Health Care Reform Articles - April 25, 2023

Maine Voices: Emphasis on revenue sabotages medical practices and hospitals

At some point, most of us who entered medicine for altruistic reasons find ourselves providing a declining quality of care. 

By Deborah Patten - Special to the Press Herald - April 9, 2023

 

Recent medical news has focused on the need to recruit more health care workers because of the departure of many from the field. Although the COVID-19 pandemic certainly added stress to the work, there were difficulties that preceded the pandemic.

When I began practicing pediatrics about 40 years ago, the ratio of help needed to support me was 3:1 – or essentially nursing, secretarial and billing positions. Now the ratio is 16:1. That’s a lot of salaries for one provider to support, despite some being new and essential, such as an IT person. However, the offloading of some tasks of past smaller practices has been replaced by other burdens.

Primary care has historically been the most poorly reimbursed of medical fields. Now these are often the empty positions. I found it shameful that insurance would reimburse more for procedures as minor as freezing warts than for an hour spent resuscitating a newborn or counseling a suicidal teen.

My eight years of college and medical school, which cost $30,000 in the 1970s, now costs $600,000 for tuition only. This pushes young doctors away from primary care in order to pay back school loans using the higher salaries that come with subspecialty and surgical care.

There are many well described challenges for those currently providing health care. Insurance companies routinely challenge charges, limit reimbursement and also change coverage rules. Drug companies frequently deny prescriptions, something that necessitates time to respond and negotiate – and often re-prescribe.

The electronic medical record may offer clarity of notes but also requires mastery of every program change, a shameful lack of eye contact with the patient, and the skill for rapid data entry, primarily for the purpose of billing. Our patients’ mental health needs have soared, and can now rarely be addressed in compressed office visits.

We need to acknowledge that health care has become a business.

As medical practices and hospitals have been taken over by the corporate world, decisions are made by non-health care individuals and are based on economics. The emphasis is on revenue, and that means seeing more patients faster, despite the complexity of or lack of familiarity with their problems. It means closing and consolidating hospitals and practices. It also means hiring less expensive and therefore less qualified people to answer phones, screen patients and even provide care. Less overhead, more visits, more procedures, more “billable moments.”

At some point, most of us who entered medicine for altruistic reasons find ourselves providing a declining quality of care. We find that we have become a high-speed data entry person for the various corporations that decide how we practice medicine – the insurance companies, the drugmakers, even the corporations that run the practices and hospitals. Some of these corporations can use the label nonprofit because they pour the revenue into administrative salaries. In response to our feedback and calls for change, we are told that we must be more “resilient.”

Until we turn some of health care management back to those who are providing the care, we will continue to see a loss of qualified nurses and doctors. The problem is not only burnout with multiple demands and clerical work, but also what has aptly been labeled “moral injury.” We cannot provide the level of care that we know to be best and that we aspired to provide.

https://www.pressherald.com/2023/04/09/maine-voices-emphasis-on-revenue-sabotages-medical-practices-and-hospitals/ 

 

Letter to the editor: A system of publicly funded health care is the answer

In her April 9 column, Dr. Deborah Patten painted a disturbing picture of doctors suffering from burnout and “moral injury” – tension between business and professional responsibilities (“Maine Voices: Emphasis on revenue sabotages medical practices and hospitals”). This matters because our health depends on those doctors.

Implementation of a publicly funded health care system covering everyone (such as described in the Medicare for All Act of 2021, quoted below) would help address five of the problems she mentioned:

• Increasing need for administrative staff. Consolidation of all payers into one public payer would reduce the expense of medical billing departments (“a uniform national system for electronic billing for purposes of making payments”).
• Lower reimbursement for primary care. Reimbursement of these providers would likely be increased to “promote policies that expand the number of primary health care practitioners.” “[R]eview board … assure … fair reimbursements for physician-delivered … services.”
• Time-consuming pre-authorizations. “Benefits provided … without any need for any prior authorization determination.”
• Distraction of the electronic medical record. Coding would be simplified through a “national fee schedule” and documentation could be minimized (“documentation as may be reasonably required”).
• Productivity demands. Self-imposed productivity goals would continue for independent physicians, but negotiated institutional global budgets would limit productivity demands on employed physicians (who “may elect to be paid through such institutional provider’s global budget”).

There are, no doubt, other solutions for burnout and moral injury. The public needs to hear what other physicians have to say on the subject and then advocate for the best solutions – before it’s too late.

Daniel Bryant
Cape Elizabeth

https://www.pressherald.com/2023/04/23/letter-to-the-editor-a-system-of-publicly-funded-health-care-is-the-answer/

Live poor, die young

Another study -- one that takes government transfers into account -- confirms living in poverty is associated with ill-health and early mortality 

by MERRILL GOOZNER - Gooznews - APR 21, 2023 Epidemiologists have long noted that people who earn less money live shorter lives and suffer more ill-health than people with more money. One recent study documenting this phenomenon found that “higher income was associated with greater longevity throughout the income distribution.” That 2016 study, led by Stanford economist Raj Chetty, found the greatest difference in longevity was between people in the bottom and top 1% of the income distribution, where the gap was about 15 years for men and 10 years for women. To put that spread in perspective, the richest 1% lived longer than people in Japan, which is ranked first in longevity, while the poorest 1% lived about as long as the average person in Russia or North Korea, which are tied for 113th. Just a few months before that study appeared, Anne Case and Angus Deaton, who had just won the Nobel Prize for economics, documented a rapidly falling longevity rate for white Americans. The main causes were “drug and alcohol poisonings, suicide, and chronic liver diseases and cirrhosis,” which they dubbed “deaths of despair.” Those studies appeared around the time the U.S. entered what has become an unprecedented long-term slide in life expectancy, which was only exacerbated by the COVID pandemic. The latest data show U.S. average life expectancy fell to 76.1 years in 2021 after peaking at 78.9 years in 2014. In other words, stagnant incomes in the lower half of the income distribution and our bungled response to the pandemic managed to chop nearly three years of life off the average American over the past decade. The average masks huge inequities. Black Americans lost four years over that span; indigenous people more than six years. Both groups include a disproportionate share of the nation’s poor. Updating the definition of poverty I was prompted to revisit that literature this week after seeing a brief research note in JAMA Internal Medicine that tried to address some of the criticism leveled at the original JAMA study. This new study also viewed its findings through a health care lens: What would our response to poverty and inequality be if we treated stagnant real income and growing income inequality like a disease? Before addressing that second question, the authors corrected for what is the most frequent conservative critique of studies that tie deteriorating health for people in the bottom 20-30% of the income distribution to enduring poverty: the impact of safety net programs like child tax credits, the earned income tax credit and food stamps on income. Conservatives claim poverty is grossly overestimated because the Census Bureau’s calculations do not include the value of transfer payments. For instance, former Sen. Phil Gramm, now at the conservative American Enterprise Institute, estimated in a Wall Street Journal commentary last November that anti-poverty programs funnel a staggering $1.9 trillion a year into the households of the poor (I’d like to know how he arrived at that number given that the entire federal budget for non-defense discretionary spending was only $800 billion in 2022). David Brady, who’s at the University of California, Riverside, and colleagues took that critique into account by wrapping all tax credits and “near cash” transfers like food stamps into their definition of income. Moreover, they expanded their definition of poverty to go up to half the median income. While progressive economists support that expanded definition of poverty, its use in the study meant more better-off but still lower-income Americans would be in the group being evaluated for the ill health effects of poverty. And here’s what they found: People living in poverty have a 42% greater chance of premature mortality than people in higher income brackets. If they remained mired in poverty for the ten-year period of the study, premature mortality rose by 71%.  Translated into annual death rates, poverty kills just under 200,000 people per year, making it the third leading cause of death. (If one includes smoking as a cause of death, it falls to fourth. The vast majority of smoking-related deaths are counted as either cancer or heart disease deaths in statistics compiled by the Centers for Disease Control and Prevention.) President Biden has launched a “moonshot” to cure cancer. The nation’s media, whether aimed at a mass audience or the specialized health care press, run articles and segments almost daily about the untreated high blood pressure, obesity, substance abuse and mental illness that is leading to early mortality and driving down longevity. Yet we rarely see stories that directly address the fact that poverty and economic stress on low-wage workers is triggering a disproportionate share of those illnesses. Nor do we hear many politicians articulating a program to address what may well be the number one cause of ill-health in our society: the impact of poverty and growing income inequality. In a commentary on the Chetty study published seven years ago, Nobel laureate Deaton expressed no surprise that the medical mainstream “emphasizes biology, genetic factors, specific diseases, individual behavior, health care, and health insurance” in its approach to improving the overall health of the population and putting America back on the path toward increasing longevity. “Even if it is true that the fundamental causes of health are social and economic, there is every reason to focus on treatment and health behaviors in a country, even one as rich as the United States, where poverty is intractable and there is little immediate prospect of making the distribution of income more equitable,” he wrote. For what it’s worth, I still believe change is possible. I only despair when I think about how much of the $4 trillion we spend on health care each year is wasted, and how even much of what gets done, even when useful, amounts to putting a band aid on the cancer of income inequality.https://substack.com/app-link/post?publication_id=106809&post_id=116105493&utm_source=post-email-title&isFreemail=true&token=eyJ1c2VyX2lkIjoyMDg5MTA3OSwicG9zdF9pZCI6MTE2MTA1NDkzLCJpYXQiOjE2ODIwNzg3NTcsImV4cCI6MTY4NDY3MDc1NywiaXNzIjoicHViLTEwNjgwOSIsInN1YiI6InBvc3QtcmVhY3Rpb24ifQ.m84huqX_e5d9WwWE1A6ITPu2y0iLOZ960RZ8LYvT1KY

Finally, medical debt under $500 has been removed from credit reports

Equifax, Experian and TransUnion have dropped low-balance medical debt, potentially boosting credit scores for some consumers

by Michelle Singletary - Washington Post - April 12, 2023

Should your credit score suffer, setting you up for higher-priced loans, because of medical debt for an accidental injury?

The cost of health care in the United States is highly expensive, unpredictable and often based on factors out of people’s control. Being billed for a medical condition or emergency isn’t the same as deciding to get a mortgage, in which you are choosing to take on the debt obligation.

If you need emergency care, you’re not likely to tell the physician, “No, I don’t think I can handle the expense of fixing my broken leg. Let me just limp home and comparison shop.”

Medical billing practices can put a strain on people’s budgets and, for many, propel them toward bankruptcy. A survey conducted by the American Journal of Public Health of bankruptcy filers found that the majority said medical expenses contributed to their seeking relief.

On Tuesday, the three major credit bureaus — Equifax, Experian, and TransUnion — announced that medical collections with balances of $500 or less would no longer appear on consumer credit reports.

This is a significant step in helping millions of people — particularly those who are young and on the lower end of the wage scale — who rely on having a good credit score to get an apartment or an affordable loan.

“We understand that medical debt is generally not taken on voluntarily, and we are committed to continuously evolving credit reporting to support greater and responsible access to credit and mainstream financial services,” the chief executives of the credit bureaus said in a joint statement.

With this change, nearly 70 percent of all medical debt sent to collections is no longer part of consumer credit files, the executives said.

The Biden-Harris administration also announced plans for medical debt reforms. It includes directing the Department of Health and Human Services to look at providers’ billing practices and helping veterans get their medical debt forgiven.

The point of credit scoring is to predict who is likely to default on their debts. In a report last year, the Consumer Financial Protection Bureau questioned whether this type of debt should be reported to the credit bureaus and thus factored into credit scores.

“Unlike many other consumer debts, people rarely plan to take on medical debt,” the CFPB report said. “Two-thirds of medical debts are the result of a one-time or short-term medical expense arising from an acute medical need. Medical debt is also unique in that people have less ability to shop around for medical services.”

Even the most cost-conscious consumers can find themselves saddled with bills for medical services. Prices vary tremendously and are usually higher for the uninsured or for people with health coverage but using out-of-network providers. Even in-network costs can vary widely between different facilities or departments.

And we know many people avoid getting the care they need because they rightly fear the financial consequences.

To grasp why this removal is so important, you have to understand the gravity of these small-dollar debts. It’s not just one bill under $500. People are often receiving multiple bills from different health-care providers. According to the CFPB, $88 billion of outstanding medical bills are in collections — affecting 1 in 5 Americans.

Here are other disturbing statistics from the CFPB about the most common collection tradeline reported on consumer credit records.

• As of the second quarter of 2021, 58 percent of bills that are in collections and on people’s credit records are medical bills.
• Medical debts constituted 68.9 percent of accounts reported by debt collection companies that base their fee on how much they collect.
• Credit scores are lower in the South largely because of medical debt.
• People with low incomes, veterans and older adults are significantly impacted by medical debt. Black and Hispanic consumers are disproportionately more likely to have medical debt. “Due to racial inequities in health and wealth, the medical debt crisis has impacted Black families more acutely than White families,” according to a 2022 report from the National Consumer Law Center.”

The action by the credit bureaus is the latest move to get rid of health-care debt plaguing Americans and contributing to lower credit scores. Even folks with good health insurance can find themselves in medical debt.

Last year, the credit bureaus removed all medical collection debt that had been paid by the consumer in full. Additionally, the time period before unpaid medical collection debt appears on a consumer’s credit report was increased from six months to one year, giving consumers more time to address such debt before it appears in their credit files. Often these debts are reported to the credit bureaus because of payment delays by people’s insurance companies. Or there are billing errors.

Despite recent steps forward, we still should be exploring whether all medical debt should be removed from people’s credit files.

“Approximately half of all people with medical collections on their credit reports will still have medical collections on their credit reports, and the majority of the bills, by dollar amount, will remain,” according to an emailed statement from CFPB spokeswoman Tia Elbaum.

Elbaum said people who live in the southern and western parts of the country, as well as those who live in lower-income neighborhoods, are least likely to benefit from the change and are most likely to continue to have medical items reported on their credit reports.

Newer credit scoring models don’t weigh medical collections as heavily as other forms of credit. And when such data is removed, people’s scores can jump significantly, as much as 25 points, according to the CFPB.

Here’s what one consumer wrote to the CFPB in a complaint about an emergency room visit: “I called and asked for an itemized invoice, trying to understand how five minutes with a doctor who essentially told me not to worry, that my daughter was fine, could cost $1,500. The response I received was that that was the flat rate the hospital charges my insurance company.”

I’m all about personal responsibility, but tell me how this kind of excessive pricing predicts someone is creditworthy.

https://www.washingtonpost.com/business/2023/04/12/medical-debt-credit-reports/ 

Opinion

Speaker Talbot Ross: ‘Health care for all’ must not rule out immigrants

It's time to close a small but unjust gap in MaineCare and return our state to its longstanding practice of greater inclusion.

By Rachel Talbot Ross - Portland Press Herald - April 12, 2023

 

All means all. It sounds simple, but when it comes to accessing healthcare in Maine, it isn’t.  

L.D. 199, my bill to provide MaineCare to all Mainers with qualifying low income, regardless of immigration status, would provide much needed fairness, equity and simplicity to our Medicaid program. And based on the heartfelt testimony I recently heard in support of the bill from parents, workers, health care providers and advocates from across the state, it is abundantly clear that the time for this legislation is now.   

Immigrants who testified at a long and often emotional public hearing shared their love of living and working in Maine, how much they care about the health and safety of their communities, and how deeply they want to be included and respected as part of our state. They desire what every generation of immigrants to Maine has – a chance to live in peace and safety, to build a life, and to give their children a strong start in this beautiful place.  

Crystal Cron, founding director of Presente! Maine said, “Immigrants have been contributing to the strength and vitality of Maine for centuries. They have resettled here with hopes and dreams of building a new life for themselves, and of investing in the communities they now call home. And they have invested. If you’ve worked thousands of hours in a lobster plant, or in the blueberry fields, or in potato packing, aren’t you a Mainer? The health of one is the health of us all, and we all reap the benefits when our communities are cared for.” 

Others testified to the tragic loss of life and livelihood that immigrants they know have experienced. A loving and involved father of two elementary students in Falmouth died of treatable cancer, orphaning them. Two young members of the Congolese community who could not afford basic health screenings died suddenly last year in Lewiston.  

L.D. 199 is a straightforward bill that would help close a small but unjust gap in our MaineCare system and return Maine to its longstanding practice of greater inclusion. It was only in 2011, under the LePage administration, that this access was restricted. This initiative would continue building on Maine’s health care progress that began with Medicaid expansion, and repair a two-tiered health care system that is divided along complex and ever-evolving immigration lines. And it would help prevent untold tragedies through affordable medicine or regular preventative medical care.

Just as we have seen with Medicaid expansion, helping more people afford health care will also have beneficial ripple effects for our workforce and economy. 

In 2018, immigrants in Maine contributed at least $193.9 million in state and local taxes. That number is certainly higher today. Yet they pay into a healthcare system that they are not allowed to access. This is unfair and tragically short-sighted. The overall costs of missed workdays, lower production, and disability far outweigh the direct costs of medical care. As we wait for Congress to make the necessary federal reforms to our broken immigration system, providing healthcare to our essential workers is something we can do now.  

Access to affordable healthcare saves lives and reduces costs in overall healthcare spending. Currently, the people who would gain coverage from my bill are only eligible for Emergency MaineCare to stabilize a life-threatening emergency. Patients who lack full health coverage often delay or go without care until a condition worsens and becomes an emergency, resulting in more costly and resource-intensive services that place unnecessary burdens on our hospitals and the entire health care system.  

Mainers voted overwhelmingly to expand Medicaid and the Maine Legislature has honored the will of the voters. It is time to finish what we started and make sure all Maine residents have the healthcare they need and deserve. 

My fellow lawmakers have a choice to make. Will we put our values into policy and practice and ensure that everyone in our state can access necessary care? Or will we continue to disregard the needs of people who keep our state running? Let’s choose equity, prosperity and a health care system that works better – no exceptions, no exclusions – for all.

https://www.pressherald.com/2023/04/12/speaker-talbot-ross-health-care-for-all-must-not-rule-out-immigrants-2/ 

 

Bill would mandate nurse-to-patient ratios in Maine hospitals

Supporters say nurses are spread thin and overworked, but the Maine Hospital Association says the mandate would restrict patient care. 

by Joe Lawlor - Portland Press Herald - April 12, 2023

A nurses union is supporting a bill that would establish minimum nurse-to-patient staffing ratios at Maine hospitals.

Supporters say it would provide relief for nurses who are spread too thin because of a hospital workforce shortage, while hospital officials oppose the bill and say such a mandate would reduce patients’ access to care.

The bill, sponsored by state Sen. Stacy Brenner, D-Scarborough, was released Wednesday and contains a lengthy list of nurse-to-patient ratios depending on conditions of patients. Averaged out, it would require roughly one nurse for every two patients.

If it is approved, Maine would become the second state, after California, to have a law mandating nurse-to-patient ratios.

Brenner, a former nurse, said she was compelled to introduce the bill because “the workplace conditions are really overwhelming right now for an inpatient hospital nurse.”

There are about 26,000 licensed nurses in Maine, according to state data.

Cokie Giles, president of the Maine State Nurses’ Association and a nurse at Northern Light Eastern Maine Medical Center in Bangor, said the problem is not an overall nursing shortage, but a shortage of those willing to work in hospitals under difficult conditions caused by high patient loads. The nurses are instead choosing primary care, outpatient clinics or other non-hospital jobs.

“Plenty of nurses are getting hired at hospitals. What’s happening is they’re not staying. We have a leaky bucket,” Giles said.

But Jeff Austin, vice president of governmental affairs for the Maine Hospital Association, disputed that characterization, arguing there’s an overall shortage of nurses, and that hospitals would be hampered by such an inflexible mandate. Austin said hospitals value nurses and want to hire more, but this bill is not the way to do it.

“This bill is the most significant threat to access to care and threat to hospitals that I’ve ever seen,” Austin said. “It will cost hospitals over $100 million, because we would have to hire 1,000 nurses. That assumes we first are able to fill all of the 1,500 positions we are currently trying to fill.”

A 2022 analysis prepared for the hospital association and the Maine Nursing Action Coalition says there was a shortage 2,250 registered nurses in 2021 and projects a shortage of 1,450 to 2,250 registered nurses by 2025. Because there has been an increase in nursing graduates in recent years, that projection is better than an earlier forecast, which predicted a shortage of 3,200 registered nurses over that time. Giles said colleges are focusing on graduating more nurses, which will help even more in the coming years.

Austin said hospitals have already blown through their personnel budgets because they have been forced to hire traveling nurses, who have been in higher demand since the pandemic but cost exponentially more. The difficult working conditions during the pandemic strained hospitals and led many nurses to leave, including many who were near retirement age.

Positions filled by traveling doctors, nurses and other medical staff have more than quadrupled because of the pandemic, from 535 traveling positions in 2019 to 5,138 in 2022, according to data from the Maine Hospital Association. The MHA did not have a breakdown of how many of those positions were nurses.

Brenner said if hospital nursing jobs become more attractive, hospitals won’t need to hire as many traveling nurses.

Austin said with hospital budgets already strained, a staffing-ratio mandate will lead to more waiting and reduced access to care for patients.

“If you don’t meet the rigid statute, you can’t see the patient,” Austin said.

Sharon Baughman, chief nursing officer for MaineHealth, the parent organization of Maine Medical Center and seven other Maine hospitals, said nurse-to-patient ratios can be good guidelines, but an inflexible mandate would reduce efficiency.

“If we have a patient ready to go home and just waiting for a few hours for family to come pick them up, that patient would still be part of the ratio,” Baughman said. “But now, a nurse might make a judgment call and could facilitate bringing in another patient. With the ratios, we would not be able to make that same level of independent decision-making.”

But Brenner said the bill is much more flexible than opponents are portraying. If a patient’s condition improves, for instance, the staffing ratio would be eased, she said.

And Giles said that if nurses know a state law requires adequate staffing for patent care, hospital jobs will be more attractive, also leading to better patient care.

“How many times have we heard patients say, ‘the nurses are so busy they can’t get to me,’ ” Giles said. “The patients’ needs are not being met. Nurses often don’t have time to break for lunch and we have nurses going home every night crying because they can’t help patients the way that they should be able to.”

Research on California’s ratio law is mixed. According to a 2010 study for Health Services Research, “hospital nurse staffing ratios mandated in California are associated with lower mortality and nurse outcomes predictive of better nurse retention in California.”

But another 2013 study found “mixed effects” on quality and a 2014 analysis by the Health Economics journal found that “in spite of years of work to establish statewide staffing regulations, there is little evidence that the (California) law was effective in attracting more nurses to the hospital workforce or improving patient outcomes.”

The bill will go before the Legislature’s Joint Standing Committee on Labor and Housing in the coming weeks.

https://www.pressherald.com/2023/04/12/maine-bill-would-mandate-nurse-to-patient-ratios-in-hospitals/ 

 

Commentary: Health care for vulnerable populations makes spiritual and economic sense

An unconditional commitment to caring for the sick, however you arrive at it, represents a fundamental quality of a decent world.  

By Peter Pressman - Maine SundayTelegram - April 16, 2023

 

House Speaker Talbot Ross’ column of April 12 was a powerful and timely essay (“‘Health care for all’ must not rule out immigrants,” April 12). However, I was struck as much by the readers’ responses to the column online as by the speaker’s eloquent plea for healthcare access regardless of immigration or low-income status.

The eminently understandable and justified frustrations resulting from the breathtaking costs of healthcare and delays in receiving timely medical interventions were comingled and contaminated with the anger and myriad xenophobias that have polarized our country and our state.

As a physician, as a teacher, and as a health care consumer, I want to address both the readers’ frustrations and fears about access to quality care in this era of unprecedented social and public health challenges.

First, let’s revisit the essence of what is arguably Martin Luther King Jr’s most important and overlooked speech, “The World House,” from the Nobel Prize Lecture at the University of Oslo in 1964. King suggested that in the world house, what affects one can affect all indirectly eventually.

COVID-19 certainly demonstrated this prophecy. Under one roof, in the world house, if someone is sick, then you may become ill as well. If someone is poor, they can be hidden away, banished into the basement with little light or access to that which helps sustain life, but they are still there. Our housemates, “essential workers” as they are often called, grow the food, harvest the food, serve the coffee and tend to the sick, often with catastrophic consequences to their own health.

Is this the sort of world we want to live in? Is this the uniquely American way, the Maine way, the Judeo-Christian way? The duty to heal the sick and provide for the poor are deep moral imperatives in the Judeo-Christian tradition. Combined with the biblical command to treat the stranger as yourself because you were once a stranger in a strange land, this duty transforms our obligations beyond the worthy interest in promoting the health and well-being of our own community.

Providing care and support to the needy are at the core of Islamic philosophy and accordingly, the Prophet Muhammad reflected the same through his services to the poor and to patients.

My point here is that every major global religious philosophy has at its core an unconditional commitment to caring for the sick. Despite sociocultural and political differences, we revere this spiritual mandate; it represents a fundamental quality of a decent world.

How do we provide the material and instrumental structure of that decent world? In the most general and modern terms, the path to universal health care is incredibly complex and no single policy solution exists. It involves political will and commitment by governments to meet the health needs of us all (to uphold our right to health); it involves putting the resources in place (financing and health services) to ensure that services are accessible to all; and it involves ensuring that the right steps are in place to protect people from financial ruin.

Again, in the broadest sense, public health interventions for vulnerable populations not only make spiritual sense, they make economic sense by reducing the burden of illness and preventing eventual and inevitable higher costs to the mainstream community.

Care must be based upon a patient’s medical need and not upon medically unrelated and irrelevant factors such as race, creed, color or nationality. Contrary to some views, undocumented immigrants are not the cause of crowding in our emergency departments. Today, most emergency rooms are crowded with patients seeking primary care treatment because they do not have access to an ongoing or real-time source of care.

And yet again, despite claims to the contrary, undocumented workers do pay taxes. They pay sales taxes on purchases, ad valorem taxes through rent or home ownership, and many pay Social Security, Medicare and worker’s compensation via payroll deductions.

Consider also that we can reduce infant mortality and days of neonatal care – all while saving thousands of dollars per child – simply by providing meaningful access to prenatal care.

If we take care to educate our underserved and vulnerable groups, and collaborate with them toward optimizing their health, we will all benefit. It cannot be over-emphasized.

We have made great progress in Maine in terms of pragmatically achieving genuinely adequate and accessible health care. The expansion of Medicaid and Emergency MaineCare are vital elements. L.D. 199, the bill proposed by Talbot Ross, is the next critical piece.

To ultimately and fully operationalize this legislation, we need to closely consider the entire northern half of our state, which is without adequate primary and specialty care, and without a school of medicine or a university hospital focused on educating, training and retaining our own most valuable health care resource: our young people, who will become the physicians, surgeons, and medical scientists of the future.

https://www.pressherald.com/2023/04/16/commentary-5/#coral_talk_stream 

 

Hospitals face new wave of competition from infusion centers

It's the latest example of insurance companies partnering with independent centers to offer lower-cost outpatient services.

By Joe Lawlor  - Portland Press Herald - April 17, 2023

 

The recently opened Novella Infusion center in Portland offers some of the latest perks in outpatient health care: private rooms where patients can sit back in recliners and watch online streaming services while receiving IV infusions to treat chronic conditions from rheumatoid arthritis to multiple sclerosis.

Novella has similar centers in Lewiston and Augusta. A second infusion company, Local Infusion, has launched a treatment center in Augusta and is opening one in South Portland this month.

The infusion centers are the latest example of insurance companies partnering with independent centers to compete directly with hospitals by providing lower-cost out-patient services such as screenings, infusions, X-rays, laboratory work, MRIs and CT scans in less clinical settings designed to appeal to patients. In this case, Anthem – Maine’s largest insurance company – and other insurers have signed agreements to provide in-network coverage for treatments at Novella Infusion and Local Infusion.

It’s a national trend that has been building for years as insurance carriers seek to contain their costs and patients become more consumer-oriented when seeking care that was once the exclusive domain of hospitals.

“I think this is perhaps a good thing,” said Ann Woloson, executive director of Consumers for Affordable Health Care, a Maine-based advocacy group. “We definitely welcome any new pathways to increase competition. This does have a chance to bring down costs. Consumers who have access to quality, less expensive care, that in theory should help with the cost of insurance premiums.”

Hospitals, however, say the competition isn’t exactly fair and creating redundant services doesn’t improve the overall efficiency of the health care system.

“The cost structure of hospitals is simply different than it is for a provider of a single service, be that an infusion center, or an imaging center or a dermatologist or anything else,” said Jeff Austin, vice president of government affairs for the Maine Hospital Association.

For Trilby Burgess, 35, of Vassalboro, who has rheumatoid arthritis, she estimates that going to Local Infusion in Augusta will save her $600-$800 out-of-pocket per visit compared to when she used to go to Pen Bay Medical Center in Rockport.

“Saving that money will be huge,” said Burgess, who gets infusions every six weeks. “Being a single mom, it wasn’t easy to come up with the money every time.” Burgess said she’s not sure exactly how much she will have to pay out-of-pocket at Local Infusion, but she believes it will be a few hundred dollars per session.

Peter Hayes, president and CEO of the Healthcare Purchaser Alliance of Maine – a nonprofit that advocates for improved health care quality, lower costs and consumer choice – said that for certain patients, the presence of infusion centers and other services will drive prices down. But for the overall picture of health care spending in Maine, the impacts of services like independent infusion centers are more murky.

From the patient’s perspective, more competition, more sites of care, more choice – that’s a good thing,” Hayes said. “These places can be more convenient than hospitals, patients can get a better care experience. But it’s unclear what impact it will have overall on the cost of care in Maine.”

Denise McDonough, president of Anthem Blue Cross and Blue Shield of Maine, said that these services up until a few years ago were almost entirely conducted in hospitals, and patients had no choice but to go to hospitals and oftentimes get overcharged.

“There’s this huge disparity in costs,” McDonough said. “Our view is the same service that can be offered in an independent facility down the street should not be hundreds of percents more expensive at a hospital.”

Anthem is offering incentives of up to hundreds of dollars in cash, depending on the service, for patients who choose the independent facilities over hospital-owned care. The insurance company is increasing awareness of the incentives to try to spur more patients to choose independent health care services.

Up until recently, there were very few independent labs, independently owned urgent cares, and very few independent imaging centers,” McDonough said. “These services were conducted almost entirely in hospital-owned facilities.”

Anthem provided some cost breakdowns of services provided at independent health centers compared to hospitals, and showed the Press Herald that a CT scan cost $436 at an independent facility, while hospital prices in Maine for the same service ranged from $802 to $1,721.

For infusions, Remicade, a treatment for Crohn’s, ulcerative colitis and rheumatoid arthritis, infusion clinic costs were $4,800, compared to a range of $14,900 to $60,000 at Maine hospitals, according to the Anthem data provided to the Press Herald. A smaller dose of the same Remicade treatment on the comparemaine.org website shows that costs at hospitals were twice as expensive when compared to clinics.

But Austin of the Maine Hospital Association, said hospitals perform many services that lose money, and so hospitals have to make up the funds by charging more for other services.

“Hospitals form the backbone of the health care system for the state,” he said. “There are parts of the health care system that lose money.  We operate many of those parts.  There are other parts of the system that finance the money-losing parts of the system.”

Austin said independent, for-profit centers “don’t run emergency rooms that are open and equipped and staffed to treat everything from a stroke to a heart attack on Christmas day. Hospitals do. It doesn’t make financial sense to stay open on Christmas day. For-profit primary care doctors don’t. For-profit urgent care centers don’t. We do.”

Austin also said that patients with more complex cases who need infusions likely need hospital-level care.

“Hospitals can’t close their clinics,” Austin said. “They have to exist for the difficult patients that other centers can’t or won’t take. Is it efficient to have a redundant for-profit clinic or would it be better to use the essential infusion clinic that must exist?”

But Hayes, of the purchaser’s alliance, said that competition by the independent health services puts pressure on hospitals to charge closer to what it actually costs to provide the service. It could also potentially reduce the market clout of hospital systems like MaineHealth and Northern Light.

“There doesn’t seem to be a logical basis to how hospitals decide what to charge for their services,” Hayes said.

But one obstacle for insurance companies is that for many patients, the cost of the service, even at an infusion center, is high enough that patients are meeting their deductible and so the cost savings is not seen by the patients. That’s where the cash incentives – called SmartShopper by Anthem – will play a role, said Anthem spokeswoman Stephanie DuBois. Some patients will save money, DuBois said, such as those who need a one-time infusion or a lower-cost infusion.

But it’s not only cost savings that’s driving the changes, but the overall patient experience, said Woody Baum, CEO and founder of Local Infusion.

“When you are introducing change, that change needs to be attractive to the patients,” Baum said. “You can’t just throw chairs in a room. You need to make it a nice experience, have private rooms, night and weekend scheduling. You need to make it a good experience if the patients are in there for hours at a time.”

For instance, Baum said initial attempts to locate infusion treatments at urgent care centers flopped because patients didn’t like the atmosphere and the immune-compromised patients needing the infusions didn’t want to be around others who could be contagious.

Burgess, the Vassalboro resident, said that the hospital experience was not pleasant, and that she felt overwhelmed sitting in a large room with numerous other patients, including some cancer patients, receiving treatment at the same time as her. Burgess said she will like the privacy of Local Infusion.

At Novella in Portland, Rebecca Greenbaum, vice president of operations, said that they can provide good services at a cost savings for patients. Novella is not only partnering with Anthem, but also all the other major insurance carriers in Maine.

“It’s a personal, comfortable space where patients can receive therapy from highly skilled clinicians,” Greenbaum said. “Patients can get in and out quick, and you are always seeing the same personnel providing the service. They are going to get to know you, where you might see different people every time you go to the hospital.”

https://www.pressherald.com/2023/04/17/hospitals-face-new-wave-of-competition-from-infusion-centers/