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CMS announces ‘Rural Health Strategy’

FierceHealthcare reports:

“The Centers for Medicare & Medicaid Services launched its first “Rural Health Strategy” on May 8—an effort, officials said, to better consider the rural impact as part of the of the agency’s work.

“The strategy, which highlights tactics such as improving access to telemedicine, is meant to avoid unintended consequences of policy and program implementation in rural health settings, officials said.”

To read the whole article, please hit this link.


CMS rejects lifetime caps on Medicaid

By PHIL GALEWITZ

For Kaiser Health News

The Trump administration’s promise of unprecedented flexibility to states in running their Medicaid programs hit its limit Monday, May 7.

The Centers for Medicare & Medicaid Services rejected a proposal from Kansas to place a three-year lifetime cap on some adult Medicaid enrollees. Since Medicaid began in 1965, no state has restricted how long beneficiaries could remain in the entitlement program.

“We seek to create a pathway out of poverty, but we also understand that people’s circumstances change, and we must ensure that our programs are sustainable and available to them when they need and qualify for them,” CMS Administrator Seema Verma said  at an American Hospital Association meeting in Washington, D.C.

Arizona, Utah, Maine and Wisconsin have also requested lifetime limits on Medicaid.

This marked the first time the Trump administration has rejected a state’s Medicaid waiver request regarding who is eligible for the program.

Critics of time limits, who say such a change would unfairly burden people who struggle financially throughout their lives, cheered the decision.

“This is good news,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families, a Medicaid advocate. “This was a bridge too far for this CMS.”

Alker’s enthusiasm, though, was tempered because Verma did not also reject Kansas’ effort to place work requirements on some adult enrollees. That decision is still pending.SIGN UP

CMS has approved work requirements for adults in four states — the latest, New Hampshire, winning approval Monday. The other states are Kentucky, Indiana and Arkansas.

All these states expanded Medicaid under the Affordable Care Act to cover everyone with incomes of more than 138 percent of the federal poverty level ($16,753 for an individual). The work requirements would apply only to adults added through that ACA expansion.

Kansas and a handful of states, including Alabama and Mississippi, that did not expand the program want to add the work requirement for some of their adult enrollees, many of whom have incomes well below the poverty level. In Kansas, an individual qualifying for Medicaid can earn no more than $4,600.

Adding work requirements to Medicaid has also been controversial. The National Health Law Program, an advocacy group, has filed suit against CMS and Kentucky to block the work requirement from taking effect, saying it violates federal law.

The Kansas proposal would have imposed a cumulative three-year maximum benefit only on Medicaid recipients deemed able to work. It would have applied to about 12,000 low-income parents who make up a tiny fraction of the 400,000 Kansans who receive Medicaid.

Kansas Gov. Jeff Colyer, a Republican, responded to the announcement saying state officials decided in April to no longer pursue the lifetime limits after CMS indicated it would not be approved.

“While we will not be moving forward with lifetime caps, we are pleased that the Administration has been supportive of our efforts to include a work requirement in the [Medicaid] waiver,” Colyer said. “This important provision will help improve outcomes and ensure that Kansans are empowered to achieve self-sufficiency.”

Eliot Fishman, senior director of health policy for the advocacy group Families USA, applauded Verma’s decision.

“The decision on the Kansas time limits proposal that Seema Verma announced today is the right one. CMS should apply this precedent to all state requests to impose time limits on any group of people who get health coverage through Medicaid — including adults who are covered through Medicaid expansion,” he said. “Time limits in Medicaid are bad law and bad policy, harming people who rely on the program for lifesaving health care.”


Value-based care worsens physician burnout, and what to do about it

 


Duke’s simple survey said to improve patient satisfaction

 

Fierce Healthcare reports:

“A simple, one-page survey developed by Duke Health has helped improve patient satisfaction with doctor visits.

“The form, given to patients ahead of their doctor visit, asks them to list three concerns they want to discuss with their physician and asks them for feedback at the conclusion of the visit.

“The form, tested with over 14,000 patients seen by a dozen doctors at the Duke Spine Center outpatient practice, improved patient satisfaction with the care they received, according to a study published in  the journal Neurosurgery.

“The survey improved communication between doctors and patients and also allowed for real-time feedback. At the end of the visit, the survey asks patients if all their questions were addressed and if they were satisfied, giving doctors immediate feedback on how well they addressed patients’ needs. The form also includes an open-ended question that asks how the clinic could better support patient care.”

To read more, please hit this link.

 

 


Jay Hancock: The popping of the proton-beam bubble

 

Proton-beam equipment at the Mayo Clinic, in Rochester, N.Y.

By JAY HANCOCK

For Kaiser Health News

The Maryland Proton Treatment Center chose Survivor as the theme for its grand opening in 2016, invoking the reality-TV show’s tropical sets with its own Tiki torches, palm trees and thatched booths piled with pineapples and bananas.

It was the perfect motif for a facility dedicated to fighting cancer. Jeff Probst, host of CBS’ “Survivor,” greeted guests via video from a Fiji beach.

But behind the scenes, the $200 million center’s own survival was less than certain. Insurers were hesitating to cover procedures at the Baltimore facility, affiliated with the University of Maryland Medical Center. The private investors who developed the machine had badly overestimated the number of patients it could attract. Bankers would soon be owed repayment of a $170 million loan.

Only two years after it opened, the center is enduring a painful restructuring with investors poised for huge losses. It has never made money, although it has ample cash to finance operations, said Jason Pappas, its acting CEO since November. Last year it lost more than $1 million, he said.

Volume projections were “north” of the current rate of about 85 patients per day, Pappas said. How far north? “Upper Canada,” he said.

For years, health systems rushed enthusiastically into expensive medical technologies such as proton beam centers, robotic surgery devices and laser scalpels — potential cash cows in the one economic sector that was reliably growing. Developers got easy financing to purchase the latest multimillion-dollar machine, confident of generous reimbursement.

There are now 27 proton beam units in the U.S., up from about half a dozen a decade ago. More than 20 more are either under construction or in development.

But now that employers, insurers and government seem determined to curb growth in health care spending and to combat overcharges and wasteful procedures, such bets are less of a sure thing.

The problem is that the rollicking business of new medical machines often ignored or outpaced the science: Little research has shown that proton beam therapy reduces side effects or improves survival for common cancers compared with much cheaper, traditional treatment.

If the dot-com bubble and the housing bubble marked previous decades, something of a medical-equipment bubble may be showing itself now. And proton beam machines could become the first casualty.

“The biggest problem these guys have is extra capacity. They don’t have enough patients to fill the rooms” at many proton centers, said Dr. Peter Johnstone, who was CEO of a proton facility at Indiana University before it closed in 2014 and has published research on the industry. At that operation, he said, “we began to see that simply having a proton center didn’t mean people would come.”

Sometimes occupying as much space as a Walmart store and costing enough money to build a dozen elementary schools, the facilities zap cancer with beams of subatomic proton particles instead of conventional radiation. The treatment, which can cost $48,000 or more, affects surrounding tissue less than traditional radiation does because its beams stop at a tumor rather than passing through. But evidence is sparse that this matters.

And so, except in cases of childhood cancer or tumors near sensitive organs such as eyes, commercial insurers have largely balked at paying for proton therapy.

“Something that gets you the same clinical outcomes at a higher price is called inefficient,” said Dr. Ezekiel Emanuel, a health policy professor at the University of Pennsylvania and a longtime critic of the proton-center boom. “If investors have tried to make money off the inefficiency, I don’t think we should be upset that they’re losing money on it.”

Investors backing a surge of new facilities starting in 2009 counted on insurers approving proton therapy not just for children, but also for common adult tumors, especially prostate cancer. In many cases, nonprofit health systems such as Maryland’s partnered with for-profit investors seeking high returns.

Companies marketed proton machines under the assumption that advertising, doctors and insurers would ensure steady business involving patients with a wide variety of cancers. But the dollars haven’t flowed in as expected

Indiana University’s center became the first proton-therapy facility to close following the investment boom, in 2014. An abandoned proton project in Dallas is in bankruptcy court.

California Protons, formerly associated with Scripps Health in San Diego, landed in bankruptcy last year.

A number of others, including Maryland’s, have missed financial targets or are hemorrhaging money, according to industry analysts, financial documents and interviews with executives.

  • The Hampton University Proton Therapy Institute in Virginia has lost money for at least five years in a row, recording an operating loss of $3 million in its most recent fiscal year, financial statements show.
  • The Provision CARES Proton Therapy Center in Knoxville, Tenn., lost $1.7 million last year on revenue of $23 million — $5 million below its revenue target. The center is meeting its debt obligations, said Tom Welch, its president.
  • Centers operated by privately held ProCure in Somerset, N.J., and Oklahoma City have defaulted on debt, according to Loop Capital, an investment bank working on deals for new proton facilities.
  • A facility associated with the Seattle Cancer Care Alliance, a consortium of hospitals, lost $19 million in fiscal 2015 before restructuring its debt, documents show. Patient volume is growing but executives “continue to be disappointed in the slower-than-expected acceptance of proton therapy treatment” by insurers, said Annika Andrews, CEO of SCCA Proton Therapy.
  • A center near Chicago lost tens of millions of dollars before restructuring its finances in a 2013 sale to hospitals now affiliated with Northwestern Medicine, documents filed with state regulators show. The facility is “meeting our budget expectations,” said a Northwestern spokesman.

Representatives from ProCure and the facilities in San Diego and Hampton did not respond to repeated requests for interviews.

“In any industry that’s really an emerging industry, you often have people who enter the business with over-exuberant expectations,” said Scott Warwick, executive director of the National Association for Proton Therapy. “I think maybe that’s what went on with some of the centers. They thought the technology would grow faster than it has.”

In the absence of evidence showing protons produce better outcomes for prostate, lung or breast cancer, “commercial insurers are just not reimbursing” for these more common tumors, said Brandon Henry, a medical device analyst for RBC Capital Markets.

The most expensive type of traditional, cancer-fighting radiation — intensity modulated radiation therapy — costs around $20,000 per treatment, while others cost far less. The government’s Medicare program for seniors covers proton treatment more often than private insurers but is insufficient by itself to recoup the massive investment, analysts said.

The rebellion by private insurers “is very, very good” and may signal the health system “is finally figuring out how to say no to low-value procedures,” said Amitabh Chandra, a Harvard health policy professor who has called proton facilities unaffordable “Death Stars.”

Proton centers are fighting back, enlisting patients, legislators and nonprofits to push for reimbursement. Oklahoma has passed and Virginia has considered legislation to effectively require insurers to cover proton therapy in more cases.

An entire day at the 2017 National Proton Conference in Orlando was dedicated to tips on getting paid, including a session titled “Strategies for Engaging Health Insurance on Proton Therapy Coverage.”

Proton facilities tell patients the therapy is appropriate for many kinds of cancer, never mentioning the cost and guiding them through complicated appeals to reverse coverage denials. The Alliance for Proton Therapy Access, an industry group, has online software for generating letters to the editor demanding coverage.

In hopes of navigating a difficult market, many new centers are smaller — with one or two treatment rooms — and not as expensive as the previous generation of units, which typically have four or five rooms, like the Baltimore facility, and cost $200 million or more.

Location is also critical. Treatment requires near-daily visits for more than a month, which may explain why larger centers such as Maryland’s never attracted the out-of-town business they needed.

To make the finances work, hospitals are combining forces. The first proton beam center in New York City is under construction, a joint project of Memorial Sloan Kettering, Mount Sinai and Montefiore Health System.

Smaller facilities, which can cost less than $50 million, should be able to keep their rooms full in many major metro areas, said Prakash Ramani, a senior vice president at Loop Capital, which is helping develop such projects in Alabama, Florida and elsewhere.

Maryland’s center hopes to break even by year’s end, executives said. That will involve refinancing, converting to nonprofit, inflicting losses on investors and issuing municipal bonds.

But plans call for four centers soon to be open in the D.C. area.

“It’s a real arms race,” said Johnstone, the former proton-center CEO, who has co-authored papers on proton-therapy economics. He is now vice chair of radiation oncology at Moffitt Cancer Center in Tampa, which doesn’t have a proton center. “What places need now are patients — a huge supply of patients.”


Video & text: Early-life trauma and the very expensive 5%

NEJM Catalyst reports on remarks by Corey Waller, M.D., about what, in NEJM’s words,
“drives the 5 percent  of patients who cost 50 percent of healthcare dollars? Why are we unable to move the needle on that percentage?”  Dr. Waller is senior medical director for education and policy at the National Center for Complex Health and Social Needs.

The article reports:

“Early life trauma affects the vast majority of patients in the 5 percent, according to Waller; it’s the brushfire that wipes away whatever genetic stability they had. These traumatic experiences could be adverse childhood events, sexual assault, being in a war zone, witnessing a loved one’s death, physical or emotional abuse, or neglect. ‘For this subset of patients, no matter what the genetic landscape looks like, they’re sliding down with the smallest amount of rain,’ explains Waller. ‘They’ve lost the buffer, that capability to interact with people around them and feel safe in that interaction. They no longer have authentic healing relationships with people where they can trust and they can interact and feel like they have a place to be.’

“Trauma often drives what Waller calls the sentinel syndromes, which in turn drive health care utilization for the 5 percent. Sentinel syndromes are addiction, mental health conditions, chronic pain, and cognitive disorders. If these syndromes are poorly treated, they significantly increase one’s risk of homelessness or incarceration.”

To see the video and read the article, please hit this link.


Humana’s ‘Hospital Incentive Program’

 

Louisville, Ky-based Humana is starting  what it calls its Hospital Incentive Program, meant to reduce duplicative services and hospital readmissions..

 FierceHealthcare reports:

“Under the program, which is available to hospitals with an active commercial contract with Humana, payments will be made to general acute care hospitals based on how they improve patient experience, safety and outcomes compared to other hospitals in their region or nationally. Measures in the program for care coordination and palliative care were developed in partnership with The Joint Commission.”

“Humana’s program, however, does not come with any financial risk to hospitals, like some Medicare programs do. Under risk-based models, providers could be subjected to financial penalties if they fail to improve outcomes or curb spending. ”

To read the whole article, please hit this link.


Physician burnout: Don’t blame resilience deficit

“The Scream,” by Edvard Munch.

Nisha Mehta, M.D., a radiologist, writes in Med Page Today that physician burnout is not primarily a matter of doctors’ having less resilience these days. Among her remarks:

“At the end of the day, if you look at what has contributed to increases in physician burnout over the last decade, it’s not that we have less resilient physicians. Physicians have always worked long hours, and physicians have always had stressful, demanding jobs. It’s the loss of autonomy, the pressure to do more with less, the ever-increasing documentation requirements, RVU-, and patient satisfaction-based reimbursement, the rise in student debt, and increasing social isolation as doctor-patient relationships and relationships among colleagues suffer as a result of time constraints, uncertainty about the future, and lack of flexible work options that reflect changing physician demographics, amongst other things.

“How do we address those things? That’s what I’m interested in talking about.”

To read her entire essay, please hit this link.

 

 


Providers, insurers say federal innovation center should push interoperability and value-based payments

 

Hospitals and insurers say that  the federal Center for Medicare & Medicaid Innovation should pay more attention to increasing interoperability, implementing more value-based payment programs, and expanding telehealth coverage.

The recommendations  resulted from the CMS Innovation Center’s recent request for information from the health sector about ways to cut spending and improve outcomes.

The agency received about 1,000 comments from insurers, associations and providers, with, FierceHealthcare reports, “many of those comments focused on speeding the transition to value-based care.”

To read more, please hit this link.


Humana starts bundled-payment model for maternity

Humana, the big insurer, is contracting with physician practices to create a bundled-payment model for maternity care.

The Louisville, Ky-based insurer  will work with five OB-GYN practices to cover beneficiaries with low-to-moderate-risk pregnancies to try to improve quality and lower costs.

The model, among other things, is meant to make available more data and analytics to improve  care, and reduce duplications and readmissions.

Interestingly, the announcement comes soon after news  that Walmart might want to buy the insurer.

The  maternity bundle  is Humana’s second  bundled-payment model. It started  its joint-replacement bundle in 2016, citing an effort to cut costly readmission rates.

To read the FierceHealthcare take on this, please hit this link.

 


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