Sunday, July 31, 2016
Friday, July 29, 2016
Thursday, July 28, 2016
Wednesday, July 27, 2016
Tuesday, July 26, 2016
Sunday, July 24, 2016
Friday, July 22, 2016
Thursday, July 21, 2016
Tuesday, July 19, 2016
Monday, July 18, 2016
Sunday, July 17, 2016
Surprise! Freestanding ERs Aren't Always What They Seem
Surprise! Freestanding ERs Aren't Always What They Seem
Freestanding ERs have been around for years. But only recently have they become profit-focused, deceptive places of care.
BY MATTIE QUINN | JULY 12, 2016 | GOVERNING
Going to the hospital is rarely a pleasant experience. In the last few years, though, it's gotten a lot easier to visit an emergency room without ever setting foot in or near a hospital. Easier for some, at least.
Freestanding ERs have become a more popular alternative for some to hospital ERs. But while they're more convenient, they often leave patients with surprise medical bills and rarely improve health-care access for the people who need it most.
There are currently 360 freestanding ERs in the U.S. -- 60 percent of which are in Colorado, Ohio and Texas. Unlike most urgent care clinics, they're usually open 24/7 and have "emergency" in their titles. The first of them opened in the 1970s as a way to provide emergency care for areas that didn't have a hospital. But in the past decade, entrepreneurs have increasingly established freestanding ERs with a more profit-focused, free-market model of health care. In other words, while most older freestanding ERs accept insurance, most newer ones don't.
A new study in the Annals of Emergency Medicine also found that most freestanding ERs are located in areas with more privately insured individuals -- people who, even if they were surprised by a bill, would be more likely to pay in full.
“They are an extremely innovative model of care,” said Jeremiah Schuur, an emergency doctor and lead researcher on the study. “They’ve provided the components of emergency care, but without the big, complicated hospital system. But the thing is, our health-care system isn’t really a free market. People think of emergency care as a public service. It is the one guaranteed health-care right given to us by law. But that’s simply not the case [with most] freestanding ERs."
This has been especially apparent in Texas, where 73 percent of all freestanding ERs are private, for-profit entities and the majority of out-of-network claims are filed from a freestanding ER, according to the Texas Association of Health Plans.
“They can be tricky. Many of them will tell a patient when they’re getting treatment that they accept insurance, but the patient gets a surprise bill down the line because they are out-of-network,” said Jamie Dudensing, executive director of Texas Association of Health Plans. “They are also typically nicer than your average ER, and it’s easier to get the care you want. They tend to cater to the consumer."
But that added convenience and luxury comes at a price. For example, getting treated at an urgent care clinic for an ear infection will generally run about $100. But at a freestanding ER, that same treatment could cost patients $760.
SOURCE: Texas Association of Health Plans
State regulations surrounding freestanding ERs vary wildly.
California, for instance, has so many regulations that “when you add it all up, it basically requires them to just be a hospital,” said Schuur.
On the other hand, Colorado and Texas -- which hold most of the country's freestanding ERs -- essentially require just three things: an application, a fee and a transfer agreement with a local hospital. Ohio is a bit more stringent, requiring all freestanding ERs to be hospital-affiliated.
Texas, however, is cracking down on the increasingly for-profit industry. The state passed a law last year that requires freestanding ERs to make patients aware that physicians might not be in their health insurance network. And according to Dudensing, the state legislature is expected to take up more patient protection measures in its next session. The aim of future legislation, said Dudensing, is to increase transparency. She's confident that will happen.
“Consumers want easier access, and they want to be seen that day. It just so happens that the people who can do that are also the most expensive right now. It’s all very confusing for consumers, but with time and more laws, it’ll work itself out."
Friday, July 15, 2016
Thursday, July 14, 2016
Per-Capita Health Spending Likely to Top $10,000 for First Time
Per-Capita Health Spending Likely to Top $10,000 for First Time
By Kerry Young, CQ Roll Call, July 13, 2016
Spending on health care in the United States is expected to inch past $10,000 per person for the first time this year, due in part to the rising tab for hospital care, insurance administrative costs and prescription drugs.
The Centers for Medicare and Medicaid Services on Wednesday released national health expenditure projections showing the cost of health care rising to $10,346 per person this year, up from $9,960 last year. The widely followed CMS report provides insights into how the aging population and recent laws have changed medical spending and may continue to do so in the future.
The nation is facing what the CMS staff called “differential pressures on health spending growth” in a paper published in the journal Health Affairs. Congress has enacted several measures that include curbs on Medicare spending, including the sequester triggered by the 2011 budget deal (PL 112-25) and the 2010 health overhaul (PL 111-148, Pl 111-152). Yet the overhaul also has helped many Americans obtain insurance and thus get costly treatments they might not otherwise have been able to afford.
“Economywide and medical-specific price growth have been very low, helping restrain inflation’s impact on health spending, and the Medicare program is experimenting with various alternative payment approaches,” wrote Sean P. Keehan, a CMS economist who is the paper’s lead author, and his colleagues. “Meanwhile, many Americans are gaining access to health coverage for the first time, aging into Medicare, or finding that a greater share of their health expenses needs to be paid out of pocket.”
The balance of cost-control efforts against rising demands for medical care appear to be stabilizing the growth of national health expenses for now. The total tab for health care rose 5.5 percent last year to $3.2 trillion, with the growth rate little changed from the 5.3 percent increase in 2014.
Contributors to this year's expected increase were hospital costs, which rose to nearly $1.1 trillion from more than $1 trillion. The tab for prescription drugs climbed to $342 billion from $322 billion. The net cost of health insurance rose to $220.4 billion from $209.7 billion.
Looking out to 2025, the growth rate for national health expenditures may inch up to 6 percent. CMS staffers noted that the growth rate of health care in recent years has lagged the annual increases of nearly 8 percent that were seen in the two decades preceding the 2007-2009 recession.
A major contributor to the continued growth of health costs will be Medicare, with spending expected to grow faster than that of other large insurers, averaging 7.6 percent in the 2020–2025 period. Baby boomers are aging into eligibility for the program, while people already in the program are getting hospital care and doctors’ offices at higher rates than have been seen recently.
By 2025, about one in five Americans will be enrolled in the Medicare program for senior citizens and people with disabilities. That's 72 million enrollees in a national population of 351 million, the CMS staff said. The program now covers 55.8 million enrollees, with the U.S. population at about 329 million.
Other key findings from the report include:
-CMS expects the number of people without health insurance to drop to 8 percent in 2025 from about 11 percent in 2014.
-Medical prices will likely rise by about 2.4 percent per year from 2017 to 2019. Growth for 2016 was estimated at 1.5 percent.
-Expenses for private health insurance increased by 5.1 percent from 2014 to 2015, reaching $1 trillion. Average annual growth through 2025 is expected to be a similar rate of roughly 5.4 percent, CMS said.
Tuesday, July 12, 2016
Monday, July 11, 2016
Thursday, July 7, 2016
Wednesday, July 6, 2016
Medicaid Overhaul Focused on Children Is Pared Back
Medicaid Overhaul Focused on Children Is Pared Back
By Erin Mershon, CQ Roll Call, July 05, 2016
A new draft of legislation aimed at improving care coordination for children with complex medical conditions simplifies changes to Medicaid that were included in earlier bills, outside groups said.
The discussion draft, released late last week, will be a central focus of a House Energy and Commerce Health Subcommittee hearing Thursday. It would allow states to opt in to a care coordination model for some of the sickest children on Medicaid, modeled on home health demonstrations currently in place in several states. Unlike an earlier bipartisan bill (HR 546) from Rep. Joe Barton, R-Texas, the new draft does not set up new, regional or national Medicaid rules for eligible children.
The changes, in part, address concerns raised by Medicaid insurers that the earlier legislation would have inappropriately preempted state efforts to improve care coordination by using the private managed care organizations they represent. They also raised concerns about how much the program would cost both states and the federal government.
Children's hospitals, however, say the new draft won't set up as effective a network of care as the earlier drafts would.
Health Subcommittee Chairman Joe Pitts, R-Pa., said in a statement the changes enhance states' ability "to improve care coordination for these children, address access challenges and collect better data to help Medicaid programs."
The proposal and hearing come as Republicans in the House have increasingly focused on large scale changes to the Medicaid program. A white paper released by Speaker Paul D. Ryan, R-Wis., last month included dramatic changes to the program, and Rep. Brett Guthrie, R-Ky., is leading a separate task force aimed at overhauling Medicaid in the next several years.
The Medicaid Health Plans of America, which represents managed care organizations and other plans that operate within 39 states, argues that the financial solvency concerns that underpin those conversations should also help shape the discussion. While the plans contend the new draft is an improvement, they are still advocating for changes to the payment structure and the quality measures included in the bill.
In essence, the group believes Medicaid managed care plans will be better at coordinating the care needs of these complex patients than providers. The bill, they argue, should better align incentives between the new program for children and the managed care program, both through federal funding amounts and through quality measure requirements. Managed care plans should be allowed to participate in the coordination, they said.
"The new bill still has some pretty significant shortcomings, and really ignores the way in which Medicaid is evolving care for these complex care kids," said Jeff Myers, the group's president. Under this draft, "you have a system with no real measurement of quality and a possibility of an uncoordinated system of [fee-for-service] payments which won't drive incentives in the same direction. From that perspective, we have a pretty serious concern."
The hospitals, meanwhile, believe the care coordination efforts should be provider-led. They say the new proposal may prompt state-by-state variations that could complicate efforts to let children travel out of state to get care -- an opportunity they say is especially crucial because there are fewer hospitals that specialize in pediatrics or rare childhood diseases.
The hospitals also take issues with the way the new draft defines the eligible population, the services that will be provided and the quality measures to which providers will be held accountable.
"It's a simplified version of what was out there, in many dimensions," said Mark Wietecha, president of the Children's Hospital Association. "The more we can make it about specialized pediatrics, the better it will be. It will work better, it will get to the right population, it will have a stronger result. . . . The more we can get consistency, the more effective the network will be, and the current draft does leave more authority for the states."
Managed care plans are more adept at dealing with healthier populations, Wietecha said, not complex needs of patients the legislation is designed to help.
Both groups say congressional drafters have recognized a real issue and that they are committed to continuing to work with the committee on the legislation.
How Telemedicine Is Transforming Health Care The Wall Street Journal
How Telemedicine Is Transforming Health Care
The revolution is finally here—raising a host of questions for regulators, providers, insurers and patients
Melinda Beck
The Wall Street Journal
June 26, 2016 10:10 p.m. ET
After years of big promises, telemedicine is finally living up to its potential.
Driven by faster internet connections, ubiquitous smartphones and changing insurance standards, more health providers are turning to electronic communications to do their jobs—and it’s upending the delivery of health care.
Doctors are linking up with patients by phone, email and webcam. They’re also consulting with each other electronically—sometimes to make split-second decisions on heart attacks and strokes. Patients, meanwhile, are using new devices to relay their blood pressure, heart rate and other vital signs to their doctors so they can manage chronic conditions at home.
Telemedicine also allows for better care in places where medical expertise is hard to come by.
Five to 10 times a day, Doctors Without Borders relays questions about tough cases from its physicians in Niger, South Sudan and elsewhere to its network of 280 experts around the world, and back again via the internet.
In the woods outside St. Louis, shifts of doctors and nurses work around the clock in Mercy health system’s new Virtual Care Center—a “hospital without beds” that provides remote support for intensive-care units, emergency rooms and other programs in 38 smaller hospitals from North Carolina to Oklahoma. Many of them don’t have a physician on-site 24/7.
In the TeleICU section, critical-care doctors sit at oversize video monitors that continually collect data on every far-flung ICU patient and can spot signs of imminent trouble. If a patient needs attention, Mercy physicians can zoom in via two-way camera—close enough to read the tiny print on an IV bag.
“It’s almost like being at the bedside—I can’t shock a patient [restart his heart with electrical paddles], but I can give an order to the nurses there,” says Vinaya Sermadevi, a critical-care specialist.
In the past year, ICUs monitored by Mercy specialists have seen a 35% decrease in patients’ average length of stay and 30% fewer deaths than anticipated. “That translates to 1,000 people who were expected to die who got to go home instead,” says Randy Moore, president of Mercy Virtual.
The Virtual Doctor Is In
The number of virtual doctor visits in the U.S.
The percentage of providers that have telemedicine programs
The percentage of large employers offering telemedicine benefits
Source: American Telemedicine Association (virtual doctor visits); Avizia survey of 280 health-care executives, March 2016 (providers); National Business Group on Health survey of 140 large employers (benefits)
THE WALL STREET JOURNAL.
As a measure of how rapidly telemedicine is spreading, consider: More than 15 million Americans received some kind of medical care remotely last year, according to the American Telemedicine Association, a trade group, which expects those numbers to grow by 30% this year.
None of this is to say that telemedicine has found its way into all corners of medicine. A recent survey of 500 tech-savvy consumers by HealthMine found that 39% hadn’t heard of telemedicine, and of those who haven’t used it, 42% said they preferred in-person doctor visits. In a poll of 1,500 family physicians, only 15% had used it in their practices—but 90% said they would it if were appropriately reimbursed.
What’s more, for all the rapid growth, significant questions and challenges remain. Rules defining and regulating telemedicine differ widely from state to state and are constantly evolving. Physicians groups are issuing different guidelines about what care they consider appropriate to deliver in what forum.
Some critics also question whether the quality of care is keeping up with the rapid expansion of telemedicine. And there’s the question of what services physicians should be paid for: Insurance coverage varies from health plan to health plan, and a big federal plans covers only a narrow range of services.
Telemedicine’s future will depend on how—and whether—regulators, providers, payers and patients can address these challenges. Here’s a closer look at some of these issues:
Do patients trade quality for convenience?
The fastest-growing services in telemedicine connect consumers with clinicians they’ve never met for one-time phone, video or email visits—on-demand, 24/7. Typically, these are for nonemergency issues such as colds, flu, earaches and skin rashes, and they cost around $45, compared with approximately $100 at a doctor’s office, $160 at an urgent-care clinic or $750 and up at an emergency room.
Many health plans and employers have rushed to offer the services and promote them as a convenient way for plan members to get medical care without leaving home or work. Nearly three-quarters of large employers will offer virtual doctor visits as a benefit to employees this year, up from 48% last year.
Web companies such as Teladoc, TDOC 0.56 % Doctor on Demand and American Well are expected to host some 1.2 million such virtual doctor visits this year, up 20% from last year, according to the American Telemedicine Association.
But critics worry that such services may be sacrificing quality for convenience. Consulting a random doctor patients will never meet, they say, further fragments the health-care system, and even minor issues such as upper respiratory infections can’t be thoroughly evaluated by a doctor who can’t listen to your heart, culture your throat or feel your swollen glands.
In a study in JAMA Dermatology last month, researchers posing as patients with skin problems sought help from 16 telemedicine sites—with unsettling results. In 62 encounters, fewer than one-third disclosed clinicians’ credential or let patients choose; only 32% discussed potential side effects of prescribed medications. Several sites misdiagnosed serious conditions, largely because they failed to ask basic follow-up questions, the researchers said.
How Patients Feel
Among consumers surveyed about virtual health-care services:
What consumers see as the top concerns
What they see as the top benefits
Source: Harris online poll of 2,033 adults, May 2016
THE WALL STREET J0URNAL.
“Telemedicine holds enormous promise, particularly in dermatology, but these sites are just not ready for prime time,” says Jack Resneck, a University of California, San Francisco, dermatologist and the study’s lead author.
The American Telemedicine Association and other organizations have started accreditation programs to identify top-quality telemedicine sites; the association also tells consumers to be wary of sites that sell products.
The American Medical Association this month approved new ethical guidelines for telemedicine, calling for participating doctors to recognize the limitations of such services and ensure that they have sufficient information to make clinical recommendations.
Yet there isn’t always agreement on what the limits of virtual medical exams are. Jason Gorevic, CEO of Teladoc, which went public last year, says its doctors use more than 100 guidelines developed specifically for delivering care remotely, including a five-point scale for determining whether a sore throat is likely due to streptococcus infection that warrants antibiotics. The Centers for Disease Control and Prevention, however, advises clinicians to prescribe antibiotics only for cases confirmed by a rapid test or throat culture.
Who pays for the services?
While employers and health plans have been eager to cover virtual urgent-care visits, insurers have been far less willing to pay for telemedicine when doctors use phone, email or video to consult with existing patients about continuing issues. “It’s very hard to get paid unless you physically see the patient,” says Peter Rasmussen, a neurosurgeon and medical director of distance health at the Cleveland Clinic.
Some 32 states have passed “parity” laws requiring private insurers to reimburse doctors for services delivered remotely if the same service would be covered in person, though not necessarily at the same rate or frequency. Medicare lags further behind. The federal health plan for the elderly covers a small number of telemedicine services—only for beneficiaries in rural areas and only when the services are received in a hospital, doctor’s office or clinic.
Bills to expand Medicare coverage of telemedicine have bipartisan support in Congress. Opponents worry that such expansion would be costly for taxpayers, but proponents say it would save money in the long run—as much as $2 billion over 10 years, according to an estimate by Avalere Health, a consulting firm.
Doctor-to-doctor consultations are also seldom covered by insurers. Health systems such as Mercy, the Mayo Clinic and the Cleveland Clinic that provide oversight and expertise on strokes, intensive-care units and other specialty care to networks of smaller hospitals typically charge those facilities a monthly fee, which generally cannot be charged to patients.
Such arrangements allow small hospitals to provide top-flight care to patients on-scene and to advertise that they partner with world-class health-care systems. And it’s less expensive than hiring their own specialists. “That’s a proverbial triple win,” says Dr. Rasmussen.
Experts say more hospitals are likely to invest in telemedicine systems as they move away from fee-for-service payments and into managed-care-type contracts that give them a set fee to provide care for patients and allow them to keep any savings they achieve.
Is the state-by-state regulatory system outdated?
Historically, regulation of medicine has been left to individual states. But some industry members contend that having 50 different sets of rules, licensing fees and even definitions of “medical practice” makes less sense in the era of telemedicine and is hampering its growth.
Currently, doctors must have a valid license in the state where the patient is located to provide medical care, which means virtual-visit companies can match users only with locally licensed clinicians. It also causes administrative hassles for world-class medical centers that attract patients from across the country.
At the Mayo Clinic, doctors who treat out-of-state patients can follow up with them via phone, email or web chats when they return home, but they can only discuss the conditions they treated in person. “If the patient wants to talk about a new problem, the doctor has to be licensed in that state to discuss it. If not, the patient should talk to his primary-care physician about it,” says Steve Ommen, a cardiologist who runs Mayo’s Connected Care program.
To date, 17 states have joined a compact that will allow a doctor licensed in one member state to quickly obtain a license in another. While welcoming the move, some telemedicine proponents would prefer states to automatically honor one another’s licenses, as they do with drivers’ licenses. “You don’t have to stop a get a new license every time to drive through a new state,” says Jonathan Linkous, the American Telemedicine Association’s CEO.
But states aren’t likely to surrender control of medical practice, and most are considering new regulations. This year, more than 200 telemedicine-related bills have been introduced in 42 states, many regarding what services Medicaid will cover and whether payers should reimburse for remote patient monitoring as well as store-and-forward technologies (where patients and doctors send records, images and notes at different times) in addition to real-time phone or video interactions. “A lot of states are still trying to define telemedicine,” says Lisa Robbin, chief advocacy officer for the Federation of State Medical Boards.
What counts as practicing medicine?
The exploding volume of health information on the internet is raising new questions about what constitutes the practice of medicine. Some web-based businesses enable consumers to consult doctors overseas, who don’t have U.S. medical licenses, but post fine-print disclaimers that they are providing information and not medical advice.
FirstDerm invites users to upload photos and a description of their skin issues and says a “board-certified dermatologist” will reply within 24 hours with a possible identification of the condition and treatment options, for $25. Most of the dermatologists are in Europe.
CEO Alexander Börve says “there is no doctor-patient relationship” because both the physicians and patients remain anonymous.
Another site, First Opinion, connects users with doctors in India for web chats, but a disclaimer states that these are merely “social interactions.” If a prescription or lab test is warranted, a locally licensed doctor joins the conversation for a $39 fee. The company didn't respond to requests for comment.
Are such services “practicing medicine” without a license? The exact definition varies from state to state, and state medical boards generally don’t investigate unless a patient files a formal complaint. Even then, boards have jurisdiction only over individual doctors licensed in their state, not companies, or physicians overseas, says Ms. Robbin of the Federation of State Medical Boards.
How will this change competition?
Telemedicine is also shaking up traditional relationships between providers and payers and fueling the rise of medical “megabrands” whose experts are increasingly competing for patients in each other’s backyards.
Insurers such as Anthem and UnitedHealth Group UNH 0.48 % are offering their own direct-to-consumer virtual doctor-visit services, rather than simply paying for plan members to use those from web-based vendors. Major health systems are making their physicians available for virtual follow-ups and chronic-disease management, as well as urgent-care visits, to new and existing patients.
Johns Hopkins Medicine, Stanford Medical Center, Harvard-affiliated Partners HealthCare and other academic centers are all offering remote consultation services. American Well, which supplies software for many hospitals’ telemedicine programs, hopes to become what CEO Roy Schoenberg calls “the Amazon of health care,” offering a marketplace of branded telemedicine programs from top hospitals
The Cleveland Clinic is working to create a “Cleveland Clinic in the Cloud” that would allow patients across the country to access its physicians without going to Ohio. Dr. Rasmussen also foresees joining with local pharmacy clinics, labs and imaging centers to provide in-person exams as needed. “This will open up a world of relationships across a spectrum of health-care providers that we haven’t seen to date,” he says.
Subscribe to:
Posts (Atom)