November 29, 2022 – HIDA has urged Congress to take steps to maintain the freight rail system and avert any threatened labor disruption.
“Transportation is a healthcare issue,” said HIDA President and CEO Matthew J. Rowan. “As Americans weather a difficult flu season and a surge in pediatric RSV cases, this is no time to disrupt the medical supply chain. If the parties cannot reach agreement, then Congress must step in and pass legislation to keep the freight rail system operating and America’s supply chains moving.”
HIDA has encouraged its members to contact Congress and support a legislative resolution to the rail labor dispute. HIDA is at the forefront of healthcare organizations who have joined multi-association letters to President Biden and congressional leadership urging action to avert a rail strike.
The amoxicillin and clavulanate combination is a penicillin antibiotic. London-based Hikma Pharmaceuticals has 10 products on allocation, Switzerland-based Sandoz has 16 on back order without an estimated resupply date and Israel-based Teva Pharmaceuticals has three on back order with resupply dates between late November and early January.
Amoxicillin has been in shortage for weeks, and the FDA confirmed the issue in late October. As of Nov. 18, resupply dates have been pushed to be between early December 2022 and August 2023, depending on the company and the product.
Texas Attorney General Ken Paxton has launched an investigation into Epic Systems over a policy that allegedly prevents parents from accessing their children’s medical records once they become teenagers.
Mr. Paxton sent a civil investigative demand to the EHR vendor after he began an investigation into Houston-based Memorial Hermann regarding an alleged policy that doesn’t allow parents to access their children’s medical records if the child is between 13 and 17 years old.
Mr. Paxton said his investigation into the health system further revealed that Epic “may have additional information regarding these concerns,” according to a Nov. 17 press release from the attorney general.
“Texas law forbids any hospital or corporate entity from denying parents access to their children’s medical records, and we’re going to ensure that the law is followed,” Mr. Paxton wrote in his press release.
Epic declined to comment.
A spokesperson for Memorial Hermann told Becker’s that it was not aware of any specific patient complaints about access to records and first learned about the complaint in question via the attorney general’s press release.
Memorial Hermann still operates on an Oracle Cerner EHR system and will transition to Epic beginning in 2023. The health system said its implementation of Epic will take “multiple years.”
Flu activity metrics are quickly ramping up in the US, with 8,707 lab-confirmed flu patients admitted to hospitals for the week ending Nov. 12, according to the CDC’s latest FluView report.
That’s up from the more than 6,400 flu patients hospitalized the week prior. The CDC now estimates there have been at least 4.4 million flu cases, 38,000 hospitalizations and 2,100 flu-related deaths so far this season. The CDC emphasizes that data in the reports are preliminary and may change as more data become available.
Seven more notes:
1. Fourteen states (Alabama, Arkansas, Tennessee, South Carolina, Virginia, New Mexico, Texas, Mississippi, Georgia, North Carolina, Maryland, New Jersey, Colorado and Kentucky), the District of Columbia and New York City reported very high flu activity for the week ending Nov. 12. Thirteen states (California, Nevada, Washington, Arizona, Kansas, Nebraska, Louisiana, Illinois, Indiana, Florida, Ohio, New York and Connecticut) and Puerto Rico reported high flu activity. The remaining states reported low or minimal activity.
2. Two flu-associated deaths were reported to the CDC for the week ending Nov. 12. This brings the total number of influenza-associated pediatric deaths to seven for the 2022-23 season.
3. The overall cumulative hospitalization rate is 8.1 per 100,000 — the highest it’s been this early in the season since the 2010-11 flu season.
4. Clinical laboratories tested 103,830 specimens for influenza for the week ending Nov. 12. Of those, 14.7 percent were positive, most of which for influenza A. The positivity rate was 12.8 percent the previous week.
5. The percentage of visits to an outpatient provider for influenza-like illness — meaning fever plus cough or sore throat, not lab-confirmed flu — was 5.8 percent for the week ending Nov. 12. This is above the national baseline of 2.5 percent.
6. Nationwide, 1.2 percent of 14,161 long-term care facilities reported at least one flu-positive test among residents for the week ending Nov. 5.
7. The national flu, pneumonia and/or COVID-19 mortality rate is 9.4 percent, which sits above the epidemic threshold of 6.2 percent for the week. Among the 2,175 deaths reported for the week, 926 had COVID-19 and 70 had the flu listed as an underlying or contributing cause of death. “While current [flu, pneumonia and/or COVID-19] mortality is due primarily to COVID-19, the proportion due to influenza remains small but is increasing,” the CDC said.
Consumer-driven trends, value-based strategies and better physician relationships encourage transition to ASCs.
October 2022 – The Journal of Healthcare Contracting
By Daniel Beaird
The healthcare sector has significantly consolidated in recent years. Large health systems have acquired smaller hospitals and the remaining hospitals have amassed existing outpatient facilities like urgent care, imaging locations and independent physician practices as outpatient care has become more popular. This has limited inpatient days and lowered hospital revenues, all while the healthcare sector tackles higher overhead and labor costs.
The preference for outpatient care is set to continue. Healthcare staffs are encouraged to expand their abilities for a variety of alternative care sites and reimbursement models are being restructured to meet the shift toward outpatient services.
Site-neutral payments
CMS implemented the Outpatient Prospective Patient System (OPPS) rule in 2019, extending a site-neutral payment policy to off-campus provider-based departments (PBDs). It reduced off-campus PBD payments to 70% of the full OPPS rate.
The OPPS rule was ruled to be invalid by a federal judge that same year, but the U.S. District Court of Appeals for the D.C. Circuit overturned the court’s ruling in 2020. The American Hospital Association (AHA) and the Association of American Medical Colleges (AAMC) are opponents of the site-neutral payment policy, but the U.S. Supreme Court declined to hear AHA’s appeal of the U.S. District Court of Appeals decision in 2021.
Melinda Hatton, general counsel for the AHA, said in a statement at the time, “America’s hospitals and health systems are disappointed in this decision because it will cause serious harm to their ability to provide care for patients. It fails to account for the fundamental differences between hospital outpatient departments and other sites of care. Hospitals are open 24/7, held to higher regulatory standards and are often the only point of access for patients with the most severe chronic conditions, all of whom receive treatment regardless of ability to pay.”
But the Medicare Payment Advisory Commission (MedPAC) said the biggest driver for physician and hospital consolidation was that Medicare paid hospital-based clinics a higher price for the same services than it did physicians’ offices, and if CMS adopted site-neutral payments between hospital and physician offices, it would reduce the incentive for those mergers.
CMS has stated that it would have saved an estimated $800 million in payments to outpatient departments during 2020 under the 2019 rule. The rule aims to remove payment disparities between clinics affiliated with hospitals that receive more Medicare reimbursement than physicians’ offices providing the same services. CMS began reprocessing claims for outpatient clinic visit services at excepted off-campus PBDs in 2021 so that they were paid the same rate as non-excepted off-campus PBDs for those services under the physician fee schedule. It affected certain claims with dates of service between Jan. 1-Dec. 31, 2019.1
In American Hospital Association v. Becerra (2022), the AHA and several hospital associations and hospitals sued HHS, alleging that it exceeded its statutory authority in the rule reducing reimbursement rates for certain hospitals, specifically 340B hospitals and Medicare Part B insured patients. In June 2022, the U.S. Supreme Court unanimously ruled that the statute does not give HHS the authority or the discretion to vary the reimbursement rates for 340B hospitals.
ASCs become must-haves for hospitals
The movement toward value-based care, growing competition for physicians and surgical cases, and the ongoing shift of non-urgent surgical procedures into the outpatient setting have all had an effect on hospitals investing in ASCs. According to a national survey conducted by Avanza Healthcare Strategies of senior executives and clinical leaders at hospitals and health systems across the country, more than six in 10 hospitals and health systems intend to increase their investments in ASCs.
Hospitals are becoming less reliant on third-party management vendors for their ASCs and more willing to partner and share ownership with physicians in joint venture ASCs. Half of the respondents in Avanza’s survey indicated current ownership of multiple ASCs in their portfolios.
“It comes as no surprise to see that hospital systems are pursuing a variety of ASC initiatives, often in partnership with physicians, that will allow them to broaden their surgery center and outpatient portfolios,” said Joan Dentler, founder and president of Avanza. “As surgical care continues its migration out of the inpatient setting, hospital systems are recognizing the need for at least one ASC, and increasingly multiple centers, in their portfolios.”
The maturity of the ASC industry is cited as a reason for more growth in the category. Dentler says that management services were often a necessity to running a viable surgery center in the early days of ASCs. But the proliferation of support services and technologies for the industry and the growth of professionals with ASC experience has neutralized the need to give up valuable equity and enter expensive management agreements for ASC success.
More than 80% of hospital systems surveyed by Avanza have one or more of their ASCs as joint ventures with physicians, and more than half are allowing employed physicians to invest in their ASCs. Third-party management and partnerships continue to decline.3
Not only have consumer-driven and payer-driven trends from the past several years solidified the need for ASCs, but the COVID-19 pandemic also stiffened the competitive positions of ASCs as the preferred setting for high-quality, low-cost surgical care.
Hospitals more likely to share ownership in ASCs
According to the Avanza survey, from 2020 to 2021, the percentage of ASCs with 100% hospital and health system ownership declined from 25% to 12%. Yet majority ownership by hospitals and health systems in ASCs increased from 54% to 58% during that same period.
The takeaways included hospitals and health systems potentially being more amenable to sharing ownership with physicians since physician financial investment in the ASC may serve to motivate physicians to be more cost-conscious, helping drive profitability. Also, physicians are interested in joint ventures as minority owners due to contracts that can be leveraged with payers and GPOs that are accessible only if the hospital is the majority owner.
Hospitals, on the other hand, are owning or affiliating with ASCs due to four primary reasons:
Responding to consumer-driven trends.
Preventing physicians from taking cases outside the hospital and health system.
Supporting a value-based strategy.
Enhancing physician relationships.
And 63% of hospitals surveyed planned to increase ASC investments or affiliations. At the same time, third-party management is declining. In 2019, 23% of hospitals and health systems with ASCs had a third-party manager. That declined to 15% in 2021. The survey also found the percentage of hospitals and health systems with ASCs that permit third-party equity partners has declined from 44% in 2018 to 27% in 2021.
HOPDs converting to ASCs
One of the fastest growing areas of freestanding ASC development is hospital-based outpatient departments (HOPDs) conversions. These departments acted like freestanding ASCs but operated as arms of the hospital, collecting hospital reimbursement.
Medicare per-payment procedures were significantly higher for HOPDs than payments to ASCs,4 and the reduction in revenue for hospitals when converting HOPDs to ASCs has come with consternation, but it’s a step toward value-based care. According to Avanza, in 2021, 53% of hospitals and health systems with HOPDs that mimic ASCs were considering converting one or more of their HOPDs to ASCs.
Shifting outpatient procedures to ASCs reduces spending for commercially insured individuals by almost 60% and saves consumers close to $700 per procedure.5 Over 6 million routine outpatient procedures are performed in HOPDs, but only 10% of those procedures are for complex patients like those with morbid obesity or those suffering from end stage renal disease, and 35% of those procedures are for patients who do not have an ASC close to their residences.
The ASC market size in the U.S. is estimated to reach almost $60 billion by 2028,6 up from $34 billion in 2020 and $36 billion in 2021.
October 24, 2022 – NBC News reports that a shortage of liquid helium, a nonrenewable element that has been dwindling in supply, is worrying physicians because MRI machines require the ultra-cold material for its magnets.
The supply of helium has been strained for years, but geopolitical tensions are blowing up the problem. According to the report, a new facility in eastern Russia was supposed to provide a third of the world’s supply, but a fire last January caused delays, and current political strains because of the war in Ukraine have halted the U.S.’ plans to acquire the helium.
Four out of 5 U.S. helium suppliers are rationing their product and prioritizing it for the healthcare industry.
“Helium is on allocation for sure,” Donna Craft, a regional construction manager for Premier Health who contracts with helium suppliers for some 4,000 hospitals, told NBC News. “We’re probably not blowing up balloons in the gift shop anymore.”
At any time, every operating MRI holds about 2,000 liters of helium.
The coldest element on Earth, liquid helium is invaluable for hospitals that use MRI scans to detect cancer, spinal cord injuries and liver diseases. MRIs run on magnetic fields and radio waves, and liquid helium is necessary to keep the magnetic current at an extremely cold temperature.
“There’s no alternative. Without helium, MRIs would have to shut down,” Craft said.
Medical device makers GE Healthcare and Siemens Healthineers are working on making MRIs, which typically use about 10,000 liters of liquid helium over a lifespan, that can run on less liquid helium. The technology is not widely available, though, according to NBC News.
Why inflationary challenges have been particularly challenging in purchased services categories.
October 2022 – The Journal of Healthcare Contracting
Stronger consumer demand coupled with global supply chain and workforce challenges are driving inflation across every sector of the U.S. economy, including healthcare, said Mickey Meehan, chief operating officer, Conductiv® and Chaun Powell, group vice president, Remitra™. And while the U.S. has been seeing and living with higher costs from the gas pump to the grocery store, there has been less discussion about inflation in the services sector.
Part of the reason for that may be due to the complexities and variabilities of purchased services and the invoicing of those services. For example, at one large IDN, the chief supply chain officer shared with Meehan and Powell that departments and hospitals nationally lack the sophistication to accurately predict the expense of a service based on complexities of the contracts, which can be 70 pages long and filled with holiday, weekend and surge pricing models. “Add to that inflationary up-charging, and it becomes increasingly apparent that technology-based solutions are more critical today than ever before,” they said.
This time last year, services inflation sat at 3%. This year in the U.S., services inflation has increased – albeit slightly – from 6.22% in June to 6.25% in July, and its share of overall inflation also increased, Meehan and Powell noted.
Today, hospital expenses continue to climb while margins shrink – the median change in margin declined 49.3% from June 2021. “This makes inflation particularly challenging to tackle in healthcare,” they said. “Broader economy-wide inflation has serious implications for providers that must absorb added costs out of existing budgets, which are already strained as a result of lost elective procedure revenue, and record-high outlays to attract and retain labor.”
What’s more, as expenses are rising, hospital payments aren’t keeping pace. CMS has adjusted the IPPS payment rate upward 4.3%, but the truth remains the update falls woefully short of reflecting the rising labor costs that hospitals have experienced since the onset of the pandemic, Meehan and Powell said. “This inadequate payment bump will only exacerbate the intense financial pressures on hospitals.”
The following are more insights on which services sectors have been hardest hit, and some possible solutions for supply chain teams to implement.
Categories that have seen the largest cost increase
When comparing third-party services to products, the total cost of the service is heavily influenced by the cost of labor, Meehan and Powell said. “In the current environment of competition for all labor types, organizations are factoring in higher wages to help attract and retain talent on top of higher prices for their business, such as fuel costs.”
Based on these factors, some services categories in healthcare experiencing cost increases include:
Staffing
Construction
Waste Management
Blood Products
Courier Services
Food Services
Environmental Services
Third-Party Logistics
It’s not just purchased services
Labor costs are having an impact on other parts of the healthcare supply chain as well, Meehan and Powell said. “This is especially true in accounts payable (AP), where manual-based financial processes have led to wasted time and money for both providers and suppliers. In fact, nearly $40 billion in healthcare waste and inefficiencies is tied to invoicing errors alone.”
A place to cut waste
One big opportunity to cut down on waste and create efficiencies is AP automation, they said. “With AP automation, providers can not only gain opportunities to strategically redeploy their labor force, but also gain better control over cash flow and the ability to unlock working capital for investing in future growth opportunities.”
The importance of a healthy market
Purchased services can account for up to 36% of hospitals’ annual indirect operating expenses. “Enterprise-wide success is increasingly reliant on purchased services and a healthy market can help generate operational efficiencies and improved outcomes for providers, including significant cost savings,” Meehan and Powell said.
This also extends to supply chain back-office operations, which is an area often overlooked by healthcare leaders as a significant opportunity to save on costs. “We estimate that as many as 70% of all invoices in healthcare are paper-based, and 68% of all healthcare purchasing is still done manually via paper checks. Across the healthcare industry, these transactions can add as much as $18 billion to $22 billion in unnecessary annual expenses.” AP automation can solve this by taking paper out of the equation and replacing it with a data- and technology-driven workflow.
Best practices to drive savings
“As the healthcare industry continues to transition into post-pandemic reality, finding new ways to increase efficiencies and reduce costs in purchased services – and in supply chain operations overall – is paramount,” Meehan and Powell said. They shared several ways healthcare providers can tackle the rising costs of services and drive savings:
“Leveraging the aggregate purchasing power of a GPO and contracts with firm, fixed pricing can help keep inflation at bay and reduce risk. Hospitals and health systems we’ve worked with have saved as much as 31% (weighted average) across purchased services categories during the pandemic and through a combination of GPO/local services-specific contracts.”
“Investing locally and building more strategic, collaborative relationships with diverse suppliers to drive competitive pricing and terms.”
“Using technology to tap into analytics, benchmarks and powerful insights to source competitive contracts and measure purchased services usage and spend. Technology can enable providers to automate RFPs, to compare prices, and to manage service targets – a strong means to counter inflation.”
“Looking beyond purchased services, technology can be used to analyze total supply spend, transform AP processes and find savings opportunities all in one place. By moving to an automated purchasing and payment solution, one health system we work with was able to recognize more than $1.8 million in savings in fewer than three years. Another was able to recoup $7 million in overpayments due to invoicing errors.”
Hospitals across the country are seeing a significant surge of respiratory syncytial virus, NBC News reported Oct. 14.
The volume of RSV patients is “two to three times what we’ve ever experienced,” John Bradley, MD, medical director of infectious diseases at San Diego-based Rady Children’s Hospital, said in the report.
Last week, nearly 5,000 tests came back positive for RSV, according to CDC data. “Some regions are nearing seasonal peak levels,” a CDC spokesperson told NBC News.
One physician from Baystate Children’s Hospital in Springfield, Mass., said her pediatric ICU was closed to new patients Oct. 12 because all beds were filled. During a normal winter, her emergency room sees around 100 children a day. Now it is seeing 130 to 150, many with RSV.
Many hospitals are sending patients to nearby states. A physician at Hasbro Children’s Hospital in Providence, R.I., said his hospital has been treating RSV patients from more than 100 miles away.
At Comer Children’s Hospital in Chicago, the emergency room is seeing a 150 percent higher volume than usual for October, and up to one-third of its ICU and emergency patients have RSV.
Physicians told NBC News that RSV is spreading earlier this year and is becoming more severe in some children because of a lack of exposure during the COVID-19 pandemic due to masking and social distancing.
October 11, 2022 – According to a report from CNN, a union of railroad track maintenance workers has rejected a tentative agreement with the nation’s freight carrier. With this development, the possibility of a strike that shuts down the vital link in an already precarious supply chain is back.
The deal in question included “an immediate 14% raise with back pay dating to 2020 and raises totaling 24% during the five-year life of the contract that runs from 2020 through 2024.” It also included cash bonuses of $1,000 a year for union members – with back pay and bonuses, that’s an average of $11,000 per worker after the deal is finalized.
However, the financial terms were not the main issue with these new contracts, but because of “work rules that unions said had brought engineers and conductors to a breaking point. Staffing shortages had required crew members to be on call seven days a week, ready to work at short notice.”
According to the report, the Biden administration is desperately trying to avoid a rail strike because of the current state of the supply chain. When measured by weight and distance traveled, the major railroads carry 30% of the country’s freight. A strike could be a devastating blow to the infrastructure of the supply chain.
AMA, AHA dropping cases; may intervene in Texas case
Texas judge has previously ruled in favor of providers
Medical providers are putting all their eggs in one basket by moving to support a federal lawsuit filed in Texas against the Biden administration’s No Surprises Act rule on settling payment disputes.
The Texas Medical Association, one doctor, and a hospital sued the US Department of Health and Human Services in the US District Court for the Eastern District of Texas on Sept. 22. The same week, the American Medical Association, and the American Hospital Association agreed to end their similar D.C.-based case and said they support the Texas case.
Medical providers and health insurers and employers that foot much of America’s health-care bill have been battling in court to try to ensure that the 2020 law designed to protect patients from many high out-of-network bills is implemented by arbitrators in a way that favors their side. The law is meant to prevent providers from billing patients in emergencies and in situations where patients have procedures at network facilities, but they are served by providers, such as anesthesiologists, who are not in their insurance network.
Rules implementing the law required arbitrators to select the amount closest to the median in-network rate in settling payment disputes between insurers and certain out-of-network health-care providers. Providers argue that relying on median contract rates gives insurers too much power, while payers say that allowing arbitrators to weigh many factors equally could inflate health-care costs.
“It seems like providers are clearing the decks for this to be litigated in Texas,” Katie Keith, director of the Health Policy and the Law Initiative at the O’Neill Institute for National and Global Health Law at Georgetown University Law Center, said in an interview. Appeals would then go through the US Court of Appeals for the Fifth Circuit, she said. Keith has been supportive of the administration’s rules implementing the dispute resolution provisions of the No Surprises Act.
Dispute Resolution Challenged
The lawsuit challenges the government’s August 2022 final rule regarding the No Surprises Act’s independent dispute resolution process. It’s the second time in less than a year that TMA has challenged federal agencies related to the same rulemaking. US District Judge Jeremy Kernodle previously ruled in favor of providers who challenged a rule issued by four federal agencies that gave preference to using the qualifying payment amount as the primary factor in deciding billing disputes.
“The Texas court previously held that the interim final rule impermissibly rewrote clear statutory terms by placing a thumb on the scale in favor of commercial insurers,” the AMA and the AHA said in a joint statement. “The final rule suffers from the same problems.”
The groups said they “want to see the law’s core patient protections move forward.”
“We look forward to supporting the Texas Medical Association’s efforts to restore the balanced, patient-friendly approach that Congress passed and the AHA and AMA supported,” the statement said.
In other words, Keith said, the provider organizations are saying, “‘We’re going to support this other challenge before a judge who I think has been sympathetic,’” to their arguments.
Several lawsuits were previously filed against the Biden administration’s 2021 interim final rule that instructed arbitrators to give precedence to the qualifying payment amount, based on median contract rates negotiated by health insurers and providers, in settling payment disputes under the No Surprises Act.
The Biden administration issued a new final rule in August in response to Kernodle’s earlier decision against the dispute resolution process.
Provider Groups Coalesce
The Georgia College of Emergency Physicians also recently ended their Georgia-based case, Keith said. And the Association of Air Medical Services, which has a separate lawsuit against the administration’s rule, said in a recent hearing in the US District Court for the District of Columbia that it might challenge the final rule “somewhere else,” which could be in Texas, Keith said.
The Physician Advocacy Institute Inc. “strongly supports the Texas Medical Association in their latest lawsuit challenging federal regulatory agencies’ flawed approach to resolving disputes between physicians and insurers under the No Surprises Act, which President Biden signed into law last year.” according to a statement issued Monday from the group’s CEO, Kelly Kenney. PAI has affiliated state medical associations representing more than 170,000 physicians and medical students.
If Kernodle, the Texas judge, rules against the most recent rule on how payment disputes should be decided, “You would lose the guardrails on the arbitration process,” Keith said. “It runs the risk that IDR would become more inflationary,” and “that out-of-network providers further use arbitration to get higher out-of-network prices,” she said.
There should be incentives for insurers and providers to work out rates through negotiation, with dispute resolution being used as a back-up, Keith said. The danger is IDR could be used “to garner higher out-of-network reimbursements, even when the circumstances don’t warrant it.”
The Department of Labor reported in August that disputing parties had more than 46,000 initial disputes through the federal independent dispute resolution portal, substantially more than what federal agencies had expected for an entire year.
