A coalition of health groups and others sued HHS March 9 over a Trump administration rule that was finalized the day before President Joe Biden’s inauguration.
The lawsuit, pending in U.S. District Court of the Northern District of California, alleges that thousands of HHS regulations could disappear because of the Securing Updated and Necessary Statutory Evaluations Timely, or SUNSET, rule. The rule requires HHS to review its existing 18,000 regulations within several years. If the review isn’t completed, the rule automatically expires, according to NPR.
“The rule does not even specify which of the department’s 18,000 existing regulations are exempted under the limited exceptions. In other words, the outgoing administration planted a ticking time bomb set to go off in five years unless HHS, beginning right now, devotes an enormous amount of resources to an unprecedented and infeasible task,” the complaint states.
The complaint further allegesthat the rule exceeds the authority of HHS and creates uncertainty and instability in the U.S. healthcare system at a time when the public needs clear guidelines because of the pandemic.
The plaintiffs are asking the court to declare that the rule is arbitrary and capricious and to vacate it.
The plaintiffs are Santa Clara County, Calif., the National Association of Pediatric Nurse Practitioners, the American Lung Association, the Center for Science in the Public Interest, the California Tribal Families Coalition and the Natural Resources Defense Council.
Strengthening the link between the ED and treatment offers an opportunity to combat the opioid epidemic.
Hospital emergency departments not only care for patients with overdose and other complications from opioid use, but they also serve as vital touch points to encourage patients into longer-term treatment. After an overdose, patients are at risk for repeat overdose and death.
Pennsylvania is unique in establishing a voluntary incentive program to improve the rate at which patients with opioid use disorder receive follow-up treatment after emergency department care. Evaluations of the program show that financial incentives are effective in producing rapid treatment innovations for opioid use disorder.
In a new study, researchers at the Perelman School of Medicine at the University of Pennsylvania found that Pennsylvania’s financial incentive policy encouraged hospitals to enact rapid system and practice changes to support treatment for opioid use disorder for patients visiting the ED.
The study, published in Psychiatric Services, evaluates the efficacy of the Opioid Hospital Quality Improvement Program (O-HQIP), which Pennsylvania pioneered in 2019. The program seeks to increase the rate of follow-up treatment for Medicaid patients within seven days of an ED encounter for opioid-related illness by offering financial compensation to hospitals who participate in the program.
WHAT’S THE IMPACT?
Strengthening the link between the ED and treatment offers an opportunity to combat the opioid epidemic, and the financial incentives have shown momentum for the efforts to improve treatment access.
The program identified four distinct treatment pathways: initiation of buprenorphine treatment during the ED encounter, warm handoff to outpatient treatment, referral to treatment for pregnant patients and inpatient initiation of methadone or buprenorphine treatment.
An initial incentive for participation was paid to hospitals in 2019, contingent on participation in all four pathways, with lesser payments for partial participation. In future years, hospitals can earn additional incentives for improvements in performance.
To evaluate the degree of the program’s success, researchers conducted 20 semistructured interviews with leaders from a diverse sample of hospitals and health systems across Pennsylvania. The interviews revealed that the incentives oriented institutional priorities toward expanding opioid treatment access.
Hospitals were often on the cusp of change and responded to this nudge to prioritize opioid treatment access. But most hospitals – specifically, smaller or independent hospitals with lower volumes of patients with opioid use disorder – were unable to justify investing in these resources internally. Some hospitals noted resources as a barrier to participation, despite the incentive payments.
While initiating buprenorphine in the ED is proven to improve patients’ health outcomes and retention in treatment, many hospitals found implementing a pathway for buprenorphine difficult and time-consuming, and all partially participating hospitals chose to forgo this pathway.
Future work will focus on overcoming barriers to implementing buprenorphine treatment.
THE LARGER TREND
In 2019, buprenorphine was found by Mayo Clinic Proceedings to be one of three FDA-approved drugs that are underused in helping patients combat opioid addiction. Patient compliance with buprenorphine, that analysis found, is relatively high and associated with improved rates of sobriety and a reduction in accidental overdoses.
The opioid epidemic has long been a challenging issue both for Americans and the healthcare system that treats them, and the mortality statistics are significant. The American Academy of Family Physicianspublished research in 2019 showing that, if there’s no change in the annual incidence of prescription opioid misuse, annual opioid deaths could hit 82,000 by 2025.
From finding new, more cost-effective care delivery models to establishing outpatient addiction treatment programs, there’s an opportunity for investors to pump some much needed cash into the efforts to curb opioid misuse. If done correctly, the investors can see a healthy ROI, while also helping patients with addiction issues and easing the burden on the healthcare system.
We spend a lot of time talking to health system leaders about growth. It’s almost an article of faith among executives that growth is paramount to success. That’s understandable for investor-owned companies—top-line growth is often the most straightforward way to generate greater earnings, which is what investors demand. But for not-for-profit systems, the answer is a little muddier.
One unspoken but obvious reason for growth is leverage—the ability to extract higher rates from third party payers.
There are other, more palatable arguments for increasing scale: it yields greater ability to drive efficiencies in purchasing and operations, to invest in talent and technology, to identify and implement best clinical practices, and to ensure financial sustainability. All of those are real and demonstrable benefits of scale, but more often it’s a desire for greater pricing leverage that underlies many “growth strategies”.
Unfortunately, that kind of growth can be downrightvalue-destroying for patients and consumers. The problem is that growth is on the wrong side of the equation, thanks to our dysfunctional, third-party payment system.
In healthcare, growth is an input to strategy—whereas in other industries, growth is an output, the result of delivering superior services to consumers. Health systems do better by getting bigger, while other firms get bigger because they are better: their growth is earned.
That doesn’t mean that health systems shouldn’t seek to grow, and we certainly spend a lot of our time helping them figure out how to capture growth opportunities. But it’s worth recognizing thatit’s the structure of the payment system, not the malevolence of health system executives, that results in leverage-driven growth.
The right focus for policymakers is restructuring incentives to encourage systems to compete on creating value for consumers, rather than punishing health systems for responding rationally to the incentives that currently exist.
The economic effects from the pandemic may place more pressure on investors to reevaluate the pay packages of CEOs in the future. But for the time being, “we are simply getting wealthier CEOs,” according to an annual report from the nonprofit shareholder advocacy group As You Sow.
For its report, As You Sow evaluated the most “overpaid” CEOs of S&P 500 companies. The nonprofit used data to compute what CEO pay would be assuming such pay is related to total shareholder return. In its methodology, a ranking of companies by excess CEO pay and by shareholder votes on CEO pay are weighted at 40 percent. The final ranking based on CEO-to-worker pay ratio is weighted at 20 percent. Find the full methodology here.
As You Sow notes some CEOs may no longer hold the positions listed below, as the rankings were calculated using data made available before June 30, 2020.
Here are 21 healthcare CEOs who made As You Sow’s list:
Larry Merlo (CVS Health) Pay: $36.5 million CEO-to-worker pay ratio: 790:1 Excess pay: $24.3 million
Alan Miller (King of Prussia, Pa.-based Universal Health Services) Pay: $24.5 million CEO-to-worker pay ratio: 629:1 Excess pay: $12.4 million
Michael Neidorff (Centene) Pay: $26.4 million CEO-to-worker pay ratio: 383:1 Excess pay: $13.3 million
Heather Bresch (Mylan) Pay: $18.5 million CEO-to-worker pay ratio: 427:1 Excess pay: $7.5 million
John Hammergren (McKesson) Pay: $17.4 million CEO-to-worker pay ratio: 458:1 Excess pay: $5.2 million
Samuel Hazen (Nashville, Tenn.-based HCA Healthcare) Pay: $26.8 million CEO-to-worker pay ratio: 478:1 Excess pay: $14.1 million
Stefano Pessina (Walgreens Boots Alliance) Pay: $19.2 million CEO-to-worker pay ratio: 562:1 Excess pay: $7.3 million
Ari Bousbib (IQVIA) Pay: $22.1 million CEO-to-worker pay ratio: 186:1 Excess pay: $8.7 million
Miles White (Abbott Laboratories) Pay: $27.8 million CEO-to-worker pay ratio: 329:1 Excess pay: $14.2 million
Javier Rodriguez (DaVita) Pay: $16.9 million CEO-to-worker pay ratio: 286:1 Excess pay: $4.3 million
Leonard Schleifer, MD, PhD (Regeneron Pharmaceuticals) Pay: $21.5 million CEO-to-worker pay ratio: 154:1 Excess pay: $8.6 million
Daniel O’Day (Gilead Sciences) Pay: $29.1 million CEO-to-worker pay ratio: 169:1 Excess pay: $16.9 million
David Cordani (Cigna) Pay: $19.3 million CEO-to-worker pay ratio: 306.7:1 Excess pay: $6.5 million
Michael Minogue (Abiomed) Pay: $19.2 million CEO-to-worker pay ratio: 166:1 Excess pay: $4.8 million
Joseph Hogan (Align Technology) Pay: $18.3 million CEO-to-worker pay ratio: 1,328:1 Excess pay: $3.5 million
Kenneth Frazier (Merck) Pay: $27.6 million CEO-to-worker pay ratio: 289:1 Excess pay: $14.5 million
Marc Casper (Thermo Fisher Scientific) Pay: $19 million CEO-to-worker pay ratio: 235:1 Excess pay: $5 million
Michel Vounatsos (Biogen) Pay: $18.2 million CEO-to-worker pay ratio: 114:1 Excess pay: $6 million
Michael Kaufmann (Cardinal Health) Pay: $15.6 million CEO-to-worker pay ratio: 272:1 Excess pay: $3.4 million
Vincent Forlenza (Becton, Dickinson and Co.) Pay: $16 million CEO-to-worker pay ratio: 379:1 Excess pay: $2.6 million
Omar Ishrak (Medtronic) Pay: $17.8 million CEO-to-worker pay ratio: 240:1 Excess pay: $4.8 million
The billboards along the interstate near our houses still flash, “Wash your hands and wear a mask to stop the spread of COVID”. As we learn more about the virus, it’s increasingly clear that those two actions are not equivalent. A new piece in the Atlanticmakes a strong argument that our obsessive surface cleaning and handwashing is largely “hygiene theater”, doing very little to stop the spread of the disease.
COVID-19 is spread almost exclusively by aerosol transmission, breathing in virus particles emitted from an infected person that remain suspended in the air. Spread by fomites, or virus particles lingering on surfaces, is responsible for little-to-no documented transmission, despite numerous studies (of varying quality) showing the virus can “live” on surfaces for up to a month. The author concedes it’s not impossible, but the attention to surfaces is misdirected: “If somebody with COVID-19 sneezes three times onto a little spot on a cold steel table, and you rub your hand around in the snot for a bit and immediately lick your fingers, that disgusting act may well result in you infecting yourself. But the threat of such unbelievably stupid behavior at a mass level shouldn’t warrant a multibillion-dollar war on fomites.”
Our obsession with surface cleaning has harmful consequences. The billions of dollars spent on regimented cleaning could be redirected toward better uses. Schools are still waiting for funding to safely reopen. The money devoted to surface cleaning should instead be spent improving ventilation and making sure all teachers and students have high-quality masks. All of the harsh cleaning chemicals we are inhaling may be harming our health. And most importantly,surface cleaning creates a false sense of security, sending a message that it’s OK to dine maskless, indoors, at a restaurant because they’re lowering risk by thoroughly cleaning the menus and tables. As we navigate our way to the end of the pandemic, we need to reinforce the point that masks, ventilation and vaccines, not Lysol and Clorox, are our best weapons against the virus.
HENRY KOTULA 