Last week, Turquoise Health released its first Price Transparency Impact Report which aims to track hospital and health insurer compliance with the Hospital Price Transparency Rule (January 2021) and the CMS Transparency in Coverage Rule (July 1, 2022). Both require specified disclosures and financial penalties for non-compliance. The current status as of September 2022 per Turquoise:
· 76% of hospitals have posted a machine-readable file.
· 65% have posted a machine-readable file with negotiated rates.
· 63% have posted a machine-readable file with cash rates.
· 80 insurers that cover 80% of the insured population
They noted “When patients do search for prices, it’s for the costs of routine procedures, such as colonoscopies, mammograms and tonsillectomies, but also some very specific–and expensive–ones” Turquoise reported. “The top 10 “shopped for” healthcare procedures in Q3 were:
Implantable cardiac loop recorder
CT scan head or brain without contrast
Surgical drainage of hematoma or seroma
Diagnostic heart catheterization
X-ray hip and pelvis
Tonsil removal patient under 12
CT scan of cervical spine without contrast
These results are impressive: participation appears “robust” as the company touted, and Turquoise partnership with actuaries in Millman and Robertson assure deeper analytics potentially linking transparency to changes in price competition, insurance premiums and outcomes will be forthcoming. That’s plausible.
But two realities might limit the impact of price transparency on healthcare spending:
Consumer price-driven behavior change: 64% of Americans have never shopped for prices on healthcare services, per an online consumer survey conducted in March 2022 for healthcare AI company AKASA. But 58% said they’d “be encouraged” to shop around if they knew the cost of a procedure or service beforehand. Though price sensitivity is growing, its impact on patient choices is still modest: A survey by HealthSparq in May found 44% avoided getting care in the past year because they weren’t sure about the upfront costs and 68% of respondents say they are more likely to book a medical appointment if they know they’re estimated out-of-pocket cost per Kyruus’ 2022 Patient Access Journey Report. But for big ticket items, it’s less a factor. US consumers are conditioned to care little about prices. .Key questions: what incentives/penalties are necessary to accelerate actionable consumer responses to prices? Are price transparency rules enough? Why aren’t prescription drugs and medical devices also included?
Long-term Impact on Healthcare Prices: In the Congressional Budget Office analysis of strategies to bring down healthcare prices, it concluded that provider price transparency produced a “very small price reduction.”. Promoting competition among providers yielded “small price reductions” but capping the rate of growth for prices produced a “moderate to large price reduction” impact. It concluded that “the prices that providers negotiate with commercial insurers are high because of several factors, including hospitals’ and physicians’ market power and consumers’ and employers’ lack of sensitivity to those prices.” As has been shown, unit price increases for prescription drugs and hospital services are the major contributors to medical care spending which have increased 6.5% in the last 12 months pr BLS. Key questions: should price controls be implemented in healthcare? And why should privately insured employers and consumers pay double or more prices paid by Medicare for the same service?
The Turquoise data is interesting. Its “python ingestion code” is the secret sauce that translates the data from machine readable files into comparisons across 60 variables. It adds to several credible report cards comparing hospitals and insurers about patient/enrollee experiences, “quality” and more: none is definitive and each is different based on the validity of data capture and analyses conducted.
In July 2018, I wrote: ”Arguing price transparency in healthcare is a misguided effort is like arguing against clean air and healthy eating: it’s senseless.” It’s still true. Making the case that price transparency has a long way to go based on current offerings and utilization is legitimate.
But the price transparency movement is gaining momentum in healthcare: though it still lacks widespread impact on spending today, it soon will.
The Keckley Report February 2018 https://www.paulkeckley.com/the-keckley-report/2018/7/9/price-transparency-in-healthcare-what-weve-learned-whats-ahead
Most consumers aren’t price shopping for healthcare services October 21, 2022 Oct 21, 2022 www.insiderintelligence.com/content/most-consumers-aren-t-price-shopping-healthcare-services
Turquoise Health October 18, 2022 https://blog.turquoise.health/turquoise-health-impact-report/
Trilliant Compass: commercial health insurance market shrinking: From the Trilliant Compass published last week:
· The overall share of commercially insured Americans dropped 0.6 percentage points from 2020 to 2021.
· Between 2022 and 2027, the under 18 population is projected to decline by 0.1% and the working-age adult population (i.e., age 18-64) is projected to decline by 1.2%. However, the 65+ population is expected to increase by 13% during the same time period.
· Over the next five years, high growth in the 45-64 population is expected in the Carolinas, Orlando, Houston, Austin, Dallas-Ft Worth, and Phoenix because of population migration, rather than underlying population growth
Trilliant Health www.trillianthealth.com
Study: HDHP associated with reduction in use of substance abuse services: Offering a high-deductible health plan (HDHP) led to a 6.6% reduction in the probability of using substance use disorder services and a shift in spending from the plan to the enrollee. Reductions were concentrated in inpatient, intermediate, and ambulatory care, as well as medication use. Being offered an HDHP was associated with a decrease of 21% on health plan spending and an increase of 14%) on out-of-pocket spending.
Eisenberg et al The Impact of HDHPs on Service Use and Spending for Substance Use Disorders the American Journal of Managed Care, October 5 2022Am J Managed Care. 2022;28(10):530-536. https://doi.org/10.37765/ajmc.2022.89250
Study: MA enrollee turnover: Researchers analyzed enrollees who joined MA between 2012 and 2016 and identified all enrollees who changed insurers (switched insurance or disenrolled to TM) at least once between the start of enrollment and the end of the study period.
Results: Among 6,520,169 new MA enrollees, 15.6% had changed insurance within 1 year after enrollment in MA and 49.2% had changed insurance by 5 years. More enrollees switched insurers rather than disenrolled, and most enrollees who changed insurers did not do so as a result of insurer exits.
Turnover Among New Medicare Advantage Enrollees May Be Greater Than Perceived the American Journal of Managed Care, October 2022, https://doi.org/10.37765/ajmc.2022.89251
Highmark advances digital therapeutics coverage: In August, Pittsburgh-based Highmark put in place a policy describing when prescription digital therapeutics may be “medically necessary,” and covered. The policy names eight products, including Pear Therapeutics’ cognitive behavioral therapy (CBT) apps for the treatment of substance use disorder, opiate user disorder, and insomnia; Akili Interactive’s video game treatment for pediatric attention deficit hyperactivity disorder; treatments for chronic lower-back pain and childhood lazy eye that are delivered through virtual reality headsets; a treatment for nightmares using the Apple Watch; and a CBT app targeting irritable bowel syndrome.
Large insurer’s decision to cover some prescription digital therapies may be a milestone for app makers Business Insider October 19, 2022 www.statnews.com/2022/10/19/highmark-insurers-decision-to-cover-prescription-digital-therapeutics
Study: Physicians vote less than overall voter population: Voter participation and registration were lower than the general population for all elections from 2006 through 2018. Pooled physician voter participation was 14% points lower than the general population (37% vs 51%) driven primarily by differences in pooled voter registration (50% vs 66%)
Lalani et al Trends in Physician Voting Practices in California, New York, and Texas, 2006-2018 JAMA Intern Med. October 22, 2020;181(3):383-385. doi:10.1001/jamainternmed.2020.6887
APG conference this week: In what might be considered a coming out party under its new leader Washington insider Susan Dentzer, , APG, America’s Physician Groups, will be hosting its fall conference Oct. 31-Nov. 2 at the Grand Hyatt in Washington, D.C. Entitled “Transitions 2022: APG Colloquium,”
Definitive Healthcare: Per Definitive, An estimated 333,942 healthcare providers dropped out of the workforce in 2021, many of whom departed due to retirement, burnout and other stressors related to the physicians lost 117,000, nurse practitioners, lost 53,295 members and physician assistants, with 22,704 positions vacated.
· Internal medicine saw the largest exodus out of any physician specialty, losing 15,000 providers in 2021, compared with 13,015 who left family practice and 10,874 in clinical psychology.
· Other healthcare professionals who left their roles include physical therapists and licensed clinical social workers.
· In 2020, large hospitals with more than 250 beds spent an average of $11 million on contract labor, versus facilities with 25 beds or fewer spending about $460,000.
· Hospitals nationwide spent a total of about $97.3 million on employees and physician salaries in 2020, compared with $82.7 million in 2016, according to data from the October 2021 Medicare Cost Report.
Definitive Healthcare www.definitivehc.com
Advisory Board: Healthcare workforce demand will increase 9% annually through 2030: A recent study found that approximately one in three healthcare workers intend to reduce their work hours, while roughly one in five intend to leave their profession altogether. This is due to many healthcare professionals feeling unprepared to meet the growing need. Research highlights mission-driven workers are 54% more likely to stay for five years at a company and 30% more likely to grow into high performers.
Sinsky et al Covid-related stress and work intentions in a sample of US Health Care Workers. Mayo Clinic Proceedings: Innovations, Quality & https://www.sciencedirect.com/science/article/pii/S2542454821001260
Berlin et al. Nursing in 2021: Retaining the healthcare workforce when we need it most. McKinsey & Company. Retrieved February 8, 2022, from https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/nursing-in-2021-retaining-the-healthcare-workforce-when-we-need-it-most
Medicare, Prescription Drugs
Study: Prescription drugs constitutes 27% of Medicare spending: The estimated proportion of total annual spending attributed to prescription drugs was 24.0% in 2008 and 27.2% in 2019, net of estimated rebates and discounts.
“The proportion of total annual spending attributed to inpatient (Part A) spending was 44.2% in 2008 and 37.6% in 2019, Part B (medical) nondrug spending represented 31.8% of total spending in 2008 and 34.5% in 2019. Part B drug spending represented 4.5% of total spending in 2008 and 8.7% in 2019. Part D net spending represented 19.4% of total spending in 2008 and 18.4% in 2019. Taken together, spending on prescription drugs (including both Part B– and Part D–covered drugs) increased from 24.0% of total per-capita spending in 2008 to 27.2% in 2019, net of estimated rebates and discounts.”
Dusetzina et al Prescription Drug Spending in Fee-for-Service Medicare, 2008-2019 JAMA October 18, 2022;328(15):1515-1522. doi:10.1001/jama.2022.17825
Care Management, Prevention
USPTF concludes evidence insufficient for depression screening for children under 11: Background: Major depressive disorder (MDD) in children and adolescents is strongly associated with recurrent depression in adulthood; other mental disorders; and increased risk for suicidal ideation, suicide attempts, and suicide completion. Suicide is the second-leading cause of death among youth aged 10 to 19 years. Psychiatric disorders and previous suicide attempts increase suicide risk.
To update its 2014 and 2016 recommendations, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening, accuracy of screening, and benefits and harms of treatment of MDD and suicide risk in children and adolescents that would be applicable to primary care settings. Recommendation:
The USPSTF recommends screening for MDD in adolescents aged 12 to 18 years. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for MDD in children 11 years or younger. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk.
US Preventive Services Task Force www.uspreventiiveservicestaskforce.org
Study: CT, MRI prices highly variable: More than a 10-fold gap exists between the highest and lowest negotiated price for common imaging services provided at the same hospital:
The average maximum negotiated price between hospitals and insurance companies for 13 imaging services analyzed was 3.8 times more than the average minimum negotiated price in the same hospital, Commercial prices for high-cost services, such as CT and MRI scans, varied the most among the “shoppable” services, as defined by the Centers for Medicare and Medicaid Services, that were studied.
In the most extreme cases, the average maximum negotiated price for a brain CT scan was 17.9 times greater than the minimum price offered in the same hospital.
Jiang et al Price Variability for Common Radiology Services within U.S. Hospitals Radiology Online: CT 18 2022https://doi.org/10.1148/radiol.221815
3Q earnings down for Tenet Healthcare, HCA: Last week, the companies released 3Q 2022 financial results:
Tenet had net income of $131 million in the third quarter, a 71% drop from the year-ago period. Revenue decreased nearly 2%, to $4.8 billion. Operating expenses at the Dallas-based for-profit system rose 9.7% to $4.31 billion–including a 1% increase in salaries, wages and benefits, but a 1.2% decrease in supply costs. Contract labor costs remained elevated, comprising 7.4% of total salary costs, compared with 6.2% in the second quarter.
HCA Healthcare reported net income of $1.13 billion in the third quarter, a 50% drop from 2021’s period. Revenue decreased 2%, to $14.97 billion. Expenses at HCA came to $13.27 billion, compared with $12.12 billion the prior-year period. Expenses related to salaries, wages and benefits decreased 2.75% while expenses for supplies dropped 5.8%. HCA reported an increase in in its “other expenses” category, in part due to provider taxes, professional fees and utility costs.
Regulation, Nursing Homes
CMS: Underperforming nursing homes face tighter scrutiny: Friday, CMS announced that poor performing nursing homes will have to meet tougher standards and demonstrate systemic quality improvements in order to avoid enforcement actions and face potential exclusion from Medicare and Medicaid.
There are 88 nursing homes with persistent records of noncompliance participating in the Special Focus Facilities Program this year, or about 0.5% of all nursing homes. To complete the program, nursing homes must pass two consecutive inspections that occur approximately every six months.
Axios: most people don’t use social media: “The rising power and prominence of the nation’s loudest, meanest voices obscures what most of us personally experience: Most people are sane and generous — and too busy to tweet. It turns out, you’re right. We dug into the data and found that, in fact, most Americans are friendly, donate time or money, and would help you shovel your snow.” Four key stats
· 75% of people in the U.S. never tweet.
· In Gallup’s 2021 polling, 29% of Americans identified as Democrats … 27% as Republicans … and 42% as independents
The new silent majority: People who don’t tweet www.axios.com/2022/03/08/political-polarization-twitter-cable-news?
Digital health down in Q3: The global digital health market continued its decline in Q3’22 as funding decreased 36% quarter-over-quarter. Findings from the latest report:
Global digital health funding reached $4.6B in Q3’22, its lowest total since Q1’19. This marks the 3rd straight quarter with a decline of at least 30% and a 72% decline from the quarterly investment peak seen in Q2’21.
· The number of deals dropped for the 4th consecutive quarter to 427, the lowest quarterly total in more than 5 years.
· US-based companies raised $3B in Q3’22. From a deals perspective, the US led with 233 deals — more than all the other regions combined. Some of the largest rounds in the US went to companies including ArsenalBio, Alma, and Senda Biosciences.
State of Digital Health Q3’22 Report CB Insights October 20, 202 /www.cbinsights.com/research/report/digital-health-trends-q3-2022