People Falling Victim To Price Gap For Tests In Surprise Billing Law

Stat: A Gap In New Surprise Billing Law Puts Patients On The Hook For Pricey Tests
For Soung Luy, it seemed easy: His primary care doctor told him he needed blood work, and that he could get it done in the same office building in Marina del Rey, Calif., which was owned by the Cedars-Sinai health system. The doctor even assured Luy, when he asked, that the lab accepted his insurance and was in-network. But even though it was down the hall from Luy’s in-network physician, and even though he asked, the lab was not in his insurance network. His bill came: $686.70 for a handful of blood tests. “If I knew it was out-of-network, I would not have done it there,” Luy said. Cedars-Sinai eventually sent Luy’s account to a debt collector. Luy paid the balance, afraid his credit would get torpedoed. (Herman, 3/8)

In other health care industry developments —

Modern Healthcare: Staff Shortages, Deferred Treatment Driving Changes In Care Models
Patients previously considered low-risk became sicker and health disparities likely widened because of clinical staff shortages and volume surges during the COVID-19 pandemic. As a result, care delivery models need to evolve to make up the backlog and meet the ongoing needs of those whose ailments manifested or became more severe because they couldn’t receive treatment. The pandemic, along with the healthcare system’s response, have had a disproportionate effect on older and sicker patients as well as people from underserved communities that’s going to linger. The public health emergency also highlighted and exacerbated staffing shortages, leaving a smaller, exhausted workforce to deal with the clinical consequences of deferred care. The pandemic eventually will go away, but the patients who didn’t get the treatment they needed will not. (Hartnett, 3/8)

Modern Healthcare: Clash Over MA Coding Intensity Continues In Rate Notice Comments
The debate over whether Medicare Advantage plans are overpaid, relative to fee-for-service Medicare, continued in comments on the Center for Medicare and Medicaid Services' advance notice on 2023 MA payment policies. In comments submitted last Friday, insurance lobbyists applauded CMS' use of the minimum coding intensity adjustment, while Medicare payment advisors said the figure doesn't account for coding differences between MA and traditional Medicare. (Goldman, 3/7)

Modern Healthcare: NYC Pediatricians Look To Scale Clinical Model Embedded In Social Services
Three pediatricians in New York left jobs at prestigious academic institutions to test a novel, holistic care model that connects underserved families to health and social services via community partnerships. Two years later, they are looking to expand. Drs. Omolara Uwemedimo, Suzette Brown and Nicole Brown founded Strong Children Wellness Medical Group in April 2020 (virtually at first because of the COVID-19 pandemic). The trio arrived at this venture with impressive credentials from universities including Johns Hopkins, Yale, Brown, Columbia and Stanford, as well as a goal to tackle social determinants of health by integrating clinical operations with not-for-profit housing organizations, food pantries, legal aid societies and other local partners. Some of those entities are even located in the same buildings as the clinics, which facilitates successful referrals. (Hartnett, 3/8)

Modern Healthcare: Medical-Legal Partnership Reduced Pediatric Hospitalizations, A New Study Found
A medical-legal partnership—first launched during the 2008 financial crisis—reduced hospitalizations among children by providing housing support and financial aid, a new study found. Amid the COVID-19 pandemic, the model could be a roadmap for tackling social determinants of health in primary care settings, as well as a pitch for reimbursement from insurers. Researchers from the University of Cincinnati found that a collaboration between Cincinnati Children's Hospital Medical Center and the Legal Aid Society of Greater Cincinnati—in order to connect children and their families to social services—reduced pediatric hospitalizations by approximately 38% after support was received. (Hartnett, 3/7)

Modern Healthcare: Pandemic Elevates Chief Quality Officers’ Importance
Over the past two years, chief quality officers were thrust from often-underfunded and non-revenue-generating safety improvement work to driving how their hospitals would handle a significant healthcare crisis. Quality departments—and their leaders—became stars. Hospital C-suites suddenly leaned on quality and safety infrastructure in a way they hadn’t before, because chief quality officers are trained to experiment, observe the results and make changes quickly. Hospitals needed those skills, and safety officers coached operational heads to implement high-stakes transformations during the pandemic, including quickly shifting all care to virtual settings and setting up large-scale vaccine clinics in parking lots and hospital lobbies. (Gillespie, 3/8)

In pharmaceutical industry news —

Modern Healthcare: Mallinckrodt To Pay $233 Million To Settle False Claims Allegations
Mallinckrodt will pay $233.7 million for allegedly shortchanging Medicaid programs, the Justice Department said Monday. The federal government in 2020 sued Mallinckrodt, which purchased Questcor Pharmaceuticals in 2014, for forcing Medicaid programs to pay for an unsubstantiated $50 to $28,000 price increase for a vial of Acthar Gel, a treatment for people with certain chronic inflammatory or autoimmune conditions, the complaint alleged. The drugmaker allegedly underpaid rebates from 2013 to 2020 as required by the Medicaid Drug Rebate Program, which was designed to insulate Medicaid from drug price increases outpacing inflation. Questcor began paying rebates for Acthar in 2013 as if Acthar was a new drug first marketed in 2013—ignoring all pre-2013 price increases when calculating Medicaid rebates, the DOJ alleged. (Kacik, 3/7)

Stat: Study Of Gilead’s Breast Cancer Drug Meets Goal, But Still Raises Doubts
Gilead Sciences said Monday that a large clinical trial of its drug Trodelvy achieved its primary goal of delaying tumor growth in women with the most common form of breast cancer. But Gilead chose not to provide any specific data from the study. It would also not even say whether the Trodelvy study results were clinically meaningful for women with HR-positive, HER2-negative breast cancer, despite reaching statistical significance. (Feuerstein, 3/7)