News & Updates

To say that it has been a tumultuous year for the healthcare industry is an understatement. Federal policy changes and recent transactions involving large insurers, health systems and retailers will affect providers, payers and patients alike.

While there are many new and emerging trends we need to pay close attention to in 2018, here are what I think are the four most significant issues that will command our attention in the year ahead.

1. Inconsistent healthcare policy will continue to dominate the headlines
The federal debacle with so-called healthcare reform this year has been a case study in confusion, inefficiency and lack of focus. Every week seemed to bring a new twist in the direction of healthcare policy, especially in regards to the ACA, with almost no consistency to the legislative thought process. In many ways, the whole focus of ACA repeal and replace efforts was misguided — you can’t take something apart without some ideas for a replacement. The federal government’s lack of direction on healthcare policy has created chaos among all industry players.

Given the healthcare provisions in the proposed tax bill and potential future action with the ACA, there are serious implications for states across the country. The confusion surrounding Medicaid and other joint federal-state partnerships has discombobulated state budgets, and it is patients who will ultimately face the harshest consequences if states are forced to slash funding for healthcare.

For the foreseeable future, we’re going to continue to see inconsistency in government policies and funding. This is especially dangerous for hospitals in underserved communities that rely almost exclusively on Medicaid and Medicare funding. Unless they are supported in some way, many of these providers will sink deeper into debt.

2. In order to keep pace with newly formed organizations and partnerships, hospitals and health systems need to innovate
The CVS-Aetna deal did not come as a surprise to industry leaders who have been keeping their ears to the ground and have paid attention to recent trends. But nevertheless, this merger is a major shake-up that cannot be ignored. Google, Amazon and IBM Watson are all looking to stake out a piece of the healthcare field, and deals such as Optum’s purchase of DaVita Medical Group underscore the ever-evolving nature of the ways people access and pay for care and services. Providers should not view this movement as a threat that must be stopped. Instead, we should spur innovation on our end. We can’t sit still. That’s why, in Northwell Health’s case, we have been forging new partnerships and pursuing ventures that will enable the organization to compete more effectively in this rapidly changing environment.

It will be especially intriguing to see what market segments CVS and Aetna pursue after the merger is finalized. Undoubtedly, they will offer prescriptions, preventive care and other primary services to supplement CVS’ “Minute Clinics,” but it remains to be seen what other health services will be provided as part of this new collaboration.

Regardless of what new competitors enter the healthcare market, the seriously ill, elderly patients with chronic conditions and those who have suffered traumatic injuries will still be relying on hospitals to take care of them. It’s highly unlikely that any of the new players will be providing inpatient care. As we all know, the bulk of healthcare funding is spent on long-term care for people at the end of life. The Amazons and Googles of the world are not targeting that population.

Recognizing that traditional healthcare providers do need to adapt to this era of consumerism, among my strategies are to continue expanding our ambulatory network, facilitating innovative partnerships, enhancing efforts in prevention, maximizing our use of artificial or augmented intelligence, and improving our already robust telemedicine program.

In the end, I believe competition is good. Market disruptions give all of us headaches, but they are ultimately beneficial because they force us to do better and be more efficient, productive and creative

3. Unless we continue to improve the customer experience, customers will go elsewhere for care
The more competitive the market becomes, the more work we as providers must do to continually improve the patient experience and develop customer loyalty. This can partly be done through improving communication and curating a more retail-focused experience.

This is unbelievably important, as patients now have more access and choice for their healthcare than ever before. This is not limited to the in-person experience, but also how hospitals and health systems communicate with patients to help them get information and make appointments. Online and mobile platforms are already important for engaging customers, and they will only grow more essential in 2018.

Online engagement is not only for younger patients. It’s a medium that has become increasingly more effective than print or broadcast advertising for reaching older patients. Equally important is creating an experience that connects families with providers. We deliver more than 40,000 babies every year in our health system. Those are 40,000 families with whom we could be creating life-long bonds. Pursuing initiatives to maintain a connection with mothers and families is essential.

Over the past five or six years, we’ve seen major changes in the way innovative organizations in all industries treat their customers. For far too long in our industry, there was a pervasive attitude of, “We’re hospitals, or we’re physicians, people will always come because we’re here in the community,” but those days are over. Consumers don’t want to be told when to come or what to do – they want to access care and services on their terms, not ours. We are in the consumer service business, and our patients are educated and knowledgeable. They value easy access, a pleasant experience and quality care, so it’s our job to adapt quickly to meet their needs and expectations.

4. Strategies about “healthcare” must now encompass behavioral and mental health
As social stigmas surrounding mental health begin to break down and more people feel comfortable confronting behavioral health issues, it is the responsibility of providers to design their systems in a way that addresses the needs of these individuals. This is especially important at a time when opioid abuse has become one of this nation’s most-challenging public health crises.

The problem goes beyond drug and alcohol abuse. For instance, studies have shown that younger generations’ increased use of technology, particularly mobile devices, can lead to increased rates of anxiety, depression or loneliness. We as providers must consider these trends and tailor services accordingly, as more and more patients turn to us seeking care for issues that are destroying lives and breaking up families. All of us need to do a better job developing and training staff to meet this demand, especially when it comes to screening those who are trying to hide their addictions to opioids. It entails not only psychiatrists but nurses, social workers, case managers and other clinicians.

Regardless of the issues we face in this ever-evolving industry, we as providers must not resist change. We must continually adapt — those that don’t will get left behind.

TORONTO — For Dr. Peter Cram, an American internist who spent most of his career practicing in Iowa City, Iowa, moving here about four years ago was almost a no-brainer.

He’s part of a small cohort of American doctors who, for personal or professional reasons, have moved north to practice in Canada’s single-payer system. Now when he sees patients, he doesn’t worry about whether they can afford treatment. He knows “everyone gets a basic level of care,” so he focuses less on their finances and more on actual medical needs.

Cram treats his move as a sort of life-size experiment. As a U.S.-trained physician and a health system researcher, he is now studying what he says is still a little-understood question: How do the United States and Canada — neighbors with vastly different health systems — compare in terms of actual results? Does one do a better job of keeping people healthy?

For all of the political talk, in many ways it is still an open question.

“The Canadian system is not perfect. Neither is the United States’,” Cram said over coffee in Toronto’s Kensington Market. “Anyone who gives you a sound bite and says this system should be adopted by this country … I think they’re being almost disingenuous.”

Still, American support for government-run, single-payer health care, once a fringe opinion, is picking up momentum.

Sen. Bernie Sanders, the Vermont independent who emphasized single-payer health care in his 2016 presidential bid, helped move Canada into the U.S. spotlight.

Lawmakers in California and New York have taken steps toward such programs on a statewide level, and the concept is a hot topic in gubernatorial campaigns in both Illinois and Maryland.

In addition, polling finds doctors and patients increasingly supportive, though the percentages in favor typically drop when questions are focused on the taxpayer costs of such a system.

In Canada, medical insurance comes through a publicly funded plan. And, while covering everyone, Canada still spends far less on health care than the United States does: just over 10 percent of its GDP, compared with the United States’ 18 percent.

To many American advocates, Canada’s health system sounds like the answer to the United States’ challenges. But in Toronto, experts and doctors say the United States first must address a more fundamental difference. In Canada, health care is a right. Do American lawmakers agree?

“The U.S. needs to get on with the rest of the world and get an answer on that issue before it answers others,” said Dr.
Robert Reid, a health quality researcher at the University of Toronto, who has practiced medicine in Seattle.

It’s an obvious disconnect, said Dr. Emily Queenan, a family doctor now practicing in rural Ontario. Queenan, 41, grew up in the United States and did her residency in Rochester, N.Y. By 2014, after about five years of frustrating battles with insurance companies over her patients’ coverage, she had enough. She found herself asking, why not Canada?

She moved north. Gone, she said, are the reams of insurance paperwork she faced in America. Her patients don’t worry about affording treatment.

“We have here a shared value that we all deserve access to health care,” said Queenan. “That’s something I never saw in the States.”

Sanders has pushed the discussion, with a “Medicare-for-All” bill in Congress and in a visit to Toronto this fall. It was part fact-finding mission and part publicity tour. On that trip, doctors, hospital leaders and patients painted a rosy picture where everyone gets top-notch care, with no worries about its cost to them.

“They have managed to provide health care to every man, woman and child without any out-of-pocket cost,” Sanders told reporters while speaking on the ground floor of Toronto General Hospital. “People come to a facility like this, which is one of the outstanding hospitals in Canada. They undergo a complicated heart surgery, and they leave without paying a nickel.”

It sounds idyllic. But the reality is more complicated.

While progressives tout the Canadian system for efficiently providing universal health care, the Commonwealth Fund, a nonprofit research group, puts it just two spots above the United States — which ranks last — in its health system assessment. It suggests that in timeliness, health outcomes and equitable access to care, Canada still has much to improve.

“If you deny there are trade-offs, I think you’re living in wonderland,” Cram said.

The Canadian Vibe
In Canada, everyone gets the same government-provided coverage. Provinces use federal guidelines to decide what’s covered, and there’s no cost sharing by patients.

“Come to our waiting room,” said Dr. Tara Kiran, a family doctor at St. Michael’s Hospital, in Toronto. “You will see people who are doctors or lawyers alongside people who are homeless or new immigrants. People with mental health issues or addiction issues together with people who don’t.”

But that insurance — which accounts for 70 percent of health spending in Canada —addresses only hospitals and doctors. Prescription medications, dentists, eye doctors and even some specialists aren’t covered. Most Canadians get additional private insurance to cover those.

In countries such as Britain or Germany people can opt out to buy private insurance. Canada prohibits private insurers from offering plans that compete with the government, a restriction some doctors are suing to lift. It’s not a popular view in Canada, experts said, but the implications are significant.

Here, the debate focuses more on bringing down health spending — a concern in the United States, too, but one often overtaken by politics.

Canada’s provinces put, on average, 38 percent of their budgets into health care, according to a 2016 report from the Canadian Institute for Health Information, a nonprofit organization. Canada’s single-payer system is supported by a combination of federal and provincial dollars, mostly raised through personal and corporate income taxes. (A few provinces charge premiums, which are income-based and collected with taxes.)

“We make improvements or change things only to have additional debates about other things. Those debates are constant, and they should be,” Reid said. “[But] most of what you hear in the U.S. is back to the tenor of the insurance framework, whether [they] should have Obamacare or not.”

Taxes in Canada are generally higher than in the United States. Canada, for instance, collects a levy on goods and services and also taxes wealthier citizens at a higher income tax rate.

But many here call that a concession worth making, and also note that they don’t have to pay separate premiums for health care as people in the United States do.

“We can’t have what we have if we don’t pay the taxes,” said Brigida Fortuna, a 50-year-old Toronto resident and professional dog groomer, while on her way to a medical appointment. “But you have to take care of your people. … If you don’t have good health care, you’re not going to have a good society.”

The Trade-Offs
That said, it’s not a perfect system. Canadian health care doesn’t cover prescriptions, physical therapy and psychotherapy. And there’s the concern that Canadians wait longer for health care than would Americans with robust health coverage.

There are cases, Reid said, when cancer care in Canada is delayed enough to yield health problems. Ex-pat Cram pointed to research that suggests low-income people are likely to wait longer for medical care — which can result in worse health outcomes.

“We do have a two-tiered system,” he said. “Most know it. Few will admit it.”

Typically, experts said, people with serious medical needs will jump to the front of the line for medical care. Kathleen Wynne, Ontario’s Liberal Party premier, said the Canadian government is actively trying to improve wait times.

But so far, it’s unclear how effective that’s been. A 2017 report from the nonprofit Canadian Institute for Health Information found that wait times had dropped for hip fracture repairs. But waits for, say, MRIs and cataract surgery have actually gotten worse. Depending on their province, the average wait for cataract removal ranged from 37 days to 148 days.

Many patients, though, said the waits were a trade-off they were willing to make. Toronto-based Nate Kreisworth, a 37-year-old music composer and producer, called it an obvious choice.

“You are not going to die because you’re waiting,” he said on a recent sunny morning while walking with his dog near Kensington Market. “Better wait times for everything? Sure, why not. But as long as the major issues are being covered, then I don’t think it’s really much of an issue.”

As Fortuna put it: “If you go for a headache and someone else is going to lose their arm, of course they’re going to take care of that person. I’m OK with that, because someday that could be me, too.”

Waits aren’t the only concern, though. There’s financing — and what it would cost for the United States to implement a system like Canada’s.

Because Americans have higher expectations about what a health plan should cover, it would be more expensive to adapt a Canadian approach, said Dr. Irfan Dhalla, an internist and health quality researcher in Toronto. And the quality may differ from what they are used to.

And in Canada, “everyone gets Kmart care,” Cram said. “There’s no Neiman Marcus care.”

Of course, some amenities that drive up costs — fancier food, softer gowns or private rooms — don’t necessarily produce better results.

A 2017 study found that patients with cystic fibrosis fared better in Canada than in the United States. But on the other hand, 2015 research comparing surgical outcomes found better results in the United States than in Canada. The Commonwealth Fund’s most recent ranking places Canadian health outcomes above America’s, but only by two slots.

Even so, many Canadians said they couldn’t imagine living with an American system. It’s a question not just of efficiency, but of fairness. Kreisworth compared his experience to that of family members in the United States.

“I talk to my brother’s girlfriend who is a part-time worker who has no [health] benefits — who would just be sick and not go to the doctor because she couldn’t afford to pay,” he said. “I can’t imagine that here. It seems like — it’s so wrong. It just seems utterly wrong.”

A group of Madison Fire Department paramedics are seeing success with a pilot program that allows them to work on prevention methods with people who are frequently calling for emergency services.

The community paramedicine program has been in place in Madison for about two years. It’s run by paramedics Gail Campbell and Mindy Dessert. They received additional health care training to start the program.

They work with people like 73-year-old Sandra Espinoza. She started using an oxygen tank a few years ago and struggled to get used to it. She was having a hard time breathing and when she ran in to trouble, she would call 911. In 2015, she called for medical help 127 times.

“Sometimes I would call two or three times a day because I just did not know what I was doing,” Sandra said.

Gail and Mindy started making home visits to help teach Sandra how to use her oxygen tank. They worked together to find ways to prevent Sandra from having to get emergency care.

“it just took a little advocating, educating and just coming and spending some time with her and finding out what was that missing piece that 911 was filling,” Mindy said.

The program is a partnership with Meriter Hospital. David Hahn, a Nurse Case Manager in the Emergency Department, says the program is part of a growing trend in health care.

“Health care is changing more towards a patient-centered model. The health care needs of the patients is going beyond the walls of the hospitals and clinics and that change is what we’re seeing right now with community paramedicine,” Hahn said.

In November, Gov. Scott Walker signed a bill in to law that would create a formal certification program that paramedics can get to create and participate in their own programs, tailored to their community’s needs.

Gail and Mindy say they’ve found a lot of success in their program over the past two years. In Sandra’s case, in 2017, she’s called 911 less than 20 times. Most of those calls were for health problems unrelated to her oxygen tank.

“I didn’t like calling 911 but i didn’t know what else to do. It was a mess. I was a mess. I didn’t know what to do but now I know,” Sandra said.

“It’s not real hard stuff it’s just kind of figuring out what is that missing piece,” Mindy said.

The CMS is ending a funding stream that states relied on to transform their healthcare systems to provide more efficient patient care, saying it’s unclear that the program is a good investment.

Over the years, states have received billions of dollars through the Designated State Health Programs, or DSHP, which can be used to finance delivery system reform. Those funds have gone toward health issues including lead poisoning prevention or supported employment programs that benefit Medicaid beneficiaries, according to Judy Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

But the CMS said Friday that it will not renew DSHP portions of Medicaid waivers when they expire, and new requests for DSHP money will be denied.

“Current demonstrations have not made a compelling case that federal DSHP funding is a prudent federal investment,” CMS Medicaid Director Brian Neale said in a letter to state officials Friday.

Health policy insiders said the news wasn’t much of a shock, as the Trump administration has previously stated it would reduce healthcare program spending.

“I am not surprised that the administration, despite its stated interest in improving healthcare quality, would cease investing in delivery system reform for the Medicaid population,” said Sara Rosenbaum, a professor health policy at the George Washington University.

DSHP funds were always supposed to be a temporary solution to help drive delivery system reform. However, states have viewed the federal dollars as a source of additional revenue, Neale said.

“This, in effect, results in increased federal expenditures without a comparable increase in the state’s investment in its demonstration,” Neale said in the letter.

The Medicaid and CHIP Payment and Access Commission has noted a similar sentiment when it evaluated delivery reform experiments around the country.

Arizona, California, New York, New Hampshire, Rhode Island and Washington now have waivers that include DSHP funds.

Spokespeople from those state Medicaid agencies noted they still had DSHP funds for several years to come. They acknowledged they may have to come up with a replacement if delivery system reform efforts continue beyond the funding’s expiration.

“We have always understood that this DSHP was only available for the five-year life of our Medicaid transformation demonstration,” Amy Blondin, a spokeswoman for Washington’s Medicaid agency, said. “We are pleased to be able to continue the transformative work we have already underway with our waiver.”

As long as states are allowed to complete their waiver terms without change, the elimination of DSHP shouldn’t be a problem in the short term, Solomon said.

“However, for states that rely on this as a way of financing their initiatives it could make it harder for them to continue their reform efforts in the future, and of course no new states would be able to utilize this method to finance future efforts to reform their delivery systems,” Solomon said.

The Obama administration shared the Trump administration’s view that DSHP funds should be a temporary aid for health system transformation, according to Eliot Fishman, who oversaw 1115 waiver under the Obama administration and is now senior director of health policy at Families USA.

However, he was disappointed that states that haven’t yet used this funding tool will never get the chance to do so, as delivery system reform is needed around the country.

“We are still in the second or third inning out of nine when it comes to Medicaid system transformation,” Fishman said. “This is something that still needs federal support.”

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Note – from an explanation provided to the National Governor’s Association in a report authored by the Center for Health Care Strategies:
https://www.chcs.org/media/Medicaid-Compendium-Overview.pdf

1115 WAIVERS/DELIVERY SYSTEM REFORM INCENTIVE PROGRAM/DESIGNATED STATE HEALTH PROGRAMS
Some states have received approval from HHS for Medicaid Section 1115 demonstrations that have provided states with the authority to make sweeping changes to their Medicaid programs while receiving additional funding from the federal government. For example, states have Section 1115 demonstrations that allow them to implement large-scale delivery system and payment reform efforts and to receive additional federal funds through the DSRIP, which states have used to make additional payments to providers and other entities, and Designated State Health Programs (DSHP), which are state-funded programs that would not otherwise be eligible for federal Medicaid matching funds.

Since the first DSRIP program was approved in California in 2010, seven additional states (Kansas, Massachusetts, New Jersey, New Mexico, New York, Oregon, and Texas) have received approval from HHS for DSRIP programs and several of these states have extended their programs.

Early DSRIP programs provided federal funding for payments to hospitals, and particularly safety net hospitals, with metrics tied to the success of individual projects. More recent DSRIP programs provide federal funding for payments to integrated delivery networks linking hospitals to other providers and social service agencies, with metrics tied to system transformation.

Significantly, in more recent waivers, both the integrated delivery networks receiving DSRIP funds and the state are at risk based on quality and cost measures – meaning that a failure to achieve these metrics results in reductions of DSRIP funds.

New York is using its DSRIP to invest in 25 Performing Provider Systems, each of which must include a network of acute, long-term care, and behavioral health providers with linkages to community- based social services organizations. Providers must form partnerships to implement innovative projects focusing on system transformation, clinical improvement, and population health improvement. DSRIP funds are used to reward performance linked to achievement of specific project milestones associated with specific projects. One keystone of New York’s demonstration is the link between DSRIP funds and demonstrable metrics with an overarching goal of reducing avoidable hospitalizations by 25 percent over five years.

Oregon is using its Section 1115 demonstration waiver to implement its CCO program. Under this demonstration, Oregon obtained a significant level of federal matching funds to support CCO implementation. The state used DSHP funds to invest in a Transformation Center, innovator agents, learning collaboratives, and other technical supports, which are part of the quality strategy that Oregon developed to meet its program goals. DSHP is tied closely to specific terms and conditions pertaining to the annual expenditure reduction in spending targets and quality and access standards. For example, CMS is authorized to reduce DSHP funding if Oregon does not meet those terms.

Kindred Healthcare (NYSE: KND), the nation’s largest home health care provider, is in advanced talks to be acquired by insurance giant Humana Inc. (NYSE: HUM) and two private equity firms, the Wall Street Journal reported Sunday. The newspaper cited “people familiar with the matter.”

Kindred and Humana did not immediately respond to requests for comment from Home Health Care News on Sunday afternoon.

Louisville, Kentucky-based Kindred would be divided up as part of the complex deal, WSJ reported.

Under terms of the rumored deal, private equity firms Welsh, Carson, Anderson & Stowe and TPG would acquire Kindred’s 77 long-term care hospital and 19 rehabilitation facilities. The private equity firms and Humana would acquire Kindred’s home and hospice business.

The deal values Kindred’s stock at $9 per share, giving the company a $750 million market value with a total enterprise value of $4 billion, according to the Journal. KND shares were trading at $8.60 at market close on Friday. Kindred’s share price was buoyed last month, when the Centers for Medicare & Medicaid Services (CMS) announced it would hold off for now on a controversial new framework for reimbursing home health agencies.

The latest takeover rumor comes as Kindred has been in a period of transformation, and follows other reports that potential takeover bids had not been successful.

After its $1.8 billion merger with Gentiva Health Services, completed in 2015, Kindred became the largest home health and hospice provider in the United States but also increased its debt load. Since then, it has made a big move to divest its large skilled nursing business.

This potential Humana deal could be announced “soon,” WSJ reported, but noted that it still could fall through.

Insurers making big moves
Humana, which is also based in Louisville, is a major health insurance provider, with more than 13 million customers. The company also has some home health care operations and executives recently expressed their desires to expand the home care business line, in discussing third quarter earnings.

Should it materialize, the Humana transaction would come on the heels of another major health care deal; at the beginning of the month, CVS Health (NYSE: CVS) announced it will be acquiring Aetna (NYSE: AET), the nation’s third-largest health insurance provider, for $69 billion.

Early in 2017, Humana and Aetna called off their proposed $34 billion merger, facing federal opposition due to antitrust concerns.

Humana’s home care division, Humana at Home, took a hit at the beginning of 2017 as the health system experienced a $400 million loss. In February, the company announced 500 home care workers were laid off in its Ohio and Florida locations.

But both Humana and Kindred have touted their ability to enhance coordination between acute and post-acute settings in general, and home health in particular, as a way to improve outcomes while keeping costs down in value-based payment models.

The CMS announced on Thursday that patient experience scores and star ratings have been added to the Physician Compare website for patients and caregivers to view.

The site will now display physicians’ 2016 performance under the Physician Quality Reporting System as star ratings.

Patient survey scores from the Consumer Assessment of Healthcare Providers and Systems surveys will be listed on “group pages” that show the overall performance of a physician practice instead of individual doctors.

The measures used to get a composite 5-star rating score for doctors involve preventive care, patient safety, care planning, diabetes, behavioral health and heart disease.

Physician Compare was also updated to show 2016 data from the Shared Savings Program.

Earlier this week, the CMS also announced it added four new quality measures for healthcare consumers to view on the Inpatient Rehabilitation Facility and Long-Term Care Hospital Compare websites.

The CMS’ suite of Compare sites were mandated under the Affordable Care Act and designed to encourage Medicare beneficiaries to seek out high-quality healthcare. However, a few of them have been flagged for having incorrect information. As recently as last week, the CMS said an update to its Hospice Compare website would be delayed while some information was corrected.

CMS Administrator Seema Verma has publicly touted her commitment to improving patients’ access to information that allows them to shop for their care.

In what is believed to be the first study to measure the impact of Uber and other ride-booking services on the U.S. ambulance business, two researchers have concluded that ambulance usage is dropping across the country.

A research paper released Wednesday examined ambulance usage rates in 766 U.S. cities in 43 states as Uber entered their markets from 2013 to 2015.

Co-authors David Slusky, an assistant professor of economics at the University of Kansas, and Dr. Leon Moskatel, an internist at Scripps Mercy Hospital in San Diego, said they believe their study is the first to explain a trend that until now has only been discussed anecdotally.

Comparing ambulance volumes before and after Uber became available in each city, the two men found that the ambulance usage rate dipped significantly.

Slusky said after using different methodologies to obtain the “most conservative” decline in ambulance usage, the researchers calculated the drop to be “at least” 7 percent.

“My guess is it will go up a little bit and stabilize at 10 to 15 percent as Uber continues to expand as an alternative for people,’’ Moskatel said.

Slusky said he and Moskatel are submitting the paper to journals for peer review.

San Francisco-based Uber quickly distanced itself from the notion that hailing an Uber driver is an acceptable substitute for calling an ambulance.

“We’re grateful our service has helped people get to where they’re going when they need it the most,” said company spokesman Andrew Hasbun. “However, it’s important to note that Uber is not a substitute for law enforcement or medical professionals. In the event of any medical emergency, we always encourage people to call 911.”

Moskatel, however, said many patients “tend to be pretty good at assessing their state and how quickly they need to come in and how sick they are.”

But at least one prominent Bay Area emergency room physician disagreed.

Paul Kivela, president of the 37,000-member American College of Emergency Physicians, said he believes that for those low-risk patients who can’t drive themselves to the emergency room, Uber is a good service.

But many people, he said, may not be able to differentiate between a life-threatening emergency and an innocuous medical issue. So, he said, calling 911 is always the safest bet.

“A paramedic has the training and the ability to deliver life-saving care en route,” Kivela said. “Where I really have a hard time is believing an Uber driver is going to attend to you.”

Kivela noted that in addition to his work as an ER doctor at Queen of the Valley Medical Center in Napa, he is also the medical director of an ambulance company in Solano County.

The researchers, however, insisted that ride-booking services such as Uber and San Francisco-based Lyft can sometimes be the best way to get to the hospital in a hurry.

Previous research, Moskatel said, “suggests that a fair number of people are using ambulances to get to the hospital because they simply don’t have another way to get there’’ — particularly those who live in areas with limited taxi service.

And, Slusky added, with health care taking a big chunk out of most people’s budgets, many consumers these days have to weigh a few factors before calling an ambulance.

“They have to think about their health — and what it’s going to cost me,” he said. “And for many of us with high-deductible plans, an ambulance ride would cost thousands of dollars.’’

Slusky added: “If we want to reduce (health care) spending, we have to find ways to do things cheaper — and that’s in all kinds of situations where you don’t need the most expensive resource. We don’t all need to fly first-class all the time.”

Moskatel and Slusky said they focused only on Uber because they needed a broad set of data and the company had been operating for a longer period of time than competing services, allowing the researchers to assess a greater number of locations.

Because Uber was not involved in the study, Moskatel had to painstakingly map all the dates the company entered a certain market, based only on the company’s public announcements.

Ambulance rates were obtained from the National Emergency Medical Services Information System, or NEMSIS, a national repository for emergency medical services data.

Slusky said Salt Lake City-based NEMSIS agreed to run the numbers for each city, but an agreement between NEMSIS and its members prevents any release of information that could be used to identify rates for specific regions at the state, city or ZIP Code level.

In Santa Clara County, Emergency Medical Services director Jackie Lowther said there had been “no significant decrease in volumes in Santa Clara County, other than the usual seasonal variation for this time of year.’’

Travis Kusman, Lowther’s counterpart in Alameda County, did not respond to a request for comment. Nor did officials from Lyft.

A person in Missouri, walking along the side of a street, was suddenly struck by a car. The patient was taken to the emergency department, where multiple imaging studies revealed that despite bad scrapes and contusions, there were no broken bones. In another case, a patient who was potentially experiencing a stroke received tPA, a life-saving medication used to dissolve blood clots in the brain, and was admitted to the ICU.

In several other instances, Missourians have sought care in the ED for what they thought were broken bones.
Indianapolis-based health insurer Anthem denied payment for each of these cases under its new program meant to curb inappropriate ED use, according to emergency physicians and hospital administrators in Missouri, where the policy took effect in June.

Under the controversial policy, which nabbed plenty of headlines when it was rolled out in some states in mid-2017, Anthem won’t cover ED visits for conditions that the insurer decides were not emergent after a review.

Now, several months after the policy went into effect in Missouri and Georgia—it was rolled out in certain parts of Kentucky in late 2015—hospitals and patients are feeling the impact. Hospitals say the claim denials are piling up, and they’re forced to go through burdensome appeal processes. Patients are reeling from large medical bills for conditions they believed were emergencies. And emergency physicians worry that the policy will have a chilling effect on patients seeking care in an emergency, which could lead to worse health outcomes.

“If they get burned one time by a large bill, the next time they will delay going to the ED when they really need to be there,” said Dr. Jonathan Heidt, an ED doctor and president of the Missouri chapter of the American College of Emergency Physicians. “They are going to have a worse outcome from their illness or injury, or it could even lead to a patient death because they were too scared to go the ER for getting a large bill.”

Insurers and self-insured employers have long tried to encourage plan members to seek care at lower-cost settings. They usually do this by providing incentives, such as lower co-pays, if the patient chooses an urgent-care center over an emergency room when accessing medical care.

Anthem’s ED policy, which will expand to Indiana, New Hampshire and Ohio next year, takes the concept much further by denying payment altogether based on a retrospective view of a claim. Anthem said the policy is meant to promote delivering non-emergent care in the appropriate setting, such as retail or urgent-care clinics, or via telehealth. The insurer will cover non-emergent care in the ED if there is no clinic within 15 miles of a patient and a nurse is available to help plan members decide where to seek care. The policy applies only to commercial members, not Medicare, an Anthem spokeswoman said. Anthem also recently started denying coverage for MRI and CT scans on an outpatient basis in hospitals.

Anthem implemented the ED program because of “an uptick in emergency room visits for non-emergency treatment, despite education campaigns to inform the public about the costs and inconvenience of going to the ER for non-emergent care,” the spokeswoman said in an email. She added that in Missouri, for instance, ED visits have increased 20% since 2014, and many of those were for non-emergency ailments, including itchy eyes from seasonal allergies, treatment for ingrown toenails and suture removal.

The policy “doesn’t reflect the reality of the situation facing physicians and patients. Sometimes we need to do a fair number of tests to figure out if a patient’s condition is emergent or not. It’s not fair to expect patients to know,” said Dr. Laura Burke, an emergency physician and researcher at Beth Israel Deaconess Medical Center in Boston.

Diagnostic codes rarely tell the whole story, physicians said. A patient who shows up in the ED with chest pain could be having a heart attack, or the patient could be suffering from heartburn, Heidt said. It may take tests to determine what’s really going on. Deciding whether the ED visit deserves payment based on the final codes fails to take into account the circumstances surrounding a patient’s choice to go to the ER.

“They are not looking at any medical records at all. It’s difficult enough to determine what a patient was thinking based off an ER note, let alone just ICD-10 codes,” Heidt said.

A Missouri Hospital Association analysis of Anthem’s list of more than 1,900 diagnostic codes for avoidable ED services found that only 15% of the codes are classified as non-emergent when compared against the widely accepted New York University ED classification algorithm. Of those, fewer than 100 codes of the total 1,900 on the list are considered non-emergent beyond a doubt.

An Anthem spokeswoman said that particular list pertains to Missouri only and is outdated, though she would not provide the updated list, adding that the list is “continually evolving based on experience and further evaluation.”

Nine diagnostic codes on Anthem’s list deal with arm pain. In a letter to the American Heart Association sent late October, the Missouri hospital and medical associations explained that the average person may suspect that symptoms of arm pain could mean a heart attack. In 2016, almost 4,500 ED visits in Missouri had an initial diagnosis related to arm pain. Of those, 1 in 3 patients was diagnosed with a secondary cardiovascular condition.

Physicians are concerned that Anthem’s policy violates the long-standing prudent layperson standard, which is a law in 47 states and included in the Affordable Care Act. The standard gives patients protection to seek emergency care and hospitals’ assurance that they will be reimbursed. It holds that ED insurance coverage should be based on whether a prudent layperson, defined as someone with reasonable medical and health knowledge, could reasonably expect their health to be in jeopardy in an emergency, and not based on the final diagnosis codes.

Anthem said its policy complies with this standard.

But even when hospitals come out on the winning end of a disputed claim, they are coming up short.

A patient recently visited Cedar County Memorial Hospital, a critical-access facility in El Dorado Springs, Mo., with symptoms of gastrointestinal illness, dehydration and fainting. The patient had initially gone to a local clinic where a provider directed her to visit the ED. Anthem denied coverage for the visit, but later overturned the decision after an appeal. Jana Witt, Cedar County’s CEO, said the hospital has yet to receive payment, however.

“It does take a substantial amount of time to deal with fighting a denial like that,” Witt said. But patient outcomes are her primary concern. “The patient actually was experiencing a gastrointestinal illness, dehydration, and fainting—how is she to judge? Anthem’s policy is leaving that patient to decide, and they don’t have the knowledge to do so.”
Of course, some ED visits are avoidable. U.S. healthcare spending continues to climb, topping $3.2 trillion in 2015, or nearly $10,000 per person, according to the CMS. Emergency department spending is a piece of that, albeit a small part, despite public belief to the contrary. ED visits rose to a record high of 141.4 million in 2014, according to the Centers for Disease Control and Prevention. But the CDC also found that only 4.3% of ED visits were because of non-urgent symptoms that year. Other studies back that up.

Anthem has not disclosed how much of its claims costs come from ED visits. And it’s unclear how the policy will affect hospitals’ bottom lines in the long run. The revenue hospitals receive from emergency care varies by hospital and depends on payer mix, contracted rates with insurers, and other factors.

Hospitals and associations are now collecting stories of patients whose claims for emergency care have been denied by Anthem. Georgia’s insurance department has also said it is tracking consumer complaints related to Anthem’s policy. Because the policy is new and so far has been implemented in only a few states, it’ll be hard to bring enforcement action against Anthem, said Laura Wooster, ACEP’s associate executive director of public affairs.

Herb Kuhn, the Missouri Hospital Association’s CEO and a former CMS official, fears the policy will trigger a “cat and mouse game between healthcare providers and insurers,” forcing providers to seek legislative changes to block insurers from implementing policies that discourage ED use.

“Rather than working together on what we all ought to be—that coordinated care is better than uncoordinated care—instead, we’re all just chasing one another, trying to go to regulators and legislators to legislate protections in areas like this,” he said.

For years I wondered why despite being a confirmed urbanite, I love camping. Then I realized that camping gives me full permission to improvise—to make creative use of the limited materials I have to get the job done. Hence, shirt tails are fair game for wiping coffee grounds out of measuring spoons.

Similarly, I am inspired by people and groups that use the resources we have at our disposal in health care in creative new ways. Like the first explorers, these folks are testing approaches to provide care that are more effectively than the status quo. Given the escalating health care costs, we need to be looking for ways to make the available financial resources work better for us. And, studies have shown that health care delivery includes a lot of wasted time, resources, and supplies, due in part to use of higher-priced services with no health benefits over less-expensive alternatives.
At a recent meeting on patient safety, I heard about a novel way of using a previously untapped resource—emergency medical technicians (EMTs), those courageous first responders to 911 calls. I followed up with Matt Zavadsky, MS-HSA, NREMT, who is the chief strategic integration officer at MedStar Mobile Healthcare, which provides emergency medical services (EMS) in the Fort Worth, Texas area, to learn more about it.

Here’s what he told me.

For decades EMS units have been paid only to respond to emergency calls and transport people to the hospital. If they were to transport a person who needed less intense care to a lower acuity setting, like a walk in center or a clinic, they would not be paid—representing overuse of higher-priced services. In addition, EMTs, especially those based in fire departments, often spend a substantial portion of their shift waiting for emergency calls—representing underutilized human resources.

The idea to change the EMS system to better match patient needs with transport location emerged decades ago, but the fee-for-services payment system provided an incentive to bill for the most intense services rather than the services actually needed by the patient. In 2010, the passage of the Affordable Care Act allowed for payment based on value (delivering what the patient actually needs) instead of volume (more high acuity, hospital admissions and emergency department [ED] visits).

Zavadsky described three examples where EMS agencies are providing care navigation rather than only transporting people to the hospital. As he pointed out, these new models of care delivery are only sustainable where the EMS units are being reimbursed for the care of a population of patients rather than the number of ambulance transports completed. Today, large health insurance companies are signing capitated agreements (for example, an in-advance per-member-per-month fee) with EMS units to use their available resources to coordinate care and help covered patients navigate to the correct setting based on their needs.

9-1-1 Nurse Triage
A 911 dispatcher uses a protocol to identify calls for non-urgent medical issues, which are transferred to a nurse who works in the 911 call center. The nurse queries the caller to determine the appropriate level of care and assists with transportation if needed. For example, if a parent calls about a child with fever, sore throat, and vomiting, and the pediatrician’s office is closed, the nurse can direct the parent to the after-hours pediatric clinic at the local children’s hospital and can provide arrange for paid transport to and from the clinic. The child avoids a long wait in the ED and has access to follow up care at the clinic if needed—and the insurance payer avoids the costly and unnecessary ambulance visit and ED cost. Plus, the EMTs and ambulance are freed up to serve people with high-acuity, emergency needs.

High-utilizer programs
Hospital case managers provide EMS agencies with information about patients who are frequently seen in the emergency department or who frequently call 911. EMTs identify the unmet needs that are driving the high ED utilization and provide or facilitate in-home care, health coaching, and round-the-clock access to health care. For example, a young man who had developed an opioid addiction after a work-related back injury was visiting one of 10 EDs every day to obtain more prescription drugs. EMTs provided education and coaching, then worked with him to complete a pain management contract. Within 12 weeks he was opioid-free and remained so when interviewed several years later. A study of the program showed that ED visits and hospitalizations were significantly reduced—and participants’ reported quality of life improved.

Readmission management
Using a similar approach to that for the high-utilizer programs, at discharge hospitals refer to the EMS agency patients believed to be at risk for a preventable readmission. Paramedics visit these patients at home, review discharge instructions, provide health education, and ensure medication compliance and safety. They also ensure that patients are following up with their physicians and facilitate care in the home or at low-acuity settings, as needed.

According to Zavadsky, these programs can be very cost effective. His organization estimates that their nurse triage program saves $1,100 per patient caller (avoided expenditure for ambulance transport and ED visit), their high-utilizer program saves $17,000 per patient enrolled (avoided expenditure for ambulance transport, ED visits, and inpatient admissions), and their readmission management program saves $9,000 per patient enrolled, using average Medicare expenditure data as a comparison.

These models sounded intriguing but I wondered about quality measures—what mechanisms were in place to prevent withholding care at high-acuity settings when it is needed? Zavadsky sent me a list of the metrics that have been developed collaboratively with input from more than 50 stakeholder groups, including EMS associations, accrediting bodies, payer associations, and patient safety organizations. I was pleased to see the list included not only cost and utilization metrics, but also measures of adverse outcomes, unplanned acute care utilization, and patient and primary care provider satisfaction. Consistent with the overall move to value-based economic models, EMS agencies are reporting a subset of these metrics as part of the new models, including capitated agreements.

In addition to these existing programs, Zavadsky explained another way that EMTs—which he described as a “standing army of resources”—could work to improve care delivery. Just as firefighters conduct building inspections to reduce fire risks, EMTs could conduct home assessments for people at risk for injury in the home, malnutrition, or elder neglect. They could then contact health care providers or community services as indicated. EMTs could complete these assessments during existing downtime during their shifts. In addition, during 911 calls for medical services firefighters could use a simple checklist to identify homes with safety concerns.

These models of care delivery are exciting because they use existing resources in a novel way and represent a triple win, with benefits for patients, care providers, and payers.

The CMS on Thursday released a list of 32 reporting measures under consideration for Medicare’s quality reporting and value-based purchasing programs.

The number of measures under review is much smaller compared to last year when CMS considered nearly 100 measures. The move is in line with CMS Administrator Seema Verma’s focus on reducing regulatory burden for providers. The agency recently launched the Meaningful Measures initiative to identify measures that will have the greatest impact on quality care improvement.

This year, CMS selected 32 measures for consideration out of a pool of 184 submitted by stakeholders. About 40% of measures on the list are outcome measures, which quality experts say are most valuable to patients and need more development.

Some of the measures focus on functional status changes after surgery and diabetes control.

The CMS publishes a list each year of quality and cost measures for consideration and works with the National Quality Forum to get input from patients, clinicians, commercial payers and purchasers, on the most suitable measures.

The NQF’s Measure Applications Partnership will present its recommendations to the CMS by Feb. 8.

In March, NQF made the unusual decision to suggest to the federal government remove 51 of 240 measures in an attempt to remove measures that no longer have value for patients or providers.

“NQF is committed to meaningful measures that focus on outcomes and aspects of care that are most important to patients, while also identifying leading measure gaps that must be addressed to achieve the nation’s healthcare priorities,” Shantanu Agrawal, president and CEO of NQF, said in a statement.