UnitedHealthcare to crack down on ER visits, potentially exposing patients to bigger bills

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Dive Brief:

  • The nation’s largest commercial insurer is taking a closer look at whether visits to the emergency room by some of its members are necessary. Starting July 1, UnitedHealthcare will evaluate ER claims using a number of factors to determine if the visit was truly an emergency for its fully insured commercial members across many states, according to a provider bulletin
  • If UnitedHealthcare finds the visit was a non-emergency, the visit will be “subject to no coverage or limited coverage,” the provider alert states.
  • However, a statement provided to Healthcare Dive said the insurer will reimburse for non-emergency care according to the member’s benefit plan. In other words, the amount paid by UnitedHealthcare may be less if deemed a non-emergency.    

Dive Insight:

Patients seeking out the pricey ER setting for minor illnesses that could have been treated elsewhere has been a perennial issue for the healthcare industry. Misuse of the nation’s emergency departments for minor ailments costs the nation’s healthcare system $32 billion a year, according to a previous report from UnitedHealth Group, the parent firm of UnitedHealthcare.

Providers worry such policies will lead to a chilling effect, causing patients to hesitate even in a true emergency such as a heart attack or stroke. Some of those concerns about the effects on patients were aired on Twitter this week after the provider bulletin became public. 

UnitedHealthcare’s policy contains exclusions, including observation stays, visits by children under the age of two and admissions from the ER.  It’s not clear precisely how many patients will be impacted but UnitedHealthcare had a total of 26.2 million commercial members at the end of 2020.

The insurer said this is an attempt to ensure healthcare is more affordable. To curb costs, they want patients to seek out treatment in a more “appropriate setting” like an urgent care facility. 

Other major insurers have enacted similar policies in the past and faced pushback from the public and providers.

Anthem in recent years has also enacted policies that put patients on the hook for the ER bill if they sought care that didn’t warrant a trip to the ER. The policy also attracted scrutiny from then Senator Claire McCaskill, a Missouri Democrat, who requested Anthem turn over internal documents over the policy and the Blues player ultimately scaled back some of its policies amid pushback from doctors and others.

Providers have argued these policies collide with federal law that require emergency rooms to treat any patient that shows up, regardless of their ability to pay.

UnitedHealthcare does have a process in place for those to contest a visit that was deemed a non-emergency.

ED volume remains persistently down, but at higher acuity

https://mailchi.mp/f42a034b349e/the-weekly-gist-may-28-2021?e=d1e747d2d8

As we shared recently, post-pandemic healthcare volume is not returning evenly. While outpatient volume is rebounding quickly, other settings remain sluggish, especially the emergency department. We partnered with healthcare data analytics company Stratasan to take a closer look at ED volume decline. As shown in the graphic above, nationally, ED visits were down 27 percent in 2020, compared to 2019. ED-only volume (cases that started and ended in the ED) took a large hit across last year, down nearly a third from 2019. We expect that a portion of this ED-only volume will never fully recover to pre-COVID levels, with patient demand permanently shifting to lower-acuity care settings, including virtual, and some patients avoiding care altogether for minor ailments as they learn to “live with” problems like back pain.
 
ED-to-observation volume saw the greatest decline in 2020, likely as a result both of patients avoiding the ED, and presenting in the ED sicker, meeting the criteria for inpatient admission. However, ED-to-inpatient volume, which fell only seven percent in 2020, has been returning. In the second half of 2020, the ED-to-inpatient admission rate was 20 to 30 percent higher than the pre-COVID baseline. Across all three categories of ED volume, pediatrics saw steeper declines compared to adult cases. While some further ED volume rebound is anticipated, health systems should expect that fewer, but sicker, patients will be the new normal for hospital emergency departments. 

Fewer low-acuity patients utilizing high-cost emergency care is good news from a public health perspective, but health systems must bolster other access channels like urgent care and telemedicine to ensure patients have convenient access for emergent care needs.

Turning to primary care for vaccine distribution

https://mailchi.mp/da8db2c9bc41/the-weekly-gist-april-23-2021?e=d1e747d2d8

U.S. Starts Vaccine Rollout as High-Risk Health Care Workers Go First - The  New York Times

Now that we’ve entered a new phase of the vaccine rollout, with supply beginning to outstrip demand and all adults eligible to get vaccinated, we’re hearing from a number of health systems that their strategy is shifting from a centralized, scheduled approach to a more distributed, access-driven model. They’re recognizing that, in order to get the vaccine to harder-to-reach populations, and to convince reticent individuals to get vaccinated, they’ll need to lean more heavily on walk-in clinics, community settings, and yes—primary care physicians.

For some time, the primary care community has been complaining they’ve been overlooked in the national vaccination strategy, with health systems, pharmacy chains, and mass vaccination sites getting the lion’s share of doses. But now that we’re moving beyond the “if you build it, they will come” phase, and into the “please come get a shot” phase, we’ll need to lean much more heavily on primary care doctors, and the trusted relationships they have with their patients.

As one chief clinical officer told us this week, that means not just solving the logistical challenges of distributing vaccines to physician offices (which would be greatly aided by single-dose vials of vaccine, among other things), but planning for patient outreach. Simply advertising vaccine availability won’t suffice—now the playbook will have to include reaching out to patients to encourage them to sign up.

There will be workflow challenges as well, particularly while we await those single-dose shots—primary care clinics will likely need to schedule blocks of appointments, setting aside specific times of day or days of the week for vaccinations. The more distributed the vaccine rollout, the more operationally complex it will become. Health systems won’t be able to “get out of the vaccine business”, as one health system executive told us, because many have spent the past decade or more buying up primary care practices and rolling out urgent care locations. Now those assets must be enlisted in the service of vaccination rollout.

Health systems will have to orchestrate a “pull” strategy for vaccines, rather than the vaccination “push” they’ve been conducting for the past several months. To put it in military terms, the vaccination “air war” is over—now it’s time for what’s likely to be a protracted and difficult “ground campaign”.
 

Urgent care centers boost spending on low-acuity visits, study finds

Where Should I go? Emergency Room vs. Urgent Care - Black Hills Parent

Although urgent care centers deter some lower-acuity patients from a costly emergency department visit, they are not associated with a drop in total healthcare spending, according to a study published in Health Affairs in April.

For the study, researchers used insurance claims and enrollment data from 2008 to 2019 from a managed care plan to understand if the presence of an urgent care center substantially decreased lower-acuity ED visits. 

The authors found that the entry of an urgent care center into a ZIP code deterred lower-acuity ED visits, but the effect was small.

The study found that the reduction of just one lower-acuity ED visit was associated with 37 additional urgent care visits. In other words, the number of urgent care visits per enrollee required to reduce one ER visit is 37. 

The study authors found that the prevention of each $1,646 lower-acuity ED visit was offset by an increase of $6,237 in urgent care center costs. 

As a result, the study authors said that despite ED visits costing more per visit, the use of urgent care centers increased net overall spending on lower-acuity care. 

“This study documents for the first time that urgent care centers are associated with increased overall costs for lower-acuity visits across the ED and urgent care settings,” the study authors concluded. 

Amazon Care goes nationwide with telehealth, courts outside employers

Dive Brief:

  • Amazon is expanding its virtual care pilot program, Amazon Care, to employees and outside companies nationwide beginning this summer in a major evolution of its telehealth initiative, as the COVID-19 pandemic continues to drive unprecedented demand for virtual care.
  • Amazon will also offer its on-demand primary care service to other Washington state-based companies and plans to expand its in-person service to Washington, D.C., Baltimore and other cities in the following months, the e-commercebehemoth announced Wednesday.
  • Amazon Care launched 18 months ago as a pilot program in Washington state offering free telehealth consults and in-home visits for a fee for its employees and their families.

Dive Insight:

The nationwide expansion, and the potential of the e-retailer’s heft and technological know-how leveraged in the medical delivery space, threatens existing telehealth providers and retail giants like CVS Health and Walgreens that maintain their own networks of community health clinics.

Amazon Care has two main components: urgent and primary care telehealth with a nurse or doctor via an app, and in-person care, along with prescription delivery, to the home. The Seattle-based company says it will offer the gamut from preventative care like annual vaccinations, to on-demand urgent care including COVID-19 testing, to services like family planning.

Amazon plans to roll out the virtual care offering for its employees and third party companies nationwide this year, but in-person services will only be available shortly after in Washington state and near its second headquarters in Washington, D.C., and Baltimore, a spokesperson said.

Making Amazon Care available to outside companies puts Amazon in direct competition with virtual care giants like Teladoc, Amwell and Doctor on Demand, which bring in a sizable chuck of their revenue through deals with employer and payer clients.

Amazon is in discussions with a number of outside companies on supplying Amazon Care, the spokesperson said.

It’s unclear what differentiates the virtual care offering alone from other vendors. Most telehealth platforms are available to consumers right now at little to no cost and offer relatively short wait times, though Amazon contends it provides free access to a medical professional in 60 seconds or less and will eventually link telehealth with in-home care across the U.S.

The timing for the broader U.S. rollout couldn’t be better for Amazon, as telehealth has seen exponential growth during the COVID-19 pandemic. As a result of historic consumer demand and investor interest, virtual care giants have spent billions to gobble up market share and build out their suite of services.

The race to offer end-to-end telehealth offerings has resulted in a flurry of recent M&A, the most notable deal being Teladoc’s $18.5 billion acquisition of chronic care manager Livongo last year. In February, Cigna’s health services arm Evernorth also bought vendor MDLive for undisclosed amount. The insurer plans to sell MDLive’s telehealth offerings to third-party clients and offer it to beneficiaries. And just on Tuesday, telemedicine company Doctor on Demand announced plans to merge with clinical navigator Grand Rounds to try and better coordinate virtual care.

Shares in publicly traded telehealth vendors dove following Amazon Care’s announcement Wednesday. As of late morning, Teladoc’s stock had dropped 7.4%, while Amwell was down 6.7%.

But heft doesn’t necessarily translate to disruption in healthcare. Earlier this year, Amazon, J.P. Morgan and Berkshire Hathaway disbanded their venture to lower healthcare costs after three years of stagnancy. One reason was a failure for its initiatives to take precedence at its three separate parent companies, all pursuing their own avenues to cut costs.

Now going at it alone, Amazon has a slew of independent initiatives to reshape the U.S. healthcare industry. The $386 billion company bought and launched its own online pharmacy, PillPack, a few years ago, and also partnered last year with employer health provider Crossover Health to offer employee primary care clinics. Currently, Amazon and Crossover operate clinics in 17 locations across Arizona, California, Kentucky, Michigan and Texas.

However, though Amazon Care does give patients the option to fill prescriptions through Amazon Pharmacy, it operates independently of the other services. It remains to be seen how Amazon Care could tie in with these other businesses, but the answer to that question could have major ramifications for current market leaders.

The pandemic brought a “double whammy” to pediatric volumes

https://mailchi.mp/05e4ff455445/the-weekly-gist-february-26-2021?e=d1e747d2d8

Sick Little Girl In Hospital Bed Stock Photo, Picture And Royalty Free  Image. Image 30227571.

Even as surgery and office visit volume rebounds, hospitals across the country continue to report that emergency department volume remains persistently depressed, down 10 to 20 percent compared to before the pandemic. The shift is even more drastic in pediatrics, with some pediatric hospitals and programs reporting that emergency care volume is seeing double the rate of decline.

Pediatric volume has been hit with a “double whammy”with many schools and day cares still closed, contagious illnesses have plummeted. Fewer kids in youth sports means fewer injuries. And unlike adult hospitals, pediatric facilities haven’t filled their beds with COVID patients. “Of all our services, pediatric hospitalists have taken the greatest hit,” one children’s hospital physician leader shared. “Their service is usually full this time of the year with flu and RSV [respiratory syncytial virus]. But with kids not interacting with each other, general pediatric admissions have cratered.” Empty EDs have led some pediatric hospitals to shutter adjacent urgent care clinics: “It doesn’t make sense to operate an empty ED and an empty after-hours clinic”.

For patients, however, this can bring unexpected financial consequences, as they’ll now get an ED bill for services they would formerly have received in urgent care. But while pediatric hospitals have taken a greater volume hit, they’re also likely to see a faster rebound. Once kids are back to school and sports, the usual illnesses and injuries will likely return, and we’d guess parents won’t hesitate to seek care.

Urgent care network to pay $12.5M in billing fraud case

https://www.beckershospitalreview.com/legal-regulatory-issues/urgent-care-network-to-pay-12-5m-in-billing-fraud-case.html?utm_medium=email

Different Types of Fraud and Abuse found in Medical Billing - Leading Medical  Billing Services | medicalbillersandcoders

A company that owned and operated more than 30 urgent care centers has agreed to pay $12.5 million to resolve overbilling allegations, the Department of Justice announced Sept. 3. 

UCXtra Umbrella, which did business in Arizona as Urgent Care Extra, previously admitted to engaging in healthcare fraud and monetary transactions derived from unlawful activity. The company admitted that it had billing procedures in place that caused its providers to overstate the complexity of the medical services provided to patients. This resulted in falsely inflated reimbursement rates from health insurance companies, according to the Justice Department. 

The company also admitted that staff were encouraged to order tests and procedures that may not have been medically necessary to justify higher billing codes and reimbursement. 

Health insurance companies overpaid the company by an estimated $12.5 million due to the fraud scheme, according to the Justice Department.

 

 

Walmart files plans for standalone clinic in Florida

https://www.beckershospitalreview.com/capital/walmart-files-plans-for-standalone-clinic-in-florida.html?utm_medium=email

Walmart Health: A Deep Dive into the $WMT Corporate Strategy in Health Care  | by Nisarg Patel | Medium

Walmart plans to open a 6,500-square-foot standalone clinic in Middleburg, Fla., according to the Jacksonville Record & Observer, which cited plans filed with the local water management district. 

The new clinic is part of the expansion Walmart Health announced July 22. The new health center will offer primary care, urgent care, labs, imagining, counseling, optical and hearing services, according to the report. A timeline for when the clinic will open has not been released.

In addition to expanding into Florida, Walmart Health is also planning to open a few clinics in the Chicago market. The company already has freestanding health centers in Georgia and Arkansas. 

 

 

 

 

Consumer confidence declines as COVID surges

https://mailchi.mp/86e2f0f0290d/the-weekly-gist-july-10-2020?e=d1e747d2d8

 

Just as consumer confidence was approaching pre-COVID levels in early June, cases began surging in many parts of the country. The graphic below shares highlights from a recent Morning Consult poll, which found reduced consumer confidence in participating in a range of activities, like dining out or going to a mall.

The poll also showed a significant consumer divide based on political affiliation, with Republicans’ confidence levels for many activities being twice that of Democrats. It remains to be seen whether the current surge will result in consumers pulling back on healthcare utilization the way they are beginning to for other activities.

A coalition of healthcare organizations is urging consumers to continue social distancing but “stop medical distancing”—in hopes that the new surge will not lead patients to avoid needed medical care. While cell tower data at thousands of hospital facilities suggest volumes may be stalling again, we anxiously await the latest national data on outpatient visit and elective procedure volumes.

We’d predict the surge will exacerbate consumer discomfort with “waiting” in healthcare settings—urgent care clinics, emergency departments and the like—though we’d expect the reduction in utilization to be less severe and more regionally varied this time around. 

Let us know what you’re seeing!

 

 

 

 

Meeting growing consumer demand for “care anywhere”

https://mailchi.mp/7d224399ddcb/the-weekly-gist-july-3-2020?e=d1e747d2d8

 

While COVID-19 provided a big push for doctors and health systems to rapidly expand telemedicine visits and other kinds of remote patient interactions, many report that they are now seeing telemedicine visits decline sharply, as in-person visits return.

While it’s natural to be glad that “things are returning to normal”, backing off virtual care is short-sighted, as recent experiences have set new expectations for patients. Survey data shows consumers like using telehealth services, both because they’re more convenient (65 percent) and help avoid COVID infection (63 percent)—and 51 percent say they would continue using them after the pandemic ends.

We’re increasingly convinced that virtual physician visits are just one part of a continuum of care that can be delivered in the convenience and safety of the patient’s home. The graphic below highlights the range of consumer-focused virtual care solutions, from asynchronous chat interactions all the way to hospital care delivered at home.

Health systems that can deliver “care anywhere”—an integrated platform of virtual services consumers can access from home (or wherever they are) for both urgent needs and overall health management, coordinated with in-person resources—have an unprecedented opportunity to build loyalty at a time when consumers are seeking a trusted source of safe, available care solutions.