THCB

Categories

Tag: Rural Hospitals

The Rural Radiologist Who Already Exists

• 6

By STEVEN GOODMAN

The future of rural healthcare won’t be determined by how much money is invested. It will be determined by how wisely that money is used.

That line gets nodded along to at every rural health conference, then quietly ignored the moment the conversation turns to solutions, because the solutions on offer are almost always capital solutions: build a wing, buy a scanner, recruit a specialist who will not, in fact, be recruited. I spent a career building infrastructure for GE Medical Systems, standing up systems for remote patient monitoring before “telehealth” was a word anyone used. The lesson that career taught me is one rural health policy still hasn’t absorbed: the expertise a small hospital needs is usually not missing. It’s just licensed in the wrong state.

The Equipment Isn’t the Bottleneck

Consider radiology, because it’s the clearest version of the problem. A critical access hospital in rural Wisconsin can afford a CT scanner. What it cannot afford, and cannot realistically recruit, is a subspecialist radiologist sitting in the building waiting to read scans that come in one or two at a time. That expertise exists — in large quantities, at hospitals and reading services in Chicago, Minneapolis, or Milwaukee, often sitting idle overnight.

The technology to connect the two has existed for two decades. A scan can move from a rural imaging suite to a subspecialist’s screen in seconds. What can’t move nearly as fast is the paperwork — and there’s more of it than most people outside a hospital credentialing office realize.

A radiologist licensed to practice in Illinois cannot legally read a scan for a patient in rural Wisconsin without a separate license, a separate credentialing process, and — even after clearing both — a payer-enrollment process that may not be worth the trouble.

Multiply that by every specialty a rural hospital can’t staff, and by every state line a patient’s data has to cross, and you get the actual shape of the rural healthcare gap. It isn’t a hospital-building problem. It’s a jurisdiction problem.

Three Fixes, None of Which Require a Capital Campaign

Fixing licensing and reimbursement rules would do more for rural healthcare than another round of capital funding

Continue reading…

Hospital Price Transparency Legislation Will Burden Poor and Rural Patients   

• 0

By DAVID INTROCASO

Last month the House Energy and Commerce and the Senate Health, Education, Labor and Pensions (HELP) committees passed three hospital price transparency (price T) bills by a combined vote 90-22. Afterward, HELP Chair, Dr. Bill Cassidy, stated he was ‘optimistic” and “confident” price T legislation would be enacted by the Congress this session.

Over the past decade federal policymakers have concluded price T will constraint or moderate hospital prices. In theory, the logic is straight-forward. By requiring hospitals to publish machine-readable files and consumer-friendly negotiated and cash rates for “shoppable” hospital services, transparency or disclosure will expose significant price variation empowering patients to comparison shop. In turn, this will spur hospital price competition and bend the healthcare cost curve.  

Because research published by several major medical and health policy journals has concluded HHS’s 2021 price T regulation has failed, the Congress has decided to weigh-in by codifying and expanding HHS price T regulations.

This assumes much. Per Ken Arrow, medical care is not a typical commercial or market commodity. Think: information asymmetry. Clinical diagnoses are often emergent, unpredictable and accompanied by acute physical and emotional distress. Focusing on price ignores or excuses the fact that in functioning markets prices are largely determined by costs. Here, they are largely ignored even though hospital prices are poorly and unpredictably correlated to costs. Price T also tends to lead to tacit collusion where hospital prices converge or what is the price ceiling increasingly becomes the price floor.

More specifically, price T presumes B2B or business-to-business transactions, here moreover ERISA plan – hospital contracting, are the product of a functioning hospital market. Based on this false assumption, price T skips passed B2B to B2C, or to the business-to-consumer market where the consumer is expected to identify favorable hospital prices. 

It is well-documented hospital concentration/consolidation has erased competition. There are simply price setting hospitals and price taking plans and patients or consumers. It’s no surprise that commercial plan hospital rates are on average north of 250% of Medicare and rates for common procedures can vary ninefold across hospitals.    

For these reasons, when evaluated from a health equity perspective, price T disproportionately places the responsibility and burden on poor and rural patients. (As an aside, this year the Congress invited at least 11 expert witnesses to provide price T testimony.  None addressed and/or had health equity expertise.)     

Among other substantial cognitive and financial burdens, these populations are already time poor, likely already face healthcare-related financial burden or vulnerability, experience higher rates of emergency care, have comparatively limited health literacy particularly when faced with opaque and intimidating cost estimates, are frequently confronted by a digital divide in accessing online estimator tools or downloading multi-gigabyte machine-readable files requiring broadband internet. For these and other reasons their response frequently is to delay or forgo care altogether. As a de facto buyer-beware mechanism, price T can act as a deterrent.

Price T also assumes geographical density and provider substitutability. In rural America single hospital systems or Critical Access Hospitals (CAHs) often serve as the sole provider within a ~100-mile radius. For a rural county resident, knowing that a hospital 75 miles away charges $250 for an MRI is largely irrelevant. Geographic distance, lack of public transit and travel costs negate price differentials. Imposing strict price T compliance requirements backed by increasingly severe civil monetary penalties for non-compliance can unintentionally strain negative margin rural providers by in part diverting personnel and capital toward maintaining data feeds.

For these populations particularly, with nowhere else to go, price T is a paradox. With information without options, it’s an oxymoron. With transparency in a concentrated market, it’s a distinction without a difference, serves as a signal for dominant hospitals to drift toward higher prices or a is non-sequitur by attempting to apply a demand side shopping remedy in a supply side monopoly. Price T can however serve as an essential prerequisite allowing even the most vulnerable to shop their way to affordable healthcare if it is paired with guardrails that create a functioning market or one with systemic accountability. This can be accomplished if the Congress decides to take the necessary step and like emerging drug pricing policy require the use of external reference pricing.  Hospitals or any supplier cannot be allowed to control price and also serve as an objective judge of it.    

David Introcaso is a healthcare research and policy consultant based in Washington, D.C