Category Archives: Uncategorized

Judge Rules 340B Cuts Unlawful, Decision Applauded by Industry Stakeholders

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A federal judge reaffirmed his view that the cuts by HHS to the discount drug program are unlawful.

KEY TAKEAWAYS

In a joint statement, three hospital plaintiffs urged HHS to follow the judge’s directive.

340B Health added their approval in a statement, asking the agency to “act quickly.”

A status report regarding HHS’ progress remedying the situation must be submitted to U.S. District Court Judge Rudolph Contreras by August 5.

U.S. District Court Judge Rudolph Contreras again ruled Monday evening that the 340B drug reimbursement rate that Health and Human Services set in the 2019 Outpatient Prospective Payment System (OPPS) rule is unlawful, a decision that earned praise from various industry stakeholders. 

Five months after first vacating the 22% cut in 340B payments that HHS Secretary Alex Azar proposed late last year, Contreras reiterated that the cuts were implemented “in contravention of the Medicare Act’s plain text.”

Medicare Part B will sell prescription drugs to hospitals participating in the program at the average selling price plus 6%, well above the average selling price minus 22.5% as HHS had proposed.

“The Court also concludes that, despite the fatal flaw in the agency’s rate adjustments, vacating HHS’ 2018 and 2019 rules is not the best course of action, given the havoc vacatur may wreck on Medicare’s administration,” Contreras wrote in the 22-page ruling.

HHS will have “first crack” at crafting appropriate remedies for the two rules, according to the ruling.

Tuesday, three hospital plaintiffs applauded the ruling as a positive development for the embattled federal program, which has been deemed wasteful and rife with abuse by critics who demand additional oversight and accountability.

“America’s 340B hospitals are pleased with the District Court’s decision and urge HHS to follow the judge’s directive to promptly resolve the harm caused by its unlawful cuts to Medicare reimbursement for certain 340B hospitals,” the American Hospital Association, Association of American Medical Colleges, and America’s Essential Hospitals said in a joint statement. “The ruling reaffirmed that the 2018 cuts were unlawful and extended that ruling to the 2019 cuts. Owing to the complexity of the Medicare program, the judge gave HHS first crack at fashioning a remedy for its unlawful actions. He also asked for a report from HHS on its progress on or before August 5, 2019. We urge HHS to promptly comply with the judge’s ruling and restore to 340B hospitals all funds that have been unlawfully withheld.”

HHS has not issued a statement regarding Monday’s ruling and did not respond to a request for comment by time of publication. 

The December ruling by Contreras did have a material impact on nonprofit hospitals, according to Moody’s Investor Service, which determined in early January that the reversion of the cuts would lead to improved operating performance.

340B Health, an advocacy group for the federal program, also issued a statement Tuesday afternoon applauding Contreras’ ruling.

“On behalf of the nearly 1,400 hospitals we represent that participate in 340B, we are pleased that the court has, once again, found that HHS exceeded its statutory authority by cutting what Medicare pays for outpatient drugs delivered to their patients,” Maureen Testoni, CEO of 340B Health, said in a statement. “The cuts made in 2018 and again in 2019 have reduced hospitals’ ability to care for those in need. The sooner this policy is reversed, the better hospitals will be able to serve the needs of patients with low incomes and those in rural communities. HHS must act quickly, as any further delay will only harm patients and the hospitals they rely on for care.”

Nearly 2,500 hospitals currently participate in the 340B Drug Pricing Program, which was created in 1992 to assist safety-net and low-income providers purchase prescription drugs.

A status report regarding HHS’ progress remedying the situation must be submitted to Judge Contreras by August 5. 

 

 

For the First Time, Employed Docs Outnumber Self-employed Docs

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https://www.healthleadersmedia.com/first-time-employed-docs-outnumber-self-employed-docs

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The milestone continues a long-term trend that has shifted the distribution of physicians away from ownership of private practices.

KEY TAKEAWAYS

Employed physicians were 47.4% of all patient care physicians in 2018, up 6% points since 2012.

Self-employed physicians were 45.9% of all patient care physicians in 2018, down 7% points since 2012.

In the aggregate, 34.7% of physicians worked either directly for a hospital or in a practice at least partly owned by a hospital in 2018, up from 29.0% in 2012.

Employed physicians outnumber self-employed physicians for the first time in the United States, according to an updated study on physician practices by the American Medical Association.

“Transformational change continues in the delivery of healthcare and physicians are responding by reevaluating their practice arrangements,” AMA President Barbara L. McAneny, MD, said in a media release.

Employed physicians were 47.4% of all patient care physicians in 2018, up 6% points since 2012.

Self-employed physicians were 45.9% of all patient care physicians in 2018, down 7% points since 2012.

Such a dramatic shift is not unprecendented. Older AMA surveys show the share of self-employed physicians fell 14% points during a six-year span between 1988 and 1994.

Given the rate of change in the early 1990s, it appeared a point was imminent when employed physicians would outnumber self-employed physicians, but the shift took much longer than anticipated.

The AMA’s researchers said that history suggests that “caution should be taken in assuming current trends will continue indefinitely.”

The majority of patient care physicians (54%) worked in physician-owned practices in 2018 either as an owner, employee, or contractor. Although this share fell from 60% in 2012, the trend away from physician-owned practice appears to be slowing since more than half of the shift occurred between 2012 and 2014, the study said.

At the same time, there was an increase in the share of physicians working directly for a hospital or in a practice at least partly owned by a hospital.

Physicians working directly for a hospital were 8% of all patient care physicians, an increase from 5.6% in 2012. Physicians in hospital-owned practices were 26.7% of all patient care physicians, an increase from 23.4% in 2012.

In the aggregate, 34.7% of physicians worked either for a hospital or in a practice at least partly owned by a hospital in 2018, up from 29.0% in 2012.

Younger physicians and women physicians are more likely to be employed. Nearly 70% of physicians under age 40 were employees in 2018, compared to 38.2% of physicians age 55 and over.

Among female physicians, more were employees than practice owners (57.6% vs. 34.3%). The reverse is true for male physicians, more were practice owners than employees (52.1% vs. 41.9%).

As in past AMA studies, physicians’ employment status varied widely across medical specialties in 2018.

The surgical subspecialties had the highest share of owners (64.5%) followed by obstetrics/gynecology (53.8%) and internal medicine subspecialties (51.7%).

Emergency medicine had the lowest share of owners (26.2%) and the highest share of independent contractors (27.3%). Family practice was the specialty with the highest share of employed physicians (57.4%).

Most physicians still work in small practices, but this share has fallen slowly but steadily since 2012. In 2018, 56.5% of physicians worked in practices with 10 or fewer physicians compared to 61.4% in 2012.

The AMA report said the transition has been driven primarily by the shift away from very small practices, especially solo practices, in favor of very large practices of 50 or more physicians.

The new study is the latest addition to the AMA’s Policy Research Perspective series that examines long term changes in practice arrangements and payment methodologies.

“Transformational change continues in the delivery of healthcare and physicians are responding by reevaluating their practice arrangements. ”

 

 

 

 

Breaking: CPR to Require Prior Authorization

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Breaking: CPR Requires Prior Authorization

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“No!” cries ICU physician

In breaking news that will infinitely complicate the already difficult process of attempting to resuscitate a patient, cardiopulmonary resuscitation (or CPR) will now require prior authorization.

The prevailing reaction to this news is best captured by Felicia Martin-Lowry, MD, a critical care physician at James Monroe University Hospital in Washington, as she crumbled into a burbling mess of defeat: “No … no … NOOOOOOOO!!!!”

Much like prior authorization requests for medications or other services, health care professionals will only learn about the need for a prior authorization right when CPR is initiated. The insurer will block CPR from continuing and the health care professional will need to go through the lengthy prior authorization process.

“We need to make sure that the health care team tried some other interventions before jumping straight into CPR,” explained a spokesperson for a major national health insurance company, who insisted on anonymity. “Expect us to ask questions like, did you try oxygen? Did you try IV fluids? Did you try an antibiotic? Did you try bicarb?”

The spokesperson went on to say that the checklist of questions will border on somewhere between 700 and 800 questions.

Insurance companies understand that CPR can be a life-saving measure. For that reason, if the insurer finds that all the appropriate steps were taken prior to the patient’s death, then they will be sure to expedite the prior authorization as an urgent request and make the decision on whether or not to approve CPR in no less than 14 days.

“Time is of the essence,” the spokesperson added, before reminding everyone that prior authorizations for CPR will only take place weekdays from 9 a.m. to 5 p.m.

In other news, Gomerblog has learned that insurers will soon require prior authorizations before physical exams and IV placement.

Once again, this post is from GomerBlog, a satirical site about healthcare.

Pensions Have Tripled Their Investment in High-Risk Assets. Is It Paying Off?

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https://www.governing.com/topics/finance/gov-public-pension-investment-returns-alternative.html?utm_term=Pensions%20Have%20Tripled%20Their%20Investment%20in%20High-Risk%20Assets.%20Is%20It%20Paying%20Off&utm_campaign=How%20Can%20a%20City%20Issue%20Pay%20Raises%20and%20Layoff%20Notices%20in%20the%20Same%20Week&utm_content=email&utm_source=Act-On+Software&utm_medium=email

Sign for Wall Street in New York City

A growing body of evidence shows that “alternative investments” may be lowering returns and costing state and local governments more.

Public pensions are more invested than ever before in high-risk and expensive assets like real estate and hedge funds. Yet research continues to show that this tactic is unlikely to improve their earnings.

According to Fitch Ratings, in the span of a decade, pensions tripled their average investment in these so-called alternative investments. In 2007, they averaged 9 percent of state and local public pension investment portfolios. By 2017, that number had risen to 27 percent.

During that period, median average returns on overall investments were 6.2 percent, according to Fitch. But during the longer period between 2001 and 2017, reflecting a time of less reliance on alternative investments, they were actually slightly better: 6.4 percent.

“If you look at trends and allocation to riskier assets and the returns we see alongside them, you clearly see that you can’t necessarily say you’re getting the bang for the buck over the last 17 years,” says Fitch analyst Olu Sonola, who authored the report.

The report adds to the growing body of evidence that alternative investments are not worth the extra cost and risk. In fact, they may be lowering pensions’ earnings and costing state and local governments more money.

Pensions’ average investment returns — overall, not just on alternatives — failed to meet expectations between 2001 and 2017, even though those expectations lowered from 8 percent to 7.5 percent. Plans that don’t meet expectations require state or local governments to put more money in pension systems. Even high-performing pension systems like Colorado, Oklahoma, Utah and Wisconsin have had to increase their payments or give up being fully funded for this reason.

Only South Dakota’s retirement system, which is fully funded and relies the least among all 50 states on alternatives and equities, met its own expectations over that time period. Seven states — Arizona, Connecticut, Hawaii, Maryland, New Hampshire, New Jersey and Rhode Island — missed theirs by 2 percent or higher, according to Fitch.

The reason alternative investments aren’t a safe bet, concludes Fitch, is because they tend to be volatile. But others dispute that idea. Andy Palmer, the chief investment officer for Maryland’s pension system, says their strategy of investing more in alternatives is to reduce risk and volatility.

Before the 2008 financial crisis, nearly 70 percent of the Maryland system’s portfolio was invested in stocks — now it’s less than 50 percent. Since then, Maryland has invested more in private equity, real estate and hedge funds.

“Reducing our risk in U.S. equities in particular and getting return from other sources, we believe, will protect us from those really sharp downturns,” says Palmer.

The system has also slightly lowered its expected rate of return over the years from 8 percent to 7.45 percent.

Palmer points to the average 9.5 percent investment return the system has earned over the last 10 years as of this March. While that exceeded state expectations, it’s not as good as some of Maryland’s peers. Palmer says that’s the result of unfortunate timing: The system shifted away from stocks at a time when the market went gangbusters.

But Jeff Hooke, a visiting fellow for the right-leaning Maryland Public Policy Institute who has been critical of pension systems that invest heavily in alternatives, argues the real winners in this larger trend are the Wall Street bankers who make money from the high fees associated with these investments.

“You can basically replicate all these alternative investment strategies through the public market and save yourself all the fees,” Hooke says.

Fitch’s report backs up Hooke’s claim. Passively managed portfolios (which are low-fee and leave Wall Street out of the equation almost entirely), have performed better than the average pension plan over the last 17 years.

 

 

Integrity Matters Most in a Leader!

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https://www.linkedin.com/pulse/integrity-matters-most-leader-brigette-hyacinth/

In every aspect of our lives we depend on the integrity of others, and others do the same with us. That’s why it’s such a big deal when we discover someone we trust hasn’t been truthful or hasn’t been playing by the rules.

Although integrity is one of the most essential and admired leadership traits, in today’s world it seems to be lacking. What you see in leaders is not often what you get.

Here are 7 masks some leaders wear:

1. Orator (The Two Face mask) – Double tongued are they. They can sound so persuasive and so sincere. Fervent lips which sound so eloquent can hide true character. Behind the dazzling mask lies their real intentions of deception. Erroneous communications are a big cause of lack of perceived trustworthiness in bosses. Politicians are notorious and highly populate this category. However, their actions always expose them. We don’t take them at face value because we don’t know which face they have on.

2. Advocate (The 3 Musketeers mask)- “One for all and one for one.” They are all for me, myself and I. The love of power is their main motivator. They outwardly proclaim they are people focused, and their priority is with the team but behind closed doors they are self- seeking. Therefore when the opportunity is presented to prove it they cannot. They will do anything to make themselves look good, or maintain their status quo even at the expense of the team.

3. Philanthropist (The Robin Hood mask) – They give with the right hand but secretly take back with the left hand. Under this disguise these type of leaders give openly so others can think highly of them. If there was no fanfare they would not support charitable initiatives. Former Tyco International Ltd. Chairman Dennis Kozlowski improperly used company funds to promote himself as a generous benefactor. He committed more than $100 million of the conglomerate’s money to good causes however, his own foundation gave little to charity. He was accused of stealing $134 million from the company and served 8 years in prison.

4. Obdurate (The Iron Man mask) – They scarcely show their true feelings or human side. They think they need to have this public tough image. Marissa Mayer, former CEO of Yahoo came across as cold and disconnected to her employees. Her policies (maternity leave and long-term telecommuting) caused outrage. Adopting this persona alienates and pushes people away. By not showing any vulnerability, such leaders do not develop deep meaningful connections or build relationships with their team.

5. Meek (The Mister Fantastic mask) – They appear so humble and act down to earth when in fact they have an entitlement and superiority complex. However, their true colors are revealed in unguarded moments. I remember once working late and overhearing a manager speaking with a supervisor. He didn’t realize I was there and openly spoke to her. As I sat there I couldn’t believe that this is the person I thought I knew. When he came out of his office and saw me by my desk, he seemed really disoriented and shocked and asked if I had overheard him. Well, my whole perception of him changed from that day.

6. Proficient – (The Phantom of the Opera mask) – Some leaders conceal imperfections in favor of a polished image. The demands or expectations that society creates leaves them feeling mediocre and inadequate. They are uncomfortable in their own skin so they try to measure up and may even employ unethical methods to fit in. Lying on his resume cost former Bausch & Lomb CEO Ronald Zarrella $1.1 million in bonus after it was revealed he did not have an MBA as recorded. Company officials declined to accept his resignation. He remained in his role for another six years before retiring in 2008. Ironically, he probably didn’t need that degree. His prior job experiences were almost certainly enough. Still, like so many people, he seemed to have yearned for a status symbol.

7. Conformist – (The Shape-Shifter mask) – In this case, top management puts pressure on these types of managers to change their principles. Their style may not fit in with the changing culture. There is a shift between their preferred style of behavior and what the company wants. They play it safe to preserve their position and privileges. They just follow orders and exude no loyalty to employees. It’s demotivating working for a manager who does not stand up for their team. If you make a mistake they quickly turn into judge, jury and executioner. It’s hard to feel passion for a job when you experience this.

In the era of social media, where leaders’ personal and professional lives are often transparently intertwined, the mask eventually becomes apparent. Trust once lost is often hard to regain. Integrity requires humble introspection.

It requires you do what is right – not what is easy. Our actions must mirror our words in all facets of life. It all starts with keeping your word, making fair decisions, communicating honestly, taking responsibility, treating others with dignity and respect and giving credit where it’s due. There are many things you can lack and still steer clear of danger. Integrity isn’t one of them. If you don’t have integrity, people will not trust, believe or follow you. If you don’t have integrity, you have nothing.

 

 

 

Meet the Canadian Doctor Who Prescribes Money to Low-Income Patients

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https://www.vox.com/future-perfect/2019/5/3/18524482/canada-health-doctor-prescribing-money-income-poverty?fbclid=IwAR1WrqjAWAz32DyqqNLpl9JbVaaqHS1LBUrM-PbUDf_GojvvM52lVATBa5o

 

 

Can States Fill the Gap if the Federal Government Overturns Preexisting-Condition Protections?

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https://www.commonwealthfund.org/blog/2019/can-states-fill-gap-preexisting-condition-protections

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Once again, the Affordable Care Act (ACA) is under threat, this time in the form of Texas v. Azar, a federal lawsuit challenging its constitutionality. This litigation, now under consideration by the Fifth Circuit Court of Appeals, took an unexpected turn in March when the U.S. Department of Justice (DOJ) sided with the plaintiffs, urging the Court to strike the ACA down in its entirety.

On May 1, the administration filed a brief in support of this action. But even before this suit, DOJ had refused to defend key provisions that guarantee coverage of preexisting conditions. If the courts agree with the DOJ, it would invalidate every provision of the 2010 law.

As many as 20 million people nationwide would lose their coverage, while millions more could face insurance company denials, premium surcharges, or high out-of-pocket costs because of their health status.

ACA Protections for People with Preexisting Conditions

  • Guaranteed issue. Health insurers are prohibited from denying an individual or employer group a policy based on their health status.
  • Community rating. Health insurers may not use an individual or small employer group’s health status to set premiums.
  • Preexisting condition exclusions. Health insurers and employer group plans are prohibited from refusing to cover services needed to treat a preexisting condition.
  • Essential health benefits. Health insurers selling to individuals and small employers must cover a minimum set of 10 “essential” benefits: ambulatory services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services; and pediatric services, including oral and vision care.
  • Cost-sharing protections. Health insurers and employer group plans must cap the amount enrollees pay out-of-pocket for health care services each year.
  • Annual and lifetime limits. Health insurers and employer group plans are prohibited from imposing annual or lifetime dollar limits on essential health benefits.
  • Preventive services. Health insurers and employer group plans are required to cover evidence-based preventive services without any enrollee cost-sharing.
  • Nondiscrimination. Health insurers must implement benefit designs for individuals and small employers that do not discriminate based on age, disability, or expected length of life.

To help blunt potential fallout and prevent adverse effects for millions of individuals, several states are enacting bills to ensure that federal ACA protections become part of state law (see box). However, before the ACA, state efforts to require insurers to cover people with preexisting conditions resulted in large premium spikes and, in some cases, caused insurers to exit the market.

The ACA’s premium subsidies have had a critical stabilizing effect. If those subsidies are invalidated, states will have a hard time restoring them with state dollars. In addition, state regulation of self-funded employer plans is preempted under the federal Employee Retirement Income Security Act (ERISA), meaning the 61 percent of people with this type of job-based coverage can regain their protections under the ACA only if Congress steps in to restore them.

States Are Stepping Up, but Power to Fully Protect Consumers Is Limited

In a previous post, we found that at least four states (Colorado, Massachusetts, New York, and Virginia) had laws that would preserve key ACA preexisting-condition protections if the federal law is overturned. Since that time, seven more states (Connecticut, Hawaii, Indiana, Maine, Maryland,1 New Mexico, and Washington) have acted to preserve the ACA’s protections for their residents.

These bills take different approaches. Maine, New Mexico, and Washington passed comprehensive bills that would preserve all the protections listed above. The Connecticut, Hawaii, and Indiana laws are more narrowly focused. Hawaii and Indiana prohibit insurers from imposing preexisting condition exclusions; Connecticut aligns its benefit standards with the ACA. Maryland took a different approach, creating a workgroup to recommend ways to protect residents if the ACA is struck down. The governors of New Jersey and Rhode Island have issued executive orders directing their state agencies to uphold the ACA’s principles, by guarding against discrimination based on preexisting conditions and strengthening consumer protections to ensure access to affordable coverage.

Looking Forward

The Fifth Circuit Court of Appeals is expected to hear arguments in Texas v. Azar in July. Whatever that court decides, the losing party is likely to ask the Supreme Court to hear the case, and a ruling could come as soon as June 2020. With the future of the ACA hanging in the balance, at least 14 other states are considering legislation codifying some of the federal consumer protections during their 2019 sessions.