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Obstetric care under threat in rural areas
Ready access to maternity services in rural areas is not a given, yet access to obstetric hospitals is associated with decreased rates of preterm birth and neonatal/perinatal mortality.
Little is known, however, about the availability of obstetric centers with respect to birth volume, geographic distribution among states, proximity of obstetric hospitals, and urban adjacency.
“This knowledge is fundamental to inform clinical and policy efforts to optimize perinatal regionalization, care delivery, and outcomes,” wrote Sara C. Handley, MD, MSCE, of the Roberts Center for Pediatric Research at the Children’s Hospital of Philadelphia, and colleagues, who undertook to fill that information gap in a study. It was published online Oct. 8 in JAMA Network Open.
Her group found birth volumes varied among obstetric hospitals, with many low-volume facilities located in rural, even isolated, areas, which suggests a need to ensure better access to perinatal care for women in these locations.
Using American Hospital Association data, the researchers examined the birth volumes and geographic distributions of 3,207 maternity hospitals from 2010 to 2018. In a cohort of 34,054,951 births, 56.8% occurred in high-volume obstetric facilities, and 37.4% in low-volume hospitals. Among the latter, 18.9% were isolated in location and not within 30 miles of any other obstetric hospital.
Most infants (19,327,487) were born in hospitals with more than 2,000 births per year, the study found, but a substantial 2,528,259, or 7.4%, were born in low-volume centers reporting 10 to 500 births annually.
“We were surprised by the number of low-volume hospitals and the number of births in low-volume hospitals,” Dr. Handley said in an interview. Many low-volume hospitals are in rural areas, which may require patients to drive long distances. These hospitals are at high risk of closure and such closures may further increase travel time.
Among low-volume hospitals, 23.9% were within the study proximity threshold of 30 miles of a hospital with more than 2,000 deliveries per year. “And when you’re in labor, even 30 miles is a long drive,” Dr. Handley said.
According to the authors, these findings highlight the need to balance care availability and sufficient patient volume by ensuring access and referral to high-quality perinatal care. They suggest perinatal care regionalization policies need review to improve maternal and infant outcomes.
But although the need is pressing, meeting it will not happen quickly, Dr. Handley said. “Change will require buy-in from multiple stakeholders and investment at many levels.”
The American College of Obstetrics and Gynecology has previously raised the alarm about general health disparities among women in underserved rural communities.
Anne L. Banfield, MD, director of women’s health services at Davis Medical Center in the mountain town of Elkins, W.V., is one obstetrician/gynecologist who is all too familiar with the problem of shrinking perinatal facilities. “Closures have impacted services,” she said in an interview, noting that one hospital in her region closed its birthing unit because of financial considerations. “The next closest facility to ours is 20 miles to the west and more than 60 miles in any other direction,” she said. “And geography can create challenges. Because we’re located in the mountains, it can take 2 hours to get to our facility.”
The hope is that these findings will inform discussions on regionalization policy for perinatal care to improve maternal and infant outcomes and address concerns about isolated obstetric hospitals, the authors said.
Dr. Banfield emphasized that obstetric facilities should be made a priority even if they’re less profitable than other services and not a major contributor to the bottom line. But that will require rethinking reimbursement models to align with community needs. “Everyone has a mother – no one springs from a pod – but the fact is, we’re not paying enough for maternal health care,” she said.
A top priority, she noted, is attracting sufficient staff; not only doctors, but also nurses and midwives with the skill sets required for perinatal care, which differ from those of general surgery and outpatient services. “We have to make financial changes to make this care feasible,” Dr. Banfield said.
In similar recent research, a study published online in the October issue of Health Affairs, showed that with rural hospitals facing increased financial distress, they may merge with other hospitals/systems, potentially reducing service lines that are less profitable or that duplicate services offered by the acquiring institution. Among those often on the chopping block is perinatal care.
“Our analysis of rural hospital discharge data found that merged hospitals were more likely than independent hospitals to eliminate maternal, neonatal, and also surgical care,” lead author Lan Liang, PhD, senior economist at the Agency for Healthcare Research and Quality (AHRQ) in Rockville, Md., said in an interview. This finding was consistent with previous AHRQ research using hospital self-reports, she added.
The study sample comprised 172 rural hospitals that merged during the period 2009-2016 in 32 states and 549 nonmerged comparison hospitals. In the premerger period, 74.5% of hospitals that merged provided maternal/neonatal care. This percentage decreased to 61.1% in the postmerger period. In contrast, the percentage of comparison hospitals providing these services remained stable during both periods (64.3% and 65.1%, respectively).
After weighting and adjusting for variables, the researchers found that from the premerger period to 1 year post merger, the percentage of hospitals providing these services decreased by 6.7 percentage points more for merged than for comparison hospitals (P = .06).
In the second year post merger, the percentage of hospitals providing maternal/neonatal services decreased by 7.2 percentage points more for merged than for comparison hospitals (P = .09).
“We did not, however, see a reduction in the volume of maternity services in rural communities, which suggests that women are just traveling farther to give birth,” Dr. Liang said.
Although mergers might salvage hospitals’ sustainability, the authors wrote, they do not necessarily mean that service lines are retained or that hospitals are as responsive to community needs as they were before the merger.
The analysis concluded that continuing access to maternal/neonatal care in rural areas is not a given. “Stakeholders, including payers, policy makers, and community-based organizations, need to monitor the availability of maternity services to ensure women have options in childbirth providers,” Dr. Liang said.
She and her associates called for payer-supported, multi-stakeholder initiatives to transform rural health care to be both financially sustainable and responsive to population needs.
The study by Dr. Handley and colleagues was supported by the National Institutes of Health (NIH) and the Eunice Shriver National Institute of Child Health and Human Development (NICHD). Dr. Handley reported grants from the NIH outside of the submitted work. Several coauthors reported grants from, variously, the NIH, the NICHD, and the Agency for Healthcare Research and Quality (AHRQ). The study by Dr. Liang and associates was supported by the AHRQ’s Center for Financing, Access, and Cost Trends, and the Healthcare Cost and Utilization Project. The authors disclosed no competing interests.
Ready access to maternity services in rural areas is not a given, yet access to obstetric hospitals is associated with decreased rates of preterm birth and neonatal/perinatal mortality.
Little is known, however, about the availability of obstetric centers with respect to birth volume, geographic distribution among states, proximity of obstetric hospitals, and urban adjacency.
“This knowledge is fundamental to inform clinical and policy efforts to optimize perinatal regionalization, care delivery, and outcomes,” wrote Sara C. Handley, MD, MSCE, of the Roberts Center for Pediatric Research at the Children’s Hospital of Philadelphia, and colleagues, who undertook to fill that information gap in a study. It was published online Oct. 8 in JAMA Network Open.
Her group found birth volumes varied among obstetric hospitals, with many low-volume facilities located in rural, even isolated, areas, which suggests a need to ensure better access to perinatal care for women in these locations.
Using American Hospital Association data, the researchers examined the birth volumes and geographic distributions of 3,207 maternity hospitals from 2010 to 2018. In a cohort of 34,054,951 births, 56.8% occurred in high-volume obstetric facilities, and 37.4% in low-volume hospitals. Among the latter, 18.9% were isolated in location and not within 30 miles of any other obstetric hospital.
Most infants (19,327,487) were born in hospitals with more than 2,000 births per year, the study found, but a substantial 2,528,259, or 7.4%, were born in low-volume centers reporting 10 to 500 births annually.
“We were surprised by the number of low-volume hospitals and the number of births in low-volume hospitals,” Dr. Handley said in an interview. Many low-volume hospitals are in rural areas, which may require patients to drive long distances. These hospitals are at high risk of closure and such closures may further increase travel time.
Among low-volume hospitals, 23.9% were within the study proximity threshold of 30 miles of a hospital with more than 2,000 deliveries per year. “And when you’re in labor, even 30 miles is a long drive,” Dr. Handley said.
According to the authors, these findings highlight the need to balance care availability and sufficient patient volume by ensuring access and referral to high-quality perinatal care. They suggest perinatal care regionalization policies need review to improve maternal and infant outcomes.
But although the need is pressing, meeting it will not happen quickly, Dr. Handley said. “Change will require buy-in from multiple stakeholders and investment at many levels.”
The American College of Obstetrics and Gynecology has previously raised the alarm about general health disparities among women in underserved rural communities.
Anne L. Banfield, MD, director of women’s health services at Davis Medical Center in the mountain town of Elkins, W.V., is one obstetrician/gynecologist who is all too familiar with the problem of shrinking perinatal facilities. “Closures have impacted services,” she said in an interview, noting that one hospital in her region closed its birthing unit because of financial considerations. “The next closest facility to ours is 20 miles to the west and more than 60 miles in any other direction,” she said. “And geography can create challenges. Because we’re located in the mountains, it can take 2 hours to get to our facility.”
The hope is that these findings will inform discussions on regionalization policy for perinatal care to improve maternal and infant outcomes and address concerns about isolated obstetric hospitals, the authors said.
Dr. Banfield emphasized that obstetric facilities should be made a priority even if they’re less profitable than other services and not a major contributor to the bottom line. But that will require rethinking reimbursement models to align with community needs. “Everyone has a mother – no one springs from a pod – but the fact is, we’re not paying enough for maternal health care,” she said.
A top priority, she noted, is attracting sufficient staff; not only doctors, but also nurses and midwives with the skill sets required for perinatal care, which differ from those of general surgery and outpatient services. “We have to make financial changes to make this care feasible,” Dr. Banfield said.
In similar recent research, a study published online in the October issue of Health Affairs, showed that with rural hospitals facing increased financial distress, they may merge with other hospitals/systems, potentially reducing service lines that are less profitable or that duplicate services offered by the acquiring institution. Among those often on the chopping block is perinatal care.
“Our analysis of rural hospital discharge data found that merged hospitals were more likely than independent hospitals to eliminate maternal, neonatal, and also surgical care,” lead author Lan Liang, PhD, senior economist at the Agency for Healthcare Research and Quality (AHRQ) in Rockville, Md., said in an interview. This finding was consistent with previous AHRQ research using hospital self-reports, she added.
The study sample comprised 172 rural hospitals that merged during the period 2009-2016 in 32 states and 549 nonmerged comparison hospitals. In the premerger period, 74.5% of hospitals that merged provided maternal/neonatal care. This percentage decreased to 61.1% in the postmerger period. In contrast, the percentage of comparison hospitals providing these services remained stable during both periods (64.3% and 65.1%, respectively).
After weighting and adjusting for variables, the researchers found that from the premerger period to 1 year post merger, the percentage of hospitals providing these services decreased by 6.7 percentage points more for merged than for comparison hospitals (P = .06).
In the second year post merger, the percentage of hospitals providing maternal/neonatal services decreased by 7.2 percentage points more for merged than for comparison hospitals (P = .09).
“We did not, however, see a reduction in the volume of maternity services in rural communities, which suggests that women are just traveling farther to give birth,” Dr. Liang said.
Although mergers might salvage hospitals’ sustainability, the authors wrote, they do not necessarily mean that service lines are retained or that hospitals are as responsive to community needs as they were before the merger.
The analysis concluded that continuing access to maternal/neonatal care in rural areas is not a given. “Stakeholders, including payers, policy makers, and community-based organizations, need to monitor the availability of maternity services to ensure women have options in childbirth providers,” Dr. Liang said.
She and her associates called for payer-supported, multi-stakeholder initiatives to transform rural health care to be both financially sustainable and responsive to population needs.
The study by Dr. Handley and colleagues was supported by the National Institutes of Health (NIH) and the Eunice Shriver National Institute of Child Health and Human Development (NICHD). Dr. Handley reported grants from the NIH outside of the submitted work. Several coauthors reported grants from, variously, the NIH, the NICHD, and the Agency for Healthcare Research and Quality (AHRQ). The study by Dr. Liang and associates was supported by the AHRQ’s Center for Financing, Access, and Cost Trends, and the Healthcare Cost and Utilization Project. The authors disclosed no competing interests.
Ready access to maternity services in rural areas is not a given, yet access to obstetric hospitals is associated with decreased rates of preterm birth and neonatal/perinatal mortality.
Little is known, however, about the availability of obstetric centers with respect to birth volume, geographic distribution among states, proximity of obstetric hospitals, and urban adjacency.
“This knowledge is fundamental to inform clinical and policy efforts to optimize perinatal regionalization, care delivery, and outcomes,” wrote Sara C. Handley, MD, MSCE, of the Roberts Center for Pediatric Research at the Children’s Hospital of Philadelphia, and colleagues, who undertook to fill that information gap in a study. It was published online Oct. 8 in JAMA Network Open.
Her group found birth volumes varied among obstetric hospitals, with many low-volume facilities located in rural, even isolated, areas, which suggests a need to ensure better access to perinatal care for women in these locations.
Using American Hospital Association data, the researchers examined the birth volumes and geographic distributions of 3,207 maternity hospitals from 2010 to 2018. In a cohort of 34,054,951 births, 56.8% occurred in high-volume obstetric facilities, and 37.4% in low-volume hospitals. Among the latter, 18.9% were isolated in location and not within 30 miles of any other obstetric hospital.
Most infants (19,327,487) were born in hospitals with more than 2,000 births per year, the study found, but a substantial 2,528,259, or 7.4%, were born in low-volume centers reporting 10 to 500 births annually.
“We were surprised by the number of low-volume hospitals and the number of births in low-volume hospitals,” Dr. Handley said in an interview. Many low-volume hospitals are in rural areas, which may require patients to drive long distances. These hospitals are at high risk of closure and such closures may further increase travel time.
Among low-volume hospitals, 23.9% were within the study proximity threshold of 30 miles of a hospital with more than 2,000 deliveries per year. “And when you’re in labor, even 30 miles is a long drive,” Dr. Handley said.
According to the authors, these findings highlight the need to balance care availability and sufficient patient volume by ensuring access and referral to high-quality perinatal care. They suggest perinatal care regionalization policies need review to improve maternal and infant outcomes.
But although the need is pressing, meeting it will not happen quickly, Dr. Handley said. “Change will require buy-in from multiple stakeholders and investment at many levels.”
The American College of Obstetrics and Gynecology has previously raised the alarm about general health disparities among women in underserved rural communities.
Anne L. Banfield, MD, director of women’s health services at Davis Medical Center in the mountain town of Elkins, W.V., is one obstetrician/gynecologist who is all too familiar with the problem of shrinking perinatal facilities. “Closures have impacted services,” she said in an interview, noting that one hospital in her region closed its birthing unit because of financial considerations. “The next closest facility to ours is 20 miles to the west and more than 60 miles in any other direction,” she said. “And geography can create challenges. Because we’re located in the mountains, it can take 2 hours to get to our facility.”
The hope is that these findings will inform discussions on regionalization policy for perinatal care to improve maternal and infant outcomes and address concerns about isolated obstetric hospitals, the authors said.
Dr. Banfield emphasized that obstetric facilities should be made a priority even if they’re less profitable than other services and not a major contributor to the bottom line. But that will require rethinking reimbursement models to align with community needs. “Everyone has a mother – no one springs from a pod – but the fact is, we’re not paying enough for maternal health care,” she said.
A top priority, she noted, is attracting sufficient staff; not only doctors, but also nurses and midwives with the skill sets required for perinatal care, which differ from those of general surgery and outpatient services. “We have to make financial changes to make this care feasible,” Dr. Banfield said.
In similar recent research, a study published online in the October issue of Health Affairs, showed that with rural hospitals facing increased financial distress, they may merge with other hospitals/systems, potentially reducing service lines that are less profitable or that duplicate services offered by the acquiring institution. Among those often on the chopping block is perinatal care.
“Our analysis of rural hospital discharge data found that merged hospitals were more likely than independent hospitals to eliminate maternal, neonatal, and also surgical care,” lead author Lan Liang, PhD, senior economist at the Agency for Healthcare Research and Quality (AHRQ) in Rockville, Md., said in an interview. This finding was consistent with previous AHRQ research using hospital self-reports, she added.
The study sample comprised 172 rural hospitals that merged during the period 2009-2016 in 32 states and 549 nonmerged comparison hospitals. In the premerger period, 74.5% of hospitals that merged provided maternal/neonatal care. This percentage decreased to 61.1% in the postmerger period. In contrast, the percentage of comparison hospitals providing these services remained stable during both periods (64.3% and 65.1%, respectively).
After weighting and adjusting for variables, the researchers found that from the premerger period to 1 year post merger, the percentage of hospitals providing these services decreased by 6.7 percentage points more for merged than for comparison hospitals (P = .06).
In the second year post merger, the percentage of hospitals providing maternal/neonatal services decreased by 7.2 percentage points more for merged than for comparison hospitals (P = .09).
“We did not, however, see a reduction in the volume of maternity services in rural communities, which suggests that women are just traveling farther to give birth,” Dr. Liang said.
Although mergers might salvage hospitals’ sustainability, the authors wrote, they do not necessarily mean that service lines are retained or that hospitals are as responsive to community needs as they were before the merger.
The analysis concluded that continuing access to maternal/neonatal care in rural areas is not a given. “Stakeholders, including payers, policy makers, and community-based organizations, need to monitor the availability of maternity services to ensure women have options in childbirth providers,” Dr. Liang said.
She and her associates called for payer-supported, multi-stakeholder initiatives to transform rural health care to be both financially sustainable and responsive to population needs.
The study by Dr. Handley and colleagues was supported by the National Institutes of Health (NIH) and the Eunice Shriver National Institute of Child Health and Human Development (NICHD). Dr. Handley reported grants from the NIH outside of the submitted work. Several coauthors reported grants from, variously, the NIH, the NICHD, and the Agency for Healthcare Research and Quality (AHRQ). The study by Dr. Liang and associates was supported by the AHRQ’s Center for Financing, Access, and Cost Trends, and the Healthcare Cost and Utilization Project. The authors disclosed no competing interests.
Docs: Insurers’ payment delays, downcoding a ‘revenue grab’
Despite reporting record profits during the COVID-19 pandemic, major insurance companies are delaying claims payments and making it more difficult for hospitals and physicians to get paid the full amount of claims, observers and physicians say.
Kaiser Health News recently reported that hospitals, in particular, are affected by the slowdown in claims payments from Anthem Blue Cross, the nation’s second largest health insurer. The investigative piece did not focus on outpatient or independent practices. Research by this news organization shows that the health plans’ new policies are also reducing cash flow and raising costs for ambulatory care groups. In addition, it showed that other payers besides Anthem have engaged in the same practices.
“What we’ve seen is that with complex claims, such as those with -25 modifiers, plans are routinely requiring documentation,” Jim Donohue, senior manager and associate principal at ECG Management Consultants, said in an interview. “It’s not a denial, it’s a request for more information for medical records prior to processing payments. That has the effect of slowing down payments.”
This is exactly what one internal medicine group in the Southeast has noticed. The internist who heads the practice, who asked not to be identified, says that about 4-6 months ago, United, Humana, and other payers started to require documentation for prepayment review on a higher percentage of complex claims such as 99214 (established patient), 99204 (new patient), and claims with -25 modifiers. (The latter are appended to evaluation and management [E/M] claims in which patients had comorbidities that were addressed in the same visit as the main complaint.)
“That’s really frustrating, because you have to print out or take the record for that particular visit and computer fax it to them,” the practice leader notes. “And invariably, they’ll say they didn’t get a certain percentage of them. It’s our fault because they lost the claim.”
In the past, he says, health plans would occasionally ask for the note related to a complex visit where they saw issues, and they’ve always done random postpayment chart audits. But the percentage of prepayment reviews has significantly increased in recent months, he says.
Until a plan does this review, the claim can’t be processed because it’s not regarded as a clean claim. And this has implications for insurers’ compliance with laws that, in most states, require them to pay claims within 30-40 days of submission. (Medicare’s limit is 30 days.) According to Mr. Donohue, the clock doesn’t start ticking on this requirement unless and until a claim is clean. So by requiring documentation on complex claims, the plans can not only justify downcoding a claim, but can also delay payment without triggering state penalties.
Insurer admits ‘challenges’ with claims processing
VCU Health, a health system affiliated with Virginia Commonwealth University, recently filed a complaint against Anthem with Virginia’s insurance commissioner, asking that the Virginia Bureau of Insurance investigate the company’s claims-processing delays. The complaint claimed Anthem owes VCU more than $385 million, of which $171 million is over 90 days old. Much of that consists of commercial claims, which are subject to the state’s 40-day claims payment rule.
VCU cited several problems it said Anthem had created that slowed claims payments:
Any claim over a certain dollar limit requires an itemized bill.
Anthem requests detailed medical records prior to considering payment of even clean claims.
Documents must be uploaded to a web portal that has technical problems, and Anthem has lost some documents as a result.
Claims are being incorrectly processed for some professionals, “resulting in multi-million-dollar underpayments of anesthesia, nurse practitioners, pathology, and behavioral health providers.”
In addition, as the Kaiser Health News article points out, hospitals have blamed the increase in payment delays or denials partly on “preauthorization hurdles for routine procedures and requirements that doctors themselves – not support staffers – speak to insurance gatekeepers.”
In response to an inquiry from this news organization, an Anthem spokesman admitted that some payments to providers have been delayed, partly because of changes in the company’s claims-processing system. “We recognize there have been some challenges as we work with care providers to update claims processing, and readjust and adapt to a new set of dynamics as we continue to manage the pandemic,” said the spokesman.
The Kaiser Health News piece reported that Anthem’s CFO had told stock analysts on a conference call that the company had slowed claims payments to build up its financial reserves during the pandemic – a statement that some physicians called “outrageous.” But the Anthem spokesman told this news organization the quote was taken out of context and that the CFO was talking not about reserves but about “days in claims payable.” The spokesman said, “The payment delays that the article focuses on are not the primary driver or even a material driver of the increase in our overall reserves or DCPs [defined contribution plans] relative to historical levels. In fact, the vast majority of our claims are being processed in a timely manner.”
Some claims routinely downcoded
Even if that were the case, it would not explain why some physicians are seeing their higher-cost claims routinely downcoded. Will Sawyer, MD, a family physician in Cincinnati, told this news organization, “Anthem has been downcoding relentlessly since October 2020.” More often than not, when his office submits a claim with a 99214 code (office visit, 30-39 minutes, moderate medical decision-making), it’s changed to 99213 (office visit, 20-29 minutes, low medical decision-making) before processing, he says.
This has resulted in a significant diminution of his income, he notes. Anthem pays him less than Medicare for E/M visits, and the downcoding reduces his payment from $86 to $68 for a complex visit that may have taken half an hour or more.
In some cases where his office manager has noticed the downcoding, Dr. Sawyer says, she has resubmitted the claim with a copy of the encounter form. But Anthem hasn’t budged. And the refiling effort takes a toll on his solo practice, which doesn’t have sufficient staff, as it is.
Dr. Sawyer acknowledges that he has sent in a higher percentage of complex claims in the past year than he did previously. But much of that is the result of two factors beyond his control: First, many patients avoided coming into the office early in the pandemic, and when they returned, their preventive and chronic care needs were greater. Second, he says, “There are many comorbidities and mental health aspects, which exacerbate many issues and become an issue. We’re not dealing with engines here; they’re human beings. And it takes time.”
In response to Dr. Sawyer’s comments, Anthem said that it uses “analytical tools to review evaluation and management (E/M) codes during the claims adjudication and processing process.” Physicians who believe that certain claims should not have been downcoded can dispute these decisions; they must supply a statement explaining why they disagree with the decision along with documentation to support their statement, the company said. Anthem added that it reviews claims to lower costs for its members.
‘Revenue-grab strategy’
Dr. Sawyer believes that what Anthem is doing to him and other physicians reflects its desire to increase profits by netting extra revenue and keeping physicians’ money while it delays payments to them – a practice known in the trade as “the float.” Moreover, he says, the company depends on many practices not keeping track of their finances during the pandemic.
“When practices are running at warp speed, trying to keep people healthy and getting burned out, they aren’t paying as close attention to the details of payment. It’s an absolute revenue-grab strategy that’s unconscionable,” says Dr. Sawyer.
The Southeast internist also thinks that insurance companies other than Anthem – including United and Humana – are profiting from the float. Besides delaying his payments with gratuitous demands for documentation, he said, they also downcode many claims, forcing the practice to refile the claims and appeal. That forces the practice to pay overtime or bring on more claims staff, which raises administrative costs.
The plans’ strategy, the internist says, is this: “If they downcode millions of claims, a certain number of physicians will give up without appealing, and they’ll raise their profits.”
A United spokesperson said in an interview, “We pay claims appropriately under members’ plans and within the required time frame.” Humana had not responded to this news organization’s request for comment at press time.
Challenge to practice economics
Insurer policies that delay payments or downcode claims, ECG’s Mr. Donohue points out, are especially harmful to primary care and other ambulatory practices that have many small-dollar claims.
“That’s where it’s challenging, because it’s not like a $10,000 case where you add $100 to it [to meet records requests]. You’re talking about something that’s relatively low dollar, where the practice makes a small surplus, and when you add administrative costs, it can change the economics,” he says.
While the economic burden on ambulatory care practices may be greater, Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association (MGMA), said that the payment delays and demands for documentation – along with prior authorization – particularly affect inpatient care. The health plans are questioning big-ticket items more than ever, he said, and most of those services occur in hospitals.
However, the greater level of insurer scrutiny also affects physicians who treat patients in the hospital, including surgeons and emergency department physicians who contract with the facilities, he adds.
Mr. Gilberg views the current situation as an exacerbation of the health plan policies that physicians have long struggled with. “It’s not new to have insurers play the float and not pay claims on time. Unfortunately, this is something that medical practices are used to.”
A version of this article first appeared on Medscape.com.
Despite reporting record profits during the COVID-19 pandemic, major insurance companies are delaying claims payments and making it more difficult for hospitals and physicians to get paid the full amount of claims, observers and physicians say.
Kaiser Health News recently reported that hospitals, in particular, are affected by the slowdown in claims payments from Anthem Blue Cross, the nation’s second largest health insurer. The investigative piece did not focus on outpatient or independent practices. Research by this news organization shows that the health plans’ new policies are also reducing cash flow and raising costs for ambulatory care groups. In addition, it showed that other payers besides Anthem have engaged in the same practices.
“What we’ve seen is that with complex claims, such as those with -25 modifiers, plans are routinely requiring documentation,” Jim Donohue, senior manager and associate principal at ECG Management Consultants, said in an interview. “It’s not a denial, it’s a request for more information for medical records prior to processing payments. That has the effect of slowing down payments.”
This is exactly what one internal medicine group in the Southeast has noticed. The internist who heads the practice, who asked not to be identified, says that about 4-6 months ago, United, Humana, and other payers started to require documentation for prepayment review on a higher percentage of complex claims such as 99214 (established patient), 99204 (new patient), and claims with -25 modifiers. (The latter are appended to evaluation and management [E/M] claims in which patients had comorbidities that were addressed in the same visit as the main complaint.)
“That’s really frustrating, because you have to print out or take the record for that particular visit and computer fax it to them,” the practice leader notes. “And invariably, they’ll say they didn’t get a certain percentage of them. It’s our fault because they lost the claim.”
In the past, he says, health plans would occasionally ask for the note related to a complex visit where they saw issues, and they’ve always done random postpayment chart audits. But the percentage of prepayment reviews has significantly increased in recent months, he says.
Until a plan does this review, the claim can’t be processed because it’s not regarded as a clean claim. And this has implications for insurers’ compliance with laws that, in most states, require them to pay claims within 30-40 days of submission. (Medicare’s limit is 30 days.) According to Mr. Donohue, the clock doesn’t start ticking on this requirement unless and until a claim is clean. So by requiring documentation on complex claims, the plans can not only justify downcoding a claim, but can also delay payment without triggering state penalties.
Insurer admits ‘challenges’ with claims processing
VCU Health, a health system affiliated with Virginia Commonwealth University, recently filed a complaint against Anthem with Virginia’s insurance commissioner, asking that the Virginia Bureau of Insurance investigate the company’s claims-processing delays. The complaint claimed Anthem owes VCU more than $385 million, of which $171 million is over 90 days old. Much of that consists of commercial claims, which are subject to the state’s 40-day claims payment rule.
VCU cited several problems it said Anthem had created that slowed claims payments:
Any claim over a certain dollar limit requires an itemized bill.
Anthem requests detailed medical records prior to considering payment of even clean claims.
Documents must be uploaded to a web portal that has technical problems, and Anthem has lost some documents as a result.
Claims are being incorrectly processed for some professionals, “resulting in multi-million-dollar underpayments of anesthesia, nurse practitioners, pathology, and behavioral health providers.”
In addition, as the Kaiser Health News article points out, hospitals have blamed the increase in payment delays or denials partly on “preauthorization hurdles for routine procedures and requirements that doctors themselves – not support staffers – speak to insurance gatekeepers.”
In response to an inquiry from this news organization, an Anthem spokesman admitted that some payments to providers have been delayed, partly because of changes in the company’s claims-processing system. “We recognize there have been some challenges as we work with care providers to update claims processing, and readjust and adapt to a new set of dynamics as we continue to manage the pandemic,” said the spokesman.
The Kaiser Health News piece reported that Anthem’s CFO had told stock analysts on a conference call that the company had slowed claims payments to build up its financial reserves during the pandemic – a statement that some physicians called “outrageous.” But the Anthem spokesman told this news organization the quote was taken out of context and that the CFO was talking not about reserves but about “days in claims payable.” The spokesman said, “The payment delays that the article focuses on are not the primary driver or even a material driver of the increase in our overall reserves or DCPs [defined contribution plans] relative to historical levels. In fact, the vast majority of our claims are being processed in a timely manner.”
Some claims routinely downcoded
Even if that were the case, it would not explain why some physicians are seeing their higher-cost claims routinely downcoded. Will Sawyer, MD, a family physician in Cincinnati, told this news organization, “Anthem has been downcoding relentlessly since October 2020.” More often than not, when his office submits a claim with a 99214 code (office visit, 30-39 minutes, moderate medical decision-making), it’s changed to 99213 (office visit, 20-29 minutes, low medical decision-making) before processing, he says.
This has resulted in a significant diminution of his income, he notes. Anthem pays him less than Medicare for E/M visits, and the downcoding reduces his payment from $86 to $68 for a complex visit that may have taken half an hour or more.
In some cases where his office manager has noticed the downcoding, Dr. Sawyer says, she has resubmitted the claim with a copy of the encounter form. But Anthem hasn’t budged. And the refiling effort takes a toll on his solo practice, which doesn’t have sufficient staff, as it is.
Dr. Sawyer acknowledges that he has sent in a higher percentage of complex claims in the past year than he did previously. But much of that is the result of two factors beyond his control: First, many patients avoided coming into the office early in the pandemic, and when they returned, their preventive and chronic care needs were greater. Second, he says, “There are many comorbidities and mental health aspects, which exacerbate many issues and become an issue. We’re not dealing with engines here; they’re human beings. And it takes time.”
In response to Dr. Sawyer’s comments, Anthem said that it uses “analytical tools to review evaluation and management (E/M) codes during the claims adjudication and processing process.” Physicians who believe that certain claims should not have been downcoded can dispute these decisions; they must supply a statement explaining why they disagree with the decision along with documentation to support their statement, the company said. Anthem added that it reviews claims to lower costs for its members.
‘Revenue-grab strategy’
Dr. Sawyer believes that what Anthem is doing to him and other physicians reflects its desire to increase profits by netting extra revenue and keeping physicians’ money while it delays payments to them – a practice known in the trade as “the float.” Moreover, he says, the company depends on many practices not keeping track of their finances during the pandemic.
“When practices are running at warp speed, trying to keep people healthy and getting burned out, they aren’t paying as close attention to the details of payment. It’s an absolute revenue-grab strategy that’s unconscionable,” says Dr. Sawyer.
The Southeast internist also thinks that insurance companies other than Anthem – including United and Humana – are profiting from the float. Besides delaying his payments with gratuitous demands for documentation, he said, they also downcode many claims, forcing the practice to refile the claims and appeal. That forces the practice to pay overtime or bring on more claims staff, which raises administrative costs.
The plans’ strategy, the internist says, is this: “If they downcode millions of claims, a certain number of physicians will give up without appealing, and they’ll raise their profits.”
A United spokesperson said in an interview, “We pay claims appropriately under members’ plans and within the required time frame.” Humana had not responded to this news organization’s request for comment at press time.
Challenge to practice economics
Insurer policies that delay payments or downcode claims, ECG’s Mr. Donohue points out, are especially harmful to primary care and other ambulatory practices that have many small-dollar claims.
“That’s where it’s challenging, because it’s not like a $10,000 case where you add $100 to it [to meet records requests]. You’re talking about something that’s relatively low dollar, where the practice makes a small surplus, and when you add administrative costs, it can change the economics,” he says.
While the economic burden on ambulatory care practices may be greater, Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association (MGMA), said that the payment delays and demands for documentation – along with prior authorization – particularly affect inpatient care. The health plans are questioning big-ticket items more than ever, he said, and most of those services occur in hospitals.
However, the greater level of insurer scrutiny also affects physicians who treat patients in the hospital, including surgeons and emergency department physicians who contract with the facilities, he adds.
Mr. Gilberg views the current situation as an exacerbation of the health plan policies that physicians have long struggled with. “It’s not new to have insurers play the float and not pay claims on time. Unfortunately, this is something that medical practices are used to.”
A version of this article first appeared on Medscape.com.
Despite reporting record profits during the COVID-19 pandemic, major insurance companies are delaying claims payments and making it more difficult for hospitals and physicians to get paid the full amount of claims, observers and physicians say.
Kaiser Health News recently reported that hospitals, in particular, are affected by the slowdown in claims payments from Anthem Blue Cross, the nation’s second largest health insurer. The investigative piece did not focus on outpatient or independent practices. Research by this news organization shows that the health plans’ new policies are also reducing cash flow and raising costs for ambulatory care groups. In addition, it showed that other payers besides Anthem have engaged in the same practices.
“What we’ve seen is that with complex claims, such as those with -25 modifiers, plans are routinely requiring documentation,” Jim Donohue, senior manager and associate principal at ECG Management Consultants, said in an interview. “It’s not a denial, it’s a request for more information for medical records prior to processing payments. That has the effect of slowing down payments.”
This is exactly what one internal medicine group in the Southeast has noticed. The internist who heads the practice, who asked not to be identified, says that about 4-6 months ago, United, Humana, and other payers started to require documentation for prepayment review on a higher percentage of complex claims such as 99214 (established patient), 99204 (new patient), and claims with -25 modifiers. (The latter are appended to evaluation and management [E/M] claims in which patients had comorbidities that were addressed in the same visit as the main complaint.)
“That’s really frustrating, because you have to print out or take the record for that particular visit and computer fax it to them,” the practice leader notes. “And invariably, they’ll say they didn’t get a certain percentage of them. It’s our fault because they lost the claim.”
In the past, he says, health plans would occasionally ask for the note related to a complex visit where they saw issues, and they’ve always done random postpayment chart audits. But the percentage of prepayment reviews has significantly increased in recent months, he says.
Until a plan does this review, the claim can’t be processed because it’s not regarded as a clean claim. And this has implications for insurers’ compliance with laws that, in most states, require them to pay claims within 30-40 days of submission. (Medicare’s limit is 30 days.) According to Mr. Donohue, the clock doesn’t start ticking on this requirement unless and until a claim is clean. So by requiring documentation on complex claims, the plans can not only justify downcoding a claim, but can also delay payment without triggering state penalties.
Insurer admits ‘challenges’ with claims processing
VCU Health, a health system affiliated with Virginia Commonwealth University, recently filed a complaint against Anthem with Virginia’s insurance commissioner, asking that the Virginia Bureau of Insurance investigate the company’s claims-processing delays. The complaint claimed Anthem owes VCU more than $385 million, of which $171 million is over 90 days old. Much of that consists of commercial claims, which are subject to the state’s 40-day claims payment rule.
VCU cited several problems it said Anthem had created that slowed claims payments:
Any claim over a certain dollar limit requires an itemized bill.
Anthem requests detailed medical records prior to considering payment of even clean claims.
Documents must be uploaded to a web portal that has technical problems, and Anthem has lost some documents as a result.
Claims are being incorrectly processed for some professionals, “resulting in multi-million-dollar underpayments of anesthesia, nurse practitioners, pathology, and behavioral health providers.”
In addition, as the Kaiser Health News article points out, hospitals have blamed the increase in payment delays or denials partly on “preauthorization hurdles for routine procedures and requirements that doctors themselves – not support staffers – speak to insurance gatekeepers.”
In response to an inquiry from this news organization, an Anthem spokesman admitted that some payments to providers have been delayed, partly because of changes in the company’s claims-processing system. “We recognize there have been some challenges as we work with care providers to update claims processing, and readjust and adapt to a new set of dynamics as we continue to manage the pandemic,” said the spokesman.
The Kaiser Health News piece reported that Anthem’s CFO had told stock analysts on a conference call that the company had slowed claims payments to build up its financial reserves during the pandemic – a statement that some physicians called “outrageous.” But the Anthem spokesman told this news organization the quote was taken out of context and that the CFO was talking not about reserves but about “days in claims payable.” The spokesman said, “The payment delays that the article focuses on are not the primary driver or even a material driver of the increase in our overall reserves or DCPs [defined contribution plans] relative to historical levels. In fact, the vast majority of our claims are being processed in a timely manner.”
Some claims routinely downcoded
Even if that were the case, it would not explain why some physicians are seeing their higher-cost claims routinely downcoded. Will Sawyer, MD, a family physician in Cincinnati, told this news organization, “Anthem has been downcoding relentlessly since October 2020.” More often than not, when his office submits a claim with a 99214 code (office visit, 30-39 minutes, moderate medical decision-making), it’s changed to 99213 (office visit, 20-29 minutes, low medical decision-making) before processing, he says.
This has resulted in a significant diminution of his income, he notes. Anthem pays him less than Medicare for E/M visits, and the downcoding reduces his payment from $86 to $68 for a complex visit that may have taken half an hour or more.
In some cases where his office manager has noticed the downcoding, Dr. Sawyer says, she has resubmitted the claim with a copy of the encounter form. But Anthem hasn’t budged. And the refiling effort takes a toll on his solo practice, which doesn’t have sufficient staff, as it is.
Dr. Sawyer acknowledges that he has sent in a higher percentage of complex claims in the past year than he did previously. But much of that is the result of two factors beyond his control: First, many patients avoided coming into the office early in the pandemic, and when they returned, their preventive and chronic care needs were greater. Second, he says, “There are many comorbidities and mental health aspects, which exacerbate many issues and become an issue. We’re not dealing with engines here; they’re human beings. And it takes time.”
In response to Dr. Sawyer’s comments, Anthem said that it uses “analytical tools to review evaluation and management (E/M) codes during the claims adjudication and processing process.” Physicians who believe that certain claims should not have been downcoded can dispute these decisions; they must supply a statement explaining why they disagree with the decision along with documentation to support their statement, the company said. Anthem added that it reviews claims to lower costs for its members.
‘Revenue-grab strategy’
Dr. Sawyer believes that what Anthem is doing to him and other physicians reflects its desire to increase profits by netting extra revenue and keeping physicians’ money while it delays payments to them – a practice known in the trade as “the float.” Moreover, he says, the company depends on many practices not keeping track of their finances during the pandemic.
“When practices are running at warp speed, trying to keep people healthy and getting burned out, they aren’t paying as close attention to the details of payment. It’s an absolute revenue-grab strategy that’s unconscionable,” says Dr. Sawyer.
The Southeast internist also thinks that insurance companies other than Anthem – including United and Humana – are profiting from the float. Besides delaying his payments with gratuitous demands for documentation, he said, they also downcode many claims, forcing the practice to refile the claims and appeal. That forces the practice to pay overtime or bring on more claims staff, which raises administrative costs.
The plans’ strategy, the internist says, is this: “If they downcode millions of claims, a certain number of physicians will give up without appealing, and they’ll raise their profits.”
A United spokesperson said in an interview, “We pay claims appropriately under members’ plans and within the required time frame.” Humana had not responded to this news organization’s request for comment at press time.
Challenge to practice economics
Insurer policies that delay payments or downcode claims, ECG’s Mr. Donohue points out, are especially harmful to primary care and other ambulatory practices that have many small-dollar claims.
“That’s where it’s challenging, because it’s not like a $10,000 case where you add $100 to it [to meet records requests]. You’re talking about something that’s relatively low dollar, where the practice makes a small surplus, and when you add administrative costs, it can change the economics,” he says.
While the economic burden on ambulatory care practices may be greater, Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association (MGMA), said that the payment delays and demands for documentation – along with prior authorization – particularly affect inpatient care. The health plans are questioning big-ticket items more than ever, he said, and most of those services occur in hospitals.
However, the greater level of insurer scrutiny also affects physicians who treat patients in the hospital, including surgeons and emergency department physicians who contract with the facilities, he adds.
Mr. Gilberg views the current situation as an exacerbation of the health plan policies that physicians have long struggled with. “It’s not new to have insurers play the float and not pay claims on time. Unfortunately, this is something that medical practices are used to.”
A version of this article first appeared on Medscape.com.
Pandemic adds more weight to burden of obesity in children
according to a new report from the Robert Wood Johnson Foundation.
“Our nation’s safety net is fragile, outdated, and out of reach for millions of eligible kids and caregivers,” said Jamie Bussel, senior program officer at the RWJF, and senior author of the report. She added that the pandemic further fractured an already broken system that disproportionately overlooks “children of color and those who live farthest from economic opportunity”.
It’s time to think ‘bigger and better’
Ms. Bussel said, during a press conference, that congress responded to the pandemic with “an array of policy solutions,” but it’s now time to think ‘bigger and better.’
“There have been huge flexibilities deployed across the safety net program and these have been really important reliefs, but the fact is many of them are temporary emergency relief measures,” she explained.
For the past 3 years, the RWJF’s annual State of Childhood Obesity report has drawn national and state obesity data from large surveys including the National Survey of Children’s Health, the Youth Risk Behavior Surveillance System, the WIC Participant and Program Characteristics Survey, and the National Health and Nutrition Examination Survey.
Similar to in past years, this year’s data show that rates of obesity and overweight have remained relatively steady and have been highest among minority and low-income populations. For example, data from the 2019-2020 National Survey of Children’s Health, along with an analysis conducted by the Health Resources and Services Administration’s Maternal and Child Health Bureau, show that one in six – or 16.2% – of youth aged 10-17 years have obesity.
While non-Hispanic Asian children had the lowest obesity rate (8.1%), followed by non-Hispanic White children (12.1%), rates were significantly higher for Hispanic (21.4%), non-Hispanic Black (23.8%), and non-Hispanic American Indian/Alaska Native (28.7%) children, according to the report.
“Additional years of data are needed to assess whether obesity rates changed after the onset of the pandemic,” explained Ms. Bussel.
Digging deeper
Other studies included in this year’s report were specifically designed to measure the impact of the pandemic, and show a distinct rise in overweight and obesity, especially in younger children. For example, a retrospective cohort study using data from Kaiser Permanente Southern California showed the rate of overweight and obesity in children aged 5-11 years rose to 45.7% between March 2020 and January 2021, up from 36.2% before the pandemic.
Another of these studies, which was based on national electronic health records of more than 430,000 children, showed the obesity rate crept from 19.3% to 22.4% between August 2019 and August 2020.
“The lid we had been trying desperately to put on the obesity epidemic has come off again,” said Sandra G Hassink, MD, MSc, who is medical director of the American Academy of Pediatrics Institute for Healthy Childhood Weight.
“In the absence of COVID we had been seeing slow upticks in the numbers – and in some groups we’d been thinking maybe we were headed toward stabilization – but these numbers blow that out of the water ... COVID has escalated the rates,” she said in an interview.
“Unfortunately, these two crises – the COVID pandemic, the childhood obesity epidemic – in so many ways have exacerbated one another,” said Ms. Bussel. “It’s not a huge surprise that we’re seeing an increase in childhood obesity rates given the complete and utter disruption of every single system that circumscribes our lives.”
The systems that feed obesity
Addressing childhood obesity requires targeting far beyond healthy eating and physical activity, Ms. Bussel said.
“As important is whether that child has a safe place to call home. Does mom or dad or their care provider have a stable income? Is there reliable transportation? Is their access to health insurance? Is there access to high-quality health care? ... All of those factors influence the child and the family’s opportunities to live well, be healthy, and be at a healthy weight,” she noted.
The report includes a list of five main policy recommendations.
- Making free, universal school meal programs permanent.
- Extending eligibility for WIC, the Special Supplemental Nutrition Program for Women, Infants, and Children, to postpartum mothers and to children through age 6.
- Extending and expanding other programs, such as the Child Tax Credit.
- Closing the Medicaid coverage gap.
- Developing a consistent approach to collecting obesity data organized by race, ethnicity, and income level.
“Collectively, over at least the course of the last generation or two, our policy approach to obesity prevention has not been sufficient. But that doesn’t mean all of our policy approaches have been failures,” Ms. Bussel said during an interview. “Policy change does not always need to be dramatic to have a real impact on families.”
Fighting complacency
For Dr. Hassink, one of the barriers to change is society’s level of acceptance. She said an identifiable explanation for pandemic weight gain doesn’t mean society should simply shrug it off.
“If we regarded childhood obesity as the population level catastrophe that it is for chronic disease maybe people would be activated around these policy changes,” she said.
“We’re accepting a disease process that wreaks havoc on people,” noted Dr. Hassink, who was not involved in the new report. “I think it’s hard for people to realize the magnitude of the disease burden that we’re seeing. If you’re in a weight management clinic or any pediatrician’s office you would see it – you would see kids coming in with liver disease, 9-year-olds on [continuous positive airway pressure] for sleep apnea, kids needing their hips pinned because they had a hip fracture because of obesity.
“So, those of us that see the disease burden see what’s behind those numbers. The sadness of what we’re talking about is we know a lot about what could push the dial and help reduce this epidemic and we’re not doing what we already know,” added Dr. Hassink.
Ms. Bussel and Dr. Hassink reported no conflicts.
according to a new report from the Robert Wood Johnson Foundation.
“Our nation’s safety net is fragile, outdated, and out of reach for millions of eligible kids and caregivers,” said Jamie Bussel, senior program officer at the RWJF, and senior author of the report. She added that the pandemic further fractured an already broken system that disproportionately overlooks “children of color and those who live farthest from economic opportunity”.
It’s time to think ‘bigger and better’
Ms. Bussel said, during a press conference, that congress responded to the pandemic with “an array of policy solutions,” but it’s now time to think ‘bigger and better.’
“There have been huge flexibilities deployed across the safety net program and these have been really important reliefs, but the fact is many of them are temporary emergency relief measures,” she explained.
For the past 3 years, the RWJF’s annual State of Childhood Obesity report has drawn national and state obesity data from large surveys including the National Survey of Children’s Health, the Youth Risk Behavior Surveillance System, the WIC Participant and Program Characteristics Survey, and the National Health and Nutrition Examination Survey.
Similar to in past years, this year’s data show that rates of obesity and overweight have remained relatively steady and have been highest among minority and low-income populations. For example, data from the 2019-2020 National Survey of Children’s Health, along with an analysis conducted by the Health Resources and Services Administration’s Maternal and Child Health Bureau, show that one in six – or 16.2% – of youth aged 10-17 years have obesity.
While non-Hispanic Asian children had the lowest obesity rate (8.1%), followed by non-Hispanic White children (12.1%), rates were significantly higher for Hispanic (21.4%), non-Hispanic Black (23.8%), and non-Hispanic American Indian/Alaska Native (28.7%) children, according to the report.
“Additional years of data are needed to assess whether obesity rates changed after the onset of the pandemic,” explained Ms. Bussel.
Digging deeper
Other studies included in this year’s report were specifically designed to measure the impact of the pandemic, and show a distinct rise in overweight and obesity, especially in younger children. For example, a retrospective cohort study using data from Kaiser Permanente Southern California showed the rate of overweight and obesity in children aged 5-11 years rose to 45.7% between March 2020 and January 2021, up from 36.2% before the pandemic.
Another of these studies, which was based on national electronic health records of more than 430,000 children, showed the obesity rate crept from 19.3% to 22.4% between August 2019 and August 2020.
“The lid we had been trying desperately to put on the obesity epidemic has come off again,” said Sandra G Hassink, MD, MSc, who is medical director of the American Academy of Pediatrics Institute for Healthy Childhood Weight.
“In the absence of COVID we had been seeing slow upticks in the numbers – and in some groups we’d been thinking maybe we were headed toward stabilization – but these numbers blow that out of the water ... COVID has escalated the rates,” she said in an interview.
“Unfortunately, these two crises – the COVID pandemic, the childhood obesity epidemic – in so many ways have exacerbated one another,” said Ms. Bussel. “It’s not a huge surprise that we’re seeing an increase in childhood obesity rates given the complete and utter disruption of every single system that circumscribes our lives.”
The systems that feed obesity
Addressing childhood obesity requires targeting far beyond healthy eating and physical activity, Ms. Bussel said.
“As important is whether that child has a safe place to call home. Does mom or dad or their care provider have a stable income? Is there reliable transportation? Is their access to health insurance? Is there access to high-quality health care? ... All of those factors influence the child and the family’s opportunities to live well, be healthy, and be at a healthy weight,” she noted.
The report includes a list of five main policy recommendations.
- Making free, universal school meal programs permanent.
- Extending eligibility for WIC, the Special Supplemental Nutrition Program for Women, Infants, and Children, to postpartum mothers and to children through age 6.
- Extending and expanding other programs, such as the Child Tax Credit.
- Closing the Medicaid coverage gap.
- Developing a consistent approach to collecting obesity data organized by race, ethnicity, and income level.
“Collectively, over at least the course of the last generation or two, our policy approach to obesity prevention has not been sufficient. But that doesn’t mean all of our policy approaches have been failures,” Ms. Bussel said during an interview. “Policy change does not always need to be dramatic to have a real impact on families.”
Fighting complacency
For Dr. Hassink, one of the barriers to change is society’s level of acceptance. She said an identifiable explanation for pandemic weight gain doesn’t mean society should simply shrug it off.
“If we regarded childhood obesity as the population level catastrophe that it is for chronic disease maybe people would be activated around these policy changes,” she said.
“We’re accepting a disease process that wreaks havoc on people,” noted Dr. Hassink, who was not involved in the new report. “I think it’s hard for people to realize the magnitude of the disease burden that we’re seeing. If you’re in a weight management clinic or any pediatrician’s office you would see it – you would see kids coming in with liver disease, 9-year-olds on [continuous positive airway pressure] for sleep apnea, kids needing their hips pinned because they had a hip fracture because of obesity.
“So, those of us that see the disease burden see what’s behind those numbers. The sadness of what we’re talking about is we know a lot about what could push the dial and help reduce this epidemic and we’re not doing what we already know,” added Dr. Hassink.
Ms. Bussel and Dr. Hassink reported no conflicts.
according to a new report from the Robert Wood Johnson Foundation.
“Our nation’s safety net is fragile, outdated, and out of reach for millions of eligible kids and caregivers,” said Jamie Bussel, senior program officer at the RWJF, and senior author of the report. She added that the pandemic further fractured an already broken system that disproportionately overlooks “children of color and those who live farthest from economic opportunity”.
It’s time to think ‘bigger and better’
Ms. Bussel said, during a press conference, that congress responded to the pandemic with “an array of policy solutions,” but it’s now time to think ‘bigger and better.’
“There have been huge flexibilities deployed across the safety net program and these have been really important reliefs, but the fact is many of them are temporary emergency relief measures,” she explained.
For the past 3 years, the RWJF’s annual State of Childhood Obesity report has drawn national and state obesity data from large surveys including the National Survey of Children’s Health, the Youth Risk Behavior Surveillance System, the WIC Participant and Program Characteristics Survey, and the National Health and Nutrition Examination Survey.
Similar to in past years, this year’s data show that rates of obesity and overweight have remained relatively steady and have been highest among minority and low-income populations. For example, data from the 2019-2020 National Survey of Children’s Health, along with an analysis conducted by the Health Resources and Services Administration’s Maternal and Child Health Bureau, show that one in six – or 16.2% – of youth aged 10-17 years have obesity.
While non-Hispanic Asian children had the lowest obesity rate (8.1%), followed by non-Hispanic White children (12.1%), rates were significantly higher for Hispanic (21.4%), non-Hispanic Black (23.8%), and non-Hispanic American Indian/Alaska Native (28.7%) children, according to the report.
“Additional years of data are needed to assess whether obesity rates changed after the onset of the pandemic,” explained Ms. Bussel.
Digging deeper
Other studies included in this year’s report were specifically designed to measure the impact of the pandemic, and show a distinct rise in overweight and obesity, especially in younger children. For example, a retrospective cohort study using data from Kaiser Permanente Southern California showed the rate of overweight and obesity in children aged 5-11 years rose to 45.7% between March 2020 and January 2021, up from 36.2% before the pandemic.
Another of these studies, which was based on national electronic health records of more than 430,000 children, showed the obesity rate crept from 19.3% to 22.4% between August 2019 and August 2020.
“The lid we had been trying desperately to put on the obesity epidemic has come off again,” said Sandra G Hassink, MD, MSc, who is medical director of the American Academy of Pediatrics Institute for Healthy Childhood Weight.
“In the absence of COVID we had been seeing slow upticks in the numbers – and in some groups we’d been thinking maybe we were headed toward stabilization – but these numbers blow that out of the water ... COVID has escalated the rates,” she said in an interview.
“Unfortunately, these two crises – the COVID pandemic, the childhood obesity epidemic – in so many ways have exacerbated one another,” said Ms. Bussel. “It’s not a huge surprise that we’re seeing an increase in childhood obesity rates given the complete and utter disruption of every single system that circumscribes our lives.”
The systems that feed obesity
Addressing childhood obesity requires targeting far beyond healthy eating and physical activity, Ms. Bussel said.
“As important is whether that child has a safe place to call home. Does mom or dad or their care provider have a stable income? Is there reliable transportation? Is their access to health insurance? Is there access to high-quality health care? ... All of those factors influence the child and the family’s opportunities to live well, be healthy, and be at a healthy weight,” she noted.
The report includes a list of five main policy recommendations.
- Making free, universal school meal programs permanent.
- Extending eligibility for WIC, the Special Supplemental Nutrition Program for Women, Infants, and Children, to postpartum mothers and to children through age 6.
- Extending and expanding other programs, such as the Child Tax Credit.
- Closing the Medicaid coverage gap.
- Developing a consistent approach to collecting obesity data organized by race, ethnicity, and income level.
“Collectively, over at least the course of the last generation or two, our policy approach to obesity prevention has not been sufficient. But that doesn’t mean all of our policy approaches have been failures,” Ms. Bussel said during an interview. “Policy change does not always need to be dramatic to have a real impact on families.”
Fighting complacency
For Dr. Hassink, one of the barriers to change is society’s level of acceptance. She said an identifiable explanation for pandemic weight gain doesn’t mean society should simply shrug it off.
“If we regarded childhood obesity as the population level catastrophe that it is for chronic disease maybe people would be activated around these policy changes,” she said.
“We’re accepting a disease process that wreaks havoc on people,” noted Dr. Hassink, who was not involved in the new report. “I think it’s hard for people to realize the magnitude of the disease burden that we’re seeing. If you’re in a weight management clinic or any pediatrician’s office you would see it – you would see kids coming in with liver disease, 9-year-olds on [continuous positive airway pressure] for sleep apnea, kids needing their hips pinned because they had a hip fracture because of obesity.
“So, those of us that see the disease burden see what’s behind those numbers. The sadness of what we’re talking about is we know a lot about what could push the dial and help reduce this epidemic and we’re not doing what we already know,” added Dr. Hassink.
Ms. Bussel and Dr. Hassink reported no conflicts.
AAN blasts ‘runaway’ costs for neurologic and other prescription drugs
This situation is also taking a toll on neurologists’ mental health, who already have the second-highest burnout rate across medical specialties, the statement adds.
The statement was published online Oct. 5, 2021, in Neurology.
Dramatic price increases
Drafted by the Ethics, Law, and Humanities Committee – a joint committee that includes the AAN, the American Neurological Association, and the Child Neurology Society – the statement was prompted by a 2018 report from the AAN Neurology Drug Pricing Task Force to address challenges associated with high drug costs.
It highlights ethical concerns from high drug costs, policy proposals that might temper the problem, and how clinicians can adjust to the current reality of pharmaceutical pricing and better advocate for changes to the healthcare system.
“Runaway drug costs continue to be a pressing problem with recent dramatic price increases not only for specialty drugs, but also generic ones,” said lead author Amy Tsou, MD, MSc, codirector of the ECRI Evidence-Based Practice Center at the Center for Evidence and Guidelines in Plymouth Meeting, Pa.
She noted that one in four Americans has difficulty paying for medication, and many report going without a medication because of cost.
“Ensuring a fair system for drug pricing and coverage rules that balance the goods of individual patients with the needs of broader populations when resources are limited remains more important than ever,” Dr. Tsou said.
Out-of-pocket costs for neurologic medications have risen dramatically over the past decade, with the fastest rise reported among drugs for multiple sclerosis. Results from a study published in 2019 showed that, between 2004 and 2016, patients’ out-of-pocket expenses skyrocketed from $15 a month to $309 a month.
The steep increases have forced some neurology patients to ration their medication or stop taking it altogether, which is one of the ethical concerns cited in the AAN statement.
Patient self-rationing
Commenting on the statement, Ilana Katz Sand, MD, associate director of the Dickinson Center for Multiple Sclerosis at Mount Sinai Medical Center, New York, noted that clinicians are already acutely aware of the effect high drug costs have on their patients’ medical decisions. However, statements such as the current one bring much-needed outside attention to the problem.
“I’ve definitely had more and more people struggling with deductibles and copays, even among people who are insured,” said Dr. Katz Sand, who was not involved with the AAN paper.
She has a number of patients who have rationed their medication or stopped taking it altogether when their copays increased or they lost access to a copay assistance program because their insurance company chose to cover a still-expensive generic drug with no assistance program over a slightly costlier brand-name medication that comes with patient discounts.
Too often, patients don’t tell her they’re not taking their medication as prescribed. At a recent appointment, Dr. Katz Sand learned about a patient’s drug rationing only after a routine MRI showed new brain lesions that regular treatment might have prevented.
Another patient, new to her clinic, questioned the treatment plan Dr. Katz Sand recommended because they could not cover the copay. This sort of self-rationing happens in patients with and without insurance, she added.
“It’s a terrible thing and it’s happening to all patients,” Dr. Katz Sand said, adding that “the old credo of ‘yeah, the drug prices are high, but they are covered by insurance’ is not a sustainable argument anymore.”
What neurologists can do
Some sort of rationing is an unavoidable outcome of steep treatment costs, the authors noted. But what does that mean in clinical practice?
Neurologists should be aware of the costs involved in ordering diagnostic tests, treatment, or medication – and shouldn’t feel compelled to order treatments or tests that they feel are medically inappropriate just because a patient requests them, the authors wrote.
The statement also encourages clinicians to include financial realities in the shared decision-making process with patients.
However, Dr. Katz Sand said that is not always possible. Drug prices aren’t fixed, with different insurance plans offering different pricing, deductibles, and copays. “It’s hard for us to attempt to incorporate discussions about price in our discussions with patients when we can’t even predict what their out-of-pocket cost is going to be,” she said.
“Every single prescription we write requires prior authorization, and that’s directly related to the fact that the cost of these drugs is so high,” she added.
As do many other clinicians, Dr. Katz Sand spends hours each week on preauthorization forms and haggling with insurance companies on behalf of her patients. To get needed medication at a cost they can afford sometimes takes creative problem solving and almost always takes a lot of time. “It all adds to the administrative burden, patients’ stress, and our stress,” she said.
Physician-advocates needed
The AAN paper identifies a number of policy reforms to address drug pricing at a national level, including giving Medicare officials the power to negotiate drug prices, allowing the safe importation of drugs from other countries, and speeding the Food and Drug Administration approval process for generic drugs.
There is also a need to address systemic problems that, the authors noted, help create and perpetuate health care disparities. Lawmakers at the state and federal level are considering a number of these policy ideas and others that could address the kinds of issues Dr. Katz Sand described. However, the chances of their success are slim at best, said Bruce H. Cohen, MD, chair of the AAN advocacy committee and director of the NeuroDevelopmental Science Center at Akron (Ohio) Children’s Hospital.
“On a federal level, we’re watching in real time how the entrenched divisions, even within parties, are resulting in continued stalemate,” said Dr. Cohen, who is not one of the statement authors.
Those ideas need advocates and the AAN paper suggests neurologists should be among the ones championing these changes, he added.
“One of the most effective strategies is to bring attention to the impact high drug costs have on neurology patients and medical practices,” Dr. Cohen said. “It’s so important to make sure policy makers know the significant impact of high drug costs in neurology and within the context of finite resources.”
One way to do that is to share statements such as the current one with members of Congress working on policy reform, Dr. Cohen said. Another is through programs such as the academy’s annual Neurology on the Hill conference.
A third strategy is to encourage individuals such as Dr. Katz Sand to speak out when and where they can, he added.
While she agrees with the idea, finding time for advocacy work amid patient care, administrative work, and research is challenging. Dr. Katz Sand would like to see groups like the AAN work with health care institutions to implement policies that allocate time and resources to train clinicians in advocacy – and then support their efforts on that front.
“I’m really glad they wrote this and think they did a good job of crystallizing the issues,” Dr. Katz Sand said. “It’s good to put it out there as a document that could help serve as the basis for the requests we make collectively. I just hope that people listen.”
The paper received no funding. The authors disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
This situation is also taking a toll on neurologists’ mental health, who already have the second-highest burnout rate across medical specialties, the statement adds.
The statement was published online Oct. 5, 2021, in Neurology.
Dramatic price increases
Drafted by the Ethics, Law, and Humanities Committee – a joint committee that includes the AAN, the American Neurological Association, and the Child Neurology Society – the statement was prompted by a 2018 report from the AAN Neurology Drug Pricing Task Force to address challenges associated with high drug costs.
It highlights ethical concerns from high drug costs, policy proposals that might temper the problem, and how clinicians can adjust to the current reality of pharmaceutical pricing and better advocate for changes to the healthcare system.
“Runaway drug costs continue to be a pressing problem with recent dramatic price increases not only for specialty drugs, but also generic ones,” said lead author Amy Tsou, MD, MSc, codirector of the ECRI Evidence-Based Practice Center at the Center for Evidence and Guidelines in Plymouth Meeting, Pa.
She noted that one in four Americans has difficulty paying for medication, and many report going without a medication because of cost.
“Ensuring a fair system for drug pricing and coverage rules that balance the goods of individual patients with the needs of broader populations when resources are limited remains more important than ever,” Dr. Tsou said.
Out-of-pocket costs for neurologic medications have risen dramatically over the past decade, with the fastest rise reported among drugs for multiple sclerosis. Results from a study published in 2019 showed that, between 2004 and 2016, patients’ out-of-pocket expenses skyrocketed from $15 a month to $309 a month.
The steep increases have forced some neurology patients to ration their medication or stop taking it altogether, which is one of the ethical concerns cited in the AAN statement.
Patient self-rationing
Commenting on the statement, Ilana Katz Sand, MD, associate director of the Dickinson Center for Multiple Sclerosis at Mount Sinai Medical Center, New York, noted that clinicians are already acutely aware of the effect high drug costs have on their patients’ medical decisions. However, statements such as the current one bring much-needed outside attention to the problem.
“I’ve definitely had more and more people struggling with deductibles and copays, even among people who are insured,” said Dr. Katz Sand, who was not involved with the AAN paper.
She has a number of patients who have rationed their medication or stopped taking it altogether when their copays increased or they lost access to a copay assistance program because their insurance company chose to cover a still-expensive generic drug with no assistance program over a slightly costlier brand-name medication that comes with patient discounts.
Too often, patients don’t tell her they’re not taking their medication as prescribed. At a recent appointment, Dr. Katz Sand learned about a patient’s drug rationing only after a routine MRI showed new brain lesions that regular treatment might have prevented.
Another patient, new to her clinic, questioned the treatment plan Dr. Katz Sand recommended because they could not cover the copay. This sort of self-rationing happens in patients with and without insurance, she added.
“It’s a terrible thing and it’s happening to all patients,” Dr. Katz Sand said, adding that “the old credo of ‘yeah, the drug prices are high, but they are covered by insurance’ is not a sustainable argument anymore.”
What neurologists can do
Some sort of rationing is an unavoidable outcome of steep treatment costs, the authors noted. But what does that mean in clinical practice?
Neurologists should be aware of the costs involved in ordering diagnostic tests, treatment, or medication – and shouldn’t feel compelled to order treatments or tests that they feel are medically inappropriate just because a patient requests them, the authors wrote.
The statement also encourages clinicians to include financial realities in the shared decision-making process with patients.
However, Dr. Katz Sand said that is not always possible. Drug prices aren’t fixed, with different insurance plans offering different pricing, deductibles, and copays. “It’s hard for us to attempt to incorporate discussions about price in our discussions with patients when we can’t even predict what their out-of-pocket cost is going to be,” she said.
“Every single prescription we write requires prior authorization, and that’s directly related to the fact that the cost of these drugs is so high,” she added.
As do many other clinicians, Dr. Katz Sand spends hours each week on preauthorization forms and haggling with insurance companies on behalf of her patients. To get needed medication at a cost they can afford sometimes takes creative problem solving and almost always takes a lot of time. “It all adds to the administrative burden, patients’ stress, and our stress,” she said.
Physician-advocates needed
The AAN paper identifies a number of policy reforms to address drug pricing at a national level, including giving Medicare officials the power to negotiate drug prices, allowing the safe importation of drugs from other countries, and speeding the Food and Drug Administration approval process for generic drugs.
There is also a need to address systemic problems that, the authors noted, help create and perpetuate health care disparities. Lawmakers at the state and federal level are considering a number of these policy ideas and others that could address the kinds of issues Dr. Katz Sand described. However, the chances of their success are slim at best, said Bruce H. Cohen, MD, chair of the AAN advocacy committee and director of the NeuroDevelopmental Science Center at Akron (Ohio) Children’s Hospital.
“On a federal level, we’re watching in real time how the entrenched divisions, even within parties, are resulting in continued stalemate,” said Dr. Cohen, who is not one of the statement authors.
Those ideas need advocates and the AAN paper suggests neurologists should be among the ones championing these changes, he added.
“One of the most effective strategies is to bring attention to the impact high drug costs have on neurology patients and medical practices,” Dr. Cohen said. “It’s so important to make sure policy makers know the significant impact of high drug costs in neurology and within the context of finite resources.”
One way to do that is to share statements such as the current one with members of Congress working on policy reform, Dr. Cohen said. Another is through programs such as the academy’s annual Neurology on the Hill conference.
A third strategy is to encourage individuals such as Dr. Katz Sand to speak out when and where they can, he added.
While she agrees with the idea, finding time for advocacy work amid patient care, administrative work, and research is challenging. Dr. Katz Sand would like to see groups like the AAN work with health care institutions to implement policies that allocate time and resources to train clinicians in advocacy – and then support their efforts on that front.
“I’m really glad they wrote this and think they did a good job of crystallizing the issues,” Dr. Katz Sand said. “It’s good to put it out there as a document that could help serve as the basis for the requests we make collectively. I just hope that people listen.”
The paper received no funding. The authors disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
This situation is also taking a toll on neurologists’ mental health, who already have the second-highest burnout rate across medical specialties, the statement adds.
The statement was published online Oct. 5, 2021, in Neurology.
Dramatic price increases
Drafted by the Ethics, Law, and Humanities Committee – a joint committee that includes the AAN, the American Neurological Association, and the Child Neurology Society – the statement was prompted by a 2018 report from the AAN Neurology Drug Pricing Task Force to address challenges associated with high drug costs.
It highlights ethical concerns from high drug costs, policy proposals that might temper the problem, and how clinicians can adjust to the current reality of pharmaceutical pricing and better advocate for changes to the healthcare system.
“Runaway drug costs continue to be a pressing problem with recent dramatic price increases not only for specialty drugs, but also generic ones,” said lead author Amy Tsou, MD, MSc, codirector of the ECRI Evidence-Based Practice Center at the Center for Evidence and Guidelines in Plymouth Meeting, Pa.
She noted that one in four Americans has difficulty paying for medication, and many report going without a medication because of cost.
“Ensuring a fair system for drug pricing and coverage rules that balance the goods of individual patients with the needs of broader populations when resources are limited remains more important than ever,” Dr. Tsou said.
Out-of-pocket costs for neurologic medications have risen dramatically over the past decade, with the fastest rise reported among drugs for multiple sclerosis. Results from a study published in 2019 showed that, between 2004 and 2016, patients’ out-of-pocket expenses skyrocketed from $15 a month to $309 a month.
The steep increases have forced some neurology patients to ration their medication or stop taking it altogether, which is one of the ethical concerns cited in the AAN statement.
Patient self-rationing
Commenting on the statement, Ilana Katz Sand, MD, associate director of the Dickinson Center for Multiple Sclerosis at Mount Sinai Medical Center, New York, noted that clinicians are already acutely aware of the effect high drug costs have on their patients’ medical decisions. However, statements such as the current one bring much-needed outside attention to the problem.
“I’ve definitely had more and more people struggling with deductibles and copays, even among people who are insured,” said Dr. Katz Sand, who was not involved with the AAN paper.
She has a number of patients who have rationed their medication or stopped taking it altogether when their copays increased or they lost access to a copay assistance program because their insurance company chose to cover a still-expensive generic drug with no assistance program over a slightly costlier brand-name medication that comes with patient discounts.
Too often, patients don’t tell her they’re not taking their medication as prescribed. At a recent appointment, Dr. Katz Sand learned about a patient’s drug rationing only after a routine MRI showed new brain lesions that regular treatment might have prevented.
Another patient, new to her clinic, questioned the treatment plan Dr. Katz Sand recommended because they could not cover the copay. This sort of self-rationing happens in patients with and without insurance, she added.
“It’s a terrible thing and it’s happening to all patients,” Dr. Katz Sand said, adding that “the old credo of ‘yeah, the drug prices are high, but they are covered by insurance’ is not a sustainable argument anymore.”
What neurologists can do
Some sort of rationing is an unavoidable outcome of steep treatment costs, the authors noted. But what does that mean in clinical practice?
Neurologists should be aware of the costs involved in ordering diagnostic tests, treatment, or medication – and shouldn’t feel compelled to order treatments or tests that they feel are medically inappropriate just because a patient requests them, the authors wrote.
The statement also encourages clinicians to include financial realities in the shared decision-making process with patients.
However, Dr. Katz Sand said that is not always possible. Drug prices aren’t fixed, with different insurance plans offering different pricing, deductibles, and copays. “It’s hard for us to attempt to incorporate discussions about price in our discussions with patients when we can’t even predict what their out-of-pocket cost is going to be,” she said.
“Every single prescription we write requires prior authorization, and that’s directly related to the fact that the cost of these drugs is so high,” she added.
As do many other clinicians, Dr. Katz Sand spends hours each week on preauthorization forms and haggling with insurance companies on behalf of her patients. To get needed medication at a cost they can afford sometimes takes creative problem solving and almost always takes a lot of time. “It all adds to the administrative burden, patients’ stress, and our stress,” she said.
Physician-advocates needed
The AAN paper identifies a number of policy reforms to address drug pricing at a national level, including giving Medicare officials the power to negotiate drug prices, allowing the safe importation of drugs from other countries, and speeding the Food and Drug Administration approval process for generic drugs.
There is also a need to address systemic problems that, the authors noted, help create and perpetuate health care disparities. Lawmakers at the state and federal level are considering a number of these policy ideas and others that could address the kinds of issues Dr. Katz Sand described. However, the chances of their success are slim at best, said Bruce H. Cohen, MD, chair of the AAN advocacy committee and director of the NeuroDevelopmental Science Center at Akron (Ohio) Children’s Hospital.
“On a federal level, we’re watching in real time how the entrenched divisions, even within parties, are resulting in continued stalemate,” said Dr. Cohen, who is not one of the statement authors.
Those ideas need advocates and the AAN paper suggests neurologists should be among the ones championing these changes, he added.
“One of the most effective strategies is to bring attention to the impact high drug costs have on neurology patients and medical practices,” Dr. Cohen said. “It’s so important to make sure policy makers know the significant impact of high drug costs in neurology and within the context of finite resources.”
One way to do that is to share statements such as the current one with members of Congress working on policy reform, Dr. Cohen said. Another is through programs such as the academy’s annual Neurology on the Hill conference.
A third strategy is to encourage individuals such as Dr. Katz Sand to speak out when and where they can, he added.
While she agrees with the idea, finding time for advocacy work amid patient care, administrative work, and research is challenging. Dr. Katz Sand would like to see groups like the AAN work with health care institutions to implement policies that allocate time and resources to train clinicians in advocacy – and then support their efforts on that front.
“I’m really glad they wrote this and think they did a good job of crystallizing the issues,” Dr. Katz Sand said. “It’s good to put it out there as a document that could help serve as the basis for the requests we make collectively. I just hope that people listen.”
The paper received no funding. The authors disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
HHS okays first U.S. pilot to mandate coverage of gender-affirming care
The approval means transgender-related care must be included as part of the essential benefits offered on the state’s Affordable Care Act marketplace, which includes private individual and small group insurance plans. The coverage will start Jan. 1, 2023. Colorado is the first state in the United States to require such coverage.
The HHS notes that gender-affirming treatments to be covered include eye and lid modifications, face tightening, facial bone remodeling for facial feminization, breast/chest construction and reductions, and laser hair removal.
“I am proud to stand with Colorado to remove barriers that have historically made it difficult for transgender people to access health coverage and medical care,” said HHS Secretary Xavier Becerra in a statement.
“Colorado’s expansion of their essential health benefits to include gender-affirming surgery and other treatments is a model for other states to follow, and we invite other states to follow suit,” said Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure in the statement.
Medicaid already covers comprehensive transgender care in Colorado.
The LGBTQ+ advocacy group One Colorado estimated that, thanks to the Affordable Care Act, only 5% of the state’s LGBTQ+ community was uninsured in 2019, compared to 10% in 2011.
However, 34% of transgender respondents to a One Colorado poll in 2018 said they had been denied coverage for an LGBTQ-specific medical service, such as gender-affirming care. Sixty-two percent said that a lack of insurance or limited insurance was a barrier to care; 84% said another barrier was the lack of adequately trained mental and behavioral health professionals.
Mental health also covered
The Colorado plan requires individual and small group plans to cover an annual 45- to 60-minute mental health wellness exam with a qualified mental health care practitioner. The visit can include behavioral health screening, education and consultation about healthy lifestyle changes, referrals to mental health treatment, and discussion of potential medication options.
The plans also must cover an additional 15 medications as alternatives to opioids and up to six acupuncture visits annually.
“This plan expands access to mental health services for Coloradans while helping those fighting substance abuse to overcome their addiction,” said Governor Jared Polis in a statement.
“This improves care for Coloradans and ensures that even more Coloradans have access to help when they need it,” he said.
A version of this article first appeared on Medscape.com.
The approval means transgender-related care must be included as part of the essential benefits offered on the state’s Affordable Care Act marketplace, which includes private individual and small group insurance plans. The coverage will start Jan. 1, 2023. Colorado is the first state in the United States to require such coverage.
The HHS notes that gender-affirming treatments to be covered include eye and lid modifications, face tightening, facial bone remodeling for facial feminization, breast/chest construction and reductions, and laser hair removal.
“I am proud to stand with Colorado to remove barriers that have historically made it difficult for transgender people to access health coverage and medical care,” said HHS Secretary Xavier Becerra in a statement.
“Colorado’s expansion of their essential health benefits to include gender-affirming surgery and other treatments is a model for other states to follow, and we invite other states to follow suit,” said Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure in the statement.
Medicaid already covers comprehensive transgender care in Colorado.
The LGBTQ+ advocacy group One Colorado estimated that, thanks to the Affordable Care Act, only 5% of the state’s LGBTQ+ community was uninsured in 2019, compared to 10% in 2011.
However, 34% of transgender respondents to a One Colorado poll in 2018 said they had been denied coverage for an LGBTQ-specific medical service, such as gender-affirming care. Sixty-two percent said that a lack of insurance or limited insurance was a barrier to care; 84% said another barrier was the lack of adequately trained mental and behavioral health professionals.
Mental health also covered
The Colorado plan requires individual and small group plans to cover an annual 45- to 60-minute mental health wellness exam with a qualified mental health care practitioner. The visit can include behavioral health screening, education and consultation about healthy lifestyle changes, referrals to mental health treatment, and discussion of potential medication options.
The plans also must cover an additional 15 medications as alternatives to opioids and up to six acupuncture visits annually.
“This plan expands access to mental health services for Coloradans while helping those fighting substance abuse to overcome their addiction,” said Governor Jared Polis in a statement.
“This improves care for Coloradans and ensures that even more Coloradans have access to help when they need it,” he said.
A version of this article first appeared on Medscape.com.
The approval means transgender-related care must be included as part of the essential benefits offered on the state’s Affordable Care Act marketplace, which includes private individual and small group insurance plans. The coverage will start Jan. 1, 2023. Colorado is the first state in the United States to require such coverage.
The HHS notes that gender-affirming treatments to be covered include eye and lid modifications, face tightening, facial bone remodeling for facial feminization, breast/chest construction and reductions, and laser hair removal.
“I am proud to stand with Colorado to remove barriers that have historically made it difficult for transgender people to access health coverage and medical care,” said HHS Secretary Xavier Becerra in a statement.
“Colorado’s expansion of their essential health benefits to include gender-affirming surgery and other treatments is a model for other states to follow, and we invite other states to follow suit,” said Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure in the statement.
Medicaid already covers comprehensive transgender care in Colorado.
The LGBTQ+ advocacy group One Colorado estimated that, thanks to the Affordable Care Act, only 5% of the state’s LGBTQ+ community was uninsured in 2019, compared to 10% in 2011.
However, 34% of transgender respondents to a One Colorado poll in 2018 said they had been denied coverage for an LGBTQ-specific medical service, such as gender-affirming care. Sixty-two percent said that a lack of insurance or limited insurance was a barrier to care; 84% said another barrier was the lack of adequately trained mental and behavioral health professionals.
Mental health also covered
The Colorado plan requires individual and small group plans to cover an annual 45- to 60-minute mental health wellness exam with a qualified mental health care practitioner. The visit can include behavioral health screening, education and consultation about healthy lifestyle changes, referrals to mental health treatment, and discussion of potential medication options.
The plans also must cover an additional 15 medications as alternatives to opioids and up to six acupuncture visits annually.
“This plan expands access to mental health services for Coloradans while helping those fighting substance abuse to overcome their addiction,” said Governor Jared Polis in a statement.
“This improves care for Coloradans and ensures that even more Coloradans have access to help when they need it,” he said.
A version of this article first appeared on Medscape.com.
CrossFit enters primary care with fitness-minded docs, data
with the launch of its newest service, CrossFit Precision Care.
Developed by family medicine physician Julie Foucher, MD, and other CrossFit-trained doctors, the new service aims to help CrossFit members build plans to protect and improve their health, according to a statement by the company.
CrossFit Precision Care plans to meet this goal through utilizing doctors who understand the CrossFit philosophy, individualized care, data-driven recommendations, proactive lifestyle changes, and continual health optimization. Informing these plans and changes are CrossFit Precision Care’s analysis through a few different methods.
CrossFit’s partner in the endeavor, Wild Health, will provide genomic testing to determine a patient’s genetic predispositions to help optimize the health plans. Blood testing reveals many things that may affect a person’s health, such as hormone status, lipid levels, thyroid function, and cardiovascular risks. An overall lifestyle review includes exercise routines, eating habits, social life, and other patterns or behaviors.
Connecting with doctors who understand CrossFit
Dr. Foucher is no stranger to CrossFit. She has competed in the CrossFit Games four times and discusses the sport regularly on Twitter and Instagram. Now, she works directly with CrossFit to help it provide users with individualized data-driven plans.
“I met Eric Roza last July,” Dr. Foucher says of CrossFit’s CEO. “We talked and saw a lot of potential for CrossFit and health care providers to work together, so we started brainstorming.”
When Dr. Foucher and Mr. Roza got to know Wild Health, specifically, two of its physician cofounders, it was a natural fit, she said. Dr. Foucher says that many who train in CrossFit or go to CrossFit-affiliated gyms feel a disconnect with their family doctors: “[CrossFit is] a pretty polarizing topic, but there are also a lot of doctors who know that people are having health improvements with these programs,” she said.
Through use of Wild Health’s precision services and algorithms, CrossFit Precision Care plans to connect its users with CrossFit-trained health care practitioners. This personalized approach allows health care practitioners to build closer relationships with users of the program, who may feel more comfortable working with doctors who understand their lifestyle. Wild Health’s precision medicine approach, with trackable data such as biomarker status and risk scores, gives doctors a more complete picture of a patient’s needs and history, according to a statement on the partnership.
A better use of data
“To me,” Dr. Foucher says of family medicine, “that was the best option coming out of residency. It was consistent with my morals.” She says much of the current health care system is algorithm based. If a patient is experiencing certain symptoms, treatment is recommended on the basis of whatever yields the best results from the data – but this doesn’t always factor in a patient’s full history and genetics. It can be difficult for doctors to build trusting and personal relationships with patients. “In our current system, there’s not a lot of time or great tools to do that,” she says.
With the approach Wild Health and CrossFit Precision Care both use, however, Dr. Foucher says she sees a huge opportunity for optimizing patient and health care practitioner relationships.
“I see huge potential here, and I really think that this should be the standard for primary care going forwards,” Dr. Foucher explains. “The nice thing about [this approach] is that it has a really quick learning curve and is relatively easy to implement with patients. Before Wild Health optimized it, the tech and data would take about 10 hours per patient to put together. But now, we can incorporate things that work with wearable tech and track results over time and allow the patient and doctor to use this platform to create relationships. And this is something that can scale to many more patients.”
According to its website, CrossFit Precision Care is currently launching an invite-only beta test version of the program in eight states ahead of an expected national release.
A version of this article first appeared on Medscape.com.
with the launch of its newest service, CrossFit Precision Care.
Developed by family medicine physician Julie Foucher, MD, and other CrossFit-trained doctors, the new service aims to help CrossFit members build plans to protect and improve their health, according to a statement by the company.
CrossFit Precision Care plans to meet this goal through utilizing doctors who understand the CrossFit philosophy, individualized care, data-driven recommendations, proactive lifestyle changes, and continual health optimization. Informing these plans and changes are CrossFit Precision Care’s analysis through a few different methods.
CrossFit’s partner in the endeavor, Wild Health, will provide genomic testing to determine a patient’s genetic predispositions to help optimize the health plans. Blood testing reveals many things that may affect a person’s health, such as hormone status, lipid levels, thyroid function, and cardiovascular risks. An overall lifestyle review includes exercise routines, eating habits, social life, and other patterns or behaviors.
Connecting with doctors who understand CrossFit
Dr. Foucher is no stranger to CrossFit. She has competed in the CrossFit Games four times and discusses the sport regularly on Twitter and Instagram. Now, she works directly with CrossFit to help it provide users with individualized data-driven plans.
“I met Eric Roza last July,” Dr. Foucher says of CrossFit’s CEO. “We talked and saw a lot of potential for CrossFit and health care providers to work together, so we started brainstorming.”
When Dr. Foucher and Mr. Roza got to know Wild Health, specifically, two of its physician cofounders, it was a natural fit, she said. Dr. Foucher says that many who train in CrossFit or go to CrossFit-affiliated gyms feel a disconnect with their family doctors: “[CrossFit is] a pretty polarizing topic, but there are also a lot of doctors who know that people are having health improvements with these programs,” she said.
Through use of Wild Health’s precision services and algorithms, CrossFit Precision Care plans to connect its users with CrossFit-trained health care practitioners. This personalized approach allows health care practitioners to build closer relationships with users of the program, who may feel more comfortable working with doctors who understand their lifestyle. Wild Health’s precision medicine approach, with trackable data such as biomarker status and risk scores, gives doctors a more complete picture of a patient’s needs and history, according to a statement on the partnership.
A better use of data
“To me,” Dr. Foucher says of family medicine, “that was the best option coming out of residency. It was consistent with my morals.” She says much of the current health care system is algorithm based. If a patient is experiencing certain symptoms, treatment is recommended on the basis of whatever yields the best results from the data – but this doesn’t always factor in a patient’s full history and genetics. It can be difficult for doctors to build trusting and personal relationships with patients. “In our current system, there’s not a lot of time or great tools to do that,” she says.
With the approach Wild Health and CrossFit Precision Care both use, however, Dr. Foucher says she sees a huge opportunity for optimizing patient and health care practitioner relationships.
“I see huge potential here, and I really think that this should be the standard for primary care going forwards,” Dr. Foucher explains. “The nice thing about [this approach] is that it has a really quick learning curve and is relatively easy to implement with patients. Before Wild Health optimized it, the tech and data would take about 10 hours per patient to put together. But now, we can incorporate things that work with wearable tech and track results over time and allow the patient and doctor to use this platform to create relationships. And this is something that can scale to many more patients.”
According to its website, CrossFit Precision Care is currently launching an invite-only beta test version of the program in eight states ahead of an expected national release.
A version of this article first appeared on Medscape.com.
with the launch of its newest service, CrossFit Precision Care.
Developed by family medicine physician Julie Foucher, MD, and other CrossFit-trained doctors, the new service aims to help CrossFit members build plans to protect and improve their health, according to a statement by the company.
CrossFit Precision Care plans to meet this goal through utilizing doctors who understand the CrossFit philosophy, individualized care, data-driven recommendations, proactive lifestyle changes, and continual health optimization. Informing these plans and changes are CrossFit Precision Care’s analysis through a few different methods.
CrossFit’s partner in the endeavor, Wild Health, will provide genomic testing to determine a patient’s genetic predispositions to help optimize the health plans. Blood testing reveals many things that may affect a person’s health, such as hormone status, lipid levels, thyroid function, and cardiovascular risks. An overall lifestyle review includes exercise routines, eating habits, social life, and other patterns or behaviors.
Connecting with doctors who understand CrossFit
Dr. Foucher is no stranger to CrossFit. She has competed in the CrossFit Games four times and discusses the sport regularly on Twitter and Instagram. Now, she works directly with CrossFit to help it provide users with individualized data-driven plans.
“I met Eric Roza last July,” Dr. Foucher says of CrossFit’s CEO. “We talked and saw a lot of potential for CrossFit and health care providers to work together, so we started brainstorming.”
When Dr. Foucher and Mr. Roza got to know Wild Health, specifically, two of its physician cofounders, it was a natural fit, she said. Dr. Foucher says that many who train in CrossFit or go to CrossFit-affiliated gyms feel a disconnect with their family doctors: “[CrossFit is] a pretty polarizing topic, but there are also a lot of doctors who know that people are having health improvements with these programs,” she said.
Through use of Wild Health’s precision services and algorithms, CrossFit Precision Care plans to connect its users with CrossFit-trained health care practitioners. This personalized approach allows health care practitioners to build closer relationships with users of the program, who may feel more comfortable working with doctors who understand their lifestyle. Wild Health’s precision medicine approach, with trackable data such as biomarker status and risk scores, gives doctors a more complete picture of a patient’s needs and history, according to a statement on the partnership.
A better use of data
“To me,” Dr. Foucher says of family medicine, “that was the best option coming out of residency. It was consistent with my morals.” She says much of the current health care system is algorithm based. If a patient is experiencing certain symptoms, treatment is recommended on the basis of whatever yields the best results from the data – but this doesn’t always factor in a patient’s full history and genetics. It can be difficult for doctors to build trusting and personal relationships with patients. “In our current system, there’s not a lot of time or great tools to do that,” she says.
With the approach Wild Health and CrossFit Precision Care both use, however, Dr. Foucher says she sees a huge opportunity for optimizing patient and health care practitioner relationships.
“I see huge potential here, and I really think that this should be the standard for primary care going forwards,” Dr. Foucher explains. “The nice thing about [this approach] is that it has a really quick learning curve and is relatively easy to implement with patients. Before Wild Health optimized it, the tech and data would take about 10 hours per patient to put together. But now, we can incorporate things that work with wearable tech and track results over time and allow the patient and doctor to use this platform to create relationships. And this is something that can scale to many more patients.”
According to its website, CrossFit Precision Care is currently launching an invite-only beta test version of the program in eight states ahead of an expected national release.
A version of this article first appeared on Medscape.com.
Alleged on-the-job violence, racism, prompts psych workers to head to D.C.
A dozen workers from a psychiatric hospital near Seattle flew to Washington, D.C. to picket the National Association for Behavioral Healthcare’s annual meeting in an effort to get their employer to meet demands for a safer work environment, better staffing, and the hiring of security professionals.
They are also demanding that their employer, Cascade Behavioral Health Hospital, a private psychiatric facility owned by Acadia Healthcare and located in Tukwila, Washington, address what they call “racist harassment” by managers who have allegedly told many workers, who are primarily people of color, that they are going to be “filtered out,” Alazar Yirgu, a mental health technician at the facility, told this news organization.
The workers have been conducting a “safety strike” to protest working conditions at Cascade since early August. The protest in Tukwila began after a dozen or more workers were hurt in an August 1 incident during which they had attempted to restrain a violent patient.
“We’ve been out there for 2 months, and we will continue until our voice is heard,” said Mr. Yirgu, who was hospitalized as a result of the August patient outburst that he said has left him unable to work since the incident.
On Oct. 7, Mr. Yirgu and coworkers brought the protest to Washington, D.C., in a continued effort to voice their need for adequate personal protective equipment, increased staffing, and the hiring of security personnel.
“Any health care professional should not be fearful to do their job, because once they are in that state of mind, once they are fearful for themselves, then they are not doing their jobs; they are preoccupied with their fears,” said Mr. Yirgu, who has worked as a technician for 6 years.
Unsafe patient load
The workers reacted quickly after the August 1 patient outburst because there have been multiple previous incidents, Mr. Yirgu said.
In a 2019 news story by the Seattle Times, the newspaper reported there had been 65 assaults on patients or staff at Cascade from 2016 to 2018, resulting in concussions and broken bones in some instances.
Mr. Yirgu said that more recently, a patient broke a second story window, jumped to the ground, and ran off.
At the facility, workers are often assigned to as many as a dozen or more patients, he said, noting that at other psychiatric institutions, he’s cared for a maximum of five patients at once.
The Tukwila police have pushed back against the workers’ description of the incident in which Mr. Yirgu was injured, and Cascade Behavioral Health has aggressively defended its facility.
According to Mr. Yirgu, the expletive-spewing patient was clearly a danger to himself and others – especially after he stole a key card that would give him access to the entire facility, including the kitchen where knives were stored.
When more than a dozen staff answered the unit’s “Code Gray,” they were unable to subdue or restrain him. Mr. Yirgu ended up on the floor underneath the patient after the patient had jumped off a table.
As the incident unfolded, several workers called the police, who initially refused to go to the facility, saying that a new law prevented them from assisting with the restraint if there was no assault.
The Tukwila Police Department report shows that officers finally did go to the facility and determined that “a crime had not been committed based on the information presented to them, that there was no imminent threat of bodily harm, and that there was no legal grounds or authority for them to assist medical staff with physically restraining a patient.”
Cascade pushes back
A Service Employees International Union (SEIU) report shows about 70 workers refused to come in to work after the incident and began picketing outside the facility.
Cascade called it an illegal strike because the protesters had not given 10-days’ notice, as required by federal law, and moved to terminate those who participated. The local SEIU chapter, 1199NW, suggested the workers call their walkout a “safety strike,” because it was organized primarily to protest working conditions.
Meanwhile Cascade, which has erected a large fence so that no one in the facility can see the protesters, has said the strike is primarily about ongoing contract negotiations with the facility’s nurses and its union.
“The Union has been trying to apply unfair – and in some cases we believe unlawful – external pressures to this process, including picketing, work stoppages, smear campaigns, and false accusations,” Cascade CEO Christopher West wrote on the company’s website in mid-August.
He said the facility had “ample personal protective equipment” and that the “well-being and safety of our patients and staff always have been and will be our key priorities.”
In response to a request for comment, Cascade said in an emailed statement that physical confrontations had decreased by almost 50% and elopements (unauthorized leaving of the facility) by 80% from 2018 to 2021.
Cascade spokesperson Gretchen Hommrich said in the statement that the workers it has terminated “were let go for cause in violation to their employment agreement” and said the company still aimed to negotiate a new agreement with the union.
The “efforts outside of the bargaining process serve no productive purpose and have only brought harm to the residents they claim to serve,” said Ms. Hommrich.
‘Safety is the sole purpose’
Mr. Yirgu said it was outrageous to suggest workers were picketing over contract negotiations. “Safety is the sole purpose of this strike,” he said.
He noted that his patient care goal is to have a lot of one-on-one time with his patients, helping them navigate back to the outside world. The facility is supposed to be a safe place, Mr. Yirgu added. Violence inside the facility traumatizes the patients and may worsen their condition and delay their progress, he said.
“If I can’t keep them safe, there’s no way I’m going to be able to see them eye-to-eye when I told them I’d keep them safe and then they’re not anymore,” said Mr. Yirgu.
So far, 22 workers have been “terminated,” meaning they received a termination notice, have been taken off the work schedule by the employer, or otherwise been informed that the employer has deemed them to be separated, the SEIU reports. The organization has filed unfair labor practice (ULPs) for all 22.
A version of this article first appeared on Medscape.com.
A dozen workers from a psychiatric hospital near Seattle flew to Washington, D.C. to picket the National Association for Behavioral Healthcare’s annual meeting in an effort to get their employer to meet demands for a safer work environment, better staffing, and the hiring of security professionals.
They are also demanding that their employer, Cascade Behavioral Health Hospital, a private psychiatric facility owned by Acadia Healthcare and located in Tukwila, Washington, address what they call “racist harassment” by managers who have allegedly told many workers, who are primarily people of color, that they are going to be “filtered out,” Alazar Yirgu, a mental health technician at the facility, told this news organization.
The workers have been conducting a “safety strike” to protest working conditions at Cascade since early August. The protest in Tukwila began after a dozen or more workers were hurt in an August 1 incident during which they had attempted to restrain a violent patient.
“We’ve been out there for 2 months, and we will continue until our voice is heard,” said Mr. Yirgu, who was hospitalized as a result of the August patient outburst that he said has left him unable to work since the incident.
On Oct. 7, Mr. Yirgu and coworkers brought the protest to Washington, D.C., in a continued effort to voice their need for adequate personal protective equipment, increased staffing, and the hiring of security personnel.
“Any health care professional should not be fearful to do their job, because once they are in that state of mind, once they are fearful for themselves, then they are not doing their jobs; they are preoccupied with their fears,” said Mr. Yirgu, who has worked as a technician for 6 years.
Unsafe patient load
The workers reacted quickly after the August 1 patient outburst because there have been multiple previous incidents, Mr. Yirgu said.
In a 2019 news story by the Seattle Times, the newspaper reported there had been 65 assaults on patients or staff at Cascade from 2016 to 2018, resulting in concussions and broken bones in some instances.
Mr. Yirgu said that more recently, a patient broke a second story window, jumped to the ground, and ran off.
At the facility, workers are often assigned to as many as a dozen or more patients, he said, noting that at other psychiatric institutions, he’s cared for a maximum of five patients at once.
The Tukwila police have pushed back against the workers’ description of the incident in which Mr. Yirgu was injured, and Cascade Behavioral Health has aggressively defended its facility.
According to Mr. Yirgu, the expletive-spewing patient was clearly a danger to himself and others – especially after he stole a key card that would give him access to the entire facility, including the kitchen where knives were stored.
When more than a dozen staff answered the unit’s “Code Gray,” they were unable to subdue or restrain him. Mr. Yirgu ended up on the floor underneath the patient after the patient had jumped off a table.
As the incident unfolded, several workers called the police, who initially refused to go to the facility, saying that a new law prevented them from assisting with the restraint if there was no assault.
The Tukwila Police Department report shows that officers finally did go to the facility and determined that “a crime had not been committed based on the information presented to them, that there was no imminent threat of bodily harm, and that there was no legal grounds or authority for them to assist medical staff with physically restraining a patient.”
Cascade pushes back
A Service Employees International Union (SEIU) report shows about 70 workers refused to come in to work after the incident and began picketing outside the facility.
Cascade called it an illegal strike because the protesters had not given 10-days’ notice, as required by federal law, and moved to terminate those who participated. The local SEIU chapter, 1199NW, suggested the workers call their walkout a “safety strike,” because it was organized primarily to protest working conditions.
Meanwhile Cascade, which has erected a large fence so that no one in the facility can see the protesters, has said the strike is primarily about ongoing contract negotiations with the facility’s nurses and its union.
“The Union has been trying to apply unfair – and in some cases we believe unlawful – external pressures to this process, including picketing, work stoppages, smear campaigns, and false accusations,” Cascade CEO Christopher West wrote on the company’s website in mid-August.
He said the facility had “ample personal protective equipment” and that the “well-being and safety of our patients and staff always have been and will be our key priorities.”
In response to a request for comment, Cascade said in an emailed statement that physical confrontations had decreased by almost 50% and elopements (unauthorized leaving of the facility) by 80% from 2018 to 2021.
Cascade spokesperson Gretchen Hommrich said in the statement that the workers it has terminated “were let go for cause in violation to their employment agreement” and said the company still aimed to negotiate a new agreement with the union.
The “efforts outside of the bargaining process serve no productive purpose and have only brought harm to the residents they claim to serve,” said Ms. Hommrich.
‘Safety is the sole purpose’
Mr. Yirgu said it was outrageous to suggest workers were picketing over contract negotiations. “Safety is the sole purpose of this strike,” he said.
He noted that his patient care goal is to have a lot of one-on-one time with his patients, helping them navigate back to the outside world. The facility is supposed to be a safe place, Mr. Yirgu added. Violence inside the facility traumatizes the patients and may worsen their condition and delay their progress, he said.
“If I can’t keep them safe, there’s no way I’m going to be able to see them eye-to-eye when I told them I’d keep them safe and then they’re not anymore,” said Mr. Yirgu.
So far, 22 workers have been “terminated,” meaning they received a termination notice, have been taken off the work schedule by the employer, or otherwise been informed that the employer has deemed them to be separated, the SEIU reports. The organization has filed unfair labor practice (ULPs) for all 22.
A version of this article first appeared on Medscape.com.
A dozen workers from a psychiatric hospital near Seattle flew to Washington, D.C. to picket the National Association for Behavioral Healthcare’s annual meeting in an effort to get their employer to meet demands for a safer work environment, better staffing, and the hiring of security professionals.
They are also demanding that their employer, Cascade Behavioral Health Hospital, a private psychiatric facility owned by Acadia Healthcare and located in Tukwila, Washington, address what they call “racist harassment” by managers who have allegedly told many workers, who are primarily people of color, that they are going to be “filtered out,” Alazar Yirgu, a mental health technician at the facility, told this news organization.
The workers have been conducting a “safety strike” to protest working conditions at Cascade since early August. The protest in Tukwila began after a dozen or more workers were hurt in an August 1 incident during which they had attempted to restrain a violent patient.
“We’ve been out there for 2 months, and we will continue until our voice is heard,” said Mr. Yirgu, who was hospitalized as a result of the August patient outburst that he said has left him unable to work since the incident.
On Oct. 7, Mr. Yirgu and coworkers brought the protest to Washington, D.C., in a continued effort to voice their need for adequate personal protective equipment, increased staffing, and the hiring of security personnel.
“Any health care professional should not be fearful to do their job, because once they are in that state of mind, once they are fearful for themselves, then they are not doing their jobs; they are preoccupied with their fears,” said Mr. Yirgu, who has worked as a technician for 6 years.
Unsafe patient load
The workers reacted quickly after the August 1 patient outburst because there have been multiple previous incidents, Mr. Yirgu said.
In a 2019 news story by the Seattle Times, the newspaper reported there had been 65 assaults on patients or staff at Cascade from 2016 to 2018, resulting in concussions and broken bones in some instances.
Mr. Yirgu said that more recently, a patient broke a second story window, jumped to the ground, and ran off.
At the facility, workers are often assigned to as many as a dozen or more patients, he said, noting that at other psychiatric institutions, he’s cared for a maximum of five patients at once.
The Tukwila police have pushed back against the workers’ description of the incident in which Mr. Yirgu was injured, and Cascade Behavioral Health has aggressively defended its facility.
According to Mr. Yirgu, the expletive-spewing patient was clearly a danger to himself and others – especially after he stole a key card that would give him access to the entire facility, including the kitchen where knives were stored.
When more than a dozen staff answered the unit’s “Code Gray,” they were unable to subdue or restrain him. Mr. Yirgu ended up on the floor underneath the patient after the patient had jumped off a table.
As the incident unfolded, several workers called the police, who initially refused to go to the facility, saying that a new law prevented them from assisting with the restraint if there was no assault.
The Tukwila Police Department report shows that officers finally did go to the facility and determined that “a crime had not been committed based on the information presented to them, that there was no imminent threat of bodily harm, and that there was no legal grounds or authority for them to assist medical staff with physically restraining a patient.”
Cascade pushes back
A Service Employees International Union (SEIU) report shows about 70 workers refused to come in to work after the incident and began picketing outside the facility.
Cascade called it an illegal strike because the protesters had not given 10-days’ notice, as required by federal law, and moved to terminate those who participated. The local SEIU chapter, 1199NW, suggested the workers call their walkout a “safety strike,” because it was organized primarily to protest working conditions.
Meanwhile Cascade, which has erected a large fence so that no one in the facility can see the protesters, has said the strike is primarily about ongoing contract negotiations with the facility’s nurses and its union.
“The Union has been trying to apply unfair – and in some cases we believe unlawful – external pressures to this process, including picketing, work stoppages, smear campaigns, and false accusations,” Cascade CEO Christopher West wrote on the company’s website in mid-August.
He said the facility had “ample personal protective equipment” and that the “well-being and safety of our patients and staff always have been and will be our key priorities.”
In response to a request for comment, Cascade said in an emailed statement that physical confrontations had decreased by almost 50% and elopements (unauthorized leaving of the facility) by 80% from 2018 to 2021.
Cascade spokesperson Gretchen Hommrich said in the statement that the workers it has terminated “were let go for cause in violation to their employment agreement” and said the company still aimed to negotiate a new agreement with the union.
The “efforts outside of the bargaining process serve no productive purpose and have only brought harm to the residents they claim to serve,” said Ms. Hommrich.
‘Safety is the sole purpose’
Mr. Yirgu said it was outrageous to suggest workers were picketing over contract negotiations. “Safety is the sole purpose of this strike,” he said.
He noted that his patient care goal is to have a lot of one-on-one time with his patients, helping them navigate back to the outside world. The facility is supposed to be a safe place, Mr. Yirgu added. Violence inside the facility traumatizes the patients and may worsen their condition and delay their progress, he said.
“If I can’t keep them safe, there’s no way I’m going to be able to see them eye-to-eye when I told them I’d keep them safe and then they’re not anymore,” said Mr. Yirgu.
So far, 22 workers have been “terminated,” meaning they received a termination notice, have been taken off the work schedule by the employer, or otherwise been informed that the employer has deemed them to be separated, the SEIU reports. The organization has filed unfair labor practice (ULPs) for all 22.
A version of this article first appeared on Medscape.com.
Telehealth for heart failure during pandemic shown effective, safe
The rapid transition to and reliance on telehealth to manage patients with heart failure during the COVID-19 pandemic does not appear to impact clinical outcomes, according to real-world data.
HF outpatients managed with telehealth visits did not show a significantly higher adjusted risk for subsequent ED visits, hospital admissions, intensive care use, or death at 30 and 90 days, the investigators reported in JACC: Heart Failure.
“Telehealth is safe and effective in probably some of our highest-risk patients who traditionally have needed hands-on, in-person assessment and evaluation – those patients who have heart failure – so we shouldn’t be afraid to use it all the time, not when needed as a minimum,” senior author Brett W. Sperry, MD, said in an interview.
Heart failure is a perfect case example to examine telehealth because the chronic condition not only requires continual assessment and medication adjustments, but HF patients are also particularly vulnerable to complications related to COVID-19 infection, he noted. A small, single-center report on telehealth early in Italy’s outbreak showed fewer HF hospitalizations and similar mortality, compared with in-person visits in 2019 but, overall, few data exist.
The current analysis took a wider sweep, comparing HF patients seen from March 15 to June 15, 2020 with those seen during the same time period in 2018 and 2019 at 16 cardiology clinics in Saint Luke’s Health System, which serves the Kansas City metro area and surrounding suburbs in Missouri and Kansas.
Among 8,263 unique patients and 15,421 visits identified, telehealth was not used in 2018 or 2019 but accounted for 88.5% of visits during the study period in 2020, 70% of which were by telephone and 30% of which were by video.
“We had zero telehealth before March 2020 and basically built an entire telehealth apparatus in a week or 2,” explained Dr. Sperry. “Initially it was a lot of telephone visits while we were getting the video stuff figured out, which is reflected in the paper, and then went to mostly video visits.”
Despite the pandemic, however, more outpatients were seen in 2020 than in 2018 and 2019 (4,063 vs. 3675 and 3,619 patients, respectively). This likely reflects the shift of personnel and resources from hospital duties to outpatient virtual visits, which were strongly recommended by the Heart Failure Society of America and other professional societies to manage patients during the pandemic, he said.
Unadjusted analyses demonstrated fewer ED visits and hospital admissions and more ICU admissions and all-cause mortality in 2020 than in previous years.
A propensity-matched analysis involving 4541 pairs of patients, however, showed admissions to the ED or hospital were lower after the telehealth visits than after in-person visits at 30 days (6.8% vs 10.4%; P < .001) and 90 days (17.9% vs. 23.3%; P < .001).
Among hospitalized patients, there was no difference between telehealth and in-patient visits in ICU admissions at 30 or 90 days. Mortality was also similar at 30 days (0.8% vs. 0.7%; P = .465) and 90 days (2.9% vs. 2.4%; P = .133).
Dr. Sperry said the pendulum has swung since 2020 and that the team is back to seeing most people in person, with about 15% of his clinic visits that day done via video. Standardized quality of life assessments prior to outpatient visits can help triage patients to telehealth in-patient visits, but in-person visits will still be needed for cases with greater acuity, older patients, and those with limited or no access to quality telephone videos or the internet.
“It isn’t for everyone,” Dr. Sperry said. “You’re going to need some kind of hybrid model with both in-person and video visits available and be able to offer both for patients and be able to titrate that as the pandemic changes in the future.”
Ankit Bhatia, MD, an advanced HF cardiologist at Christ Hospital in Cincinnati, who was not part of the study, said in an interview the use of telehealth in 85% of patients may be higher than the norm at most centers but that the study provides much-needed data.
“I’m really appreciative of a study like this because we were all in such a rush last year to get patients seen that very few people thought how could we design a study to really ensure we’re treating our patients within an equipoise with prior practices,” he said.
“The fact that they were able to do that [85%] and demonstrate in a propensity-matched analysis that outcomes were similar really just shows that telehealth is a strategy that we can use well in patients with heart failure to extend our ability to take care of them,” said Dr. Bhatia, a member of the American College of Cardiology Health Care Innovation Council.
Even beyond the pandemic, he said, the trend in health care is for patients to want health care delivered closer to home and for health care systems to become more patient centric. “This accelerated that but what I think this study showed me was that it’s okay to have this be part of my care model and I’m not sacrificing on my patient care if I choose to intersperse telehealth with inpatient visits.”
Besides the inherent limitations of retrospective studies, the authors noted that diagnoses in the study were based on ICD-10 codes and that subsequent ED visits or hospitalizations outside the single system may have been underreported. A further limitation is that they could not identify the cause of death or reasons for hospital encounters.
“Further data are needed to confirm the relative safety of a telehealth strategy in the HF population over a more sustained period of time, although we hypothesize that greater risks would be observed early after telehealth visits, where patients’ acuity might be misjudged,” they wrote.
Dr. Sperry is a consultant to Pfizer and Alnylam. Coauthor John A. Spertus is the principal investigator of grants from National Institutes of Health, Abbott Vascular, and the American College of Cardiology Foundation; is a consultant to Janssen, Novartis, Amgen, Myokardia, AstraZeneca, Bayer, and Merck; serves on the scientific advisory board of United Healthcare and the board of directors for Blue Cross Blue Shield of Kansas City; owns the copyright to the Kansas City Cardiomyopathy Questionnaire, Seattle Angina Questionnaire, and Peripheral Artery Questionnaire; and has an equity interest in Health Outcomes Sciences. All other authors and Dr. Bhatia reported no relevant conflicts.
A version of this article first appeared on Medscape.com.
The rapid transition to and reliance on telehealth to manage patients with heart failure during the COVID-19 pandemic does not appear to impact clinical outcomes, according to real-world data.
HF outpatients managed with telehealth visits did not show a significantly higher adjusted risk for subsequent ED visits, hospital admissions, intensive care use, or death at 30 and 90 days, the investigators reported in JACC: Heart Failure.
“Telehealth is safe and effective in probably some of our highest-risk patients who traditionally have needed hands-on, in-person assessment and evaluation – those patients who have heart failure – so we shouldn’t be afraid to use it all the time, not when needed as a minimum,” senior author Brett W. Sperry, MD, said in an interview.
Heart failure is a perfect case example to examine telehealth because the chronic condition not only requires continual assessment and medication adjustments, but HF patients are also particularly vulnerable to complications related to COVID-19 infection, he noted. A small, single-center report on telehealth early in Italy’s outbreak showed fewer HF hospitalizations and similar mortality, compared with in-person visits in 2019 but, overall, few data exist.
The current analysis took a wider sweep, comparing HF patients seen from March 15 to June 15, 2020 with those seen during the same time period in 2018 and 2019 at 16 cardiology clinics in Saint Luke’s Health System, which serves the Kansas City metro area and surrounding suburbs in Missouri and Kansas.
Among 8,263 unique patients and 15,421 visits identified, telehealth was not used in 2018 or 2019 but accounted for 88.5% of visits during the study period in 2020, 70% of which were by telephone and 30% of which were by video.
“We had zero telehealth before March 2020 and basically built an entire telehealth apparatus in a week or 2,” explained Dr. Sperry. “Initially it was a lot of telephone visits while we were getting the video stuff figured out, which is reflected in the paper, and then went to mostly video visits.”
Despite the pandemic, however, more outpatients were seen in 2020 than in 2018 and 2019 (4,063 vs. 3675 and 3,619 patients, respectively). This likely reflects the shift of personnel and resources from hospital duties to outpatient virtual visits, which were strongly recommended by the Heart Failure Society of America and other professional societies to manage patients during the pandemic, he said.
Unadjusted analyses demonstrated fewer ED visits and hospital admissions and more ICU admissions and all-cause mortality in 2020 than in previous years.
A propensity-matched analysis involving 4541 pairs of patients, however, showed admissions to the ED or hospital were lower after the telehealth visits than after in-person visits at 30 days (6.8% vs 10.4%; P < .001) and 90 days (17.9% vs. 23.3%; P < .001).
Among hospitalized patients, there was no difference between telehealth and in-patient visits in ICU admissions at 30 or 90 days. Mortality was also similar at 30 days (0.8% vs. 0.7%; P = .465) and 90 days (2.9% vs. 2.4%; P = .133).
Dr. Sperry said the pendulum has swung since 2020 and that the team is back to seeing most people in person, with about 15% of his clinic visits that day done via video. Standardized quality of life assessments prior to outpatient visits can help triage patients to telehealth in-patient visits, but in-person visits will still be needed for cases with greater acuity, older patients, and those with limited or no access to quality telephone videos or the internet.
“It isn’t for everyone,” Dr. Sperry said. “You’re going to need some kind of hybrid model with both in-person and video visits available and be able to offer both for patients and be able to titrate that as the pandemic changes in the future.”
Ankit Bhatia, MD, an advanced HF cardiologist at Christ Hospital in Cincinnati, who was not part of the study, said in an interview the use of telehealth in 85% of patients may be higher than the norm at most centers but that the study provides much-needed data.
“I’m really appreciative of a study like this because we were all in such a rush last year to get patients seen that very few people thought how could we design a study to really ensure we’re treating our patients within an equipoise with prior practices,” he said.
“The fact that they were able to do that [85%] and demonstrate in a propensity-matched analysis that outcomes were similar really just shows that telehealth is a strategy that we can use well in patients with heart failure to extend our ability to take care of them,” said Dr. Bhatia, a member of the American College of Cardiology Health Care Innovation Council.
Even beyond the pandemic, he said, the trend in health care is for patients to want health care delivered closer to home and for health care systems to become more patient centric. “This accelerated that but what I think this study showed me was that it’s okay to have this be part of my care model and I’m not sacrificing on my patient care if I choose to intersperse telehealth with inpatient visits.”
Besides the inherent limitations of retrospective studies, the authors noted that diagnoses in the study were based on ICD-10 codes and that subsequent ED visits or hospitalizations outside the single system may have been underreported. A further limitation is that they could not identify the cause of death or reasons for hospital encounters.
“Further data are needed to confirm the relative safety of a telehealth strategy in the HF population over a more sustained period of time, although we hypothesize that greater risks would be observed early after telehealth visits, where patients’ acuity might be misjudged,” they wrote.
Dr. Sperry is a consultant to Pfizer and Alnylam. Coauthor John A. Spertus is the principal investigator of grants from National Institutes of Health, Abbott Vascular, and the American College of Cardiology Foundation; is a consultant to Janssen, Novartis, Amgen, Myokardia, AstraZeneca, Bayer, and Merck; serves on the scientific advisory board of United Healthcare and the board of directors for Blue Cross Blue Shield of Kansas City; owns the copyright to the Kansas City Cardiomyopathy Questionnaire, Seattle Angina Questionnaire, and Peripheral Artery Questionnaire; and has an equity interest in Health Outcomes Sciences. All other authors and Dr. Bhatia reported no relevant conflicts.
A version of this article first appeared on Medscape.com.
The rapid transition to and reliance on telehealth to manage patients with heart failure during the COVID-19 pandemic does not appear to impact clinical outcomes, according to real-world data.
HF outpatients managed with telehealth visits did not show a significantly higher adjusted risk for subsequent ED visits, hospital admissions, intensive care use, or death at 30 and 90 days, the investigators reported in JACC: Heart Failure.
“Telehealth is safe and effective in probably some of our highest-risk patients who traditionally have needed hands-on, in-person assessment and evaluation – those patients who have heart failure – so we shouldn’t be afraid to use it all the time, not when needed as a minimum,” senior author Brett W. Sperry, MD, said in an interview.
Heart failure is a perfect case example to examine telehealth because the chronic condition not only requires continual assessment and medication adjustments, but HF patients are also particularly vulnerable to complications related to COVID-19 infection, he noted. A small, single-center report on telehealth early in Italy’s outbreak showed fewer HF hospitalizations and similar mortality, compared with in-person visits in 2019 but, overall, few data exist.
The current analysis took a wider sweep, comparing HF patients seen from March 15 to June 15, 2020 with those seen during the same time period in 2018 and 2019 at 16 cardiology clinics in Saint Luke’s Health System, which serves the Kansas City metro area and surrounding suburbs in Missouri and Kansas.
Among 8,263 unique patients and 15,421 visits identified, telehealth was not used in 2018 or 2019 but accounted for 88.5% of visits during the study period in 2020, 70% of which were by telephone and 30% of which were by video.
“We had zero telehealth before March 2020 and basically built an entire telehealth apparatus in a week or 2,” explained Dr. Sperry. “Initially it was a lot of telephone visits while we were getting the video stuff figured out, which is reflected in the paper, and then went to mostly video visits.”
Despite the pandemic, however, more outpatients were seen in 2020 than in 2018 and 2019 (4,063 vs. 3675 and 3,619 patients, respectively). This likely reflects the shift of personnel and resources from hospital duties to outpatient virtual visits, which were strongly recommended by the Heart Failure Society of America and other professional societies to manage patients during the pandemic, he said.
Unadjusted analyses demonstrated fewer ED visits and hospital admissions and more ICU admissions and all-cause mortality in 2020 than in previous years.
A propensity-matched analysis involving 4541 pairs of patients, however, showed admissions to the ED or hospital were lower after the telehealth visits than after in-person visits at 30 days (6.8% vs 10.4%; P < .001) and 90 days (17.9% vs. 23.3%; P < .001).
Among hospitalized patients, there was no difference between telehealth and in-patient visits in ICU admissions at 30 or 90 days. Mortality was also similar at 30 days (0.8% vs. 0.7%; P = .465) and 90 days (2.9% vs. 2.4%; P = .133).
Dr. Sperry said the pendulum has swung since 2020 and that the team is back to seeing most people in person, with about 15% of his clinic visits that day done via video. Standardized quality of life assessments prior to outpatient visits can help triage patients to telehealth in-patient visits, but in-person visits will still be needed for cases with greater acuity, older patients, and those with limited or no access to quality telephone videos or the internet.
“It isn’t for everyone,” Dr. Sperry said. “You’re going to need some kind of hybrid model with both in-person and video visits available and be able to offer both for patients and be able to titrate that as the pandemic changes in the future.”
Ankit Bhatia, MD, an advanced HF cardiologist at Christ Hospital in Cincinnati, who was not part of the study, said in an interview the use of telehealth in 85% of patients may be higher than the norm at most centers but that the study provides much-needed data.
“I’m really appreciative of a study like this because we were all in such a rush last year to get patients seen that very few people thought how could we design a study to really ensure we’re treating our patients within an equipoise with prior practices,” he said.
“The fact that they were able to do that [85%] and demonstrate in a propensity-matched analysis that outcomes were similar really just shows that telehealth is a strategy that we can use well in patients with heart failure to extend our ability to take care of them,” said Dr. Bhatia, a member of the American College of Cardiology Health Care Innovation Council.
Even beyond the pandemic, he said, the trend in health care is for patients to want health care delivered closer to home and for health care systems to become more patient centric. “This accelerated that but what I think this study showed me was that it’s okay to have this be part of my care model and I’m not sacrificing on my patient care if I choose to intersperse telehealth with inpatient visits.”
Besides the inherent limitations of retrospective studies, the authors noted that diagnoses in the study were based on ICD-10 codes and that subsequent ED visits or hospitalizations outside the single system may have been underreported. A further limitation is that they could not identify the cause of death or reasons for hospital encounters.
“Further data are needed to confirm the relative safety of a telehealth strategy in the HF population over a more sustained period of time, although we hypothesize that greater risks would be observed early after telehealth visits, where patients’ acuity might be misjudged,” they wrote.
Dr. Sperry is a consultant to Pfizer and Alnylam. Coauthor John A. Spertus is the principal investigator of grants from National Institutes of Health, Abbott Vascular, and the American College of Cardiology Foundation; is a consultant to Janssen, Novartis, Amgen, Myokardia, AstraZeneca, Bayer, and Merck; serves on the scientific advisory board of United Healthcare and the board of directors for Blue Cross Blue Shield of Kansas City; owns the copyright to the Kansas City Cardiomyopathy Questionnaire, Seattle Angina Questionnaire, and Peripheral Artery Questionnaire; and has an equity interest in Health Outcomes Sciences. All other authors and Dr. Bhatia reported no relevant conflicts.
A version of this article first appeared on Medscape.com.
An MD and a health care exec sued their employers for fraud: What happened?
James Taylor, MD, a former physician director of coding and medical director of revenue cycle at Kaiser’s Colorado Permanente Medical Group, just wanted Kaiser to do the right thing and stop submitting false claims to Medicare Advantage.
Dr. Taylor, who describes himself as tenacious to a fault, says he waited 7 years to file his lawsuit because he thought he could convince Kaiser to fix the coding problems on their end. He alternated between optimism and despair as Kaiser’s management supported some solutions only to shut them down later.
Finally, Dr. Taylor had had enough – the stress was getting to him, and his job was on the line.
As a last resort, he consulted a law firm that specializes in whistle-blower cases. Soon afterward, they filed a civil lawsuit in Colorado.
“My wife says that I have a justice gene – she can tell when it’s vibrating because I get amazed, not because people do wrong things, which they do all the time, but to that scale where it’s millions of dollars, and they’re being smug and acting like a bully. They thought they would never get caught and just kept going and even ramped it up in some situations,” says Dr. Taylor.
Several other whistle-blowers filed five lawsuits also alleging that Kaiser knew it was committing Medicare Advantage fraud amounting to tens of millions of dollars. The U.S. Department of Justice (DoJ) announced in July that it will join the six lawsuits and that it would file its complaint by late October.
Martin Mansukhani, a former regional CFO for Prime Health Care, was out of the country when the CEO signed a multimillion dollar contract with a cardiologist that went into effect immediately. At first, he tried to make the agreement work financially but then realized there were serious problems with the contract. He consulted a law firm, which confirmed that this was a kickback scheme in which the cardiologist was being overpaid in exchange for referring patients to Prime hospitals. The attorneys filed his whistle-blower lawsuit in 2017.
“My goal in filing the lawsuit was to get the company to stop these business practices,” says Mr. Mansukhani.
For being a whistle-blower, Mr. Mansukhani will receive nearly $10 million from the $37 settlement the DoJ negotiated. The False Claims Act entitles whistle-blowers to receive a higher reward (25% to 30%) when the DoJ doesn’t join a case than when it does (15% to 25%).
His lawsuit alleges that Prime Health Care, a hospital chain in California, its CEO, Prem Reddy, MD, and cardiologist Siva Arunasalam, MD, violated the federal Anti-Kickback Statute and the Stark Law, which generally make it illegal for anyone to offer or to provide something of value in exchange for a referral for a federal health care service. The suit also alleges that Prime had engaged in fraudulent billing practices.
The most challenging aspect was the decision to file the case. “It was a big-time commitment to pull together the evidence and to spend time interviewing law firms to determine who would best represent me, before I chose Phillips & Cohen,” says Mr. Mansukhani.
When management fails to listen
Dr. Taylor loved working at Kaiser Colorado and used to joke that he had job security as director of revenue cycle because doctors don’t like mixing business with medicine. He earned less money than when he was a family physician but “loved the lifestyle because it gave me time to spend with my wife and two young children.”
He was well thought of by the medical group – they elected him to serve on its board of directors for 4 years (2009-2013), during which time he served 2 years as chairman. They also sent him to Harvard’s executive leadership program.
As a certified risk adjustment coder and EPIC (the electronic medical records system that Kaiser used at that time) certified physician builder, Dr. Taylor had the expertise to recognize problems and fix them.
The audits that Kaiser and Dr. Taylor conducted showed high rates of errors for conditions related to cancer, stroke, and vascular disease.
“I hired a physician to review thousands of stroke codes and catch the false ones and created a filter in EPIC that weeded out incorrect codes before they were submitted,” Dr. Taylor says.
But these changes didn’t last because Kaiser managers would cancel or defund them, says Dr. Taylor. “That’s why I stayed for so many years. I would make one change and it would go very well and then they would shut it down. I would think, ‘This is great, they’re listening,’ but then it was gone. If all that had happened at once, I would have left immediately, but it was over time,” says Dr. Taylor.
He informed Kaiser Colorado’s upper management and its national organization about the problems, but he got nowhere.
Becoming a target
Dr. Taylor’s efforts to stop Kaiser from submitting false diagnosis codes didn’t sit well with the CFO.
Things came to a head in 2014 when Dr. Taylor discovered that a board meeting had been called to push him out of the company. “They said I failed a work improvement plan and that was why they needed to get me out.
“When they started saying that I was part of the problem after all the work I had done to keep their noses clean, I couldn’t tolerate it any longer. That’s when I filed the lawsuit,” says Dr. Taylor.
The stress from the “chaos and craziness” was also starting to affect his health, and he was worried that Kaiser would damage his reputation further.
He resigned in 2015. “I left 14 months before being fully vested in their retirement program.”
Employer retaliation?
Prime first sidelined and then fired Mr. Mansukhani (not for cause) in 2017 just before he filed his lawsuit. It offered him only 30 days of severance pay, which he didn’t accept. He didn’t think his firing was in retaliation for being a whistle-blower because his relationship with the chief operating officer had soured long before, in 2013, and the lawsuit was sealed.
At the time, he owned a nursing home in England that was doing well financially. He worried whether “Prime would try to retaliate against me in the U.K. I was a senior executive in a fairly high-profile position in the health care sector, and lots of informal networks exist,” says Mr. Mansukhani. But that never happened.
He found a new job right away. “At that stage of my life, I was 53 years old, and I wasn’t looking for another job. But College Healthcare in California offered me one as the CFO, which I accepted,” says Mr. Mansukhani.
Did it ruin his career?
Dr. Taylor also found a new job right away as chief medical officer of Colorado Access, where he trained practitioners on the Medicare Advantage model and documentation standards required by the Centers for Medicare & Medicaid Services (CMS). He is now an independent consultant with Principled Advantage.
Dr. Taylor’s lawsuit was filed under the False Claims Act, which requires that court documents be kept confidential (“sealed”) for at least 60 days while the DoJ investigates the case. Judges often extend that time frame.
In Dr. Taylor’s case, it took 7 years for the DoJ to unseal the documents. “The bad news is the wheels of justice turned really slowly. The good news was that I could seek employment and not have them worry about hiring a whistle-blower. As much as I didn’t like it, it was truly a blessing in disguise,” he says.
Dr. Taylor doesn’t know what the outcome of his case against Kaiser will be. When it was unsealed recently, he worried that local TV stations would show up at his doorstep and hound him or that Kaiser’s administrators would try to dig up dirt on him, which hasn’t happened.
He has no regrets about filing the lawsuit and feels vindicated because the managers/administrators who didn’t support him have been fired, including the CFO “who threw the biggest obstacles at me and defunded my work,” says Dr. Taylor.
The DoJ’s recent decision to join the consolidated whistle-blower case “was an indication that I was correct that Kaiser wasn’t doing what they should have been doing. You can’t have dishonest scales – if you’re purposely cheating the government to get promotions, more bonuses, that’s just wrong.”
Kaiser Permanente declined to comment on Dr. Taylor’s allegations and referred to its statement. “We are confident that Kaiser Permanente is compliant with Medicare Advantage program requirements, and we intend to strongly defend against the lawsuits alleging otherwise.”
“Our medical record documentation and risk adjustment diagnosis data submitted to the Centers for Medicare & Medicaid Services comply with applicable laws and Medicare Advantage program requirements. Our policies and practices represent well-reasoned and good-faith interpretations of sometimes vague and incomplete guidance from CMS,” according to the statement.
Did it make a difference?
When the government settles whistle-blower cases, the defendants usually admit no liability or wrongdoing, which some whistle-blowers find frustrating.
“I think the company was hurt by the lawsuit. It may make them think twice about doing this again,” says Mr. Mansukhani. However, he is cynical about whether the culture will change.
As part of its settlement, Prime agreed to amend its current corporate integrity agreement (CIA) from a previous 2018 settlement to include testing on physician compensation arrangements.
CIAs are standard monitoring agreements in the health care industry, and Prime asserts that it remains in full compliance, according to its statement.
Prime Health Care and Arunasalam did not respond to several interview requests. A statement from Prime in July says, “The settled matters related to an isolated, single physician practice in Southern California between 2015-2017 and billing of forty-five implantable device claims. The allegations did not involve patient care, but instead related to the valuation of a physician practice and the appropriate documentation for a limited number of implant claims totaling approximately $200,000. As soon as these matters were identified, Prime conducted an exhaustive internal review, fully cooperated with the DOJ, and negotiated a mutually acceptable resolution.”
A version of this article first appeared on Medscape.com.
James Taylor, MD, a former physician director of coding and medical director of revenue cycle at Kaiser’s Colorado Permanente Medical Group, just wanted Kaiser to do the right thing and stop submitting false claims to Medicare Advantage.
Dr. Taylor, who describes himself as tenacious to a fault, says he waited 7 years to file his lawsuit because he thought he could convince Kaiser to fix the coding problems on their end. He alternated between optimism and despair as Kaiser’s management supported some solutions only to shut them down later.
Finally, Dr. Taylor had had enough – the stress was getting to him, and his job was on the line.
As a last resort, he consulted a law firm that specializes in whistle-blower cases. Soon afterward, they filed a civil lawsuit in Colorado.
“My wife says that I have a justice gene – she can tell when it’s vibrating because I get amazed, not because people do wrong things, which they do all the time, but to that scale where it’s millions of dollars, and they’re being smug and acting like a bully. They thought they would never get caught and just kept going and even ramped it up in some situations,” says Dr. Taylor.
Several other whistle-blowers filed five lawsuits also alleging that Kaiser knew it was committing Medicare Advantage fraud amounting to tens of millions of dollars. The U.S. Department of Justice (DoJ) announced in July that it will join the six lawsuits and that it would file its complaint by late October.
Martin Mansukhani, a former regional CFO for Prime Health Care, was out of the country when the CEO signed a multimillion dollar contract with a cardiologist that went into effect immediately. At first, he tried to make the agreement work financially but then realized there were serious problems with the contract. He consulted a law firm, which confirmed that this was a kickback scheme in which the cardiologist was being overpaid in exchange for referring patients to Prime hospitals. The attorneys filed his whistle-blower lawsuit in 2017.
“My goal in filing the lawsuit was to get the company to stop these business practices,” says Mr. Mansukhani.
For being a whistle-blower, Mr. Mansukhani will receive nearly $10 million from the $37 settlement the DoJ negotiated. The False Claims Act entitles whistle-blowers to receive a higher reward (25% to 30%) when the DoJ doesn’t join a case than when it does (15% to 25%).
His lawsuit alleges that Prime Health Care, a hospital chain in California, its CEO, Prem Reddy, MD, and cardiologist Siva Arunasalam, MD, violated the federal Anti-Kickback Statute and the Stark Law, which generally make it illegal for anyone to offer or to provide something of value in exchange for a referral for a federal health care service. The suit also alleges that Prime had engaged in fraudulent billing practices.
The most challenging aspect was the decision to file the case. “It was a big-time commitment to pull together the evidence and to spend time interviewing law firms to determine who would best represent me, before I chose Phillips & Cohen,” says Mr. Mansukhani.
When management fails to listen
Dr. Taylor loved working at Kaiser Colorado and used to joke that he had job security as director of revenue cycle because doctors don’t like mixing business with medicine. He earned less money than when he was a family physician but “loved the lifestyle because it gave me time to spend with my wife and two young children.”
He was well thought of by the medical group – they elected him to serve on its board of directors for 4 years (2009-2013), during which time he served 2 years as chairman. They also sent him to Harvard’s executive leadership program.
As a certified risk adjustment coder and EPIC (the electronic medical records system that Kaiser used at that time) certified physician builder, Dr. Taylor had the expertise to recognize problems and fix them.
The audits that Kaiser and Dr. Taylor conducted showed high rates of errors for conditions related to cancer, stroke, and vascular disease.
“I hired a physician to review thousands of stroke codes and catch the false ones and created a filter in EPIC that weeded out incorrect codes before they were submitted,” Dr. Taylor says.
But these changes didn’t last because Kaiser managers would cancel or defund them, says Dr. Taylor. “That’s why I stayed for so many years. I would make one change and it would go very well and then they would shut it down. I would think, ‘This is great, they’re listening,’ but then it was gone. If all that had happened at once, I would have left immediately, but it was over time,” says Dr. Taylor.
He informed Kaiser Colorado’s upper management and its national organization about the problems, but he got nowhere.
Becoming a target
Dr. Taylor’s efforts to stop Kaiser from submitting false diagnosis codes didn’t sit well with the CFO.
Things came to a head in 2014 when Dr. Taylor discovered that a board meeting had been called to push him out of the company. “They said I failed a work improvement plan and that was why they needed to get me out.
“When they started saying that I was part of the problem after all the work I had done to keep their noses clean, I couldn’t tolerate it any longer. That’s when I filed the lawsuit,” says Dr. Taylor.
The stress from the “chaos and craziness” was also starting to affect his health, and he was worried that Kaiser would damage his reputation further.
He resigned in 2015. “I left 14 months before being fully vested in their retirement program.”
Employer retaliation?
Prime first sidelined and then fired Mr. Mansukhani (not for cause) in 2017 just before he filed his lawsuit. It offered him only 30 days of severance pay, which he didn’t accept. He didn’t think his firing was in retaliation for being a whistle-blower because his relationship with the chief operating officer had soured long before, in 2013, and the lawsuit was sealed.
At the time, he owned a nursing home in England that was doing well financially. He worried whether “Prime would try to retaliate against me in the U.K. I was a senior executive in a fairly high-profile position in the health care sector, and lots of informal networks exist,” says Mr. Mansukhani. But that never happened.
He found a new job right away. “At that stage of my life, I was 53 years old, and I wasn’t looking for another job. But College Healthcare in California offered me one as the CFO, which I accepted,” says Mr. Mansukhani.
Did it ruin his career?
Dr. Taylor also found a new job right away as chief medical officer of Colorado Access, where he trained practitioners on the Medicare Advantage model and documentation standards required by the Centers for Medicare & Medicaid Services (CMS). He is now an independent consultant with Principled Advantage.
Dr. Taylor’s lawsuit was filed under the False Claims Act, which requires that court documents be kept confidential (“sealed”) for at least 60 days while the DoJ investigates the case. Judges often extend that time frame.
In Dr. Taylor’s case, it took 7 years for the DoJ to unseal the documents. “The bad news is the wheels of justice turned really slowly. The good news was that I could seek employment and not have them worry about hiring a whistle-blower. As much as I didn’t like it, it was truly a blessing in disguise,” he says.
Dr. Taylor doesn’t know what the outcome of his case against Kaiser will be. When it was unsealed recently, he worried that local TV stations would show up at his doorstep and hound him or that Kaiser’s administrators would try to dig up dirt on him, which hasn’t happened.
He has no regrets about filing the lawsuit and feels vindicated because the managers/administrators who didn’t support him have been fired, including the CFO “who threw the biggest obstacles at me and defunded my work,” says Dr. Taylor.
The DoJ’s recent decision to join the consolidated whistle-blower case “was an indication that I was correct that Kaiser wasn’t doing what they should have been doing. You can’t have dishonest scales – if you’re purposely cheating the government to get promotions, more bonuses, that’s just wrong.”
Kaiser Permanente declined to comment on Dr. Taylor’s allegations and referred to its statement. “We are confident that Kaiser Permanente is compliant with Medicare Advantage program requirements, and we intend to strongly defend against the lawsuits alleging otherwise.”
“Our medical record documentation and risk adjustment diagnosis data submitted to the Centers for Medicare & Medicaid Services comply with applicable laws and Medicare Advantage program requirements. Our policies and practices represent well-reasoned and good-faith interpretations of sometimes vague and incomplete guidance from CMS,” according to the statement.
Did it make a difference?
When the government settles whistle-blower cases, the defendants usually admit no liability or wrongdoing, which some whistle-blowers find frustrating.
“I think the company was hurt by the lawsuit. It may make them think twice about doing this again,” says Mr. Mansukhani. However, he is cynical about whether the culture will change.
As part of its settlement, Prime agreed to amend its current corporate integrity agreement (CIA) from a previous 2018 settlement to include testing on physician compensation arrangements.
CIAs are standard monitoring agreements in the health care industry, and Prime asserts that it remains in full compliance, according to its statement.
Prime Health Care and Arunasalam did not respond to several interview requests. A statement from Prime in July says, “The settled matters related to an isolated, single physician practice in Southern California between 2015-2017 and billing of forty-five implantable device claims. The allegations did not involve patient care, but instead related to the valuation of a physician practice and the appropriate documentation for a limited number of implant claims totaling approximately $200,000. As soon as these matters were identified, Prime conducted an exhaustive internal review, fully cooperated with the DOJ, and negotiated a mutually acceptable resolution.”
A version of this article first appeared on Medscape.com.
James Taylor, MD, a former physician director of coding and medical director of revenue cycle at Kaiser’s Colorado Permanente Medical Group, just wanted Kaiser to do the right thing and stop submitting false claims to Medicare Advantage.
Dr. Taylor, who describes himself as tenacious to a fault, says he waited 7 years to file his lawsuit because he thought he could convince Kaiser to fix the coding problems on their end. He alternated between optimism and despair as Kaiser’s management supported some solutions only to shut them down later.
Finally, Dr. Taylor had had enough – the stress was getting to him, and his job was on the line.
As a last resort, he consulted a law firm that specializes in whistle-blower cases. Soon afterward, they filed a civil lawsuit in Colorado.
“My wife says that I have a justice gene – she can tell when it’s vibrating because I get amazed, not because people do wrong things, which they do all the time, but to that scale where it’s millions of dollars, and they’re being smug and acting like a bully. They thought they would never get caught and just kept going and even ramped it up in some situations,” says Dr. Taylor.
Several other whistle-blowers filed five lawsuits also alleging that Kaiser knew it was committing Medicare Advantage fraud amounting to tens of millions of dollars. The U.S. Department of Justice (DoJ) announced in July that it will join the six lawsuits and that it would file its complaint by late October.
Martin Mansukhani, a former regional CFO for Prime Health Care, was out of the country when the CEO signed a multimillion dollar contract with a cardiologist that went into effect immediately. At first, he tried to make the agreement work financially but then realized there were serious problems with the contract. He consulted a law firm, which confirmed that this was a kickback scheme in which the cardiologist was being overpaid in exchange for referring patients to Prime hospitals. The attorneys filed his whistle-blower lawsuit in 2017.
“My goal in filing the lawsuit was to get the company to stop these business practices,” says Mr. Mansukhani.
For being a whistle-blower, Mr. Mansukhani will receive nearly $10 million from the $37 settlement the DoJ negotiated. The False Claims Act entitles whistle-blowers to receive a higher reward (25% to 30%) when the DoJ doesn’t join a case than when it does (15% to 25%).
His lawsuit alleges that Prime Health Care, a hospital chain in California, its CEO, Prem Reddy, MD, and cardiologist Siva Arunasalam, MD, violated the federal Anti-Kickback Statute and the Stark Law, which generally make it illegal for anyone to offer or to provide something of value in exchange for a referral for a federal health care service. The suit also alleges that Prime had engaged in fraudulent billing practices.
The most challenging aspect was the decision to file the case. “It was a big-time commitment to pull together the evidence and to spend time interviewing law firms to determine who would best represent me, before I chose Phillips & Cohen,” says Mr. Mansukhani.
When management fails to listen
Dr. Taylor loved working at Kaiser Colorado and used to joke that he had job security as director of revenue cycle because doctors don’t like mixing business with medicine. He earned less money than when he was a family physician but “loved the lifestyle because it gave me time to spend with my wife and two young children.”
He was well thought of by the medical group – they elected him to serve on its board of directors for 4 years (2009-2013), during which time he served 2 years as chairman. They also sent him to Harvard’s executive leadership program.
As a certified risk adjustment coder and EPIC (the electronic medical records system that Kaiser used at that time) certified physician builder, Dr. Taylor had the expertise to recognize problems and fix them.
The audits that Kaiser and Dr. Taylor conducted showed high rates of errors for conditions related to cancer, stroke, and vascular disease.
“I hired a physician to review thousands of stroke codes and catch the false ones and created a filter in EPIC that weeded out incorrect codes before they were submitted,” Dr. Taylor says.
But these changes didn’t last because Kaiser managers would cancel or defund them, says Dr. Taylor. “That’s why I stayed for so many years. I would make one change and it would go very well and then they would shut it down. I would think, ‘This is great, they’re listening,’ but then it was gone. If all that had happened at once, I would have left immediately, but it was over time,” says Dr. Taylor.
He informed Kaiser Colorado’s upper management and its national organization about the problems, but he got nowhere.
Becoming a target
Dr. Taylor’s efforts to stop Kaiser from submitting false diagnosis codes didn’t sit well with the CFO.
Things came to a head in 2014 when Dr. Taylor discovered that a board meeting had been called to push him out of the company. “They said I failed a work improvement plan and that was why they needed to get me out.
“When they started saying that I was part of the problem after all the work I had done to keep their noses clean, I couldn’t tolerate it any longer. That’s when I filed the lawsuit,” says Dr. Taylor.
The stress from the “chaos and craziness” was also starting to affect his health, and he was worried that Kaiser would damage his reputation further.
He resigned in 2015. “I left 14 months before being fully vested in their retirement program.”
Employer retaliation?
Prime first sidelined and then fired Mr. Mansukhani (not for cause) in 2017 just before he filed his lawsuit. It offered him only 30 days of severance pay, which he didn’t accept. He didn’t think his firing was in retaliation for being a whistle-blower because his relationship with the chief operating officer had soured long before, in 2013, and the lawsuit was sealed.
At the time, he owned a nursing home in England that was doing well financially. He worried whether “Prime would try to retaliate against me in the U.K. I was a senior executive in a fairly high-profile position in the health care sector, and lots of informal networks exist,” says Mr. Mansukhani. But that never happened.
He found a new job right away. “At that stage of my life, I was 53 years old, and I wasn’t looking for another job. But College Healthcare in California offered me one as the CFO, which I accepted,” says Mr. Mansukhani.
Did it ruin his career?
Dr. Taylor also found a new job right away as chief medical officer of Colorado Access, where he trained practitioners on the Medicare Advantage model and documentation standards required by the Centers for Medicare & Medicaid Services (CMS). He is now an independent consultant with Principled Advantage.
Dr. Taylor’s lawsuit was filed under the False Claims Act, which requires that court documents be kept confidential (“sealed”) for at least 60 days while the DoJ investigates the case. Judges often extend that time frame.
In Dr. Taylor’s case, it took 7 years for the DoJ to unseal the documents. “The bad news is the wheels of justice turned really slowly. The good news was that I could seek employment and not have them worry about hiring a whistle-blower. As much as I didn’t like it, it was truly a blessing in disguise,” he says.
Dr. Taylor doesn’t know what the outcome of his case against Kaiser will be. When it was unsealed recently, he worried that local TV stations would show up at his doorstep and hound him or that Kaiser’s administrators would try to dig up dirt on him, which hasn’t happened.
He has no regrets about filing the lawsuit and feels vindicated because the managers/administrators who didn’t support him have been fired, including the CFO “who threw the biggest obstacles at me and defunded my work,” says Dr. Taylor.
The DoJ’s recent decision to join the consolidated whistle-blower case “was an indication that I was correct that Kaiser wasn’t doing what they should have been doing. You can’t have dishonest scales – if you’re purposely cheating the government to get promotions, more bonuses, that’s just wrong.”
Kaiser Permanente declined to comment on Dr. Taylor’s allegations and referred to its statement. “We are confident that Kaiser Permanente is compliant with Medicare Advantage program requirements, and we intend to strongly defend against the lawsuits alleging otherwise.”
“Our medical record documentation and risk adjustment diagnosis data submitted to the Centers for Medicare & Medicaid Services comply with applicable laws and Medicare Advantage program requirements. Our policies and practices represent well-reasoned and good-faith interpretations of sometimes vague and incomplete guidance from CMS,” according to the statement.
Did it make a difference?
When the government settles whistle-blower cases, the defendants usually admit no liability or wrongdoing, which some whistle-blowers find frustrating.
“I think the company was hurt by the lawsuit. It may make them think twice about doing this again,” says Mr. Mansukhani. However, he is cynical about whether the culture will change.
As part of its settlement, Prime agreed to amend its current corporate integrity agreement (CIA) from a previous 2018 settlement to include testing on physician compensation arrangements.
CIAs are standard monitoring agreements in the health care industry, and Prime asserts that it remains in full compliance, according to its statement.
Prime Health Care and Arunasalam did not respond to several interview requests. A statement from Prime in July says, “The settled matters related to an isolated, single physician practice in Southern California between 2015-2017 and billing of forty-five implantable device claims. The allegations did not involve patient care, but instead related to the valuation of a physician practice and the appropriate documentation for a limited number of implant claims totaling approximately $200,000. As soon as these matters were identified, Prime conducted an exhaustive internal review, fully cooperated with the DOJ, and negotiated a mutually acceptable resolution.”
A version of this article first appeared on Medscape.com.
Major insurers running billions of dollars behind on payments to hospitals and doctors
Anthem Blue Cross, the country’s second-biggest health insurance company, is behind on billions of dollars in payments owed to hospitals and doctors because of onerous new reimbursement rules, computer problems and mishandled claims, say hospital officials in multiple states.
Anthem, like other big insurers, is using the COVID-19 crisis as cover to institute “egregious” policies that harm patients and pinch hospital finances, said Molly Smith, group vice president at the American Hospital Association. “There’s this sense of ‘Everyone’s distracted. We can get this through.’ ”
Hospitals are also dealing with a spike in retroactive claims denials by UnitedHealthcare, the biggest health insurer, for ED care, the AHA said.
Hospitals say it is hurting their finances as many cope with COVID surges – even after the industry has received tens of billions of dollars in emergency assistance from the federal government.
“We recognize there have been some challenges” to prompt payments caused by claims-processing changes and “a new set of dynamics” amid the pandemic, Anthem spokesperson Colin Manning said in an email. “We apologize for any delays or inconvenience this may have caused.”
Virginia law requires insurers to pay claims within 40 days. In a Sept. 24 letter to state insurance regulators, VCU Health, a system that operates a large teaching hospital in Richmond associated with Virginia Commonwealth University, said Anthem owes it $385 million. More than 40% of the claims are more than 90 days old, VCU said.
For all Virginia hospitals, Anthem’s late, unpaid claims amount to “hundreds of millions of dollars,” the Virginia Hospital and Healthcare Association said in a June 23 letter to state regulators.
Nationwide, the payment delays “are creating an untenable situation,” the American Hospital Association said in a Sept. 9 letter to Anthem CEO Gail Boudreaux. “Patients are facing greater hurdles to accessing care; clinicians are burning out on unnecessary administrative tasks; and the system is straining to finance the personnel and supplies” needed to fight Covid.
Complaints about Anthem extend “from sea to shining sea, from New Hampshire to California,” AHA CEO Rick Pollack told KHN.
Substantial payment delays can be seen on Anthem’s books. On June 30, 2019, before the pandemic, 43% of the insurer’s medical bills for that quarter were unpaid, according to regulatory filings. Two years later that figure had risen to 53% – a difference of $2.5 billion.
Anthem profits were $4.6 billion in 2020 and $3.5 billion in the first half of 2021.
Alexis Thurber, who lives near Seattle, was insured by Anthem when she got an $18,192 hospital bill in May for radiation therapy that doctors said was essential to treat her breast cancer.
The treatments were “experimental” and “not medically necessary,” Anthem said, according to Ms. Thurber. She spent much of the summer trying to get the insurer to pay up – placing two dozen phone calls, spending hours on hold, sending multiple emails and enduring unmeasurable stress and worry. It finally covered the claim months later.
“It’s so egregious. It’s a game they’re playing,” said Ms. Thurber, 51, whose cancer was diagnosed in November. “Trying to get true help was impossible.”
Privacy rules prevent Anthem from commenting on Ms. Thurber’s case, said Anthem spokesperson Colin Manning.
When insurers fail to promptly pay medical bills, patients are left in the lurch. They might first get a notice saying payment is pending or denied. A hospital might bill them for treatment they thought would be covered. Hospitals and doctors often sue patients whose insurance didn’t pay up.
Hospitals point to a variety of Anthem practices contributing to payment delays or denials, including new layers of document requirements, prior-authorization hurdles for routine procedures and requirements that doctors themselves – not support staffers – speak to insurance gatekeepers. “This requires providers to literally leave the patient[’s] bedside to get on the phone with Anthem,” AHA said in its letter.
Anthem often hinders coverage for outpatient surgery, specialty pharmacy and other services in health systems listed as in network, amounting to a “bait and switch” on Anthem members, AHA officials said.
“Demanding that patients be treated outside of the hospital setting, against the advice of the patient’s in-network treating physician, appears to be motivated by a desire to drive up Empire’s profits,” the Greater New York Hospital Association wrote in an April letter to Empire Blue Cross, which is owned by Anthem.
Anthem officials pushed back in a recent letter to the AHA, saying the insurer’s changing rules are intended partly to control excessive prices charged by hospitals for specialty drugs and nonemergency surgery, screening and diagnostic procedures.
Severe problems with Anthem’s new claims management system surfaced months ago and “persist without meaningful improvement,” AHA said in its letter.
Claims have gotten lost in Anthem’s computers, and in some cases VCU Health has had to print medical records and mail them to get paid, VCU said in its letter. The cash slowdown imposes “an unmanageable disruption that threatens to undermine our financial footing,” VCU said.
United denied $31,557 in claims for Emily Long’s care after she was struck in June by a motorcycle in New York City. She needed surgery to repair a fractured cheekbone. United said there was a lack of documentation for “medical necessity” – an “incredibly aggravating” response on top of the distress of the accident, Ms. Long said.
The Brooklyn hospital that treated Ms. Long was “paid appropriately under her plan and within the required time frame,” said United spokesperson Maria Gordon Shydlo. “The facility has the right to appeal the decision.”
United’s unpaid claims came to 54% as of June 30, about the same level as 2 years previously.
When Erin Conlisk initially had trouble gaining approval for a piece of medical equipment for her elderly father this summer, United employees told her the insurer’s entire prior-authorization database had gone down for weeks, said Ms. Conlisk, who lives in California.
“There was a brief issue with our prior-authorization process in mid-July, which was resolved quickly,” Gordon Shydlo said.
When asked by Wall Street analysts about the payment backups, Anthem executives said it partly reflects their decision to increase financial reserves amid the health crisis.
“Really a ton of uncertainty associated with this environment,” John Gallina, the company’s chief financial officer, said on a conference call in July. “We’ve tried to be extremely prudent and conservative in our approach.”
During the pandemic, hospitals have benefited from two extraordinary cash infusions. They and other medical providers have received more than $100 billion through the CARES Act of 2020 and the American Rescue Plan of 2021. Last year United, Anthem and other insurers accelerated billions in hospital reimbursements.
The federal payments enriched many of the biggest, wealthiest systems while poorer hospitals serving low-income patients and rural areas struggled.
Those are the systems most hurt now by insurer payment delays, hospital officials said. Federal relief funds “have been a lifeline, but they don’t make people whole in terms of the losses from increased expenses and lost revenue as a result of the COVID experience,” Mr. Pollack said.
Several health systems declined to comment about claims payment delays or didn’t respond to a reporter’s queries. Among individual hospitals “there is a deep fear of talking on the record about your largest business partner,” AHA’s Ms. Smith said.
Alexis Thurber worried she might have to pay her $18,192 radiation bill herself, and she’s not confident her Anthem policy will do a better job next time of covering the cost of her care.
“It makes me not want to go to the doctor anymore,” she said. “I’m scared to get another mammogram because you can’t rely on it.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
Anthem Blue Cross, the country’s second-biggest health insurance company, is behind on billions of dollars in payments owed to hospitals and doctors because of onerous new reimbursement rules, computer problems and mishandled claims, say hospital officials in multiple states.
Anthem, like other big insurers, is using the COVID-19 crisis as cover to institute “egregious” policies that harm patients and pinch hospital finances, said Molly Smith, group vice president at the American Hospital Association. “There’s this sense of ‘Everyone’s distracted. We can get this through.’ ”
Hospitals are also dealing with a spike in retroactive claims denials by UnitedHealthcare, the biggest health insurer, for ED care, the AHA said.
Hospitals say it is hurting their finances as many cope with COVID surges – even after the industry has received tens of billions of dollars in emergency assistance from the federal government.
“We recognize there have been some challenges” to prompt payments caused by claims-processing changes and “a new set of dynamics” amid the pandemic, Anthem spokesperson Colin Manning said in an email. “We apologize for any delays or inconvenience this may have caused.”
Virginia law requires insurers to pay claims within 40 days. In a Sept. 24 letter to state insurance regulators, VCU Health, a system that operates a large teaching hospital in Richmond associated with Virginia Commonwealth University, said Anthem owes it $385 million. More than 40% of the claims are more than 90 days old, VCU said.
For all Virginia hospitals, Anthem’s late, unpaid claims amount to “hundreds of millions of dollars,” the Virginia Hospital and Healthcare Association said in a June 23 letter to state regulators.
Nationwide, the payment delays “are creating an untenable situation,” the American Hospital Association said in a Sept. 9 letter to Anthem CEO Gail Boudreaux. “Patients are facing greater hurdles to accessing care; clinicians are burning out on unnecessary administrative tasks; and the system is straining to finance the personnel and supplies” needed to fight Covid.
Complaints about Anthem extend “from sea to shining sea, from New Hampshire to California,” AHA CEO Rick Pollack told KHN.
Substantial payment delays can be seen on Anthem’s books. On June 30, 2019, before the pandemic, 43% of the insurer’s medical bills for that quarter were unpaid, according to regulatory filings. Two years later that figure had risen to 53% – a difference of $2.5 billion.
Anthem profits were $4.6 billion in 2020 and $3.5 billion in the first half of 2021.
Alexis Thurber, who lives near Seattle, was insured by Anthem when she got an $18,192 hospital bill in May for radiation therapy that doctors said was essential to treat her breast cancer.
The treatments were “experimental” and “not medically necessary,” Anthem said, according to Ms. Thurber. She spent much of the summer trying to get the insurer to pay up – placing two dozen phone calls, spending hours on hold, sending multiple emails and enduring unmeasurable stress and worry. It finally covered the claim months later.
“It’s so egregious. It’s a game they’re playing,” said Ms. Thurber, 51, whose cancer was diagnosed in November. “Trying to get true help was impossible.”
Privacy rules prevent Anthem from commenting on Ms. Thurber’s case, said Anthem spokesperson Colin Manning.
When insurers fail to promptly pay medical bills, patients are left in the lurch. They might first get a notice saying payment is pending or denied. A hospital might bill them for treatment they thought would be covered. Hospitals and doctors often sue patients whose insurance didn’t pay up.
Hospitals point to a variety of Anthem practices contributing to payment delays or denials, including new layers of document requirements, prior-authorization hurdles for routine procedures and requirements that doctors themselves – not support staffers – speak to insurance gatekeepers. “This requires providers to literally leave the patient[’s] bedside to get on the phone with Anthem,” AHA said in its letter.
Anthem often hinders coverage for outpatient surgery, specialty pharmacy and other services in health systems listed as in network, amounting to a “bait and switch” on Anthem members, AHA officials said.
“Demanding that patients be treated outside of the hospital setting, against the advice of the patient’s in-network treating physician, appears to be motivated by a desire to drive up Empire’s profits,” the Greater New York Hospital Association wrote in an April letter to Empire Blue Cross, which is owned by Anthem.
Anthem officials pushed back in a recent letter to the AHA, saying the insurer’s changing rules are intended partly to control excessive prices charged by hospitals for specialty drugs and nonemergency surgery, screening and diagnostic procedures.
Severe problems with Anthem’s new claims management system surfaced months ago and “persist without meaningful improvement,” AHA said in its letter.
Claims have gotten lost in Anthem’s computers, and in some cases VCU Health has had to print medical records and mail them to get paid, VCU said in its letter. The cash slowdown imposes “an unmanageable disruption that threatens to undermine our financial footing,” VCU said.
United denied $31,557 in claims for Emily Long’s care after she was struck in June by a motorcycle in New York City. She needed surgery to repair a fractured cheekbone. United said there was a lack of documentation for “medical necessity” – an “incredibly aggravating” response on top of the distress of the accident, Ms. Long said.
The Brooklyn hospital that treated Ms. Long was “paid appropriately under her plan and within the required time frame,” said United spokesperson Maria Gordon Shydlo. “The facility has the right to appeal the decision.”
United’s unpaid claims came to 54% as of June 30, about the same level as 2 years previously.
When Erin Conlisk initially had trouble gaining approval for a piece of medical equipment for her elderly father this summer, United employees told her the insurer’s entire prior-authorization database had gone down for weeks, said Ms. Conlisk, who lives in California.
“There was a brief issue with our prior-authorization process in mid-July, which was resolved quickly,” Gordon Shydlo said.
When asked by Wall Street analysts about the payment backups, Anthem executives said it partly reflects their decision to increase financial reserves amid the health crisis.
“Really a ton of uncertainty associated with this environment,” John Gallina, the company’s chief financial officer, said on a conference call in July. “We’ve tried to be extremely prudent and conservative in our approach.”
During the pandemic, hospitals have benefited from two extraordinary cash infusions. They and other medical providers have received more than $100 billion through the CARES Act of 2020 and the American Rescue Plan of 2021. Last year United, Anthem and other insurers accelerated billions in hospital reimbursements.
The federal payments enriched many of the biggest, wealthiest systems while poorer hospitals serving low-income patients and rural areas struggled.
Those are the systems most hurt now by insurer payment delays, hospital officials said. Federal relief funds “have been a lifeline, but they don’t make people whole in terms of the losses from increased expenses and lost revenue as a result of the COVID experience,” Mr. Pollack said.
Several health systems declined to comment about claims payment delays or didn’t respond to a reporter’s queries. Among individual hospitals “there is a deep fear of talking on the record about your largest business partner,” AHA’s Ms. Smith said.
Alexis Thurber worried she might have to pay her $18,192 radiation bill herself, and she’s not confident her Anthem policy will do a better job next time of covering the cost of her care.
“It makes me not want to go to the doctor anymore,” she said. “I’m scared to get another mammogram because you can’t rely on it.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
Anthem Blue Cross, the country’s second-biggest health insurance company, is behind on billions of dollars in payments owed to hospitals and doctors because of onerous new reimbursement rules, computer problems and mishandled claims, say hospital officials in multiple states.
Anthem, like other big insurers, is using the COVID-19 crisis as cover to institute “egregious” policies that harm patients and pinch hospital finances, said Molly Smith, group vice president at the American Hospital Association. “There’s this sense of ‘Everyone’s distracted. We can get this through.’ ”
Hospitals are also dealing with a spike in retroactive claims denials by UnitedHealthcare, the biggest health insurer, for ED care, the AHA said.
Hospitals say it is hurting their finances as many cope with COVID surges – even after the industry has received tens of billions of dollars in emergency assistance from the federal government.
“We recognize there have been some challenges” to prompt payments caused by claims-processing changes and “a new set of dynamics” amid the pandemic, Anthem spokesperson Colin Manning said in an email. “We apologize for any delays or inconvenience this may have caused.”
Virginia law requires insurers to pay claims within 40 days. In a Sept. 24 letter to state insurance regulators, VCU Health, a system that operates a large teaching hospital in Richmond associated with Virginia Commonwealth University, said Anthem owes it $385 million. More than 40% of the claims are more than 90 days old, VCU said.
For all Virginia hospitals, Anthem’s late, unpaid claims amount to “hundreds of millions of dollars,” the Virginia Hospital and Healthcare Association said in a June 23 letter to state regulators.
Nationwide, the payment delays “are creating an untenable situation,” the American Hospital Association said in a Sept. 9 letter to Anthem CEO Gail Boudreaux. “Patients are facing greater hurdles to accessing care; clinicians are burning out on unnecessary administrative tasks; and the system is straining to finance the personnel and supplies” needed to fight Covid.
Complaints about Anthem extend “from sea to shining sea, from New Hampshire to California,” AHA CEO Rick Pollack told KHN.
Substantial payment delays can be seen on Anthem’s books. On June 30, 2019, before the pandemic, 43% of the insurer’s medical bills for that quarter were unpaid, according to regulatory filings. Two years later that figure had risen to 53% – a difference of $2.5 billion.
Anthem profits were $4.6 billion in 2020 and $3.5 billion in the first half of 2021.
Alexis Thurber, who lives near Seattle, was insured by Anthem when she got an $18,192 hospital bill in May for radiation therapy that doctors said was essential to treat her breast cancer.
The treatments were “experimental” and “not medically necessary,” Anthem said, according to Ms. Thurber. She spent much of the summer trying to get the insurer to pay up – placing two dozen phone calls, spending hours on hold, sending multiple emails and enduring unmeasurable stress and worry. It finally covered the claim months later.
“It’s so egregious. It’s a game they’re playing,” said Ms. Thurber, 51, whose cancer was diagnosed in November. “Trying to get true help was impossible.”
Privacy rules prevent Anthem from commenting on Ms. Thurber’s case, said Anthem spokesperson Colin Manning.
When insurers fail to promptly pay medical bills, patients are left in the lurch. They might first get a notice saying payment is pending or denied. A hospital might bill them for treatment they thought would be covered. Hospitals and doctors often sue patients whose insurance didn’t pay up.
Hospitals point to a variety of Anthem practices contributing to payment delays or denials, including new layers of document requirements, prior-authorization hurdles for routine procedures and requirements that doctors themselves – not support staffers – speak to insurance gatekeepers. “This requires providers to literally leave the patient[’s] bedside to get on the phone with Anthem,” AHA said in its letter.
Anthem often hinders coverage for outpatient surgery, specialty pharmacy and other services in health systems listed as in network, amounting to a “bait and switch” on Anthem members, AHA officials said.
“Demanding that patients be treated outside of the hospital setting, against the advice of the patient’s in-network treating physician, appears to be motivated by a desire to drive up Empire’s profits,” the Greater New York Hospital Association wrote in an April letter to Empire Blue Cross, which is owned by Anthem.
Anthem officials pushed back in a recent letter to the AHA, saying the insurer’s changing rules are intended partly to control excessive prices charged by hospitals for specialty drugs and nonemergency surgery, screening and diagnostic procedures.
Severe problems with Anthem’s new claims management system surfaced months ago and “persist without meaningful improvement,” AHA said in its letter.
Claims have gotten lost in Anthem’s computers, and in some cases VCU Health has had to print medical records and mail them to get paid, VCU said in its letter. The cash slowdown imposes “an unmanageable disruption that threatens to undermine our financial footing,” VCU said.
United denied $31,557 in claims for Emily Long’s care after she was struck in June by a motorcycle in New York City. She needed surgery to repair a fractured cheekbone. United said there was a lack of documentation for “medical necessity” – an “incredibly aggravating” response on top of the distress of the accident, Ms. Long said.
The Brooklyn hospital that treated Ms. Long was “paid appropriately under her plan and within the required time frame,” said United spokesperson Maria Gordon Shydlo. “The facility has the right to appeal the decision.”
United’s unpaid claims came to 54% as of June 30, about the same level as 2 years previously.
When Erin Conlisk initially had trouble gaining approval for a piece of medical equipment for her elderly father this summer, United employees told her the insurer’s entire prior-authorization database had gone down for weeks, said Ms. Conlisk, who lives in California.
“There was a brief issue with our prior-authorization process in mid-July, which was resolved quickly,” Gordon Shydlo said.
When asked by Wall Street analysts about the payment backups, Anthem executives said it partly reflects their decision to increase financial reserves amid the health crisis.
“Really a ton of uncertainty associated with this environment,” John Gallina, the company’s chief financial officer, said on a conference call in July. “We’ve tried to be extremely prudent and conservative in our approach.”
During the pandemic, hospitals have benefited from two extraordinary cash infusions. They and other medical providers have received more than $100 billion through the CARES Act of 2020 and the American Rescue Plan of 2021. Last year United, Anthem and other insurers accelerated billions in hospital reimbursements.
The federal payments enriched many of the biggest, wealthiest systems while poorer hospitals serving low-income patients and rural areas struggled.
Those are the systems most hurt now by insurer payment delays, hospital officials said. Federal relief funds “have been a lifeline, but they don’t make people whole in terms of the losses from increased expenses and lost revenue as a result of the COVID experience,” Mr. Pollack said.
Several health systems declined to comment about claims payment delays or didn’t respond to a reporter’s queries. Among individual hospitals “there is a deep fear of talking on the record about your largest business partner,” AHA’s Ms. Smith said.
Alexis Thurber worried she might have to pay her $18,192 radiation bill herself, and she’s not confident her Anthem policy will do a better job next time of covering the cost of her care.
“It makes me not want to go to the doctor anymore,” she said. “I’m scared to get another mammogram because you can’t rely on it.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.