DCMedical News: Thursday, September 29, 2022
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS Thursday, September 29, 2022
Cancer Screening Harms Reported Only Irregularly and Inconsistently
An NCI-funded study in the Annals of Internal Medicine (here) noted “Cancer screening should be recommended only when the balance between benefits and harms is favorable.” The study explains that “research and guidelines on cancer screening in the United States have historically emphasized the benefits of screening, whereas harms from screening tests and procedures have received less attention. The delivery of cancer screening can result in pain or discomfort, iatrogenic complications, distress from abnormal results, a cascade of additional tests and procedures accompanied by their own set of harms, and patient costs. Understanding and mitigating such harms is important because most persons having cancer screening will not have detectable disease at the time of screening and will therefore not benefit from early detection. Thus, cancer screening should be recommended only when the balance between benefits and harms is favorable.”
But the study found that “Harms reporting was inconsistent across organ types and at each step of the cancer screening process. Guidelines did not report all harms for any specific organ type or for any category of harm across organ types. The most complete harms reporting was for prostate cancer screening guidelines and the least complete for colorectal cancer screening guidelines.”
Doctor-Owned Hospitals Are the Answer to Problems of Hospital Competition, Cost and Quality
So says an association of “Doctor-Led” hospitals, in a new report (here). InsideHealthPolicy reports that “Physician-led hospitals are pushing Congress to remove restrictions that hamper their expansion after a report they commissioned found hospitals that are owned or invested in by referring physicians performed better and offered more cost savings for Medicare than hospitals in general . . . The study also found that physician-led hospitals were more likely to receive the highest patient experience rating from CMS' Hospital Consumer Assessment of Healthcare Providers and Systems, with 41% of physician-led hospitals achieving the rating compared to 6% of hospitals overall.” The United States has about 250 physician-led hospitals, half of them completely physician-owned, the others jointly owned with corporations.
The number of physician-owned and physician-led hospitals would be higher, and the hospitals larger, if passage of section 6001 of the Patient Protection and Affordable Care Act (PPACA), which limits the physician-owned hospitals, had not been a high priority for the organized hospital industry. A brief history: studies from Casalino (“Focused Factories”) on the early growth of physician-owned hospitals (here), and Igelhart (here) in an overview in NEJM in 2005, presaged a “study” of physician ownership of hospitals called for in the Medicare expansion of 2003 and completed in 2005 (here). The follow-on history, after passage of PPACA with section 6001, is reflected in efforts to quickly complete the construction of doctor-owned hospitals soon after passage of PPACA (here), and, in later years (here), in comments submitted in response to the proposed Inpatient Prospective Payment System (for hospitals) of 2018.
HOSPITALS, NURSING HOMES AND OTHER HEALTH FACILITIES
Surprise Billing Limitations May Inadvertently Increase Utilization
A contrarian theme emerges in a study (here) from The American Journal of Managed Care, proposing that limitations on out-of-pocket surprise payments may be a moral hazard in encouraging over-utilization of hospital emergency departments. “We find that the [balance billing] bans reduced spending per visit by 14% but spurred a demand response, an increase of 3 percentage points in ED visits, which wiped away the cost savings. Based on an ED severity index, these extra ED visits were 9% less urgent than prior to the bans . . . Health plans must be prepared to manage this spike in ED visits as the No Surprises Act takes effect.”
CDC Study Finds 80% of Maternal Deaths Avoidable
The study (here, USA Today report on the study here) noted that “Among deaths for which timing in relation to pregnancy is known, approximately 22% of deaths occurred during pregnancy, 25% occurred on the day of delivery (within 24 hours of the end of pregnancy) or within a week after delivery, 23% occurred from 7 to 42 days postpartum, and 30% occurred in the late postpartum period (43–365 days postpartum).”
Reviewing Maternal Mortality Review Committee records from 36 states for the period 2017-2019, the study concludes “Among the 1,018 pregnancy-related deaths, a preventability determination was made for 996 deaths. Among these, 839 (84%) were determined to be preventable.”
DRUGS & DEVICES
A 340B Scam in the Spotlight
The New York Times featured Richmond Community Hospital on the front page (here). “Ringed by public housing projects, Richmond Community consists of little more than a strapped emergency room and a psychiatric ward. It does not have kidney or lung specialists, or a maternity ward. Its magnetic resonance imaging machine frequently breaks, and was out of service for seven weeks this summer, said two medical workers at the hospital, who requested anonymity because they still work there. Standard tools like an otoscope, a device used to inspect the ear canal, are often hard to come by. Yet the hollowed-out hospital — owned by Bon Secours Mercy Health, one of the largest nonprofit health care chains in the country — has the highest profit margins of any hospital in Virginia, generating as much as $100 million a year, according to the hospital’s financial data.”
Where does the $100 million come from? The 340B program, which enables Bon Secours to use the safety net hospital Richmond as a network distributor of expensive pharmaceutical products, which federal law (§340B of the Public Health Act) allows Richmond to buy at low prices, and sell them (third party reimbursement) at higher prices, keeping the difference. This type of arrangement, not the solo safety net hospital envisioned by Congress in 1992 as the beneficiary of 340B, is at the heart of litigation between the major pharmaceutical firms, HHS and the hospital industry, including the lobbying group 340B Health. “The drug program was created with the intention that hospitals would reinvest the windfalls into their facilities, improving care for poor patients. But Bon Secours, founded by Roman Catholic nuns more than a century ago, has been slashing services at Richmond.”
“Starting in the mid-2000s, big hospital chains figured out how to supercharge the program. The basic idea: Build clinics in wealthier neighborhoods, where patients with generous private insurance could receive expensive drugs, but on paper make the clinics extensions of poor hospitals to take advantage of 340B. Since 2013, Bon Secours has opened nine such satellite clinics in wealthier parts of the Richmond area, according to federal records. Even though the outposts are miles from Richmond Community, they are legally structured as subsidiaries of the hospital, which entitles them to buy drugs at the discounted rate. The Bon Secours Cancer Institute at St. Mary’s, for example, administers cancer drugs to patients in an office suite on the tree-lined campus of St. Mary’s Hospital. Thanks to 340B, Richmond Community Hospital can buy a vial of Keytruda, a cancer drug, at the discounted price of $3,444 . . . but the hospital charges the private insurer Blue Cross Blue Shield more than seven times that price — $25,425, according to a price list that hospitals are required to publish. That is nearly $22,000 profit on a single vial. Adults need two vials per treatment course. Though better equipped, St. Mary’s Hospital in the city generated $27 million less for Bon Secours Mercy Health in 2020 than Richmond Community did.”
“‘Bon Secours was basically laundering money through this poor hospital to its wealthy outposts,’ said Dr. Lucas English, who worked in Richmond Community’s emergency department until 2018. ‘It was all about profits.’”
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
September 30
October 11, 12, 13, 14, 17, 18, 19, 20, 21
November 14, 15, 16, 17, 18, 29, 30
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org