Archives for 2023

Debt Deal Claws Back COVID Relief, Spares Medicaid

White House says it won't link talks on debt limit hike to spending cuts :  NPRDemocrats beat back efforts to attach Medicaid work requirements to a debt limit deal, but the agreement reached over the weekend will claw back about $30 billion of unspent COVID relief funds and likely bring more budget austerity to federal health agencies.

Why it matters: GOP negotiators had increasingly insisted that Medicaid work requirements needed to be part of the deal, but Democrats were aggressively against such measures.

Driving the news: The 99-page agreement, if passed by both chambers of Congress, avoids steep health care funding cuts that some had feared while restraining spending levels enough to have implications for federal health agencies, experts tell Axios’ Victoria Knight.

  • Non-defense discretionary spending levels will be kept roughly flat for 2024 and then given a 1% increase in 2025.
  • It improves the chances Congress will write fiscal 2024 spending bills with at least modest increases for the National Institutes of Health, said Erik Fatemi, a principal at Cornerstone Government Affairs.
  • “Worst case is the 1% automatic cut for NIH if they do not pass a Labor-HHS bill. That is manageable even if not ideal,” said Chris Meekins, an analyst for Raymond James. “It is plausible NIH could see an increase if they can pass a Labor-HHS bill, but disagreements over policy riders will make that a heavy lift in my view.”

The deal also will rescind about $30 billion in unspent COVID relief funds from a variety of federal programs. It does preserve funding for veterans’ health care and developing next-generation COVID treatments.

What we’re watching: Democratic lawmakers will likely supply the votes to pass the bill through the narrowly divided House, given the vows from right-wing House Freedom Caucus members to oppose it, Axios’ Andrew Solender and Alex Thompson write.

  • Senate Majority Leader Chuck Schumer wrote Democratic colleagues that they should prepare for potential Friday or weekend votes in the upper chamber.
  • The Biden administration has been pitching Democrats on what the bill doesn’t do, like touching entitlement programs, and the way it would raise the debt ceiling past the presidential election into 2025.

27 Natural Health and Nutrition Tips That Are Evidence-Based

27 Health and Nutrition Tips That Are Actually Evidence-Based

If you want to boost your health and wellbeing, there are plenty of natural and home remedies to choose from, ranging from avoiding charred meats and added sugars to practicing meditation.

When it comes to knowing what’s healthy, even qualified experts often seem to hold opposing opinions. This can make it difficult to figure out what you should actually be doing to optimize your health.

Yet, despite all the disagreements, a number of wellness tips are well supported by research.

Here are 27 health and nutrition tips that are based on scientific evidence.


1. Limit sugary drinks

Sugary drinks like sodas, fruit juices, and sweetened teas are the primary source of added sugar in the American diet.

Unfortunately, findings from several studies point to sugar-sweetened beverages increasing risk of heart disease and type 2 diabetes, even in people who are not carrying excess body fat.

Sugar-sweetened beverages are also uniquely harmful for children, as they can contribute not only to obesity in children but also to conditions that usually do not develop until adulthood, like type 2 diabetes, high blood pressure, and non-alcoholic fatty liver disease.

Healthier alternatives include:

  • water
  • unsweetened teas
  • sparkling water
  • coffee


2. Eat nuts and seeds

Some people avoid nuts because they are high in fat. However, nuts and seeds are incredibly nutritious. They are packed with protein, fiber, and a variety of vitamins and minerals.

Nuts may help you lose weight and reduce the risk of developing type 2 diabetes and heart disease.

Additionally, one large observational study noted that a low intake of nuts and seeds was potentially linked to an increased risk of death from heart disease, stroke, or type 2 diabetes.


3. Avoid ultra-processed foods

Ultra-processed foods (UPFs) are foods containing ingredients that are significantly modified from their original form. They often contain additives like added sugar, highly refined oil, salt, preservatives, artificial sweeteners, colors, and flavors as well.

Examples include:

  • snack cakes
  • fast food
  • frozen meals
  • packaged cookies
  • chips

UPFs are highly palatable, meaning they are easily overeaten, and activate reward-related regions in the brain, which can lead to excess calorie consumption and weight gain. Studies show that diets high in ultra-processed food can contribute to obesity, type 2 diabetes, heart disease, and other chronic conditions.

In addition to low quality ingredients like refined oils, added sugar, and refined grains, they’re usually low in fiber, protein, and micronutrients. Thus, they provide mostly empty calories.


4. Don’t fear coffee

Despite some controversy over it, coffee is loaded with health benefits.

It’s rich in antioxidants, and some studies have linked coffee intake to longevity and a reduced risk of type 2 diabetes, Parkinson’s and Alzheimer’s diseases, and numerous other illnesses.

The most beneficial intake amount appears to be 3–4 cups per day, although pregnant people should limit or avoid it completely because it has been linked to low birth weight.

However, it’s best to consume coffee and any caffeine-based items in moderation. Excessive caffeine intake may lead to health issues like insomnia and heart palpitations. To enjoy coffee in a safe and healthy way, keep your intake to less than 4 cups per day and avoid high-calorie, high-sugar additives like sweetened creamer.


5. Eat fatty fish

Fish is a great source of high-quality protein and healthy fat. This is particularly true of fatty fish, such as salmon, which is loaded with anti-inflammatory omega-3 fatty acids and various other nutrients.

Studies show that people who eat fish regularly have a lower risk for several conditions, including heart disease, dementia, and inflammatory bowel disease.


6. Get enough sleep

The importance of getting enough quality sleep cannot be overstated.

Poor sleep can drive insulin resistance, can disrupt your appetite hormones, and reduce your physical and mental performance.

What’s more, poor sleep is one of the strongest individual risk factors for weight gain and obesity. People who do not get enough sleep tend to make food choices that are higher in fat, sugar, and calories, potentially leading to unwanted weight gain.


7. Feed your gut bacteria

The bacteria in your gut, collectively called the gut microbiota, are incredibly important for overall health.

A disruption in gut bacteria is linked to some chronic diseases, including obesity and a myriad of digestive problems.

Good ways to improve gut health include eating fermented foods like yogurt and sauerkraut, taking probiotic supplements — when indicated — and eating plenty of fiber. Notably, fiber serves as a prebiotic, or a food source for your gut bacteria.


8. Stay hydrated

Hydration is an important and often overlooked marker of health. Staying hydrated helps ensure that your body is functioning optimally and that your blood volume is sufficient.

Drinking water is the best way to stay hydrated, as it’s free of calories, sugar, and additives.

Although there’s no set amount that everyone needs per day, aim to drink enough so that your thirst is adequately quenched.


9. Don’t eat heavily charred meats

Meat can be a nutritious and healthy part of your diet. It’s very high in protein and a rich source of nutrients.

However, problems occur when meat is charred or burnt. This charring can lead to the formation of harmful compounds that may increase your risk for certain cancers.

When you cook meat, try not to char or burn it. Additionally limit your consumption of red and processed meats like lunch meats and bacon as these are linked to overall cancer risk and colon cancer risk.


10. Avoid bright lights before sleep

When you’re exposed to bright lights — which contain blue light wavelengths — in the evening, it may disrupt your production of the sleep hormone melatonin.

Some ways to help reduce your blue light exposure is to wear blue light blocking glasses — especially if you use a computer or other digital screen for long periods of time — and to avoid digital screens for 30 minutes to an hour before going to bed.

This can help your body better produce melatonin naturally as evening progresses, helping you sleep better.


11. Take vitamin D if you’re deficient

Most people do not get enough vitamin D. While these widespread vitamin D inadequacies are not imminently harmful, maintaining adequate vitamin D levels can help to optimize your health by improving bone strength, reducing symptoms of depression, strengthening your immune system, and lowering your risk for cancer.

If you do not spend a lot of time in the sunlight, your vitamin D levels may be low.

If you have access, it’s a great idea to have your levels tested, so that you can correct your levels through vitamin D supplementation if necessary.


12. Eat plenty of fruits and vegetables

Vegetables and fruits are loaded with prebiotic fiber, vitamins, minerals, and antioxidants, many of which have potent health effects.

Studies show that people who eat more vegetables and fruits tend to live longer and have a lower risk for heart disease, obesity, and other illnesses.


13. Eat adequate protein

Eating enough protein is vital for optimal health, as it provides the raw materials your body needs to create new cells and tissues.

What’s more, this nutrient is particularly important for maintenance of a moderate body weight.

High protein intake may boost your metabolic rate — or calorie burn — while making you feel full. It may also reduce cravings and your desire to snack late at night.


14. Get moving

Doing aerobic exercise, or cardio, is one of the best things you can do for your mental and physical health.

It’s particularly effective at reducing belly fat, the harmful type of fat that builds up around your organs. Reduced belly fat may lead to major improvements in your metabolic health.

According to the Physical Activity Guidelines for Americans, we should strive for at least 150 minutes of moderate intensity activity each week.


15. Don’t smoke or use drugs, and only drink in moderation

Smoking, harmful use of drugs, and alcohol abuse can all seriously negatively affect your health.

If you do any of these actions, consider cutting back or quitting to help reduce your risk for chronic diseases.

There are resources available online — and likely in your local community, as well — to help with this. Talk with your doctor to learn more about accessing resources.


16. Use extra virgin olive oil

Extra virgin olive oil is one of the healthiest vegetable oils you can use. It’s loaded with heart-healthy monounsaturated fats and powerful antioxidants that have anti-inflammatory properties.

Extra virgin olive oil may benefit heart health, as people who consume it have a lower risk for dying from heart attacks and strokes according to some evidence.


17. Minimize your sugar intake

Added sugar is extremely prevalent in modern food and drinks. A high intake is linked to obesity, type 2 diabetes, and heart disease.

The Dietary Guidelines for Americans recommend keeping added sugar intake below 10% of your daily calorie intake, while the World Health Organization recommends slashing added sugars to 5% or less of your daily calories for optimal health.


18. Limit refined carbs

Not all carbs are created equal.

Refined carbs have been highly processed to remove their fiber. They’re relatively low in nutrients and may harm your health when eaten in excess. Most ultra-processed foods are made from refined carbs, like processed corn, white flour, and added sugars.

Studies show that a diet high in refined carbs may be linked to overeating, weight gain, and chronic diseases like type 2 diabetes and heart disease.


19. Lift weights

Strength and resistance training are some of the best forms of exercises you can do to strengthen your muscles and improve your body composition.

It may also lead to important improvements in metabolic health, including improved insulin sensitivity — meaning your blood sugar levels are easier to manage — and increases in your metabolic rate, or how many calories you burn at rest.

If you do not have weights, you can use your own bodyweight or resistance bands to create resistance and get a comparable workout with many of the same benefits.

The Physical Activity Guidelines for Americans recommends resistance training twice per week.


20. Avoid artificial trans fats

Artificial trans fats are harmful, man-made fats that are strongly linked to inflammation and heart disease.

Avoiding them should be much easier now that they have been completely banned in the United States and many other countries. Note that you may still encounter some foods that contain small amounts of naturally occurring trans fats, but these are not associated with the same negative effects as artificial trans fats.


21. Use plenty of herbs and spices

There is a variety of herbs and spices at our disposal these days, more so than ever. They not only provide flavor but also may offer several health benefits as well.

For example, ginger and turmeric both have potent anti-inflammatory and antioxidant effects, which may help improve your overall health.

Due to their powerful potential health benefits, you should aim to include a wide variety of herbs and spices in your diet.


22. Nurture your social relationships

Social relationships — with friends, family, and loved ones you care about — are important not only for your mental well-being but also your physical health.

Studies show that people who have close friends and family are healthier and live much longer than those who do not.


23. Occasionally track your food intake

Some people may benefit from working out how many calories they eat is by weighing their food and using a nutrition tracker. Tracking can also provide insights into your protein, fiber, and micronutrient intake.

However, while tracking, may help some people manage their weight, there is also evidence it can lead to disordered eating tendencies.

Always speak with a doctor before using this strategy.


24. Get rid of excess belly fat

Excessive abdominal fat, or visceral fat, is a uniquely harmful type of fat distribution that is linked to an increased risk of cardiometabolic diseases like type 2 diabetes and heart disease.

For this reason, your waist size and waist-to-hip ratio may be much stronger markers of health than your weight.

Reducing refined carbs, eating more protein and fiber, and reducing stress (which can reduce cortisol, a stress hormone that triggers abdominal fat deposition) are all strategies that may help you get rid of belly fat.


25. Avoid restrictive diets

Diets are generally ineffective and rarely work well long term. In fact, past dieting is one of the strongest predictors for future weight gain.

This is because overly restrictive diets actually lower your metabolic rate, or the amount of calories you burn, making it more difficult to lose weight. At the same time, they also cause alterations to your hunger and satiety hormones, which make you hungrier and may cause strong food cravings for foods high in fat, calories, and sugar.

All of this is a recipe for rebound weight gain, or “yoyo” dieting.

Instead of dieting, try adopting a healthier lifestyle. Focus on nourishing your body instead of depriving it.

Weight loss should follow as you transition to whole, nutritious foods — which are naturally more filling while containing fewer calories than processed foods.


26. Eat whole eggs

Despite the constant back and forth about eggs and health, it’s a myth that eggs are bad for you because of their cholesterol content. Studies show that they have minimal effect on blood cholesterol in the majority of people, and they’re a great source of protein and nutrients.

Additionally, a review involving 263,938 people found that egg intake had no association with heart disease risk.


27. Meditate

Stress has a negative effect on your health. It can affect your blood sugar levels, food choices, susceptibility to sickness, weight, fat distribution, and more. For this reason, it’s important to find healthy ways to manage your stress.

Meditation is one such way, and it has some scientific evidence to support its use for stress management and improving health.

In one study involving 48 people with high blood pressure, type 2 diabetes, or both, researchers found that meditation helped lower LDL (bad) cholesterol and inflammation compared with the control group. Additionally, the participants in the meditation group reported improved mental and physical wellness.


The bottom line

A few simple steps can go a long way toward improving your eating patterns and wellness.

Still, if you’re trying to live a healthier life, do not just focus on the foods you eat. Exercise, sleep, and social relationships are also important.

With the evidence-based tips above, it’s easy to introduce small changes that can have a big impact on your overall health.

Healthcare Must Set Guardrails Around AI For Transparency And Safety

AI in healthcare: The tech is here, the users are not | CIOFour in 10 patients perceive implicit bias in their physicians, according to a MITRE-Harris survey on the patient experience. In addition to patients being extra sensitive to provider bias, the use of AI tools and machine learning models also have been shown to skew toward racial bias.

On a related note, a recent study found 60% of Americans would be uncomfortable with providers relying on AI for their healthcare. But between provider shortages, shrinking reimbursements and increasing patient demands, in time providers might have no option but to turn to AI tools.

Healthcare IT News sat down with Jean-Claude Saghbini, an AI expert and chief technology officer at Lumeris, a value-based care technology and services company, to discuss these concerns surrounding AI in healthcare – and what provider organization health IT leaders and clinicians can do about them.

  1. How can healthcare provider organization CIOs and other health IT leaders fight implicit bias in artificial intelligence as the popularity of AI systems is exploding?
  2. When we talk about AI we often use words like “training” and “machine learning.” This is because AI models are primarily trained on human-generated data, and as such they learn our human biases. These biases are a significant challenge in AI, and they are especially concerning in healthcare, where a patient’s health is at stake, and where their presence will continue to propagate healthcare inequity.

To fight this, health IT leaders need to develop a better understanding of the AI models that are embedded in the solutions they are adopting. Perhaps even more important, before they implement any new AI technologies, leaders must be sure the vendors delivering these solutions have an appreciation for the harm that AI bias can bring and have developed their models and tools accordingly to avoid it.

This can range from ensuring the upstream training data is unbiased and diverse, or applying transformation methods to outputs to compensate for inextricable biases in the training data.

At Lumeris, for example, we are taking a multipronged approach to fighting bias in AI. First, we are actively studying and adapting to health disparities represented in underlying data as part of our commitment to fairness and equity in healthcare. This approach involves analyzing healthcare training data for demographic patterns and adjusting our models to ensure they don’t unfairly impact any specific population groups.

Second, we are training our models on more diverse data sets to ensure they are representative of the populations they serve. This includes using more inclusive data sets that represent a broader range of patient demographics, health conditions and care settings.

Finally, we are embedding nontraditional healthcare features in our models, such as social determinants of health data, thereby ensuring predictive models and risk scores account for patients’ unique socioeconomic conditions. For example, two patients with very similar clinical presentations may be directed toward different interventions for optimal outcomes when we incorporate SDOH data in the AI models.

We also are taking a transparent approach to the development and deployment of our AI models, and incorporating feedback from users, and applying human oversight to ensure our AI recommendations are consistent with clinical best practices.

Fighting implicit bias in AI requires a comprehensive approach that considers the entire AI development lifecycle and can’t be an afterthought. This is key to truly promoting fairness and equity in healthcare AI.

  1. How do health systems strike a balance between patients not wanting their physicians to rely on AI and overburdened physicians looking to automation for help?
  2. First let’s examine two facts. Fact No. 1 is that in the time between waking up in the morning and seeing each other during an in-office visit, chances are both patient and physician already have used AI multiple times in instances such as asking Alexa about the weather, relying on a Nest device for temperature control, Google maps for optimal directions, and so on. AI already is contributing to many facets of our lives and has become unavoidable.

Fact No. 2 is that we are heading toward a shortage of 10 million clinicians worldwide by 2030, according to the World Health Organization. The use of AI to scale clinicians’ capabilities and reduce the disastrous impact of this shortage is no longer optional.

I absolutely understand that patients are concerned, and rightfully so. But I encourage us to consider the use of AI in patient care, versus patients “being treated” by AI tools, which I believe is what most people are worried about.

This scenario has been hyped up a lot lately, but the fact of the matter is that AI engines aren’t replacing doctors anytime soon, and with newer technologies such as generative AI, we have an exciting opportunity to provide the much-needed scale for the benefit of both patient and physician. Human expertise and experience remain critical components of healthcare.

Striking a balance between patients not wanting to be treated by AI and overburdened physicians looking to AI systems for help is a delicate issue. Patients may be concerned their care is being delegated to a machine, while physicians may feel overwhelmed by the volume of data they need to review to make informed decisions.

The key is education. Many headlines in the news and online are created to catastrophize and get clicks. By avoiding these misleading articles and focusing on real experiences and use cases of AI in healthcare, patients can see how AI can complement a physician’s knowledge, accelerate access to information, and detect patterns that are hidden in data and that may be easily missed even by the best of physicians.

Further, by focusing on facts, not headlines, we can also explain that this tool, and AI is just a tool, if integrated properly in workflows, can amplify a doctor’s ability to deliver optimal care while still keeping the physician in the driver’s seat in terms of interactions and responsibility toward the patient. AI is and can continue to be a valuable tool in healthcare, providing physicians with insights and recommendations to improve patient outcomes and reduce costs.

I personally believe the best way to strike a balance between patient and physician AI needs is to ensure that AI is used as a complementary tool to support clinical decision-making rather than a replacement for human expertise.

Lumeris technology, for example, powered by AI as well as other technologies, is designed to provide physicians with meaningful insights and actionable recommendations they can use to guide their care decisions while empowering them to make the final call.

Additionally, we believe it is essential to involve patients in the conversation around the development and deployment of AI systems, ensuring their concerns and preferences are taken into account. Patients may be more willing to accept the use of AI if they understand the benefits it can bring to their care.

Ultimately, it’s important to remember that AI is not a silver bullet for healthcare, but rather a tool that can help physicians make better decisions and exponentially scale and transform healthcare processes, especially with some of the newer foundational models such as GPT, for example.

By ensuring AI is used appropriately and transparently, and involving patients in the process, healthcare organizations can strike a balance between patient preferences and the needs of overburdened physicians.

  1. What should provider executives and clinicians be wary of as more and more AI technologies proliferate?
  2. The use of AI in health IT is indeed getting a lot of attention and is a top investment category, according to the latest AI Index Report published by Stanford, but we have a dilemma as healthcare leaders.

The excitement about the possibilities is urging us to move fast, yet the newness and sometimes black-box nature of the technology is raising some alarms and urging us to slow down and play it safe. Success is dependent on our ability to strike a balance between accelerating the use and adoption of new AI-based capabilities while ensuring implementation is done with the utmost safety and security.

AI relies on high-quality data to provide accurate insights and recommendations. Provider organizations must ensure the data used to train AI models is complete, accurate and representative of the patient populations they serve.

They should also be vigilant in monitoring the ongoing quality and integrity of their data to ensure AI is providing the most accurate and up-to-date information. This also applies to the use of pretrained large language models, where the goal of quality and integrity remains, even if the approach to validation is novel.

As I mentioned, bias in AI can have significant consequences in healthcare, including perpetuating health disparities and reducing the efficacy of clinical decision-making. Provider organizations should be wary of AI models that do not adequately compensate for biases.

As AI becomes more pervasive in healthcare, it’s critical that provider organizations remain transparent about how they are using AI. Additionally, they should ensure there is human oversight and accountability for the use of AI in patient care to prevent mistakes or errors from going unnoticed.

AI raises a host of ethical considerations in healthcare, including questions around privacy, data ownership and informed consent. Provider organizations should be mindful of these ethical considerations and ensure their use of AI, both directly as well as indirectly via vendors, aligns with their ethical principles and values.

AI is here to stay and evolve, in healthcare and beyond, especially with the new and exciting advances in generative AI and large language models. It is virtually impossible to stop this evolution – and not wise to do so, since, after a couple of decades of rapid technology adoption in healthcare, we have yet to deliver solutions that reduce clinician burden while delivering better care.

On the contrary, most technologies have added new tasks and additional work for providers. With AI, and more specifically with the advent of generative AI, we see great opportunities to finally make meaningful advances toward this elusive objective.

Yet, for the reasons I’ve listed, we must set guardrails for transparency, bias and safety. Interesting enough, if well thought out, it is these guardrails that will ensure an accelerated path to adoption by keeping us away from failures that would cause counter-evolutionary overreactions to AI adoption and usage.

‘We’re At A Standstill’: Patients Can Face Agonizing Waits For Hospital Transfers

We're at a standstill': Patients can face agonizing waits for hospital  transfers #Shorts - YouTube

When the pain kicked in again in February, Lahisha Marquez-Soto held off on going to the hospital for days, until she was struggling to walk out of her college dorm in Carson.

Eight days into her stay at MLK Community Hospital, doctors knew she needed another facility. She needed a medical procedure that would allow doctors to peer inside her digestive tract and perform a biopsy to find out what was wrong with her pancreas. That was something that the small hospital in South Los Angeles could not do.

But week after week, the 20-year-old lay waiting in frustration. Stranded in her hospital bed, she missed college classes, birthday celebrations, a scheduled visit with her siblings in foster care. She read novels, watched HGTV and tried not to think about what she was missing.

“It messes with you mentally,” she said. “You’re just stuck in a room.”

Marquez-Soto was at the mercy of a haphazard process that plays out through phone calls and faxes, as smaller hospitals try to find help for patients who need medical procedures that those hospitals cannot provide.

Hospitals are generally required under federal law to accept transfer patients suffering from medical emergencies if the facilities have space and capability; but federal officials said that does not obligate them to accept those like Marquez-Soto, who have already been admitted to a hospital. Hospital employees armed with phone lists often need to call, and call, and call until they can secure a spot. One MLK staffer likened it to throwing spaghetti against the wall to see if it sticks.

Delays in transfers can put people at higher risk of complications and derail day-to-day life for patients. Hospital officials from around the state say that transferring patients has generally gotten harder as many health facilities struggle with staffing, which cramps hospital capacity to accept transfers. Some said that in Southern California, demand for ambulances is also exacerbating delays.

“The general public has no idea of what it takes to transfer a patient,” said Dr. Ferdinand Panoussi, medical director of Horizon Multicare, which provides hospitalist services for Antelope Valley Medical Center in Lancaster. “They think that it’s just as easy as picking up the phone.”

At Antelope Valley Medical Center, some patients who need to be transferred have grown so tired of waiting that they have decided to leave against medical advice, hoping to show up and get in through the emergency department at another facility, Panoussi said.

“This is a mess right now,” even for emergency patients, said Dr. Michael Gertz, president-elect of the California chapter of the American College of Emergency Physicians. He also works at Antelope Valley Medical Center. Even if another facility accepts an emergency patient, “we’re often holding that patient for 12 to 24 hours until we can actually get an ambulance that is willing to take them.”

Gertz said the state does not collect data on such delays in transfers, making it difficult to quantify the problem. MLK hospital officials said their data show that over roughly a year, patients admitted to the hospital had an average wait of more than three days after their transfer had been requested — and that average waits have been longer for those covered by Medi-Cal, the California Medicaid program.

Marquez-Soto, who has Medi-Cal coverage, said she had held off on going to MLK because she expected to end up waiting. In fall, she waited to be transferred to another hospital for the same kind of procedure, but it took so long that she was discharged and told to follow up for an appointment.

She hadn’t gotten that procedure before the pain sent her back to the hospital.

“It makes me feel very helpless,” said Dr. Maita Kuvhenguhwa, who treated Marquez-Soto at MLK. “Even when we’re doing our best and putting in a ton of work, if the patient can’t get to where they need to go, then we’re not helping them.”

Decades ago, federal lawmakers passed the Emergency Medical Treatment and Labor Act to prevent emergency rooms from refusing to treat uninsured patients or “dumping” them on other hospitals. The law requires emergency rooms to treat people who come in suffering from a medical emergency.

If a transfer is medically appropriate, it also requires hospitals to accept people with emergency conditions from another hospital if they have space and “specialized capabilities” to help those patients, as long as the transfer is medically appropriate. But nothing in federal law requires a hospital to accept a transfer patient who has been admitted to another hospital as an inpatient, according to the Centers for Medicare and Medicaid Services.

When patients need a medical procedure that their hospital does not offer, but are not in an emergency state, “there’s not a whole lot of guidelines to direct hospitals in terms of how to manage those transfer requests,” said Dr. Stephanie K. Mueller, assistant professor of medicine at Harvard Medical School.

The process “is in no way systematically thought out,” and bias can creep in when clear standards are lacking, said Dr. Evan Shannon, an assistant professor at the David Geffen School of Medicine at UCLA. He and Mueller found in one study that Black patients were less likely to be transferred out of hospitals than white patients, as measured among Medicare inpatients with medical conditions that typically benefit from transfer.

Another study found that once they were admitted to the hospital, uninsured patients were less likely to be transferred out than those with private insurance. Insurance coverage can decide where a patient goes or slow the process, community hospital officials told University of Michigan researchers.

La Shaunta Harris, manager of emergency department care management and transitional care at MLK, said that as she tried to transfer an inpatient, one hospital told her that “there’s only so much charity we have.” That hits her especially hard because she is from this community, she said.

“Every day,” Harris said, “a little bit of my heart is chipped.”

Under federal law, nothing prohibits hospitals from turning down an inpatient transfer because of the insurance coverage of the patient, a CMS spokesperson said. The problem spilled into public view during the COVID-19 pandemic, when the Wall Street Journal obtained emails indicating that some California hospitals refused or delayed accepting COVID patients from overrun hospitals because of their insurance status.

Doctors said some patients suffered lung damage and other complications because of delays, the newspaper reported.

The back-and-forth over relocating patients usually happens out of public view, but the emails became public because California had hired a contractor to help relieve the pressure on overwhelmed hospitals earlier in the pandemic. The California Emergency Medical Services Authority also steps in to help transfer patients during disasters such as wildfires when hospitals must be evacuated, but does not get involved with transfers on a day-to-day basis.

Many hospital systems have set up their own centers to manage requests to transfer patients into their facilities, including the hospitals run by Los Angeles County. Some hospitals have agreements with others about accepting patients. But there is no central clearinghouse to check every nearby hospital for suitable beds.

Gertz argued that COVID-19 “was a crisis, but now we’re in a permanent crisis. There’s going to have to be a government intervention.”

At MLK Community Hospital, Lourdes Beltrán strategized before her computer monitor, trying to figure out how to free Marquez-Soto from her misery. She pulled out a weathered piece of paper from a folder — a printed list of phone numbers jotted with handwritten notes — and dialed.

“Good afternoon. My name is Lourdes. I’m one of the case managers here at Martin Luther King Community Hospital,” she said when someone answered at a medical center, explaining that she was following up on a transfer request.

She listened, her pencil hovering over a printed summary of the case, as someone at the medical center explained they were still awaiting paperwork. After she hung up, she dialed up the health plan to ask if it could push things along. “We’re still trying to move that patient,” Beltrán told them.

Beltrán glanced at the row of names on her screen, many tagged with a red bar labeled “Exceeded” because they had stayed longer than expected. The health plan said it already sent the needed paperwork, so she dialed the medical center again. It had taken nearly half an hour, she said, to get a “non-answer.”

Beltrán then turned her attention to Ernesto Chavez, a 65-year-old man who had arrived at the hospital more than a week earlier after enduring many days of vomiting. He had lost 10 pounds in two weeks, he told them.

The problem was a giant obstruction in his small intestine, but “we can’t do anything about it here,” said Dr. Tiffany Maggi-Maidinetti. “We don’t have the surgical specialists to remove or biopsy it safely.”

If it turned out to be cancer, Maggi-Maidinetti worried, a holdup could delay the care he needed. And if the thing inside him grew, she feared it could damage his intestine.

It had been three days since MLK issued a transfer order, and Beltrán had no luck. She dialed another number and punched in digits on an automated menu before someone picked up and she rattled off his medical details. Then came the question of health insurance: Chavez was in the process of getting Medi-Cal coverage.

In a dimly lit room, Chavez lay with an arm draped over his forehead, grimacing with pain. He strained to speak, his throat painfully dry. The patient, who had been working as a carpenter, had spent days at home, unable to eat or drink anything without vomiting, before his co-workers took him to the emergency room.

“I want to cry and scream,” he said faintly in Spanish from his hospital bed. “But I have to put up with it.”

One week later, Beltrán said Chavez had been approved for Medi-Cal and another hospital had agreed to accept him. But they were still waiting on an available bed. So Chavez remained in limbo. Doctors at MLK were trying to quell his pain and nausea, keep him hydrated, and stave off any complications or infections from the tubes threading his body, including one snaking from his nasal passages to his stomach to clear out bile.

“We’re at a standstill, basically,” Maggi-Maidinetti said.

That evening, Chavez was finally transferred. Chavez, reached weeks later, said he had undergone an operation there and that he was finally able to eat and drink again without vomiting.

Before he was transferred, “I felt desperate,” he said.

Transferring patients has long preoccupied smaller community hospitals because their patients may need medical interventions that they do not offer themselves. But getting patients where they need to be has become a concern for hospitals of all kinds as they grapple with the effects of the COVID-19 pandemic.

People have returned to hospitals after years of delaying care, but a staffing crunch has limited the number of beds available, hospital officials say. Medical centers have lamented that because nursing facilities are also short on staff, hospitals cannot discharge patients who no longer need a hospital bed but still need nursing care. That ties up beds in the hospital, gumming up the usual flow of patients from the emergency department into inpatient beds.

UC Davis Medical Center said it accepted more than 7,600 transfer requests in a little over a year — but turned down more than 9,900 due to limited capacity. And it too is struggling to move patients to other, less specialized hospitals once they can be safely cared for elsewhere.

“We run over 100% occupancy essentially every day of the week,” said Dr. J. Douglas Kirk, chief medical officer. “We absolutely have to get those patients out of the hospital because we have to produce that bed for the next patient who needs it.”

And “moving Medi-Cal patients typically is more sluggish than the commercially insured patients,” Kirk said.

Statewide data on median lengths of hospital stays show that Medi-Cal inpatients spent one day longer before transferring to another hospital, compared with transfer patients who have private insurance. At MLK, the average wait for a transfer was more than 50% longer for Medi-Cal inpatients than those with other coverage, according to figures provided by hospital officials.

Ambulance availability can also delay transfers, hospital officials said. Antelope Valley Medical Center Chief Executive Edward Mirzabegian said he has grown so frustrated with the waits that he is trying to create an ambulance company dedicated to his facility at an annual cost of more than $2 million. The Los Angeles County Ambulance Assn. faulted low reimbursements for ambulance providers to transport Medi-Cal patients, especially those not suffering a medical emergency.

“Very few people are willing to accept reimbursement rates that low, so there’s a limited pool of contractors that serve this patient population,” association president Chad Druten said. Last fall, American Medical Response said it would stop providing nonemergency transport in Los Angeles County, blaming low rates under Medi-Cal.

In January, MLK hospital officials were so worried about how long one patient had lingered there that the chief executive, Dr. Elaine Batchlor, got on the phone herself to try to find him a bed at another hospital. Because of its small size, MLK doesn’t offer cardiothoracic surgery, which physicians feared he needed.

As he waited for a transfer, “he just sat here and sat here,” growing sicker and more lethargic, said Dr. Eriko Masuda, an infectious disease physician at MLK.

The man was suffering from a bacterial infection that his blood was ferrying throughout his body, showering the infection to his brain and elsewhere, Masuda said. As the weeks passed, the man suffered kidney failure and needed dialysis. His family members asked Masuda when he could leave. She had no answer.

“I’m doing my best, but I can’t do any more than what I can do here,” Masuda recounted.

Batchlor called physicians together to figure out what else they could do to help him transfer, and staff worked to upgrade his insurance coverage. Three weeks after MLK started trying to transfer him, the patient was finally taken to another medical center for heart surgery, and he survived.

Others in L.A. County have not been as lucky: Gertz wrote that in one case, a 45-year-old man who suffered a sudden, agonizing headache had been taken by his family to a San Gabriel hospital, where he was diagnosed with a ruptured aneurysm.

Because the hospital did not offer neurosurgery, it hustled to transfer him elsewhere, but arranging for transportation took so long that the man ended up in a vegetative state and was taken off life support, Gertz wrote to a Los Angeles County supervisor.

“Had the family taken him to the other hospital,” Gertz wrote, “he would have likely survived.”

Marquez-Soto was transferred to UCLA one month after MLK started trying to move her. There, she said, she was told her pancreas was too inflamed to move forward with the procedure that would have examined her digestive tract.

But doctors there spotted a rash and ended up diagnosing Marquez-Soto with a rare inflammatory disease that could be treated with an infusion of antibodies, she said. Finally, she started feeling better.

Denials of Health Insurance Claims Are Rising — And Getting Weirder

Denials of Health Insurance Claims Are Rising — And Getting Weirder -  Nashville Medical News - Healthcare News & Marketplace

Millions of Americans in the past few years have run into this experience: filing a health care insurance claim that once might have been paid immediately but instead is just as quickly denied. If the experience and the insurer’s explanation often seem arbitrary and absurd, that might be because companies appear increasingly likely to employ computer algorithms or people with little relevant experience to issue rapid-fire denials of claims — sometimes bundles at a time — without reviewing the patient’s medical chart. A job title at one company was “denial nurse.”

It’s a handy way for insurers to keep revenue high — and just the sort of thing that provisions of the Affordable Care Act were meant to prevent. Because the law prohibited insurers from deploying previously profit-protecting measures such as refusing to cover patients with preexisting conditions, the authors worried that insurers would compensate by increasing the number of denials.

And so, the law tasked the Department of Health and Human Services with monitoring denials both by health plans on the Obamacare marketplace and those offered through employers and insurers. It hasn’t fulfilled that assignment. Thus, denials have become another predictable, miserable part of the patient experience, with countless Americans unjustly being forced to pay out-of-pocket or, faced with that prospect, forgoing needed medical help.

recent KFF study of ACA plans found that even when patients received care from in-network physicians — doctors and hospitals approved by these same insurers — the companies in 2021 nonetheless denied, on average, 17% of claims. One insurer denied 49% of claims in 2021; another’s turndowns hit an astonishing 80% in 2020. Despite the potentially dire impact that denials have on patients’ health or finances, data shows that people appeal only once in every 500 cases.

Sometimes, the insurers’ denials defy not just medical standards of care but also plain old human logic. Here is a sampling collected for the KFF Health News-NPR “Bill of the Month” joint project.

  • Dean Peterson of Los Angeles said he was “shocked” when payment was denied for a heart procedure to treat an arrhythmia, which had caused him to faint with a heart rate of 300 beats per minute. After all, he had the insurer’s preapproval for the expensive ($143,206) intervention. More confusing still, the denial letter said the claim had been rejected because he had “asked for coverage for injections into nerves in your spine” (he hadn’t) that were “not medically needed.” Months later, after dozens of calls and a patient advocate’s assistance, the situation is still not resolved.
  • An insurer’s letter was sent directly to a newborn child denying coverage for his fourth day in a neonatal intensive care unit. “You are drinking from a bottle,” the denial notification said, and “you are breathing on your own.” If only the baby could read.
  • Deirdre O’Reilly’s college-age son, suffering a life-threatening anaphylactic allergic reaction, was saved by epinephrine shots and steroids administered intravenously in a hospital emergency room. His mother, utterly relieved by that news, was less pleased to be informed by the family’s insurer that the treatment was “not medically necessary.”

As it happens, O’Reilly is an intensive-care physician at the University of Vermont. “The worst part was not the money we owed,” she said of the $4,792 bill. “The worst part was that the denial letters made no sense — mostly pages of gobbledygook.” She has filed two appeals, so far without success.

Some denials are, of course, well considered, and some insurers deny only 2% of claims, the KFF study found. But the increase in denials, and the often strange rationales offered, might be explained, in part, by a ProPublica investigation of Cigna — an insurance giant, with 170 million customers worldwide.

ProPublica’s investigation, published in March, found that an automated system, called PXDX, allowed Cigna medical reviewers to sign off on 50 charts in 10 seconds, presumably without examining the patients’ records.

Decades ago, insurers’ reviews were reserved for a tiny fraction of expensive treatments to make sure providers were not ordering with an eye on profit instead of patient needs.

These reviews — and the denials — have now trickled down to the most mundane medical interventions and needs, including things such as asthma inhalers or the heart medicine that a patient has been on for months or years. What’s approved or denied can be based on an insurer’s shifting contracts with drug and device manufacturers rather than optimal patient treatment.

Automation makes reviews cheap and easy. A 2020 study estimated that the automated processing of claims saves U.S. insurers more than $11 billion annually.

But challenging a denial can take hours of patients’ and doctors’ time. Many people don’t have the knowledge or stamina to take on the task, unless the bill is especially large or the treatment obviously lifesaving. And the process for larger claims is often fabulously complicated.

The Affordable Care Act clearly stated that HHS “shall” collect the data on denials from private health insurers and group health plans and is supposed to make that information publicly available. (Who would choose a plan that denied half of patients’ claims?) The data is also supposed to be available to state insurance commissioners, who share with HHS the duties of oversight and trying to curb abuse.

To date, such information-gathering has been haphazard and limited to a small subset of plans, and the data isn’t audited to ensure it is complete, according to Karen Pollitz, a senior fellow at KFF and one of the authors of the KFF study. Federal oversight and enforcement based on the data are, therefore, more or less nonexistent.

HHS did not respond to requests for comment for this article.

The government has the power and duty to end the fire hose of reckless denials harming patients financially and medically. Thirteen years after the passage of the ACA, perhaps it is time for the mandated investigation and enforcement to begin.

Employers Face Soaring Demand For Obesity Care Benefits. Virtual Care Players Are Jumping In With A Slew Of Offerings

Telehealth offers potential for health specialists | Fierce HealthcareEmployers are seeing surging demand from their workers for benefits that cover obesity treatment and this is opening up considerable market opportunities for virtual care players.

A recent survey found that 44% of people with obesity would change jobs to gain coverage for treatment. And more than half of workers would stay at a job they didn’t like to retain that coverage, according to the survey from the Obesity Action Coalition.

“I think very much that where we were on mental health as an employee benefit 10 years ago is where we are today on metabolic health. In 10 years, employees will move with their feet to employers who cover holistic metabolic health benefits,” said Isabelle Kenyon, founder and CEO of Calibrate, a digital metabolic health platform.

Increasingly, as part of this focus on metabolic health, there is excitement around new and emerging obesity medications like semaglutide (Wegovy) and tirzepatide (Mounjaro). But drugs like Ozempic and Wegovy come with a hefty price tag, at least $1,000 per month. Neither drug is covered for weight loss by most insurance plans.

Semaglutide, which is sold under the brand names Ozempic, Wegovy and Rybelsus, accounted for $10.7 billion in drug spending in 2021, up 90% over the year before, which ranked it fourth among drug expenditures, according to a study published last year in the American Journal of Health-System Pharmacy.

Last year, the American Gastroenterology Association recommended coverage of weight loss drugs for those with BMI (body mass index) over 30 or BMI over 27 with complications. Currently, about 42% of people in the U.S. are obese, or have a BMI of 30 or higher, according to CDC data.

Health plan sponsors are facing increasing pressure to cover these medications. If these drugs are used by a substantial portion of those with obesity, the increase in medical costs will be high, according to Jeff Levin-Scherz, M.D., managing director and population health leader at insurance services company Willis Towers Watson (WTW).

And these advances in game-changing obesity drugs come as employers are already facing the highest medical inflation rate in decades.

“Among our clients, about two-thirds of them are covering GLP-1 drugs for obesity, however, what we’re seeing is rapid uptake and costs that are unsustainable,” Levin-Scherz said. “Coverage right now is pretty good, but if these drugs continue to be as expensive as they are now, I don’t know if we could project that they will continue to be covered this way.”

Virtual care companies are now jumping into the market as they see big opportunities to combine prescriptions for GLP-1 drugs with online programs that focus on lifestyle and behavior change. The idea, digital health executives say, is to improve long-term clinical outcomes and ultimately reduce costs by helping people keep the weight off.

“When we talk to employers, it’s not, ‘I don’t want to cover these drugs.’ In fact, I literally have never heard that from an employer,” said Kenyon, whose company, Calibrate, launched an enterprise business late last year. “What I hear from employers is, ‘I want to cover these drugs and I want to do it in a way that guarantees outcomes and I want to do it in a way that contains cost.’ And that does not mean one-way prescribing of GLP-1s.”

She added, “Employers are feeling this already. They see it in their Ozempic spend, they see it in their Trulicity spend. I would say two-thirds of employers that we meet want a solution for this category today. And a solution means cost control and it means outcomes.”

Employers will need to make some strategic decisions going forward. They can continue to cover these next-generation drugs for obesity but “will not save as much money as the drugs cost,” Levin-Scherz said, or they can choose to not cover them at all but could find it harder to recruit employees.

But there’s a high cost to not addressing obesity as well. Being significantly overweight contributes to many other chronic conditions and can lead to downstream health costs. Organizations spend twice as much on healthcare costs for individuals with obesity compared with individuals at a healthy weight, one study found.

Companies also could choose to cover the drugs but use different criteria than the one established by the FDA and set a higher BMI threshold in order for members to qualify for coverage of obesity treatment.

“Employers can also put in a prior authorization or step therapy that people have to go through such as medically guided diets or try less expensive medicines before they go to these more expensive medicines,” Levin-Scherz noted.

Digital weight loss company Wondr Health recently rolled out a new program to help health plans and employers navigate the complexities of weight and anti-obesity medications. Through Wondr’s program, individuals are assessed and triaged to determine if they qualify for anti-obesity medications and are then connected to practitioners and certified health coaches who provide tailored medication management paired with behavior change support.

“You can call it step therapy, you can call it “pre-auth” into the drug and then we stay with them while they are taking the drug and work with them to change their behaviors so when they do come down off these drugs, they don’t revert back to those old habits and put that weight back on,” CEO Scott Paddock said. Wondr currently works with 1,600 employers and 80 health plans, covering 11 million lives, according to Paddock.

Some companies like direct-to-consumer health and wellness company Ro and telehealth giant Teladoc have recently expanded beyond their core conditions to launch new obesity-focused programs.

Building on its chronic condition management services as a result of its Livongo acquisition in 2020, Teladoc rolled out a new provider-based care service for employers to include weight management and prediabetes programs. “The feedback we are hearing from employers and health plans is that they recognize the benefits these drugs can have but are also mindful of both the cost and the potential for the drugs to be used outside of evidence-based clinical indications,” said Jason Tibbels, M.D., Teladoc Health Chief Quality Officer.

“We know that these drugs work best in conjunction with the range of solutions and tools that address the foundational pillars impacting cardiometabolic health including nutrition logging and coaching, activity tracking, sleep management and stress and mental health in-the-moment tools and virtual care,” Tibbels said. “Without any lifestyle modifications members will need to continuously be on these drugs to retain their weight loss, thereby increasing an employer or health plan’s healthcare costs.”

Virtual obesity care solutions that have historically focused on behavior change such as Calibrate and Found are also building out their offerings by adding new prescription service lines. Found developed a new platform that aims to help employers manage services and cost for workers struggling with weight, including GLP-1 drugs.

Calibrate’s Kenyon says the startup’s approach is to create a total cost of care equation that works for payers and employers. “We focus on ‘right medication, right person, right amount of time’ where some people are on the drugs, some people are off the drugs, but everyone’s getting to a healthier weight that’s leading to less total medical expense,” she said.

Kenyon refers to Calibrate’s approach to obesity drugs as “continuous authorization management.” “I, as the provider, am on the hook for delivering that cost of care return for making sure that you actually get outcomes or I take you off the meds. That means, month in month out, we are constantly reauthorizing whether or not the patient gets access to the medication. We do that through partnerships with PBMs to really control the pharmacy spend.”

Calibrate recently released data that showed members had 15% average sustained weight loss at 12, 18 and 24 months.

Noom unveiled this week Noom Med, which offers GLP-1s to “medically qualified individuals.” Noom’s Chief of Medicine Linda Anegawa, M.D., told Fierce Healthcare that the consumer-facing weight loss company is exploring the idea of a “potential enterprise offering.”

Virtual chronic condition management company Omada Health also launched a new service designed to address cost concerns and support behavior and lifestyle change in conjunction with GLP-1 drugs. The company does not prescribe or fill prescriptions for the medications, CEO Sean Duffy said, as there are many providers, both in-person and online, that offer access to the drugs.

“These breakthrough medicines clearly have captured the zeitgeist but leave a lot of open questions, especially around the cost profile and affordability,” Duffy said in an interview. “Listening to our employers and our payer partners, they’re very concerned about costs and they’re saying, ‘If I am going to pay for this medicine for a subset of the population, I want to make sure that there’s as much value out of that as possible.’”

Omada rolled out services to support employers and pharmacy benefit managers with administering coverage policies around GLP-1s, Duffy said. Medication coverage coupled with behavior change gives people the best chance to achieve long-term, sustained weight loss, and avoid a lifetime reliance on the medicines, he noted.

Make no mistake, the market opportunity is gigantic. Rock Health estimates that the serviceable obesity care market hovers around $13 billion in the U.S. Medication for obesity care makes up a large portion of the market at 40%—and it’s expected to increase as more drugs are approved beyond the six FDA-approved weight loss drugs and insurance coverage is expanded. Digital health solutions make up a burgeoning 55% of the market, according to the digital health investment firm.

“Some estimates suggest that the obesity care market may grow to as much as $54 billion by 2030, assuming access to medication-led treatment expands. Digital solutions with and without a medication component are key to that expansion and play a role in increasing access to scalable and sustainable care,” wrote Rock Health researchers.

Insurers footing the bill for expensive GLP-1s

So far insurers have taken a cautious approach to covering this pricey new class of weight loss drugs.

UnitedHealth Group Chief Executive Officer Andrew Witty recently signaled that the insurer will take a stringent approach to reimbursing these next-generation obesity medications.

“I think as time plays out, what’s going to be super critical here is that we need to get focused on the facts and reality of this marketplace. We need to really be clear about which patients really do benefit from these medicines and make sure we properly understand how they’re going to use those medicines,” he said during a Q&A with Wall Street analysts following the company’s first-quarter 2023 earnings call. “There’s a lot still to learn as these things progress through their final phases. And then finally, of course, we got to see the prices be affordable and that’s going to be a key element of how this evolves.”

When pressed by a Wall Street analyst to share Cigna’s approach to GLP-1 drugs, CEO David Cordani acknowledged that the treatment protocols “represent a positive step forward, specifically for diabetics.”

But he added that employers have had a “more limited appetite to expand coverage beyond clinical diagnoses such as diabetes for certain lifestyle treatments.”We’ve seen more limited adoption of that, thus far,” he said during the company’s Q1 earnings call.

As a vertically integrated insurer, Cigna owns pharmacy benefit management company Express Scripts, which sits within its Evernorth business division, and that will help insulate the company from some of the drug cost pressures, Cordani said.

“As the evidence and demand for these medications continues to mount, we hope that employers and health plans act swiftly to extend coverage to more people who could improve their health and lives through high-quality obesity care and treatment,” said Melynda Barnes, M.D., Ro’s chief medical officer. Ro recently launched a weight loss program that provides access to GLP-1 medications.

She added, “It’s safe to say that the status quo in weight management treatment isn’t working for any stakeholder with rising obesity rates, associated costs and poor health outcomes–payers should see GLP-1s for the rare opportunity they present to reset how things are done and to dramatically help patients.”

As Pandemic Flexibilities Unwind, Here’s How Enrollment In Different Types Of Coverage Could Change

The End of the COVID-19 Public Health Emergency: Details on Health Coverage  and Access | KFF

As flexibilities rolled out during the COVID-19 pandemic wind down, there will be plenty of factors at play that could impact uninsured rates in the coming years.

Analysts at the Congressional Budget Office (CBO) project that while the rate will increase from current levels, it will decline over the next decade from pre-pandemic levels. They estimate that 10.1% of people will be uninsured in 2033, down from 12% in 2019, according to a new study published in Health Affairs.

By comparison, the CBO estimated that 248 million people under 65 in the U.S. have coverage this year, and 23 million people in that age group, or about 8.3%, are uninsured.

“Importantly, those projections take into account many estimated components, including demographic, economic and behavioral variables, and are conditioned on the assumption that current laws stay in place,” the researchers wrote.

The CBO analysts said that the current record lows in the number of uninsured people are tied to continuous coverage provisions in Medicaid and expanded subsidies for plans on the Affordable Care Act’s (ACA’s) exchanges. Those continuous coverage mandates have expired with the public health emergency, and states have begun the lengthy process of working through that backlog of eligibility determinations.

CBO projects that 9.3 million people under aged 65 will move from Medicaid to other forms over coverage over the next two years, and 6.2 million people will become insured.

The enhanced ACA subsidies led to record enrollment in exchange plans, and those were extended for several years. However, should they expire in 2025 as they’re currently set to do, it will likely lead to 4.9 million people signing up for marketplace coverage, according to the report.

Some of this population will shift to unsubsidized group coverage or employer plans, and some will become uninsured, CBO projected.

Even as these coverage shifts occur, the CBO analysts said that employer-sponsored coverage will remain the largest source of insurance. They projected that average monthly enrollment will be between 155 million and 159 million over the next decade.

In addition to examining how people may move between types of coverage, the CBO report also estimates how premiums could change over the next several years. The researchers projected that premiums will go up by 6.5% in 2023 and then by an average of 5.9% between 2024 and 2025.

In the 2026 to 2027 time frame, premiums could increase by 5.7% on average and then by an average of 4.6% from 2028 to 2033.

“The higher short-term growth rates partly reflect a bouncing back of medical spending from the suppressed levels of utilization during the initial months of the COVID-19 pandemic in 2020,” the analysts wrote.

Senate Scrutinizes MA Payment Denials, Including Use Of Algorithms

Impossible' Medicare Advantage denials decried during Senate hearing

Medicare Advantage plans’ use of third-party algorithms for coverage determinations is facing some scrutiny in the Senate.

Lawmakers in a Wednesday hearing argued something must be done to pare back burdensome prior authorization requirements allowing payers to delay or deny medical care that would be covered under traditional Medicare — including the use of artificial intelligence — as insurer profits continue to rise.

“Insurers are in effect denying Americans necessary care in order to fatten and pad their bottom lines, and that phenomenon is unacceptable,” said Sen. Richard Blumenthal, D-Conn., chair of the Permanent Subcommittee on Investigations, which held the hearing.

“I want to put these companies on notice. If you deny lifesaving coverage to seniors, we’re watching, we will expose you, we will demand better, we will pass legislation if necessary, but action will be forthcoming,” Blumenthal said.

The subcommittee on Wednesday sent bipartisan letters to some of the biggest MA payers, including UnitedHealth, Humana and CVS, which collectively cover more than 50% of MA beneficiaries. The letters asked for internal documents showing how decisions are made to grant or deny access to care, including the use of AI in coverage determinations, Blumenthal said.

Payment denials

Although the majority of requests for services are approved, it’s not uncommon for private MA plans to wrongly deny medically necessary care that would be covered under traditional Medicare, according to an HHS Office of Inspector General report from last April.

Federal investigators found 13% of prior authorization requests and 18% of payment denials were wrongly denied and should have been approved under Medicare coverage rules.

In addition, a 2018 government audit found MA plans ultimately approved 75% of appealed requests that were originally denied.

MA plans, which can offer more benefits than traditional Medicare, continue to grow in popularity. Currently, 30 million Americans, or roughly half of all Medicare enrollees, are in the privately run Medicare plans. And the number of plans has grown, with the average beneficiary choosing between 43 plans offered by nine different insurers as payers flood into the lucrative market.

“Fast growth has increased vulnerabilities and the need for robust program integrity measures,” testified Megan Tinker, HHS OIG chief of staff, during the hearing.

AI determinations

To cut costs, MA insurers are routinely using algorithms from third-party companies like NaviHealth for coverage determinations, sparking many of the inappropriate denials, according to a STAT investigation earlier this year.

Insurers’ use of the unregulated technology was a major focus of the hearing with senators arguing the need for more oversight.

“Insurers may refer to these algorithms as tools used for guidance, but the denials they generate are too systematic to ignore,” said Blumenthal. “Insurance companies insist those AI mechanisms are proprietary, but part of what needs to happen is to make them more transparent so patients and providers know along with the public how they are being used.”

Gloria Bent, an MA enrollee, shared her husband’s experience with melanoma and how NaviHealth, which is owned by payer giant UnitedHealth, frequently denied care prescribed by his clinician. That resulted in a stressful cycle of coverage denials and appeals and his premature departure from a skilled nursing facility.

“The reappearance of melanoma in 2022 pulled a rug out from under my husband and my family. Then came the added trauma which piled on steadily of having to fight to keep him receiving the care he needed,” Bent testified. “This should not be happening to families and patients. It’s cruel.”

Still, utilization management tools like prior authorization can be valuable for cost containment, testified Lisa Grabert, a visiting research professor at the Marquette College of Nursing. Insurers argue prior authorization is necessary to curb waste and unnecessary medical expense.

Earlier this year, the Biden administration finalized a rule reiterating that MA plans are required to comply with coverage rules in traditional Medicare. Where there isn’t a Medicare coverage determination, MA plans can establish their own internal coverage criteria. That criteria must follow widely accepted available clinical guidelines and be reviewed annually by a clinical committee, the final rule says.

In addition, if a utilization management policy like a prior authorization could lead to a partial or full denial of care, it needs to be reviewed by a clinician. CMS plans to enforce the rule through audits.

Large private health insurers, like UnitedHealthcare, have been paring back their prior authorization requirements in advance of the regulation.

Senator Roger Marshall, R-Kans., asked witnesses if it would be valuable to force plans to report more detailed information on prior authorization delays, denials and appeals by CPT code or individual service level, as the new CMS rule only requires MA payers to share aggregate data.

Witnesses said more data is always helpful for research, oversight and beneficiary shopping between plans.

“The information that is available right now, you have to dig very, very, very deep to get any information on whether a prior authorization may or may not be required, and certainly not at the service level,” testified Jeannie Fuglesten Biniek, associate director of Medicare policy for KFF. “It would be a step in a direction that would help.”

Kaiser Permanente Discloses Timeline, Financial Commitments For Its VBC Megadeal With Geisinger Health

Regulatory filing sheds new light on Kaiser-Geisinger megadealDisclosures included in Kaiser Permanente’s quarterly financial statements offer new details on the timeline for its major value-based care deal with Geisinger Health, as well as the upper and lower limits of its investment commitments toward the new entity and expanding Geisinger’s Pennsylvania market presence.

The statements, released late Monday, recap the definitive agreement announced by the integrated health systems in late April—Kaiser will create a separate non-profit called Risant Health, that would then acquire Geisinger and become its sole member.

Risant would, according to the statements, strategically aim to “expand and accelerate the adoption of value-based care in diverse, multi-payer, multi-provider and community-based health system environments.” Kaiser leadership has also said that Risant would accomplish those goals with “five or six” additional health system acquisitions.

Monday’s filing, however, shares that Kaiser doesn’t expect its deal to close until some time in 2024.

Additionally, the system’s financial commitments into Risant are slated to be made “over the five-year period following closing,” while committed investments and support by Risant into Geisinger will be made through Dec. 31, 2028, according to the filing.

As for the investments themselves, Kaiser leadership previously said it planned to shift $5 billion of the system’s funds into support for the new entity. Per the filing, that $5 billion toward “core Risant Health capabilities, technologies, tools and future investments” represents the upper limit of Kaiser’s potential support, with Kaiser also committing to a minimum investment of $400 million over five years “inclusive of funds generated by Risant Health.”

Risant would then be on the hook to make available to Geisinger a minimum of $2 billion (inclusive of funds generated internally by Geisinger and Risant) through the end of 2028 to “support necessary hospital, ambulatory facility, technology and other strategic and routine capital,” Kaiser wrote.

Further, Risant must assure funding “of no less than $100 million” through 2028 to support expansions of Geisinger’s health plan and care delivery services into bordering Pennsylvania communities (again inclusive of internally generated funds), according to the statements.

Finally, Kaiser wrote that the agreement requires Risant to keep a minimum of $115 million available annually (inclusive of internally generated funds, and adjusted for inflation and other factors) to fund Geisinger’s research and education efforts for at least 10 years after the deal’s close, the system wrote.

Kaiser and Geisinger’s deal is still subject to regulatory approvals, though antitrust agencies have so far been hesitant to challenge deals involving healthcare entities operating in different markets.

Monday’s disclosures came alongside a more fleshed-out report of Kaiser’s first-quarter financials. The integrated giant said it brought in $1.2 billion in net income and $233 in operating income, a welcome turnaround after it lost $4.5 billion across 2022.

The Oakland, California-based nonprofit reports over $95 billion in annual operating revenues and spanned 624 medical offices, 39 hospitals and 43 retail and employee clinics as of March 31. It counted a total of 12.7 million members as of March 31.

Danville, Pennsylvania-based Geisinger reported $6.9 billion in revenue, a $239 million operating loss and a $842 million net loss across 2022. Its 133 care locations, including 10 hospital campuses, are primarily focused in central and northeastern Pennsylvania. It counted roughly 612,050 members as of Dec. 31 and had cared for nearly 1.2 million people across 2022.

House Panel Advances Transparency And PBM Bills

House panel advances bill to promote PBM transparency

A House Energy and Commerce Committee health markup on Wednesday offered more evidence that price transparency and pharmacy benefit manager regulation are two issues that have enough bipartisan support to move ahead in this Congress.

Among the measures the panel advanced on a unanimous 27-0 vote:

  • Codifying and strengthening Trump-era rules for hospitals and insurers to make health care prices available and more transparent.
  • Imposing new transparency requirements on PBMs and banning “spread pricing” in Medicaid, where PBMs charge more than they pay for a drug and keep the difference.

Yes, but: The committee took a pass on major measures to provide for site neutral payment reforms in Medicare that address the way hospitals charge more for outpatient services that can be done in less-expensive settings.

  • In a sign the issue is not dead, Chair Cathy McMorris Rodgers (R-Wash.) offered and withdrew an amendment, saying there is “more work to do” on the measures.
  • “It’s not a secret that hospitals have concerns with these proposals,” she said, but argued that there should be other ways to support hospitals than overpaying for certain services.

The bottom line: Versions of transparency and PBM bills could end up in a broader legislative package later this year, given the need to reauthorize programs like community health centers.

  • PBM measures have particular momentum, given that the Senate HELP Committee also advanced measures aimed at providing drug savings.

Last Updated 05/31/2023

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