DCMedical News: Thursday, March 7, 2019
DCMedical News-DCMN
Washington, D.C.
Thursday, March 7, 2019
The publication schedule and subscription information for DCMedical News will be found below.
THE BIG STORY IN HEALTH CARE:
Judge Blasts United for Limits on Mental Health Coverage:
United Behavioral Health (UBH), UnitedHealth’s unit that administers treatments for mental illness and addiction in private health plans, used restrictive and deceptive guidelines to make decisions on coverage of mental health services. This was the finding of Judge Joseph Spero, Chief Magistrate Judge in the U.S. District Court, Northern District of California. “There is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members’ underlying conditions,” he said. He dismissed much of the testimony by UnitedHealth’s experts as “evasive — and even deceptive.” The 106-page ruling in Wit v. United and Alexander v. United, here, was on two class-action law suits filed in 2014. United is the nation’s largest behavioral health insurer (60 million members). A report on the decision in The New York Times (here) noted that the judge “described the company’s guidelines as ‘unreasonable and an abuse of discretion’ and having been ‘infected’ by financial incentives meant to restrict access to care.”
Statutory protection of mental health benefit parity at both the federal and state levels was circumvented by United, according to Judge Spero. Psych-Appeal, Inc., a law firm appointed as one of two counsel for the class action, reports (here) that “While the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 requires parity for mental health and substance use benefits, insurers are permitted to evaluate claims for medical necessity. However, by using flawed medical necessity criteria, insurers can circumvent parity in favor of financial considerations and prevent patients from receiving the type and amount of care they actually require.” Also, “In its decision, the court also held that UBH misled regulators about its guidelines being consistent with the American Society of Addiction Medicine (ASAM) criteria, which insurers must use in Connecticut, Illinois and Rhode Island. Additionally, the court found that UBH failed to apply Texas-mandated substance use criteria for at least a portion of the class period.”
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Life-Threatening Childbirth Complications Increasing in all Ethnic Groups, Some More Than Others:
The NIH reports (here) on a study analyzing more than 8 million live births in California between 1997 and 2014. Severe maternal morbidity was highest among non-Hispanic black women (1.63 percent). “During the study period, severe maternal morbidity increased roughly 170 percent for each group.”
HOSPITALS, NURSING HOMES AND OTHER HEALTH CARE FACILITIES
Strategies to Address Health Care Costs:
Senator Alexander, chairing the HELP Committee, is collecting suggestions for strategies to address heath care costs. Here is the (14-page) offering from the American Hospital Association.
Accreditation and Conflict of Interest:
CMS, responding to stories in The Wall Street Journal (the latest here) has collected comments reflecting on whether they should continue to approve accreditation groups that also have “consulting arms” after the Journal raised concerns about conflict of interest and patient safety. This March 5 story builds on an earlier series from September 8, 2017, December 18, 2018 and December 26, 2018, all on the same general theme (problems with accredited facilities, possibility of conflict of interest with consulting activity).
England’s National Health Aims to Reduce the Private Sector Role:
A report in the Financial Times (here) indicates that the role of the private sector in England’s National Health Service is likely to be significantly reduced, through elimination of that part of the Health and Social Care Act of 2012 which requires all services above a certain cost to be offered for bid. A spokesperson for NHS Improvement indicated that while competition “can in some circumstances help provide benefits to patients,” as implemented it acts as a “drag on efforts to improve collaboration between NHS bodies and provide integrated care.”
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
CMS Looks to Expand Health Insurance Plan Sales Across State Lines:
In a “Request for Information” (here) CMS “[S]olicits comment from interested parties on how to eliminate barriers to and enhance health insurance issuers’ ability to sell individual health insurance coverage across state lines, primarily pursuant to Health Care Choice Compacts.” The formal notice will be published in the March 11 Federal Register.
High Deductible Health Plans Don’t Encourage Price Shopping:
A report in Health Affairs (here) finds (again) that high deductible plans shift cost to employees but do not lead to price shopping. “Among HDHP enrollees sampled, saving for future healthcare services was the most widespread consumer behavior the researchers documented. About 25 percent of enrollees talked with a provider about how much a service would cost. Only 14.4 percent price-shopped for a service at a different place.” Himmelstein, Woolhandler and colleagues continue to monitor medical bankruptcy, finding (here) in the American Journal of Public Health no change in the proportion of bankruptcies due to medical expenses, notwithstanding the passage of the Patient Protection and Affordable Care Act.
DRUGS & DEVICES
Oncology Impact on Drug Costs:
The Magellan RX 2018 Medical Pharmacy Trend Report (here) demonstrates the impact of oncology prices on drug spending, overall. For commercial plans, oncology was 43% of the drug benefit per member per month spending. For Medicare, oncology was 58%. For Medicaid, oncology was 46%.
Part B to Part D:
A Harvard/Brigham/Zurich group reports (here) that the proposal by the Department of Health and Human Services to move drugs from Medicare Part B to Medicare Part D may reduce total drug spending, but it may also increase out-of-pocket costs for some Medicare beneficiaries. The study examined retrospective use of 75 brand name drugs associated with the highest Part B expenditures. Helpfully, the study distinguishes patient impact for the low-income subsidy program in Part B and for patients with Medigap insurance.
Fentanyl Prescription Abuse:
Pharmacists, physicians and patients had high levels of knowledge about proper Fentanyl prescribing, according to a JAMA investigation (here), yet between 35 and 55% of patients received inappropriate prescriptions (based on claims data).
READING AND REFERENCE
Three-part series in The New England Journal of Medicine on teamwork and communication in hospitals, here, here and here.
U.S. House of Representatives:
Members at https://www.house.gov/representatives, Committees and Members at https://www.house.gov/committees
U. S. Senate:
Members at https://www.senate.gov/general/contact_information/senators_cfm.cfm, Committees and Members at https://www.senate.gov/committees/membership_assignments.htm
House and Senate 2019 Calendar of Regularly Scheduled Sessions, here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
March publication dates: 8, 11, 12, 13, 14, 25, 26, 27, 28
April publication dates: 1, 2, 3, 4, 9, 10, 11, 12, 29, 30
May publication dates: 1, 2, 7, 8, 9, 10, 14 15, 16, 17, 20, 21, 22, 23
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com.