DCMedical News: Thursday, April 28, 2022
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Thursday, April 28, 2022
Telehealth a Help, Especially for Patients With Chronic Conditions
During the pandemic, patients seen for most acute conditions via telehealth were slightly more likely to need a follow-up visit, compared to patients who sought in-person care to begin with. This finding comes from a study published in JAMA Network Open (here), which also reported that telehealth patients with chronic conditions were less likely to need follow-up care. The results conflict with some previous studies, for example one from RAND in 2017 which found that telehealth increased health care utilization and spending in California.
Here, researchers reviewed almost 41 million claims from commercially insured adults for the period July 1 to December 31, 2020. "Telehealth accounted for a large share of ambulatory encounters at the peak of the pandemic and remained prevalent after infection rates subsided. Telehealth encounters for chronic conditions had similar rates of follow-up to in-person encounters for these conditions, whereas telehealth encounters for acute conditions seemed to be more likely than in-person encounters to require follow-up."
Congress has already approved Medicare coverage for expanded telehealth services for five months after the end of the COVID-19 Public Health Emergency, most likely mid-July. The virtues of another expiring Medicare waiver (the hospital-at-home) are extolled in a report in STAT (here).
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Losing Heart
The problem, as stated in a viewpoint (here) in JAMA Cardiology: "The constellation of factors surrounding ischemic systolic HF [heart failure] and CABG [coronary artery bypass graft] fulfills the criteria of an important unmet clinical need: a highly prevalent and lethal condition with a major burden to health care systems, an effective therapeutic strategy with RCT [randomized clinical trial] evidence of significant mortality reduction, and underutilization of that therapy across the population."
The authors elaborate: "Ischemic heart disease is the leading cause of death in countries of all income groups and the most common cause of left ventricular systolic dysfunction (LVSD) and heart failure. Patients with underlying coronary artery disease (CAD) have a worse prognosis and require distinct therapeutic treatment pathways that include evaluation for potential revascularization and tailored guideline-directed medical therapy (GDMT). Despite this . . . few patients undergo evaluation for CAD and fewer yet undergo CABG. Observational studies suggest that patients presenting with HF are among the least likely to be offered revascularization, and among those hospitalized, only 1.3% undergo CABG within 90 days of their index HF hospitalization."
HOSPITALS AND OTHER HEALTH CARE FACILITIES
Hospitals Decry Increasing Hospital Expenses
In a new initiative to stimulate federal interest in provider relief for COVID-19 expenses, the American Hospital Association has published a report (here, summary here) headlined "Massive Growth in Expenses and Rising Inflation Fuel Continued Financial Challenges for America’s Hospitals and Health Systems."
Citing Bureau of Labor Statistics records, the report says "Hospital employment is down approximately 100,000 from pre-pandemic levels. At the same time, hospital labor expenses per patient through 2021 were 19.1% higher than pre-pandemic levels in 2019." A big part of the expense increase went to contract staff, but also to drug costs and medical supplies. "In 2019, hospitals spent a median of 4.7% of their total nurse labor expenses for contract travel nurses, which skyrocketed to a median of 38.6% in January 2022. Contract staff agencies have increased the rates they bill hospitals significantly. In fact, hourly billing rates that hospitals pay staffing firms for contract employees increased 213% compared to pre-pandemic levels and led to a 62% profit margin for contract staff agencies."
AHA's report noted that "Drug expenses also increased dramatically, 36.9% on per patient bases, compared to pre-pandemic levels. As a share of non-labor expenses, drug expenses grew from approximately 8.2% in January 2019 to 10.6% in January 2022. Medical supply expenses grew 20.6% through the end of 2021, compared to pre-pandemic levels. When focusing on hospital departments most directly involved in care for COVID-19 patients − ICUs and respiratory care departments − medical supply expenses increased 31.5% and 22.3%, respectively, from pre-pandemic levels."
Care Cascades and the Communicability of Low Value Treatments
Low value preoperative EKGs and chest radiographs lead to follow-on low value services and increased risk to patients, according to a study published in the Journal of General Internal Medicine (here), from the VA system. "Among a national cohort of Veterans undergoing low- or intermediate-risk surgeries, low-value care cascades following two routine low-value preoperative tests are common, resulting in greater unnecessary care and costs beyond the initial low-value service." A report on the study (here) published in ACP Hospitalist noted that "Chest X-rays and EKGs of low-risk patients before low- or intermediate-risk surgery were followed by high rates of repeat tests, follow-up imaging, and follow-up visits."
Quality indicators of low value services in trauma were chronicled in an expert panel review published in JAMA Surgery (here). "Selected indicators targeted low-value clinical practices in the following aspects of trauma care: (1) initial diagnostic imaging (head, cervical spine, ankle, and pelvis), (2) repeated diagnostic imaging (post transfer computed tomography [CT] and repeated head CT), (3) consultation (neurosurgical and spine), (4) surgery (penetrating neck injury), (5) blood product administration, (6) medication (antibiotic prophylaxis and late seizure prophylaxis), (7) trauma service admission (blunt abdominal trauma), (8) intensive care unit admission (mild complicated traumatic brain injury), and (9) routine blood work (minor orthopedic surgery)."
Nursing Home Peril
A report in STAT (here) summarizes the demography of American nursing homes: "About 1.3 million Americans live in the country’s 15,000 nursing homes, where they are cared for by roughly 3 million staff members . . . nearly 170,000 nursing home residents are estimated to have died from Covid-19. Many, many more were isolated from family and friends during the 20-month lockdown. Bed sores, severe weight loss, depression, and mental and functional decline have spiked among nursing home residents. And nurses, certified nurse aides, and others who work in these facilities, putting their own lives at risk, have worked in the most challenging of conditions without adequate pay or support."
For 18 months a Committee of the National Academy of Medicine has studied these issues, finding that "The way the U.S. finances, delivers, and regulates care in nursing home settings is ineffective, inefficient, inequitable, fragmented, and unsustainable." The Committee report (604 pages) is here.
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
Could Employees Sue if Their Employer is Imprudent in Paying Hospital Prices Which Are Too High?
Bloomberg Health & Law reports (here) that "The Consolidated Appropriations Act enacted in 2020 requires employer-sponsored health plans, acting as fiduciaries, to pay a fair price for services provided, and it requires hospitals and health plans to make the prices paid public. If health plans don’t, there could be legal action from plan members." New trade associations and purchaser coalitions are pursuing members using this theme.
READING & REFERENCES
Select Coronavirus Public Health Resources and References may be found here. The JAMA Patient Page explains the current status of oral anti-viral medications for COVID-19, here.
2022 CQ Congressional Calendar here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
April 29
May 10, 11, 12, 13, 16, 17, 18, 19
June 7, 8, 9, 10, 13, 14, 15, 16, 21, 22, 23, 24
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org