DCMedical News: Wednesday, March 30, 2022
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Wednesday, March 30, 2022
Hospitals in the War
A report from the WHO in BMJ (here) says "Sixty four healthcare facilities have been attacked by the Russian military since it launched an invasion of Ukraine a month ago . . . The attacks violate international law and have become increasingly common since Russian forces began intensifying their bombardment of Ukrainian towns and cities in recent weeks . . . Two to three healthcare facilities on average are being hit each day . . . Around 1000 health facilities are also near conflict lines or in changed areas of control, meaning that they have little or no access to medicines, facilities, or health professionals. Treatment of chronic conditions has largely been suspended."
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
AHA Stands With Nurse Convicted of Manslaughter
Robyn Begley, DNP, RN, CNO of the AHA, CEO of the American Organization for Nursing Leadership: "The verdict in this tragic case will have a chilling effect on the culture of safety in health care. The Institute of Medicine’s landmark report To Err Is Human concluded that we cannot punish our way to safer medical practices. We must instead encourage nurses and physicians to report errors so we can identify strategies to make sure they don’t happen again. Criminal prosecutions for unintentional acts are the wrong approach. They discourage health caregivers from coming forward with their mistakes, and will complicate efforts to retain and recruit more people in to nursing and other health care professions that are already understaffed and strained by years of caring for patients during the pandemic."
Physician Office EHR Documentation Time Inappropriate, Takes Away From Patient Care
A survey of more than 1500 physicians reported (here) in JAMA Internal Medicine found that time spent in documenting their care was inappropriate and reduced time spent with patients. "Overall, physicians spent a mean of 1.77 hours daily [h/d] completing documentation outside office hours." Scribes didn't help, or at least the differences were "small and nonsignificant." The mean of hours for physicians using EHRs was 1.84, compared to the analog group who spent 1.1 hours. "Physicians participating in VBP [Value Based Payment] spent 2.02 h/d on documentation outside office hours."
"Assuming a 5-day work week and 47-week work year, we estimated US physicians spent 125 million hours [about 50,000 FTE physicians] documenting outside office hours in 2019 . . . documentation burdens US physicians. Most respondents indicated that documentation time is inappropriate and takes time from patients."
Focus on billing (in the U.S. system) extends documentation time: "Relative to EHR users in other nations, US physicians spend more time documenting in the EHR, with outpatient notes approximately 4 times longer." "Value based" payment schemes also add, "Per our analysis, VBP participation is associated with a higher documentation burden, a finding consonant with the doubling in length of EHR ambulatory notes in the VBP era (among EHR users)."
As California Goes . . .
A study (here) sponsored by the California Health Care Foundation examined the organization, structure and financing of that State's physician practices. "The practice settings of the approximately 75,000 physicians in active practice in California are many and varied . . . At the health system level, market consolidation has accelerated, raising concerns about market power, increasing prices, and the erosion of independent practices." In California, as in the US, an increasing share of physician practices are owned by hospitals and health systems. A 2019 study showed that the share of primary care physicians in practices owned by hospitals and health systems increased from 24% to 42% between 2010 and 2018; an even greater increase was observed among specialists, from 25% to 52%."
Largest systems consolidate the greatest numbers: "An analysis of California health systems using AHRQ’s Comparative Health System Performance database found increasing concentration in the largest health systems . . . In 2018, the 10 largest systems accounted for 46.0% of all physicians in California, up from 30.7% just two years earlier."
Extensive attention is given in the report to physician participation in risk bearing organizations.
HOSPITALS AND OTHER HEALTH CARE FACILITIES
Who Owns the Hospital-at-Home? Not Only Hospitals
A report (here) in STAT+ profiles the growing interest of third party insurers in controlling the "at home" market, for hospital level care, as well as more traditional home health. "UnitedHealth Group’s proposed $5.4 billion buyout of home health and hospice provider LHC Group serves as another example of the health insurance industry’s ravenous appetite to own more parts of health care delivery, especially the care people receive in their homes."
The report notes that interest in the home setting for health care "has also come from a host of other companies with money to burn, including hospitals and financial investors like private equity firms . . . Home health deals have proliferated in the past year, especially among conglomerates that house insurance companies. Humana fully acquired Kindred and smaller post-acute-care company One Home, turning the Medicare Advantage insurer into one of the largest home health companies in the country. Aetna, owned by CVS Health, partnered with Landmark Health to help bring doctors into the homes of its Medicare Advantage enrollees in New York. Anthem bought out MyNexus, a company that coordinates home care for people on Medicare."
The background: "Whoever the buyer, the fundamentals are the same: The over-65 crowd is growing. Covid-19 sped up the evolution toward treating people in their homes instead of in hospitals and nursing homes. Older adults already preferred getting care that way well before the pandemic. And the clamoring to lower the cost of care isn’t going away."
More clamoring: A report (here) from the Commonwealth Fund recommending "global budgets" for hospitals.
DRUGS & DEVICES
340B Disappears as Pharma Walks Away
The 340B program, a 1992 provision in that section of the Public Health Service Act meant to provide a supplement to income for safety net hospitals, grew from two to three hundred eligible hospitals to more than 12,000 participants, many of them community pharmacies enlisted by hospitals as distribution channels for drugs that the hospitals buy through the program.
STAT+ reports that 340B "requires drug companies to offer discounts that are typically estimated to be 25% to 50% — but could be higher — on all outpatient drugs to hospitals and clinics that primarily serve lower-income patients. There are approximately 12,400 entities participating in the program, a number that has grown substantially in recent years. But in 2020, several drugmakers began eliminating some discounts when hospitals or clinics bought medicines and then shipped them to contracted retail or specialty pharmacies for patients to pick up or for delivery, instead of using their own in-house pharmacies."
The program, opaque for understandable reasons, is frequently criticized, especially by pharmaceutical manufacturers, and has its own trade lobby ("340B Health," https://www.340bhealth.org).
Now individual manufacturers are walking away from the program, objecting to the hospitals' enlisting the community pharmacies. HHS and HRSA have attempted to penalize the manufacturers, but to no avail, and without support in all but one court. Reports STAT+, "So far, more than a dozen large pharmaceutical companies have curtailed discounts or restricted the number of contract pharmacies that can distribute their medicines. The list includes Eli Lilly, Pfizer, Merck, Boehringer Ingelheim, Sanofi, Novo Nordisk, Amgen, and AbbVie, among other leading companies . . . discounts offered through the 340B program amounted to approximately $19.6 billion in lost revenue, or roughly 16% of the U.S. prescription drug market. And in 2020, roughly 28% of 340B revenue was generated by the use of contract pharmacies, specifically."
READING & REFERENCES
Select Coronavirus Public Health Resources and References may be found here.
2022 CQ Congressional Calendar here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
March 31
April 1, 4, 5, 6, 7, 26, 27, 28, 29
May 10, 11, 12, 13, 16, 17, 18, 19
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org