U.S. health care costs a lot, and not just in money

Administrative Burden | RSF

Health spending in the United States is highest in the world, driven in part by administrative complexity. To date, studies examining the administrative costs of American health care have primarily focused on clinicians and organizations—rarely on patients.

A new study in Health Services Research finds administrative complexity in the U.S. health care system has consequences for access to care that are on par with those of financial barriers like copays and deductibles. In other words, we pay for health care in two ways: in money and in the hassle of dealing with a complex, confusing, and error-riddled system. Both are barriers to access. The study was led by Michael Anne Kyle, and coauthor, Austin Frakt.

Main Findings

  • Nearly three-quarters (73%) of people surveyed reported doing at least one health care-related administrative task in the past 12 months. Such administrative tasks include: appointment scheduling; obtaining information from an insurer or provider; obtaining prior authorizations; resolving insurance or provider billing issues; and resolving premium problems.
  • Administrative tasks often impose barriers to care: Nearly one-quarter (24.4%) of survey respondents reported delaying or foregoing needed care due to administrative tasks.
  • This estimate of administrative barriers to access to care is similar to those of financial barriers to access: a 2019 Kaiser Family Foundation survey, found that 26% of insured adults 18-64 said that they or a family member had postponed or put off needed care in the past 12 months due to cost.
  • Administrative burden has consequential implications for equity. The study finds administrative burden falls disproportionately on people with high medical needs (disability) and that existing racial and socioeconomic inequities are associated with greater administrative burden.

Methods

To measure the size and consequences of patients’ administrative roles, we used data from the nationally representative March 2019 Health Reform Monitoring Survey of insured, nonelderly adults (18-64) to assess the annual prevalence of five common types of administrative tasks patients perform: (1) appointment scheduling; (2) obtaining information from an insurer or provider; (3) obtaining prior authorizations; (4) resolving insurance or provider billing issues; (5) and resolving insurance premium problems. The study examined the association of these tasks with two important measures of their burden: delayed and forgone care.

Conclusions

High administrative complexity is a central feature of the U.S. health care system. Largely overlooked, patients frequently do administrative work that can create burdens resulting in delayed or foregone care. The prevalence of delayed or foregone care due to administrative tasks is comparable to similar estimates of cost-related barriers to care. Administrative complexity is endemic to all post-industrial health systems, but there may be opportunity to design administrative tools with greater care to avoid exacerbating or reinforcing inequities.

Is the perception of safety in healthcare settings declining?

https://mailchi.mp/13ef4dd36d77/the-weekly-gist-august-27-2021?e=d1e747d2d8

Improving Patient Safety—Why Data Matters

When COVID volumes waned in the spring and early summer, most health systems “de-escalated” dedicated COVID testing and triage facilities. But with the Delta variant surging across the country, consumers are now once again looking for services like drive-through testing, which is perceived as more convenient and safer.

One physician leader told us patients in the ED are asking why the hospital got rid of the “COVID tent”, which provided a separate pathway for patients with respiratory and other COVID symptoms—and a highly visible signal that the rest of the department was as COVID-free as possible.

Another system is now fielding questions from the media about whether they’ll bring back their dedicated COVID hospital: “We spent a lot of time last year convincing the community that the dedicated hospital was key to safely managing care during the pandemic. Now we’ve got almost as many COVID admissions spread across our hospitals.” 

Over the past year, providers have learned how to safely manage COVID care and prevent spread in healthcare settings—but consumers may perceive the lack of dedicated facilities as a decline in safety. 

Unlike last year, hospitals are full of non-COVID patients, as those who delayed care reemerge. And with the current surge likely to continue into flu season, emergency rooms will only get more crowded, necessitating a new round of communication describing how hospitals are keeping patients safe, and reassuring patients that healthcare settings remain one of the safest places to visit in the community. 

Shortage of healthcare workers amid high demand for jobs

https://mailchi.mp/13ef4dd36d77/the-weekly-gist-august-27-2021?e=d1e747d2d8

The US now has more job openings than any time in history—and the mismatch in workforce supply and demand in the broader economy is even more acute in the healthcare sector. While the industry saw significant job losses in April 2020, employment in many healthcare subsectors quickly rebounded to slightly below pre-pandemic levels, according to data from the Bureau of Labor Statistics. 

While ambulatory and hospital employment has mostly recovered, employment in nursing and residential care facilities has continued to decline. 

Healthcare’s sluggish return to pre-pandemic employment levels is not for lack of demand. The number of job listings has grown nearly 30 percent since the second quarter of 2020, to nearly 4.5M openings, while new hires have flatlined, resulting in over half of healthcare job listings remaining unfilled as of Q2 2021. 

In a recent McKinsey & Company survey of over 100 large US hospitals, health system executives ranked workforce shortages among nurses and clinical staff as their greatest barrier to increasing capacity.

Amid the current COVID surge, many systems are offering sizeable bonuses to attract new employees. These strategies will be critical across the next year, as systems look to reduce spending on costly travel nurses, manage COVID surges while continuing to offer elective care, and forestall further burnout.

But longer term, rethinking job functions, integrating new technology and finding ways to educate and upskill critical clinical talent will be key to winning the war for talent.

Scripps delays nonurgent procedures amid staffing shortages

Scripps delays some procedures over staff shortage, COVID spike

Scripps Health is temporarily postponing some medical procedures because of significant staffing shortages and a jump in COVID-19 cases, the San Diego, Calif.-based system said Aug. 20, according to CBS News 8.

Medical staff is deciding which procedures to delay based on clinical factors and emergency status, with time-sensitive care still being delivered, Scripps leaders said. 

The health system said it is also considering temporarily consolidating some ambulatory care sites due to workforce shortages. 

At present, Scripps said it is looking to fill 1,309 open positions. In August 2019, the system had just 832 openings. About 430 of the openings are for nursing positions, up from 220 open positions in 2019, according to the report.

At the same time, the health system is seeing its COVID-19 patient volume grow. Scripps has 173 patients admitted at its five hospitals, up from 13 patients on June 13.

“The COVID pandemic has taken a serious toll on healthcare workers across the nation, and many have decided to leave the field entirely for reasons such as fatigue and burnout,” said Scripps’ President and CEO Chris Van Gorder, according to CBS News 8. “We’re doing all we can to fill open positions and shifts, but options are currently limited across the board in healthcare, so we’re doing what’s necessary to ensure we have staff available for our most urgent cases.”

To view the full article, click here.

A Delta-driven decline in consumer confidence

https://mailchi.mp/c5fab2515162/the-weekly-gist-august-20-2021?e=d1e747d2d8

After a calmer start to the summer, the Delta variant is eroding consumer confidence as COVID-19 surges across many parts of the US once again. Using the latest data from Morning Consult’s Consumer Confidence Index, the graphic above shows the fluctuations in consumer confidence levels across the last year. 

The most recent COVID surge has caused a five-point drop in confidence in the past month and, with cases still rising, we expect this trend to continue into the fall. Notably, with renewed masking guidance and increasing reports of breakthrough infections, confidence has dropped more among fully vaccinated individuals than among the unvaccinated.

Consumers’ comfort levels aren’t only dropping when it comes to daily activities, like grocery shopping or dining at a restaurant, but also with respect to healthcare. A recent survey from Jarrard Phillips Cate & Hancock finds that while consumers feel safer visiting healthcare settings in August 2021 than they did back in January, more than a third of consumers report the current COVID situation is making them less likely to seek non-emergency care, and 44 percent say they are more likely to pursue virtual care alternatives. 

Health systems must be able to seamlessly “dial up” or “dial down” their virtual care capabilities in order to meet fluctuating consumer demand and avoid another wave of missed or deferred care.

1 in 3 Americans skip care due to cost concerns, survey shows

Americans most likely to skip health care due to cost: survey

In the past year, cost was a bigger factor driving Americans to skip recommended healthcare than fear of contracting COVID-19, according to a report released June 1 by Patientco, a revenue cycle management company focusing on patient payment technology.

Patientco surveyed 3,116 patients and 46 healthcare providers, finding 34 percent of female patients and 30 percent of male patients have avoided care in the past year citing concerns about out-of-pocket costs.

Below are three more notable findings from the report:

  1. Healthcare affordability is not an issue that affects only Americans with low incomes, as 85 percent of patients with household incomes greater than $175,000 are less likely to defer care when flexible payment options are offered.
  2. Across all ages, income levels and education levels, most patients said they struggled to understand their medical bills and what they owed. Nearly two-thirds of patients said they did not understand their explanation of benefits, did not know what they should do with the information in their explanation of benefits, or waited too long to obtain their explanation of benefits.
  3. Forty-five percent of patients said they would need financial assistance for medical bills that exceed $500, and 66 percent of patients said the same for medical bills that exceed $1,000.

Hospital admissions not linked to COVID-19 fell dramatically in fall, especially in Midwest

Dive Brief:

  • As COVID-19 cases surged last fall, non-COVID-19 hospital admissions fell substantially, particularly in the Midwest and West, according to a new analysis by the Kaiser Family Foundation of 2020 inpatient admission data from electronic medical records through Dec. 5.
  • The analysis also highlights admission trends by age and sex, and found that patients 65 and over — those most at risk of complications from the novel coronavirus  —  delayed care at greater rates than those under 65 again in the fall. Still, the discrepancy between visits based on age was more pronounced in the spring.
  • On average, males and females had almost identical admission patterns throughout the entire year. Though looking at the raw numbers, women’s total admissions trended above their male counterparts, which researchers attributed to childbirth.

Dive Insight:

The latest analysis from the think tank provides a fuller picture of how the COVID-19 pandemic influenced admission trends throughout 2020.

Overall, total admissions bottomed out in April and March but have remained near normal, or above 90% of expected admissions since June, according to electronic medical record data from the Epic Health Research Network, which pools information from 20 million patients across 97 hospitals in the U.S.

However, while total admissions — which includes those sick with COVID-19 — remained near normal, the pattern differed when zeroing in on non-COVID-19 admissions, or those admitted who did not have the virus.

Non-COVID-19 admissions started to fall again in November and by Dec. 5 they fell to 80% of expected volume, which is likely to put financial pressure on hospitals, particularly those with smaller reserves of cash on hand, Kaiser noted.

The decline was steepest in the Midwest and West, dropping to about 76% of expected volume between early November and December.

Researchers fear the drop in non-COVD-19 admissions may have long-term consequences.

“The levels of non-COVID-19 admissions seen in the fall of 2020 suggest that people may be delaying care in ways that could be harmful to their long-term health,” according to the study.

Insurers observed similar patterns of depressed volume in the fourth quarter.

Humana, which largely covers seniors in Medicare plans, noted non-COVID-19 volume dropped the last two months of the quarter after previously returning to near normal. It led Humana to report a loss in the fourth quarter as COVID-19 testing and treatment accelerated. Centene, which reported a Q4 loss, echoed a similar pattern.

One-third of US adults postponed care during pandemic: reports

Image result for One-third of US adults postponed care during pandemic: reports

Dive Brief:

  • About 36% of nonelderly adults and 29% of children in the U.S. have delayed or foregone care because of concerns of being exposed to COVID-19 or providers limiting services due to the pandemic, according to new reports from the Urban Institute and Robert Wood Johnson Foundation.
  • Of those who put off care, more than three-quarters had one or more chronic health conditions and one in three said the result of not getting treatment was worsening health or limiting their ability to work and perform regular daily activities, the research based on polling in September showed.
  • However, the types of care being delayed are fairly routine. Among those surveyed, 25% put off dental care, while 21% put off checkups and 16% put off screenings or medical tests.

Dive Insight:

The early days of the pandemic saw widespread halts in non-emergency care, with big hits to provider finances. 

In recent months, health systems have emphasized the services can be provided in hospitals and doctors offices safely as long as certain protocols are followed, and at least some research has backed them up. Groups like the American Hospital Association have launched ad campaigns urging people to return for preventive and routine care as well as emergencies.

But patients are apparently still wary, according to the findings based on surveys of about 4,000 adults conducted in September.

The research shows another facet of the systemic inequities harshly spotlighted by the pandemic. People of color are more likely to put off care than other groups. While 34% of Whites said they put off care, that percentage rose to 40% among Blacks and 36% among Latinos.

Income also played a role, as 37% of those with household incomes at or below 250% of the poverty level put off care, compared to 25% of those with incomes above that threshold.

Putting off care has had an impact industrywide, as the normally robust healthcare sector lost 30,000 jobs in January. Molina Healthcare warned last week that utilization will remain depressed for the foreseeable future.

Younger Americans were also impacted, with nearly 30% of parents saying they delayed at least one type of care for their children, while 16% delayed multiple types of care. As with adults, dental care was the most common procedure that was put off, followed by checkups or other preventative healthcare screenings.

The researchers recommended improving communications among providers and patients.

“Patients must be reassured that providers’ safety precautions follow public health guidelines, and that these precautions effectively prevent transmission in offices, clinics, and hospitals,” they wrote. “More data showing healthcare settings are not common sources of transmission and better communication with the public to promote the importance of seeking needed and routine care are also needed.”

Molina expects utilization to remain depressed in 2021

https://www.healthcaredive.com/news/molina-expects-utilization-to-remain-depressed-in-2021/594895/

Dive Brief:

  • Molina’s net income fell sharply in the fourth quarter as the insurer was forced to refund rates to some of its state partners as COVID-19 continues to depress normal care utilization, CEO Joe Zubretsky told investors Thursday.
  • Although utilization remained curtailed, COVID-19 costs were higher in the fourth quarter than any other quarter in 2020, Zubretsky said. As such, Molina’s medical care ratio for the quarter increased to 90.8% from 86% the prior-year period.
  • Still, Molina remained in the black for the full year of 2020. Looking ahead, the company expects utilization to improve, though does not expect it to rebound entirely. At the same time, the company expects direct COVID-19 costs to come in lower than last year.

Dive Insight:

Insurers have largely remained unbruised from the pandemic, unlike some providers, but the fourth quarter was a different story.

The pandemic took a bite out of Molina’s net income in the fourth quarter as the company reported that figure fell to $34 million from $168 million in Q4 2019.

The biggest contributor to the impact on the bottom line was Medicaid refunds to states, including California, Michigan and Ohio. States have clawed back some of the money they pay insurers like Molina as members continue to defer care, which is a benefit to insurers as they then pay out less.

Molina painted a clearer picture of this scenario during Thursday’s conference call with investors.

For the full year, Molina estimated that medical cost suppression amounted to $620 million while direct COVID-19 costs amounted to $200 million. In other words, curbed utilization continued to outweigh direct COVID-19 costs, resulting in a $420 million benefit from the pandemic, which the company characterized as a surplus.

But states took back a total of $565 million through rate refunds. Overall, the net impact of COVID-19 was a $180 million hit to Molina for 2020 when factoring in other costs.

Looking ahead, executives seemed cautiously optimistic for 2021 but noted headwinds from the pandemic will persist. While the forecast reflects future growth, Zubretsky said, “it is a constrained picture” of the company’s potential earnings.

Some of those headwinds include Medicare risk scores that don’t fully capture the acuity of their Medicare members. As seniors put off care in 2020, companies like Molina were unable to capture diagnosis codes to help them determine how sick members are and the ultimate risk they pose.

Still, there are some bright spots. As the public health emergency is likely to be continued throughout the remainder of the year, it means that redeterminations will remain halted, or, in other words, Medicaid members will not be kicked off coverage.

This was a boon for Molina in 2020, as it allowed them to pick up a significant number of new members. Overall, it was a major catalyst for Medicaid membership growth in 2020, Zubretsky said.

Molina expects care utilization to improve this year but not fully return to normal. Instead, it expects utilization suppression to be about one third of 2020 levels.

Molina, which solely focuses its portfolio on government sponsored and marketplace plans, said it expects to pick up as many as 30,000 additional members during the Affordable Care Act special enrollment period.

Opening up a special enrollment period was one of the first moves made by the new administration in the White House. Zubretsky seems enthused by the recent moves through executive orders and the unfolding bill developments in Congress that are looking to raise premium subsidies on the exchanges.

Those early actions “just couldn’t be better for government sponsored managed care, and we’re pleased to see that progress already being made,” Zubretsky said.

ACA plan enrollment for 2021 ticked up slightly

Healthcare.gov (ACA) 2021 Enrollment Information | Congressman Steve Cohen

Dive Brief:

  • Consumers choosing insurance via the federal Affordable Care Act exchanges reached 8.25 million over the 2021 open enrollment period, about the same number as the year before, CMS said Wednesday.
  • Because two fewer states are participating in the federal marketplace this year, adjusted year-over-year growth in plan selections was 7%, the agency said.
  • Of the total, 23% of consumers were new, down by 3.6%Renewing consumers who actively chose a new plan and those who were automatically re-enrolled both increased.

Dive Insight:

The figures are the last from the Trump administration, which has drastically reduced money toward navigators who help people use the Healthcare.gov website and find the best ACA plan for them. The administration has made no secret of its opposition to the law and after failing to overturn it in Congress has used executive actions to undermine it.

Still looming is the Trump administration’s lawsuit seeking to overturn the landmark law.

President-Elect Joe Biden and his pick for HHS chief, California Attorney General Xavier Becerra, however, are eager supporters and are likely to take a number of actions to restore and burnish it. That could be increasing tax credits and subsidies, increasing navigator funding and building on protections like essential health benefits.

The U.S. Supreme Court is expected to make its ruling on the ACA case later this spring or summer, but the Biden administration could essentially make it moot by walking back the zeroing out of the individual mandate penalty that is the linchpin of the lawsuit against it.

The relatively steady enrollment could be increased through those actions and the possibility of a special enrollment period to account for needs during the coronavirus pandemic. The COVID-19 crisis and the recession it has caused have kicked millions of people off their employer-sponsored insurance, and they could turn to the exchanges for coverage, especially with higher tax credits and subsidies.