Will blockchain save the healthcare system?

Blockchain 101

Blockchain is a log of activity that is time-stamped, tamper-proof and shared across a network of computers.

Originally dreamed up in 2009 by an unknown person or group—it’s not known for sure which—called Satoshi Nakamoto as a means to move the digital currency bitcoin, its uses have since been broadened to exchange other types of digital assets, such as data, in private, permissioned networks suitable for businesses.

Each transaction that goes into the log of activity is enclosed in a block and linked together in chronological order to form a chain, giving it the name blockchain.

Blockchain is gaining traction as a tool that could help solve some of the healthcare industry’s age-old problems that have resulted in wasteful spending and higher costs for providers, insurers and patients. Once-reluctant competitors are joining forces to find out just what the technology can do and in the process are developing new transparent business models. 

A senior distinguished engineer at the healthcare services company Optum, had been experimenting with how to solve healthcare industry problems with that emerging, exciting, little understood technology called blockchain. He had heard rumors that health insurer Humana, like Optum, had been testing blockchain’s applications.

So during lunch at the Distributed Health conference in September 2017, Jacobs and Humana Lead Enterprise Architect Kyle Culver described their projects in careful terms (there was no nondisclosure agreement in place) and learned that both companies were attempting to use blockchain to improve the accuracy of healthcare provider directories—a perennial, costly issue for the insurance industry. Their experiments had revealed that blockchain works best when multiple partners are involved.

Just two months later, Optum, Humana and three others—MultiPlan, Quest Diagnostics and Optum’s corporate sibling UnitedHealthcare—had solidified an agreement to form the Synaptic Health Alliance, which in June 2018 piloted the use of blockchain to fix errors in provider directories and lower the cost of keeping that information up to date by sharing the data and workload. Aetna and health system Ascension have since joined the group. With “multiple people looking at the same information, the quality of that information should go up and operational costs for the provider and the payers should go down because there’s less-frequent contact being done between those two stakeholders. And because the quality goes up there should be a better experience for the patient,” Jacobs said.

It’s early, but the companies have already found they are able to locate inaccurate information faster than they would on their own while also protecting information from cyberattacks. The goal is to scale the tool to a national level. But fixing provider directories is an initial foray. “We have a general agreement that, boy, if we can get this to work, this is just the first area of focus,” Jacobs said.

They anticipate that blockchain will be the key that unlocks barriers to healthcare data-sharing and ultimately enables an industrywide shift to value-based care.

“When we talk about healthcare today, we talk about the silos a lot—the silos of data and the barrier for exchanging information,” Humana’s Culver explained. “The hope is that blockchain allows us to connect those silos and … enable new capabilities (so that) access to information no longer is where we compete, but we compete much more on the value-added service and the trust and transparency of the companies that are providing those things.” 

In the simplest terms, blockchain is a shared record of transactions. It enables participants in a group to securely share data with each other without a middleman and keep track of what was exchanged and when. Instead of that record being located on a single, hackable computer, it is maintained across multiple computers, which makes the information extremely difficult to tamper with or delete. That tamper-proof characteristic, along with a process that ensures any information put into the blockchain is valid, enables trust between the group participants.

So in the case of the blockchain-enabled provider directory, if one insurance company in the alliance calls a doctor’s office to verify an address and updates that information in the record, all members of the alliance would see the change. That means less work for the rest of the insurers and the doctor’s office.

Unnecessary ED visits from chronically ill patients cost $8.3 billion

About 30% of emergency department visits among patients with common chronic conditions are potentially unnecessary, leading to $8.3 billion in additional costs for the industry, according to a new analysis.

The report, released Thursday by Premier, found that six common chronic conditions accounted for 60% of 24 million ED visits in 2017; out of that 60%, about a third of those visits—or 4.3 million—were likely preventable and could be treated in a less expensive outpatient setting.

The frequency of unnecessary ED visits from the chronically ill is unsurprising given the fee-for-service payment environment the majority of providers remain in, said Joe Damore, senior vice president of population health consulting at Premier. On average, only 10% of providers’ payment models are tied to value-based models, he said, so providers don’t have an incentive to effectively manage patients to prevent disease progression and promote wellness.

Premier’s findings are in line with other research on patients with chronic diseases, finding they are more likely to use the ED and get admitted to hospitals because they experience poor care coordination. 

“Value-based care is managing a chronically ill patient in a coordinated way, and the traditional payment model hasn’t rewarded that. It’s episodic,” Damore said. 

The six chronic conditions used in the analysis are asthma, chronic obstructive pulmonary disease, diabetes, heart failure, hypertension and behavioral health conditions, such as mental health or substance abuse issues. They were selected because they are often cited in the academic literature as the most common and costly conditions in the healthcare system, Premier said. 

The data from the 24 million ED visits at 747 hospitals comes from Premier’s database, which has information on 45% of U.S. patient discharges, according to Premier. To get the results, Premier identified hospitals with the lowest quartile visit rate, or those that had the lowest ED admission rates by condition, and calculated how many visits at the remaining hospitals could be prevented if all hospitals achieved those rates for the six chronic conditions. 

And then to arrive at the $8.3 billion in costs, Premier used the average cost for an ED visit estimated by the Health Care Cost Institute, which is $1,917. 

Damore said that although the industry is “mostly fee-for-service at this time,” he expects an eventual transition to value. “More and more providers are convinced that the future is going to be value-based payment,” he said.

Five Reasons Why Patient Data Privacy and Control is so Important by Dr. Moira Schieke

The ancient Greek father of medicine, Hippocrates, knew that trust was a fundamental tenet for the effective practice of medicine.  How can a patient seek the care of a stranger without the establishment of a fiduciary trust?  A patient must reveal the most personal, private information about themselves and therefore must possess the utmost confidence in their physician to keep their information in confidence and all uses of their data transparent.  Yet, in today’s digital social media age, does privacy really exist?  Large companies make unfathomable fortunes harvesting all manner of data from financial information to the mundane minutia of daily life.  In this environment, here are five reasons why patient data privacy and control are more important than ever:

1.  Maintain the fundamental fiduciary doctor-patient relationship.

            “Things that are holy are revealed only to men who are holy.”  – Hippocrates, Greek physician (460 BC – 377 BC)

It is critical for the health care system to maintain the trust between doctor and patient in a patient-centric dynamic.  If patients believe that information they give their doctors and healthcare professionals, and by extension, these larger institutions is going to be used against them and not in the patient’s best interest, then patients will be reticent to provide needed details for their own health and well-being thus deteriorating their own healthcare.  If patients believe in the ultimately altruistic interests of their doctors, they will be more likely to provide critical details and take an active role in their care.  In addition, there is great financial pressure to utilize algorithms to automate care decisions to reduce costs, thereby increasing institutional and industry profits.  The doctor-patient relationship prevents direct access of industry-designed algorithms that could work more in the interest of industry profits, rather than to improve patient health.

2.  Higher data quality.

            “Conclusions which are merely verbal cannot bear fruit, only those do which are based on demonstrated fact.”  – Hippocrates, Greek physician (460 BC – 377 BC)

The equation is simple: higher quality data means higher quality medical care.  One of the advantages of the digital age is the ability to synthesize huge amounts of data quickly.  However, the data used must be accurate.  Electronic health records are known to contain many errors, and patients can assure accuracy of their personal health data when they have access to check it.  With patient trust through data use transparency and data control comes more detailed and better data in, better and more accurate and precise conclusions out. 

3.  Bringing back fairness and balance to current industry-centric data monopolies.

“...while calling on the gods, a man should himself lend a hand.”  – Hippocrates, Greek physician (460 BC – 377 BC)

It is currently a data “gold rush” given current U.S. data and privacy regulations, and many large companies have made fortunes by making their customers into their commodity.  They sell consumer data non-transparently to unidentified entities that use the data for uncertain purposes with ambiguous ethics, creating a data economy with network effects favoring a few platforms able to collect and lock up the largest masses of personal data.  The data being recorded about a patient forms a remarkably detailed picture of their life. This picture is incredibly valuable when unified and stored both as a singularity and in conjunction with thousands, even millions of other lives.  These pictures reveal patterns that permits the personalization of medicine, insurance, finances and more but the question is, who owns and controls this valuable picture?  And what about the risks associated with massive data leaks through hacking and other data breaches?  Transparency and personal data controls are keys to creating a balanced and fair patient-centric digital data economy that promotes diverse and open competition.

4.  Assure patient access to their data.

A wise man ought to realize that health is his most valuable possession.”  – Hippocrates, Greek physician (460 BC – 377 BC)

Patient control of access to their own data is needed for a number of reasons.  First, it promotes data exchange across healthcare systems to assure access to critical health data wherever the patient may seek care.  Healthcare systems should be required to provide patients with their full medical record in electronic in a timely manner, and those systems who do not comply should be held accountable for data-blocking.  If we assure patients control their data, it will allow them to choose healthcare systems or associated third parties, thereby redistributing data across the economy to allow smaller companies, who may be more ethical and have better solutions, to compete.  In addition, patients could allow researchers access to their personal data.  Many researchers currently have trouble gaining access to data now in data silos created by industry purchases and other private sector agreements.  Researchers do not have access to big data needed to discover tomorrow’s cures and medical advancements.   Last, patients who are more engaged in their own healthcare tend to have better health outcomes overall, and patient data access allows patients to become more engaged in their own health.

5.  Preserve basic human rights.

“Wherever the art of medicine is loved, there is also a love of humanity.”  – Hippocrates, Greek physician (460 BC – 377 BC)

The “Right to Privacy” is a fundamental human right as declared by the UN Universal Declaration of Human Rights drafted after WWII that has been adopted around the world.  When this Declaration was adopted in 1948, the world had not yet imagined our new digital age.   Recently, however, some prominent leaders who remember the excesses of totalitarian regimes, have started to work to sharpen public opinion and remind us that our privacy is indeed a basic human right.  The right to privacy and control of data about our bodies is essential to preserving the dignity and respect of each individual, as well as trust in the medical community.  In the digital age, it will become the fiduciary duty of each doctor to protect the digital data privacy rights for each patient as a basic human right.

We are entering a new technological era for healthcare where we must commit to new standards of patient data privacy, data use transparency, and personal data control.  We have outlined five key reasons why this general topic is now more important than ever.  It will take many years of work on the part of academics, healthcare systems, industry, and government to fully assimilate all associated ethical, societal, technological, and business considerations to assure that we manage patient data in the right way.

Dr. Moira Schieke Bio
Founder and CEO of Cubismi, Dr. Moira Schieke is a cancer imaging clinical and research Radiologist based in Madison, WI.  Dr. Schieke completed her fellowship in cancer imaging at Dana Farber Cancer Institute in Boston, research fellowships at the National Institutes of Health in Bethesda, MD, and is adjunct Assistant Professor at the University of Wisconsin at Madison.  Dr. Schieke is a nationally recognized artist and painter. Cubismi was born of a critical need for cancer imaging innovation for earlier detection and better management of cancer.

Sanford Health and Good Samaritan close merger

Sanford Health and the Evangelical Lutheran Good Samaritan Society completed their merger, the organizations announced Wednesday.

Sanford, which has 45 hospitals, more than 1,300 physicians and 28,000 employees, adds Good Samaritan and its 200-plus post-acute, skilled-nursing, hospice, assisted-living, rehabilitation and home-health facilities to its network, along with Good Samaritan’s 19,000 employees. Their combined footprint spans 26 states.

The combination of the Sioux Falls, S.D.-based not-for-profits earned the necessary government approvals in August. Merger talks began in late 2017, when they started mapping out the integration process and growth opportunities, executives said.

David Horazdovsky remains CEO of Good Samaritan and has joined Sanford’s corporate leadership team. Randy Bury has transitioned to president of Good Samaritan from his previous role as Sanford’s chief administration officer.

“Wherever you combine acute-care operations with post-acute care you are going to find opportunities,” Kelby Krabbenhoft, president and CEO of Sanford Health, told Modern Healthcare.

Good Samaritan adds home and community-based services that can fill any gaps in care, Horazdovsky said.

“We see great growth opportunities,” he said.

The merger’s close is the latest transaction in an active post-acute sector as organizations and investors look to capitalize on the huge number of aging baby boomers. Coordinating care after patients leave the hospital is a key strategy for health systems that want to avoid health complications that can bring readmission penalties.

“The organization that can provide care in the most coordinated way will be the most successful—that is what we are shooting for,” Bury said.

Not-for-profit health system ProMedica expanded beyond its core business in its acquisition of struggling nursing home provider HCR ManorCare. Humana and private equity firms bought Kindred Healthcare and Curo Health to create the country’s largest hospice operator. LHC Group and Almost Family also combinedto form the second-largest home health provider in the country.

Consolidation is not expected to wane, experts said.

Sanford will continue to talk with other health systems about additional merger, acquisition or joint-venture opportunities as it looks to build out its long-term care operations, Krabbenhoft said. That marks a departure from the organization’s traditional focus on acute-care partnerships and acquisitions, he said.

“This moment today is an inflection point for the company as we are required as a function of our responsibility to now think about our facilities and operations like we never have before,” Krabbenhoft said.

From Modern Healthcare

Partners, Harvard Pilgrim table merger talks

Partners HealthCare and Harvard Pilgrim Health Care are tabling their planned merger after executives reportedly felt the deal was getting too complicated.

Boston-based Partners, Massachusetts’ dominant health system, and Wellesley, Mass.-based Harvard Pilgrim, the state’s second-largest health plan, announced in May they were considering a possible merger. On Friday, the not-for-profit companies confirmed the merger talks were on hold.

“Our discussions with Partners HealthCare have always been focused on exploring ways we can improve and enhance the patient experience while helping to control costs,” Harvard Pilgrim CEO Michael Carson said in a statement. “We continue to evaluate opportunities to collaborate with Partners on this important mission.”

Partners CEO Dr. David Torchiana told the Boston Globe the deal was getting too complicated and was bound to face regulatory scrutiny. He said the announcement doesn’t rule out the possibility of a future deal.

“I don’t think either organization is sure that it’s something that’s actually possible to achieve … in this environment right now where there’s such intense scrutiny of every move,” Torchiana told the newspaper.

Partners’ existing health plan, Neighborhood Health Plan, reported an operating loss of $5 million in the third quarter of 2018, compared with an operating gain of $34 million in the prior year period. NHP’s premium revenue dropped 64% during the quarter. Partners is rebranding the health plan, and beginning Jan. 1, will call it AllWays Health Partners.

Partners, whose hospitals include Brigham and Women’s Hospital and Massachusetts General Hospital, is still awaiting regulatory approval to acquire Care New England Health System of Providence, R.I.

Beth Israel Deaconess Medical Center and Lahey Health are still awaiting regulatory approval to form a health system they say will be large enough to compete with Partners. The combined entity would have 10 acute-care hospitals, compared with Partners’ eight, and would have three affiliate hospitals and more than 4,000 physicians.

The Massachusetts Health Policy Commission issued a highly critical report on that proposed deal in July. The report said the Beth Israel Deaconess-Lahey deal’s cost outweighed its benefits, and nothing would prevent the combined entity from raising prices, other than the state’s annual 3.1% cost growth limit.

In June, Harvard Pilgrim’s long-time CEO, Eric Schultz, abruptly resigned due to unspecified behavior he said violated the company’s code of conduct. A Harvard Pilgrim spokeswoman said the resignation didn’t affect its discussions with Partners.

John Hopkins Nurses Speak Out!

Nurses, Community Leaders to Discuss New Reports Documenting Johns Hopkins Hospital’s Failure to Provide Adequate Charity Care and Address Problems in Patient Care.

Johns Hopkins nurses will present three new reports documenting patient care concerns at the hospital and how these concerns extend far into the city of Baltimore at a town hall planned for Saturday, Dec. 1, 2018. The town hall, titled “Hopkins Nurses Speak Out!” will be held at the Reginald F. Lewis Museum of Maryland African-American History & Culture in Baltimore.

Also participating in the town hall will be Baltimore Councilmembers, Shannon Sneed, Kristerfer Burnett, Zeke Cohen, and Robert Stokes, Sr. as well as, Maryland Delegate Brooke Lierman. Reverend Marlon Tilghman, co-chair of Bridge Maryland, and Pastor of Ames United Methodist Church, Betty Robinson, community organizer and former Senior Research Coordinator at Johns Hopkins School of Public Health and Marisela Gomez, M.D., Ph.D., author and community organizer, will participate as community respondents to the report findings.

The new reports cover three main areas: A unit-by-unit survey of patient care conditions in the hospital, an analysis of Johns Hopkins tax exemptions and public rate support and the community benefits and charity care it provides in exchange, and an assessment of how the institution is responding to the ongoing problem of workplace violence.

What:  Town Hall featuring presentation of new reports on Johns Hopkins Hospital patient care and public accountability.

When: Saturday, Dec. 1, 10:30 a.m. – 12:30. p.m.

Where: Reginald F. Lewis Museum of Maryland African-American History & Culture, 830 E Pratt St., Baltimore. (Discounted parking available in garage at 815 E. Pratt Street.)

The reports, which will be available at the town hall and on request, include:

Foundations of Care:  Upholding the Legacy of Hopkins’ Nurse Pioneers

Johns Hopkins Hospital Patient Care Report – This report’s findings are based on a recent unit-by-unit survey conducted by nurses that work at Johns Hopkins Hospital. It flags chronic hospital-wide problems such as short and inappropriate staffing, high turnover, a lack of critical supplies, and shoddy equipment.

Breaking the Promise of Patient Care: How Johns Hopkins Hospital Management Shortchanges Baltimore and Puts Patients and the Community at Risk – This report, produced by researchers from National Nurses United and the AFL-CIO, documents that the hospital receives far more in annual tax exemptions and public rate support than it provides in charity care and community benefits, despite the tremendous need for both in the communities surrounding the hospital.

Nurses at Risk: Insufficient Protections at Johns Hopkins Hospital Compromise Nurse and Patient Health and Safety – This report reveals the institution’s failure to adopt robust policies to prevent and respond to workplace violence and how this undermines and endangers patients and nurses.

“We are very excited to share and discuss the report findings with our community,” said Kimberly Henriquez, RN, Oncology. “They reveal a wide discrepancy between the image the institution projects, and what’s really going on day-to-day, unit-by-unit. Nurses are organizing to close that gap so that our patients and our community get the care they deserve.

“We are inviting nurses and the wider community to come to the town hall so that together we can hold Johns Hopkins Hospital accountable to its founder’s vision and to the community he meant it to serve,” said Annie Embertson, RN. Endoscopy. “We are inspired by the legacy of Hopkins’ own nurse pioneers who showed us that to be effective patient advocates we absolutely must speak out.”

Megan Callahan Will Head up Lyft’s Health Care Efforts

After a months-long search, Lyft has hired a leader for its growing health care business, which helps patients get rides to non-emergency medical appointments. The company is set to announce it’s hired Megan Callahan, formerly the chief strategy officer for Change Healthcare, a company that merged with McKesson in 2017, as its health lead.

The hire comes as Lyft is looking to ramp up revenues ahead of a possible IPO 2019. The company’s chief business officer David Baga told CNBC by phone that health represents a “sizable chunk” of Lyft Business, which is set to achieve a annualized revenue run rate of $1 billion by the end of the year. Lyft told CNBC that the number of health care rides tripled from the third quarter of 2017 to the same period a year later.

Lyft’s primary competitor, Uber, also views health as a growth opportunity. Both companies have built out dedicated teams in health, and have formulated a strategy to work with stakeholders in the industry to help patients who need help to get to the doctor’s office on time.

Non-emergency medical transportation is attractive for both ride-sharing companies because insurers, including some Medicaid and Medicare plans, will often cover the cost of the ride for patients. There’s a huge incentive for health plans to make transportation easier, as studies have found that a lack of transportation is a key reason why patients avoid the doctor’s office.

Lyft’s focus is to forge partnerships in health care with traditional players, including health systems, medical transportation brokers and health IT companies. For instance, in March it signed an exclusive deal with medical record technology provider Allscripts to make it easier for doctors to book Lyft rides for their patients.

To that end, Baga, the chief business officer, told CNBC it needed to hire an operator from the industry to maintain and build on these relationships.

“We wanted someone for the job who lives and breathes health care,” he explained. “But we also wanted someone who could understand the key challenges, and be willing to break from the status quo.”

Callahan told CNBC she joined Lyft because of the opportunity to improve access to health care services, particularly for low-income or elderly users.

She also said that Lyft’s deep knowledge about health stood out relative to other technology players.

“I was gobsmacked by the level of understanding on HIPAA and PHI,” she said, referring to the complex web of federal privacy rules and regulations that govern how health data is stored and shared. “They (Lyft) had clearly taken the time to understand the industry.”

Lyft is also moving into other areas, including working with pharmaceutical companies to people get to clinical trial sites and arranging rides for physical therapists to treat patients in their homes.

Experts say that’s the tip of the iceberg for Lyft and other new transportation entrants.

“There’s home care, there’s delivery of goods and supplies — it becomes a market in the tens of billions of dollars if you’re looking at logistics opportunities in health care,” said John Brownstein, co-founder of a company in the space called Circulation Health that partners with Lyft. Circulation was recently acquired by one of the largest brokers in the space, Logisticare.

Callahan didn’t rule out any of these sorts of opportunities, but said her near-term goal was to look for more ways to increase rides and reduce missed appointments.

Athenahealth sold to Veritas Capital for $5.7 billion

Athenahealth has agreed to be acquired by a Veritas Capital and Evergreen Coast Capital affiliate for $5.7 billion, the companies announced Monday morning.

Athenahealth will continue to be its own brand, but Veritas and Evergreen will merge it with Virence Health, the analytics and software firm formerly known as the Value-Based Care Solutions Group, which GE Healthcare acquired earlier in 2018.

Virence Chairman and CEO Bob Segert will lead the newly combined company.

“Combining with Virence will create new opportunities for collaboration and growth,” Athenahealth Executive Chairman Jeff Immelt said in a statement.

Athenahealth has been facing takeover attempts since at least 2017, when Elliott Management first tried to buy the company. Elliott Management supports the Veritas-Evergreen acquisition. The transaction “represents an outstanding, value-maximizing outcome for Athenahealth shareholders,” Elliott partner Jesse Cohn said in a statement.

Athenahealth will hold an earnings call later Monday. In a third-quarter earnings report released Friday, the company reported it booked less business compared to the same period of 2017. Revenue for the quarter was $329.5 million, according to the company’s new accounting standards, and $331.4 million according to the old standards, up 9% over the year-before quarter.

Athenahealth’s stock was up nearly 10%, to $131.97 a share at the end of trading Monday.

2018 Mid-Year Elections

Democrats secured the House majority Tuesday night for the first time in nearly a decade with a projected majority of as many as 35 seats. The victory promises a new era of checks on the Trump administration’s healthcare regulatory agenda as well as a possible odd-couple alliance with the White House against Big Pharma.

The GOP held the Senate as expected, gaining on its slim margin with at least two pickups in Indiana and North Dakota. This tightly calibrated Congress likely won’t push any major healthcare legislation. And Obamacare will remain in place—albeit tweaked at the state level and through administration policies so the law increasingly looks like a mix of competing Democratic and GOP visions.

Analysts don’t expect any big-picture legislation as the sprint to the 2020 presidential election begins. In the especially polarized politics of healthcare, each party bends with their voters, said Robert Blendon, a Harvard University professor of health policy and political analysis. While healthcare polls as a top issue with the majority of voters, priorities shift fast depending on which party is surveyed.

“If I were (saying this) in the mid-1990s, I would say the issues top of mind for all voters would determine what the new House would actually do,” Blendon said.  Pundits called this midterm cycle a base election: healthcare in the 116th Congress will depend on finding the give in the gridlock over a divisive topic.

Drug pricing

Democrats have framed drug pricing as a rare policy area where they can work with the president—the common enemy there is Big Pharma.

Still, following an election that swept them to power as a referendum on Trump, some Beltway insiders doubt Democrats will bend much. Pharma’s panic level will depend on how well this relationship can work, and that’s not only up to Democrats: it’s up to the White House and Trump’s top lieutenants as well.

In her victory speech Tuesday night, House Minority Leader Nancy Pelosi (D-Calif.)—expected to stay on as speaker of the House given the party’s success—said Democrats would pass legislation for direct Medicare negotiation with drug companies. This was a core part of Trump’s own campaign platform. But HHS Secretary Alex Azar has pushed back on such a policy.

Key lawmakers poised to step into influential committee positions have criticized the Trump administration’s drug pricing strategy for not going far enough. These include Cummings on oversight; Rep. Lloyd Doggett of Texas who may get the House Ways and Means health subcommittee gavel; and Vermont’s Rep. Peter Welch, who sits on the House Democratic Steering and Policy Committee and the House Energy and Commerce Committee. As a counterpoint, however, Pharma ally Rep. Anna Eshoo, a Democrat who represents a biotech-dominated district in California, is next in line for the Energy and Commerce health subcommittee gavel.

Criticisms notwithstanding, Azar stunned industry and experts last month with a proposal to tie U.S. drug prices to their lower-cost counterparts abroad. Some industry analysts viewed that as leverage to get Big Pharma to the negotiating table despite that being the boldest move of any administration yet, even as House Democrats said it needed to be bolder.

“Instead of nibbling around the edges, (Trump) should demand in his State of the Union speech that Congress send to his desk within 30 days a broad price negotiation bill that applies to all drugs in the Medicare program,” Welch said in a release after Trump unveiled the policy proposal.

Healthcare costs

Smaller measures targeted at cost could pass bipartisan muster.

This year the Senate Health, Education, Labor and Pensions Committee has focused its hearings on cutting healthcare costs. A bipartisan group of senators has pushed variations of a bill to curb outsize balance bills from hospitals.

As health insurance co-pays and deductibles rise and provider networks narrow, price woes will stay top of mind even as the ACA becomes more entrenched in insurers’ business models. Nearly 75% of individual market plans restrict their provider networks, according to the consulting group Avalere—a steep rise from 2014. Nearly 90% of people in exchange plans hold the IRS definition of a high-deductible plan of more than $1,300.

So as 2020 approaches, voters’ focus may stray from the Obamacare coverage arguments while remaining keenly focused on their wallets—as Pelosi and Senate Republicans seem to be aware.

One longtime House Democrat said she for one wants to see more compromise on the many healthcare issues “that really aren’t partisan.”

“Everybody’s up again in two years and that includes a number of key Republicans in the Senate,” said Rep. Jan Schakowsky (D-Ill.). “In terms of bipartisanship I look rather fondly back to the Bush administration when we actually got things passed and done. And in part that’s because the definition of the job included the word compromise—it wasn’t a dirty word back then.”

It remains to be seen what levels of compromise a base election can yield.

Clinics catering to immigrants take a hit from White House policy

It was just a couple of years ago that Sinai Health System’s Touhy Health Center in Chicago stood as the primary site in the state for newly arrived refugees. At that time, as many as 60% of all refugees who arrived in the U.S. and resettled in Illinois visited the clinic, which saw an average of about 500 new refugees a month.

These days, the Touhy clinic is preparing to close its doors permanently.

Sinai Health President and CEO Karen Teitelbaum announced last week the clinic will close in December. She attributed the closure to the Trump administration’s decision in the past year to significantly limit how many refugees can enter the country, which has led to an 85% drop in new patient visits to the clinic since January 2017, which now has less than 50 visits a month.

“We held off on any action for as long as we could, hoping for a reversal or stabilization of the immigration activity,” Teitelbaum said. “With none in sight, and with the clinic requiring a large subsidy, we had to make the decision to close the clinic and transition care to other agencies. We were left with little choice.”

But what’s happened at Touhy speaks to the growing financial pressures that U.S. clinics specializing in caring for refugees face because of the Trump administration’s hard-line immigration policies.

Such clinics play a valuable role in helping refugees navigate the complexities of the healthcare system, which advocates say goes far toward to getting them to better acclimate to their new surroundings. At Touhy, the staff of 15 speak up to 25 different languages, which allows patients to get health screenings, follow-up care,and other services in their native language, in a culturally sensitive manner.

But the bulk of the Touhy clinic’s funding comes from federal grant money distributed by the state to provide health assessments to new refugees. Refugees are required to receive a health assessment within 90 days after arriving in the country. Grant funding allocated to clinics like Touhy is based on the number of new patients they receive for health assessments.

While much of the health screening across the country is conducted by state and local public health departments, a number of clinics like Touhy also serve as comprehensive care sites where patients are referred by public and private resettlement agencies, and they can receive their health assessment as well as follow-up care if needed. Teitelbaum said the decline in new refugees because of the federal policy shift has caused a steep drop in funding for assessing new patients. She estimated it has left a funding gap of around $800,000.

“Isolated (screening) programs that stand alone fill a check box,” said Dr. Gary Kaufman, medical director of the Touhy clinic. “But if you’re talking about the actual care to a patient, that’s when things fall short.”

Over the past year the Trump administration has drastically lowered how many refugees are admitted to the country in a series of moves seen by many as part of an overall agenda to impose tougher immigration restrictions and make claiming refugee status more difficult.

It began in January 2017, when President Donald Trump signed an executive order to reduce the Obama administration’s limit of 110,000 admitted refugees to 50,000, suspend all admissions for 120 days, and ban admissions from seven majority-Muslim countries. The result has been the lowest number of refugee admissions in more than 40 years.

Over a 12-month period ended Sept. 30, 22,491 refugees were allowed entry into the U.S., the fewest number admitted under the program since 1977, according to data from the State Department. The number of new refugees actually admitted into the country fell way short of the cap of 45,000 refugees set by the administration for fiscal 2018. Last month, the White House announced plans to lower the cap on refugee admissions even further to 30,000 next year.

Declines in the number of new arrivals has also meant fewer visits to refugee health clinics. For many, the decrease has begun to cause financial strain and to raise uncertainty for some about their ability to meet the needs of refugees already living here and help them better integrate into society.

“The number of people that have come in through that pathway has pretty much disappeared,” said Dr. Sarah Kimball, director of resident education for the Immigrant and Refugee Health Program at Boston Medical Center, which also provides healthcare services to individuals with any immigration status as well as asylum seekers.

Since 2011, an average of 1,800 to 2,400 refugees a year have resettled in Massachusetts and received care through one of 10 designated refugee clinics in the state. In 2018, the state has received just 464 individuals.

Refugees can get up to eight months of federal medical assistance. Once that period ends, they are expected to either find employment that provides health insurance or purchase a plan on the market if they are not eligible to receive Medicaid or disability coverage. But many have difficulty after the eight-month period gaining coverage on their own.

The uninsured rate among lawfully present non-elderly immigrants, which include refugees, asylum seekers and lawful permanent residents, among others, was 17% in 2016, according to a Kaiser Family Foundation analysis, nearly double the uninsured rate among non-elderly U.S. citizens.

Kimball said many of BMC’s clients have needs beyond their medical conditions and that the clinic provides assistance to help them better integrate into society. Like Touhy, BMC offers culturally sensitive mental health services that includes trauma-related care, as well as case management to connect them with social service supports.

She said while the decrease in refugee visits had strained the hospital financially, Kimball felt the impact was buffered because the clinic is part of Boston Medical Center’s primary-care clinic. She said the clinic’s decision to serve all immigrants regardless of their status has also helped to offset the loss in refugee visits.

“It would definitely have (financial) consequences for our clinic if that was the only type of care we were doing,” Kimball said regarding refugee clinic visits. “Because our model is that we’re seeing any immigrant who needs our services, we are able to stay afloat.”

Dr. Jeffrey Walden, director of Cone Health’s Refugee and Immigrant Health Clinic, said the number of new refugee visits have fallen from an average of five patients a week to just two new patients between June and the beginning of October. It has been able to sustain itself because it’s part of the family medicine residency program at the Greensboro, N.C.-based health system.

Like Sinai, Cone Health’s refugee clinic specifically serves refugees. But similar to BMC, Cone Health’s clinic does not rely solely on patient volume, but instead benefits from its status as an educational training program for residents.

“If you were trying to rely specifically on refugee patients to maintain viability, from a financial standpoint that would be close to impossible to do,” Walden said. He said the clinic is not really affected financially by a drop in the number of refugee visits, but there were concerns over whether the dearth in patients would jeopardize its viability as a training resource. “For four months over the summer we were really having discussion about what we were going to do next,” Walden said.

For the Touhy clinic, its closure means the loss of the only site within Chicago and all of Cook County designated to provide new refugee health screenings, which means patients will have to travel nearly an hour to be assessed beginning next year. Teitelbaum said Sinai has been working with the state’s Bureau of Refugee and Immigrant Services to develop a plan to transition patients to other providers and is also working on finding other employment opportunities for Touhy’s 15 staff members.

For many, Touhy’s closure will signify the loss of a trusted resource that will be hard to replace. As of Oct. 26, more than 2,100 people had signed a petition on Change.org calling for the Touhy clinic to remain open. When asked about the possibility of re-opening the clinic if the federal government began admitting more refugees, Teitelbaum said it would be difficult to once again find personnel that have the right clinical, language and cultural skills.

“Once you dismantle a program that is as special as this, I don’t know how you really put it back together,” Teitelbaum said. “It’s an unfortunate fatality of bad federal policy.”

Published by Modern Health on 10/26/2018