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University Hospitals, SummaCare to offer co-branded Medicare coverage

Lerner Tower, part of the University Hospitals complex in Cleveland.

University Hospitals, based in Cleveland, and SummaCare, an Akron, Ohio-based health insurer,  will offer co-branded Medicare coverage.

Called University Hospitals Medicare Advantage from SummaCare, the coverage will be available in markets with University Hospitals facilities. The partnership  says that the plan is to encourage more holistic, value-based care than fee-for-service care.

“We expect our members to achieve improved quality of care, better health outcomes and an overall outstanding patient experience,” Anne Armao, SummaCare vice president of marketing and consumer engagement, said.

UH will provide special care managers to help coordinate services with SummaCare.

To read more, please hit this link.

Probe suggests Joint Commission accreditation a joke

The Joint Commission, the accrediting organization for about 80 percent of U.S. hospitals,  rarely revokes its approval of facilities out of compliance with Medicare rules, reports The Wall Street Journal.

The WSJ, after digging into  Joint Commission inspection reports from 2014 through 2016, found that in 2014, about 350 hospitals with Joint Commission accreditation had violated Medicare requirements that year, and about a third had additional violations in 2014, 2015 and 2016.

The paper reported that the commission  revoked accreditation for just 1 percent of hospitals out of compliance with Medicare. More than 30 hospitals retained their accreditations even though the Centers for Medicare & Medicaid Services found their violations important enough to cause, or likely cause, serious patient injury or death.

“It’s clearly a failed system and time for a change,” said Ashish Jha, M.D., a health policy researcher at Harvard’s T.H. Chan School of Public Health and a practicing internist, told the paper.  The probe “shows accreditation is basically meaningless—it doesn’t mean a hospital is safe.”

To read more, please hit this link.

When hospital giants hire your GPs


For Kaiser Health News


When Dr. Sarah Azad followed her mother into the field of obstetrics eight years ago, she thought she’d be in private practice for the rest of her career. At the time, independent practices abounded in Silicon Valley.

“From the time we were young, my mom’s patients loved her. She was a part of their lives. That’s just always how I’ve seen medical care,” she said.

But over the past decade, she’s watched as physician after physician sold their practices and went to work for one of the large hospital systems in town. Today, Dr.,  Azad runs one of the last remaining independent OB-GYN practices in Mountain View.

The number of physician practices employed by hospitals increased by 86 percent from 2012 to 2015, according to a study conducted by Avalere Health for the Physicians Advocacy Institute, a health policy-focused nonprofit.

Perhaps nowhere has the trend been more pronounced than in Northern California.

As large hospital systems like Sutter Health, Stanford Medicine and the University of California at San Francisco gobble up doctor practices, they gain market muscle that pushes costs upward. It’s a key reason why Northern California is now the most expensive place in the country to have a baby.

A study published this week in Health Affairs found that large doctor practices, many owned by hospitals, exceed federal guidelines for market concentration in more than a fifth of the areas studied. But the mergers are typically far too small for federal antitrust authorities to notice.

“When you have less competition, prices go up,” said Martin Gaynor, a healthcare economist at Carnegie Mellon University. “If you’re an insurance company and you don’t reach an agreement with Sutter, then you have a hard time offering an attractive insurance product because it’s so big and pervasive. So you don’t have the same negotiating power, and Sutter can extract higher prices.”

In the San Francisco Bay Area, the reimbursement rate for a vaginal delivery is two to four times higher for physicians who work for large hospital systems than for those who are independent, according to a Kaiser Health News analysis. The news organization examined claims data provided by Amino, a health-cost transparency company, plus results from medical cost calculators available from certain employers to help workers comparison shop.

The extra money for physician services goes to the hospital system, and doctors, now on salary, might take home no more than before. Although switching from independent practice spares OB-GYNs the considerable hassles of negotiating with insurers and running an office, doctors say the lion’s share of the benefit goes to hospital systems — not to physicians or patients.

In Northern California, Sutter, Stanford and UCSF all mentioned quality as a reason why their physician prices are higher, and it might seem intuitive that integrating care among disparate physicians leads to better care.

“Sutter Health-affiliated doctor groups consistently rank among California’s highest performers,” Dr. Jeffrey Burnich, senior vice president at Sutter Health Medical and Market Networks, wrote in an email. In the long run, “by improving care quality and efficiency, we reduce costs.”

But in general, research suggests bigger is not necessarily better.

Fewer patients of small physician-owned practices, for example, are admitted to the hospital for preventable conditions than those of large hospital-owned practices, according to a 2014 study published in Health Affairs. A report from the National Academy of Social Insurance showed that the integrated delivery networks of large hospital systems have raised physician costs without evidence of higher quality. And a recent paper, also published in Health Affairs, found that high-price physician practices, which cost at least 36 percent above average, had no better quality than low-cost practices.

“All of the evidence that we see shows that the quality in these larger systems is the same or worse,” said Kristof Stremikis, associate director for policy at the Pacific Business Group on Health, which represents employers that provide health insurance.

A Personal Connection

On a sunny day last spring, Dr. Azad walked into her patient’s room wearing a colorful headscarf. Just weeks from her due date, Ruby Lin sat on the end of the exam table holding her belly. The two women greeted each other like old friends.

“Hi! You look great,” Ms. Lin told Dr. Azad.

“Thanks — I’m not where I hoped I’d be,” Dr. Azad replied, rolling her eyes and touching her stomach. The doctor gave birth to her fourth child just months earlier and hadn’t lost the “baby weight” she wanted to yet.

Dr. Sarah Azad examines patient Ruby Lin in Mountain View, Calif.  Dr. Azad’s mother was also an obstetrician.

Photo by Jenny Gold/KHN

This was Ms. Lin’s second baby with Dr. Azad as her physician. “I get very nervous about seeing doctors and especially OB-GYNs, and Dr. Azad is the only one I’m comfortable with,” said Ms. Lin.

This sort of well-established, personal relationship is Dr. Azad’s favorite part of being a doctor, and she considers it a hallmark of independent practice. At the larger practices owned by hospital systems, she said, patients may be more likely to have the doctor on call deliver their baby rather than the obstetrician whom they’ve grown to know over months.

But  Dr. Azad says that running a medical practice in one of the most expensive parts of the country is getting harder. “Rent goes up 3 percent per year. Water and utilities went up 18 percent last year alone. But seven years later, [the insurers] are still paying me the same amount, despite any efforts to negotiate.”

At first, Dr. Azad tried reaching out to the insurance companies directly to ask for higher rates. They refused even to meet with her, she said. Then she hired a consultant to negotiate on her behalf. Nothing worked.

“One insurance contract responded saying, ’You don’t even have 2 percent of market share. Basically drop our contract or not — it doesn’t affect us,’” she said. Another insurer told her they couldn’t raise her rates because they had to pay too much to the larger health systems in town, she said.

Independent doctors in the Bay Area are reimbursed, on average, a median $2,408.45 for a routine vaginal delivery, which includes prenatal and postnatal visits, according to the Kaiser Health News analysis of Amino claims data.

That compares with $5,238.13 for the same bundle of services for Stanford physicians and $8,049.84 for doctors employed by University of California-San Francisco.

Health data company Amino provided Kaiser Health News (KHN) with median billing amounts for Bay Area obstetricians. KHN used a Medicare provider database to determine where each doctor worked. In cases where the doctor’s employment status was unclear, a reporter retrieved the information by calling the health system or physician directly. KHN then calculated the average median billing amount for a routine vaginal birth for each health system.

The Amino database did not contain many claims from doctors employed by Sutter, so KHN also reviewed OB-GYN charges on several insurers’ online cost estimators. The review found that obstetricians employed by Sutter Health are reimbursed about three times more for the same service than independent doctors, or about $6,452 for a vaginal delivery.

Many doctors are mystified as to why prices vary so dramatically — independent or not.

Same Office, Same Pay

After nearly a quarter-century in independent practice, OB-GYN Ken Weber sold his practice to Stanford, where he now works. His office is in the same place, across the street from  Dr. Azad. Both physicians admit patients to the same local hospital.

But insurers now pay about twice as much for his services as before.

He still makes the same amount, he said. Stanford’s health system gets the rest.

“It doesn’t make sense to me from the insurance company’s standpoint, because they’re losing all these doctors to the bigger groups and having to pay more. And if they just had negotiated with us fairly, I think we could come to some middle ground,” Weber said.

Dr. Weber said he hung on to his independent practice as long as possible, but he grew increasingly frustrated. “It’s hard to know that you’re doing the same work someone else does at Sutter or Stanford or wherever,” yet insurers are paying more for patients to see the other person, he said.

Nonetheless, there have been some real benefits to selling his practice, he added: He no longer has to worry about dealing with billing or maintaining compliance with the new electronic health-record regulations.

For their part, the big Bay Area hospital systems caution against oversimplifying the many factors that go into paying for obstetrical care. A Stanford spokeswoman, Samantha Dorman, said the health system incurred significant costs when it integrated new provider groups. For instance, many were not yet on electronic health records and needed updated equipment. Dorman added that Stanford reduced physician charges a few years ago to be more in line with other practices.

A UCSF spokeswoman said that just looking at physician reimbursement rates was misleading because while the system charges more for physician services, it charges less for other hospital services. Overall, she said, their costs are competitive.

For its part, Sutter suggested that it was not accurate or fair to judge physician price discrepancies on online cost calculators. According to  the aforementioned Dr. Burnich of its Medical and Market Networks service, the rates provided are inconsistent and often out-of-date.

The agreements between hospitals and insurers have “gag clauses” barring either party from divulging rates. The bottom line, for many patients, is that it’s almost impossible to determine either the cost or the value of the various health care providers available to them. This is particularly problematic for patients with high-deductible plans, who may be on the hook for a significant portion of those costs.

Meanwhile, the type of consolidation that  Dr. Azad has witnessed in Northern California is spreading quickly throughout the country, and it is extremely difficult to reverse.

The most consolidated places like Northern California, Pittsburgh and Boston have become a “poster child of what not to do,” said economist Gaynor of Carnegie Mellon. “We should look at places that have consolidated and think about how to avoid that.”

Kaiser Health News correspondent Sydney Lupkin contributed to this report.

Study: Preferred skilled nursing facility networks linked to greater readmission-rate cut

A new study in Health Affairs says that hospitals that refer patients to a preferred network of skilled nursing facilities reduced readmissions for those patients more than hospitals that offered a wider list of facilities for patients to choose from.

FierceHealthcare reported that researchers “identified four ‘case hospitals’ with a preferred SNF network and 12 that did not use such a network, and compared Medicare readmissions data. Between 2009 and 2013, the rate of readmissions from SNFs in the network fell  by 6.1 percentage points, while it decreased by 1.6 percentage points for the other hospitals.” To read the Fierce article, please hit this link.

Fierce reported that “The researchers found that in the four case hospitals, patients were more likely to have coordinated care plans that shared the load between the hospital and SNF, which can be crucial as these patients are often among the sickest. In one case, a hospital nurse practitioner visited patients at the in-network SNFs each day. Those patients also received a weekly visit by a physician, in addition to care from the team at the nursing facility.”

Among the findings, reports Fierce:

  • “Hospitals with networks took advantage of existing provider relationships. These existing relationships also offered more leverage to improve performance, instead of relying solely on quality ratings.
  • “An understanding of cost drivers led hospitals to create a SNF network. Some of the case hospitals decided to implement a network because they saw they were spending a lot on nursing home care, and others were pushed by outside motivators, like Accountable Care Organization participation.
  • “Data management is key. Gathering data from the SNFs in the network is necessary to maintaining quality and can make it more successful.
  • “Interpretations of ‘patient choice’ vary. Many of the hospitals without networks had a very strict view of ‘patient choice,’ and thought a preferred network was too limiting.”


How off-the-radar mergers create healthcare near-monopolies


For Kaiser Health News

Hospitals have gone on a doctor-buying spree in recent years, in many areas acquiring so many independent practices they’ve created near-monopolies on physicians.

Research published on Sept. 5 throws new light on the trend, showing that large doctor practices, many owned by hospitals, exceed federal guidelines for market concentration in more than a fifth of the areas studied.

But it goes further, helping answer some of health policy’s frequently asked questions: How could this happen? Where are the regulators charged with blocking mergers that have been repeatedly shown to drive up the price of health care?

The answer, in many cases, is that they’re out of the game.

Doctor deals are typically far too small to trigger official notice to federal antitrust authorities or even attract public attention, finds a paper published in the journal Health Affairs.

When it comes to most hospital-doctor mergers, antitrust cops operate blind.

“You have a local hospital system and they’re going in and buying one doctor at a time. It’s onesies and twosies,” said Christopher Ody, a Northwestern University economist and one of the study’s authors. “Occasionally they’re buying a group of five. But it’s this really small scale” that adds up to big results, he said.

The paper, drawing from insurance data in states covering about an eighth of the population, found that 22 percent of markets for primary-care doctors, surgeons, cardiologists and other specialties were “highly concentrated” in 2013. That means that, under Federal Trade Commission guidelines, a lack of competitors substantially increased those doctors’ ability to raise prices without losing customers.

The research didn’t sort physician groups by ownership. But other studies show that large, predominant practices are increasingly owned by hospitals, which see control of doctors as a way to both coordinate care and ensure patient referrals and revenue.

According to one study, hospitals owned 26 percent of physician practices in 2015, nearly double the portion from 2012. They employed 38 percent of all physicians in 2015, up from 26 percent three years earlier.

In the study by Ody and colleagues, only 15 percent of the growth by the largest physician groups from 2007 to 2013 came from acquisitions of 11 doctors or more.

About half the growth of the big practices involved acquisitions of 10 or fewer doctors at a time. About a third of the growth came not from mergers but from hiring doctors out of medical school or other sources.

Federal regulations require notification to anti-monopoly authorities only for mergers worth some $80 million or more — far larger than any acquisition involving a handful of doctors.

Very few of the mergers that drove concentration over the market-power red line — or even further — in the studied areas would have surpassed that mark or a second standard that identifies “presumably anti-competitive” combinations.

But the little deals add up. In 2013, 43 percent of the physician markets examined by the researchers were highly or moderately concentrated according to federal guidelines that gauge monopoly power by market share and number of competitors.

(A market with three practices in a particular specialty, each with a third of the business, would be at the lower end of what’s considered highly concentrated. A market with one doctor group doing at least 50 percent of the business would be highly concentrated no matter how many rivals it had.)

Bigger and fewer doctor practices, fueled largely by hospital acquisitions, do drive up prices for patients, employers and taxpayers, several studies confirm.

Part of the increase results from a reimbursement quirk. Medicare and other insurers pay hospital-based doctors more than independent ones. But another part comes from the lock on business held by large practices with few rivals, Ody said.

“It’s a problem,” said Martin Gaynor, a healthcare economist at Carnegie Mellon University and former head of the FTC’s Bureau of Economics. “All the evidence that we have so far … indicates that these acquisitions tend to drive up prices, and there’s other evidence that seems to indicate it doesn’t do anything in terms of enhancing quality.”

The American Hospital Association, a trade association, declined to comment on the study since officials hadn’t seen it. But the AHA often argues that “hospital deals are different”and that doctor acquisitions keep patients from falling through the cracks between inpatient and outpatient care.

The FTC has moved to block or undo a few sizable doctor mergers, including an orthopedics deal in Pennsylvania and an attempt by an Idaho hospital system to buy a medical practice with dozens of doctors.

But the agency largely lacks the tools to challenge numerous smaller transactions that add up to the same result, said Ody.

An FTC spokeswoman declined to comment on the study’s findings.

Ody urged state attorneys general and insurance commissioners to look more closely at doctor combos. Sometimes state officials can question mergers overlooked by federal authorities. Or they can block anti-competitive practices, such as when hospitals seek to exclude competitor physicians from insurance networks.

Beyond that, “I hope that people notice this [research], and I hope people think creatively about what kinds of solutions might be appropriate for this,” he said. “I don’t know what they are.”

Giving patients pills to take home at hospital discharge may cut readmissions

To try  to reduce the number of hospital readmissions, many hospitals across America across America are starting “meds to beds” and/or “meds in hand” programs in which patients get prescription drugs to take home with them just before they’re discharged.  Indeed a 2016 survey by the American Society of Health-System Pharmacists found that about 35 percent of U.S. hospitals offer discharge prescriptions.

The Washington Post reports: “Many hospitals begin the meds-to-beds program with a single department, such as cardiology or transplant medicine, see how well it works and then add more.”

“And once Medicare acted {to penalize hospitals for what deems excessive readmissions}, other insurers began levying penalties for early readmission as well,”  Joshua Seidman, a senior vice president at the health-care consulting firm Avalere, told The Post. Thus many hospitals have started “transitions of care” programs that link patients with such post-discharge services  as follow-up physician visits and medications to be used at home.

“Data published this year by the Kaiser Family Foundation suggests such efforts work: Hospital readmissions have fallen since 2012, although how much can be attributed to the new prescription programs isn’t broken out by Kaiser. Tricia Neuman, senior vice president and director of Kaiser’s program on Medicare policy, told The Post: “For older patients with complex medical conditions or dementia, taking their drugs, as prescribed, can be a serious challenge unless they have the support they need once they get home. Programs that target patients as they transition from one setting to another can help avoid preventable U-turns to the emergency room or hospital — which could lead to better patient care and lower costs.”

To read more, please hit this link.


AHA sends Congress suggestions for regulatory relief

The American Hospital Association has forwarded some options to Congress to consider for regulatory relief for healthcare organizations.

Tom Nickels, the AHA’s executive vice president for government relations and public policy, told Congress that although the government has eased some  rules, a huge burden on hospitals remains.

He wrote: “Indeed, the regulatory burden faced by hospitals is substantial and unsustainable. In addition to the sheer volume, the scope of changes required by the new regulations is beginning to outstrip the field’s ability to absorb them.

 Here are a few highlights as summarized by FierceHealthcare:

  • “Offer an Anti-Kickback safe harbor and Stark exemption for clinical integration agreements and patient assistance, as these laws can hinder care coordination.
  • “Issue an enforcement moratorium on the ‘96-hour’ rule, which requires critical access hospitals to certify that a patient could reasonably be transferred or discharged within 96 hours.
  • “Allow providers access to patient substance abuse treatment records without an individual patient’s consent.
  • “Suspend the “deeply flawed” star ratings on Hospital Compare, which Nickels said experts have disputed as accurate indicators of clinical quality.
  • “Reduce the number of clinical quality measures to the ones that ‘matter,’ as the Centers for Medicare & Medicaid Services currently uses upwards of 90 measures.
  • “Protect Medicare payments to disproportionate share hospitals.
  • “Adjust readmission rate evaluations to account for social risk factors.
  • “Make bundled-payment programs voluntary.”

To read the AHA letter, please hit this link.

To read the FierceHealthcare commentary, please hit this link.

CMS to cancel 2 bundled-payment models, but data encourage providers to have voluntary ones

Todd Johnson, CEO of HealthLoop, has written a very good description in Med City News of the Medicare bundled-payments situation. He starts: “While last week’s announcement that CMS plans to cancel two bundled payment models and reduce the geographic area required to participate in a third is not necessarily a surprise, it’s an unfortunate miscalculation by the current administration. We know this for two reasons:

  1. “Bundled payments work (and we have extensive data to prove it).
  2. “Bundled payments save American taxpayers money.”

He continues:

“This latest decision by the administration might indicate that forward momentum in payment reform is coming to a grinding halt. While we appear to be lacking the leadership to move this initiative forward, we’re certainly not moving backwards. The administration knows that bundled payments work — research indicates that if every hospital in the nation employed these payment models, Medicare would save $2 billion annually — which is why they’ve made the decision for providers to participate in voluntary bundles, as opposed to mandatory.

‘Additionally, private insurers, employers, and providers have all expressed interest in sticking with value-based care as they’ve seen the results first hand, and they believe that the reduction in costs and improvement in quality are reason enough to push ahead.

“It’s going to come down to the providers who believe in innovation, progress, and better patient care to lead the pack on bundled payments. The findings have revealed substantial cost savings and better quality outcomes. There’s an opportunity for providers to accept the challenge and willingly participate regardless of whether they’ve been mandated to or not. Our partners have shown better financial performance under bundles vs. traditional fee-for-service and see this as another way to further differentiate from their competitors…”

To read all of this commentary, please hit this link.

Physician-compensation issues in value-based-payment systems

In a Hospital Impact piece, Tom Dobosenski, president of AMGA Consulting, looks at the intersection of physician compensation and value-based payment systems. Among his remarks:

“Value-based care delivery also focuses on high-cost, high-need patients. If patient mix is unaccounted for in productivity measures, this could threaten physicians’ compensation, given the longer visits needed for complex patients. To this end, we’re seeing a shift—which we expect to accelerate—from measuring physician productivity by pure relative value units to a model that reflects variations in patient mix.

“If your schedule system is based on a 15-minute average visit and 50 percent of your patients are Medicare patients who are older than 65, it may be impossible to meet productivity goals. This will only contribute to the frustration driving physician burnout.

“In sum, the 2017 report shows that where the delivery and payment system goes, compensation will follow, but we have serious challenges ahead for creating compensation models if compensation continues to rise and productivity remains flat. ”

To read his entire piece, please hit this link.



CMS to reduce audit burden on physicians


In what might be seen as further evidence that Health & Human Services Secretary Tom Price, M.D., is taking a much more pro-physician  stance toward physicians paid by Medicare than his predecessors, the Centers for Medicare & Medicaid Services (CMS) is, in the words of Medscape “lightening the audit burden on physicians by rolling out a new approach to claims review that targets fewer providers and requires the review of fewer claims than the current approach does. This new policy reduces the likelihood that physicians who follow sound billing practices will be audited.”

“CMS explained that it was revising its medical review process to target only specific providers or suppliers who have billed Medicare for particular services, rather than all of them. Referring to the two-step process of identifying providers who have made billing errors and then educating them, the agency calls this new approach Targeted Probe and Educate (TPE). It replaces the current Probe and Educate program, which began in 2014 and targets all providers who bill for particular services or items.”

To read more, please hit this link.


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