There’s been a lot of hand wringing over the ongoing feeding frenzy among private equity (PE) firms for physician practice acquisition, which has caused health system executives everywhere to worry about the displacement effect on physician engagement strategies (not to mention the inflationary impact on practice valuations).
While we’ve long believed that PE firms are not long-term owners of practices, instead playing a roll-up function that will ultimately end in broader aggregation by vertically-integrated insurance companies, a recent conversation with one system CEO reframed the phenomenon in a way we hadn’t thought of before. It’s all about a demographic shift, she argued.
There’s a generation of Boomer-aged doctors who followed their entrepreneurial calling and started their own practices, and are now nearing retirement age without an obvious path to exit the business. Many didn’t plan for retirement—rather than a 401(k), what they have is equity in the practice they built.
What the PE industry is doing now is basically helping those docs transition out of practice by monetizing their next ten years of income in the form of a lump-sum cash payout. You could have predicted this phenomenon decades ago.
The real question is what happens to the younger generations of doctors left behind, who have another 20 or 30 years of practice ahead of them? Will they want to work in a PE-owned (or insurer-owned) setting, or would they prefer health system employment—or something else entirely?
The answer to that question will determine the shape of physician practice for decades to come…at least until the Millennials start pondering their own retirement.
FDA on Monday issued its full approval for the Pfizer-BioNTech vaccine, making it the first Covid-19 vaccine to receive approval from the agency.
Up until now, the vaccine—which FDA said will be marketed under the brand name Comirnaty—was authorized for use under an emergency use authorization (EUA). Now, however, the vaccine is fully approved for the prevention of Covid-19 in individuals ages 16 and older.
FDA said the vaccine will remain available under an EUA for individuals ages 12 to 15. A third dose of the vaccine is also still available under the EUA for certain immunocompromised individuals.
Peter Marks, director of FDA’s Center for Biologics Evaluation and Research, said FDA “evaluated scientific data and information included in hundreds of thousands of pages, conducted our own analyses of Comirnaty’s safety and effectiveness, and performed a detailed assessment of the manufacturing process, including inspections of the manufacturing facilities.”
“The public and medical community can be confident that although we approved this vaccine expeditiously, it was fully in keeping with our existing high standards for vaccines in the U.S.,” Marks added.
What does FDA’s approval mean for you?
This new FDA approval, new guidance from the federal government, and new regulations from schools and private business have the potential to shift the posture of the currently unvaccinated. Today, just over 70% of American adults have had at least one dose Covid-19 vaccines. The question now is, how far can we get? The answer is up to you.
It may feel like decisions about the treatment and prevention of Covid-19 are out of your control. And while federal agencies and private businesses are making decisions quickly, every one of you has a vital role to play in this next phase of the pandemic. But there are three constituencies I want to speak to directly.
Many employers have been hesitant to come down hard on vaccine mandates or implementing clear consequences for the unvaccinated (such as submitting to weekly tests). Much of that fear had to do with the fact that vaccines were only approved for emergency use. Today’s announcement of the full approval of the Pfizer-BioNTech vaccine should offer many employers enough comfort to move forward with vaccine mandates. In fact, on the heels of announcing full approval, New York City announced that it would require all education staff to be vaccinated. I expect to see more employers inside and outside of health care following suit. If you are still questioning whether a vaccine mandate is appropriate, we recommend asking yourselves these five questions:
- Are you complying with federal and state guidance?
- Is a Covid-19 vaccine mandate the best way to achieve your goals?
- How will you manage individuals who have legitimate exemptions if you impose a Covid-19 vaccine mandate?
- How will you collect ‘proof of vaccination’?
- How will you address workforce retention concerns?
Since the start of the Covid-19 crisis, we’ve recommended that providers adopt a single source of truth mentality to combat misinformation associated with the virus, it’s treatment, and concerns over vaccination. Today, vaccine skepticism is largely why adults continue to pass on their shot, and while the FDA’s full approval of the Pfizer-BioNTech vaccine isn’t going to appease all of their fears, full approval really does matter to some vaccine hesitant patients, at least according to polling from the Kaiser Family Foundation.
Your job is to identify those patients, offer custom outreach that shares the good news of full approval, and direct patients to the right next steps. The more customized the communication can be, the better. But there are some common principles everyone can take when developing strong Covid-19 vaccine communication strategies. In fact, we’ve built a readiness assessment for this purpose. And while this readiness assessment was built for initial rollout, the questions within should continue to guide your organization in addressing key factors such as patient navigation, equity in vaccine access, public health messaging, and vaccine hesitancy and mistrust.
The best communication strategy generates action—action for the patient (e.g., making an appointment for their first dose) but also action steps for frontline providers. Leaders must make sure that their staff is equipped to recognize vaccine hesitancy vs. skepticism, which is rooted in misinformation. Leaders must train staff to listen to personal narratives and not merely default to scientific facts, and leaders must make sure clinicians feel equipped to ease potential patient concerns.
Doctors must also be equipped to handle individual conversations with patients and discuss what this full approval means. Since patients typically turn to their doctors as a top, trusted source of insight, frontline clinicians are more important than ever in driving vaccine confidence. Yet in a recent poll from SymphonyRM, 41% of patients lost trust in their doctors amid the pandemic—and among those individuals, just over half noted it was because their provider rarely or never communicated with them about Covid-19. To regain trust and communicate the importance of the full approval, frontline clinicians should be prepared to proactively communicate and answer the following questions:
- How does full approval differ from an emergency use authorization? Under what conditions is a full approval granted?
- Why did the FDA decide to grant this approval? What data or evidence led to their increased confidence in the vaccine?
- How should patients view this approval? What concerns, fears, or questions about the vaccine should this approval counter?
- How might this full approval lead to increased mandates or pushes for vaccination, and what does that mean for patients?
Doctors should also continue to be prepared to answer any skepticism or misinformation about the full approval, which may come up during these discussions. In a July poll from KFF, 34% of unvaccinated adults were not at all confident about the safety of Covid vaccines, and 31% were not too confident. Today’s full approval should be used as an opportunity to help increase patient confidence in the safety of the vaccine.
The best defense we have against this virus is vaccination, and full approval of the Pfizer-BioNTech vaccine gives employers, providers, and frontline clinicians the shot in the arm they need to keep motivating Americans to get vaccinated (pun intended). It’s up to you to capitalize on the momentum of the FDA announcement, whether through your own vaccine regulations or through direct communication to the “watchful waiters” who have been waiting for this moment to get vaccinated.
Clinician burnout, lay-offs, and other healthcare workforce challenges coming out of the COVID-19 pandemic are creating issues for primary care, according to a new survey.
About 40 percent of over 700 primary care clinicians recently surveyed by the Larry A. Green Center, Primary Care Collaborative (PCC), and 3rd Conversation worry that primary care won’t exist in five years’ time. Meanwhile, about a fifth say they expect to leave primary care within the next three years.
“Primary care is the front door to the healthcare system for most Americans, and the door is coming off its hinges,” Christine Bechtel, co-founder of 3rd Conversation, a community of patients and clinicians, said in a press release. “The fact that 40 [percent] of clinicians are worried about the future of primary care is of deep concern, and it’s time for new public policies that value primary care for the common good that it is.”
The threat to primary care comes as practices ramp up vaccination efforts. The survey found that more than half of respondents (52 percent) report receiving enough or more than enough vaccines for their patients, and 31 percent are partnering with local organizations or government to prioritize people for vaccination.
Stress levels at primary care practices are also decreasing compared to the height of the pandemic, according to survey results. However, over one in three, or 36 percent, of respondents say they are experiencing hardships, such as feeling constantly lethargic, having trouble finding joy in anything, and/or struggling to maintain clear thinking.
Clinician fatigue could spell trouble for the primary care workforce and the field itself, researchers indicated.
“The administration has now recognized the key role primary care is able to play in reaching vaccination goals,” Rebecca Etz, PhD, co-director of The Larry A. Green Center, said in the release. “While the pressure is now on primary care to convert the most vaccine-hesitant, little has been done to support primary care to date. Policymakers need to bear witness to the quiet heroism of primary care – a workforce that suffered five times more COVID-related deaths than any other medical discipline.”
Many primary care clinicians are hoping the federal government steps in to change policy and bolster primary care and the healthcare workforce. The government can start with how primary care is paid, respondents agreed.
About 46 percent of clinicians responding to the survey said policy should change how primary care is financed so that the field is not in direct competition with specialty care. The same percentage of clinicians also said policy to change how primary care is paid by shifting reimbursement from fee-for-service.
Over half of clinicians (56 percent) also agreed that policy should protect primary care as a common good and make it available to all regardless of ability to pay.
Alternative payment models helped providers during the COVID-19 pandemic, research from healthcare improvement company Premier, Inc. showed. Their study found that organizations in alternative payment models were more likely to leverage care management, remote patient monitoring, and population health data during the pandemic compared to organizations that relied on fee-for-service revenue.
“Many of the practices, especially in primary care, have been extremely cash strapped and have been struggling for many years,” Sanjay Doddamani, MD, told RevCycleIntelligence last year.
“This has been a big moment for us to act in accelerating our performance-based incentive payments to our primary care doctors. We moved up our schedule of payments so that they could at least have some continued flow of funds,” added the chief physician executive and COO at Southwestern Health Resources, a clinically integrated network based in Texas.
Value-based contracting could be the key to primary care’s existence in the future, that is, if practices get on board with alternative payment models. A majority of respondents to the latest Value-Based Care Assessment from Insights said over 75 percent of their organization’s revenue is from fee-for-service contracts. This was especially true for respondents working in physician practices, of which 64 percent relied almost entirely on fee-for-service payments.
We’ve been hearing a growing number of stories from patients about difficulties scheduling appointments for specialist consults.
A friend’s 8-year-old son experienced a new-onset seizure and was told that the earliest she could schedule a new patient appointment with a pediatric neurologist at the local children’s hospital was the end of November. Concerned about a five-month wait time after the scary episode, she asked what she should do in the meantime: “They told me if I want him to be seen sooner, bring him to the ED at the hospital if it happens again.”
A colleague shared his frustration after his PCP advised him to see a gastroenterologist. Calling six practices on the recommended referral list, the earliest appointment he could find was nine weeks out; the scheduler at one practice noted that with everyone now scheduling colonoscopies and other procedures postponed during the pandemic, they are busier than they’ve been in years. Recent conversations with medical group leaders confirm a specialist access crunch.
Patients who delayed care last year are reemerging, and ones who were seen by telemedicine now want to come in person. “We are booked solid in almost every specialty, with wait times double what they were before COVID,” one medical group president shared. The spike in demand is compounded by staffing challenges: “I pray every day that another one of our nurses doesn’t quit, because it will take us months to replace them.”
Doctors and hospitals are now seeing a rise in acuity—cancers diagnosed at a more advanced stage, chronic disease patients presenting with more severe complications—due to care delayed by the pandemic. If patients can’t schedule needed appointments and procedures, this spike in severity could be prolonged, or even made worse.
For medical groups who can find ways to open additional access, it’s also an opportunity to capture new business and engender greater patient loyalty.
- Telehealth claim lines as a percentage of all medical claims dropped 13% in April, marking the third straight month of declines, according to new data from nonprofit Fair Health.
- The dip was greater than the drop of 5.1% in March, but not as large as the decrease of almost 16% in February. However, overall utilization remains significantly higher than pre-COVID-19 levels.
- The decline appears to be driven by a rebound in in-person services, researchers said. Mental health conditions bucked the trend, however, as the percentage of telehealth claim lines associated with mental conditions — the No. 1 telehealth diagnosis — continued to rise nationally and in every U.S. region.
The coronavirus spurred an unprecedented increase in telehealth utilization early last year. But early data from 2021 suggests demand is slowing as vaccinations ramp up and COVID-19 cases decrease across the U.S.
Fair Health has used its database of over 33 billion private claims records to analyze the monthly evolution of telehealth since May last year. Telehealth usage peaked among the privately insured population last April, before easing through September and re-accelerating starting in October, as the coronavirus found a renewed foothold in the U.S.
In January, virtual care claims made up 7% of all medical claim lines, but that fell to 5.9% in February, 5.6% in March and just 4.9% in April, suggesting a steady deceleration in telehealth demand.
The deceleration in April was seen in all U.S. regions, but was particularly pronounced in the South, Fair Health said, which saw a 12.2% decrease in virtual care claims.
The trend doesn’t bode well for the ballooning virtual care sector, which has enjoyed historic levels of funding during COVID-19. Just halfway through the year, 2021 has already blown past 2020’s record for digital health funding, with a whopping $14.7 billion. This latest data suggests dampening utilization could throw cold water on the red-hot marketplace.
And policymakers are still mulling how many telehealth flexibilities should be allowed after the public health emergency expires, expected at the end of this year. Virtual care enjoys broad support on both sides of the aisle and the Biden administration’s top health policy regulators, including CMS administrator Chiquita Brooks-LaSure, have said they support permanently adopting virtual care coverage waivers, but returned restrictions on telehealth access could also stymie use.
Fair Health also found that nationally, mental health conditions increased from 57% from all telehealth claims in March to 59% in April. That month, psychotherapeutic/psychiatric codes jumped nationally as a percentage of telehealth procedure codes, while evaluation and management codes dropped, suggesting a continued need for virtual access to mental health services, which can be some of the rarest and most expensive medical services to find in one’s own geographic area.
Also in April, acute respiratory diseases and infections increased as a percentage of claim lines nationally, and in the Midwest and South, while general signs and symptoms joined the top five telehealth diagnoses in the West. Both trends suggest a return to non-COVID-19 respiratory conditions, like colds and bronchitis, and more ‘normal’ conditions like stomach viruses, researchers said.
- A Cleveland Clinic-owned hospital system in Akron, Ohio, is paying the federal government $21.3 million to settle claims it illegally billed the Medicare program.
- Akron General Health System allegedly overpaid physicians well above market value for referring physicians to the system, violating the Anti-Kickback Statute and Physician Self-Referral Law, and then billed Medicare for the improperly referred business, violating the False Claims Act, between August 2010 and March 2016.
- Along with an AGHS whistleblower, the Cleveland Clinic Foundation, which acquired the system at the end of 2015, voluntarily disclosed to the federal government its concerns with the compensation arrangements, which were enacted by AGHS’ prior leadership, the Department of Justice said Friday.
The Anti-Kickback Statute forbids providers from paying for or otherwise soliciting other parties to get them to refer patients covered by federal programs like Medicare, while the Physician Self-Referral Law, otherwise known as the Stark Law, prohibits a hospital from billing for those services. Despite the laws and a bevy of other regulations resulting in a barrage of DOJ lawsuits and been a thorn in the side of providers for decades, fraud is still rampant in healthcare.
Of the more than $3 billion recovered by the government in 2019 from fraud and false claims, almost 90% involved the healthcare industry, according to DOJ data.
“Physicians must make referrals and other medical decisions based on what is best for patients, not to serve profit-boosting business arrangements,” HHS Office of Inspector General Special Agent in Charge Lamont Pugh said in a statement on the AGHS settlement.
Cleveland Clinic struck a deal with AGHS in 2014, agreeing to pay $100 million for minority ownership in the system. The agreement gave the clinic the option to fully acquire AGHS after a year, which it exercised as soon as that period expired in August 2015.
The settlement stems from a whistleblower suit brought by AGHS’s former Director of Internal Audit Beverly Brouse, who will receive a portion of the settlement, the DOJ said. The False Claims Act allows whistleblowers to share in the proceeds of a suit.
As fraud has increased in healthcare over the past decade — the DOJ reported 247 new matters for potential investigation in 2000, 427 in 2010 and 505 in 2019 — the federal government has renewed its efforts to crack down on illegal schemes. That’s resulted in the formation of groups like the Medicare Fraud Strike Force in 2007 and the Opioid Fraud and Abuse Detection Unit in 2017, which has in turn resulted in the DOJ recovering huge sums in stings, settlements and guilty verdicts.
Some of the biggest settlements reach into the hundreds of millions, and involve billions in false claims.
In 2018, DOJ charged more than 600 people for falsely billing federal programs more than $2 billion; last year federal agencies charged almost 350 people for submitting more than $6 billion in false claims. That last case led to creation of a rapid response strike force to investigate fraud involving major providers in multiple geographies.
Other large settlements include Walgreens’ $270 million fine in 2019 to settle lawsuits accusing the pharmacy giant of improperly billing Medicare and Medicaid for drug reimbursements; hospital operator UHS’ $122 million settlement last summer finalizing a fraudulent billing case with the DOJ after being accused of fraudulently billing Medicare and Medicaid for services at its behavioral healthcare facilities; and West Virginia’s oldest hospital, nonprofit Wheeling Hospital, agreeing in September to pay $50 million to settle allegations it systematically violated the laws against physician kickbacks, improper referrals and false billing.
EHR vendor eClinicalWorks paid $155 million to settle False Claims Act allegations around misrepresentation of software capabilities in 2017, while Florida-based EHR vendor Greenway Health was hit with a $57.3 million fine in 2019 to to settle allegations the vendor caused users to submit false claims to the EHR Incentives Program.