Published on NorthJersey.com

When it comes to their health, end-of-life planning isn’t a popular topic of conversation with our patients. Frankly, it’s a difficult discussion to have. But what could be more important than having a conversation with your doctor and loved ones about how you want to spend the final stage of your life?

A 2018 survey, conducted by the Conversation Project, reported that more than 92 percent of Americans think it is important to discuss their wishes for end-of-life care. However, only 32 percent of those surveyed have actually had these discussions. Clearly, we need to make it easier for patients to have these difficult conversations with their families – at their kitchen table and not in the emergency room.

To that end, Gov. Phil Murphy declared April 16 as Healthcare Decisions Day in New Jersey and encouraged people to join him at events focusing on advance care planning throughout the state. The events are sponsored by Conversation of Your Life (COYL), a program of the New Jersey Health Care Quality Institute and the New Jersey League of Municipalities. COYL events help guide people in discussions with their families and health care providers, with the goal of making these uncomfortable conversations easier.

Indeed, a major problem in our healthcare system today is the lack of expertise in conducting these sensitive conversations with patients and having the appropriate mechanisms in place for making decisions in care.  That’s why Holy Name Medical Center is leading a statewide effort to improve end-of-life care through the use of electronic advanced directives.

Advanced directives are powerful tools in giving patients the power to decide how they would want to live out their final moments.  A patient’s advanced directive is a valuable resource for a patient’s family and the medical team as they collaborate to care for a patient unable to voice their own wishes.

Historically, advanced directives are physical legal documents. In emergency circumstances, these documents may not be readily accessible to the health care team. 

In 2019, it’s imperative we have advanced directives stored electronically in a universal database to access a patient’s wishes and critical information at any time or place. To ensure certainty and avoid confusion, advance directives need to be included as a component of a patients’ electronic health record (EHR).

Personalized video messages, in which a patient articulates specific wishes and customized written instructions, are powerful components of this tool, assisting family members and decision makers at difficult times. Much like the way we digitally access our bank accounts, the ease of access through an electronic platform allows individuals the ability to create, update and share their wishes with relevant family, friends, and providers.

As part of a statewide end-of-life-care initiative, Holy Name Medical Center is committed to ensuring all patients and staff have advanced directives in place and is partnering with ADVault through their MyDirectives.com platform to accomplish this. We look forward to demonstrating this new technology with New Jersey Department of Health Commissioner Elnahal at the Villa Marie Claire in the coming months.

In talking about the Conversation of Your Life, Linda Schwimmer, President and CEO of the New Jersey Health Care Quality Institute said, “We are doing nothing less than changing the culture in New Jersey around end-of-life care.” 

We couldn’t agree more, and we look forward to continuing the conversations on this important issue in the months to come. Talking about end-of-life care isn’t about death – it’s about living. 

It’s about how you choose to spend your last days, weeks and months. Our goal is to help all patients maximize their quality of life in their final months, weeks, days and hours.

Published in NJBiz.com

New Jersey Institute of Technology President Joel Bloom welcomed visitors Thursday to hear about technological innovation and value-based health care at the fifth annual Innovation Showcase.

Donald Sebastian, president of the New Jersey Innovation Institute, an NJIT corporation, explained that the evolution of the health care innovation labs connects business with academic research. The Innovation Institute is helping to save $160 million in Medicare, Sebastian said.

“We formed NJII not just to tap into the power of our research but to work together collaboratively,” Sebastian said. “Hospital systems are doing their best to achieve efficiency. Our system is a bucket of bolts that has not been assembled into a chassis and a well-oiled machine. People are the source of innovation and the Innovation Labs provides the framework to connect these people into the business marketplace,” he said.

Linda Schwimmer, president and chief executive officer of the nonprofit New Jersey Health Care Quality Institute which seeks to improve health care in New Jersey, said the institute focuses on quality, safety and affordability.

“We’ve been working with NJII helping them with their practice transformation to work together on alternative payment models,” Schwimmer said. “I am excited today to discuss the themes of using data to drive value innovation. As you know, moving into a values-based system is difficult.”

Meanwhile, former Utah Gov. Michael Leavitt discussed the economics and politics of health care. He said the American health care system is moving toward a system of value-based care. Leavitt is also a former secretary of health in the American federal government.

“If the global economy had a voice, it would say there is no place on the economic leaderboard to spend 25 percent on health care,” Leavitt said. “It pits two essential values against each other. It is our sense of compassion. When people are cared for when they are sick, we want them to have care. It is the reason we have social policy that moves us in that direction. It is the reason we have Medicare and Medicaid,” he stated.

“If we give up our compassion, we give up our leadership,” Leavitt said. “Both are unacceptable. We have to invest a values-based health care system.”

Starting in the middle 1990s, doctors were directed by insurance companies how to treat patients, Leavitt said. “This was a very important lesson in American health care,” Leavitt said. “Anytime an economic sector makes a transition, it takes 40 years.”

The U.S. Congress approved President Barack Obama’s Affordable Care Act in 2010.

“We are at a race in our society to create a uniquely American solution,” Leavitt said.

Leavitt grew up handling cattle. He used this experience to make an analogy with health care.

“It is a dirty, messy, confusing experience,” Leavitt said. “Mother cows and baby cows know there is a time to nurse. They have an instinct. They will turn around and go back to the last place where they nursed. That is called a stampede and you do not want to be there.”

“If you move the health care system too fast, people will move back to the system they know well,” Leavitt said. “We are in a process that has some unevenness in its pace.”

Leavitt specified that he thinks fee-for-service medicine will always exist in part.

Published in WBGO.org

It’s been a little more than seven years since New Jersey’s Practitioner Orders for Life-Sustaining Treatment law, or POSLT was signed by former Governor Chris Christie, empowering patients to work with their preferred medical professional to create advance directives. But still people end up in hospitals with no living will. The Governor’s Advisory Council Report on End of Life Care says more than a quarter of adults, including seniors, have no documentation available if they’re not able to make healthcare decisions for themselves.

“It’s never ever too soon to make these decisions ahead of time,” said Christopher Kellogg, founder of Nightingale NJ, an Eldercare Consulting firm. He says his clients have fears in conversation, but most of the time it’s not death.

“What they are afraid of is not living in a place that they want to live in and being able to receive the care, the pain management that they want and need,” he said.

Which Medicare data suggests could be an issue for families in New Jersey. Analysis from The Dartmouth Atlas Project shows that patients experienced more aggressive end-of-life care without evidence to suggest any medical benefit.

“We are failing at this as a state,” said New Jersey Department of Health Commissioner Shereef Elnahal. He suggests there isn’t enough end of life training for medical providers.

“I got one one-hour class on how to approach difficult discussions on how to approach difficult decisions in health care,” he said. “And they weren’t necessarily just focused on end of life discussions. That is a big system issue because we haven’t invested enough in education and in the proper level in medical training throughout. Not just in medical school but throughout residency and even after in continuing medical education.”

Advocates for improving end of life care in New Jersey are stepping in to create new ways to start the conversation. Michael Maron, President of Holy Name Medical Center in Teaneck says they’re close to piloting a program that creates a living will online.

“You video tape yourself in your own voice, with your own inflection, and your own emotion. This all then gets forwarded to who you want to be your proxy. The beauty of that is when family or clinical controversy arises and people want to read the text and interpret differently, we turn on the video and say why don’t we listen,” Maron said.

Some organizations take a community-based approach to create a comfortable setting for end of life discussions. Adelisa Perez with New Jersey Health Care Quality Institute works with townships across the state.

“We utilize community book reads, we utilize facilitated film screenings, panel discussions. Sometimes we have an author come in,” she said. “There’s game nights where we use go wish. It’s a card game that helps participants prioritize end of life wishes. It’s really focused on taking these conversations outside of the hospitals, and outside of the providers office. Where they really need to be happening much earlier in the community setting where residents feel comfortable having these kinds of conversations.”

The Governor’s end of life planning advisory council report lays out a roadmap to create a more comfortable life for New Jersey residents in their final days. But another issue the report warns of is no clear vision of how the state’s healthcare system will meet the need, with an aging population and increased prevalence of people living with serious illnesses.

Published in Cape May County Herald Online

WILDWOOD CREST – The Borough of Wildwood Crest has received special recognition through its participation in the statewide Mayors Wellness Campaign for the 2018 calendar year.

According to a release, Wildwood Crest has been designated as a “Healthy Town in the Making” by the New Jersey Health Care Quality Institute, in partnership with the New Jersey State League of Municipalities.

A total of 18 municipalities were recognized by the New Jersey Health Care Quality Institute. Eight were awarded a “Healthy Town” designation, while seven others were recognized as “Healthy Towns to Watch.”

Wildwood Crest is one of the three New Jersey municipalities designated as a 2018 “Healthy Town in the Making,” along with Jefferson Township and Vernon Township.

Each year communities participating in the Mayors Wellness Campaign (MWC) complete a comprehensive application outlining the research they’ve done to identify their community health needs, explain how they have organized their local MWC committee, and highlight the actions they’ve taken to make their communities a healthier place to live, work, and play.

Wildwood Crest first promoted its Mayors Wellness Campaign initiatives in 2018 after establishing the Wildwood Crest Wellness Committee, made up of community volunteers as well as staff members from the Wildwood Crest Recreation Department.

Programs in 2018 included a Wellness Weekend that included an employee basketball game and a wellness walk hosted by Wildwood Crest Mayor Don Cabrera. In addition, the borough also hosted a community bike ride hosted by Cabrera that included discussions on bicycle safety.

Additional wellness initiatives are planned for Wildwood Crest for 2019.

The borough will host its wellness walk April 6, and its employee basketball game April 12.

The Wildwood Crest Recreation Department and Wellness Committee will also host a seven-part lecture series by various healthcare professionals on a variety of health and wellness topics beginning March 27.

In addition, the Wildwood Crest Mayors Wellness Campaign also includes plans to install walkway markers along the Wildwood Crest Bike Path and along Sunset Lake to help walkers, runners and bikers determine distances traveled.

“Wildwood Crest is proud to receive this recognition from the New Jersey Health Care Quality Institute,” Cabrera said. “The Crest has just started to scratch the surface in its wellness initiatives. You can’t find a more perfect community setting for wellness with our excellent beach, parks, events, pool, bike path — not to mention our dedicated residents and vacationers. There’s more to come.”

Now in its 12th year, the Mayors Wellness Campaign is a program of the New Jersey Health Care Quality Institute in partnership with the New Jersey State League of Municipalities.

The program empowers mayors across New Jersey with evidence-based tools, strategies, and support to champion health and wellness in their communities.

Published in NJSpotlight.com

Proposals are aimed at easing development of generic medications, reducing protection of brand-name patents, and improving transparency of drug development process.

Spending on pharmaceuticals is on the rise in New Jersey, a scenario that has forced hospitals here to more than double their budgets for medications over the past decade. The rising cost of drugs also contributes to an estimated four in 10 older residents not filling their prescriptions as recommended.

And while lower-cost generic drugs make up the majority of those dispensed nationwide, spending on brand-name formulations absorbs more than three-quarters of the total cost, according to industry reports.

To address that disparity, U.S. Rep. Frank Pallone (D-NJ) is rallying support for bipartisan federal proposals designed to promote the development of generic medications, reduce the power of drug companies to protect brand-name patents and improve transparency around the drug development process.

Pallone joined healthcare advocates at Boyt Drugs in Metuchen Monday to highlight seven related bills that were subject to a hearing earlier this month in the Congressional Energy and Commerce Committee, which he chairs. Several of the proposals — sponsored by Democrats and Republicans from around the country — call for technical changes to various regulations that he said have put those who make generic drugs at a competitive disadvantage.

“The American people have been clear: We need to take action to lower the soaring costs of prescription drugs,” Pallone said. “These bipartisan bills will lower costs for consumers by removing barriers to competition that prevent cheaper generic drugs from coming to market. Preventing companies from gaming market loopholes is a commonsense approach to reduce costs for consumers right away.”

Fill prescriptions or buy groceries?
The issue is also a priority for the AARP, which launched a national campaign last week urging federal officials to take action to address these rising costs and supports several of the bills Pallone identified. Some 72 percent of those over age 50 are concerned about the high cost of their medications and nearly 40 percent do not fill their prescriptions, usually because of the high cost, according to a recent national survey the group conducted.

“It’s unfair that Americans pay the highest prescription drug prices in the world. And it’s just wrong that many seniors are forced to choose between filling a prescription or buying groceries,” said Ev Liebman, the director of advocacy for AARP New Jersey, who joined Pallone on Monday.

Pharmaceutical companies — which have continued to play a large role in the economy of New Jersey, long known as the nation’s medicine chest — have argued that the high costs required by some of their formulations reflect the long, expensive and often circuitous path to developing successful treatments. The costs can be particularly steep in the process of developing drugs to treat rare disease, which naturally have a limited market.

Spending on prescription drugs actually accounts for a relatively small percentage of the country’s overall healthcare tab. But studies show these costs tend to be more volatile and are rising at an alarming rate. A review of healthcare claims data from 2012 to 2016, commissioned by the New Jersey Health Care Quality Institute, showed that while overall healthcare spending in the Garden State rose 18 percent — outpacing the national rate (15 percent) — pharmaceutical costs shot up 27 percent during that time.

Hospitals have been hit hard
Hospitals have been particularly hard hit by these escalations, according to survey findings released in February by the New Jersey Hospital Association, whose members may be suffering more than their counterparts nationwide. While drug spending rose 18.5 percent between 2015 and 2017 at acute-care facilities nationwide, it jumped more than 25 percent in New Jersey.

Data from New Jersey hospitals also shows that overall expenses for acute-care facilities here rose less than 30 percent between 2008 and 2017, but spending on drugs doubled during that decade, to reach nearly $1.6 billion. The per-patient cost of medications also escalated 132 percent in that time.

“These skyrocketing drug prices are handcuffing hospitals in New Jersey and beyond by forcing them to divert resources that could be better used to enhance patient care,” the NJHA notes in the report.

The increase is actually driven by a small share of the total prescription drug pie, according to a report based on 2017 claims from 88 million Americans insured through various Blue Cross Blue Shield plans, and released in November by Horizon BCBS, the state’s largest health insurance company. Nationwide, these groups spent $100 billion on pharmaceuticals that year, or 20 percent of their total costs.

Nationwide, Blue Cross found that 83 percent of the prescriptions it covered were for generic brands and only 17 percent involved brand-name pills. But the latter brands accounted for most of the spending, or nearly $8 out of $10 the company paid for pharmaceuticals; this totaled almost $80 billion in 2017 alone.

Looking toward 2018, for which claims data is still being compiled, Blue Cross predicted the use of more costly, branded drugs was expected to grow even more. There is limited competition for certain patent-protected and specialty formulations, the report notes, which allows these costs to continue to rise.

Similar concerns drove Pallone to advocate for the legislative reforms, which he said would boost competition and help control prescription drug prices.

The Bills
The proposed legislation includes measures that address issues with drug testing, competition, and access to information:

  • H.R. 965, CREATES Act of 2019 would establish a process through which generic manufacturers could request that the U.S. Food and Drug Administration authorize them to obtain sufficient quantities of samples for testing; this would reduce the ability of brand-name drugmakers to restrict the development of generic alternatives.
  • H.R. 985, FAST Generics Act of 2019 creates an authorization process that would allow generic drugmakers to gain access to samples of brand-name products that they are seeking to replicate.
  • H.R. 1499, Protecting Consumer Access to Generic Drugs Act of 2019 would make it illegal for brand-name and generic drug manufacturers to enter into anti-competitive agreements in which the generic manufacturer is paid to keep more affordable products off the market.
  • H.R. 938, BLOCKING Act of 2019 would allow the Federal Drug Administration to approve a second company’s application to manufacture a generic medication before the first company that produced the generic version started marketing the drug commercially, if certain conditions are met.
  • H.R. 1506, FAIR of Generic Drugs Act seeks to discourage exclusivity by the first company to make a generic version of a drug and ensure that it gets to market on time.
  • H.R. 1503, Orange Book Transparency Act of 2019 refers to the Orange Book, an interactive, electronic database of all approved drugs and their relevant patents and exclusivities, which is often essential to generic manufacturers. The bill would require this publication be accurate and up-to-date, reflecting recent court decisions.
  • H.R. 1520, Purple Book Continuity Act of 2019 refers to the Purple Book, which is like the Orange Book, but for biological products; this legislation would ensure the Purple Book is updated regularly and easily available online.

Published on NJSpotlight.com

Experts largely agree on steps New Jersey should take to create a more effective and efficient Medicaid system and reform plans have already been drafted for some changes, like reforming how doctors are paid for their care and improving services for those with complex needs.

Now state officials have launched an office whose specific job will be to institute some of these changes, which have been long under discussion. And the project will have the support of independent policy experts backed by a foundation dedicated to improving care for those in under-served communities.

New Jersey’s Department of Human Services announced Thursday that it has created the Office of Medicaid Innovation to “improve quality, delivery and cost of care” within the massive system, which provides health insurance for nearly one in five state residents. Advocates have long said that it would take a dedicated effort — independent of daily operations and focused on change — to achieve real reform.

And on Friday, the New Jersey Health Care Quality Institute, a nonprofit advocate for safety and cost control, said it had created its own Medicaid Policy Center to pursue similar goals. That program is funded by The Nicholson Foundation, which has backed several studies and planning initiatives focused on improving Medicaid.

The DHS said the state’s Medicaid innovation office will lead efforts to implement changes like a shift to value-based payments, in which physicians and other healthcare providers are reimbursed based on patient outcomes, not the number or type of procedures they perform. It will also look to improve the system of care for patients covered by Medicaid and Medicare, who often have complex and costly healthcare needs.

DHS Commissioner Carole Johnson told NJ Spotlight that one opportunity for payment reform involves addiction treatment; the innovation office will build on new efforts to expand access to the most effective techniques, like medication assisted treatment, through the primary-care system, she said. The model involves new financial incentives for community-based providers to expand treatment services where people need it most.

“As it begins its work, the new Innovation Office’s immediate goal is to look for opportunities to use our available levers to drive the best possible care and value,” Johnson said, and the new addiction treatment model “is an example of how we are thinking anew about what we pay for, where, and when, so that we can better leverage our dollars to drive the best possible health outcomes.”

To lead the state’s efforts — which will also focus on creating a more sustainable system — the DHS hired Gregory Woods, who recently led a federal initiative to reform Medicaid in Baltimore. Woods, who will be paid $122,000 a year, will lead a staff of 11 for the program.

“With Greg’s extensive background on issues and policies directly impacting (our Medicaid program) we look forward to this new office helping to expand on our work to date and opportunities to transform our health care delivery system,” said Meghan Davey, the DHS division director who oversees Medicaid.

At the quality institute, Matthew D’Oria, a former deputy commissioner at the DHS, will lead the Medicaid reform work, along with Kate Shamszad, a former clinical director at Cincinnati Children’s Hospital Medical Center. The team will work in consultation with the state’s Medicaid innovation office helping government officials behind the scenes to implement shared strategies, D’Oria explained.

Medicaid covers more than 1.8M NJ residents
“We’re really trying to work in partnership with [the state] and not trying to duplicate efforts,” D’Oria said. While the quality institute program will continue to identify new strategies for improving the Medicaid system, most of its work will be focused on implementing existing plans, he explained, adding, “We want to help get to the finish line.”

After expanding significantly in recent years, New Jersey’s Medicaid program — also known as FamilyCare — covers more than 1.8 million residents, including roughly 40 percent of the state’s children. Funded by a mix of federal and state dollars, Medicaid is slated to cost $17 billion this year and absorbs nearly 20 percent of the state’s total spending, according to the quality institute.

For policy experts, the aim is to improve care while better controlling costs. To do so, Medicaid reform plans call for expanding preventive care and instituting best clinical practices, changes that many want to see applied to benefit maternity care in particular. (New Jersey has a comparatively high rate of maternal mortality, especially among black women.)

The quality institute identified dozens of opportunities for change in its Medicaid 2.0 report, published nearly two years ago with funding from Nicholson. As a blueprint for reform, the document recommended testing value-based payment models for maternity care and other services, greater integration of mental and physical health systems, and administrative efficiencies, like streamlining the credentialing process for doctors who participate in multiple Medicaid managed-care plans.

Some of the changes, recommended in that report and in other forums, have been implemented or are underway in the Garden State. The DHS has significantly expanded Medicaid coverage for preventive care — like smoking cessation, diabetes care and family planning — and also created a Medicaid data dashboard, a step toward greater transparency that is also a priority for reformers.

Changes made in other states
Other states, like Ohio, have institutionalized these quests for change by establishing healthcare or Medicaid transformation programs within the government structure. In New York, a charitable organization, the United Hospital Fund, formed the state Medicaid Institute in 2005 in an effort to build a more effective healthcare system for low-income residents.

Now New Jersey will join the ranks of these organized Medicaid reform efforts. The state’s innovation office demonstrates the administration’s commitment to long-term change and the use of evidence-based models for care, DHS said, and will also allow officials to identify new opportunities for improvements and savings.

“This new office will prove beneficial to consumers and providers alike,” said DHS’s Johnson. She said the department is “delighted” by the creation of the quality institute’s reform program, which she said, “will create opportunities for us to collaborate and advance the best health care outcomes.”

D’Oria explained that the quality institute’s center will assist the state with certain “administrative and infrastructure-type work,” like collaborating with insurance providers to iron out changes to managed-care contracts, or to set up new value-based payment programs. The state will always have the sign-off, he said, but the institute’s team can help with legwork — and quickly hire contractors to conduct key tasks, without going through the same complicated contracting process required for state agencies.

Linda Schwimmer, president and CEO of the quality institute — a collaborative effort involving healthcare providers, payers and other stakeholders — said the Medicaid center will also serve as a resource to private institutions. The institute recruited national healthcare leaders to serve as an advisory committee to the new program, including a vice president from the New York Medicaid Institute.

“Medicaid is a vital part of New Jersey’s healthcare safety net,” said Arturo Brito, Nicholson’s executive director. “By bringing to light the best policy ideas and research, the policy center will help New Jersey make the structural changes necessary to strengthen and sustain Medicaid for the future.”

Published on the Intelligencer.com

On Jan. 1, the U.S. Centers for Medicare and Medicaid Services began requiring all hospitals across the country to post machine-readable lists of their standard charges, also known as chargemasters, on their websites.

$106,744.84

That’s the difference between the top charge for the same thing at two area hospitals.

At St. Mary Medical Center in Middletown, the top charge for 200 milligrams or a 40 milliliter vial of ipilimumab, a monoclonal antibody used in the treatment of certain types of cancer, is $172,169. Across the Delaware River at Virtua Memorial Hospital in Mount Holly, New Jersey, the top charge for the same treatment is $278,913.84.

The difference is significant, but according to hospitals and groups that represent them, it also doesn’t mean much. That’s because they are standard charges and not typically what patients, insurance companies and others pay.

However, they are not meaningless, according to some experts.

On Jan. 1, the U.S. Centers for Medicare and Medicaid Services, also known as CMS, began requiring all hospitals across the country to post machine-readable lists of their standard charges, also known as chargemasters, on their websites. While the goal of the rule was to promote price transparency, some experts say the charges have mainly caused confusion.

“It’s the right idea but it’s just the wrong execution,” said Linda Schwimmer, president and CEO of the New Jersey Health Care Quality Institute, which advocates for quality, cost-containment and other changes in health care. “If the point was to tell people what they’re going to pay or what their insurance companies are going to pay, it really doesn’t give you any of that.”

CMS Administrator Seema Verma has acknowledged as much, and wrote in a November blog post that the rule is just a first step.

“We also need to drive towards consumer-friend tools presenting information that is both personal and actionable at the time people seek care,” she wrote. “We need to meet patients where they are and integrate cost information into their health care decision-making, making it easy for patients to analyze cost differences across all care options.”

CHARGES & COSTS

In response to the rule, more than a dozen area hospitals posted their chargemasters between mid-December and early January. Some are easier to find than others, commonly under links for patient information, and page titles like “Price Estimates” or “Financial Information.” Site searches for terms like “chargemaster” or “hospital charges” usually return the right result.

All area hospitals provide Excel files with hundreds or thousands of rows of technical descriptions of products and services and their charges. But along with the lists, most also provide definitions of terms like charges and costs, as well as disclaimers about the chargemasters.

“There can be variations, sometimes large ones, in the charges that hospitals set for the same item or service — even within the same health system. This is due to the many factors that go into determining the hospital’s cost of delivering those items and services. Some hospitals have higher cost structures due to the complexity and expense associated with the services they provide (such as trauma, transplant and neonatal intensive care services). Others have higher mission-related costs, such as teaching, research and providing care for low-income populations,” Jefferson Bucks (formerly Aria) Hospital’s page states.

“No one pays these specific charges, including uninsured patients and those who pay their own costs out-of-pocket. Medicare and virtually all other health insurance companies pay inpatient and outpatient costs based on various fee schedules, and their policies have different requirements for deductibles and co-payments or coinsurance,” Doylestown Hospital’s page states.

In light of the CMS rule, health care advocates and industry groups have encouraged hospitals to post such information as well as provide resources to help patients figure out their individual costs based on insurance coverage, income and other factors.

Most area hospitals already have such resources in place, including financial counselors who are available by phone or in person to go over patients’ insurance information and provide them with estimates.

“While we charge all patients the same, regardless of whether they have insurance or not, charges, by themselves, do not tell a patient what their personal liability will be for a service,” said Kim Roberts, vice president of revenue cycle at Abington-Jefferson Health.

For those with insurance, the health system estimates their financial responsibility based on their plan and out-of-pocket coverage, the hospital’s typical charges for the services, and the health system’s contract and expected payment from their insurance company.

“All of those three elements help to determine our best ‘estimate’ of the patient’s liability,” Roberts said.

For those who are uninsured, the health system will work with them to determine self-pay rates and whether they are eligible for financial assistance, as well as help them to get coverage.

St. Luke’s University Health Network also offers a PriceChecker tool online that allows people to search for tests, procedures and other services, then plug in their insurance information, and receive estimates as well as discounted cash prices.

Some area hospitals also linked to a video created by the Hospital and Healthsystem Association of Pennsylvania that explains the chargemasters and how to utilize the hospital resources as well as contact their insurers to figure out their individual costs.

In a December blog post about the rule, association President and CEO Andy Carter outlined similar information for patients.

Like Verma, he explained that chargemasters are an incomplete tool and simply give the total amount that a hospital can bill.

“The chargemaster shows a hospital’s ‘list prices,’” Carter wrote. “These charge rates represent standard or regular prices, not the actual — and typically much lower — payment rates that hospitals receive from health insurers, Medicare, and uninsured patients with low incomes.”

Michael Keen, chief financial officer for Grand View Health, said the West Rockhill hospital calculates charges based on purchase price, the time involved and resources utilized.

“We also consult any available sources of already established fee schedules with a department manager,” he said.

Other factors such as pharmaceutical costs and vendor pricing also can play a role in the charges. And Schwimmer noted that chargemasters don’t include charges for other providers or facilities that may be involved in procedures and services, however.

For example, a pregnancy in some places can cost between $9,000 and $16,000 and a C-section between $16,000 and $25,000, but there are a lot of providers, services, tests and other charges included in those amounts that wouldn’t be captured on chargemasters.

“It’s not a number that anybody pays and it’s not a complete number so it doesn’t really do much,” Schwimmer said.

Niall Brennan, president and CEO of Health Care Cost Institute in Washington, D.C., agreed that the charges, by themselves, aren’t helpful to people.

“Charges are arbitrarily high fantasy numbers produced by hospital accounting departments as all part of the cat-and-mouse game that exists between both public and commercial payers and hospitals,” he explained.

But based on her research, Ge Bai, an associate professor of accounting at the Johns Hopkins Carey Business School, said that’s a myth.

“Most hospitals say (it) is not relevant but it is in fact very relevant,” she said.

Especially for two groups: one includes patients covered by automobile, workers’ compensation and other non-traditional commercial health insurers, which typically have less negotiating power with hospitals. And the other includes patients with traditional commercial or private health insurance, such as what many employers offer.

“On the surface, (patients in the second group) are not affected by the chargemaster prices because the insurance plans are negotiating a price for us,” she said. “However, fundamentally, the chargemaster prices do play a large role in the price we pay. Higher chargemaster prices give hospitals leverage when they enter the negotiations.”

If insurance companies don’t agree to pay more for services, Bai explained, their members may not have in-network access to hospitals, and they may be balance billed based on the higher chargemaster prices.

“It’s a credible threat,” Bai said.

And, when insurance companies pay more for services, members ultimately pay more for things like premiums, she added.

Bai said patients with rare or complicated conditions also are affected by high chargemaster prices because there are fewer places for them to go and shop around.

“Due to the emergent nature of the episode or due to the complexity of the service, the patients don’t have options and they are more likely to face a high chargemaster price,” she said.

“(The chargemaster) is really a revenue-generating tool for hospitals.”

Medicare and Medicaid pay standard rates for services, so patients with those types of coverage are not affected, but Bai added that there are “definitely” others facing chargemaster prices, or close to them.

In a 2014 blog post, former New Jersey Hospital Association president and CEO Betsy Ryan wrote that at the time about 4.5 percent of the state’s hospital patients, most of whom were uninsured, were being charged the prices.

Most uninsured patients in New Jersey are protected, however, by a state law passed in 2009 that prohibits hospitals from charging those who earn below 500 percent of the federal poverty level more than 115 percent of Medicare rates.

“Yes, it’s complicated, and we admit that hospital charges don’t make much sense,” Ryan wrote. “No one actually designed this system; it just evolved over time as hospitals tried to adapt and survive in our broken reimbursement system.”

PRICE & TRANSPARENCY

No area hospitals reported an increase in calls from people about the charges since they’ve been posted on their websites, but chargemasters have been publicly available, and a source of confusion, for years.

“There’s no doubt that hospital charging, physician charging, is confusing to the end user,” said Doug Hughes, chief strategy officer for Grand View.

“Unfortunately, every scenario is different,” Hughes said.

There are a lot of questions that have to be answered, the first being about insurance.

“Is your deductible paid up for that year? Are you in an in-network hospital or an out-of-network hospital?” Hughes continued.

Throughout his career in health care, Hughes has seen copays and deductibles go up, and recently there’s been a greater shift in costs onto patients. It’s also resulted in a rise in people’s interest in charges and costs.

“Suddenly that factor means so much more now because you’re sharing some of that expense,” Hughes said.

Schwimmer agreed.

“If people are paying more, or if they’re going to have a (health savings account), they really have to have a sense of what they’re in for in terms of what they’re going to pay,” Schwimmer said.

In 2018, nearly half of people under age 65 who had private health insurance were enrolled in a high-deductible plan without a health savings account, according to an August report from the U.S. Centers for Disease Control and Prevention’s National Center for Health Statistics.

The percentage increased more than 21 percent since 2010. And over the same time period, the percentage of people under 65 who were enrolled in a similar type of high-deductible health plan with a health savings account nearly tripled, according to the report.

That’s one of the reasons CMS passed the rule and is taking further steps toward price transparency, according to Verma.

“The case for price transparency throughout the health care system is clear, and the need to shop is growing ever more compelling as high-deductible plans become the norm,” she wrote in the November blog post.

The chargemasters rule may not go far enough, but it is reigniting the conversation about price transparency, Schwimmer said.

“If (the chargemasters rule) is where the conversation ends or if the execution means let’s give up on price transparency, then it’s a failure. But I don’t think that’s the way it’s going to go because there’s enough voices saying … let’s look at transparency and discuss it and see where transparency can lead,” she said.

Carter, of the Hospital and Healthsystem Association of Pennsylvania, agreed.

“This mandate and the public discussion it will likely engender does indeed have the potential to foster a better understanding of what useful health care price transparency might look like — if policymakers, the media, and consumers can agree on some basic realities of how we in America pay for our health care,” he wrote in the December blog post.

He added that it will take time, effort and collaboration.

“Let’s start by developing a common understanding of concepts like hospital charges as compared to hospital payments and what consumers pay out of pocket for health care, as determined by their health plans,” he wrote.

The need for price transparency has led to startups and sites like the Health Care Cost Institute’s Guroo, which allows people to search for services and find bundled costs for their area.

It gives people more power over their health care decisions, but it’s indicative of a broader issue, Brennan said.

“The first thing consumers should do is take a step back and ask why they, as the weakest actor in the health care system, are suddenly having the important decisions of pricing and choices of where to go foisted upon them,” he said. “While I’m in support of transparency and more consumer empowerment, it is indicative of how badly payers and providers have failed to adequately address rising costs.”

He added that not every service is shoppable.

“If you get hit by a car the last thing you want to do in the back of an ambulance is whip out your phone and figure out who has the best rates for car trauma,” Brennan said.

It’s not all just about the cost, but that’s another, broader issue, Brennan said.

“Most people would say you shouldn’t base your decisions purely on cost and you should base them on cost and quality, but I think we’ve struggled to present consumer-friendly information about that cost/quality continuum,” Brennan said.

Schwimmer agreed. There’s a lot of quality information out there, but not as much as is needed, and there’s a disconnect with cost.

“Just because something is the highest cost place doesn’t mean it’s better in terms of quality, and the other way as well,” she said. “It’s so murky, this is not in anyway a transparent, free market.”

It’s something CMS also wants to move toward improving, according to Verma.

“Putting patients in the driver’s seat means we also need to integrate quality information with price transparency,” she wrote. “Once consumers can see the whole picture, they will be truly empowered to seek out high value care among providers competing on both cost and quality.”

Published in Philadelphia Business Journal.com

The number of area hospitals reporting safety and outcome data to the Leapfrog Group continued to climb last year to a new record level.

Thirty hospitals — out of a possible 55 — in southeastern Pennsylvania and Delaware submitted survey data, according to the Greater Philadelphia Business Coalition of Health. The GPBCH serves as a Leapfrog regional roll-out organization in a partnership with the Delaware Valley Health Care Coalition.

The information is collected by the Leapfrog Group, a independent group of employers and health experts working together to improve health care quality and efficiency, to enable people and business to make more informed purchases of health care services.

Neil Goldfarb, President and CEO of the GPBCH, said the number of Philadelphia-area hospitals that submitted surveys last year represents a 10-fold increase since the coalition first began advocating 2012.

Just three hospitals participated in the survey three years ago.

“Over the last four years, we have been able to make considerable impact on the number of hospitals reporting their data to the Leapfrog Survey because [the coalition] has employer members that represent more 750,000 lives in this region,” Goldfarb said. “That is a significant portion of the population who utilize our region’s hospitals.”

Nationwide, 1,750 out of 2,500 hospitals completed the Leapfrog Hospital Survey in 2015, a 17% increase over 2014.

Here’s the list of local hospitals that submitted surveys in 2015:

Abington Health Lansdale Hospital and Abington Memorial Hospital;
Alfred I. duPont Hospital for Children;
Aria Health – Bucks County, Frankford and Torresdale divisions;
Beebe Healthcare;
Cancer Treatment Centers of America at Eastern Regional Medical Center;
Christiana Care Health System – Christiana Hospital, Wilmington Hospital;
Crozer Keystone Health System – Crozer Chester Medical Center, Delaware County Memorial Hospital, Springfield Hospital, Taylor Hospital;
Doylestown Hospital;
Grand View Hospita;l
Hahnemann University Hospital;
Jeanes Hospital;
Lower Bucks Hospital;
Mercy Health System – Mercy Fitzgerald Hospital, Mercy Suburban Hospital, Nazareth Hospital, Mercy Philadelphia Hospital;
Nanticoke Memorial Hospital;
Roxborough Memorial Hospital;
St. Christopher’s Hospital for Children;
St. Mary Medical Center;
Temple University Hospital; and
Thomas Jefferson University Hospital – Center City and Methodist Hospital campuses.

Under the “regional roll-out” efforts of the New Jersey Health Care Quality Institute, the following 14 hospitals in South Jersey – out of 17 total – submitted surveys:

Cape Regional Medical Center;
Cooper University Health Care;
Inspira Medical Center – Elmer, Vineland, and Woodbury campuses;
Kennedy University Hospital – Cherry Hill, Stratford, and Washington Township hospitals;
Our Lady of Lourdes Medical Center and Lourdes Medical Center of Burlington;
Shore Medical Center; and
Virtua Hospital – Virtua Memorial Hospital, and Marlton and Voorhees campuses.

Published on NJBiz.com

The New Jersey Health Care Quality Institute, based in Princeton, announced on Thursday that it has launched a new policy center committed to advancing the quality and cost-effectiveness of the state’s Medicaid program.

According to Linda Schwimmer, president and chief executive officer of NJHCQI, The Medicaid Policy Center will deliver independent research, analysis and policy solutions to improve health outcomes while also controlling costs. It will also work in partnership with other organizations and the state government agencies that operate the New Jersey Medicaid program, including the Department of Human Services – Office of Medicaid Innovation.

The MPC is funded by a grant from The Nicholson Foundation.

Quality Institute staff members Matt D’Oria, a former New Jersey Deputy Health Commissioner, and Kate Shamszad, who served as clinical director of Child Life and Integrative Care at Cincinnati Children’s Hospital Medical Center, will lead the center.

“The Medicaid program is essential to so many children, seniors and families in our state, and it’s a significant part of the state budget,” D’Oria said. “We are eager to support state decision makers and state officials as they work to improve the state’s Medicaid program for people today — and also to strengthen the program for the future.”

The new DHS office will provide a platform for collaboration with the MPC to improve the quality, delivery, and cost of care. Common focus areas include developing “alternative payment models and purchasing strategies that drive improvement in patient outcomes,” according to Schwimmer.

“The Department is delighted that the New Jersey Health Care Quality Institute, with support from The Nicholson Foundation, is creating a dedicated Medicaid Policy Center to help bring together thought leaders and expertise to inform our shared goal of strengthening and improving the quality and value of New Jersey’s Medicaid program,” said New Jersey Human Services Commissioner Carole Johnson, in a statement.

According to NJHCQI, New Jersey’s Medicaid program has a $17 billion annual budget, financed by Federal and State government, and accounts for nearly 20 percent of New Jersey’s state budget. To improve the program, the MPC will research health care delivery innovations, including patient-centered models that support and reward providers for good outcomes.