Maine Voices: University abandons students’ health care needs
by Isabel Ruffin - Maine Press Herald - January 17, 2022
Financially strapped students can no longer get coverage through the university system, leaving many in the lurch.
There is already substantial blood on the hands of America’s broken healthcare system. Barring any large societal change, the livelihood of the American people will soon be in grave jeopardy. A jeopardy, I fear, is teetering on the brink of crisis as we enter the third year of the COVID-19 pandemic.
I am just an average 25-year-old graduate student working two jobs and navigating the consistent challenge year-to-year of securing somewhat-decent health coverage without breaking the bank. Last July, my university wrote to us: “In response to student concerns related to the cost of student health insurance…”
Now, you might hope the sentence that followed would’ve been: “We have found a more affordable option.” Instead, the university was removing the insurance requirement altogether. Students needed to secure coverage via a guardian, job or the government marketplace. The same (unaffordable) plan remained available voluntarily, except it would now not be included in tuition (and therefore loans or aid can’t be used to cover the cost) and the students would have to pay the university’s insurance broker directly.
This wouldn’t be so bad, if the adjustments actually accounted for the holes in our current health and education systems. Instead of fixing the hole (i.e., offering an affordable plan), the university applied a bandaid suitable for a paper cut, except that the hole is actually a broken leg. What these “solutions” fail to address is a myriad of barriers including navigating our country’s confusing marketplace platforms, needing access to resources to make informed decisions, the lack of affordable options and the reality that low-income students often fall through the cracks of educational systems not designed to keep them afloat. This is coupled with the light that the ongoing pandemic is shedding on how disjointed, politicized and monetized our current approach to mental and physical care is.
Regardless of beliefs, it is clear that at the root of nearly every concern is the unabashed truth that we work for capitalism and capitalism does not work for us. The system is designed in a way that takes money directly from an individual’s pocket. In exchange, that individual might receive mediocre care but only if they’re lucky enough to afford it. Thus, breaking down barriers should be the goal, not building more walls. Regardless of identity or place in this world: all people deserve to be able to afford the care they need. Period.
Last October, a survey was conducted in Maine that focused on health care affordability. The data is stark and alarming. What stuck out the most to me is that 80% of Mainers are worried about affording health care in the future and 63% had difficulty affording care presently. This was true across income levels. Younger Maine residents faced the most burdens of all surveyed age groups. Additionally, across party lines, these are burdens that Mainers are seeking to resolve.
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What’s abundantly clear is that we have a huge problem to face. The people of Maine need a cultural shift in the way that the state approaches and thinks about the accessibility, affordability and availability of robust mental and physical care before the problem’s severity far outweighs our collective capacity to produce solutions.
When everyday Mainers – like myself – are having to make the choice between paying rent on time or receiving necessary care; it’s [past] time to take action. This isn’t a paper cut. Hell, it’s not even a broken leg. The people of Maine are on ventilators – literally and figuratively – fighting for our lives. At some point – literally and figuratively – those ventilators will run out. When they inevitably do, the lives of real, Maine people will be, and have already been, lost. These people matter. They always mattered. It’s the system that didn’t value them to begin with.
So, Gov. Janet Mills and the Maine Legislature, here’s what I have to say: the clock is ticking. How long until it times out?
https://www.blogger.com/blog/post/edit/3936036848977011940/2960257660014878020
Single-payer healthcare is the right system. Can California build it on its own?
by Michael Hiltzik - LA Times - January 14, 2022.
California, which has shown the determination to go it alone in areas such as environmental protection, scientific research and workers’ rights when its values conflict with policies at the federal level, is moving forward with its most audacious effort yet.
That’s a plan to create a universal single-payer healthcare system.
Called CalCare, the program would take over health coverage for more than 40 million residents from government policies such as Medicare and Medicaid and from private plans whether sponsored by employers or purchased through the Affordable Care Act marketplace.
We can’t have that cost containment ability without having the massive bargaining power of every single Californian.
This would mean placing $400 billion in annual expenditures in the hands of a state governing board. Say goodbye to the dead hand of private health insurers, to navigating in-network and out-of-network charges, to deductibles and co-pays, to substandard dental, vision and hearing services. Every resident of the state, regardless of where they get their their coverage now, would be eligible for the new system.
At least, that’s the promise. Whether the Legislature will be able to bring this idea to fruition is anyone’s guess.
Under its rules, the measure embodying the program, AB 1400, must be sent by Jan. 31 from the Assembly to the Senate, where it is likely to be masticated into the summer. The proposal, like its several predecessors introduced in recent years, is sponsored by the California Nurses Assn.
Not a few Assembly members have already expressed skepticism, but it’s a bit early to pull the plug. I agree with my colleague George Skelton that this is “a debate worth having.”
But it’s not a debate coming out of the blue. Indeed, it is sure to have a heavy component of déja vu. California has tried to enact a universal single-payer program many times in the past. Each time, it foundered over concerns about its cost and opposition from politically potent interests such as the commercial insurance industry and the California Medical Assn.
In 2018, for instance, a proposal almost identical to AB 1400 was torpedoed by Assembly Speaker Anthony Rendon (D-Lakewood). The uproar his action generated, however, forced him to establish a legislative committee to examine how achieve universal health coverage in the state.
The 2018 proposal, like the new version, would have taken over responsibility for almost all medical spending in the state while relieving employers, their workers and buyers in the individual market of premiums and out-of-pocket expenses.
In both versions, California residents would be eligible to obtain treatment from any licensed doctor in the state. Insurance companies would be barred from replicating any services offered by the program.
Many of the details of the system would be subject to further discussion in the Legislature and ultimately subject to policies set by a nine-member governing board appointed by the governor and Legislature.
It has always been clear that a single-payer program would help to relieve some of glaring deficiencies of the U.S. healthcare system. It would relieve doctors and hospitals of the need to employ brigades of billing clerks to chase down reimbursements from insurers.
It would give the single payer the leverage to control prices through negotiation and provide consistent standards governing the suitability of treatments. It would relieve consumers of the perplexity involved in selecting an insurance plan that doesn’t exclude the doctors they need to manage their conditions.
A couple of things have changed since 2018 that give the single-payer plan additional luster. For one thing, California casts an even bigger fiscal footprint. Then, the state had a population of 39 million; now it tops 40 million. Then, the state’s gross domestic product was about $2.6 trillion; today it’s more than $3 trillion.
Another factor is COVID-19. As UC San Francisco associate professor of medicine Rupa Marya observed in a recent op-ed in The Times, “the pandemic provides a powerful case study on the need” for a universal system. Most private insurers are no longer waiving cost-sharing for COVID treatment, “leaving even insured and vaccinated patients with potentially astronomical bills,” she warned.
“Without coverage like CalCare, this will be a recipe for the virus to go untreated or for patients to face financial ruin,” Marya wrote.
The big numbers being thrown around by critics to scare people about the cost of a California single- payer plan are misleading. That’s because they tell only part of the story, like eavesdropping on only one end of a telephone call. The GOP’s legislative caucus says a single-payer system in California would cost $400 billion and require $163 billion annually in new taxes.
The new taxes don’t necessarily represent new spending, however. They would substitute for spending that California’s government, residents and employers spend now. The fundamental question is how thoroughly the substitution would cover existing costs.
The answer depends on several factors. One is how successful California’s new system would be at reducing costs. The proposal’s sponsors say that the state is uniquely well-positioned to extract the billions in savings by negotiating with drug companies, hospitals and physician groups.
That’s plausible. Through a universal single-payer program, California would present providers with a massive ready-made market — fully 10% of the entire United States.
You want to play in this market, you’ll have to come to the table; the only question is how adept the state’s negotiators might be at extracting the maximum discounts. Tying provider reimbursements to Medicare rates, as is proposed in AB 1400, would produce cost reductions of as much as 40% compared with reimbursements paid by private insurers.
“We can’t have that cost containment ability without having the massive bargaining power of every single Californian,” says Carmen Comsti, lead regulatory policy specialist for the California Nurses Assn. “It’s as if we’re asking the CalCare system to be our collective bargaining representative with hospitals and doctors.”
The nurses association says the system would cost less overall than is currently spent on healthcare in the state. “We would get more, cover everyone and pay less,” Comsti said in testimony Jan. 11 to the Assembly Health Committee.
The nurses association and Assemblyman Ash Kalra (D-San Jose), who is carrying the legislation in the lower chamber, have tried to finesse the cost issue this year by bifurcating the single-payer proposal into an authorizing measure, AB 1400, and a separate constitutional amendment, ACA 11, providing for the system’s financing.
Their goal is to pass the first to establish the principle in state law and put off the second until after the state secures all the federal waivers necessary for its takeover of federal programs such as Medicare and Medicaid, which is known in the California as Medi-Cal.
As currently drafted, the financing amendment calls for financing the program through a business tax of 2.3% of gross receipts over $2 million a year; a payroll tax of at least 1% on wages above $49,900 per employee; and an income tax increase starting at 0.5% of income over $149,509 and up to 2.5% on income over $2.48 million.
You’ll hear antitax agitators squealing that California already levies the highest state taxes in the nation, but of course, if the program comes to fruition, California would be the only state to outlaw health plan premiums, deductibles and copays and to guarantee health coverage to all.
An analysis of an earlier version in 2017 performed at the University of Massachusetts found that with a combination of a 2.3% gross receipts tax and a 2.3% increase in the sales tax, money would be saved by business across the board and by all households except for the highest-earning 20%, with income starting at $227,600 that year.
Republicans in Sacramento cast further doubt on the state’s takeover of health coverage by arguing that Democrats have “proven themselves incapable of simple things like building a railroad, providing clean drinking water, keeping the lights on and filling potholes,” in the words of Assembly Republican Leader Marie Waldron of San Diego County.
That’s essentially cherry-picking. The best model for the state’s oversight of healthcare is Covered California, our Affordable Care Act exchange.
Covered California’s approach of actively supervising health insurance carriers in the individual market has not only worked exceptionally well, but it also is arguably the most successful ACA exchange in the country — and has helped bring down the level of uninsured Californians to about 6% from more than 17% in 2013.
As much as Republicans want to cavil about the efficiency of state government, the truth is that the healthcare system in place now is the very antithesis of effectiveness and efficiency.
Medicare works well as far as it goes, but the holes in its coverage force beneficiaries to purchase separate “Medigap” policies or sign up for Medicare Advantage plans, which consistently overcharge the government for their services. Nor is it capable of expanding beyond its traditional base of consumers over 65, without radical reform.
Private insurers boast of their ability to control costs and extract efficiencies from providers, but they’ve never delivered on that claim, even as they underwent a wave of mergers they said would create mega- carriers with the leverage to demand lower prices.
They suppress spending less by applying rational standards to treatment protocols than by erecting roadblocks to discourage enrollees from accessing the services they need. They are now, and always have been, profit-seeking entities, and the profits come out of their customers’ hides.
The vast majority of Americans have very little need for expensive medical care in any given year; that’s why most people are satisfied with their coverage. But what if they have a big claim? (NIHCM)
It’s well understood that the obstacles to enacting single-payer health coverage in California, as in the country as a whole, arise less from policy than from politics.
One obstacle is the notion that people are happy with their existing health coverage. As I’ve observed in the past, this is mostly a mirage. It’s more accurate to say that most people are complacent about their coverage, for the simple reason that the vast majority of Americans don’t have complicated interactions with the healthcare system through most of their lifetimes. It’s an immutable truism in healthcare that
the top 5% of all patients account for half of all spending, and the bottom 50% account for only 3% of spending.
Broken bones, pregnancies, even cardiac events are routinely managed by the system in a way that’s good enough for the 49% of Americans who receive care through their employers. For them too, the ridiculously inflated costs are largely invisible, buried in their employers’ share of premiums.
It’s on the margins, however, where the system breaks down. “A lot of people with really, really lousy health insurance didn’t know it because they never had to use it,” healthcare commentator Jonathan Cohn told me last year. “If they did get a tragic healthcare problem — a car accident, or cancer, or a child with a congenital problem — for the first time they have to use their health insurance and now they’re discovering what it doesn’t cover.”
The problem of uninsured and underinsured Americans is also largely invisible to those with coverage, but it should be a concern for everybody. Healthcare is a communal benefit, undermined by the inequities that deprive too many Americans and too many Californians of access to healthcare.
Nothing illustrates the risks to the entire community of the difficulty we’ve had in fighting the pandemic, thanks to the determined efforts of anti-vaccine crusaders to push policies that leave millions of Americans exposed to the virus and encourage its spread.
CalCare would address those marginal but significant costs. Yes, it would be audacious, but in the context of a country in which healthcare reform has stagnated and compared with states that appear resolved to move backward in their standards of public health, it could be another policy to make Californians proud.
Editor's Note -
The links to the videos accompanying the following NYT clipping will take you to video essays about what it's like in an ICU occupied by Covid-19 patients and a separate video essay about the role of greed in degrading nursing in American hospitals.
These videos are not for the faint of heart. Watch them only if you have a strong stomach.
FAIR WARNING!
- SPC
We Know the Real Cause of the Crisis in Our Hospitals. It’s Greed.
Nurses would like to set the record straight on the hospital staffing crisis.
We’re entering our third year of Covid, and America’s nurses — who we celebrated as heroes during the early days of lockdown — are now leaving the bedside. The pandemic arrived with many people having great hope for reform on many fronts, including the nursing industry, but much of that optimism seems to have faded.
In the Opinion Video above, nurses set the record straight about the root cause of the nursing crisis: chronic understaffing by profit-driven hospitals that predates the pandemic. “I could no longer work in critical care under the conditions I was being forced to work under with poor staffing,” explains one nurse, “and that’s when I left.” They also tear down the common misconception that there’s a shortage of nurses. In fact, there are more qualified nurses today in America than ever before.
To keep patients safe and protect our health care workers, lawmakers could regulate nurse-patient ratios, which California put in place in 2004, with positive results. Similar legislation was proposed and defeated in Massachusetts several years ago (with help from a $25 million “no” campaign funded by the hospital lobby), but it is currently on the table in Illinois and Pennsylvania. These laws could save patient lives and create a more just work environment for a vulnerable generation of nurses, the ones we pledged to honor and protect at the start of the pandemic.
https://www.nytimes.com/2022/01/19/opinion/covid-nurse-burnout-understaffing.html
Maine Voices: We are parenting during COVID. We are tired. And we’re the lucky ones
My wife and I have good jobs and day care, and we’re still stressed out right now. How are other families even managing?
by Heather Chase - Portland Press Herald - January 19, 2022
I’m writing this on Martin Luther King Jr. Day, working from home full time with my kids, ages 2 and 4, climbing all over me as day care is closed for the holiday. Going into calendar year 3 of the pandemic, this setup is now more norm than exception.
The parents are not OK.
I love our day care. We struck gold in finding one as great as ours. But even they are not immune to COVID quarantines and closures. Three times this fall, our kids were home for 10 days at a time because of a COVID-positive case at day care. And this is only counting COVID closures. When once parents could keep their sick kid home and send the rest to day care, one sick kid now means they all have to quarantine at home. I’m on board with the public health reasons behind this. I have my COVID vaccine and booster shots and still mask in public. My wife and I work in health care, so you don’t need to convince us to take the right precautions. All I’m saying is that what was already a difficult job with limited support – parenting and working full time – is now even harder.
And the parents are not OK.
I’m 39 years old. The last time inflation was this high was the year I was born. Since the beginning of the pandemic, our cost of food has tripled – and that includes me growing a lot of ours. We just paid over $900 for oil. Day care for two children, at a reduced fee for two of them being enrolled, is $402 a week. Mortgage, car payments and the financially crippling impact of student loans – I can’t see how any of this is sustainable.
The parents are not OK.
Especially those of us with chronic illness. I was diagnosed with Type 1 diabetes when I was 6, in 1988. Insulin, insulin pump supplies, test strips and medications for the complications that come with having this disease for so long. Throw in a type of autism that was once called Asperger’s, along with parenting during the pandemic and working to keep our kids housed and clothed, and our burnout has burnout.
The parents are not OK.
And my wife and I are extremely lucky. We have two incomes and good jobs. I may not be able to get food until payday sometimes, but our fridge and cupboards are never bare – they just don’t always have exactly what my kids want at the moment. We pay our bills, though we’ve had to take out personal loans at times to make ends meet. We have a home and a safe place for our children. They are loved and well cared for. Having grandparents from the Great Depression generation, my wife and I know how much worse it could be.
But we’re so, so tired. Tired of worrying that our kids, who are too young to be vaccinated, are getting the social experiences they need without putting their health at risk. Tired of navigating health insurance for us and our kids through a ridiculous system of hoops, when our cousins abroad just go get medical attention when they need it without fearing it will mean financial ruin. We’re tired of working, parenting and teaching all at the same time at home, holding a crying baby on a Zoom meeting, while a preschooler yells “I’m peeing!” in a work world that still expects parents and all employees to work as if they don’t have personal lives. And my current boss is fantastic about me parenting while working from home. I can’t say that for all previous bosses. And, hey, at least I don’t have to take a pay cut when I’m home with my kids because of COVID or an illness or a holiday. Many do, and I don’t know how they’re making it.
The parents are not OK. And my family is one of the very, very lucky ones.
Factors Associated With Overuse of Health Care Within US Health Systems
by Jodi B. Segal, MD, MPH1,2; Aditi P. Sen, PhD2; Eliana Glanzberg-Krainin, MPH, MBA2; et al - JAMA Network - January 14, 2022
Key Points
Question What features of health care systems in the US are associated with overuse of health care?
Findings In this cross-sectional study of 676 US health care systems, those that were overusing health care had more beds, had fewer primary care physicians, had more physician practice groups, were more likely to be investor owned, and were less likely to include a major teaching hospital.
Meaning In-depth exploration of the drivers of health care overuse is needed at the level of health systems as their incentives may not be aligned with high-value care.
Importance Overuse of health care is a pervasive threat to patients that requires measurement to inform the development of interventions.
Objective To measure low-value health care use within health systems in the US and explore features of the health systems associated with low-value care delivery.
Design, Setting, and Participants In this cross-sectional analysis, we identified occurrences of 17 low-value services in 3745 hospitals and affiliated outpatient sites. Hospitals were linked to 676 health systems in the US using the Agency for Healthcare Research and Quality (AHRQ) Compendium of Health Systems. The participants were 100% of Medicare beneficiaries with claims from 2016 to 2018.
Exposures We identified occurrences of 17 low-value services in 3839 hospitals and affiliated outpatient sites.
Main Outcomes and Measures Hospitals were linked to health systems using AHRQ’s Compendium of Health Systems. Between March and August 2021, we modeled overuse occurrences with a negative binomial regression model including the year-quarter, procedure indicator, and a health system indicator. The model included random effects for hospital and beneficiary age, sex, and comorbidity count specific to each indicator, hospital, and quarter. The beta coefficients associated with the health system term, normalized, reflect the tendency of that system to use low-value services relative to all other systems. With ordinary least squares regression, we explored health system characteristics associated with the Overuse Index (OI), expressed as a standard deviation where the mean across all health systems is 0.
Results There were 676 unique health systems assessed in our study that included from 1 to 163 hospitals (median of 2). The mean age of eligible beneficiaries was 75.5 years and 76% were women. Relative to the lowest tertile, health systems in the upper tertile of medical groups count and bed count had an OI that was higher by 0.38 standard deviations (SD) and 0.44 SD, respectively. Health systems that were primarily investor owned had an OI that was 0.56 SD higher than those that were not investor owned. Relative to the lowest tertile, health systems in the upper tertile of primary care physicians, upper tertile of teaching intensity, and upper quartile of uncompensated care had an OI that was lower by 0.59 SD, 0.45 SD, and 0.47 SD, respectively.
Conclusions and Relevance In this cross-sectional study of US health systems, higher amounts of overuse among health systems were associated with investor ownership and fewer primary care physicians. The OI is a valuable tool for identifying potentially modifiable drivers of overuse and is adaptable to other levels of investigation, such as the state or region, which might be affected by local policies affecting payment or system consolidation.
Overuse of health care, or the provision of low-value or no-value care, is consistently identified as contributing to high costs in the US health care system.1-3 This wasteful care is physically, psychologically, and financially harmful to patients.4-6 Some interventions that seek to encourage high-value care delivery and limit low-value care are implemented nationally, such as the national coverage determinations of the Medicare program7 or bundled payment models.8-10 Other interventions are delivered locally, within a clinical unit, and are implemented through practice change initiatives. Many of these are motivated by the Choosing Wisely Initiative,11 and have had varying effects on reducing low-value care.12-16
Health systems may play an important role in the overuse of health care. They balance financial interests when making decisions about strategic consolidations or new service lines, complying with state and federal regulations, and aiming for high-quality care delivery and best patient outcomes. Presently, there is scant quantification regarding low-value health care at the health system level despite the importance of this information for state and federal policy setting.17
We previously created an Overuse Index that uses billing codes for diverse clinical services that act as indicators to reflect the latent tendency of a region to overuse health care resources relative to other regions.18-21 Conceptually, the Overuse Index should function like the Consumer Price Index, which uses the average price of a “market-basket” of goods and services to track inflation. In the present work, we have updated the Overuse Index to use International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes and have adapted it to describe low-value care at the level of health care systems in the United States. Here, we describe US health care systems by their Overuse Index and explore system level factors that are associated with overuse.
This is a serial cross-sectional study approved by the Johns Hopkins Institutional Review Board. The Review Board did not require individual patient consent owing to use of deidentified data.
We accessed 100% of the inpatient and outpatient claims, and Master Beneficiary Summary files, from Medicare beneficiaries from July 2015 through December 2018 through the Center for Medicare & Medicaid Services’ (CMS) Virtual Research Data Center (VRDC). As required, we did not export pooled information describing between 1 and 10 individuals.
Identifying Hospitals and Health Systems
The Agency for Healthcare Research and Quality (AHRQ) commissioned a Compendium of US Health Systems.22,23 For Compendium inclusion, health systems needed to include at least 1 non-federal acute care hospital and at least 1 group of physicians connected with the hospital through common ownership or joint management.
The Compendium, first generated in 2016, used many data sources including the Healthcare Organization Services and SK&A Healthcare databases, and the American Hospital Association (AHA) survey of hospitals.22 The file includes the Center for Medicare & Medicaid Services certification number (CCN) and health system and hospital names and addresses. The hospital linkage file, updated in 2019, more accurately reflects the 2016 relationships, and describes 626 health systems and their hospitals. The linkage information was re-released in 2018, used data from OneKey (owned by IQVIA) and AHA as the primary source of linkage information, and described 637 health systems.
We excluded children’s hospitals, behavioral health centers, psychiatric hospitals, and rehabilitation hospitals by searching for key words in their names. When using the claims from 2016 and 2017, we used the hospital-to-health system linkage information from 2016. When using the 2018 claims, we updated the hospitals’ health systems linkage with the 2018 information.
We began with the Overuse Index previously described,20,21 which included 20 clinically diverse claims-based measures of overuse (indicators), and reviewed the indicators for their continued clinical relevance. We considered additional indicators by reviewing recommendations of the US Preventive Services Task Force and clinical practice guidelines, with the goal of retaining diverse indicators in the Index.
Identifying Indicator Count for Each Hospital
We identified individuals who were eligible to have each indicator procedure (eg, individuals with mild head trauma could have imaging) with a combination of demographic information, ICD-10-CM diagnosis codes, and, rarely, common procedural (CPT) codes (eTable 1 in the Supplement). These eligible individuals were then attributed to the hospital or hospital-associated outpatient facility (clinics or surgical centers) by the CCN associated with the claim having the diagnosis that established their eligibility.
We then identified the subset of individuals, among the eligible, who received the indicator procedure of interest. They were identified by a claim with the relevant ICD-10-PCS procedure code or CPT code on any day on which they were eligible. For the indicators for which eligibility was based solely on demographics (eg, women over age 85), the attribution was made based on where the indicator procedure occurred.
We divided the 3 years of data into quarters and included, for any individual, only the first occurrence of a given indicator in a given quarter in a given hospital. An individual could experience multiple different indicators in any quarter-hospital. We conducted our analyses in the spring and summer of 2021.
To generate the index, we used a generalized linear mixed model, with a negative binomial distribution, where the dependent variable was the count of the occurrences of the indicator procedures at each hospital in the ith quarter (1 to 12), for the jth indicator (1 to 17). The offset was the count of individuals eligible in that quarter for that indicator in each hospital. The model included fixed effects for quarter-year, indicator, and health system, as well as random effects for each hospital (Equation 1). The model included patient-level characteristics for the eligible population, specifically mean patient age, proportion of women, and the median count of chronic conditions as generated with CMS’s Chronic Conditions algorithm,24 for each hospital-indicator-quarter. The model used the Newton–Raphson optimization option and 1 quadrature point.
Cijk = Ѡi + ψj + Φk + βXi + hospital+ εij
Where Ѡi is a set of quarter fixed effects, ψj is a set of indictor fixed effects, and Φk is a set of health system fixed effects, and Xl represents a vector of patient characteristics for each hospital-quarter-indicator.
The beta coefficients generated as each health-system’s fixed effects (Φk) are the metrics of interest; they represent composite low-value care use by that health system relative to a reference health system. This measure was standardized to create the Overuse Index as a Z score, where the value of the index for the kth health system is calculated as in equation 2,
OIk = (Φk − Φ) / SD(Φ)
where OI is the Overuse Index, Φ is the average of the health system fixed effect, and SD(Φ) is the SD across the fixed effects that were estimated in equation 1.
We categorized the health systems according to their standardized Overuse Index into 5 categories based on the Z score. Category 1 health systems have an Overuse Index more than 1 SD below the mean, category 2 is between −1 and −0.5 SD below the mean, category 3 is between −0.5 and 0.5 SD of the mean, category 4 is between 0.5 and 1 SD of the mean, and category 5 is more than 1 SD beyond the mean.
Describing Health Systems
The Compendium includes rich information including whether the system has a hospital with a high disadvantaged patient share, or a major teaching hospital.22 Other descriptors indicate system-wide uncompensated care burden, teaching intensity, whether the system is predominantly investor-owned, and participation in CMS alternative practice models. We used the characteristics of the health systems in 2018 for description; if the health system existed only in 2016 or 2017, we used the 2016 information. Some variables available in the 2016 data were not available in 2018, and vice versa. For the continuous data, we created indicator variables by tertile as the count data were right-skewed. The health system was attributed to the state where its headquarters were located.
We fit ordinary least squares regression models to estimate independent associations between the Overuse Index and health system characteristics. There were 2 models, the first of which included all health systems (n = 676) and the subset of covariates present in both the 2016 and 2018 Compendiums. The second included a smaller set of health systems (n = 486) having the same CCNs in 2016 and 2018, which could be characterized using both the 2016 and 2018 Compendiums. We did not impute missing health system characteristics. Characteristics in the final model were chosen to avoid collinearity and to explain the most variance. We included fixed effects for state expecting regional variation.18,21 Models were compared with a likelihood ratio test.
We excluded hospitals from contributing to a given indicator if there were fewer than 20 individuals eligible for a given indicator in a hospital, as is done in CMS’s Merit-based Incentive Payment System.25 We also tested the relationships between the health system characteristics and the Overuse Index with inclusion of random effects for state using a mixed-effects generalized linear model. The modeling on the VRDC used SAS 9.4; the health system characteristic modeling was done using STATA 15.0.
The final data set included 676 health systems. A total of 70 health systems had data in the Compendium in 2016 but not in 2018, and 81 systems newly appeared in the Compendium data in 2018 (Table 1). The 5 health systems with the most hospitals, consistently between 2016 and 2018, were Catholic Health Initiatives, Ascension Health, Universal Health Services, Community Health Systems, and HCA Health care, each having more than 100 hospitals. One health system in New Hampshire was excluded from modeling owing to missing data. The number of hospitals contributing to these data was 3839. The health systems ranged in size from 1 to 163 hospitals with a median of 2 hospitals (mean of 5.7 hospitals, SD 13.9).
By design, the patients who were eligible for each overuse event varied (eTable 2 in the Supplement). The mean age of the beneficiaries eligible for experiencing 1 or more of the overuse events was 73.4 years; 68% were women, and their mean CMS Chronic Conditions count was 7.6.
A total of 17 indicators contributed to the Overuse Index. This set included 5 new indicators compared to our earlier work18,21; we retired 8 indicators (eTable 3 in the Supplement). The counts of overuse events, for any of the 17 possible events, in a hospital-quarter ranged from 0 to 1414 events. The fewest hospitals contributed to the brain MRI measure (n = 2041) and the most contributed to the hysterectomy measure (n = 3305). Each of the 17 indicators contributed to the Overuse Index proportional to its indicator rate, which might be described as the number of events among all individuals eligible for the indicator event.
The overuse index, before standardization, had a mean of −0.36 (SD 0.40) with a median of −0.30 and range of −3.8 to 0.89 across the 676 systems (Figure). By design, the standardized Overuse Index has a mean of 0 and an SD of 1, with a median of 0.15 with a range from −8.5 to 3.1. There were 101 health systems beyond −1 SD, 67 between −1 and −0.5, 294 between −0.5 and 0.5, 137 between 0.5 and 1.0, and 77 beyond 1 SD. The 214 health systems in the fourth and, particularly, fifth categories can be considered to be health systems that are overusing services relative to the average health system (eTable 4 in the Supplement).
Health Systems Characteristics Associated With Overuse
In the unadjusted analyses (Table 2), many health system characteristics were strongly associated with higher values on the Overuse Index, including the counts of hospitals, acute care hospitals, and beds. Having a teaching hospital was strongly associated with less overuse. In the multivariable analyses, we observed largely consistent patterns of characteristics that were associated with more or less overuse when looking at the full set of systems (n = 675) and the reduced set (n = 486) (Table 3). Metrics reflecting the size of the health system (ie, number of beds) suggested that the large systems were more often overusing health care relative to small systems; yet, the number of hospitals was not independently associated with higher Overuse Index scores. Health systems with a higher number of medical groups were more likely to be overusing systems, with a dose-response relationship. Strongly negatively associated with overuse was the number of primary care physicians in the system, also demonstrating a dose response relationship; health systems in the upper tertile of primary care physician counts were more than one-half of a SD lower on the Overuse Index than those in the lowest tertile. Health systems that were investor-owned, although few (n = 20), were markedly overrepresented in the highest overuse categories.
Health systems that were involved in teaching, particularly with the inclusion of a very major teaching hospital, had lower Overuse Index values. Systems in the upper quartile of uncompensated care, relative to those that were not, had an Overuse Index nearly one-half of a SD lower. Participation in CMS programs such as accountable care programs or bundled payment programs was not associated with more or less overuse. Similarly, the ownership of a Medicare Advantage plan or a Medicaid managed care plan was minimally associated with more or less overuse.
When we allowed hospitals to contribute observations only if they had 20 or more eligible people for a given indicator, the results were minimally different (eFigure and eTable 5 in the Supplement). Specifically, 92 of 676 health systems changed by one category (eg, from the third overuse category to the fourth), and only 1 health system changed by 2 categories. The use of random effects models in place of fixed effects models to control for state effects resulted in similar inferences although the sizes of the effects were less extreme (eTable 6 in the Supplement).
Herein, we generated an Overuse Index, with ICD-10 codes, to report on overuse by individual health systems. This study also demonstrated strong associations between health system factors and overuse that provide additional support for recent observations of similar relationships.26 We expect that these findings should further motivate researchers toward designs that allow establishment of causal relationships. Additionally, this study identified novel associations that may generate new testable hypotheses about how system factors affect overuse.
The present study method uses 17 tracers that we consider to be indicators of overuse. We do not consider these to be individually important; we expect that health systems that are overusing these indicator procedures are likely to be globally overusing health services. Although there is variation in overuse across health systems, this variation was less than was demonstrated in our earlier work at a regional level, which used both commercial claims and Medicare claims.18,21
The present study methodology is novel and unlike that which is presently most used by others, the MedInsight Health Waste Calculator (from Milliman). The Health Waste Calculator asserts that it measures the absolute amount of care that is wasteful, or likely to be wasteful. Although the contents of the tool are not publicly available, 35 services are described in an article published in 2020.27 That tool has been used with state all-payer claims28 and to describe trends over time in use of wasteful services by Medicare beneficiaries.29 The recent article by Ganguli and colleagues26 used some of the Milliman measures.
Like the present work, Ganguli and colleagues26 measured overuse of health care by health systems, and there is much concordance in our findings. Ganguli and colleagues tabulated the rates of 20 events and averaged these for a summary measure across their 2 years of data. In comparison, the present study used a model to generate the measure of overuse and was thus able to control for differences across hospitals, by adjusting for mean age, sex, and comorbidities in each hospital, in each quarter, for each indicator, over the 3 years of data we used.
Despite the differences in our approaches, there is much agreement in the rankings of the health systems and concordance in factors associated with overuse. Both studies found that the number of physicians in a health system and that the number of primary care physicians is inversely related to overuse in a health system. Both found no significant association of overuse with insurance plan ownership by a health system and no association with an accountable care organization’s presence in a health system. Both found that having a teaching hospital in the health system is inversely associated with overuse. Ganguli and colleagues26 found that dual Medicare and Medicaid eligibility within a health system did not meaningfully contribute to overuse. The present study found that health systems in the upper quartile of uncompensated care were much less commonly overusing health systems. We suspect that the variable we used may identify health systems having safety net hospitals, which we expect is different from the dual-eligibility measure.
A related work was published in 2020, when the Lown Institute prepared a measure of waste at the level of 3100 US hospitals.30,31 These researchers used 100% of Medicare claims from 2015 through 2017 to measure 13 low-value services, which have much overlap with the 17 that we included. The authors adjusted their observed overuse rates to account for volume differences across hospitals, and then used principal components analysis to reduce the information to one variable that serves as their overuse score. We note that their 10 least overusing teaching hospitals, as listed on their website, are within health systems that we categorized as not highly overusing systems (categories 1, 2, or 3), suggesting concordance of our measures. Similarly, 2 of the hospitals that are ranked by Lown Institute has having a very high likelihood of being overusing hospitals are part of Universal Health Services system, which is a category 4 system with our Overuse Index.
We propose that the Overuse Index has good face validity. The health systems that we expected to be lower in overuse, specifically, those that are integrated health care delivery systems, were indeed lower in overuse: Kaiser Permanente was in category 1. Other systems which are known for their attention to high-value care were also in lower overuse categories: University of Utah Hospitals and Clinics was in category 1 and Intermountain Health Care was in category 3. Other health systems in category 1 are health systems that we suspect are under-resourced as they include large public and safety-net hospitals: these include New York City Health and Hospitals Corporation and Cook County Health and Hospital System. Also supportive of validity, systems that have attracted attention owing to their intensively competitive markets are overusing health systems: UPMC and Allegheny Health Network, both in Pittsburgh, Pennsylvania, are in the fourth and fifth categories, respectively. Systems that are in geographic regions that we previously identified as overusing are prominent in category 5 (systems in Fort Lauderdale and Boynton Beach, Florida, and in Los Angeles, California, and Seattle, Washington.)
The use of AHRQ’s Compendium data allowed the present study to explore factors associated with of health system-level overuse. As described above, we demonstrated, once again, that the availability of primary care is associated with less overuse of services. In our earlier work, which focused on measuring overuse regionally, we found that the density of primary care doctors was associated with less overuse of health care, when we examined both commercially insured beneficiaries data and Medicare beneficiaries data.32,33 Presently, the measure is the count of primary care physicians in the health system, and we suspect that the density may be inequitable across large systems. This requires further study.
The present study also found a strong relationship between investor ownership of a health system and overuse. There were only 20 investor-owned systems but 12 of the 20 were in category 4 or 5, with only a single one in category 1. The latter was a very small system (25-bed hospital) in Missouri that we suspect may be under-resourced. In 2014, there were federal investigations of several investor-owned health systems with allegations of questionable hospital admissions, procedures, and billings at many hospital systems. Among those investigated were HCA and Health Management Associates that was soon bought by Community Health Systems.34 In our work, HCA and Community Health Systems both were category 4 health systems in the years after the investigation.
There are limitations to this approach. Some may challenge the indicators that we chose to include the index; we suspect that fewer indicators might even be sufficient to order health systems similarly. We believe that the inclusion of diverse indicators provides some stability to the index. The investigation of determinants of overuse relies on the validity of the Compendium data, which we did not independently verify. Additionally, we used Medicare claims and the included patients were predominantly older adults. We expect, however, that practice patterns within health systems are similar across patients with diverse insurance types—indeed, in our earlier work, the regions that were overusing were largely concordant when we examined commercial claims and Medicare claims.18,21
https://jamanetwork.com/journals/jama-health-forum/fullarticle/2788097
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