A Decade of Change
A Decade of Change
Looking back on the trending topics in healthcare over the last 10 years
Change is the one thing that remains constant in the healthcare industry. Expectantly, the last decade proved healthcare is one of the most important social and economic issues for the United States. As we enter a new decade, we can expect for this to become even more significant as the industry continues to evolve.
Take a step back and review some of the trending topics and headlining news of the decade. Change becomes more evident with each passing year.
The Affordable Care Act (ACA) legislation was signed into law by President Barack Obama on March 23, 2010. The law aimed to provide more Americans with access to affordable, quality healthcare by putting comprehensive health insurance reforms in place. The legislation is often referred to as one of the longest, most complex reforms since the inception of Medicare and Medicaid. The ACA initiated a decade of change and steered many of the industry’s trends for the next nine years.
According to the Agency for Healthcare Research and Quality in 2011, healthcare spending had risen at a faster rate than the economy almost every year in the previous 30 years. This placed a large financial burden on many American households. As a result, and a part of the ACA legislation, Accountable Care Organizations (ACO) were developed through CMS’ Medicare Shared Savings Programs.
CMS.gov defines ACOs as “groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients.” The goal of these organizations is to work in collaboration with other voluntary groups to ensure high-quality healthcare is performed while avoiding duplication of services, which in turn spends healthcare dollars more wisely.
“Currently, 700 ACOs serve an estimated 23 million American beneficiaries covered by Medicare, Medicaid and commercial insurance in all 50 states,” according to the National Association of ACOs.
Overutilization of radiation was a major concern exiting 2010 which posed a challenge, and question, for the industry in 2011. According to a study published in the Journal of the American Medical Association, “the average dose from medical imaging has increased more than 6-fold” and the average dose a U.S. patient is exposed to nearly doubled since the previous 30 years. With these concerns top of mind, there was a big push for regulation of appropriate ordering and in response, CMS launched a demonstration project to help develop an appropriate use decision support system. The goal was to build tools for physicians to use in order to guide the appropriate utilization decisions.
Imaging Overutilization Additional Resources: RSNA: Addressing Overutilization in Medical Imaging; The American Journal of Medicine: Curbing the Urge to Image
On Feb. 9, 2012, the Obama administration issued the final rule in the Summary of Benefits and Coverage legislation which is a section of the larger ACA legislation. This ruling requires health insurers and group health plans/employers to provide a clear, concise, standardized and comprehensible Summary of Benefits and Coverage (SBC) document to all current and potential health plan participants. The goal was to give consumers access to easy-to-understand information and to assist employers in selecting the appropriate coverage for their organizations.
Additional Summary of Benefits and Cover Law Resource: Federal Register
The CMS Two-Midnight Rule originally went into effect on Oct. 1, 2013. This rule created a benchmark to instruct physicians and admitting practitioners when it is generally appropriate to admit as an inpatient. The original rule stated physicians, or other practitioners, should admit a beneficiary as an inpatient if:
- the provider expects that the beneficiary will remain in the hospital for more than one Medicare utilization day (which CMS defines as an admission that crosses two midnights);
- the beneficiary requires a procedure categorized as inpatient only.
New updates and amendments to the rule were proposed in 2015 and implemented in the 2016 calendar year which are currently in practice today.
Additional Two-Midnight Rule Sources: 10 things to Know about the Two-Midnight Rule (2013); CMS Issues Additional Guidance on Two-Midnight Hospital Admissions Rule (2013); The Hospitalist: Medicare’s Two-Midnight Rule (2019)
According to CDC.gov, The World Health Organization (WHO) reported the first cases of Ebola Virus Disease (EVD) in West Africa on March 23, 2014. Almost six months later on Sept. 30, 2014, the WHO reported the first case of EVD in the United States. This kicked off what is known as the largest Ebola virus epidemic in history. This epidemic prompted mass Ebola preparedness initiatives to be rolled out by the CDC in hospitals and health systems nationwide to educate hospital staff, physicians and other clinicians on how to identify, treat and protect from the disease. Over the course of two years (2014-2016), a total of 28,656 cases and 11,325 deaths were reported. Of the total reported cases, four cases were reported in the United States resulting in one death.
Additional Ebola Outbreak Resources: CDC’s Ebola Resource Page
On April 16, 2016, President Barack Obama signed The Medicare Access and CHIP Reauthorization Act (MACRA) into law. The legislation included a number of provisions. Some examples of these provisions include:
- Social Security Numbers were required to be removed from Medicare cards by April 2019.
- Temporary reauthorization of funding for the Children’s Health Insurance Program (CHIP).
- Delay enforcement of the Two-Midnight Rule until Oct. 1, 2015.
- Establish an incentive payment program, the Quality Payment Program, which repealed Sustainable Growth Rate (SGR) formula previously used to determine Medicare payments to clinicians and created two pathways to participate, the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).
- Streamline quality reporting programs with requirements for the United States Department of Health and Human Services to draft a plan for the development of quality measures to assess clinical professionals, including non-patient facing.
- Expansion of the use of Medicare data to be provided to Qualified Clinical Data Registries (QCDR) to help quality improvement initiatives.
Zika virus kicked off the year 2016 with large outbreaks in the Americas region which later transmitted into a nationwide outbreak in the United States due to an increase in travel associated cases. The CDC recognized Zika as a “nationally notifiable condition.” As with any unfamiliar major disease outbreaks, hospitals and health systems nationwide leaned on education from the CDC to drive initiatives for treatment, prevention and transmission for clinical providers. According to the CDC, the final 2016 data reported to ArboNET for Zika virus disease included:
- US States: 5,168 symptomatic Zika virus disease cases reported with 4,897 cases in travelers returning from affected areas, 224 cases acquired through presumed local mosquito-borne transmission in Florida and Texas, and 47 cases acquired through other routes, including sexual transmission, laboratory transmission, and person-to-person through an unknown route
- US Territories: 36,512 symptomatic Zika virus disease cases reported with 145 cases in travelers returning from affected areas, 36,367 cases acquired through presumed local mosquito-borne transmission and 0 cases acquired through other routes
Zika virus wasn’t the only major headline of 2016. Mergers and acquisitions took over the industry in almost every area of healthcare. In a Becker’s Hospital Review Article, Trine Tsouderos, Director of Pricewaterhouse Coopers’ Health Research Institute, mentioned a domino effect of mergers in one part of the industry leading other parts of the industry to do the same. She also predicted the election year would cause M&As to make way into campaign trails.
According to Fierce Healthcare’s article from December 2016, 52 hospital and health system transactions occurred in the first six months of the year. Many private equity firms and physician groups also consolidated. M&As have continued to surpass the previous year since 2016.
Additional Merger Resources: Healthcare Finance – Healthcare M&A in 2016: Running List; 6 forecasts for healthcare M&A in 2016; Fierce Healthcare – A look back at hospital mergers and acquisitions in 2016
First MIPS Performance Year
2017 kicked off the first Merit-Based Incentive Payment System (MIPS) performance year for all eligible clinicians. MIPS is the Centers for Medicare and Medicaid Services’ (CMS) largest value-based care payment program for physicians and one of the pathways under the QPP. The program attempts to incentivize quality over quantity by adjusting payments for physicians based on quality and cost effectiveness. Using a composite performance score, physicians and APCs may receive a payment bonus, a payment penalty, or no payment adjustment. The Composite Performance Score is based on four performance categories: Quality, Promoting Interoperability (formerly Advancing Care Information), Improvement Activities and Cost.
MIPS Performance reporting began on Jan. 1, 2017 and will continue to measure providers on an annual basis to derive an individual’s MIPS score (0 to 100-point scale). The MIPS score can significantly impact a provider’s Medicare reimbursement with positive or negative adjustments in each payment year. These adjustments follow the individual provider, wherever practicing, two years following the performance year.
In Oct. 2017, the Trump Administration declared the opioid epidemic a public health emergency. The misuse of and addiction to opioids has devastatingly impacted public health and social and economic welfare of communities nationwide. Altarum, a healthcare research firm, estimated a $90 billion economic burden as a result of opioid misuse. The CDC reported a 30 percent increase in emergency department visits due to opioid overdose in all parts of the U.S.
As a result of the epidemic, organizations nationwide stepped up to develop and deploy opioid monitoring, prevention and education initiatives. Some of these examples include:
- HEAL (Helping to End Addiction Long Term) Initiative by the National Institutes of Health (NIH)
- CDC In Action, Response to Opioid Overdose Epidemic, Opioid Rapid Response Teams by the Centers for Disease Control and Prevention
- Stop Opioid Abuse Initiative by the Trump Administration
- Five Point Opioid Strategy by U.S. Department of Health and Human Services
The opioid crisis still remains but with more knowledge, education and resources. We continue to work towards a better solution for the patients and communities we serve.
Additional Opioid Crisis Resources: Becker’s Hospital Review Opioid Related Search
Throughout the 2019-year, surprise billing has continuously garnered attention from the media, hospitals and health systems, patients, other healthcare stakeholders and the federal government. As we work toward the close of the year, the iron of surprise billing remains hot. Here is a quick breakdown of what surprise billing is, how it impacts patients, hospitals and physicians, and what is happening right now in congress.
What is surprise billing? Surprise billing (some call it Surprise Insurance Denials) occurs when a patient seeks care at an in-network hospital covered by his/her health insurance plan but is treated by an out-of-network physician and the physician or hospital subsequently bills the patient for the amount the patient’s insurance does not cover.
How does this impact patients? Unfortunately, insurance companies continue to narrow provider networks (limiting patient access to medical services) and reduce payments to both hospitals and physicians with whom they contract. At the same time, insurance companies have shifted costs to patients through higher premiums, deductibles and cost-sharing, leaving patients paying more for less coverage. Additionally, insurance companies’ lack of contracting with physicians may lead to surprise bills (also known as surprise insurance denials). In many cases, patients are unable to afford the unexpected medical costs which directly impact the financial stability of the physician group and/or the hospital.
How does surprise billing/surprise insurance gaps impact providers, health systems and physician practices? Decreased insurance payments and surprise bills/insurance denials threaten hospitals’ and physician groups’ bottom line and overall ability to operate, especially in rural areas with hospitals already struggling to keep their doors open for their communities. These hospitals already have trouble retaining nurses and other staff. Frequently these hospitals must also pay large subsidies to physician groups to staff their hospital as the limited reimbursements from low patient volumes and low insurance payments do not support the cost of physician services. Further cuts from insurance companies in the form of reduced payments or surprise billing/shifting of cost to the patients increase the financial burden of many hospitals, forcing some, especially the smaller hospitals, to close.
What is happening now? Revised surprise billing legislation sponsored by Senator Lamar Alexander, Representative Frank Pallone and Representative Greg Walden was unveiled Dec. 9, 2019. Many have accused the Alexander Bill of being quite friendly to insurance companies, essentially giving them carte blanche to dictate physician rates. Others have submitted competing bills. Physicians across the country, including those of ApolloMD, and other patient advocates have been working hard to educate members of Congress and ensure legislation for surprise billing focuses on three main points:
- Keeping patients out of the middle of payer-provider disputes and protecting them from surprise bills/insurance gaps
- Fair reimbursement for physician services, including an independent dispute resolution process which has been proven to be highly effective in several states that employ this approach
- Improving transparency in healthcare
Surprise Billing/Surprise Insurance Gap Resources: Medical Association of Georgia; American Hospital Association; American College of Emergency Physicians; American College of Surgeons; Florida Medical Association; Medical Society of the State of New York; Texas Medical Association; Physicians for Fair Coverage
Another major outbreak is also closing out 2019. As of Dec. 5, 2019, 1,276 individual cases of measles were confirmed in 31 states beginning Jan. 1, 2019, according to the CDC. This is the largest number of reported measles cases in the United States since 1992.
A majority of the cases are among individuals who were not vaccinated for measles. Of the cases reported, 124 people were hospitalized and 61 were reported for having complications including pneumonia and encephalitis.
States that reported cases to the CDC include: Alaska, Arizona, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kentucky, Maine, Maryland, Massachusetts, Michigan, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Tennessee, Texas, Virginia, and Washington. A majority of these outbreaks are linked to New York state. The current count of reported cases is close to doubling the U.S. outbreak of 2014.
As an organization, we look forward to the start of a new decade and hope to bring positive changes and forward movement to the industry.