May
24

Happy Memorial Day Weekend!

Hope yours is filled with family and friends…and time to reflect on those who gave their lives for us.

Thanks to them, we have much to be thankful for.

Starting with…despite what many think we’re NOT in a recession…

From the Guardian’s survey…

The vast majority of respondents, 72%, indicated they think inflation is increasing. In reality, the rate of inflation has fallen sharply from its post-Covid peak of 9.1% and has been fluctuating between 3% and 4% a year.

In April, the inflation rate went down from 3.5% to 3.4% – far from inflation’s 40-year peak of 9.1% in June 2022 – triggering a stock market rally that pushed the Dow Jones index to a record high.

And job creation has been pretty darn great.

Government works!

Remember the botched start-up of the ACA aka “ObamaCare” way back in 2014?

Well, like many new and really big change, its gotten a whole lot better. Almost 2/3rds of Americans view the ACA favorably.

For some, “Obamacare saved my life”…

Support for recovering addicts…

This is really good news…The Feds and California are partnering on a program that pays addicts continuing to remain sober.  The program – “contingency management” –

is the gold standard for stimulant use disorder because you can win things for good behavior. But not a lot of places are providing it yet,” said PK Fonsworth, a psychiatric emergency room doctor and addiction psychiatrist in Los Angeles. (cite WaPo)

Research shows promise for contingency management. For instance, study participants achieve significant periods of sobriety, agree to long-term addiction treatment and even reduce risky sexual behavior.

The Biden administration is pushing more states to consider the approach, calling it a “proven treatment” that “remains underutilized.”

Kudos to CMS (Medicare and Medicaid) and the Golden State for the collaboration.


May
13

Research indicates state abortion bans will deprive residents of healthcare. Newly minted MDs are avoiding states with restrictive abortion policies, as are physicians seeking advanced training in OB/GYN and primary care.

AAMC-sponsored research found there are fewer applications for residency and more advanced training in states with abortion limits. These are the physicians who deliver a lot of care to folks in the hospital and outpatient facilities.

Implications – untrained physicians and reduced access to healthcare.

From FierceHealthcare:

physicians without adequate abortion training may not be able to manage miscarriages, ectopic pregnancies, or potential complications such as infection or hemorrhaging that could stem from pregnancy loss…

“The geographic misalignment between where the needs are and where people are choosing to go is really problematic,” she said. “We don’t need people further concentrating in urban areas where there’s already good access.”

What does this mean for you?

Poor people will suffer, not-poor people will be able to access care.

Remind me…is this how a great country treats its least fortunate?


May
10

Lots of really good stuff to end your week…

the Economy…

remains quite good with 175,000 new jobs last month. This was not as many in previous months…

BUT it looks increasingly like (From NYT) “the exuberance of the last two years might be settling into a more sustainable rhythm”.

Stock markets jumped (the Dow is up 723 (!!!) points this week), interest rates declined modestly,

Seniors’ lower drug costs…

Insulin prices are capped at $35 per month, a major reduction from an average of $300…even better, next year President Biden’s Inflation Reduction Act will limit seniors’ out-of-pocket costs for all prescription medications $2,000 per year.

There’s activity in Congress and by the Biden Administration that would limit everyone’s cost – young, old, and in-between – for insulin to no more than $35 a month…here’s hoping the pols get this done.

This means...With diabetes affecting more Americans, improving access to insulin means healthier families and employees, which leads to lower healthcare costs.

More good news…the Medicare Hospital Trust Fund’s financial solvency was extended to 2036, a five year extension. Not to worry, there’s no doubt this will be extended again.

This means…better finances for hospitals and seniors.

Lots more jobs in Wisconsin and…No more noncompetes!

In the “government CAN actually make life better” category,  we have…lots of great jobs coming to Wisconsin…AND a ban on non-competes.

Microsoft is building a giant AI Center near Racine, Wisconsin. The city was hit hard by the collapse of the Foxconn deal which promised gazillions of dollars and jobs…but never happened. Supported by the Investing in America project, this brings new investment why private companies in Wisconsin to $5 billion – and counting.

The Federal Trade Commission effectively banned non-competes...thereby freeing you up to…actually control where you want to work.

Non-competes are contractual controls that effectively prohibit employees from working at specific jobs, customers, or companies for a defined period in exchange for a/some defined “benefit(s).”

This is a MAJOR bonus for anyone working today as it allows you – not some corporate entity – to control your life. And, the rule is quite broad, clearly empowering workers.

This from Harvard Business Review…

“Worker” is defined not just as an employee but also includes independent contractors, externs, interns, volunteers, apprentices, or a sole proprietor who provides a service. The rule also broadly defines noncompete clauses not only as terms or conditions of employment that explicitly prohibit a worker from competing with a former employer, but also to mean any other clauses that “penalize a worker for” or “function to prevent a worker from” competing. With this definition, the FTC also prohibits clauses that operate as de facto noncompetes, including overly broad NDAs, nonsolicitation clauses, and TRAPs — training repayment agreement provisions. [Emphasis added]

Have a most excellent weekend!


Apr
9

Consolidation among health systems and hospitals continues apace, and with it comes higher costs, more utilization, and longer disability durations.  Get the details from WCRI’s much-watch webinar on the impact of vertical provider integration on prices, medical utilization and outcomes.

It’s on Thursday May 2 at 2 pm eastern.

You can access the written report (free for members) here.

Another major factor that will greatly affect a state’s health, outcomes and costs is Medicaid expansion. A thorough yet simple discussion of implications of one state’s refusal to expand Medicaid is here.

The benefits of Medicaid expansion are broad, deep, and impactful.

Among the findings

  • A 2020 national study found that expansion was associated with a significant 3.6% decrease in all-cause mortality,
  • Two studies found significant declines in maternal mortality
  • expansion is associated with improvements in access to care and outcomes related to substance use disorder (SUD) as well as other mental health care.
  • hospitals in non-metropolitan areas and small hospitals experienced improved profit margins
  • Analyses find effects of expansion on numerous economic outcomes, including state budget savings, revenue gains, and overall economic growth
  • rural hospitals experienced particularly substantial improvements in financial performance following expansion

KFF on Texas’ uninsured population [note Texas is just one of 10 states yet to expand Medicaid]…

(a) significant proportion of adults in the coverage gap are employed unless they are elderly or disabled. The most common jobs among adults in the coverage gap are construction laborer, cashier, cook, waiter, house cleaner, retail salesperson, and janitor. These workers usually do not have access to employer-based health insurance and cannot afford plans on the federal insurance exchange. [emphasis added]

Crossover

Most of the non-expansion states:

  • have major problems with rural hospital cutbacks and closures
  • have significantly worse health outcomes
  • have healthcare access challenges

What does this mean for you?

Pay attention to the real drivers of healthcare outcomes and costs – they have more impact on duration and ultimate costs than anything else.

 


Apr
5

Another April snowstorm here in New Hampshire…weather is getting weirder by the week.

Not to worry  – we are keeping the just-arrived birds well fed!

Jobs…

WOW. This just in from BLS

Total nonfarm payroll employment rose by 303,000 in March, and the unemployment rate changed
little at 3.8 percent, the U.S. Bureau of Labor Statistics reported today. Job gains occurred 
in health care, government, and construction.
March's growth was significantly higher than the average monthly
gain of 231,000 over the prior 12 months.

Payroll company ADP predicted booming private sector job growth with an estimated 184,000 new jobs created last month – a big jump over the forecasted growth of 148,000 jobs.

Construction, financial services, and manufacturing sectors saw significant job growth.

Women’s NCAA tournament

Is breaking every record in sight…ticket prices for the semis are more than twice that for the men’s, viewership is off the charts, and everyone with a pulse knows who Caitlin Clark is.

Gotta love the increasing exposure for women’s sports – this will have incalculable impact on girls for generations to come.

Medicare – is NOT about to go bankrupt.

It is highly likely Medicare funding will be more than sufficient to its pay bills for decades to come. Merril Goozner provides a summary of funding’s vagaries, concluding government policy changes and economic ups and downs bounce around, but nonetheless the Trust Fund survives.

Junk fees..

Cost Americans billions as big finance companies hoover dollars out of our pockets.

Good news – efforts to drastically reduce credit card payment late fees got a big boost when a financial industry challenge to those limits was moved to a court much more likely to protect consumers.

Medicare drug prices

About 60 million folks are covered by Medicare – including your author.

Government action is helping reduce drug costs…the cost of insulin for diabetics on Medicare is limited to $35 per month, a huge drop…

From PBS…

The three major manufacturers we’re talking about, Sanofi, Novo Nordisk, and Eli Lilly, who cap their co-pays at $35, make up more than 90 percent of the insulin market. And the Medicare provisions in the Inflation Reduction Act mean that now about 1.7 million Medicare beneficiaries stand to benefit from that $35 monthly co-pay cap on their insulin. [emphasis added]

But wait…there’s more!

  • prescription costs of certain drugs for Medicare recipients is going to be capped at $3,300 annually.
  • In September the new list prices of 10 major drugs are going to be made public. That was made possible by the Inflation Reduction Act’s provision allowing Medicare to negotiate drug prices with manufacturers. Those prices go into effect in 2026
  • The annual cap on prescription costs will drop to $2,000.

The net – Medicare recipients will save big bucks.

 


Mar
27

They lied to you.

A really scary study was just published…one that shows just how deadly healthcare misinformation is.

Not “can be”, but is.

Remember those politicians promoting hydroxychloroquine as a cure for COVID – AFTER studies showed it had little to no benefit – and was dangerous?

Well, they have blood on their hands.

A very well done meta-analysis (rigorous review of all available research studies)  estimated there were 16,990 hydroxychloroquine related deaths in hospitalized patients in six countries.

One of the studies, known as the RECOVERY trial, showed a significant increase in cardiac mortality among patients receiving hydroxychloroquine (HCQ). 

The study published in PubMed this February is here.

Two things.

First, anyone willfully lying – or passing along someone else’s lies – to people terrified of a deadly disease has much to apologize for. Would these people tell friends and family to eat rat poison?

Drive drunk?

Inject fentanyl?

Of course not – yet by pushing HCQ misinformation out to friends and family, they did much the same thing.

Second, in a case before the Supreme Court, some politicians are trying to argue that spreading misinformation – like “hydroxychloroquine cures COVID” is “protected free speech.”

What utter BS. Again, is it okay to tell kids – “hey, vaping is good for you!”… or “Sure, unprotected sex is fine!” or “No car seat needed – just carry your baby sister in your lap!”

Tobacco companies and the opioid business are just two examples of industries forced to pay billions for publishing lies.

 

As noted in yesterday’s post, thousands of us are dying from preventable causes…that’s really, really bad…what’s much worse is politicians legitimizing deadly disinformation. 

What does this mean for you?

Spreading deadly misinformation is NOT “free speech”. It is a cynical and disgusting abuse of power.

 

 

 


Mar
26

The Pro-Life solution to the US health crisis

There’s a health crisis in the US – more people are dying younger, most from preventable diseases.

The good news is this is fixable. Sure there are any number of causes –

  • the opioid epidemic continues to destroy lives,
  • more kids are killed by firearms than anything else;
  • cancers associated with pollution are a major killer in some states;

all of which require thoughtful and very well-executed policy changes…which will take a lot of time, during which many more of us will die.

Like any complex problem the first task is to determine where the problem is. Thanks to the CDC, we know.

The lightest shaded states have the lowest life expectancy…

And the deepest red indicates states have the longest life expectancy.

8 of the States with the two lowest life expectancies have not expanded access to Medicaid…

And all of the States with the highest life expectancy HAVE expanded Medicaid.

Healthier people – kids, moms, grandparents, the disabled – live longer, more productive lives. And people with access to healthcare are far healthier than those without.

What does this mean for you?

If you are pro-life, the solution is blindingly obvious.

 


Mar
6

To know why some think the US healthcare system is going to get better and cheaper – and why I strongly disagree, read on.

David Cutler PhD led off the WCRI’s confab with a discussion of the future of healthcare. It was GREAT that a conference has finally tried to educate work comp people about healthcare – after all that is the biggest driver of workers’ comp.  Sorely needed.

But…(more on that in a minute)

Dr Cutler noted that US healthcare is about as unstable as it has been for some time. And there is much more uncertainty to come.

He then asked the audience to vote on whether healthcare will get better and cheaper, stay the same, or collapse.

I voted collapse.

He also differentiated between “Trend” and “Wiggle”, noting it is important to consider what is actually a trend vs what is more likely slight ups and downs – need to differentiate between one-time factors and overall structural issues with long-lasting implications.

Cutler attributes consolidation among small providers to the drop off in patient service demand; that is, demand for providers’ services declined and therefore the smaller providers needed to merge or be acquired. I’d note that Cutler did not mention other factors driving consolidation, namely:

  • Interoperability (CMS IT requirements that can be a big lift)
  • small office staffing woes,
  • office operational expense increases, and
  • PE buyouts that make owners wealthy overnight.

Why Cutler is positive about the future of the US healthcare system

  • Delivery of medical care (number of services rendered) fell off during covid and really hasn’t fully recovered, which implies there are fewer unnecessary procedures/visits/treatments these days. (assumes the decline was mostly in unneeded services)
  • Elective stuff didn’t come back – such as hip replacements, shoulder surgery, etc.
  • Staff shortages are less of an issue of late

Dr Cutler also noted that in his view, medical staff burnout and labor force withdrawal from healthcare delivery roles will be temporary…Employment is coming back.

Very briefly, Dr Cutler’s thinking is that hospitals have too many beds; a lot of care has moved to outpatient facilities and ambulatory surgical centers (ASCs)…as a result hospitals will close floors, other hospitals will close, and the need for nurses in hospitals will thus decline.

Notably, Dr Cutler provided data from CMS to build a case that healthcare itself is better controlled – Medicare growth has been relatively flat over the last few years, and some analysts believe this has reduced total spend by several trillion dollars.

Finally, Dr Cutler also discussed value-based care and the move to bundled care, I suppose as evidence that healthcare is getting more efficient.

So here’s the “But…” in which I respectfully disagreed – and and still do disagree – with Cutler’s optimistic outlook.

Cutler – Shift of care away from and hospital closures will reduce costs and staffing needs

MCM – I don’t have the data, and I’m sure Dr Cutler does, but there’s both anecdotal “evidence” (family members have left patient care for other jobs in healthcare) and actual research that clinical staff shortages are NOT moderating.

Here’s rather compelling evidence that the shortage is NOT going away.

According to the United States Registered Nurse Workforce Report Card and Shortage Forecast published in the September/October 2019 issue of the American Journal of Medical Quality, a shortage of registered nurses is projected to spread across the country through 2030. In this state-by-state analysis, the authors forecast a significant RN shortage in 30 states with the most intense shortage in the Western region of the U.S.

Perhaps Dr Cutler is talking over the very long term – and perhaps the Journal’s authors are not accounting for the shift in care to outpatient facilities.

Perhaps. On the other hand, change is very, very slow in healthcare.

Also, hospitals are major assets, assets which are providing a ton of revenue to the health system or hospital’s owners. Sure, many owners might like to walk away…but they can’t – not without huge pressure from unions, workers, communities and politicians. So, they’ll do anything they can to keep the patients coming, to keep the hospital open – if they don’t they will go belly up – oh and some of the hospital’s execs will not have jobs.

Cutler – Value-based care is saving money…

MCM – There is very little evidence that VBC actually saves money, and a lot of evidence that it doesn’t. In fact, a CBO study indicates that overall, well-funded, well-designed and well-run VBC initiatives actually resulted in higher costs. I’d note that some disagree with CBO’s results. – however those disagreements generally focus around better outcomes, health indicators and the like – NOT on cost reductions.

Cutler – Medicare spending is below predictions thus healthcare is less costly

MCM – But other payer spend has not.

Yes, Medicare’s costs have been below predictions…but that’s NOT the case for individual insurance, group health and Medicaid spend – which has has increased.

To be fair, Cutler agreed with my comment (which I made after his talk), but noted Medicaid spend per enrollee has declined.

He is correct…however in my view but likely because the expansion of Medicaid involved more healthier people being signed up before and during the COVID emergency.  And, their costs prior to enrollment were likely uncompensated care…so my take is overall medical costs weren’t reduced, just shifted to a different payer.

At least for the next few years – and likely longer – the “shiftee”, dear reader, is often workers’ comp.

Finally, good friend and colleague Gary Anderberg PhD of Gallagher Bassett commented that all of us are getting older and sicker and how does that factor into predictions re cost. Cutler indicated he sees it as a mixed picture as cognitive and CV health are improving while others – obesity-related such as diabetes in particular – are declining.

What does this mean for you?

I still vote collapse.

 


Feb
20

Rural hospitals – and healthcare – are in deep trouble.

With the unwinding of Medicaid post-COVID emergency, rural healthcare is falling deeper into financial trouble.

Consulting form Chartis just published their review of rural healthcare…among the findings

The unwinding issue is exacerbating problems in states that failed to expand Medicaid…the vast majority of which are those with the most hospitals in financial distress.  Simply put – they have to deliver way more healthcare to people without health insurance.

FromChartis:

Across the 10 remaining non-expansion states (Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming), the percentage of facilities with a negative operating margin increased year-over-year from 51% to 55%. These states are home to more than 600 rural hospitals…Several of these states are among the most severely affected by hospital closures and a loss of access to care.

The percentage of America’s rural hospitals operating in the red jumped from 43% to 50% in the last 12 months.

418 rural hospitals are “vulnerable to closure” according to a new, expanded
statistical analysis.

Healthcare deserts are a huge problem for rural America, especially in areas with lots of extractive industries (mining, energy, agriculture. Workers in those industries are much more likely to suffer severe occupational injuries, injuries that benefit greatly from care delivered in the “golden hour”.

What does this mean for you?

Not expanding Medicaid is killing rural healthcare.


Feb
7

Signs of the coming apocalypse

Medicare is slashing what it pays physicians, an annual event that – till now – was almost always rejected by Congress.

That will reduce old folks’ access to care, cut workers’ comp fee schedules, and likely lead to more provider consolidation. 

This from Becker’s:

In its 2024 Physician Fee Schedule Final Rule released Nov. 2, CMS reduced overall physician pay by 1.25% and updated the Medicare conversion factor to $32.74, a 3.4% decrease from last year.

Nope, a fix wasn’t in any of the “continuing resolutions” Congress passed last year and earlier in January (“CRs” are a stop-gap, emergency funding step more often seen in desperately poor banana republics than in the “greatest nation in the world.)

As a result, docs’ pay will be cut about 3 1/2%…and they are none too happy about it. (Read this for details on potential implications)

Okay that’s bad, right?

Not as bad as what’s coming.

Reminder – if Congress doesn’t pass a budget – in exactly one month – all Federal agenciesincluding Medicare, the VA, Defense, the FAA… face budget cuts. Weapons procurement, care for veterans, agriculture inspections, airplane safety inspections (this isn’t a problem, right??) are just a few.

Remember way back (as in two years ago) when Congress’ wait-till-the-last-minute-to-get-stuff-done made us all nuts…if we knew then how dysfunctional the House would be now we’d have been quite happy for what we did have.

Yep, Republicans in the House of Representatives’ refused to even vote on an immigration reform bill – THE hot issue in Washington and around the country – a bill that gave them everything they wanted.

House GOP – Yay, we finally got the soccer ball!  Let’s play! Wait…how do you play? I dunno…you know?  Nope – you? Nuh-uh…you? No clue…you? Uh…I thought it had pointy ends…Someone pick it up…NO way dude! Not me…

What does this mean for you?
To quote HL Mencken, you get the government you deserve, and you deserve to get it good and hard.

PS – Over the lastly 20 years I’ve written a lot about the incredibly screwed-up Medicare reimbursement  process…