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Landmark Antitrust Suit Settled: Game Changer for Anticompetitive Behavior

Posted By Louise Probst, Tuesday, January 7, 2020
Updated: Tuesday, January 7, 2020

Kamala Harris’ presidential campaign may have sputtered out, but an investigation that she initiated in 2011 has resulted in a settlement that is sure to have employers, insurers, and health systems taking notice, including many BHC employer members with worksites in Northern California.

 

Harris, then California’s Attorney General, began investigating whether Sutter Health’s market power led to predatory pricing and unfair financial burden on the people and businesses of Northern California. Sutter Health’s sprawling network of hospitals, surgery centers, and urgent care clinics makes it one of the nation’s largest health systems, with annual revenue of about $13 billion. 

 

The price hikes were striking in Sutter Health’s case. Health care costs in Northern California run 20% to 30% higher than in Southern California, with patient admissions averaging $4,000 more than at other hospitals around the state. A cesarean delivery in Sacramento costs $27,067, nearly double the price in Los Angeles and New York. Health care economists view Sutter Health’s actions as part of an alarming consequence of hospital consolidation that has resulted in higher prices. 

 

Harris’ successor, Attorney General Xavier Becerra, joined a class action suit by unions and over 1,500 self-funded employers. The case, expected to deliver about $2.5 billion in damages, was settled in October 2019. Details of the final agreement show that Sutter Health agreed to:

  • Make a $575 million payment to compensate employers, unions, and the state and federal governments, without any admission of wrongdoing;
  • Stop "all-or-nothing" contracting deals with insurers and cease anticompetitive bundling of services and products;
  • Limit what it charges patients for out-of-network services; and
  • Be subject to a court-approved compliance monitor to oversee its contracting practices for the next 10 years.   

We all know that initiating legal action such as this takes significant investment and fortitude. UFCW & Employers Benefit, the group of unions and employers who brought this suit, deserve our recognition. They said in a statement: “From the outset, our goal has been to not only achieve justice for the members of the class, but to also put an end to the anticompetitive behavior that has allowed Sutter to charge inflated prices.” 


California Attorney General Becerra claimed,
"When one health care provider can dominate the market, those who shoulder the cost of care — patients, employers, insurers — are the biggest losers. Today’s settlement will be a game changer for restoring competition in our health care markets."


While the impact of this case and the other pending anticompetitive suits will take time to fully appreciate, let us hope it spurs much-needed competition in health care. It is the first sign that courts and antitrust regulators are ready to focus on the impact of health care consolidation on the American public.

 

Warm regards,

Louise Y. Probst

BHC Executive Director

 

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Looking to 2020 with Appreciation and Optimism

Posted By Lauren Remspecher, Wednesday, December 11, 2019
Updated: Wednesday, December 11, 2019

As we end 2019, I would like to acknowledge BHC members' commitment to improving health care and employee and community well-being. Your engagement in the coalition and with each other is greatly appreciated as we learn and work together toward better health and health care value. This energy was demonstrated by recording-breaking registration numbers for our 2019 Annual Meeting, totaling 436 members and community partners. The conversations sparked by our national speakers and local thought leaders were full of opportunity.
 
Andy Waldeck, Senior Partner at Innosight, painted U.S. health care as an industry ripe for disruptive innovation. He explained that “disruption" is a change that will transform an industry and bring meaningful improvements in affordability and accessibility to its customers. While he did not offer a specific timeline for when such innovation would occur, he created confidence that transformation is coming to U.S. health care and highlighted opportunities for purchasers and providers to accelerate desired change and thrive in the shifting landscape. 

Dr. Reena Duseja represented the Centers for Medicare and Medicaid Services, perhaps the greatest disruptor of U.S. health care to-date, and offered insight into CMS' use of measures and incentives to expedite the value and performance of their plans. As with other innovations, employers can learn from CMS' experience implementing alternative models for payment and delivery of care.


Dr. Wendy Levinson, Chair of Choosing Wisely Canada and Choosing Wisely International, reminded us that "more is not always better," especially when it comes to health care. Using educational toolkits and creative messaging, the Choosing Wisely campaign offers practical tips for engaging patients and physicians in reducing the culture of overuse in health care. Dr. Levinson reminded us that this is a problem across nations, not just in the United States, and offered several examples of success that has been achieved in provinces across Canada, other nations, and in many medical schools. Along with the St. Louis Metropolitan Medical Society and the Midwest Health Intiative, BHC has been working to identity situations of overuse in regional data and prioritize possible target areas for attention. A community collaboration to tackle overuse through diverse stakeholder engagement is preparing to launch in spring 2020. The work will align with the BHC Board's priority to develop a communication campaign to help the public become more informed consumers of health care. We would welcome your team's participation in this important initiative - please contact the BHC if you are interested in getting involved.

 

Linda Brady, Boeing’s health care strategy leader, provided an update on Boeing’s Accountable Care Organizations, advanced primary care efforts, and other strategies to achieve better value. She underscored the importance of leveraging relationships with health plan or provider partners to understand and influence care enhancements for employees. While a direct ACO contract is not feasible for all employers, there are many opportunities for employers with smaller or geographically-diverse populations to leverage puchasing power for better value. Moving into the coming year, the BHC’s new Value-based Purchasing Roundtable will explore advanced primary care solutions, including a visit to two local sites that have taken this approach.

 

Incoming BHC Board President and Chief Operating Officer for Francis Howell School District, Kevin Supple, closed the Annual Meeting with a heartfelt reminder of how peoples' lives are impacted by employer-provided health benefits and the difficult challenges that are faced by many patients. He inspired all of us to use our influence to make health care work better for employees, their families, and our community members. The BHC looks forward to answering this call in 2020 in collaboration with you.

 

Warm regards,

Louise Y. Probst

BHC Executive Director

 

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U.S. Health Care System: Ripe for Disruptive Innovation

Posted By Louise Probst, Tuesday, November 5, 2019

The idea of disruptive innovation in health care gets a lot of buzz. Electronic medical records, interconnectivity, Accountable Care Organizations, and the Amazon, Berkshire, and JPMorgan partnership are just a few of the innovations that have promised to transform health care in ways that delight customers. So far, though, the public is still waiting.

 

According to Harvard professor Dr. Clayton Christensen, the hallmarks of an industry ripe for disruption are high cost and uneven levels of access. He explains disruption as a process by which “simple applications take root at the bottom of a market—typically by being less expensive and more accessible—and then relentlessly move upmarket, eventually displacing established market leaders.” Successful disruptive innovators are comfortable challenging the status quo. Examples of success from other industries illustrate the concept well: the iPhone, Amazon, Uber, and Airbnb, to name a few.

 

Could Walmart be health care’s disruptive innovator, decreasing cost and closing the care gap while wowing customers? In September, Walmart announced that it would begin covering costs for any of its 1.5 million U.S. workers who want to earn a health care degree. For a fee of $1.00 a day, employees can apply for bachelor’s degrees in seven different programs, such as health care management and supply chain logistics, and two career diplomas—as pharmacy technicians or opticians. The program will help the company recruit employees and also staff its growing line of retail health clinics. It’s the latest in a series of moves that show Walmart’s potential to disrupt our dysfunctional health care system, and perhaps, higher education as well.

 

Consider this: Together, Walmart and Sam’s Club operate more than 5,000 retail pharmacies, 3,000 vision centers, and 400 hearing centers, and provide low-cost Quest Diagnostics lab services. The big box behemoth is accelerating its push to co-locate health clinics by its stores, most recently launching a Walmart Health Center that offers a full menu of primary care, dental, and even mental health services to customers in the underserved region of Dallas, Georgia. Walmart says its new clinic will serve consumers regardless of insurance status and offer convenient, online scheduling and transparent, low pricing. Consumers can also access resources for preventive health and wellness.

 

Rising health care costs and poor outcomes disproportionately hurt lower-income and middle-class families. Walmart wants to bring affordable services to underserved people right where they shop, including preventive care for the chronic conditions that bust health care budgets. Their retail health care model could improve population health on a broad scale while putting downward pressure on prices. If they succeed, that could be a game changer for our health care delivery system.

 

Join us at the 2019 BHC Annual Meeting to learn what employers can do to spur disruptive innovation in health care.


Warm regards,

Louise Probst
BHC Executive Director


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Advancing Primary Care: Interventions to Support and Replicate

Posted By Louise Probst, Tuesday, October 1, 2019
Updated: Tuesday, October 1, 2019

For half a century, the U.S. health care system has undervalued and underpaid primary care providers relative to other specialists. The unintended consequences of this chronic underinvestment loom large: out-of-control cost, declining and inadequate access to primary care physicians, outcomes that lag behind other nations, high rates of overuse and medical mistakes, and growing evidence that financial incentives too often drive clinical decision-making.

 

According to the Patient-Centered Primary Care Collaborative (PCPCC), overall U.S. health care spending on primary care is assumed to be between 5% to 7%, half or less that which is spent in other developed nations. A recent study by the Milbank Memorial Fund found that primary care spending in Medicare was only 2% to 4% of its overall spending.  

 

Yet, considerable evidence has shown that a strong primary care foundation is essential for a high-performing health system. By example, regions with a higher ratio of primary care physicians have better health and lower rates of mortality from heart disease, cancer, stroke, and other causes, even after controlling for sociodemographic measures. Data from the Midwest Health Initiative confirms that commercially insured patients in St. Louis who regularly see a primary care physician are less likely to visit the emergency department.

 

Since it takes about a decade to train a primary care physician, and demand for their services is growing faster than the supply of new primary care providers, the time for action is now. Below are examples of truly meaningful strategies that warrant our attention and support.

 

(1) CMS recently announced that it is considering using different E&M (Evaluation and Management) codes for primary care and medical subspecialist physicians compared to those used for surgeons and other procedure-based physicians. The use of separate codes would enable CMS and private sector payers to begin to rebalance payments by offering higher increases to primary care providers, without automatically increasing reimbursements to other specialists. These codes would also better enable measurement of primary care spending relative to other specialties. On behalf of employers, the BHC recently offered its support for this proposal to CMS Adminstrator, Seema Verma.  

 

(2) State governments are taking real actions to require greater investment in primary care. By example, between 2009 and 2014, as a condition of having their rates approved, Rhode Island required commercial insurers to raise their primary care spending rate by one percentage point per year (in ways other than by increasing fee-for-service rates). The state’s primary care spending was 5.7% in 2008 and increased to 9.1% in 2012, while total health care expenditures fell 14%. Check out this quick summary of Rhode Island’s and five other state's efforts. 

 

(3) The PCPCC issued a call for a consensus process to define a common definition and standardized measurement of primary care spending. This would enable the value of primary care to be quantified over time, as well as comparisons across states, health plans, and accountable care organizations. It would also help guide future investments and the evaluation of new value-based payment models across payers and payer types. Read PCPCC’s call to action here

 

The BHC recognizes that many of its members have taken action to strengthen primary care through ACO arrangements, worksite clinics, or other health plan programs. If you are interested in sharing what you are doing or connecting with others on this path, please let me know. 

Warm regards,

Louise Probst
BHC Executive Director


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Private Equity: Your New Local Health Care Provider

Posted By Louise Probst, Wednesday, September 4, 2019
Could private equity own your physician’s practice? You may not have noticed, but over the past decade, private equity firms have been making significant investments in physician practices and other health care services. According to PwC’s report, Private Equity: Healthcare’s New Growth Accelerator, provider deals led U.S. private equity investments in 2018 and are shaping up to do so again. The PwC chart to the right provides insight into the growth of these deals.
 


Looking for returns on investment of 2.5:1 to 4:1, private equity firms can find a lot to like in the health care environment, including high margins, service fragmentation, and aging baby boomers with multiple chronic illnesses. To top it off, the recession-proof nature of health care makes these investments less risky compared to others.

So what is in it for physicians? Private physician practices, particularly those that seek to remain independent of a local health system or insurer, find it increasingly difficult to raise capital for new technologies, enter into risk-sharing contracts, negotiate favorable rates with insurers, and otherwise manage the business of their practice. Private equity offers them investment capital and greater advantage in all of these areas, including some hope of remaining clinically independent. Physicians also benefit from a lucrative financial agreement with the potential for sizeable future payouts.

Specialty practices, such as dermatology, orthopedics, gastroenterology, and ophthalmology, have been early private equity targets, especially when combined with the opportunity to own ambulatory surgery, imaging, lab, pathology, or other service centers acting as referral sites for these practices. Corporate and private equity acquisitions are becoming more diverse, including investments in mental health and autism services, new health care technology companies, clinical research organizations, convenient care, and long-term care services.

Those in favor claim that private equity firms bring better and more efficient business practices to an industry with little cost management discipline. Yet, not all physicians think private equity is a good thing for patients or the profession of medicine. Some claim that ownership relationships pressure physicians to provide unneeded care, diminish the patient-physician relationship, and lessen professional autonomy.

An optimist might say that this is a sign that the health care industry is feeling the heat to produce better quality care at more affordable prices. The skeptic might suggest it simply a way to share the wealth with a new set of players. What do you think? Will private equity firms deliver higher value care and a better patient experience?

Warm regards,

 

Louise Probst

BHC Executive Director

 

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Getting to Health Care Affordability: Dr. Zeke Emanuel’s Top Four Strategies

Posted By Louise Probst, Wednesday, August 7, 2019

Last week, I had the opportunity to listen to Dr. Zeke Emanuel, an accomplished clinician, health policy expert, and key architect of the ACA (bio here), during an interview at the 2019 Optum Forum. When asked what health care advice he would offer the next administration, he said that he had four “low-hanging fruit” strategies that could be undertaken on the administration's first day for meaningful impact:

  1. Cap hospital prices for commercial payers at 140% of Medicare (a more than adequate payment for any hospital).

  2. Enact an immediate 10% reduction in drug prices. While not as large of a reduction as needed—the U.S. would still remain the nation with the highest drug prices—it would reduce spending by about $50 billion annually, or almost $700 per family.

  3. Require standardized claims forms and administrative procedures across carriers to achieve seamless claims processing, freeing up administrative waste and aiding physician offices.

  4. Require all insurers who participate in Medicare or Medicaid to have at least 50% of their payments across all products be an alternative to fee-for-service, with upside and downside risk.

Dr. Emanuel’s recommendation to cap hospital payments from commercial plans at a percentage of Medicare is getting a lot of traction among state employee benefit plans. With two years under their belt, Montana’s state employee program is leading the way, and Oregon’s plan is starting this fall. North Carolina, supported by the State Treasurer, is in the throes of a very public debate that has seen substantial pushback from hospitals that say they will go out of business.

 

Join other BHC employers for the August 13th Member Meeting to see the results of a recent national study by RAND Corporation of commercial plan payments as a percentage of Medicare, including all of St. Louis’ major hospitals. The lead study author, Dr. Chapin White, will also discuss opportunities for employers to apply this data to benefit plan strategies to achieve higher value. We hope to see you there in-person or via our webinar option (please contact Todd Boedeker with registration questions).

 

Warm regards,

 

Louise Probst

BHC Executive Director

 

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Price-Sensitive Consumers' Preferences on Value-Based Insurance Designs

Posted By Louise Probst, Wednesday, July 10, 2019

Amid rapidly expanding health care spending, the financial burden on patients has grown. With consensus holding that 30% of health care costs go to services of little to no clinical value, even slight reductions in such services could have meaningful financial benefits for patients and employers. However, achieving this requires an engaged patient population.

 

Health policy and consumer researchers from two California academic institutions conducted 15 focus groups with 125 price-sensitive (low-mid income) health plan enrollees to assess their understanding and preferences toward three potential waste-minimizing solutions: narrow networks, reference pricing, and value-based insurance designs (lower copayments for higher value services). The full article can be found in the March 2019 Health Affairs Journal, Consumers’ Perceptions and Choices Related to Three Value-Based Insurance Design Approaches.

 

Researchers learned that price-sensitive consumers: 

  • Highly value choice; however, when they are given information on cost, they are willing to trade choice for lower spending.
  • Do not understand that health care costs can vary widely from hospital to hospital. 
  • Believe there is a correlation between cost and quality and are unaware that equal or better quality could be had at a lower price. 
  • Are skeptical and mistrusting of plan designs that require them to rely on their health plan to define “high-value health care."
  • Take little meaning from existing quality measures and are generally unwilling to consider quality measures that conflict with their personal experience with their physicians.

The different interventions were explained to the group, and participants were asked to rate their preference for each strategy. The results are below: 

 

Focus Group Participants' Attitudes Toward 
Cost Containment Strategies

Approaches

Negative

Neutral

Positive

Didn’t
Understand

Narrow Network

23%

39%

21%

17%

Reference Pricing

12%

30%

28%

30%

Value-Based Benefit Design

8%

28%

41%

24%

 

To encourage openness to these common strategies, researchers recommend supplying consumers with consistent support through educational tools regarding plan options, providers, and health care spending. Consumers value information on clinic location, office hours, patient experience, etc. Therefore, it can be helpful to juxtapose these items next to quality measures.

 

These findings underscore what BHC members have consistently identified as a top challenge: engaging their workforce to take an active role in managing their own health and using their consumer power to drive safer and higher value health care. The findings also provide direction to BHC’s goal of developing effective communication strategies for the working public.

Warm regards,

 

Louise Probst

BHC Executive Director
 

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RAND Study Reveals Private Health Plans Pay Hospitals 241% of Medicare on Average

Posted By Todd Boedeker, Wednesday, June 5, 2019
Updated: Tuesday, July 16, 2019

The results are in. The RAND Corporation has published findings from an analysis of $13 billion of hospital spending in 25 states during 2015-2017. Their goal was to assess how much commercial health plans pay, compared to Medicare, for the same procedures in the same facilities and to reveal variation in hospital payments within communities and among different regions. The analysis includes payments (allowed amounts) and not the amount charged. Adjustments were made for intensity of services.

 

Key findings from the report: 

  1. On average, commercial plans paid hospitals 241% of Medicare payments, with wide variation.

  2. Low-range payments were 150% to 200% of Medicare, found in Michigan, Kentucky, New York, and Pennsylvania. High-range states included Colorado, Illinois, Maine, Montana, Wisconsin, and Wyoming, at 250% to over 300% of Medicare.

  3. Missouri was somewhere in the middle range at 221%.

  4. Relative to Medicare payments, commercial plans paid hospitals considerably more for outpatient services than for inpatient care in 17 of the 25 states, including Missouri.

Since Medicare payments are sufficient to cover a hospital’s expenses with a fair margin, these high payment levels are worth noting. Research dispels the myth of “cost shifting” by demonstrating that many hospitals make money on Medicare payments. Yet, those with “market clout” and plenty of commercially-insured lives in their market tend to add more expenses of marginal value and extract higher prices from commercial payers to cover them. The increased payments are needed to cover their inefficiencies. This article from Health Affairs explains this phenomenon.

Findings for the major St. Louis hospitals are consolidated for your review (BHC member-only access). The sample size for the St. Louis area is particularly small, and while the aggregate and directional findings are reliable, limited comparison should be made across individual hospital findings. Another important nuance is that Medicare payments for hospitals can be different. For instance, an inner-city teaching hospital’s payment will be larger than a community hospital. The percent of Medicare payment shown is based on the hospital’s actual Medicare payment amount. As you will see, the research finding about Medicare payments and market power is actually supported by the reimbursement levels in the St. Louis example.

So what can be done? RAND recommends that private insurers:

  • Shift to contracting models that are based on a percent of Medicare or similarly fixed prices.

  • Share data with state all-payer claims databases in order to increase transparency.

  • Support the 2020 Hospital Payment Comparison by sharing data with RAND now. The more employers contributing data, the more accurate the results.

The BHC encourages employers to get engaged with the 2020 RAND analysis, and we are available to assist. Contact Michael Hely, BHC’s Senior Director, Legal & Policy Services, at mhely@stlbhc.org to learn more.

 

Warm regards, 

Louise Probst
BHC Executive Director

 

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Recognizing St. Louis as a Top Place to Do Business, Work, and Live

Posted By Todd Boedeker, Wednesday, May 8, 2019
Updated: Tuesday, July 16, 2019

The BHC is all in when it comes to nudging improvements in health care value for commercially-insured populations. The quality and cost performance of a region’s health care system is of critical importance to the people and employers it serves. Health care value is also central to ensuring that a region competes favorably in attracting and maintaining business. Population growth in the U.S. is fairly flat; yet, some U.S. cities report 15-20% growth in recent years. St. Louis is not one of them. Several initiatives are underway to advance the region’s brand and economic engine. Three notable efforts are:

 

STL Made works to brand St. Louis globally as an inclusive and innovative community undergoing a “renaissance." A three-year, multi-million-dollar effort will highlight the people of the area, encouraging them to tell their stories and share what they like most about living in the region. Connecting with the St. Louis Economic Development Partnership and the St. Louis Regional Chamber, there is strong interest in attracting young talent to the region. STL Made will monitor the community for increases in commercial expansion as an indication of the success of the initiative’s efforts.

St. Louis’ Better Together program seeks to unite St. Louis City and County in ways that preserve the unique personalities of the region’s communities while building an integrated, innovative, and united approach to capturing opportunities and addressing concerns. Conversations paused on May 7th, but keep an eye out for the reinvention of this well-intended endeavor.
 

Global STL aims to attract innovative international companies seeking access to U.S. markets. Their annual summit, featuring “elevator pitches” from potential recruits, will be June 5th, and BHC members are invited. BJC’s new President and CEO, Richard Liekweg, will keynote the event. Anyone wanting to attend the summit is asked to please contact me at lprobst@stlbhc.org.

 

It is only a matter of time before Medicare or another entity ranks regions on health care value, exposing the impact of variations in safety, quality, and cost of health care on corporate productivity and profitability. Data indicates that with some improvements in safety and quality performance, St. Louis’ health care value would be top tier. Let’s build St. Louis' brand as a high-value health care community - another lever for economic development. 

Warm regards, 

Louise Probst
BHC Executive Director
  

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Caution: Electronic Health Records More Deadly Than Imagined

Posted By Todd Boedeker, Wednesday, April 3, 2019
Updated: Tuesday, July 16, 2019

A recent report revealed that the problems with electronic health records (EHRs) are more serious and widespread than has been generally understood. The report Death by 1,000 Clicks: Where Electronic Health Records Went Wrong is the result of an extensive, collaborative investigation between Kaiser Health News and Fortune. The patient stories give a painful view of how faulty system interfaces, software glitches, user errors, incorrect patient input and wrong information occurrences can cause preventable harm and even death. Thousands of deaths, injuries and near misses have been reported to various databases, but these have not been connected or acted upon. Also problematic are the proprietary interests of EHR vendors and some hospitals, leading to information blocking, gag clauses, and barriers to patient access to needed medical information.

 

The federal government has been given primary responsibility for the current situation. A belief in the power of EHRs to make health care safer and less wasteful, combined with the 2008 financial crisis, encouraged the government to invest in a $36 billion dollar “stimulus” for EHRs. Doctors and hospitals were financially incentivized to adopt EHRs, before the products were mature and without adequate industry oversight to ensure interoperability and data sharing.

 

Last month, as a remedy, the U.S. Department of Health and Human Services proposed new rules to remove barriers to data sharing. EHR vendors will have to fashion their systems to easily enable a complete medical record to be exported, and health systems must give patients their exported medical records for free. Gag clauses that keep doctors from discussing software problems and potential for medical errors will be prohibited. The Senate is currently considering these and other actions. While these steps are positive, these is still much to be done to remove the safety risks introduced by EHRs. In the meantime, it is advisable that patients monitor and correct the information in their medical records, ensure that they receive recommended care, and speak up if anything seems amiss.

 

Warm regards,

 

Louise Probst

BHC Executive Director

 

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