Editor's Note -
The link below will take you to the On Point episode on NPR for February 13, 2024, It focuses on the futility of relying on laws to increase "transparency" of prices and other data to solve the many problems, including the rapidly costs of healthcare in our badly broken health care system. The show is well worth listening to in its entirelty.
- SPC
Who owns your medical records?
Hint: It's not you. Nor do they belong to taxpayers, who paid for their collection.
Cyber thieves hacked their way into the computer system at Lurie
Children’s Hospital in Chicago last week, shutting down the patient
portal, email and telephone systems at an institution that serves a
quarter of a million children annually. None have returned to normal as
of this writing.
Lurie is not the only health care facility
victimized by data thieves, who often demand ransom to end their online
disruption. There have been nearly 6,000 healthcare data breaches since
2009. In 2023, hackers gained access to a record 133 million patient and
employee files. That was 2 ½ times the level of 2022, which was the
previous high year, according to the Office for Civil Rights inside the
Health and Human Services Department.
Apparently, “known criminal
actors” (Lurie’s description of the perpetrator) have easy access to
patient and hospital data. I wish the same could be said for physicians
at one hospital trying to get records for a patient previously admitted
to a different hospital system. Or specialists in one practice trying to
get records from a primary care doctor in an unaffiliated practice. Or
patients trying to transfer their medical records from one facility to
another. Or researchers trying to obtain de-identified records from
various hospitals to see how well they compare on safety, outcomes and
cost.
Stealing medical records is easy for criminal hackers. But
obtaining them legally remains a difficult or even impossible task for
patients, even though both hospitals and physicians are required by law
to share data if given permission by the people they care for.
It wasn’t supposed to be that way. Shortly after President Barack
Obama took office, Congress passed legislation that granted $30 billion
to hospital and physician offices to buy computers and digitize their
medical records. When the law passed, most of those records resided in
manila folders, which put the health care industry about three decades
behind the rest of America in joining the information age.
If
health care providers took the money, and almost all eventually did, the
2009 Health Information Technology for Economic and Clinical Health
(HITECH) Act required they and their software vendors meet rigorous
standards. First and foremost, they had to protect patient privacy,
which was already required by law.
The HITECH Act added a new set
of requirements to promote better health care. The new systems had to
use standardized data protocols so patient records could be easily
exchanged between providers — so-called interoperability. The law’s
architects believed health record interoperability was key to overcoming
the fragmentation that plagues America’s health care delivery system,
where primary care physicians, specialists and hospital clinicians
maintain separate medical records for an individual patient.
In
addition to enabling better coordination of care, interoperability would
eliminate duplicative tests. It would reduce medication and treatment
errors. It would relieve patients of the onerous task of filling out the
same forms every time they visit a hospital, clinic or physician’s
office. Its most fervent proponents hoped it would foster better health
outcomes in a country, which, while devoting over 17% of its economy to
improving health, achieves middling results in life expectancy, infant
and maternal mortality and many other basic indicators of public health.
The
law also gave states grants to set up health information exchanges
(HIEs), which would serve as clearinghouses where providers could
deposit their patient records. This would allow other providers
instantaneous access to their patients’ records after the patients had
given permission to share.
The HIEs would serve as a research
repository where the data, de-identified to protect individual privacy,
could be used by public health officials to highlight major societal
health challenges; track vaccination rates; and monitor cancer,
hypertension and diabetes screenings. It would empower public agencies
to spot geographic disease hotspots – those communities hardest hit by
the opioid, behavioral health, hypertension and obesity/diabetes
epidemics. This would enable public health departments to deploy their
scarce resources in the most needy areas.
Health researchers could
use the data in HIEs to create what came to be known as a learning
health care system. Analyzing the real-world outcomes from the use of
drugs, medical devices and surgical procedures would provide valuable
information to improve the clinical practice guidelines issued by scores
of government agencies, medical professional societies and patient
advocacy groups. It could be used to inform clinicians what works best
and under what circumstances, especially when there are competing
approaches to treating a particular disease.
Provider
organizations could use HIEs to get feedback on the quality of care they
provided. They could compare their outcomes to rivals; compare resource
use; and compare the outcomes obtained by individual clinicians within
their own organizations to see if unnecessary variation in clinical
choices was harming patients or wasting resources on costly procedures
and tests that didn’t lead to better outcomes. States could use the data
from HIEs to make hospital and physician performance transparent, thus
allowing patients to make better informed choices when choosing
hospitals, physicians or other providers.
In short, the dawn of
the medical informatics era over a decade ago was greeted with the same
fervor that is greeting artificial intelligence in medicine today. It
was going to change everything.
Things did not turn out as planned. Providers took the money, of course. According to the most recent report
issued last March by the Health and Human Services Department’s Office
of the National Coordinator (ONC), which was created to oversee the
digitization of America’s medical records, nearly all hospitals and
four-fifths of physician offices have installed electronic health record
systems (EHRs).
Indeed, near universal EHR adoption had
been achieved as early as 2014. But what we have seen since is an almost
complete failure to achieve the most ambitious goals of information
sharing. Progress on every front has been “inconsistent and influenced
by different priorities across industry actors,” the ONC report said.
Indeed,
flagrant disregard of the interoperability requirements in the original
HITECH Act led Congress in 2016 to include a section in the 21st
Century Cures Act that imposed up to $1 million in fines on health care
providers that refuse to share data. The ONC maintains a portal where
patients or providers can report alleged instances of what the
regulators called information blocking.
To date, it has
received nearly 900 complaints. None has led to fines by the HHS Office
of the Inspector General, a spokesman for the agency said via email. The
agency also refused to comment on whether any investigations are
underway.
What’s behind this systemic refusal to use digitized
medical records to reduce fragmentation, lower costs, improve quality,
and get better outcomes?
The answer, in short, is the
financialization of health care. Every player in the health care
ecosystem has a proprietary interest in maintaining a stranglehold over
what they consider to be their data. They resist interoperability
because it impedes their ability to make money. They say they want to
share, but in practice, they act like a bunch of high school bullies
stealing lunch money from the nerdy kids.
Hospitals, especially
those that belong to large systems that are both horizontally and
vertically integrated (they own multiple facilities in multiple markets,
each attached to large physician practices with extensive outpatient
and surgical centers) are reluctant to share data with other systems in
their service territories. They have no interest in making it easy for
their patients to switch providers.
These dominant organizations use a variety of illegal and quasi-legal tactics to block information exchange. They include:
Charging excessive fees to create electronic health record interfaces;
Requiring recipients adopt their brand of EHR before sending data;
Imposing unduly restrictive contractual limitations on the use of the data; and
Simply delaying the exchange, which in health care is tantamount to denying the request.
I
spoke last week with Dr. David Blumenthal, the first head of the ONC.
He recently returned to teaching public health at Harvard University
after running the Commonwealth Fund. The original proponents of the law
were naïve, he said.
“No one expects a BMW dealer to exchange his
client list or his client’s purchasing patterns with the Toyota dealer
down the street,” he said. “But somehow, we expected that hospitals
would do that out of the goodness of their hearts. It turned out it
costs money, aggravation, and there’s no return on investment to them.
In fact, there is a potential loss of business.”
But from the
patient point of view, there are many reasons for wanting to switch
providers. They may want to see a different doctor. They may have a new
insurer with a narrower physician or hospital network. They may want
lower out-of-pocket costs.
Such switching would be seamless if they could easily move data from
one provider to another. Hospital systems and large physician practices,
afraid of losing the revenue, have no interest in seeing that happen.
Concentration
within the medical-industrial complex has made it easier for big health
care systems to resist interoperability. Today, the nation’s 600-plus
hospital systems, which own three-quarters of the nation’s 5,000-plus
hospitals, employ over half the nation’s physicians and surgeons. Throw
insurance- and corporate (often private equity)-owned physician
practices into the mix and that number rises to 73% of all doctors, up
from just a third two decades ago, according to a recent study by the Physicians Advocacy Institute.
Most
metropolitan areas are dominated by a handful of large systems.
Patients today no longer switch doctors. They switch systems. And when
markets are concentrated, there can be a tacit agreement among those
systems to avoid sharing patient data — what in essence is a cartel for
pursuing information blocking.
Providers are aided and abetted by
the EHR software vendors. Though there are dozens of companies selling
EHR software, the market is dominated by four firms that control over
80% of the hospital market. The physician office EHR market is similarly
skewed.
Vendors’ reasons for avoiding interoperability are the
same as their customers: They want to limit competition by making it
harder to switch. It would also cut off a lucrative sideline business
selling the add-on software needed to exchange data between otherwise
incompatible EHRs.
Epic Systems, a privately-held company
headquartered near Madison, Wis., dominates the market. It set the
standard for building firewalls to prevent information sharing between
health care systems.
Founded in 1979 by Judith Faulkner, now 80,
Epic posted an estimated $4.6 billion in sales in 2022, earning its
primary owner third place on Forbes Magazine’s list of richest American
women with an estimated net worth of $7.4 billion. That value has grown
fourfold since the dawn of the government-funded EHR era.
I
interviewed Faulkner at the 2014 HIMSS meeting, the industry’s largest
trade show. I asked her if Epic promotes interoperability. She pointed
to Care Everywhere, a trademarked service launched in 2008 that allows
any Epic user to share data with any other Epic user. In other words, if
you want to exchange data with a hospital that uses Epic, all you have
to do is buy an Epic product for your health care office or facility.
A few years ago, Epic added Share Everywhere,
which allows patients to access their data on a smart phone or
computer, which they can then share with other providers. But there’s a
catch. It’s only available when the patient is logged in. Epic’s patient
information sheet on Share Everywhere makes no mention of allowing that
data to be downloaded, much less sent to another provider. However,
“the person who views your information can also write a note back to
your health system to help keep your care team informed of the care they
provided.” Ah. Another provider can share its data with Epic, but it is
not reciprocal. Epic won’t share its data with them.
The
section of the 21st Century Cures Act that aimed to put an end to
information blocking set up the Trusted Exchange Framework and Common
Agreement (TEFCA) – a common set of standards for information exchange.
Shortly after it passed, a survey
of state- and regionally-run health information exchanges (HIEs) —
there are more than 100 across the country that were set up to
facilitate data exchange — reported over half of EHR vendors and nearly a
third of health systems engaged in information blocking. The HIEs cited
the unreasonably high prices providers and their vendors put on
transferring data as the number one cause of information blocking.
In
theory, the law had teeth. The final rule set a $1 million maximum
penalty for information blocking. Four years later, the OIG has yet to
impose a single penalty despite receiving nearly 700 complaints from
patients and 100 from providers.
That oversight failure provides a
textbook example of agency capture (economist-speak for when regulated
companies control or successfully limit regulators’ actions). The final
rule identified eight “exceptions” when regulators would allow
information blocking.
You do not have to be a legal genius to use
those exceptions to deny requests for data, especially given how rampant
data breaches are today among health care providers. The eight
exceptions include: Situations where sharing might harm patients,
compromise privacy or risk data theft; if sharing is unfeasible for
technological reasons or unforeseen events; if fees for obtaining data
(including profits) are “reasonable”; and if providers want to to
license the data, which can be used to restrict downstream uses, even if
de-identified.
Since that rule didn’t solve the problem, HHS has come up with
another rule. Last month, the agency finished collecting public comment
on a rule that creates “disincentives” for information blocking. It
would cut bonus payments to hospitals that took government cash to buy
computers and EHRs but failed to provide easy data exchange. Physician
offices would see their quality bonuses cut by as much as 25%. And
accountable care organizations, which share savings with the federal
government when they lower costs, would see those bonuses cut.
Reading
the comments to the proposed rule gives one a good picture of how
seriously the leading trade groups for hospitals and physician practices
take the interoperability requirements contained in the original HITECH
law. The Federation of American Hospitals, the trade group for the
for-profit section of the industry, wants CMS to take “an educational
and not a punitive approach, at least initially, until agencies and
providers have much greater experience in investigating claims and
working with providers to remedy any potential information blocking.”
America’s
Essential Hospitals, which represents 200 mostly urban hospitals that
provide a high proportion of their care to the poor and uninsured, said
the group was “firmly on board with the need to seamlessly share
information.” However, it called the rule excessively punitive and
premature. “There is still significant confusion about the types of
conduct that would constitute information blocking,” CEO Bruce Siegel
wrote.
Meanwhile, America’s Physician Groups, which represents the
nation’s 360 largest physician practices with over 200,000 doctors,
complained that lowering both quality bonuses and shared savings at
physician practices that participate in ACOs represents “double
jeopardy.”
Even the Sequoia Project, an industry-wide
consortium set up in 2012 to promote interoperability, suggested the
proposed “disincentives” went too far, even though the proposed cuts to
bonus payments and shared savings are minuscule, a tiny fraction
of annual revenue. “We recommend that investigations be limited to
egregious acts and persistent, bad behavior,” wrote CEO Marianne Yaeger.
Moreover, “providers should always have the right to appeal the
decision that information blocking occurred.”
Only Families
U.S.A., which represents health care consumers, voiced unconditional
support for the penalties in the proposed rule. “Access to interoperable
and transparent data enables hospitals, clinicians, and payers to
provide higher quality, less costly care,” wrote Sophia Tripoli, the
senior policy director for the group. “It is vital that data be made
more broadly available and interoperable across the payment and delivery
system.”
With that alignment of forces — all providers, payers
and vendors lined up against a handful of consumer groups — it looks
like it is still going to be a long time before patients can walk into a
doctor’s office, download their entire medical record onto a thumb
drive, and transfer it to another doctor’s office.
https://gooznews.substack.com/p/who-owns-your-medical-records?utm_source=post-email-title&publication_id=106809&post_id=141578819&utm_campaign=email-post-title&isFreemail=true&r=cfrnr&utm_medium=email
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| by Robert Kuttner - The Ameriican Prospect - February 6, 2024 |
| A couple of weeks ago, a good friend found herself in the emergency room at one of our world-class hospitals, the Brigham and Women’s Hospital in Boston. After emergency surgery, the medical team decided to admit her for at least another day to monitor her recovery. What she encountered next was something out of a makeshift battlefield hospital, as rendered by Hieronymus Bosch. There were no beds available in the patient rooms, so “admitted” patients were being stashed in beds laid end to end in the emergency area. A bit of delay getting a bed is not unusual. But in this case, there were seriously ill admitted patients in 73 beds crammed into the emergency area. They had no privacy, and many were not masked. The beds wound around an overwhelmed nursing station, where a couple of nurses were mainly dealing with new patients. This makeshift field hospital was so large that it was sectioned off into subareas that had been given Boston street names (my friend was in the Exeter Street area), so that family and physicians could find them. What the hell? In exploring the deeper causes of the backup, you encounter a story of multiple, cascading failures of our health system. And no, it doesn’t have a lot to do with COVID overload. There are few patients hospitalized with COVID. The immediate cause is a shortage of skilled nursing facilities, rehabs, and home care options into which still-impaired patients can be released. So patients are kept in acute care hospitals because there is no place else for them to go. This means that the normal process of beds opening up, as patients are discharged, backs up and bogs down. This is completely at odds with deliberate incentives in Medicare and private insurance plans to get patients released from expensive acute care hospitals as soon as medically feasible. There are approximately 1,200 such patients currently occupying hospital beds in Massachusetts. In December, according to the Massachusetts Health & Hospital Association, 44 percent of hospitalized patients awaiting discharge to a skilled nursing facility were waiting for 30 days or more. They were basically in residence at a hospital, taking up scarce beds at the most expensive venue for care. And hospitals do not have rehab staff. This mess is a vivid example of how reliance on commercialized health care with piecemeal regulation has failed and backfired. Dig deeper, and there are the multiple causes of this mess: There is a severe shortage of slots in skilled nursing facilities. Much of this is driven by a shortage of staff, mostly nurse aides, known as certified nursing assistants (CNAs). To be precise, there were an incredible 6,900 unfilled vacancies. Why the staff shortage? The biggest single reason is that the work is hard and the pay stinks. A CNA typically earns between $18 to $21 an hour. Given Boston rents, this is not enough to live on. Many people trained as CNAs are working at other jobs. Many others working in nonclinical jobs at nursing homes could be trained as CNAs if the pay were decent. This staffing shortage, in turn, has caused at least 20 skilled nursing facilities to close since the start of the pandemic; there are now 3,000 fewer beds in such facilities available than in 2020. Many nursing homes that are open are running at about two-thirds capacity and not accepting new patients, due to staffing shortages. Their business model calls for them to operate at capacity, so they are losing money and at risk of closing. In addition, consolidations and mergers have cut the total number of inpatient hospital beds. These include the ongoing collapse of the Steward hospital chain, which converted a nonprofit Catholic health system to a for-profit one and then ran short of operating money after being milked by a private equity fund owner. Another prime cause is the evil of Medicare Advantage, the privatized, for-profit system that leaches off Medicare. As the Prospect has reported, Medicare Advantage pretends to increase coverage. But because Medicare Advantage programs are so intensely “managed” to deny needed care, they are great when you are well but not when you are sick. While conventional Medicare provides 20 days’ coverage in a skilled nursing facility at no cost to the patient and another 80 days with a co-pay, Medicare Advantage plans often refuse to pay for post-hospital nursing care at all, according to a report by the HHS Office of Inspector General. The Mass Health & Hospital Association’s own report puts insurance denials for skilled nursing care as the top cause of the crisis. A further problem is that health plans often don’t pay for case managers. An elderly patient facing discharge from a hospital, with multiple conditions, often complicated by dementia, is not competent to manage her own case. When a hospitalized patient cannot safely go home, three options are a skilled nursing facility, a rehab, or home care. All are short of staff, largely because of profiteering and inadequate pay. Incidentally, the Republican policy blueprint for 2025 includes a suggestion to make Medicare Advantage the default option for all seniors coming into the program. Yet another problem is the shortage of physical therapists, key staffers in rehabs. A decade ago, most licensed physical therapists had B.A. degrees. Then, their professional association, in order to raise pay, launched a successful lobbying campaign to require doctoral degrees. Result: a PT shortage. Jessica Pastore, the director of external communications and media relations for Brigham and Women’s Hospital, responded to my questions in an extended email, pointing out that there is only so much that the hospital can do, but that they have actually cut waiting times for inpatient beds by 33 percent over the past year. Their strategies have included better coordination with nursing homes and home care options, as well as improved discharge planning. The system is now so bad that its structural failures affect even the most privileged among us. Where might some real system-wide progress be made? Most long-term nursing home patients are on Medicaid, which pays nursing homes at a far lower rate than Medicare. Even at capacity, nursing homes financed by Medicaid are barely in the black. During the pandemic, emergency federal and state aid financed extra help for nursing homes, provided that much of it would be passed along in higher wages. That aid is now finished. It would help if Medicaid paid at the Medicare rate, with the increased reimbursement earmarked for wages. We also need real leadership from Gov. Maura Healey. Three weeks ago, the Mass Health & Hospital Association, working with Blue Cross and the state’s secretary of health and human services, Kate Walsh, came up with a palliative plan that will help only marginally. Blue Cross will streamline approvals for nursing homes, and nursing homes will stay open weekends to process admissions. Other insurers were not party to the deal; and in an indication of sheer cynicism, Steward Health Care was. Gov. Healey needs to make better, and better-targeted, state reimbursements a budgetary priority. SEIU Local 1199, representing nursing home workers, argues that the solution is both better pay, training, and reimbursement, and also incentive bonus payments for nursing homes that score well on staffing and low turnover. This syndrome is simply not a problem in nations with universal health systems. Ours is a systemic failure in the broadest sense. Think of it as a supply chain crisis. It won’t be fixed piecemeal solely by better pay and more training for CNAs, though that would sure help. It certainly won’t be fixed by adding more refined incentives for cost containment, which has been the obsessive focus of health policy for decades. The shortage of post-hospital facilities and the backup effect on acute care hospitals can be fixed only in the context of a universal system, which includes planning at every level. That means planning for facilities, for needed levels of health professionals, their training, and their compensation. This mess is a vivid example of how reliance on commercialized health care with piecemeal regulation has failed and backfired. Single-payer, long the goal of progressive reformers, is only part of it. We also need de-commercialization and comprehensive planning, which is only possible in the context of a universal and noncommercial system. At 4 a.m., with no prospect of a room in sight, my friend gave up on the Brigham field hospital, and decided to risk her health and go home. She is a professional, married to a doctor. They figured that if anything really bad happened, they could go back to the ER. In sum, the system is now so bad that its structural failures affect even the most privileged among us. Some rich people get boutique medicine for their outpatient needs. But Brigham and Women’s is where Boston’s elite go for quality inpatient care. If that’s a mess because of deeper systemic problems, there is no place to buy your way out. My friend, as it happens, has long been a single-payer advocate. But as the systemic failure compromises the health of well-off conservatives as well as progressives, maybe that will provide some momentum for change. Note: This piece is about Massachusetts. The problem is national. A follow-up article will look at trends nationally and federal policy. === Robert Kuttner is co-founder and co-editor of The American Prospect, and professor at Brandeis University’s Heller School. |
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National advocacy group blames hospital consolidation for Maine’s high health care costs
Hospitals contend other factors – such as Maine being the oldest state – are driving up costs in the state.
by Joe Lawlor - Portland Press Herald - February 4, 2024
A national health advocacy group is blaming hospital consolidation in
Maine for spurring higher prices at hospitals for patients with private
insurance.
But Maine hospital officials say consolidation is not the force
driving the prices, and that the explanation lies with the state’s older
population and low Medicare reimbursement rates that shift the costs of
health care to younger people with private insurance.
Maine’s two biggest hospital systems – MaineHealth and Northern Light
Health – have both grown larger over the last 20 years, with formerly
independent hospitals joining their networks.
Mid-Coast Hospital in Brunswick and the former Goodall Hospital
in Sanford are among the more recent additions to the MaineHealth
system, which includes Maine Medical Center in Portland. Mercy Hospital
in Portland and Mayo Regional Hospital in Dover-Foxcroft are among the
hospitals that in recent years joined Northern Light Health, which
includes Eastern Maine Medical Center in Bangor.
While independent hospitals and other networks remain – including
Central Maine Healthcare in Lewiston and MaineGeneral Medical Center in
Augusta – MaineHealth and Northern Light dominate the state’s health
care market.
“What causes prices to rise uncontrollably, leaving patients subject to thousands
of dollars in medical bills? Look no further than consolidation, where
dominant hospital systems control markets and set prices as high as
they’d like,” said Darbin Wofford, health policy adviser for Third Way, a
center-left think tank based in Washington, D.C. Health care reforms
are among the topics that Third Way advocates for, including clean
energy, reforming gun laws and abortion access, among many other issues.
Third Way is releasing a case study analysis of Maine’s hospital
costs on Thursday and provided the Press Herald with an early look at
the findings.
In an interview, Wofford said consolidation in states such as Maine
tips the scales heavily in favor of hospital networks when negotiating
contracts with insurance companies. Those contracts influence the health
insurance premiums, deductibles and other costs that people pay.
“Insurance companies can’t say to hospitals, ‘No, we don’t want to take your prices,’ ” Wofford said.
According
to the Health Care Cost Institute, the Portland market was the 21st
“most concentrated” health care market of 183 markets measured, which
means Portland has less hospital choice for patients than much of the
country. The Portland market was the only market measured in Maine.
Wofford pointed to hospital prices for private insurers, which are on
average 275% of the prices Medicare pays for services, or nearly three
times as high. Maine’s average costs are the highest in New England, and
far above the national average of 224% of Medicare, it found. Maine’s
average costs rank 19th among states. South Carolina is the state with
the highest hospital prices for private insurers, at 322% of Medicare
prices.
But Dr. Andy Mueller, CEO of MaineHealth, said the explanation for
private insurance prices at hospitals has far more to do with Maine’s
demographics.
When a higher percentage of the hospital patient mix is insured by
Medicare – generally patients 65 and older – that skews hospital prices.
Because Medicare’s reimbursements are so low and do not cover
hospitals’ actual costs, the difference has to be made up by private
insurers, Mueller said.
That’s true of any hospital in the country. But, he said, “we’re the oldest state in the nation.”
OLDEST STATE IN THE NATION
According to the U.S. Census, Maine’s median age is 44.8 years, the
oldest in the nation. “That puts a greater burden on those who have
commercial insurance to make up the difference,” Mueller said.
Terri Canaan, chief marketing and communications officer for
MaineHealth, pointed to an analysis that showed Maine’s Medicare
spending per enrollee – which includes hospital and non-hospital
spending – is below the national average. The national average is
$11,080, while Maine’s spending is $9,159 per enrollee, according to
KFF, a national health policy think tank.
Health care costs are influenced by a number of factors, such as the
push and pull of health care network contract negotiations with
insurers, the health and demographics of the population served, federal
and state regulations, and competition among health care providers,
among other things.
A Forbes Advisor analysis in 2022 combined 11 key health care cost
metrics to try to determine the difference in health care costs by
state. By that measurement, Maine has the seventh-highest health care
costs in the nation, at $11,505 per person. South Dakota was the most
costly in the nation, with $11,736 per capita, while Michigan had the
lowest health care costs at $9,524. The analysis includes all health
care costs, not just the costs incurred at hospitals or costs paid with
private insurance.
Denise McDonough, president of Anthem Blue Cross and Blue Shield in
Maine, said hospital consolidation is one of the factors driving up
costs in Maine.
“We have seen significant hospital consolidation in Maine over the
years, which has reduced competition, increased costs, and limited
access to care – leaving Mainers with less choice,” McDonough said.
Anthem and MaineHealth became embroiled in a public contract dispute
in 2022, with Maine Medical Center nearly withdrawing from Anthem’s
network in 2023 before an agreement was reached in August 2022. The
dispute became public with both sides providing the media with examples
of hospital overcharging of patients, and of the insurance company
denying needed care.
Both Anthem and MaineHealth officials have claimed that the other side has too much leverage in negotiations.
Mueller, on Wednesday, countered the argument made by Third Way that Maine’s hospitals have leverage over insurers.
“We’re still a ‘mom and pop’ industry in comparison to the
consolidation that has happened on the health insurance side,” Mueller
said. “These are massive companies, and we are not, relative to
(insurers). We are a tiny speck on the wall compared to them.”
REFORMS PROPOSED
Third Way has proposed a number of reforms, including tougher price
transparency laws, and laws that they say would help insurers when
negotiating with hospital systems.
Maine is debating regulation of facility fees, which can reach
hundreds of dollars for patients for just walking into a hospital for
care and are often hidden in medical bills and passed onto the patients.
After a Press Herald report in 2022
that featured patients complaining about facility fees, the Maine
Legislature passed a bill that created a task force, which is studying
possible changes to state law.
The federal government requires hospitals to disclose prices, but
some say the law doesn’t go far enough and lacks an enforcement
mechanism. Maine has the CompareMaine.org website, which allows for
comparison pricing of some procedures, such as colonoscopies, blood
tests and hip replacements.
McDonough, the Anthem president, agrees that more needs to be done, and calls Third Way’s suggestions a “good first step.”
But Mueller, the MaineHealth CEO, said that one of the bills
currently under consideration by the Maine Legislature would protect
insurers’ ability to reduce costs, such as by giving financial
incentives to patients to go to less expensive clinics. MaineHealth does
not prevent such cost-saving efforts, he said.
But Mueller said also built into the bill – L.D. 1708 – is a
provision that would prevent hospital networks from terminating
contracts with insurers.
“The only leverage we have is to terminate a contract,” Mueller said.
“We believe we ought to have the ability to terminate an agreement the
other party is not living up to.”
McDonough said, “we hope we can continue the conversation about
greater transparency and advance legislation to protect members’ access
to affordable care.”
https://www.pressherald.com/2024/01/04/national-advocacy-group-blames-hospital-consolidation-for-maines-high-health-care-costs/
Mills administration and hospitals reach agreement on new MaineCare reimbursement rates
by Patty Wight - Maine Public - February 6, 2024
Maine's Department of Health and Human Services and the Maine
Hospital Association have reached an agreement to reform reimbursement
rates for MaineCare, which provides insurance for 400,000 low-income
individuals.
They say that hospitals would receive see the same or
higher rates under the proposal, by being more aligned with Medicare
rates.
If approved, the groups say it would devote an additional $90 million in federal and state funding to hospitals.
The new reimbursements will be included in the upcoming supplemental budget proposal.
https://www.mainepublic.org/health/2024-02-06/mills-administration-and-hospitals-reach-agreement-on-new-mainecare-reimbursement-rates
by Sonali Kolhatkar - Counterpunch - February 16, 2024
Pharmaceutical companies are angry with Bernie Sanders. The Vermont
senator has vowed to force pharma CEOs to publicly answer for why their
drug prices are so much higher in the United States than in other
nations.
Brazenly, the CEOs of Johnson & Johnson and Merck initially refused.
An attorney for Johnson & Johnson accused the senator of
using Senate committee hearings to “punish the companies who have
chosen to engage in constitutionally protected litigation.” The company,
along with Merck and Bristol Myers Squibb, issuing the Biden administration for allowing Medicare to regulate certain prescription drug prices.
For the last two decades, it’s been a free-for-all for pharmaceutical companies in the U.S.
In 2003, then-President George W. Bush signed a Medicare reform bill into law, promising help for seniors struggling to pay for medications. But that law stripped the federal government of its power to negotiate drug prices for Medicare’s participants. And that’s driven drug prices up for everyone.
The Inflation Reduction Act (IRA),
which Biden signed in 2022, tied Medicare drug prices to inflation and
required companies to issue rebates if prices rose too fast. It was the
first time since Bush’s 2003 law that drug manufacturers were subject to
any U.S. price regulations.
Pharmaceutical companies aren’t having it. And that’s why it’s not
enough for Medicare to be able to cut drug prices — there needs to be
nationwide regulation on all drug prices for all Americans.
American taxpayers generously subsidize the research and development of most drugs, as a report by
Sanders’ staff explained. But “the government asks for nothing in
return for its investment,” giving private corporations “the unilateral
power to set the price of publicly funded medicines.”
People in other nations, the report adds, pay less for drugs that
American taxpayers have paid global pharmaceutical companies to
develop. Symtuza,
an HIV medication that the U.S. National Institutes of Health helped
develop, costs U.S. patients a whopping $56,000 a year. Patients in the
UK pay $10,000 a year for the same drug.
The difference is simple: countries like the UK, France, and Germany regulate drug prices. The U.S., for the most part, doesn’t.
There’s a strong public desire for price controls. According to a Kaiser Family Foundation poll in
August 2023, bipartisan majorities “say there is not enough regulation
over drug pricing.” A whopping 83 percent “see pharmaceutical profits as
a major factor contributing to the cost of prescription drugs.”
They’re right. Economists studying the pharmaceutical industry have
found that for years, companies have been so flush with cash that
they’ve spent hundreds of billions of dollars on stock buybacks and exorbitant executive bonuses and pay packages.
The Center for American Progress’s October 2023 report, “Following the Money: Untangling U.S. Prescription Drug Financing,” delves deep into how prices are determined for medications and suggests interventions at every stage.
Frankly, such complex solutions wouldn’t really be necessary if all Americans could simply join Medicare —
and if Medicare’s bargaining power to negotiate drug prices could be
applied to all drugs. But in the absence of this commonsense approach,
even complex price controls would be better than no price controls.
Instead, pharmaceutical companies launched the new year by announcing price hikes on at least 500 medications — a massive effort to gouge the public. In contrast, the IRA’s drug price controls apply to only 10 medications so far. They’ll be expanded to 15 drugs per year for the next four years, and 20 drugs per year thereafter.
Rather than removing price controls on the paltry numbers of
medications the IRA can regulate, an easy fix is to apply those same
regulations to most or all drugs. Best of all, pharmaceutical company
CEOs wouldn’t even have to drag themselves into committee hearings to
explain away their corporate greed.
