News & Updates

Kaiser Health News Source Article | Comments Courtesy of Matt Zavadsky

Interesting approach to a problem that vexes most communities – wonder how an MIH program using trained community paramedics could help medically clear psych patients for appropriate navigation to these types of resources.

Stanislaus County, California has arguably the most successful model for this – the outcomes are excellent!

https://www.chcf.org/wp-content/uploads/2017/12/PDF-CommunityParamedicsStanislaus.pdf

-------------------------------

She Was Dancing On The Roof And Talking Gibberish. A Special Kind Of ER Helped Her.

With mental health beds in short supply, emergency rooms increasingly have become the care of first and last resort for people in the grips of a psychiatric episode. Now, hospitals around the country are opening emergency units that calmly cater to patients with mental health needs.

By Anna Gorman   MARCH 25, 2019

https://khn.org/news/she-was-dancing-on-the-roof-and-talking-gibberish-a-special-kind-of-er-helped-her/

For decades, hospitals have strained to accommodate patients in psychiatric crisis in emergency rooms. The horror stories of failure abound:

Patients heavily sedated or shackled to gurneys for days while awaiting placement in a specialized psychiatric hospital, their symptoms exacerbated by the noise and chaos of emergency medicine. Long wait times in crowded ERs for people who show up with serious medical emergencies. High costs for taxpayers, insurers and families as patients languish longer than necessary in the most expensive place to get care.

“If you are living with schizophrenia or bipolar disorder, that is a really tough way to begin that road to recovery,” said Dr. Jack Rozel, president of the American Association for Emergency Psychiatry.

In pockets across the country, hospitals are trying something new to address the unique needs of psychiatric patients: opening emergency units specifically designed to help stabilize and treat patients and connect them to longer-term resources and care. These psychiatric ERs aim to address the growing number of patients with mental health conditions who end up hospitalized because traditional emergency rooms don’t have the time or expertise to treat the crisis.

The rate of ER visits involving psychoses, bipolar disorder, depression or anxiety jumped more than 50 percent from 2006 to 2013, according to the federal Agency for Healthcare Research and Quality. Roughly 1 in 8 emergency department visits now stem from mental illness or substance use disorders, the data show.

The psychiatric ERs, staffed with nurses, social workers and psychiatrists, work to treat and release patients in under 24 hours, much as traditional emergency rooms handle physical ailments. Those who are well enough to go home get discharged, while those who need more treatment are admitted to the hospital or transferred to an inpatient facility.

There are now roughly 100 such units across the country, said Dr. Scott Zeller, vice president of acute psychiatry at Vituity, a physician-led organization that provides staffing and consulting services to medical centers nationwide.

Zeller pioneered the approach while working as chief of psychiatric emergency services at John George Psychiatric Hospital in Alameda County, Calif. Over time, he transformed the center from a traditional ward where restraints were common into one that treated patients in a more supportive, living-room like setting. The results — in terms of both patient outcomes and cost-savings — made Zeller a believer.

He is helping design 10 new units, including in California, Florida, Illinois and Tennessee. Each is distinct, accepting patients in somewhat different circumstances and offering a slightly different range of services.

Patients who arrive at an emergency room for psychiatric or substance use disorders are more than twice as likely to be admitted than other patients, federal data show. And yet about 80 percent of the time, Zeller said, patients’ mental health crises can be resolved without a costly inpatient hospital stay. A patient may be having a psychotic episode because he fell off his medications, for example, or having drug-induced hallucinations.

“We need to treat people at the emergency level of care,” he said. “The vast majority of psychiatric emergencies can be resolved in less than 24 hours.”

Nowhere To Hide

Wearing a hospital gown, Rachel Diamond lay back in her recliner in a spacious room in a relatively new ward at Providence Little Company of Mary Medical Center San Pedro, a hospital near the Port of Los Angeles. Nearby, a few patients slept on identical recliners, draped in soft blankets. Others communed at a kitchen table over microwaved meals. A nurse walked through the locked unit with a rolling cart, dispensing medications.

Except for a nursing station in the middle of the room, the unit didn’t look much like a health care facility. The room was divided into men’s and women’s sides, with separate TVs. A few smaller rooms — where patients could meet with a psychiatrist or social worker — lined the unit’s edge.

Anya Price, interim clinical supervisor and a nurse, said the unit was designed to feel more like a home than a hospital.

“We’re operating from an understanding that they’re coming here to get better,” Price said.

The open design of the unit, known as the “Outpatient Behavioral Health Center,” allows patients to move freely. Staff said it also helps reduce problems because they can quickly spot a patient who may be getting agitated. Dr. Herbert Harman, a psychiatrist and medical director for the facility, said violence and the need for restraints are rare.

The unit is in a building a short walk from the medical center emergency room. It opened in 2017 and accepts patients from emergency rooms across Los Angeles County once they are deemed stable medically. So far this year, its staff has treated about 400 patients, Price said.

One recent morning, the patients included a man in his 40s found on the railroad tracks after an alcohol binge, and a woman with a history of schizophrenia who said she was seeing spirits. Some were there on involuntary holds because authorities had decided they were at risk of hurting themselves or others because of their illness.

Diamond, 30, said she has been diagnosed with depression and anxiety and has landed in multiple ERs over the past decade when her symptoms spiked out of control. During those stays, she said, she often felt isolated and in the dark about her treatment. Doctors typically numbed her with medications and consigned her to a guarded room. “No one really talked to me,” said Diamond, who lives in Torrance, Calif. “It was like I was a caged animal.”

She had been living in a car and fighting with her boyfriend in late February when she decided she wanted to end her life. She tried jumping out of a moving car, and when that didn’t work, she grabbed a bottle of pills. She gets help for her mental health issues, but sometimes, she said, the stress becomes too much. This time, she was taken to a hospital emergency room in Torrance before being transferred to the San Pedro unit.

During her time in the behavioral health center — about 26 hours — she slept, received medications and met with nurses, a social worker and a psychiatrist. She said it was calmer than a regular ER, and the staff had time to talk, listen and help her through the worst of the crisis.

“I genuinely feel better enough to leave,” she said. “I haven’t been able to say that in a while.”

 

A Return On Investment

Zeller argues that the use of emergency psychiatric clinics is both humane and cost-effective. Research on the Alameda County model found such units can dramatically reduce how long patients spend in medical emergency rooms, and that about three-quarters of patients treated in the units can be discharged to the community rather than to inpatient care. That, Zeller said, can lessen the overwhelming demand for inpatient psychiatric beds and preserve available spots for those who truly require them. The model saves money for hospitals in part because the patients spend less time in emergency care.

“The return on investment is exponential,” he said.

In Montana, the Billings Clinic opened a psychiatric stabilization unit last April across the street from the traditional ER. Dr. Eric Arzubi, psychiatry department chair, said nearly 10 percent of the visits in the Billings Clinic emergency room involve people in psychiatric crisis. Since the new unit opened, wait times for psychiatric patients have dropped from about 10 hours to four hours, and fewer patients are being admitted to the inpatient unit. Arzubi said his staff isn’t trying to cure people of their mental illness but rather stabilize them and get them the care they need.

“Just like in the emergency room, you don’t get comprehensive care,” Arzubi said. “But you can stop the bleeding, you stabilize the patient and get them to the right level of care.” In some cases, that means a transfer to an inpatient facility.

Staff at the San Pedro unit decided soon after Chantelle Unique arrived that she would be one of those patients. Unique, who is 23, has been diagnosed with bipolar disorder and schizophrenia. She had been dancing on the roof and speaking gibberish when her mother called 911.

Unique said she has had a hard time in regular emergency rooms. “There are a million people,” she said. For most of a morning at the San Pedro facility, she sat calmly watching TV, talking to nurses and eating spaghetti. But at one point, she started pacing and yelling at other patients. Nurses and security guards quickly surrounded her and persuaded her to return to her recliner and take additional medication.

Finding an inpatient bed for a patient like Unique with more progressed mental illness is not always easy, said clinical social worker Mark Tawfik. But he’s committed to finding a way. “We have to make sure we find them adequate resources,” he said. “Otherwise, they will come right back.”

For Price, the clinical supervisor, even when a patient requires a transfer for more intensive care, there’s satisfaction in knowing that person is headed in the right direction. If Unique hadn’t been brought in, Price said, she would have been out in the community, lost to her delusions, putting herself at risk of accident or arrest.

In the unit, staff made sure she was safe, Price said, in addition to providing “a warm bed, some food and some compassion.”

Modern Healthcare Source Article | Comments Courtesy of Matt Zavadsky

Very interesting discussions related to the balance billing issues…

------------------------

Analysts, some legislators want regulation of contracts to stop surprise billing

SUSANNAH LUTHI  

March 23, 2019

As Congress eyes legislation to end surprise medical bills, policy experts are lining up behind an idea to regulate hospital contracts with emergency physicians. The idea is that emergency physicians could no longer bill on top of the hospital charges, and it has already raised red flags for hospitals since it would essentially force them to include emergency physicians’ pay in the facility fee they charge patients.

Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), the leaders of the Senate health committee, have sent a model of the idea, among others, to the Congressional Budget Office for financial analysis, The Hill newspaper reported. A Senate aide told Modern Healthcare that the committee is still reviewing “a number of different options” and lawmakers are “still in the preliminary stages.”

Hospitals and insurers already have been publicly tangling over two different ideas: using rate-setting or binding arbitration to resolve pay disputes between the two types of stakeholders. But advocates for the contract-reform approach argue it’s a far less invasive way for lawmakers to deal with a political linchpin problem.

“What makes the most sense is to look at the root cause of the problem, which is the group of physicians you don’t choose and can’t avoid, as part of a wider package of services,” said Zach Cooper, associate professor of public health and economics at Yale University. “The simplest and easiest solution is for the groups of physicians that aren’t chosen by patients to be part of a package of care that a hospital sells.”

Policy analysts have been discussing the idea on Capitol Hill, and it was included in a recent paper from the Brookings Institution.

Furthermore, a new white paper by Benedic Ippolito of the American Enterprise Institute and David Hyman, professor of law at Georgetown University Law Center, contended this approach would “prevent surprise bills in the first place.”

Still it’s far from clear which policy Congress, under pressure from the White House, will ultimately opt for in the legislation expected to come up this year amid intense industry lobbying. Molly Smith, vice president for coverage and state issues at the American Hospital Association, has urged lawmakers simply to ban balance billing and let insurers and hospitals work out the rest.

Some people working on policy are wary about contract reform, however. 

Jane Bayer, senior health policy adviser to the Washington state insurance commissioner, warned an audience at the Brookings Institution on Friday that the model could shift costs, particularly in concentrated health systems. 

“I would respectfully say that I don’t think having a hospital bundle all the rates is separate from the market dynamics that we have around market concentration in hospital systems,” she said. “I think it’s the example of, if you squeeze the balloon in one place it pops up in another.”

While both the Senate health committee and the House Energy and Commerce Committee are still in the early stages of legislating, Sen. Bill Cassidy (R-La.) has led a bipartisan effort in the Senate. Cassidy sits on the health committee and is consulting with Alexander, but he plans soon to release his own new bill, co-led with Sen. Michael Bennet (D-Colo.). Sen. Maggie Hassan (D-N.H.), who dropped a proposal last fall to require insurers and providers to settle balance billing issues through binding arbitration, is also part of the effort.

The insurance and hospital industries have publicly focused on the policy ideas offered by Cassidy and his group, who have solicited industry data and feedback.

In a letter last week to congressional leaders, a coalition including America’s Health Insurance Plans urged lawmakers to steer clear of the arbitration approach and instead advocated for rate-setting—which hospitals adamantly oppose. The coalition advocated that lawmakers protect consumers by passing legislation that would include “setting reimbursement rates that will not increase premiums or impact access for consumers by basing amounts on market rates determined by reasonable, contracted amounts paid by health insurance providers to similar doctors in a geographic area or a percentage of Medicare.”

Hospitals immediately responded in a joint statement from American Hospital Association CEO Rick Pollack and the Federation of American Hospitals CEO Chip Kahn. “Not only is it a dangerous precedent for the government to start setting rates in the private sector, but it could also create unintended consequences for patients by disrupting incentives for health plans to create comprehensive networks,” Pollack and Kahn said. 

This month, Cassidy said in an interview that he was leaning toward the arbitration approach although he hadn’t decided yet. He cited New York as a reason to opt for that model. The state was an early adopter of its own curbs to balance billing within its individual market. “If the states are laboratories of democracy, we can see a laboratory experiment which seems to be worked,” Cassidy said. 

But the model of using a national system of arbitration is drawing a range of skepticism from the consulting policy world. Ippolito and Loren Adler of the USC-Brookings Schaeffer Initiative for Health Policy contend New York’s system could lead to general inflation of healthcare costs since the benchmark for the state arbitration is tied to a percentile of regional charges.

Benjamin Chartock, associate fellow at the Leonard Davis Institute of Health Economics at the Wharton School, has found in his ongoing research on New York’s system that the state’s final arbitration agreements have so far tracked with that benchmark. This has stayed consistent even though people have the perception that arbitration is fairly flexible, Chartock said. “Arbitration doesn’t loosen it up completely,” he added. “There’s only a narrow window in which the arbitrator can wiggle around.”

Cooper, whose research found that in-network rates in New York have declined since the state adopted its arbitration law, doesn’t believe the benchmark rate inflates cost. Still, he is wary about whether the arbitration method could work if it’s rolled out nationwide.

“Arbitration is tough to do on a national level—for one thing, who are the arbitrators?” he said. “Do you have mass lines of people lining up to seek remediation?”

He also noted that since New York already had fairly low out-of-network rates, it doesn’t necessarily serve as a model for other states, and warned physicians could lobby regulators or arbitrators on the state level and eke out higher rates.

Contract reform, however, has already sparked sharp hospital industry criticism.

Kahn, of the Federation of American Hospitals, said in an interview last month that he finds it a “terrible idea” that undermines the way hospitals currently staff physicians. “You can’t own your medical staff in that way,” he said. “I think it’s a very problematic.”

Governing Source Article | Comments Courtesy of Matt Zavadsky

Interesting article in Governing Magazine….

Are State Policies Preventing Stroke Patients From Getting the Care They Need?

BY STATELINE | MARCH 22, 2019 AT 7:40 AM

By Christine Vestal

https://www.governing.com/topics/health-human-services/sl-stroke-patient-care-state-policies.html  

When Hollywood actor Luke Perry suffered what would be a fatal stroke last month, he was taken to Cedars-Sinai Medical Center in Los Angeles, one of only 178 hospitals in the country licensed to provide a key advanced stroke treatment.

No matter what type of treatment they receive, more than 140,000 Americans die from stroke every year. Perry died March 4, five days after his Feb. 27 stroke. He was 52.

But getting to the best hospital as quickly as possible after a stroke improves your chances of survival. And where an ambulance takes you could depend on state law.

Unlike state rules for accident victims, which uniformly require first responders to take severely injured patients to the most advanced trauma unit available, state policies for stroke patients vary widely.

Most state rules direct paramedics to the closest hospital with a stroke unit, regardless of the attack’s severity. And some states limit paramedics to taking stroke patients to hospitals within state borders.

But most of those rules came before the recent advent of thrombectomy surgery to remove blood clots from the brain. New research shows the procedure gives patients who suffer a severe stroke a much better chance of survival without impairments.

As a result, about half of states are working to change their EMS rules and policies to ensure the most-critical patients get the surgery as quickly as possible. Neurological professional groups recommend that if a comprehensive stroke unit is within a two-hour flight or drive, then severe stroke patients should be transported there, even if a lower-level stroke unit is closer.

In January, Ohio joined Arizona, Colorado, Rhode Island, Tennessee and Virginia in requiring paramedics to take patients with a severe stroke directly to a hospital with a comprehensive stroke center that has been licensed to perform thrombectomies, provided it’s possible to reach one within a specified amount of time.

Florida, Massachusetts and New York are close to adopting similar updates to their emergency stroke policies this year.

Statewide mandatory stroke protocols don’t require paramedics in Florida, Georgia, Indiana and Oklahoma to transport severe stroke patients directly to a hospital that can perform thrombectomies. But some paramedics in those states are using a free smartphone app called Fast-ED to screen stroke patients for severity, locate a comprehensive stroke unit, notify the unit, and drive there as quickly as possible.

Other local and regional cooperative efforts among hospitals and paramedics are helping ensure that patients are transported to the most appropriate hospital. But nationwide, emergency stroke protocols are a jumble.

“In any state in the country, if a person is shot, first responders know where the trauma unit is. They’ll bypass a little community hospital and go straight to the trauma center. The same thing needs to happen for stroke victims,” said Dr. Adam Arthur, a neurosurgeon at the Semmes Murphey Clinic in Memphis, Tennessee.

Still, not everyone agrees that getting more patients to comprehensive stroke centers is the most critical issue in preventing stroke fatalities.

U.S. Centers for Disease Control and Prevention stroke expert Dr. Sallyann Coleman King said it wouldn’t be practical to take every patient to a comprehensive stroke center. “Even if we had all the money and resources needed to make all centers a comprehensive stroke center,” she said, “it just wouldn’t make sense.”

First, the public needs to know to call 911 if someone is having a stroke, she said.

About half of all stroke patients arrive at a hospital by other means than an ambulance. They get a ride from a friend or neighbor, or they take a taxi. “We’re trying to get the word out that stroke care starts in the ambulance,” King said.

“What makes sense is creating a system of care where the community and patients know the signs and symptoms of stroke and to call 911,” she said. “The EMS system is prepared to gather the needed information, assess the patient, and take them to the appropriate facility to best treat their stroke.”

Growing Evidence

The need for new emergency stroke protocols sprang largely from the results of recent clinical trials showing that thrombectomies are highly effective at preventing stroke fatalities and limiting disabilities.

In 2004, the U.S. Food and Drug Administration approved the first device for manual thrombectomy surgery — in which a catheter is inserted into an artery in the groin and threaded up through the neck until it reaches an arterial blood clot in the brain. Then the artery is expanded and the clot is grabbed by a special device at the end of the catheter and removed.

It took 11 years to improve the device design and ultimately prove the surgery’s effectiveness at treating stroke.

By 2015, the surgery had been performed on thousands of patients, and catheters and instruments designed to remove arterial clots had improved. More recently, two landmark clinical trials — one in Germany and one in the

Netherlands — proved its effectiveness for wider use.

Increasingly, paramedics and emergency physicians began realizing that thrombectomy surgery could be more important for patients with blood clots in large brain arteries than lower levels of treatment, such as clot-busting medications that, in many cases, could be administered more quickly.

A 2018 study conducted by researchers at Grady Memorial Hospital in Atlanta and the University of Pittsburgh Medical Center showed that severe stroke patients who received a thrombectomy within 24 hours of a stroke survived without disabling brain damage at a much higher rate than those who received only traditional treatments.

Until recently, however, nearly all first responders were taking stroke patients to the closest hospital, where emergency physicians typically would decide whether to transfer patients by ground or air to a comprehensive stroke unit for a thrombectomy.

A study published in January by Duke University researchers showed that patients who were taken directly to a hospital capable of performing a thrombectomy had better outcomes than those who were first transported to a local hospital and later transferred to a comprehensive stroke center.

A dose of clot-busting medicine costs more than $6,000. Mechanical thrombectomy costs about twice as much.

The rate of stroke deaths varies widely among states. Some states are enacting laws and policies to improve the chances of survival for stroke victims by ensuring that emergency medical services take patients to the closest and most appropriate stroke emergency center available.

The vast majority of strokes, nearly 800,000 a year in the United States, are ischemic strokes involving a blood clot in an artery in the brain. Of those, about 11 percent are severe, involving clots in large arteries that cut off a substantial amount of blood flow. Those patients could benefit from a thrombectomy.

But fewer than 10 percent of eligible patients receive the surgery, according to the Society of NeuroInterventional Surgery, an international scientific organization that advocates for greater public access to thrombectomies.

In 2018, in a set of guidelines on emergency procedures for stroke victims, the American Heart Association wrote: “When several [stroke] capable hospital options exist within a defined geographic region, the benefit of bypassing the closest to bring the patient to one that offers a higher level of stroke care, including mechanical thrombectomy, is uncertain. Further research is needed.”

But after an outcry from neurosurgeons familiar with the procedure and the research behind it, the organization retracted the guidelines. A representative of the American Heart Association wrote in an email to Stateline that the organization is working on an update.

 

Improving Survival

Stroke and related heart disease are the leading cause of death in the world, accounting for a combined 15.2 million deaths in 2016, according to the World Health Organization.

The fifth-leading cause of death in the United States, strokes also are a major cause of adult disability. The condition, sometimes called a “brain attack,” occurs every 40 seconds, according to the CDC.

Thanks to improved diets, increased physical activity and reduced smoking, the incidence of strokes has been declining in the United States since the 1970s, according to a statement by the American Heart Association. At the same time, survival rates have been rising.

But among patients who survive a major stroke, about 40 percent have impairments that require specialized care, sometimes for life. Age and the severity of a stroke are major determinants of how a person will fare following a stroke.

According to the Society of NeuroInterventional Surgery, 65 percent of patients taken directly to a comprehensive stroke center survive without long-term disabilities, compared with 42 percent of people taken to the nearest hospital with a less-advanced stroke center.

Advocates predict that as more hospitals develop the expertise to perform thrombectomies, and as more patients get access to the surgery, disability-free survival rates for stroke victims will rise even higher.

D Magazine Source Article | Comments Courtesy of Matt Zavadsky

Interesting.  Note the reference to the 64% of premium $ spent in healthcare services for the ACA plans. 

There is a requirement that these plans (and some others) spend 85% of premium $ on healthcare services, or potentially rebate the premiums to the premium payers.

This has been a conundrum for some health plans desiring to invest in EMS-based MIH programs.  Since most MIH programs are not a covered health benefit, insurers would pay the cost for MIH services from their “margin” and, if it’s successful, have lower healthcare costs – potentially leading to rebates if their healthcare expenses are less than 85%

Blue Cross Blue Shield of Texas Parent Company More Than Tripled Profits to $4.1B in 2018

03/15/2019| by Will Maddox

Health Care Services Corporation, the parent company for Blue Cross Blue Shield of Texas, did not pay federal taxes in 2018 and netted $4.1 billion, receiving a $1.7 billion tax refund last year, according to financial statements. In 2017, the company had a net income of $1.3 billion, an increase of over 315 percent for this year.

The tax overhaul passed by Congress and increasing profitability of health insurance played a large role in the increase, according to Axios. Profits don’t include fees from self-insured employers pay to HCSC, and the Affordable Care Act Marketplace was a big winner for HCSC. Only 64 percent of healthcare marketplace premiums were spent on medical care, resulting in $2.7 billion in gross profit. ACA plan holders may be in store for rebates due to premiums that were too high. Axios reports that there were certain tax loopholes that benefitted the Blue Cross companies.

HCSC launched a $1.5 billion initiative called Affordability Cures to reduce healthcare costs of health plan holders, teaming up with research institutions around the state to focus on behavioral health, vaccine adherence, and analyzing usage data to improve efficiency. As a part of the initiative, BCBS of Texas will launch a healthy meal delivery service to neighborhoods that lack access to quality food.

The initiative looks to address social determinants of health and learn about how to head off healthcare costs before they become too expensive.

Becker's Source Article | Comments Courtesy of Matt Zavadsky

Couple of interesting highlights in Becker’s review…

Trump's 2020 budget proposal: 5 healthcare takeaways

Ayla Ellison

March 12, 2019

President Donald Trump released his $4.75 trillion budget for fiscal year 2020 on March 11. The proposal, titled "A Budget for a Better America: Promises Kept. Taxpayers First," calls for reductions to Medicare and Medicaid over 10 years and includes provisions related to drug pricing and many other health-related issues.

Below are five healthcare-related proposals in the president's budget:

1. Discretionary funding for HHS. The budget requests $87.1 billion in discretionary spending for HHS, a 12 percent decrease from 2019 funding levels.

2. Efforts to curb HIV. Keeping with President Trump's promise in his State of the Union address to end the spread of HIV in the U.S. over the next decade, the budget plan calls for HHS to receive $291 million next year to help curb the spread of the virus. A large portion of the funding — $140 million — would go to the CDC to improve diagnosis and testing for HIV in areas of the U.S. where the virus is continuing to infect people not getting proper treatment.

3. Broad overhaul of Medicaid. Under the budget, nearly $1.5 trillion would be cut from Medicaid over 10 years. However, the budget seeks $1.2 trillion over the next decade for block grants or per-person caps that would start in 2021, according to The Washington Post. The budget plan would also end funding for Medicaid expansion.

4. Medicare funding changes. Under the budget, Medicare spending would be reduced by an estimated $800 billion over 10 years. The budget would reduce the growth of various Medicare provider payments and includes changes aimed at addressing waste and abuse in healthcare and lowering drug prices, according to The Washington Post.

5. Medical research. The plan includes a proposal to cut $897 million from the National Cancer Institute's budget and an additional $1 billion in cuts to other institutes that do medical research, according to Politico.

Opinion of Chris Kelly, PWW | Comments Courtesy of Matt Zavadsky

DOWNLOAD PDF

Special thanks to Chris Kelly of PWW for sharing this OIG Advisory Opinion regarding an MIH program.

This opinion is very interesting and worth reading – a couple of the most interesting statements include:

“Under the Arrangements, Requestor provides the Services to qualifying patients, some of whom may be Federal health care program beneficiaries. The Services provide a significant benefit to patients in the form of free health care services and care management furnished in their home. While not dispositive, the fact that a Medicaid program in the Health System’s service area reimburses for similar community-paramedic services also indicates their value. For these reasons, we believe the Services constitute remuneration from Requestor to patients participating in the Arrangements.”

“…although the remuneration provided under the Arrangements implicates the Beneficiary Inducement CMP because it could influence a patient to select Requestor or the Clinic for federally reimbursable items or services, we believe that the Arrangements’ benefits outweigh any risk of inappropriate patient steering that the statute was designed to prevent.”

“Finally, the scope and duration of the Services provided by the community paramedics appear reasonably tailored to accomplish Requestor’s goals of increasing patient compliance with discharge plans, improving patient health, and reducing hospital inpatient admissions and readmissions. It is reasonable to assume these patient populations—who Requestor certified are at higher risk of hospital inpatient admission or readmission—will benefit from the continuity of care offered by the Arrangements. For instance, the Arrangements make available a health care professional who can assist patients with following the discharge plan or treatment plan developed by Requestor or the Clinic, as applicable. In addition, the community paramedics can keep patients’ providers apprised of patients’ health by documenting all activities and interventions in their electronic medical records between discharge and a follow-up appointment. Access to free care also may foster patient safety and improve quality of care by preventing or detecting health care issues after discharge or after a treatment plan has been developed.”

“Based on the facts certified in your request for an advisory opinion and supplemental submissions, we conclude that, although the Current Arrangement and the Proposed Arrangement could potentially generate prohibited remuneration under the anti-kickback statute if the requisite intent to induce or reward referrals of Federal health care program business were present, the OIG will not, and would not, respectively, impose administrative sanctions on [name redacted] under sections 1128(b)(7) or 1128A(a)(7) of the Act (as those sections relate to the commission of acts described in section 1128B(b) of the Act) in connection with the Current Arrangement or the Proposed Arrangement. In addition, the OIG will not, and would not, respectively, impose administrative sanctions on [name redacted] under section 1128A(a)(5) of the Act in connection with the Current Arrangement or the Proposed Arrangement.”

USCF Source Report (PDF) | Comments courtesy of Matt Zavadsky

With special thanks to Lou Meyer from the California Healthcare Foundation and the California EMS Authority, here is the most recent report by UCSF on the 13 California CP Pilot programs.

With all the interest in ET3, we’ve attached highlights of the Alternate Destination – Urgent Care programs. The results from these programs could provide agencies with specific information you may want to consider when researching keys to success for alternate destination models.

In the next few days, we’ll also send out the report findings from RTI on the REMSA Ambulance Transport Alternative (ATA) program they did as part of their CMMI Healthcare Innovation Award (HCIA).

The full report is available here.

From the UCSF Report 

All three Alternate Destination – Urgent Care projects enrolled patients who had any of the following five

conditions: isolated closed extremity injury, laceration with controlled bleeding, soft tissue injury, isolated

fever or cough, and other minor injury. One site, Carlsbad, also enrolled patients who had generalized weakness.

Forty-eight persons were enrolled in the three Alternate Destination – Urgent Care projects through November 2017. Orange County’s project had the largest enrollment (34 patients), and Carlsbad’s project had the smallest enrollment (two patients). UCLA’s Alternate Destination – Urgent Care project closed in May 2017, and Carlsbad’s and Orange County’s projects closed in November 2017. All closures of Alternate Destination – Urgent Care projects were due to low enrollment.

There are multiple reasons why enrollment in the Alternate Destination – Urgent Care projects was substantially lower than anticipated. All three sites had fewer patients than expected who met all of the criteria for inclusion in the pilot project. In addition, many 911 calls occurred at times of the day during which urgent care centers were closed. In the case of Carlsbad’s project, enrollment was limited to non-elderly adults who had insurance coverage through a single health plan.

Safety

The Alternate Destination – Urgent Care projects did not harm patients. Among the 48 patients enrolled in the Alternate Destination – Urgent Care projects, two patients (4%) were subsequently transferred to an ED within six hours of arrival at an urgent care center. In addition, nine patients (19%) were transported to an urgent care center but then rerouted to an ED because clinicians at the urgent care center declined to treat the patient. None of these patients had life-threatening conditions, and there were no adverse outcomes. The reasons for transport from an urgent care center to an ED are listed in Table 11. Additional detail about the two transfers to an ED within six hours of arrival at an urgent care center can be found in the initial public report on the community paramedicine pilot projects.

Conclusion

The community paramedicine pilot projects have demonstrated that specially trained paramedics can provide services beyond their traditional and current statutory scope of practice in California. No adverse outcome is attributable to any of these pilot projects.

These pilot projects integrate with existing health care resources and utilize the unique skills of paramedics and their availability 24 hours per day, 7 days per week. The community paramedics operate at all times under medical control – either directly or by protocols developed by physicians experienced in EMS and emergency care.

Research conducted to date indicates that community paramedicine programs are improving the effectiveness and efficiency of the health care system. The seventh concept, Alternate Destination – Urgent Care, shows potential, but further research involving a larger volume of patients transported to urgent care centers with wider ranges of services and expanded hours is needed to draw definitive conclusions.

Thank you to AIMHI's leaders for serving mobile healthcare with passion, dedication, and integrity. The 2019 AIMHI Board Leadership is listed below.

• President: Chip Decker, Richmond Ambulance Authority  (2021)
• President-Elect: Kevin Smith, Niagara EMS (2021, then President 2021-2023)
• Treasurer: Dean Dow, REMSA (2021)
• Secretary: Jon Swanson, MEMS (2021)
• Immediate Past President Doug Hooten, Medstar Mobile Healthcare (2022)
• Director Joe Penner, Medic (Mecklenburg EMS Agency) (2022)
• Director Gary Booher, Three Rivers Ambulance Authority (2022)
• Director Craig Hare, Pinellas County (2021)
• Director Linda Frederiksen, Medic EMS (Davenport) (2020)
• Director Jim Winham, EMSA (2020)
• Director Alan Schwalberg, Northwell Health (2020)

FierceHealthcare Source Article | Comments Courtesy of Matt Zavadsky

The report is over 1mb, so not attached, but it is very good – strongly recommend to download it at the link below… 

During NAEMT visits with key congressional committee leaders this week in DC, this was a hot topic for them!

Lauren Block and her team at the Health Division of the National Governors Association Center for Best Practices, has done a wonderful job bringing stakeholders together to try and mitigate these issues!

---------------------

How states can take the lead on mitigating surprise out-of-network billing

by Jacqueline Renfrow | 

Feb 20, 2019 4:08pm

There are policy options, at the state level, which could help mitigate the costs of surprise out-of-network billing. According to a recent report from the USC-Brookings Schaeffer Initiative for Health Policy, surprise out-of-network costs, such as ambulance transports or care delivered by an out-of-network physician at an in-network hospital, are a huge burden.

If not prohibited by the state’s law, 1 in 5 visits to the emergency department results in a surprise out-of-network bill. And 50% of all ambulance cases involved an out-of-network ride in 2014, according to the report.

“The financial consequences of surprise out-of-network bills can be substantial,” noted the paper. Especially for patients enrolled in HMOs, who can be liable to provide payment for all charges on out-of-network care. 

Just how pricey?

According to data in the report, collected from a large national insurer, out-of-network emergency physicians charged about eight times what Medicare pays for the same service. And a survey of American Society of Anesthesiologists reports that contracted payments to anesthesiologists averaged 350% of the Medicare rates in 2018.

Plus, the costs can also be high for the physicians who are charging for out-of-network billing. These doctors often end up settling with patients or health plans for payments below what was fully charged. Collecting an out-of-network bill has more administrative hassle, too, according to the report. 

But the problem lies at the hospital level, where it would be more expensive to require its out-of-network physicians to go in network, in turn, making it more expensive for insurers to encourage hospitals to take this approach, the report found. Then, physicians would most likely require higher stipends to compensate for the loss of income.

Therefore, the demand would likely need to come from patients asking that hospitals pay the balance to physicians, which is unlikely as many patients only require these arrangements in an emergency or are not aware of surprise out-of-network charges at all, the report said.

Still, the American Hospital Association (AHA) and several other hospital groups sent a letter (PDF) urging Congress to enact legislation that protects patients from surprise medical payments. 

"The last thing a patient should worry about in a health crisis is an unanticipated medical bill,” AHA President and CEO Rick Pollack said in a statement. "We must protect patients from surprise bills that could unintentionally impact their out-of-pocket costs and undermine the trust and confidence patients have in their caregivers.”

The Brookings paper sets forth five approaches that individual states need to consider in order to change the current policies surrounding surprise out-of-network billing. 

• Take the patient out of the equation and require insurers and providers to resolve the problem and payment. 
• Patients should be made aware of all out-of-network services within a facility before a procedure occurs. 
• States should limit or ban all billing without prior consent, in writing, from patients. 
• States have the power to manage enforcement through existing processes for managing licensure and certification and resolving patient disputes. 
• Due to ERISA—which bars states from regulating self-insured employer health plans—state policy needs to focus on the regulation via health care providers. 

Brookings suggests a policy setting “billing regulation,” which caps or sets limits on what out-of-network providers can charge patients in surprise situations.

The second approach, “contracting regulation”, makes it impossible for services to be out-of-network when the facility itself is in network. Although if new contracts are formed, facilities will need to be mindful of state kick-back laws and rules about the contracts between healthcare providers and insurers. 

The paper also suggests a billing regulation approach or a hybrid approach, drawing upon billing regulation and contracting regulations. The authors believe either two options could be enacted on the federal level as well, with only a few modifications. 

“If pursuing option No. 1, the federal government could require self-insured (in addition to fully-insured) health plans to hold enrollees harmless for any costs beyond normal in-network cost- sharing amounts associated with surprise out-of-network services,” the paper noted. “If enacting a federal solution, Congress would also have to decide whether to supersede existing state reforms, which range widely in their comprehensiveness and effectiveness.” 

The letter to Congress agreed with the sentiment that federal decisions should be mindful of state regulations and ultimately leave patients out of any payment debates.

Modern Healthcare Source Article | Comments Courtesy of Matt Zavadsky

Something we should all keep a close eye on – could have serious financial impact on safety-net providers, including EMS agencies.

--------------------

New Medicaid barrier: Waivers ending retrospective eligibility shift costs to providers, patients

By Harris Meyer  | February 9, 2019

Last year, Jackson Memorial Hospital in Miami admitted an uninsured, low-income patient who stayed in the hospital for 86 days and ran up total charges of more than $1 million.

It took the public hospital's staff 65 days to complete a Medicaid application for the patient. Once it was approved, the Florida Medicaid agency covered bills for the previous 90 days, as per federal Medicaid policy in effect across the country since 1972. Jackson received a payment of $82,000, based on the state's limit of 45 covered hospital days per year.

But on Feb. 1, Florida ended retrospective Medicaid eligibility under a waiver granted by the CMS in November and effective through June, which likely will be extended. Now it will only cover claims back to the first day of the month in which an application is filed. The state projects this will save it and the federal government $100 million a year. The Trump administration so far has granted similar waivers to five other states.

If the waiver had been in effect last year, Jackson would have eaten that patient's entire bill. It estimates the new policy will cost the hospital at least $4 million a year in uncompensated care, and likely far more.

“We get trauma cases where we can't identify the patient or get documentation for weeks,” said Myriam Torres, Jackson's vice president of revenue cycle. “This will save Medicaid dollars at providers' and patients' expense.”

A costly incentive

Over the past two years, despite strong objections from hospitals and other provider groups, the CMS has granted waivers of 90-day retrospective eligibility to Arizona, Arkansas, Florida, Iowa and Kentucky. Some were part of broader Medicaid Section 1115 demonstrations of work requirements. Maine also received a waiver but its new Democratic governor announced she won't implement it. The CMS is considering similar waiver requests from Ohio and other states. 

In its approval letters, the CMS argued that demonstrations ending 90-day retrospective eligibility will test whether that gives beneficiaries an incentive to enroll in Medicaid before they need healthcare services, so they can receive preventive services and stay healthier. It also says the change will facilitate a smoother transition of beneficiaries into commercial health plans, which don't offer retroactive coverage. 

The CMS is requiring states to develop outreach and education strategies to encourage providers and beneficiaries to submit Medicaid applications as early as possible, though providers say they haven't seen any significant new state activity there.

A CMS spokesman said that as in all Section 1115 demonstration waivers, the agency is requiring states to monitor and regularly report the outcomes and financial impact.

But experts say there's no evidence that eliminating retrospective eligibility encourages Medicaid-eligible people to sign up earlier, and there are plenty of reasons why that hypothesis is implausible.

“Many people who aren't enrolled are not aware they are eligible or they have difficulty with the enrollment process,” said Dr. Benjamin Sommers, an associate professor of health policy and economics at Harvard University. “The notion that most people will sign up by getting rid of retrospective eligibility is unlikely. They typically do not even understand it.”

Critics say eliminating retrospective eligibility is one more administrative barrier the Trump administration has erected to make Medicaid and other public benefits harder to access. These include work and reporting requirements, premium payments, healthy behavior incentives, benefit lockouts, and proposed penalties for legal immigrants who use public programs. States like Arkansas that have added new hurdles have seen sharp drops in Medicaid enrollment.

“Shortening the (retrospective eligibility) window gives people less time to figure out they'd be eligible,” said Pamela Herd, a public policy professor at Georgetown University, who calls that form of administrative burden a learning cost. “Republicans have employed these types of changes to reduce use of social welfare programs.”

Changing nature of waivers

Under previous administrations, Delaware, Indiana, Maryland, Massachusetts, New Hampshire and Tennessee received waivers of the federal requirement for retrospective eligibility, typically as part of coverage expansions. In contrast, the Trump administration's waivers have been part of programs to restrict coverage.

Most of these waivers retain retroactive coverage for pregnant women, infants, disabled people and those in nursing homes. Florida's waiver, however, excludes such coverage for the nursing home population.

Herd and other experts say that if the goal is to get people to enroll as soon as they are eligible, there are proven ways to achieve that, such as streamlining the enrollment process and doing more aggressive outreach. The Trump administration has sharply cut funding for enrollment education and assistance.

On the other hand, if the goal is to reduce federal and state spending on Medicaid and shift costs to providers and patients, eliminating retroactive eligibility likely is effective. 

Actuarial analyses of Medicaid payments have shown that about 5% of Medicaid payments occur during the retrospective eligibility period. Ending retrospective coverage would reduce Medicaid outlays by an estimated $13.3 billion from 2017 to 2026, according to the Commonwealth Fund.

In 2016, Indiana reported that 14% of beneficiaries to whom the waiver applied ran up significant out-of-pocket medical expenses as a result, averaging more than $1,500 per person. Sixteen percent of providers said they saw charity cases and bad debt increase as a result of the policy.

“If this is really an experiment, what is the policy goal other than to reduce program costs?” asked Joseph Antos, a conservative health policy analyst at the American Enterprise Institute. “Presumably this should have something to do with patient outcomes or efficiencies. I don't see the word efficiency in any of this. I see cut.”

A history lesson and the impact on beneficiaries

Retrospective eligibility was built into federal Medicaid law early on as a safety net protection for very low-income people and their medical providers. It encourages providers to treat patients knowing they'll get paid and to help them sign up quickly for the program. 

Another key rationale is that unlike in private insurance, many Medicaid beneficiaries “churn” on and off coverage due to changes in income and because states impose a demanding annual eligibility redetermination process. It's estimated that 25% or more of beneficiaries are at least temporarily disenrolled as a result of the redetermination process and other factors. 

Many other people aren't even aware they are eligible. The Kaiser Family Foundation recently reported that 6.8 million uninsured adults and children were eligible for Medicaid but were uninsured in 2017. 

All these factors leading to loss of coverage for eligible people makes retrospective eligibility an important backstop, patient advocates say.

But some state and federal officials long have complained about the cost of retroactive coverage, which generally can't be passed on to the private Medicaid plans that administer most state programs. 

Tennessee received a waiver in 1994 as part of its major Medicaid coverage expansion program known as TennCare. Even though that program largely has been rolled back and the state has not expanded Medicaid under the Affordable Care Act, the elimination of 90-day retroactive coverage remains in place for nearly all beneficiaries.

That has led to many Medicaid-eligible people incurring large medical bills before their Medicaid applications are approved, with some facing lifetime debt, said Michele Johnson, executive director of the Tennessee Justice Center, which tries to help people clear up these bills.

The problem was exacerbated by a recent major computer glitch in the state's Medicaid enrollment system, which left thousands unable to file their annual enrollment redetermination applications online.

Before her Medicaid application was approved, one Memphis woman racked up $250,000 in bills resulting from her baby being born with severe health problems. “She said that was the hardest thing in her life—going home with a disabled child and being consigned to poverty for the rest of her life,” said Johnson, whose group helped with her case. 

After a nine-month court fight, the woman finally got Tennessee's Medicaid program to pick up the entire bill.

Yet there has never been a study of the policy's impact in Tennessee. “It hasn't led people to sign up ahead of time,” Johnson said. “All these other policies make it almost impossible to sign up. If the state were interested in that, they would make the whole process less bureaucratic.”

In 2017, Iowa received a CMS waiver of the 90-day retrospective eligibility requirement, including for nursing home residents, despite warnings that nursing homes would refuse to admit people who were awaiting Medicaid eligibility. Last year, under pressure from nursing homes, the state Legislature restored retroactive coverage for that population.

Brent Willett, CEO of the Iowa Health Care Association, said it takes an average of 71 days to assemble complicated income and assets information, file the application, and receive approval for Medicaid nursing home coverage. Under the policy the state reversed, facilities only received payment back to the first day of the month when the application was filed, even though they may have admitted the resident many weeks earlier. 

The association projected that policy would cost Iowa nursing homes $7 million in the first year. “It sounds nice that people should start the application process early and we agree, but it's not practical in practice,” Willett said. “If we are maintaining a system to ensure coverage for people who don't have assets for care, it makes no sense to penalize providers for providing that care. That policy wasn't cost containment, it was a cost shift to providers.”

Iowa hospitals looking for a reversal

As to the broader group of beneficiaries affected by Iowa's waiver, the Iowa Hospital Association is pushing to have 90-day retroactive eligibility reinstated this year. The policy hurts urban trauma centers that provide intensive care to people before an application can be completed, as well as rural hospitals that lack a profit cushion to absorb those unexpected costs, said Scott McIntyre, the association's vice president of communications.

The Legislature ordered it as a cost-containment measure, with the state projecting it would affect nearly 40,000 Iowans and save it and the feds $36.7 million a year. The CMS waiver required the state to provide outreach and education to the public to ensure that eligible people apply for Medicaid as soon as possible.

But McIntyre said the state has not ramped up enrollment outreach to mitigate the end of retrospective eligibility. 

In addition, Iowa, which expanded Medicaid in 2014, has not conducted any review of the cost savings to the government or of the financial impact on providers and beneficiaries, according to a spokesman for the Iowa Department of Human Services. The CMS, he said, did not require the state to conduct such a report on the impact of eliminating retrospective eligibility. “We've made so much progress with Medicaid expansion to reduce uncompensated care, and this really undermines that progress,” McIntyre lamented.

There's already an effort to roll back the new retrospective eligibility waiver in Florida, which didn't expand Medicaid, so that it applies to nursing home residents and all other Medicaid eligibles except pregnant women and children. 

It's basically impossible for many people who may need a nursing home placement to apply for Medicaid ahead of time because they're living in the community and don't qualify until they enter institutional care, explained Tom Parker, director of reimbursement for the Florida Health Care Association. 

“I would think that undercuts the main argument for this policy,” he said.