News & Commentary

Briefly Noted April 2019


Medicare ACOs that have successfully taken on downside risk share certain characteristics, according to an analysis by Leavitt Partners. As FierceHealthcare reports, those ACOs tend to be bigger and more experienced and are more likely to be found in urban settings. Robert Richards, one of the report’s authors, tells FierceHealthcare that “there seems to be something about just being able to pool more resources or to have access to more resources, especially in the startup phases, that seems to give a better launch pad to downside risk.”

Study after study has found no link between autism and the measles, mumps, and rubella vaccine. That includes a new study involving 657,461 Danish children that was impressive because of its size and length. It’s doubtful, though, that antivaxxers will be swayed. As Stat reports, just the size of the study “should, in theory, bolster the argument that doctors and public health professionals still find themselves forced to make in the face of entrenched and growing resistance to vaccination in some quarters.”

If hospitals don’t soon address the problem of surprise billing, then either Congress or the Trump administration will, warns Joe Grogan, the director of the White House Domestic Policy Council. Grogan was speaking recently at the annual conference of the Federation of American Hospitals. The Hill reported that Grogan warned the for-profit hospital executives “you have to come up with a solution, or bad things could happen because you’ll have policymaking being made by people that don’t understand the system nearly as well as you.”

The New York Times talked about the plight of Harold and Ramona Labrensz in its story illustrating the human cost of the closing of 440 rural nursing homes in the last decade. As a result of one such closing, 89-year-old Harold had to be moved from a nursing home close to his residence in South Dakota, where Ramona still lives, to a nursing home 220 miles away in North Dakota. “The relocations can be traumatic for older residents, and the separation creates agonizing complications for families,” the Times reports.

Nearly one out of every five claims (19%) submitted for in-network services among ACA issuers (health plans, self-insured companies, large companies) in 2017 were denied, according to an analysis by the Kaiser Family Foundation. Researchers also found wide variation among plans, with some denial rates of less than 1% to others with more than 40%. The Kaiser researchers noted, though, that the large range might be a sign of problems with the quality of the CMS data used in their analysis.

It’s an ugly domino effect. The opioid epidemic has caused a related spike in methamphetamine use. Meth is cheaper and is being used by itself or in combination with opioids. Meth is also associated with riskier sexual behavior. As a result, more infants are being born with syphilis, according to Stateline, a Pew Charitable Trusts publication. The number of congenital syphilis cases increased by 154% between 2013 and 2017, according to CDC statistics reported by Stateline.

New Mexico Gov. Michelle Lujan Grisham’s multi­pronged plan to address the shortage of physicians in that state includes using some Medicaid funding to pay for more graduate medical residency slots, reports the Albuquerque Journal. Jerry Harrison, executive director of New Mexico Health Resources, tells the newspaper that “unfortunately, we train a lot of people for export. I don’t care what the discipline is. From nursing through physicians, we train for export to other states, primarily adjoining states and California.”

Growing up near green spaces may be good for your mental health, according to researchers in Denmark. In results reported in the Proceedings of the National Academy of Sciences, the researchers found that the lowest level of exposure to green space was associated with a 55% higher risk of developing a psychiatric disorder. Even after they adjusted for urbanization, socioeconomic factors, parental history of mental illness, and parental age, the link between lack of green space and mental health problems remained.

CAR-T therapies such as Kymriah (tisagenlecleucel) and Yescarta (axicabtagene ciloleucel) will be covered by Medicare under a recent CMS national coverage determination. But CMS is making coverage contingent upon two years’ worth of data collection on patients who receive the expensive treatments (the list price for Kymriah is $475,000; for Yescarta, it is $373,000). “CMS said it plans to use the information to decide what treatments are most beneficial to patients and which CAR-T therapies to fund in the future,” according to Market­Watch.

Baby boomers seem to like Medicare Advantage, because hospitals are seeing record numbers of patients with MA coverage, reports HealthLeaders Media. MA critics say the plans are chronically overpaid so they can offer extras to entice people to sign up. Regardless, the wave of Medicare beneficiaries into MA is “ratcheting up pressure on these providers to improve quality and health outcomes or potentially be excluded from insurer networks as part of value-based models that are proliferating,” according to HealthLeaders Media.

Just who’s to blame for rising drug prices? Why, the pharmaceutical industry, of course, according to a press release from America’s Health Insurance Plans summarizing its statement for a House Ways and Means Committee hearing. Drugmakers have been defending themselves by saying that rising drug costs are due to PBM and insurer influence. Not so fast, said AHIP, arguing that the “drug-pricing process is dictated by the original list price of a branded drug—which is determined solely by the drugmaker, not by the market or any other participant in the pharmaceutical supply chain.”

Black residents in urban areas are five times more likely to develop extreme high blood pressure, or hypertensive emergency, than the national average. That’s especially true for black residents who are male, have diabetes, chronic kidney or heart disease, or who are 65 or older, according to a study published in Blood Pressure.

A former Managed Care editor would always change “nonprofit” to “not-for-profit,” arguing that the institutions in question couldn’t survive if they were profitless. Some municipalities across the country have taken that stance, wondering if it’s fair that not-for-profit hospital systems pay no taxes while operating like for-profits. In December, Modern Healthcare published an in-depth piece about what hospitals tally up as “community benefit spending.” The magazine’s editor, Aurora Aguilar, notes that if “hospitals don’t have specific instructions on what interventions qualify as a community benefit, or how much they need to spend, they will define and report those dollars and programs in ways that can be challenged by public officials and community leaders.”

Haven is the official name of the Amazon–Berkshire Hathaway–JP Morgan Chase health venture. Its website says Haven was picked to reflect the goal of partnering with individuals and familes while working with clinicians and others to “make the overall system better for all.” A few journalists had been calling the venture “Berkmorgazon.”

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Legislation and regulation
By Richard Mark Kirkner
Legislation and regulation
By Richard Mark Kirkner