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Editor’s note: Comments from the American Medical Association were added to the original article.

The patients underwent elective surgery with primary surgeons and in facilities that were in their private insurer’s network. Yet, one in five got a surprise bill after their procedure for out-of-network services, according to a new study.

The patients were left with an average potential balance of $2,011, according to the JAMA study released today.

Case Study

Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

See how

As politicians in Washington look at how to address the problem of surprise bills, researchers examined claims data from a large health insurer to examine how often patients unexpectedly received out-of-network bills after having in-network elective surgery. In 20% of the surgeries, patients received out-of-network charges, the study found.

Members of Congress have been grappling with ways to end surprise medical bills. The House Ways & Means Committee on Friday released largely provider-friendly legislation as a bid to end an impasse over how to handle surprise billing with a proposal to use a “mediation” process to handle disputes.

In the study, most commonly, the out-of-network bills occurred when patients received care from anesthesiologists and surgical assistants who were not part of their insurance network, which happened in 37% of the cases where patients received a surprise bill, the study found.

In cases where a surgical assistant was not in the insurance network, patients faced an average potential bill of $3,633. With out-of-network bills that resulted from the anesthesiologist being out of the patient’s network, the average potential bill was $1,219, the study found.

The analysis included almost 350,000 commercially insured patients who underwent one of seven common elective surgeries at in-network facilities with in-network primary surgeons between 2012 and 2017. Researchers said one limitation of their study was that the claims data came from only on insurer.

Patients had a greater risk of receiving an out-of-network bill when they were members of a health insurance exchange plan. Risks were also significantly higher when there were surgical complications, the study found.

In an accompanying editorial, JAMA editors said it’s time to stop surprise medical bills, which they described as “both common and potentially financially devastating.”

“Such billing practices are particularly pernicious because patients usually have no knowledge that they will occur, and no way to avoid them,” wrote Karen E. Joynt Maddox, M.D., of the Washington University School of Medicine and associate editor of JAMA, and Edward Livingston, M.D., deputy editor at JAMA.

It’s up to both clinicians and policymakers to act to end surprise billing, they said, arguing that surgeons have an ethical responsibility to speak out.

“When feasible, surgeons should ensure that all the personnel involved in the care team that they are leading accept the same insurance plans and should consider refusing to work in facilities that allow surprise billing,” they wrote.

The American Medical Association, the country’s largest physician organization, Tuesday came out in support of the bipartisan efforts of the House Ways and Means Committee to craft legislation to protect patients from surprise medical bills.

The legislation creates a two-step process for resolving disputes over reimbursement, first through a 30-day negotiation process that encourages parties to resolve their differences before using a mediation process administered by a third party.

“We support the underlying mechanism for resolving these disputes, including the eligibility of all disputed claims for negotiation and mediation. We also appreciate that the mediator must consider a wide range of supporting information submitted by physicians in rendering a final determination,” said Patrice A. Harris, M.D., AMA president, in a statement.

Harris said the AMA plans to work with the committee and others to refine the legislation so it is fair to everyone involved.

While hospitals and physicians support the legislation, payers have pushed to link out-of-network payments to a benchmark rate, rather than the arbitration process favored by providers.

Small physician-led Accountable Care Organizations (ACOs) have shown success in reducing costs while improving quality. But they need more support to continue down that road, according to a new report.

Those ACOs would benefit from more guidance and support from the Centers for Medicare & Medicaid Services (CMS), private insurers and other sources as they take on greater financial risk and move farther away from traditional fee-for-service payments, according to a new report (PDF) from the Duke-Margolis Center for Health Policy.

Case Study

Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

See how

“ACOs, especially smaller ones and those in more resource-deprived settings, need additional support in building the organizational competencies (such as clinical care redesign and forecasting costs) to take on increased risk,” authors of the report, who conducted interviews with ACO leaders, concluded.

ACO leaders interviewed by researchers have concerns about meeting the new requirements of Medicare’s “Pathways to Success” program that shifts financial risk from CMS to ACOs more quickly, the report indicated. 

“By asking physician-led ACOs to take on more financial risk, CMS is trying to encourage better care at a lower cost,” said Robert Saunders, research director for payment and delivery reform at Duke-Margolis. “Transitioning to new payment models is always challenging, and CMS should do all it can to support smaller physician groups in joining effective ACOs at this pivotal time or risk their longer-term sustainability.”

Some of the challenges faced by small physician-led ACOS in taking on more risk include the structure of their ACO contracts—including the cost benchmark they are expected to improve on, their limited capital reserves and their need for advance investment and technical assistance, the report said.

The report noted that many small physician-led ACOs are partnering with third-party companies, what they called “ACO enablers,” such as Aledade, Caravan, Evolent and others, to access needed upfront capital and additional services to help them participate in risk-bearing models.

Others have dropped out of ACO programs at high rates in recent years, the report said.

CMS is pushing ACOs to more quickly transition to downside risk under its Medicare Shared Savings Program, or in new ACO-type programs, such as the Direct Contracting program or complementary programs, such as the Primary Care First program.

The report, which was prepared with funding from the Robert Wood Johnson Foundation, recommended three steps CMS can take to assist these ACOs:

  • Reduce regulatory burdens. For instance, ACO leaders interviewed by researchers said that regulations such as the Stark Law and Anti-Kickback Statutes limited their ability to coordinate and manage care effectively. CMS has proposed changes to both rules to provide greater flexibility for organizations in value-based payment arrangements
     
  • Provide more support for ACOs to develop technical capabilities. The report said CMS can identify and share successful strategies used by ACOs to improve the cost and quality of healthcare.
     
  • Simplify program rules. ACO leaders expressed difficulty keeping up with changing policies and priorities, the report said. Smaller organizations will be more likely to participate in new tracks or programs when the rules are certain and simpler to understand.

When Carol Pak-Teng, M.D., an emergency room doctor in New Jersey, hosted a fundraiser in December for Democratic freshman Rep. Tom Malinowski, her guests, mostly doctors, were pleased when she steered the conversation to surprise medical bills.

This was a chance to send a message to Washington that any surprise billing legislation should protect doctors’ incomes in their battle over payments with insurers. Lawmakers are grappling over several approaches to curtail the practice, which can leave patients on the hook for huge medical bills, even if they have insurance.

As Congress begins its 2020 legislative session, there is evidence the doctors’ message has been received: The bills with the most momentum are making more and more concessions to physicians.

Case Study

Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

See how

As surprise medical billing has emerged as a hot-button issue for voters, doctors, hospitals and insurers have been lobbying to protect their own money flows. All that lobbying meant nothing got passed last year.

Television and internet ads are the most visible manifestation of the battle. But in taking their cause to politicians, doctors like Pak-Teng have waged an extraordinary on-the-ground stealth campaign to win over members of Congress. Their professional credentials give them a kind of gravitas compared with other lobbyists, who are merely hired guns.

Ending the practice of billing patients for the amount of their treatment not covered by insurance—sometimes triggered by unwittingly seeing a doctor out of network—is ultimately a fight between doctors and insurers over rate-setting and reimbursement. But as more patients balk at surprise bills—or suffer the enormous financial strain—lawmakers are under pressure to protect patients. In turn, powerful lobbying forces have activated to protect doctors and insurers who don’t want to pay the price for a fix.

The main message physicians are using to bring lawmakers into their corner? “We just want to be paid a fair amount for the services rendered,” Pak-Teng said.

Her congressman, Malinowski, has not endorsed any surprise billing legislation. In congressional testimony in July, he cited the “extra $420 million” in medical debt patients in New Jersey reckon with each year.

“There are many things that Republicans and Democrats sincerely disagree about in this body,” he said. “I don’t think that this is one of them. I don’t see any philosophical difference amongst us about whether people should be stuck with massive surprise medical bills.”

Doctors say they are taking the brunt of the criticism.

But little has been as powerful in shaping surprise billing legislation as the clout of hospitals and their doctors, many of whom are, in fact, employed by private equity-backed companies and armed with years of experience shaping surprise billing legislation at the state level.

 

They are throwing in a lot of money, too, funneling millions to lawmakers ahead of the 2020 elections. Four physician organizations that have heavily lobbied on surprise medical bills and have private equity ties—the American College of Emergency Physicians, Envision Healthcare, US Acute Care Solutions and U.S. Anesthesia Partners—gave roughly $1.1 million in 2019 to members of Congress, according to a Kaiser Health News analysis of Federal Election Commission records.

The biggest recipients, from all four PACs combined, were Reps. Donna Shalala and Stephanie Murphy, Florida Democrats who got $26,000 each. Sen. Thom Tillis (R-N.C.) took in $25,500, Senate Majority Leader Mitch McConnell got $25,000, and Rep. Brett Guthrie (R-Ky.) received $22,500.

That was in tandem with a ground game led by local doctors. ER doctors, anesthesiologists, radiologists and other specialists who most often charge out-of-network prices—and also are among the highest-compensated practitioners—fanned out to shape legislation in a way that maintains their pay, and to voice their concern to lawmakers that insurance companies would have too much leverage to control their compensation.

“We by necessity place a tremendous amount of trust in our physicians,” said Zack Cooper, an assistant professor at Yale University who has extensively researched surprise medical bills. “Frankly, they have an easier time lobbying members [of Congress] than the folks who are affected by surprise billing.”

Arguing over the fix

Lawmakers in both parties appear unified on the need to resolve the problem of surprise billing. But as was clear when all the air blew out of legislative proposals on the table at year’s end, that is largely where the agreement ends.

Fixing the problem comes down to settling on a system for deciding how much to pay for a disputed bill. One approach is to set up an outside arbitration process, in which doctors and insurance companies would negotiate payment—this is the model preferred by doctors, who contend it puts them on better footing against insurance companies. Another option would be to resolve surprise billing disputes by having insurance companies pay doctors based on the median in-network rate for the service, an approach known as benchmarking. Large employers, labor unions and insurance companies prefer this.

The failure to get legislation through Congress set up a potentially explosive battle in an election year. Republicans and Democrats who have vowed to do something about healthcare costs must reckon with powerful industry groups whose influence transcends party lines.

Meanwhile, physicians and hospitals have made their case in Washington and back home through in-person meetings and phone calls with lawmakers and congressional staff. They’ve hosted dinners and fundraisers and organized fly-ins to swarm Capitol Hill with in-person meetings. They’ve even led tours of their emergency rooms.

Pak-Teng is among them, coming to Washington this month with other physicians to petition lawmakers. She is employed by Envision, a physician staffing company backed by private equity firm KKR. She’s also on the board of the American Academy of Emergency Medicine, a trade organization representing ER doctors.

“There is a lot of anti-physician rhetoric out there,” said Pak-Teng, who is pushing her physician colleagues to be more active in shaping public policy by sharing stories about the reality of caring for patients.

The lobbying by hospitals and physicians trying to protect their reimbursements has divided key lawmakers, compounding disagreements among senior House Democrats over the policy details of a bill and turf wars in Congress. Three House committees have now unveiled legislation to ban surprise medical bills, each with different details.

“We are not trying to stop legislation. We are trying to stop bad legislation,” said Anthony Cirillo, M.D., an emergency medicine physician who describes a “bad” bill as one that favors insurance companies over doctors.

Cirillo is also a lobbyist for US Acute Care Solutions, a physician staffing company backed by private equity firm Welsh, Carson, Anderson & Stowe. WCAS, which manages $27 billion in assets and is focused on healthcare and technology investments, is based in New York City and co-founded US Acute Care Solutions in 2015.

In an interview, Cirillo said he met with lawmakers and their aides about “10 to 12 times” in Washington last year. Financial disclosures show he spent $340,000 between July and September lobbying on surprise billing on behalf of US Acute Care Solutions. USACS’ political committee also contributed $134,500 to lawmakers in 2019, according to FEC records.

Tilt toward doctors

Before the private equity-fueled dark-money group Doctor Patient Unity started running ads warning of the dangers of government price controls as an argument against legislation, surprise billing legislation being drafted in one of Congress’ most powerful healthcare committees was already tilting to be more favorable to doctors.

“People on the Hill are very sympathetic to hospitals and physicians because they’re actually providing the care itself,” said one Democratic aide, speaking on the condition of anonymity to candidly describe sensitive political dynamics. “Nobody wants to defend the insurers.”

In May, a House Energy and Commerce Committee draft proposal included no mention of outside arbitration. The same was true for a bill the Senate Health, Education, Labor and Pensions Committee approved in June. Instead, under those proposals, surprise billing disputes would be resolved by insurance companies paying doctors based on similar rates in that area.

By mid-July, though—roughly a week before Doctor Patient Unity registered as a business in Virginia—the Energy and Commerce legislation was amended to allow doctors to appeal to an independent arbiter if their payments exceed $1,250. The revision was pushed by two physicians on the committee—Democrat Raul Ruiz, M.D., of California and Republican Larry Bucshon, M.D., of Indiana—and was a moment Sherif Zaafran, M.D., a Texas anesthesiologist, describes as a “turning point” in negotiations over the bill.

“It’s all about fairness,” said Zaafran, who works for private equity-backed U.S. Anesthesia Partners. He has been involved for a decade in surprise billing fights in Texas, which enacted a new law with an arbitration process last year. U.S. Anesthesia Partners gave $197,900 in campaign contributions to members of Congress last year.

Zaafran chaired another coalition of medical specialists, Physicians for Fair Coverage, in 2019, and pressured Congress to pursue a surprise billing approach modeled on a New York law under which insurers and providers rely on arbitration. Under that process, if there is a payment dispute between doctors and insurers, the two sides submit a proposed dollar amount to an independent mediator, who then selects one.

In New York, the mediators were told to base their decisions on the 80th percentile of the prices set by the hospital or physician. Research has suggested that the model is broadly making healthcare more expensive for state residents because of higher payments to doctors, according to findings from the USC-Brookings Schaeffer Initiative for Health Policy.

Still, on Capitol Hill, doctors complained that many procedures would fail to cost enough to qualify for arbitration as proposed in the Energy and Commerce bill, bolstered by data ER doctors presented to lawmakers showing that prices mainly fall below $1,250.

“It’s largely out of reach,” said Laura Wooster, a lobbyist with the American College of Emergency Physicians, whose political action committee contributed $708,000 to lawmakers in 2019. “The problem with a threshold is, you just have one threshold. It’s going to impact different specialties so differently.”

By December, House Energy and Commerce Committee leaders and Sen. Lamar Alexander, a Republican who chairs the Senate HELP Committee, agreed to lower the arbitration threshold to $750 as part of a bipartisan agreement on a bill. Notably, several hospital lobbying organizations, such as the American Hospital Association and the Greater New York Hospital Association—the latter a strong financial backer of Senate Minority Leader Chuck Schumer—refused to back the deal.

Pak-Teng and other physicians also say that arbitration threshold is still too high. The House Education and Labor Committee has unveiled surprise billing legislation with a similar framework.

“I’m open to listening to all sides on this,” Rep. Greg Walden of Oregon, the top Republican on the House Energy and Commerce Committee, said in an interview. “We want to make sure doctors are adequately compensated.”

Walden had harsh words for private equity firms that have attacked the Energy and Commerce legislation in a series of TV and internet ads, saying they were “misleading and scaring people” and just made lawmakers dig in deeper. The ads prompted a bipartisan probe from Walden and committee Chairman Frank Pallone (D-N.J.) into how the companies have influenced surprise billing practices.

“I’m not trying to hurtle a rock at them, but they’ve been throwing a few my way,” he said.

What’s coming

Arvind Venkat, M.D., a Pittsburgh emergency physician employed by US Acute Care Solutions, traveled to Washington multiple times last year to meet with congressional offices representing Pennsylvania. But he also made sure to bring up surprise bills on his home turf, giving his congressman, freshman Democrat Conor Lamb, a tour of the emergency room at Allegheny General Hospital last summer.

“There are two issues here,” said Venkat, who leads the Pennsylvania chapter of the American College of Emergency Physicians and has practiced at Allegheny General for 12 years. “Patients need to be protected, [and] we need to avoid anything that disrupts in-network relationships between insurers and clinicians.”

The call seems to have been heard: Legislation is likely to change further this year as the House Ways and Means Committee pushes an approach that is friendlier to hospitals and doctors. It builds off a one-page document committee leaders issued Dec. 11 that blunted momentum for a bipartisan deal that was to be included in a December spending bill.

The latest proposal from the committee includes an arbitration process to resolve payment disputes, with no minimum dollar amount needed to trigger it, and doesn’t ban surprise billing from air ambulance companies—a win for yet another special-interest lobbying group. The patient protections would not take effect until 2022.

Richard Neal, a Massachusetts Democrat who chairs the committee, remains an ally of Massachusetts hospitals. He released the brief December surprise billing document two days after the Massachusetts Medical Society and Massachusetts Hospital Association wrote a joint op-ed in The Boston Globe arguing that benchmarking physician payments—as the Senate HELP and Energy and Commerce deal would do—would wreck the state’s healthcare system.

“The heavy hand of government would create an unfair imbalance in the healthcare marketplace and insurers would have no incentive to engage physicians in building robust healthcare networks. The connected system of care we have all been working toward in Massachusetts would immediately become fragmented and disjointed,” the two groups wrote in The Boston Globe.

“They weren’t asking for favorable treatment. They were asking for fair treatment, and there’s a big difference,” Neal said in an interview. “I don’t want to rule anything out, but I think that the momentum right now is arbitration.”

“We need to get a little bit more balance,” added Shalala, who endorsed the Ways and Means legislation unveiled earlier this month.

Shalala has at least two hospitals in her Miami-area district that rely on private equity-supported physician staffing companies.

“I’m worried about the hospitals,” she said. “And the providers obviously include the docs.”

Victoria Knight contributed to this story.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

Small physician-led Accountable Care Organizations (ACOs) have shown success in reducing costs while improving quality. But they need more support to continue down that road, according to a new report.

Those ACOs would benefit from more guidance and support from the Centers for Medicare & Medicaid Services (CMS), private insurers and other sources as they take on greater financial risk and move farther away from traditional fee-for-service payments, according to a new report (PDF) from the Duke-Margolis Center for Health Policy.

Case Study

Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

See how

“ACOs, especially smaller ones and those in more resource-deprived settings, need additional support in building the organizational competencies (such as clinical care redesign and forecasting costs) to take on increased risk,” authors of the report, who conducted interviews with ACO leaders, concluded.

ACO leaders interviewed by researchers have concerns about meeting the new requirements of Medicare’s “Pathways to Success” program that shifts financial risk from CMS to ACOs more quickly, the report indicated. 

“By asking physician-led ACOs to take on more financial risk, CMS is trying to encourage better care at a lower cost,” said Robert Saunders, research director for payment and delivery reform at Duke-Margolis. “Transitioning to new payment models is always challenging, and CMS should do all it can to support smaller physician groups in joining effective ACOs at this pivotal time or risk their longer-term sustainability.”

Some of the challenges faced by small physician-led ACOS in taking on more risk include the structure of their ACO contracts—including the cost benchmark they are expected to improve on, their limited capital reserves and their need for advance investment and technical assistance, the report said.

The report noted that many small physician-led ACOs are partnering with third-party companies, what they called “ACO enablers,” such as Aledade, Caravan, Evolent and others, to access needed upfront capital and additional services to help them participate in risk-bearing models.

Others have dropped out of ACO programs at high rates in recent years, the report said.

CMS is pushing ACOs to more quickly transition to downside risk under its Medicare Shared Savings Program, or in new ACO-type programs, such as the Direct Contracting program or complementary programs, such as the Primary Care First program.

The report, which was prepared with funding from the Robert Wood Johnson Foundation, recommended three steps CMS can take to assist these ACOs:

  • Reduce regulatory burdens. For instance, ACO leaders interviewed by researchers said that regulations such as the Stark Law and Anti-Kickback Statutes limited their ability to coordinate and manage care effectively. CMS has proposed changes to both rules to provide greater flexibility for organizations in value-based payment arrangements
     
  • Provide more support for ACOs to develop technical capabilities. The report said CMS can identify and share successful strategies used by ACOs to improve the cost and quality of healthcare.
     
  • Simplify program rules. ACO leaders expressed difficulty keeping up with changing policies and priorities, the report said. Smaller organizations will be more likely to participate in new tracks or programs when the rules are certain and simpler to understand.

When it opened its first center in Chicago in 2013, Oak Street Health wanted to show that its model of providing value-based primary care to seniors could work.

It’s doing just that, as the network of primary care centers announced today that it will open clinics in two more states this year—Texas and Tennessee.

“Our mission is to rebuild healthcare as it should be,” Oak Street’s CEO Mike Pykosz told FierceHealthcare. It’s a job the company has done by bringing primary care to seniors in underserved areas, improving patients’ health and their healthcare experience.

Case Study

Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

See how

“We can generate phenomenal results. The challenge for us and our team is to do that in a lot of places, for a lot more patients and really transform healthcare,” said Pykosz, one of Oak Street’s founders.

Mike Pykosz
(Oak Street Health)

The health organization will now operate in nine states with more than 50 centers that serve about 70,000 Medicare patients.

It’s entry into two southern markets—it will open two locations in Memphis within the Frayser and Audubon Park neighborhoods this winter followed by a center in the Dallas-Fort Worth area this summer—caps a year of growth for the healthcare startup.

It also plans to expand in states where it already has clinics. It plans a fourth center in Cleveland, three new centers in Detroit and a second location in the Greensboro-High Point metro area of North Carolina—all expected to open in late spring.

In Rhode Island, a second center in South Providence celebrated its grand opening in a partnership with Blue Cross Blue Shield earlier this month.

It also has clinics in Illinois, Indiana and Pennsylvania, with plans to continue its geographic expansion in 2020.

That growth will significantly increase access to Oak Street Health’s innovative approach to primary care for older adults across the country, the company said.

Getting going

The first several years of operation at Oak Street were about proving its primary care model and approach would work, Pykosz said. “We had some pretty big ideas,” he said. That included opening up primary care centers in underserved areas, investing to keep patients healthy, creating a much more consumer-centric model and paying for those investments by taking full risk. By driving improved health outcomes, Oak Street believed it could become a national model for healthcare.

The next phase is to expand and bring that model to a lot more people. “We’re not moving the needle yet on healthcare,” he said about the problems of low quality and high cost that plague the healthcare system. “This is just the beginning.”

Oak Street Health measures its success in two key ways: by showing improved health outcomes of its patients and by improving the patient experience. “Are patients healthier?” Pykosz said.

Oak Street has seen patient hospitalizations reduced by 41%, compared to standard Medicare benchmark, and measured a 49% percent reduction in emergency room visits. Oak Street has an 89% Net Promoter Score used to guage the loyalty of its patients and their satisfaction with care.

Oak Street has funded its expansion by raising capital from a variety of different individual and institutional investors, he said. Securities and Exchange Commission filings show they’ve raised at least $200 million over six funding rounds. It’s investors include General Atlantic and Harbour Point Capital.

As the country tries to shift to value-based care, Oak Street has made national headlines as it offers a change from traditional fee-for-service healthcare.

“Our centers don’t look like doctor’s offices,” he said. They are not located in medical office buildings, but are in retail areas, all with a 1,000-square-foot community center in the front.

Patients who visit an Oak Street Health center will have a healthcare experience they may not have encountered before, the company says. Patients can expect extended time with their clinicians and individualized treatment plans. There’s community-centered support for social wellness, a 24/7 patient support line and access to transportation to and from the center for eligible patients. To create a one-stop shop for healthcare, Oak Health also offers supplementary services, such as behavioral health support and Medicare education classes.

Two-thirds of every dollar the government spends on Medicare goes toward paying for acute care episodes, Pykosz said. Only 3% of those dollars go to primary, preventive care or preventing bad things from happening to patients. “We feel like that is backward,” he said. “That is what we are trying to change.”

“We are at a place at Oak Street, where the model works. The quality of care and the patient experience are significantly better than what patients can find in other places. Not only does it work in our home market of Chicago, it’s worked in all the other major cities like Philadelphia, Detroit, Indianapolis,” he said.

In lawsuits around the U.S. that blame major pharmacy chains, such as Walgreens and CVS, for the country’s opioid crisis, the healthcare giants appear to be following a similar legal strategy: Blame the doctors instead.

In Florida earlier this month, Walgreens and CVS filed a third-party complaint that says that 500 anonymous physicians—Dr. John and Jane Doe—are responsible for fueling that state’s opioid epidemic, not the pharmacists who filled the opioid prescriptions.

It comes after a group of major pharmacy chains that included CVS and Walgreens, filed legal action in an Ohio court in January to shift the responsibility to physicians in a major federal opioid trial that claims the large companies are culpable for prescribing the drugs that have fueled the opioid crisis.

Case Study

Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

See how

In those filings, the pharmacy chains, which also included Walmart, Rite Aid, HBC and Discount Drug Mart, said it was actually hundreds of Ohio physicians and other healthcare practitioners who write the prescriptions that bear the blame for providing opioids to patients—not the pharmacists who filled those prescriptions.

Florida’s Attorney General Ashley Moody was having none of that legal argument. “This stunt is simply a tone-deaf distraction by two of the wrongdoers in the national opioid crisis that is claiming 15 lives in Florida every single day,” Moody said in a statement.

She filed a motion to strike or sever the third-party complaint (PDF) filed by CVS Pharmacy Inc. and the Walgreen Company, pharmacy retailers who were named as co-defendants in a suit brought by the Attorney General’s office against Purdue Pharma, the maker of OxyContin, and other manufacturers, distributors and chain pharmacies. 

In her motion to throw out the third-party complaint in Florida, Moody said CVS and Walgreens have records that include the names of the doctors who wrote the opioid prescriptions, “Yet, CVS and Walgreens have not named a single prescriber and, instead, have filed this pleading against 500 John and Jane Doe defendants,” she wrote. “Our complaint alleges that these national pharmacies are responsible for knowingly flooding Florida with billions of dangerous and addictive pills all while the opioid crisis continued to spiral out of control.”

Like several other states seeking to recoup millions of dollars spent battling the costly opioid epidemic, Florida filed a lawsuit in 2018 that named the two retail pharmacy giants as defendants.

The defendants should have known they were fueling an opioid epidemic, the lawsuit said. A Walgreen’s drug distribution center sent 2.2 million opioid tablets to a single pharmacy in tiny Hudson, Florida, in 2011 a roughly six-month supply for each of its 12,000 residents, the lawsuit said. CVS distributed more than 700 million opioid doses in Florida between 2006 and 2014, it said.

In response, Walgreens and CVS filed a third-party complaint in January saying they are not liable for the opioid crisis and asking the court to focus on the physicians who prescribe the drugs.

“Pharmacists do not write prescriptions and do not decide for doctors which medications are appropriate to treat their patients,” the complaint says. “While pharmacists are highly trained and licensed professionals, they did not attend medical school and are not trained as physicians. They do not examine or diagnose patients. They do not write prescriptions.”

U.S. physicians aren’t confident about the country’s preparedness to cope with the novel coronavirus as they are put their own protocols in place for potentially infected patients.

The survey of 150 doctors found only 9% feel confident they could identify a patient who has contracted what is now known as COVID-19, the novel respiratory illness with flu-like systems that originated in Wuhan, China, according to a new survey from InCrowd.

Just one in four physicians feels very prepared to treat a patient that has potentially contracted COVID-19.

Case Study

Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

See how

Of the government response to COVID-19, only one in three respondents agrees that the U.S. is taking strong precautions to prevent the spread of the illness. Nearly half (45%) agree that the World Health Organization and governments outside of the U.S. are taking strong precautions to prevent the spread of the disease.

So far, 14 people in the U.S. have been confirmed to have the 2019 novel coronavirus, according to the Centers for Disease Control and Prevention (CDC). The latest patient is among a group of people quarantined in California after returning on a State Department-chartered flight from China.

Coronavirus has been blamed for 1,367 deaths worldwide, all but two recorded in mainland China, which has been the center of the outbreak, according to USA Today. The total number of confirmed cases has spiked to over 60,000.

InCrowd surveyed emergency medicine or critical care specialists, pediatricians and primary care physicians about COVID-19 between January 31 and February 4 and found most report a lack of confidence in their preparedness to treat COVID-19. Of those surveyed, 65% said they don’t have access to a COVID-19 test kit made available by the CDC for laboratory testing. Seventy-two percent of respondents say if a patient traveled to a country where COVID-19 is prevalent, they would automatically want to test for the virus if the test were available.

Yet the majority of physicians confirm that their practices are recommending protocols to follow for potentially affected patients. While 75% of respondents said that their clinic or hospital has recommended a protocol for patients that could potentially have COVID-19, only 38% think the hospitals or facilities where they have privileges are prepared to treat people with the disease.

While only 9% of respondents rated themselves as being very concerned about COVID-19, 28% said their patients are very concerned. “I’m not particularly concerned about it, however, we are forced by media hype to feed into the fear,” a 42-year-old male emergency medicine and critical care specialist said in the survey.

But doctors said patients should be more concerned about the flu. “I try to emphasize to my patients that they should be more worried about the influenza virus,” said a 36-year-old female emergency medicine and critical care specialist.

In fact, 21% of respondents said their patients are more concerned about the threat of the flu, which the CDC estimates has killed 12,000 patients in the U.S. this season and resulted in 210,000 hospitalizations.

As Congress considers efforts to rein them in, private equity firms are buying up more physician practices, according to a new study.

Private equity firms acquired 355 physician practices from 2013 to 2016, a number that jumped each year of the study, according to a research letter published today in JAMA. The number increased from 59 practices in 2013 to 136 practices in 2016.

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Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

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With approximately 18,000 group medical practices in the U.S., researchers said while private equity acquisitions increased across specialties during the study period, they still constituted a small proportion of practices. Those acquisitions continued in the years beyond those in the study period.

The 355 practices bought up included 1,426 sites and 5,714 physicians.

The majority of acquired practices (43.9%) were in the southern U.S., the study found. Practices acquired by private equity firms had several sites (a mean of four) and many physicians (a mean of 16.3 in each practice) with a mean of 6.2 physicians affiliated with each site.

The study, which identified group practice acquisitions using the Irving Levin Associates Health Care M&A data set that includes information on healthcare mergers and acquisitions, also looked at which specialties private equity firms were most interested in.

The most commonly acquired medical groups from 2013 to 2016:

  • Anesthesiology practices (19.4%)
     
  • Multispecialty practices (19.4%)
     
  • Emergency medicine (12.1%)
     
  • Family practice (11.0%)
     
  • Dermatology (9.9%)

From 2015 to 2016 there was an increase in the number of acquired cardiology, ophthalmology, radiology, and obstetrics/gynecology practices, according to the research letter.

Industry reports suggest further growth in acquisitions in 2017 and 2018, particularly in ophthalmology, dermatology, urology, orthopedics, and gastroenterology.

Within the acquired practices, anesthesiologists represented 33.1% of all physicians; emergency medicine specialists, 15.8%; family practitioners, 9%; and dermatologists, 5.8%.

That profile of practices with several sites and many doctors matches “private equity firms’ typical investment strategy of acquiring ‘platform’ practices with large community footprints and then growing value by recruiting additional physicians, acquiring smaller groups and expanding market reach,” said the study authors Jane M. Zhu, M.D., of the division of general internal medicine and geriatrics at the Oregon Health & Science University in Portland; Lynn M. Hua, of the department of health care management at the Wharton School of the University of Pennsylvania, in Philadelphia; and Daniel Polsky, Ph.D., of the Carey Business School at Johns Hopkins University in Baltimore.

They noted that more research is needed to understand the effect of the acquisitions to mitigate unintended consequences.

“Private equity firms expect greater than 20% annual returns and these financial incentives may conflict with the need for longer-term investments in practice stability, physician recruitment, quality, and safety,” wrote the researchers.

Ownership by private equity firms may create additional pressures to increase revenue streams (such as elective procedures and ancillary services), direct more referrals internally, and rely on lower-cost clinicians, the authors said.

A limitation of the study is that its data is based on publicly announced transitions and therefore may underestimate the total number of acquisitions, particularly of smaller practices, they said.

A Miami woman sentenced to serve 35 years in prison for Medicare fraud had her sentenced commuted by President Donald Trump.

Judith Negron, 48, was among the 11 federal inmates Trump announced pardons and commutations for Tuesday, according to the Tampa Bay Times.

Negron was sent to prison for her part in a $205 million fraud case in what was then the country’s biggest mental health billing scheme, according to the report.

Case Study

Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

See how

Negron, the owner of a Miami mental health care company, American Therapeutic Corporation, was the only defendant in the case who refused a plea deal and went to trial. A federal jury convicted her in August 2011 on 24 counts of conspiracy, fraud, paying kickbacks and money laundering.

Prosecutors said the company submitted more than $205 million in fraudulent claims to Medicare.

Negron served eight years of her 35-year sentence at a federal prison in central Florida. Her family told the Associated Press they were waiting to hear when she would be released from the Coleman Federal Correctional Complex.

Negron’s husband, Hector Negron, told the AP a clemency advocate put his wife’s case on Trump’s radar, and she was among the high-profile cases whose sentences were commuted Tuesday.

Federal prosecutors said Judith Negron and two co-defendants paid bribes and kickbacks to owners and operators of assisted living facilities and halfway houses, as well as patient brokers, in exchange for sending ineligible patients to their mental health facilities.

Throughout her trial, Negron maintained she was unaware of the billing scheme. “She has steadfastly insisted on her own integrity,” Bill Norris, the attorney who had tried unsuccessfully to appeal her sentence, told the Tampa Bay Times. “Integrity is a little more complicated than innocence or guilt.”

Co-owners of American Therapeutic Corporation, Lawrence Duran and Marianella Valera, pleaded guilty to the charges against them and were sentenced to 50 years and 35 years in prison, respectively.

Tom Catena, M.D., has been described as ”the world’s most important doctor,” and he is, to more than a million patients.

That’s because the 55-year-old American doctor is the only surgeon for 1.3 million people in the Nuba Mountains of Sudan—a region nearly twice the size of Massachusetts. A Catholic medical missionary in a region torn apart by war, he was just awarded the annual Gerson L’Chaim Prize for “outstanding Christian medical missionary service” from Florida-based nonprofit African Mission Healthcare.

Case Study

Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

See how

The international medical missionary prize comes with a $500,000 award—money Catena plans to use to cover some of the running costs of his hospital and to help establish a school to train nurses, midwives and clinical officers (the equivalent of physician assistants in the U.S.).

“The $500,000 goes a long way here,” Catena said via email to FierceHealthcare. “We feel the school is key to just start creating a cadre of trained Nuba health professionals.”

Tom Catena, M.D., with a mother and young child
(African Mission Healthcare)

Catena, who grew up in upstate New York, has served in Africa for more than 20 years. Since 2008, he has practiced in Gidel in the Nuba Mountains, living in the middle of the war-torn and besieged territory, which is fiercely contested by its inhabitants and the former government of Sudan.

“The two things that keep me here are the toughness and resilience of the Nuba people and what I see as my role as a medical missionary,” he said.

“My role is simply to show the love of Christ to others and that can only be done by sticking it out during the times that are most difficult.”

In 2011, when the fighting started in Sudan and the capital began bombing its own people in the southernmost region, all of the other expatriate workers in the country left, he said. It was the missionaries who stayed with the people.

Catena was among those who insisted on staying. A graduate of Duke University Medical School and a former U.S. Navy doctor, Catena has been the medical director at Gidel Mother of Mercy Hospital, which he helped establish.

The 435-bed Catholic hospital is the only major medical facility in the Nuba Mountains, and Catena is on call 24/7, sometimes seeing as many as 350 or more patients in a single day.

At one point subject to bombings by Sudanese fighter jets, the hospital compound now has several foxholes where patients and staff can flee in case of more attacks.

A deserving recipient

The L’Chaim (Hebrew for “to life”) Prize is sponsored by Jewish philanthropists Rabbi Erica and Mark Gerson.

“Dr. Tom Catena has given up everything that we in the U.S. take for granted in order to bring healthcare to more than a million people who, without him, would otherwise not have access to any medical care,” said Mark Gerson, co-founder of African Mission Healthcare, which has been supporting mission hospitals in Africa since 2010, in an announcement about the 2019 award.

The L’Chaim prize, launched in 2016, comes with the world’s largest annual award of its kind dedicated to direct patient care in Africa. Catena will receive the award April 14 at a dinner in New York City.

“For more than a decade, Tom has endured bombings, epidemics, rainy seasons and flooding, loss of power, lack of equipment and staff, and very little connection with the outside world, all because of his dedication to the Nuba people. He exemplifies what it means to ‘walk in all God’s ways and to love Him,’ and we are honored to be his partner in his sacred work,” said Rabbi Erica Gerson, who co-sponsors the prize with her husband.

The $500,000 award will go toward the Nuba 2020 campaign, the goal of which is to raise $7.5 million to keep the only major hospital in the Nuba Mountains fully operational for the next two decades. The money also will help strengthen and expand the hospital and its network of clinics, Catena said.

Mark Gerson commented on Catena’s commitment. “The sheer amount of good he does—as measured in clinic visits, surgeries, deliveries, community clinic patients treated, and children vaccinated—with the amount of resources he has is completely stunning. It is simply incredible to even think about how many lives Tom and the team he has built can save and transform with the money that he is provided,” he said.

A challenging place

Catena, who has also had his face on a 2018 Armenia stamp after he was awarded the second annual Aurora Prize for Awakening Humanity, said he was pleasantly surprised to receive the L’Chaim prize.

“The previous awardees had pretty major accomplishments,” he said. “The prize money will give us a big boost and hopefully help to put us on some solid financial footing. We are completely dependent on individual donors yet are the only major referral hospital for a population of over one million.”

Tom Catena, M.D., with his wife Nasima,
a nurse (African Mission Healthcare)

Catena said it is the people who have kept him in Africa. He recalls a young girl, who was about three or four years old and was being cared for by her elderly grandmother. The girl’s mother was killed in an airstrike by the Sudan Air Force, and the grandmother was struggling to look after her. 

“When the girl came to us, she was skin and bones and unable to walk due to TB of the spine. With TB medicines and good care by our nursing staff, the girl was restored to full health,” he said.

His advice for other doctors? “Working in these remote and challenging settings can be very frustrating yet incredibly rewarding,” he said.

But it’s work he recommends others try. “I’d recommend anyone to do perhaps a short-term mission to see if it’s for them and then something more long term, where they would be able to contribute more.”