By George W. Chapman
The Centers for Medicare & Medicaid Services developed the five-star system so consumers could make informed decisions. Based on a survey of 46 quality measures, CMS assigns ranking from one to five stars. Undoubtedly, COVID-19 has had a significant impact on ratings. According to the ranking, 766 hospitals received four stars; 825 received three; 595 received two stars and 277 got just one star. You can check any hospital ranking at the Hospital Care Compare website. It should be noted CMS will penalize a hospital for deficiencies, but will not reward a hospital for good or improved performance. Hospitals are still reeling from the devastating impact of the pandemic, including staffing shortages, continuing inflation and fragile finances. Despite having fought the COVID-19 war, CMS chooses to kick hospitals when they are down. Lowering hospital ratings makes little sense in lieu of what they have been through. Penalizing them is pouring salt on their wounds. CMS continues to be stingy when it comes to hospital payments. Effective Oct. 1, battle weary hospitals will get just a 2.9% increase from Medicare and Medicaid. Private insurers typically follow suit. Skilled nursing facilities, also subject to the five-star rating system and also still reeling from the COVID-19 war, will fare slightly better with a 4.2 % increase Oct. 1.
Hospitals and Charitable Care
In order to maintain their tax-exempt status, nonprofit hospitals must provide charitable (free) care. Several states have established oversight of their nonprofit hospitals in order to determine whether or not the amount of charitable care provided is adequate enough to remain tax exempt. Charitable care can include free or discounted care, health education, free screenings and clinics. The obvious dilemma is just how much charitable care is enough to satisfy oversight committees? Ten states require their NFP hospitals to establish broad community benefit plans. Another 25 states require hospitals to publicize their financial assistance policies. Industry analysts believe it is far too difficult to establish fair metrics. Most likely, no steadfast rules are forthcoming and the whole issue may be kicked down the road. 90% of all NFP hospitals are already cash strapped and a 2.9% increase from payers certainly won’t make up for historical operating losses and increasing expenses associated with charitable or free services. About half of our 5,000 hospitals are NFP. There is roughly $220 billion in medical debt among consumers.
Self-Managed Abortions Increasing
Since the Supreme Court overturned Roe v Wade a couple years ago, according to JAMA, the Journal of the American Medical Association, self-managed abortions are increasing. (All abortions are increasing.) Per the JAMA report, women cite privacy, the cost of travel to another state, fear of reprisal, the criminalization of abortion, the cost of child care and lost wages as reasons for self-managed abortions. Eleven percent used the abortion pill mifepristone. This has doubled since the overturning of Roe v. Wade. Others have resorted to drugs, alcohol, heavy lifting and hot baths to induce an abortion. States like Louisiana have moved mifepristone to the dangerous and controlled substance category meaning any illegal use could result in 10 years imprisonment. Legal use would now be only via prescription from a physician. Two hundred and fifty physicians in Louisiana signed a letter in opposition to changing the status of the abortion pill to a dangerous and controlled substance as mifepristone has been proven to be safe and not addicting.
988 Suicide Hotline
Most of us are unaware of this potential life saver. Since being established in July 2022, monthly calls, texts, chats now average more than half a million. That is up 90% in just two years. The 988 hotline provides crisis counseling, resources and referrals. There is an 89% answering rate and wait times are down to less than a minute and a half. Both of these metrics are constantly pressured by the massive increase in volume. The White House has recently granted more than $45 million to organizations fighting our mental health crisis. Between 2012 and 2022, we have lost more than half a million lives to suicide, more than half by gun.
Medical Fraud
Since the establishment of the Healthcare Fraud Strike Force in 2007, 5,400 defendants have been convicted of defrauding Medicare, Medicaid and commercial payers more than $27 billion. Despite this success, ripping off insurers and harming patients must still be worth risking your reputation and license to practice medicine. Physician Adrian Talbot operated Medex Clinical Consultants in Louisiana. He knowingly took cash from drug seekers. Prescriptions were pre signed and he rarely saw the patient. He falsified records to cover his tracks. He illegally distributed 1.8 million pills including opioids and morphine. He has been convicted of conspiracy and unlawful distribution of controlled substances. He is facing 20-40 years in prison.
Denied Claims
Less than half of us challenge them. But half of us who do challenge denials prevail per a Commonwealth Fund survey. One third of us who disputed a medical bill had their balance reduced or eliminated. Medicare and Medicaid patients were more prone to disputing denied claims or questionable bills than those commercially insured. Most people are not aware of their right to dispute denied claims or questionable balances due. The Commonwealth Fund suggests more consumer protections and education and increased public awareness. Fifteen percent of all claims submitted to commercial insurers are initially denied. Three percent of all denied claims were actually pre approved via prior authorization. About half of all denied claims are ultimately paid. But that wouldn’t happen unless disputed.
George W. Chapman is a healthcare business consultant who works exclusively with physicians, hospitals and healthcare organizations. He operates GW Chapman Consulting based in Syracuse. Email him at gwc@gwchapmanconsulting.com.