district court for the district of Columbia. The plaintiffs content the regulations are a violation of free speech. Stay tuned. The principles involved could have a profound effect on advertising and the government’s desire for transparency.

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The top 20 drugs by 2018 U.S. sales: This article is more of a FYI. The top seller, by far, was Humira. It does not have to worry about a US biosimilar until 2023.

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Allscripts acquires prescription drug startup ZappRx: Another example of a cross-sector purchase in health care. The IT company Allscripts purchased specialty drug prescribing startup ZappRx. The link is Allscript’s subsidiary Veradigm, described as “an integrated data systems and services company that delivers superior data-driven insights to improve the efficiency, value, and quality of healthcare delivery.” Specifically, the functionality is to get into the e-prescribing space.

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Bluebird bio prices beta thalassaemia gene therapy Zynteglo at 1.575 million euros over five years: Other than being the second most expensive medication, this story is noteworthy to emphasize the continuing trend of value-based payments. Payment will be based on “a five-year installment plan… 315 000 euros ($354 000) to be paid up front and additional annual payments due only if the treatment continues to be effective, for a total of 1.575 million euros ($1.8 million).”

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Aerosol chemo may treat stomach cancer: Chemotherapy has been administered through infusions or pills. This new method raises the promise of yet another route of administration.

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About health insurance

Trump touts administration's expansion of HRAs as win for small business: I reported this story last week, but this article is another reminder of a plan that could disrupt the marketplace. One twist I should emphasize is that these payments can be used to pay for non-qualified plans under the ACA.

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Florida ‘Patient Savings Act’ adds financial incentive to transparency tools: This article is a nice summary of some healthcare innovations in Florida (such as telemedicine). Its focus is on a new law that “directs health insurers who choose to offer such a program to develop a website outlining the range of ‘shoppable’ health care services available to clients…. When a consumer obtains a ‘shoppable’ healthcare service for less than the average listed price, the new law requires the savings [no less than 25%] to be shared by the health insurer and the insured.”

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Humana asked experts to define 'value-based care.' They couldn't do it: Definitions drive actions. Humana convened a panel of healthcare experts to define some important and commonly-used terms. Although “the participants could find common ground on what ‘value-based payment’ is, they couldn't agree when it came to ‘value-based care’ or ‘population health."‘“ How do we know if we have achieved something if we can’t define it?

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Trump says he will roll out new health care plan in next couple of months: While this announcement was made yesterday, President Trump previously mentioned this initiative for the 2020 campaign. No details are yet available and the broad range of possibilities make speculation fruitless at this time.

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Top Trump health official warned against controversial ObamaCare changes in private memo: In a just- released confidential memo from August of 2018, CMS Administrator Verma warned the Trump administration of the disruptive consequences of changes eventually made to the ACA. So the White house either did not believe her analysis or made the changes, knowing it would make the ACA look dysfunctional. Perhaps it was to bolster the upcoming Trump proposal (see above)?

Read the story (and click the link to the memo)

About healthcare IT

AMA policy aims to ensure doctors have a role as AI gains traction: At its annual meeting last week, the AMA developed policies to help physicians deal with Artificial Intelligence (AI). Measures include educational programs on how to use and evaluate AI, a call for accreditation and licensing, and evaluations on outcomes of its use.

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Variation in Physicians’ Electronic Health Record [EHR] Documentation and Potential Patient Harm from That Variation: EHRs were supposed to standardize data gathering to make analysis easier. This study, however shows that there are important, statistically significant variations in the documentation. Specifically: “Five clinical documentation categories had substantial and statistically significant (p < 0.001) variation at the physician level after accounting for state, organization, and practice levels: (1) discussing results…; (2) assessment and diagnosis…; (3) problem list…; (4) review of systems…; and (5) social history…. Drivers of variation from interviews included user preferences and EHR designs with multiple places to record similar information. Variation was perceived to create documentation inefficiencies and risk patient harm due to missed or misinterpreted information.” The article discusses mitigation strategies.

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Senate privacy bill aims to set new federal standard for consumer health apps: “Sens. Amy Klobuchar (D-Minn.) and Lisa Murkowski (R-Alaska) have introduced a bill that would create new privacy regulations protecting consumer health data collected through health tracking apps, fitness wearables and direct-to-consumer DNA testing kits.” Consumer health data is not HIPAA protected so these measures are needed, especially in light of recent leaks.

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OIG found cybersecurity gaps in NIH's All of Us precision medicine research project: The NIH-sponsored project, called All of Us, aims to gather very large amounts of genetic data for research purposes. The Office of the Inspector General (OIG) of HHS “reviewed information system general controls at two of the seven components of the All of Us program: the Participant Technology Systems Center (PTSC), awarded to Vibrent Health, and the Data and Research Center, awarded to Vanderbilt University Medical Center. These controls included security plans, access controls, information protection and system maintenance, audit logging, data and physical security, incident response, and disaster recovery. The PTSC did not have adequate controls to protect All of Us participants’ sensitive data. NIH did not adequately monitor the PTSC to ensure that the PTSC had implemented adequate cybersecurity controls to protect the participants’ sensitive data. Based on the results of our penetration testing at the PTSC, we identified vulnerabilities that could expose personally identifiable information, including personal health information of the All of Us participants, and allow access to their data.”

Read the summary of the report