CVS + Aetna. Are we sure this adds up?

CVS and Aetna. Love at second sight?

Many of the stories I’m reading about CVS’s acquisition of Aetna suggests the deal is a bold move to expand CVS’s retail clinic business.  See for example, CVS-Aetna deal has major implications for retail health, primary care practices in FierceHealthcare.

If the merger goes through, CVS plans to expand health services at its retail pharmacies, according to CVS and Aetna officials. Although it will take several years to accomplish, CVS will increase its number of clinics and add staff and equipment for a wider variety of treatments.

This seems like silly reasoning. If the idea is to get health insurers to offer plans that favor retail clinics, why not just contract with those plans? Aetna is a big company but as a national plan its market share in many geographies is relatively modest. Often –like here in Massachusetts– the local Blue Cross has the biggest market share. If CVS is big and powerful enough to actually buy Aetna, surely it can get that company and others to come to terms on retail clinics.

If there’s strategic logic behind the deal it’s more likely to be in the pharmacy management side of the business, where, for example, the combined CVS/Aetna will be the biggest player –but not a dominant one– in Medicare Part D pharmacy plans. That’s not so compelling.

Possibly, the two companies just wanted to do a big deal that wouldn’t get blocked by the Justice Department. Aetna already got slapped down for its attempt to merge with Humana, and CVS doesn’t have a lot of options for horizontal takeovers of other drug chains or pharmacy benefit managers.

There is some kinship between the companies. Both are New England based and CVS’s Chief Medical Officer, Troy Brennan previously held the same role at Aetna.

It seems just as likely that CVS will offer Aetna “products” through its stores. As @WilliamGerber points out on Twitter, CVS could sell Part D plans at retail. I’m thinking maybe CVS will eventually offer consumer friendly health plans from Aetna that go beyond pharmacy.

Certainly, the shadow of Amazon is hanging over the deal. CVS is extremely nervous about Amazon coming in and eating its lunch in a way that Walgreens never could. So it’s doing something Amazon won’t –getting more into third-party reimbursement.

Stay tuned. I look forward to seeing how this one plays out.

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By healthcare business consultant David E. Williams, president of Health Business Group.

Ambulance bill rip-off: There’s always a public option

A Kaiser Health News story on sky-high ambulance bills caught my attention; I have a long-standing interest in out-of-network billing and a more recent experience of taking a pricey ambulance trip myself.

Taken for a ride? Ambulances stick patients with surprise bills, is not a new story. To sum it up: it’s not unusual for a patient to get a bill for thousands of dollars and then to be stuck with a big part of the charge, even if that patient is insured. That’s because many ambulance companies can make more money by being out-of-network. Unlike physicians and hospitals, ambulance companies don’t lose patients by being out of network and refusing to offer discounts. After all, if you need an ambulance you wouldn’t have time to shop around, and it doesn’t affect repeat business either.

The article cites an example of a Fallon ambulance in Chestnut Hill, MA, one town away from where I live. A patient was transported to Brigham and Women’s hospital four miles away and charged $3,660, which the article points out is $915 per mile. The insurer paid about half and half was the responsibility of the patient.

In my own case I was crossing the street in a crosswalk and was struck by a car making a left turn. My bill from Fallon was $3,427.50 for a one-mile ride, so at least on a per mile basis it was much higher than the Chestnut Hill example.

But to be fair, the bill comprises a base fee of $3,350 for an advanced life support ambulance plus $77.50 per mile. That works out to exactly the same rate as what the suburbanite paid ($3,350+4x$77.50=$3,660) and demonstrates that Fallon is not mainly charging for mileage, it’s charging for the equipment and personnel being ready to show up on a moment’s notice.

Much of the ire is directed at the ambulance company for price gouging and the insurance company for leaving patients hanging. There are calls to regulate prices and otherwise tighten the rules, and I’m sympathetic.

But notice this point a little further down:

” If the injury had happened just a mile away inside Boston city limits, he could have ridden a city ambulance, which would have charged $1,490, according to Boston EMS, a sum that his insurer probably would have covered in full.”

When you call 911 to report a fire or a crime in Chestnut Hill and anywhere else near Boston, fire fighters and police officers are dispatched at no charge. It doesn’t matter what insurance you have –or whether you have insurance– it’s a service provided by the local government as part of its budget. Police and fire fighters responded to my crash, too, but they aren’t sending a bill.

Cities and towns could do the same with ambulances if they want. Some, like Boston, do. Public ambulances can still bill insurance and individual patients, but they’re less likely to antagonize patients and insurers with outrageous bills.

So while we think of policy solutions for ambulance bill rip-offs, let’s not forget that there are public options and lots of hybrid solutions, too.

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By healthcare business consultant David E. Williams, president of Health Business Group.

What free market healthcare really looks like

Get while the gettin’ is good!

As an economics graduate, MBA, and entrepreneur I’m a fan of the free market system. The invisible hand is a beautiful thing, and it’s certainly been good for me.  A healthcare management consultant and board member, I make my living from the business of health.

Capitalism has a place in healthcare, but in developing policies we should also recognize the limits of free market approaches and be open to the benefits of socialist ideas. For example, before the Affordable Care Act, people with pre-existing conditions or high healthcare costs would experience “job lock.” They couldn’t afford to leave their employers’ group insurance plans even if they wanted to start their own small business. Would-be entrepreneurs used to call me asking for advice –not about business plans, raising money, hiring, or product development– but about how I handled health insurance. Fortunately in Massachusetts this was not a problem, even before the ACA, because we had guaranteed issue (could not be denied coverage for pre-existing conditions) and community rating (premium based on larger group, not individual risk). In most parts of the country, though, it was a problem, and  if the ACA is repealed it may become a problem again.

A recent New York Times article (The Company Behind Many Surprise Emergency Room Bills) provides another example of the limitations of a free market approach. It’s worthwhile for free market ideologues to understand this before setting policy. To recap:

• Some hospitals hire outside companies like EmCare to staff their emergency rooms. To maximize profits, those companies sometimes decide not to negotiate contracts with insurance companies. Hence they are “out of network” on purpose
• When patients come in to the emergency department –suffering a heart attack, stab wound or whatever– they are treated by these out of network doctors, who then bill the insurance company at a rate that may be a multiple of in-network rates. This is true even if the hospital itself, and most of its doctors, are in network
• The insurance company may pass along some or all of the expense to the patient, especially if the patient has a high deductible plan
• Patients get angry, and a story appears in the New York Times

The Times story ends there, and it’s bad enough. I guess you could argue that the free market is sort of working here. After all, physicians are setting their own rates, and in theory patients could decide to go elsewhere. The consumer making noises helps to bring the market into equilibrium. And maybe the problem is not enough capitalism. Maybe EDs shouldn’t be required to take patients who can’t pay…

What the Times doesn’t say –probably because they don’t know about it– is that there’s an additional capitalist ecosystem that comes into play here. Let’s say a physician charges the insurance company $100,000 for something that would be reimbursed at $10,000 under a network contract. In case you think I’m exaggerating, this kind of thing actually happens –if not with emergency physicians then with ambulatory surgery centers and behavioral health.

The insurance company or third party administrator may then hire a cost containment vendor to ‘re-price’ or negotiate the claim. The cost containment vendor negotiates with a separate “revenue cycle management” company hired by the physician group.

Let’s say for the sake of argument that they agree to a reduced payment of $15,000 instead of $100,000. The cost containment company might take 20% of the savings (20%*$85,000=$17,000) as a commission and the revenue cycle management company might make $1500 or so for their efforts. So everyone in this scheme is happy:

• The physician still collects $13,500 compared to $10,000 in a network deal. (And in some circumstances if the insurer isn’t paying attention they’ll get the full $100,000.)
• The revenue cycle management company takes its cut, even if it’s less than the others
• The cost containment companies makes more than the physician ($17,000 v $13,500). It doesn’t usually work that way but sometimes it does. [Note that I had these numbers wrong until I was corrected in the comments.]
• And the health plan pays $15,000 rather than $100,000. If the payer is acting as a TPA or ASO rather than bearing risk, they may even get a fee from their employer customer for the cost containment service

While it’s great that so many new jobs and business opportunities are created, this is not exactly the way to hold down the cost of healthcare and improve affordability.

Contrast this scenario with one where the patient is covered by a government program: Medicare or Medicaid. The government determines the fee for services rendered and pays it to the physician. The patient contributes at most a $50 co-pay. The physician may or may not like what he’s being paid, but there are no shenanigans.

If you adore the free market and abhor government interference, maybe the first scenario is best. Having seen it up close, I have a hard time arguing for it.

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By healthcare business consultant David E. Williams, president of Health Business Group.

Tufts nursing impasse: I’m quoted in the Boston Globe

Who “wins” in a strike?

The first nursing strike in Boston in three decades is an ugly situation. I feel badly about it, especially for patients and their families who are collateral damage. Even if the quality of care is the same with the replacement nurses, the extra stress and aggravation really are a problem.

I’m quoted on the dispute in today’s front page Boston Globe story (At Tufts Medical Center, pressure to cut costs in a city rich with hospitals). I’m not directly involved with Tufts management or nursing leadership, so I commented on the overall environment in which its occurring.

“I think the root cause is that Tufts has to compete with the other academic medical centers in the city, and they don’t get the same level of reimbursement,” said David E. Williams, a consultant at Health Business Group in Boston. “The disparities of the payments actually cause friction in the labor market.”

The story of unequal payments to Boston area hospitals is not a new one, and people have heard about it so often that they’ve tended to zone out. But this is the first time I can think of that labor relations have taken a public hit as a result, so perhaps it will reinvigorate the debate.

Meanwhile, few of the articles about the strike provide broader context about where nurses fit in to hospital finances. A couple of statistics are worth mentioning:

• A 2015 study published in the Journal of Nursing Administration (Hospital Nursing Workforce Costs, Wages, Occupational Mix, and Resource Utilization) concluded that nursing labor accounts for just over 30 percent of total hospital costs. That means nursing costs are central to hospital finances and it explains why Tufts isn’t just giving in in the face of the strike.
• Nurses in Boston earn six-figure incomes. According to Tufts, its senior nurses (which represent 60 percent of the total staff) “earned an average of $152,000 in 2016.” That’s comparable to what some primary care physicians make.

I hope the dispute is resolved soon, so that the nurses and the rest of the Tufts team can get on with the job of caring for patients. If the strike ends up stimulating a serious debate about inequities in hospital reimbursement, that will be its only silver lining.

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By healthcare business consultant David E. Williams, president of Health Business Group.

Trump presidency hurts economic growth

I disagree with the general sentiment that the Trump Administration is good for economic growth. While certain economic policies might be mildly positive, these are overwhelmed by negative economic and social policies, and by Trump’s disdain for democracy.

The Wall Street Journal’s survey of economists neatly sums up the conventional wisdom, concluding that the long-term growth rate of the economy could increase modestly –from 2% to 2.3%– if all of Trump’s agenda were implemented. The policies they focus on include infrastructure spending, rollback of regulations, and tax cuts. Even if we accept that these are the right things to consider, there are problems with the analysis:

• Infrastructure spending, which if done right could provide the biggest boost, is unlikely to be enacted
• Rollback of regulations may speed growth, but eliminating environmental regulations –as Trump has done– causes negative impacts on the environment that GDP doesn’t measure

But beyond this, we need to consider a variety of growth killers:

• Dismantling Obamacare’s progress on universal coverage leads us back to “job lock” –where employees fear leaving their positions to start new businesses because they are worried about whether they or their dependents will be able to get insurance coverage due to pre-existing conditions. I started my business in 2001, well before Obamacare. When prospective entrepreneurs called me for advice, the number one concern about getting started wasn’t about business plans, financing, or hiring, but rather health insurance.
• I put healthcare first (this is the Health Business Blog after all) but reducing immigration is what could really kill the economy. Consider:
  • Population growth drives economic growth; reducing net immigration directly slows growth
  • Many of the big job creating companies –think Apple, Google, eBay — were founded by immigrants. But we see this on a smaller scale, too. Of the four, fast growing healthcare companies whose boards I serve on, three were founded by immigrants (from Finland, Russia and Tanzania). Immigrants have higher rates of labor force participation and are more likely to start small businesses, too.
• Erecting trade barriers hurts growth. Trade wars have no winners
• There are a variety of non-economic policies and actions taken by Trump that are likely to harm long-term growth. I can’t think of any that help it. For example:
  • Undermining the rule of law and attacking democratic institutions such as the courts and Congress, while praising dictators. The US has long been a safe haven in economic and political crises due to its justified reputation for being a nation of laws, not men. Trump is throwing that away and is being abetted by the Republican leadership in Congress
  • Adopting harsher policies on incarceration for non-violent drug offenders, which reduces the workforce
  • Creating uncertainty on policy by flip flopping dramatically on. It’s hard to plan and invest in those cases

I’m convinced Trump harms growth. If I turn out to be wrong I’ll be the first to admit it.

Urgent care clinics just for cancer patients

It’s tough being a cancer patient. The illness is serious and sometimes fatal, treatments can have serious side effects, and the fatigue and stress can be overwhelming. It gets worse when patients end up in the emergency room where they are exposed to people who may be contagious and encounter medical staff who may not know how to address the special needs of an oncology patient.

So I was heartened to read about urgent care centers specifically for cancer patients. Centers like the one at University of Texas Southwestern Medical Center in Dallas cater to the requirements of cancer patients. They provide same-day appointments, are open early and late, and coordinate with the rest of the patient’s oncology care givers. It’s a good example of patient-centered care.

Of course there are some strong economic incentives as well (hospitals aren’t doing this for their health, so to speak). Cancer patients are lucrative for hospitals –that’s one reason you hear so much advertising for cancer care. And hospitals are wise to treat their best customers well to encourage loyalty. In the value-based care era, we can also expect pressure for hospitals to improve outcomes, control costs and improve the patient experience of care. Urgent care cancer centers contribute to addressing all these goals.

It does raise the question of why only cancer patients get their own urgent care while the rest of the population has to put up with all the challenges and downsides of the regular healthcare system. Perhaps other parts of the healthcare system can learn from these urgent care centers and emulate them more broadly.

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By healthcare business consultant David E. Williams, president of Health Business Group.

Are Massachusetts healthcare costs ok after all?

The best defense is a good offense. I assume that’s what Partners HealthCare CEO David Torchiana had in mind when he penned First do no harm in the Boston Globe. In a nutshell, he argues that healthcare costs in Massachusetts are more affordable for businesses and individuals than elsewhere in the country, that they are becoming relatively more affordable, and that the state should resist the urge to impose further cost controls.

I’ve made similar arguments about affordability myself. See for example, Massachusetts: Land of affordable health insurance from back in 2011.

And yet…

While Massachusetts has retained its affordability relative to other states, healthcare is taking up a higher and higher percentage of families’ incomes, including in Massachusetts. Medicaid and other healthcare spending dominates the state government’s spending growth, squeezes out discretionary initiatives for priorities such as education, and necessitates the tough budget cuts Governor Charlie Baker is making.

I’m sure I’m not the only one whose eyebrows were raised by Torchiana’s sanguine perspective.

Partners also should not claim too much credit for the reasonableness of healthcare spending in Massachusetts, considering that its own costs are among the highest. Despite receiving substantially higher reimbursement from commercial payers than other providers and enjoying a richer payer mix, Partners recently reported a record loss of $108 million for the year. Meanwhile, its smaller rivals –including those who treat a higher proportion of Medicaid patients and receive lower commercial reimbursement rates– are reporting better financial results.

If Partners had remained just Massachusetts General Hospital and the Brigham & Women’s Hospital I don’t think its executives and lobbyists would have to expend so much effort fending off the state. Massachusetts residents are justifiably proud of the worldwide reputations of these hospitals, which draw tremendous research dollars from the NIH and elsewhere, attract patients from around the world, and are equipped with the medical expertise and equipment to treat the most complex conditions.

No, the issue is that over the years Partners has dramatically expanded its footprint throughout the region, buying up or partnering with community hospitals and physician practices, and expanding its own overheads as it grapples with the balance between central and devolved management. Partners is now in the business of providing routine care throughout the region, and that helps drive up costs and puts the company in the spotlight. As the state grapples with bringing costs in line with benchmarks, Partners cannot expect to be given a free pass.

So there are a couple of alternatives: #1: Partners can bring its own costs closer in line with rivals or #2 it can divest its community assets and focus on being a great academic medical center. From what I can see, Partners is pursuing a light version of #1 while simultaneously slowing its plans to further expand in the community and mounting a charm and lobbying offensive with the state and the public.

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By healthcare business consultant David E. Williams, president of Health Business Group.

BIDMC and Lahey talk merger; I’m quoted

Beth Israel Deaconess Medical Center and Lahey Health are talking again about a merger. From the Boston Globe:

Top executives from the two hospital systems are discussing a possible merger, according to people with direct knowledge of the negotiations, the fourth time they have explored a deal in the past five years.

I’m quoted:

David E. Williams, president of Health Business Group, a Boston consulting firm, said Beth Israel Deaconess has been looking for ways to grow its network since its biggest rivals, Mass. General and Brig-ham, merged in 1994 to create Partners.

“Beth Israel Deaconess never got involved in the original Partners transaction, and ever since then they’ve been looking for a way to get bigger and be stronger like Partners,” he said. “Lahey is a strong, medium-sized player that’s come up time and again.”

From what I understand, this may actually be the fifth set of talks, not the fourth. Both players are high quality and relatively low cost, so a combination could create a strong, efficient alternative to Partners.

But mergers are complex and risky, so there are reasons not to move too fast. In particular, the board and management of each institution has to decide if the specific deal is good for their own organization. In the past that case hasn’t been made convincingly. It’s not clear that it will be any different this time.

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By healthcare business consultant David E. Williams, president of Health Business Group.

PCSK9 experience shows drug market isn’t completely broken

 

Why isn’t this thing growing?

Everyone knows that the market mechanisms that make most of the US economy efficient are lacking in healthcare. That’s especially true for pharmaceuticals, where drug companies can raise prices at will, and only the government can step in with price controls to put things right. At least that’s what we’ve been hearing in the press and on the campaign trail for the last year or more.

So I read with interest a recent STAT article These pricey cholesterol drugs aren’t selling. And that has the biotech industry sweating, about how the market is blocking high-priced drugs –and preventing pharma companies from doing all the things we’ve been told they can do at will.

No one disputes that the new drugs, Repatha and Praluent, are excellent at lowering bad cholesterol, or LDL. They often succeed where the traditional treatment — an inexpensive class of drugs called statins — fails. The problem boils down to doctors who are reluctant to write prescriptions, insurers who are unwilling to pay for them, and drug companies that have failed to understand a fast-changing marketplace.

The failures could send a chill through the still-booming biotech business, which relies on the idea that the risky, expensive process of developing new drugs can one day pay off big.

Contrary to the views expressed in the STAT article, I think the market is actually doing an ok job here. There are two main reasons why the drugs haven’t sold well:

• First and foremost, while they are proven to lower cholesterol they are not proven to reduce heart attacks or strokes or to lower death rates
• Second, most patients do just fine with generic statins, which are inexpensive and have a long track record, compared with the new drugs that have list prices of about $14,000 per year

The result is that doctors who want to prescribe the drugs have to jump through a lot of hoops to get insurance company approval. That’s a hassle and it’s expensive and time consuming, so I sympathize. But by the way, before we get mad at the PBMs and insurers, consider that the experience for prescribers might not be that different under a fully capitated payment model since health system administrators would still be worried about their budgets.

The companies that make these drugs are conducting studies of the impact on outcomes that people really care about: heart attack, stroke, death. If they demonstrate that the drugs are effective on these measures, they will have no problem generating prescriptions or charging premium prices –at least in the United States.

Image courtesy of iosphere at FreeDigitalPhotos.net

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By healthcare business consultant David E. Williams, president of Health Business Group.

 

 

 

Justifying EpiPen pricing, once again

Back with more

I enjoyed Medical hackers create $30 DIY EpiPen in defiance of corporate greed over at inhabitat. The Four Thieves Vinegar collective cobbled together an “EpiPencil” from an auto injector for insulin, a hypodermic needle, and epinepherine. It’s a pretty cool trick but it proves nothing about EpiPen pricing nor does it help real patients.

Actually, it unwittingly reinforces the points I made in my very unpopular EpiPen may still be too cheap post, which is that the pricing of EpiPen has almost nothing to do with the cost of its parts.

Consider these caveats about the DIY EpiPencil from the inhabitat post:

However, it is worth mentioning that many experts have voiced concern about the EpiPencil and warned that it’s not advisable to try to create a piece of medical equipment at home – it can be difficult to ensure the correct dose is being administered, the epinephrine inside is delicate and might lose its effectiveness if stored this way, and of course, if someone were to create the device without paying close attention to hygiene, it could become contaminated. A miscalibration of the device could even cause the medicine to be injected into a vein, which can have dangerous side effects.

To recap, here’s what you’re paying for when you buy a real EpiPen:

• The ability to send your kids to school, playdates, summer camp, hikes, and restaurants with reasonable confidence that they’ll survive an allergic reaction
• An auto-injector that works. Remember, Twinject was rejected by the market for being clumsy, Auvi-Q was recalled because it could administer the wrong dose, and Teva’s autoinjector was rejected by FDA for “major deficiencies”
• A device that many, many people know how to use: school nurses, babysitters, passers-by. That means someone is likely to be there to help you if you need it. Good luck with getting someone to learn how to use your EpiPencil in an emergency, even if somehow it worked as advertised

EpiPen’s maker, Mylan has done a lot of sleazy things, which I don’t defend, and as a result they may well deserve the opprobrium that is being directed at them. But I stand by my argument that EpiPen is not $2 of epinephrine and a syringe. Instead its a differentiated solution that provides plenty of value to users.

If someone can come up with something better and cheaper, please do!

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By healthcare business consultant David E. Williams, president of Health Business Group.