Air Ambulance Costs Are Soaring

Air ambulance transport costs have skyrocketed in recent years, according to a new report from FAIR Health.

Notably, the average estimated in-network allowed amount for air ambulance transport increased 76.4%, from $8,855 in 2017 to $15,624 in 2020.

The jump was part of a general rise in costs for both airplane and helicopter air ambulance transport during this time period, FAIR Health said, which included increases in charge amounts (the amount charged to a patient who is uninsured or obtaining an out-of-network service), estimated in-network allowed amounts for privately insured patients (the total fee negotiated between an insurance plan and a provider for an in-network service), and Medicare reimbursement amounts.

The average charges associated with a fixed-wing air ambulance rose 27.6%, from $19,210 in 2017 to $24,507 in 2020, according to the report, and the average Medicare reimbursement amount increased by 4.7%, from $3,071 to $3,216.

For helicopter transport, the average charges associated with a rotary-wing air ambulance rose 22.2%, from $24,924 in 2017 to $30,446 in 2020. The average estimated in-network allowed amount increased 60.8%, from $11,608 to $18,668, and the average Medicare reimbursement amount again rose 4.7%, from $3,570 to $3,739.

Air ambulance services have been the subject of substantial policy focus,” said Robin Gelburd, president of FAIR Health, in a statement. “We hope that this study of air ambulance transport proves productive to policy makers, researchers, payors, providers, and consumers seeking to better understand this corner of the healthcare system.”

FAIR Health’s report also found that air ambulance claims increased 30% from 2016 to 2020 (0.7% to 0.9%) as a percentage of all ambulance (ground and air) claims.

In 2020, the most common diagnoses associated with fixed-wing air ambulance transport were chronic respiratory diseases, including chronic obstructive pulmonary disease and chronic respiratory failure, and the second most common was COVID-19, which accounted for 7% of fixed-wing air ambulance claims.

Because air ambulance transport is often used for patients in life-threatening situations, they generally have no control over type of transport or provider used, FAIR Health said. As a result, surprise bills occur frequently.

A number of states have made efforts to regulate air ambulance charges, but these attempts have been overturned by court rulings that state that such efforts are preempted by the Airline Deregulation Act of 1978, the report noted.

However, the federal No Surprises Act, signed into law in December 2020, contained provisions to protect consumers from surprise bills, including those from out-of-network air ambulance service providers.

On September 30, HHS held a press call on one of its surprise billing rules, which would require companies to give patients “good faith estimates” of charges upfront and to submit a dispute resolution for out-of-network surprise bills.

Asked by MedPage Today whether air ambulances would be included, a senior administration official responded, “Yes, air ambulances are covered by this rule. They will go through a very, very similar independent dispute resolution process [as other providers]. I think the only thing different about the air ambulance process is the list of allowable information that the parties can bring to be considered in addition to the qualifying amount.”

AMA report: U.S. has “highly concentrated” payer markets that stifle competition  

https://medcitynews.com/2021/10/ama-report-u-s-has-highly-concentrated-payer-markets-that-stifle-competition/?utm_campaign=MCN%20Daily%20Top%20Stories&utm_medium=email&hsmi=166812730&_hsenc=p2ANqtz–Z_7y9-ZOPkhC7HI4RXSwuM5xDzd2B0uZi9sApeW1J89hQBktG-rqujxpBFiXmxEEnaK77vlq-7vHhr-qK8mxRgBmwA&utm_content=166812730&utm_source=hs_email

About 73% of health insurance markets are highly concentrated, and in 46% of markets, one insurer had a share of 50% or more, a new report from the American Medical Association shows. The report comes a few months after President Joe Biden directed federal agencies to ramp up oversight of healthcare consolidation.

The majority of health insurance markets in the U.S. are highly concentrated, curbing competition, according to a report released by the American Medical Association.

For the report, researchers reviewed market share and market concentration data for the 50 states and District of Columbia, and each of the 384 metropolitan statistical areas in the country.

They found that 73% of the metropolitan statistical area-level payer markets were highly concentrated in 2020. In 91% of markets, at least one insurer had a market share of 30%, and in 46% of markets, one insurer had a share of 50% or more.

Further, the share of markets that are highly concentrated rose from 71% in 2014 to 73% last year. Of those markets that were not highly concentrated in 2014, 26% experienced an increase large enough to enter the category by 2020.

In terms of national-level market shares of the 10 largest U.S. health insurers, UnitedHealth Group comes out on top with the largest market share in both 2014 and 2020, reporting 16% and 15% market share, respectively. Anthem comes in second with shares of 13% in 2014 and 12% in 2020.

But the picture looks different when it comes to the market share of health insurers participating in the Affordable Care Act individual exchanges. In 2014, Anthem held the largest market share among the top 10 insurers on the exchanges, with a share of 14%. By 2020, Centene had taken the top spot, with a share of 18%, while Anthem had slipped to fifth place, with a share of just 4%.

Another key entrant into the top 10 list in 2020 was insurance technology company Oscar Health, with 3% of the market share in the exchanges at the national level.

“These [concentrated] markets are ripe for the exercise of health insurer market power, which harms consumers and providers of care,” the report authors wrote. “Our findings should prompt federal and state antitrust authorities to vigorously examine the competitive effects of proposed mergers involving health insurers.”

The payer industry hit back. In a statement provided to MedCity News, America’s Health Insurance Plans, a national payer association, said that Americans have many affordable choices for their coverage, pointing to the fact that CMS announced average premiums for Medicare Advantage plans will drop to $19 per month in 2022 from $21.22 this year.

“Health insurance providers are an advocate for Americans, fighting for lower prices and more choices for them,” said Kristine Grow, senior vice president of communications at America’s Health Insurance Plans, in an email. “We negotiate lower prices with doctors, hospitals and drug companies, and consumers benefit from lower premiums as a result.”

Further, the report does not mention the provider consolidation that also contributes to higher healthcare prices. Mergers and acquisitions among hospitals and health systems have continued steadily over the past decade, remaining relatively impervious to even the Covid-19 pandemic.

Scrutiny around consolidation in the healthcare industry may grow. In July, President Joe Biden issued an executive order urging federal agencies to review and revise their merger guidelines through the lens of preventing patient harm.

The Federal Trade Commission has already said that healthcare businesses will be one of its priority targets for antitrust enforcement actions.

Hospital mergers and acquisitions are a bad deal for patients. Why aren’t they being stopped?

Contrary to what health care executives advertise, hospital mergers and acquisitions aren’t good for patients. They rarely improve access to health care or its quality, and they don’t reduce prices. But the system in place to stop them is often more bark than bite.

During 2019 and 2020, hospitals acquired an additional 3,200 medical practices and 18,600 physicians. By January 2021, almost half of all U.S. physicians were employed by a hospital or health system.

In 2018, the last year for which complete data are available, 72% of hospitals and more than 90% of hospital beds were affiliated with a health care system. Mergers and acquisitions are increasing the number of health care systems while decreasing the number of independently operated hospitals.

When hospitals buy provider practices, it leads to more unnecessary care and more expensive care, which increases overall spending. The same thing happens when hospitals merge or acquire other hospitals. These deals often increase prices and they don’t improve care quality; patients simply pay more for the same or worse care.

Mergers and acquisitions can negatively affect clinician morale as well. Some argue they lead to providers’ loss of autonomy and increase the emphasis on financial targets rather than patient care. They can also contribute to burnout and feeling unsupported.

Considerable machinery is in place at both the federal and state levels to stop “anticompetitive” mergers before they happen. But that machinery is limited by a lack of follow through.

The Federal Trade Commission (FTC) and the U.S. Department of Justice have always had broad authority over mergers. By law, one or both of these entities must review for any antitrust concerns proposed deals of a certain size before the deals are finalized. After a preliminary review, if no competition issues are identified, the merger or acquisition is allowed to proceed. This is what happens in most cases. If concerns are raised, however, the involved parties must submit additional information and undergo a second evaluation.

Some health care organizations seem willing to challenge this process. Leaders involved in a pending merger between Lifespan and Care New England in Rhode Island — which would leave 80% of the state’s inpatient market under one company’s umbrella — are preparing to move forward even if the FTC deems the deal anticompetitive. The companies will simply ask the state to approve the merger despite the FTC’s concerns.

The reality is that the FTC’s reach is limited when it comes to nonprofits, which most hospitals are. While the FTC can oppose anticompetitive mergers involving nonprofits, it cannot enforce action against them for anticompetitive behavior. So if a merger goes through, the FTC has limited authority to ensure the new entity plays fairly.

What’s more, the FTC has acknowledged it can’t keep up with its workload this year. It modified its antitrust review process to accommodate an increasing number of requests and its stagnant capacity. In July, the Biden administration issued an executive order about economic competition that explicitly acknowledges the negative impact of health care consolidation on U.S. communities. This is encouraging, signaling that the government is taking mergers seriously. Yet it’s unclear if the executive order will give the FTC more capacity, which is essential if it is to actually enforce antitrust laws.

At the state level, most of the antitrust power lies with the attorney general, who ultimately approves or challenges all mergers. Despite this authority, questionable mergers still go through.

In 2018, for example, two competing hospital systems in rural Tennessee merged to become Ballad Health and the only source of care for about 1.2 million residents. The deal was opposed by the FTC, which deemed it to be a monopoly. Despite the concerns, the state attorney general and Department of Health overrode the FTC’s ruling and approved the merger. (This is the same mechanism the Rhode Island hospitals hope to employ should the FTC oppose their merger.) As expected, Ballad Health then consolidated the services offered at its facilities and increased the fees on patient bills.

It’s clear that mechanisms exist to curb potentially harmful mergers and promote industry competition. It’s also clear they aren’t being used to the fullest extent. Unless these checks and balances lead to mergers being denied, their power over the market is limited.

Experts have been raising the alarm on health care consolidation for years. Mergers rarely lead to better care quality, access, or prices. Proposed mergers must be assessed and approved based on evidence, not industry pressure. If nothing changes, the consequences will be felt for years to come.

America’s major medical debt problem

https://mailchi.mp/d953ea288786/newsletter031821-4639518?e=ad91541e82

Concerns Mount Over Looming Surge in Bankruptcy as COVID Medical Debt Soars

Medical debt can be a crushing burden for families, and it is a major problem in the United States. The nonprofit RIP Medical Debt says it’s wiped out debt for 2.7 million patients since 2014, totalling more than $4.5 billion. One of the most famous health policy studies ever conducted — the Oregon Health Insurance Experiment — found that having Medicaid coverage reduced a person’s likelihood of having an unpaid medical bill sent to collection by 25%. Now a study published last month in JAMA offers new evidence on the relationship between Medicaid and medical debt, and the scale of the country’s medical debt problem.

Using a subset of credit reports from one major U.S. credit agency for every year between 2009 and 2020, researchers Raymond Kluender, Neale Mahoney, Francis Wong and Wesley Yin looked at the total amount of medical debt and new medical debt each year. They found that while both measures of medical debt have decreased almost every year since 2014, nearly 1 in 5 Americans were under collections for medical debt as of early 2020. They also found that since 2014, medical debt has been the largest source of debt for Americans, surpassing all other types of debt — credit cards, personal loans, utilities and phone bills — combined. And the medical debt was not evenly distributed around the country. Approximately, 1 in 4 individuals in the South were under collection for medical debt in 2020, but only 1 in 10 in the Northeast.

To assess the impact of Medicaid coverage on medical debt, Kluender and colleagues compared the total amount of new debt accrued by people living in states that expanded Medicaid and those that have not between 2009 and 2020, allowing them to confirm that any trends they identified didn’t pre-date Medicaid expansion in 2014. They found that between 2013 and 2020 the average amount of new medical debt decreased 34 percentage points more in states that expanded in 2014 compared to non-expansion states, and the drops were most prominent in the lowest income zip codes. The analysis can’t prove a causal relationship between medical debt and Medicaid expansion, but interestingly, the authors found no statistically significant difference in nonmedical debt between expansion and non-expansion states. This lack of an effect on nonmedical debt supports the association between Medicaid and reductions in medical debt.

The article does have limitations: It doesn’t include debts paid on a credit card or through payment plans; it doesn’t reflect the impact of COVID-19; and it can’t account for unobservable changes in policy or circumstance that might have coincided with Medicaid expansion and impacted medical debt. But it does add evidence to support the value of Medicaid coverage — a particularly timely finding, with more than 11 million people joining Medicaid since the start of the pandemic and Democrats in Congress looking to cover the more than 2 million people in the so-called coverage gap in the 12 non-expansion states.

Americans’ medical debt tops $140B, study finds

What Are The Best Ways to Clear Medical Debt?

Collection agencies held $140 billion in unpaid medical debt in 2020, according to a study published July 20 in JAMA.

Researchers examined a nationally representative panel of consumer credit reports between January 2009 and June 2020. Below are four other notable findings from their report.

  1. An estimated 17.8 percent of Americans owed medical debt in June 2020. The average amount owed was $429.
  2. Over the time period studied, the amount of medical debt became progressively more concentrated in states that don’t participate in the Affordable Care Act’s Medicaid expansion program.
  3. Between 2013 and 2020, states that expanded Medicaid in 2014 experienced a decline in the average flow of medical debt that was 34 percentage points greater than the average medical debt flow in states that didn’t expand Medicaid.
  4. In the states that expanded Medicaid, the gap in the average medical debt flow between the lowest and highest ZIP code income levels decreased by $145, while the gap increased by $218 in states that did not expand Medicaid.