Thursday, January 29, 2015

Medicare Spending on Children Results is Good for Income, New York Times Reports

Recently, Margot Sanger-Katz wrote the following article outlining a study that showed providing government health care to children correllated with a boost in future earnings that may result in the government recouping some of the funds used to provide the medical care with income taxes.

The article follows:

"When advocates talk about the advantages of government health care, they often talk about a moral obligation to ensure equal access. Or they describe the immediate health and economic rewards of giving people a way to pay for their care.

Now a novel study presents another argument for the medical safety net, at least for children: Giving them health coverage may boost their future earnings for decades. And the taxes they pay on those higher incomes may help pay the government back for some of its investment.

The study used newly available tax records measured over decades to examine the effects of providing Medicaid insurance to children. Instead of looking at the program’s immediate impact on those children and their families, it followed them once they became adults and began paying federal taxes.

People who had been eligible for Medicaid as children, as a group, earned higher wages and paid higher federal taxes than their peers who were not eligible for the federal-state health insurance program. And the more years they were eligible for the program, the larger the difference in earnings.

“If we examine kids that were eligible for different amounts of Medicaid over the course of their childhood, we see that the ones that were eligible for more Medicaid ended up paying more taxes through income and payroll taxes later in life,” said Amanda Kowalski, an assistant professor of economics at Yale and one of the study’s authors.

The results mean that the government’s investment in the children’s health care may not have cost as much as budget analysts expected. The study, by a team that included economists from the Treasury Department, was able to calculate a return on investment in the form of tax revenue.

The return wasn’t high enough to pay the government back for its investment in health insurance by the time the children reached age 28, when the researchers stopped tracking the subjects. By that age, the Treasury had earned back about 14 cents for every dollar that the federal and state governments had spent on insurance. But it did suggest that, if the subjects’ wages continued to follow typical trajectories as they aged, the federal government would earn back about what it spent on its half of the program by the time the children reached 60 — about 56 cents on the dollar, calculated using a formula that took into account the time value of money.

The split in spending between the federal and state governments for Medicaid varies by state, but, on average, federal taxpayers pay 57 cents of each dollar. There may also be some return on investment for states that collect income taxes, but the researchers didn’t measure that.

Here’s what that means in real numbers: The average person in the study with no Medicaid earned a total of $149,000 by age 28. For each year a person was eligible for Medicaid, that income went up by $250, and the taxes the person paid went up accordingly.

“What’s exciting about this is how good the outcome variables that they can look at,” said Janet Currie, a professor of economics and public affairs at Princeton. A few studies have tracked the health outcomes of children who were eligible for Medicaid over time, including one Ms. Currie wrote, but the study’s measures of economic outcomes are new.

The new paper was made possible by a series of policy changes throughout the 1980s and 1990s that slowly expanded Medicaid to cover more and more American children. The changes essentially happened in two phases: First, the federal government allowed the program to include older children, and then individual states approved expansion to those groups. The slow, state-by-state spread of the policy enabled the researchers to compare children who were eligible for Medicaid with a control group of similar children of the same age and family income level who were not eligible for the program. The study looked at children who were eligible for Medicaid, even though not every eligible child actually signed up.

Ms. Currie said that earlier studies of children’s health outcomes also suggest that children with serious illnesses often go on to be sick as adults as well — meaning they are more likely to miss work or have limited career options. Medicaid supports and funds a lot of important preventive health care for very young children. She said the lesson could be that “an ounce of prevention is worth a pound of cure.”

Now that the earlier expansions have had a chance to spread, nearly every low-income child in the country is eligible for Medicaid, and more than a third of all American children are currently enrolled in either Medicaid or a closely related federal-state program, called the Children’s Health Insurance Program.

“If this is right, then we’re going to be seeing a lot more impact for the kids that are born now and in the future,” said Judy Solomon, a vice president for health policy at the left-leaning Center on Budget and Policy Priorities."

Wednesday, January 21, 2015

New York Times Discusses Decline in New Ebola Cases Impact on Vaccine Development

A recent New York Times article examined the complications that arise when there are too few cases of a disease to test the vaccine. A recent meeting of public health and viral disease experts discussed the plans for testing Ebola vaccines in Liberia, Guinea, and Sierra Leone. To date the Ebola epidemic has infected nearly 21,000 individuals and killed more than 8,000 people. 


The New York Times reports: “For this reason, it’s very urgent that we get into the field very quickly to do these clinical trials, because if there are very, very, very few cases of Ebola, as I’m sure you understand, it’s going to be difficult to test whether the vaccines work or not,” Dr. Helen Rees, an adviser to the World Health Organization, said during a news conference on Friday at the organization’s headquarters in Geneva.

Dr. Marie-Paule Kieny, an assistant director general of the W.H.O., said two vaccines had been found safe enough in early testing in countries outside the outbreak zone to justify wider testing in the affected countries. But she said it would take two to four weeks more to determine the proper doses.

She said a clinical trial in Liberia could begin as soon as the end of this month, with studies in Sierra Leone and Guinea starting in February.

Dr. Kieny said it could take up to six months to determine if the vaccines are effective. Production has already begun, so if any of the vaccines proves safe and effective, millions of doses could be quickly made available.

Vaccine effectiveness is determined by how many vaccinated people come down with a disease compared with those who are not vaccinated, or vaccinated later. If few new cases of the disease are occurring, it would be harder to see any difference. Dr. Kieny said plans were being made to increase the size of the trial in Liberia if needed.

In Liberia, there were eight confirmed new cases and 40 probable new cases recorded in the five days ending Jan. 2, down from a peak of 300 confirmed new cases a week in August and September, according to the W.H.O. The number of new cases has been falling in Sierra Leone, but it remains the most heavily affected country. In Guinea, it is not clear if case numbers are falling, the health organization said.

If the epidemic continues to ebb, it may be too late for the vaccines to make a difference in this outbreak. Dr. Rees said that a working group had been formed to discuss how to deploy the vaccines, should they prove safe and effective, but that the situation was changing too rapidly to make such a decision now.


“Hopefully, we will have broken the back of this epidemic by the time we finish these trials,” she said.

Even if that is the case, she and Dr. Kieny said, sporadic cases would most likely occur, and vaccinations might be given to people nearby to protect them and help prevent further spread of the disease — a strategy known as ring vaccination. And it might be wise to vaccinate health workers for long-term protection, they said.

The two vaccines that are most advanced in testing are being developed by GlaxoSmithKline and Merck. The Glaxo vaccine is being developed with theNational Institutes of Health; Merck’s was originally developed by the Public Health Agency of Canada and licensed to a small Iowa company, NewLinkGenetics, which in turn enlisted Merck.

Testing of the Merck vaccine at a hospital in Switzerland was suspended in December after a number of patients developed pain in the joints of their fingers and toes. Testing resumed this week using a lower dose. Dr. Kieny said the pain was generally transient and mild and “not of sufficient concern to stop the development of this vaccine.”

A third vaccine, being developed by Johnson & Johnson, began early safety testing in volunteers this month. That company is also planning tests in West Africa.

There has been debate over how to conduct the studies. Some experts say testing the vaccines against a placebo would be the surest way to determine whether they work. Others counter that it would be unethical to administer a placebo during a deadly epidemic.

The trials will cover all the approaches, with different designs in each country. In Liberia, the Merck and Glaxo vaccines will be tested against each other and against a control, with about 9,000 people in each of the three arms of the study.

In Sierra Leone, vaccine doses will be given to health care workers and others directly involved in responding to the disease. There will be no placebo, and effectiveness will be determined by looking at whether there are fewer cases of Ebola among workers who are vaccinated earlier compared with those who are vaccinated later. Which vaccine is used will depend on which one appears to be the best after data on immune responses is analyzed, Dr. Kieny said.

Guinea will test using the ring vaccination strategy, vaccinating communities when a case of Ebola occurs. Some communities will be given vaccine right away, and others will receive it later, based on random assignment."

Friday, January 16, 2015

Advance Life Support Measures Show No Benefit Over Basic Life Support Measures

Aaron E. Carroll discusses the negative health and economic impacts of using advanced life support measures in the following article, "Doing More for Patients Often Does No Good," featured in the New York Times.  Please share your thoughts as professionals on the impacts of these studies on medical billing and care provided. 

"Given the remarkable advances that have been made in the last 50 or so years in pharmaceuticals, medical devices and surgical procedures, it’s not a surprise that people want more, and more invasive, care than they have had in the past. Just as it’s hard to do nothing when you’re ill, it’s sometimes hard to do less than the maximum when there are different treatments to choose from.

Unfortunately, doing more often does no good. Sometimes, it even leads to harm.

In the United States, when it appears that someone might be in trouble, emergency medical services are dispatched. Many patients die from an out-of-hospital cardiac arrest, but steps taken out in the field can make a difference. Basic life support, the kind you might be taught in a CPR class — involving the use of bag valve masks, cardiopulmonary resuscitation and automated external defibrillators— can absolutely save a life.

Advanced life support, usually requiring a trained paramedic, involves much more. Trained providers may put in endotracheal breathing tubes; start intravenous lines; deliver sophisticated cardiac drugs; and defibrillate patients manually.

We’ve assumed, for the most part, that advanced life support is better than basic life support — so much so that in most areas where both options are available, advanced life support is almost always used. But a recent study in JAMA Internal Medicine brings this assumption into question. Researchers examined Medicare patients who were billed for either advanced life support or basic life support before admission to the hospital from 2009 through most of 2011. They looked at how often patients survived to hospital discharge, and then months later.

What they found was that about 13 percent of patients who received basic life support survived and were discharged versus 9 percent of patients who received advanced life support. More patients who received basic life support lived for 90 days after discharge, too (8 percent versus 5 percent). Basic life support patients also had better neurological outcomes.

Now, of course, this is not a randomized controlled trial. It’s possible that sicker patients received advanced life support and that people who didn’t appear as sick received basic life support. But the authors called all of the state agencies, and they reported that this can’t really happen. After all, a 911 dispatcher can’t tell if it’s a “mild” or “severe” heart attack from a third party on the phone with no medical training. Dispatchers send out advanced life support if it’s available, and basic life support if it’s not.

It’s also possible that there could be differences in bystander CPR administration until help arrives. But the authors attempted to control for that, too. They conducted a number of sensitivity analyses, and in none of them did advanced life support outperform basic life support.

It would also be easier to dismiss this finding if it weren’t corroborated in many other studies. In 2004, results from the Ontario Prehospital Advanced Life Support Study were published in the New England Journal of Medicine. This was a multicenter controlled trial in 17 cities in Canada comparing advanced life support with basic life support. They found that if an instance of cardiac arrest were witnessed by a bystander, the chance of survival significantly improved. They also found that CPR administered by bystanders improved survival, and so did rapid defibrillation. These are all components of basic life support. The addition of advanced life support, however, made no difference in survival.

A 2007 study conducted in Taipei also found that advanced life support did not improve survival to discharge. Even the main components of advanced life support have failed to show results in studies. A 2008 systematic review showed no efficacy for emergency intubation. A 2010 cohort study found advanced airway methods — basically, putting in an airway tube rather than using a bag mask — to be associated with decreased survival compared with basic life support methods, as did a 2013 study in Japan.

A 2012 JAMA study found that the use of epinephrine was associated with worse outcomes, and a 2008 New England Journal of Medicine study found that adding vasopressin (another drug that, likeepinephrine, constricts blood vessels to raise blood pressure) didn’t improve things. A randomized controlled trial of these drugs, published in 2009 in JAMA, found that their use didn’t improve survival either.

The evidence is compelling. Advanced life support does not seem to provide any benefits in the randomized controlled trials, and it’s often associated with worse outcomes in the cohort studies. How can this be so? Some theorize that the things that work have already been incorporated into basic life support. All that the advanced life support may be doing is slowing things down in the field, distracting people from the useful basic life support measures, and delaying the time until a patient can get to the hospital.

It’s hard not to do more if we can, though. We see this in all sorts of areas of care. A few months ago, a study was published in JAMA that examined the outcomes of women with stage 0-III unilateral breast cancer who underwent breast conserving surgery with radiation compared with those who had a unilateral mastectomy and those who had a bilateral prophylactic mastectomy. The 10-year survival differences between the groups were negligible. Breast conservation therapy is more tolerable, is much less invasive and costs less.Continue reading the main story

In fact, breast conservation therapy has become a “standard of excellence” in breast cancer care. But a study published even more recently showed that from 1998 through 2011, the odds of a woman eligible for breast conservation therapy receiving a mastectomy increased. Rates of bilateral mastectomy went up over this time period as well, from 2 percent in 1998 to 11 percent in 2011.

And based on the data from many randomized controlled trials, we know that women who have radiation therapy for early breast cancer do well with less of it. The use of “hypofractionated” whole breast irradiation, which consists of fewer treatments with higher levels of radiation, has been shown to be equally effective for women without any excess side effects. It’s cheaper, easier and just as good. Hypofractionated whole breast radiation has been endorsed by the American Society for Radiation Oncology for women who satisfy certain criteria since 2011.

But a study published a month ago that looked at the use of radiationin women with early stage breast cancer found that in 2013, only about a third of women who qualified for hypofractionated radiation therapy were getting it. The rest got more, but not better, care.

The reasons for this are varied. With respect to the radiation therapy, it’s hard not to lay some of the blame on economics. After all, in a fee-for-service system, more visits and more treatments mean more money. Research shows that twice as many women want hypofractionated radiation therapy as want conventional therapy, but only half of radiation oncologists offer it.

But it’s not all money. It’s also probably fear. Many radiation oncologists are concerned that doing fewer treatments will lead to worse outcomes. That’s most likely the concern of women who choose much more invasive surgery than necessary as well.

It’s certainly the rationale for why advanced life support is so prevalent. The Ontario Prehospital Advanced Life Support Trial was supposed to be a randomized controlled trial, but the paramedicsevidently refused to do it because they felt that holding back advanced life support was unethical. This was in spite of the lack of evidence that it was effective.

More is expensive. More sometimes does no good. Sometimes, more is even harmful. When our policies and care ignore these facts, we all suffer."

Thursday, January 8, 2015

NAHAM Webinar: Introducing NAHAM AccesKeys

Join NAHAM for a Webinar January 14th, 2:00-3:00pm EST, to discover NAHAM's exciting new tool for members: 
AccessKeys


NAHAM is excited to announce the unveiling of a project more than two years in the making, created from the minds of a dedicated group of your NAHAM member peers. Unprecedented in the field of Patient Access, this new tool will fill a gap in the front-end of the revenue cycle, helping define the complex and ever-changing registration processes, oftentimes little understood by revenue cycle managers. Furthermore, this new offering will reshape your understanding of how your facility’s Patient Access department’s performance compares to other, similar healthcare organizations across the United States.

Never before have Patient Access managers been able to use standardized, simple equations to measure, for example, Point of Service Collections to Revenue, and then compare that score against industry benchmarks, thus measuring outcomes, not merely activities.

The AccessKeys® are set up as a series of equations created by NAHAM’s Industry Standards Committee (ISC), which was formed as a new standing committee of NAHAM tasked with continually updating these Access Keys and develop other industry standards and best practices. The 23 different KPIs measure how well front-end departments and staff are doing across six Patient Access domains:
  • Collections
  • Conversions
  • Patient Experience
  • Process Failures
  • Productivity
  • Quality
For each KPI, the committee has provided a simple equation, using easy-to-find data, and each equation comes with some helpful “tips and tricks” provided by the committee. Upon plugging in the corresponding numbers for your organization, you can see if your score falls into the “Good,” “Better,” or “Best” benchmark.

Members-Only Benefit

The NAHAM AccessKeys® are a members-only benefit. To access them when they are released in mid-January, renew your membership today!  

Register Today for the AccessKeys® Webinar

Wednesday, January 14, 2015
2:00 pm Eastern 


Paul Shorrosh, NAHAM Industry Standards Committee chair and key contributor to the AccessKeys® will present a webinar to describe how to implement the tool in your facility. 

Register today!

Tuesday, December 23, 2014

Negative Consequences Abound When Nonprofits Hospitals Sue Poorest Patients

Nonprofit hospitals receive a tax-exempt status based on their work to serve the poor by addressing their medical needs. However, the medical billing practices of hospitals was recently called into question by a Consumer Financial Protection Bureau report. The report examined medical debt in this country and found that 1 in 5 consumers, or 43 million individuals, have a negative mark on their credit report from a medical debt. The debt collections practices employed by hospitals raise several concerns including releasing private medical information covered by HIPAA to outside parties not involved in treatment, unfair billing practices that disproportionately impact low-income patients, a failure to provide and educate patients on available aid, the need for aid to retroactively cover eligible medical costs, and the legality of nonprofit hospitals suing their poorest patients. 

A recent NPR story highlighted the issues that arise for low-income patients when nonprofit hospitals sue for unpaid medical bills. In addition to the aribtrarily higher prices many low-income patients are charged for medical treatment, the debts associated with their medical care negatively impact nearly every area of their lives. Medical debts reported to credit agencies lower credit scores which in turn, raises the prices for many basic needs such as car insurance, mortgages, credit cards, and loans. Additionally, some employers examine the credit report in the hiring process and a low credit score or history of medical debt may negatively impact an individual's chance to get a job because they are viewed as irresponsible or the employer feels they will not be reliable due to the medical issues insinuated in the report. 

Hospitals are turning to the courts to recover these inflated debts from their low-income patients. When the hospitals are successful they may be able to recover the debt, in addition to court costs, debt collection administration fees, and interest by garnishing the low-income individual's wages. This practice creates a cycle of poverty that is nearly impossible to escape and discourages individuals from receiving medical care. It particularly provides a disincentive for low-income individuals to receive preventative care, which would be beneficial to all parties involved. 

Reform is imperative. Hospitals and health access managers must be diligent in educating patients about aid, prudently billing, and limiting the debts that move to collection agencies. 

Resources to help those with medical debt may be found at the following websites:

Monday, December 22, 2014

CMS Proposes 3-Year Penalty Delay for Accountable Care Organizations & New ACO Model

Accountable Care Organizations (ACO) are voluntary organizations that providers may choose to participate in which are comprised of doctors, hospitals, and other health care providers. The Centers for Medicare and Medicaid (CMS) created Accountable Care Organizations with the goal of coordinating care to ensure that patients get the right care at the right time while avoiding unnecessary duplicaiton of services an preventing medical errors. Currently Medicare offers the Medicare Shared Savings Program that allows ACOs to share in the savings it achieves for the Medicare program. ACOs may also be penalized for poor performance. 

Penalty Delay
However, CMS recently proposed that health care systems experimenting with a new way of being paid by Medicare would have three extra years before they could be punished for poor performance. This three-year delay is in addition to the three-year extension currently in place, for a total of six years. The proposal can be found here. The new rule applies to both new and existing ACOs. 

While ACOs wouldn't face penalties for an additional three years, any ACO that chose to avoid penalties after the initial delay period of three years would be limited to 40-percent of the money they save Medicare. There is a 50-percent maximum cut off of savings ACOs are able to keep during the first three years. 

Track Three ACO Model
The new ACO model, known as "Track Three," allows ACOs to keep up to 75-percent of the money they save Medicare. Track Three ACOs would be responsible for 15-percent of any excess spending they cost Medicare. This is higher than the 10-percent limit to the other models of ACOs that are in place now. 

Friday, December 19, 2014

Omnibus Continues Tax Breaks for Blue Cross and Blue Shield Insurance & Ups Spending to Detect Healthcare Fraud and Abuse

The 2015 Fiscal Year Omnibus Appropriations Bill provides just over $1 trillion in discretionary spending in compliance with the Murray-Ryan budget agreement and funds the majority of the federal government through Sept. 30, 2015. 

Nongermane Riders
The New York Times reports that "Steve Ellis, vice president of Taxpayers for Common Sense, a nonprofit research group that tracks federal spending, said the bill bestowed favors on all sorts of constituencies.

“Authors of the bill and lobbyists behind these provisions know they are in there,” Mr. Ellis said. “But the public will not find out about most of them for weeks or months, if ever.” Congress supposedly forswore spending earmarks several years ago, after federal largess led to several scandals. But lawmakers can still steer money in less conspicuous ways."

One example of a nongermane rider that went into the bill without public debate provides relief to nonprofit Blue Cross and Blue Shield plans, which have special tax breaks that may have been threatened by provisions in the Affordable Care Act. While Blue Cross is not mentioned by name in the legislation, the deduction is only available to Blue Cross and Blue Shield plans. Blue Cross and Blue Shield have been lobbying Congress for a clarification since the Affordable Care Act was signed in 2010.

Fraud Prevention
The Committee on Appropriations executive summary also explains that the bill provides $1.484 billion for cap adjustment funding to prevent waste, fraud, abuse and improper payments in the Medicare, Medicaid and Social Security programs. This is a $560 million increase in funding from last year's level.

A significant portion of those funds, $672 million, are dedicated to the Health Care Fraud and Abuse Control program at the Centers for Medicare and Medicaid Services. That amount more than doubles the level enacted in fiscal year 2014. 
One reason for the increase is that preventing fraud creates a significant savings for the government. The latest data shows that for every $1 spent on fraud and abuse control, $8.10 is recovered by the Department of Treasury. That recovery ration is the highest three-year average return on investment in the entire 17-year history of the Health Care Fraud and Abuse Control program.

Further Information
For a more comprehensive discussion of nongermane riders passed in the Omnibus see this New York Times article, "In Final Spending Bill, Salty Food and Belching Cows are Winners." The Senate Committee on Appropriations executive summary of the bill can be found here.