From Medicine and Health

White House Unveils Finalized Health Care Price Transparency Rule

Hospitals will soon have to share price information they have long kept obscured — including how big a discount they offer cash-paying patients and rates negotiated with insurers — under a rule finalized Friday by the Trump administration.

In a companion proposal, the administration announced it is also planning to require health insurers to spell out beforehand for all services just how much patients may owe for out-of-pocket costs for all services. That measure is now open for public comment.

“What is more clear and sensible than Americans knowing what their care is going to cost before going to the doctor?” said Joe Grogan, director of the White House Domestic Policy Council.

The hospital rule is slated to go into effect in January 2021. But it is controversial and likely to face court challenges.

It is part of an effort by the Trump administration to increase price transparency in hopes of lowering health care costs on everything from hospital services to prescription drugs.

When that rule was first proposed in July, hospitals and insurers objected. They argued it would require them to disclose propriety information, could hamper negotiations and could backfire if some medical providers see they are underpriced compared with peers and raise their charges.

Shortly after the final rule’s release, four major hospital organizations said they would challenge it in court.

“This rule will introduce widespread confusion, accelerate anticompetitive behavior among health insurers and stymie innovations,” according a joint statement from these groups, which made clear their intent to soon “file a legal challenge to the rule on the grounds including that it exceeds the administration’s authority.” The statement was signed by the American Hospital Association, the Association of American Medical Colleges, the Children’s Hospital Association and the Federation of American Hospitals.

Insurers also pushed back. “Tthe rules the administration released today will not help consumers better understand what health services will cost them and may not advance the broader goal of lowering health care costs,” said Scott Serota, president and CEO of the Blue Cross Blue Shield Association, in a statement.

Requiring disclosure of negotiated rates, he said, could lead to price increases “as clinicians and medical facilities could see in the negotiated payments a roadmap to bidding up prices rather than lowering rates.” The rule, he added, could confuse consumers.

It’s also a potentially crushing amount of data for a consumer to consider. However, the administration said it hopes the data will also spur researchers, employers or entrepreneurs to find additional ways of making the data accessible and useful.

The amount of information the rule requires to be disclosed will be massive — including gross charges, negotiated rates and cash prices among them — for every one of the thousands of services offered by every hospital, which they will be required to update annually.

In a nod to how hard it might be for a consumer to add up items from such an a la carte list of prices, the rule also requires each hospital to include a list of 300 “shoppable” services, described in plain language, with all the ancillary costs included. So, in effect, a patient could look up the total cost of a knee replacement, hernia repair or other treatment.

Insurers, under the proposed rule, would have to disclose the rates they negotiate with providers like hospitals. They would also be required to create online tools to calculate for individual consumers the amount of their estimated out-of-pocket costs for all services, including any deductible they may owe, and make that information available before the consumer heads to the hospital or doctor.

It would go into effect one year after it is finalized, although it is not known when that will occur.

Although consumer advocates say price information can help patients shop for lower-cost services, they also note that few consumers do, even when provided such information.

Earlier this year, the administration ordered drugmakers to include their prices in advertisements, but the industry sued and won a court ruling blocking the measure. The administration has appealed that ruling.

Nonetheless, Health and Human Services Secretary Alex Azar said the administration is confident.

“We may face litigation, but we feel we are on sound legal footing for what we are asking,” Azar said. “We hope hospitals respect patients’ right to know the prices of services and we’d hate to see them take a page out of Big Pharma’s playbook and oppose transparency.”

He and other officials on a call with reporters admitted they don’t have any estimates on how much the proposal would save in lowered costs because such a broad effort has never been tried in the U.S. before.

Still, “point me to one sector of the American economy where having pricing information actually leads to higher prices,” said Azar.

Azar cited some studies that show that when prices are disclosed, overall spending can go down because patients choose cheaper services. However, such efforts also generally require financial incentives for the patient, such as sharing in the cost savings.

The proposed rule for insurers urges them to create such incentives, said Seema Verma, who oversees the federal government’s Center for Medicare & Medicaid Services.

George Nation, a business professor at Lehigh University in Pennsylvania who studies hospital pricing, called the final rule and the insurer proposal “exactly a move in the right direction.”

Among other things, he said, the price information may prove useful to employers comparing whether their insurer or administrator is doing a good job in bargaining with local providers.

Today, “they just see a bill and a discount. But is it a good discount? This will now all be transparent,” said Nation.

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Must-Reads Of The Week From Brianna Labuskes

Happy Friday! Well, friends, we have apparently arrived in the “post antibiotic era” (according to some), which any reader of the Breeze will know is up there with eyeballs and ticks on my list of phobias. I have no solace to offer you in this trying time beyond distraction: Here is what you might have missed this week (in case you were busy paying attention to historic hearings or something like that).

A California high school became the latest mass shooting site this year after a 16-year-old gunmen opened fire on students, killing two and injuring three others before he turned the gun on himself. “We are one of those schools now,” one student said to the Los Angeles Times. “Just like Parkland.” There have been a total of 84 incidents of gunfire on school grounds in 2019.

Los Angeles Times: A 16-Second Spasm Of Violence Leaves 2 Dead At Saugus High School

Earlier in the week, Attorney General William Barr unveiled the Department of Justice’s plan to address gun violence. The proposal focused mostly on strengthening partnerships with law enforcement, agencies and community organizers in an effort to better enforce existing law. It was met with swift disappointment from advocates who said there were no new tangible policies in it.

The New York Times: Justice Dept. Unveils Gun Plan, Sidestepping A Preoccupied Washington

And even earlier in the week, the Supreme Court handed gun control advocates a win when the justices denied a bid to block a lawsuit against Remington, the maker of the gun used in the Sandy Hook shooting. The case, which has survived a roller coaster of twists and turns, has been closely watched because gun-makers have enjoyed broad immunity from prosecution under the 2005 Protection of Lawful Commerce in Arms Act. Although the suit started out making a different argument, it now hinges on whether Remington marketed the military-style guns for use by civilians.

NPR: Supreme Court Allows Sandy Hook Families’ Case Against Remington Arms To Proceed


No one gets any credit for predicting this correctly: Health law sign ups dropped 20 percent from where we were last year at this point. But with a lawsuit on the Affordable Care Act’s constitutionality looming, a chipping away of any enrollment outreach services, and just general confusion about where the law stands these days, the decrease seems all but inevitable.

CNBC: Obamacare Early Enrollment Rate Drops 20% Amid Trump-Backed Lawsuit


The Wall Street Journal dropped a privacy bombshell with its reporting that Google has been amassing health data on millions of patients without their knowledge. Privacy experts say “Project Nightingale” is perfectly legal (because business partners can share information with each other). But that doesn’t address the “ick factor” of something that may be totally above board legally but is kind of creepy anyway. Doing so is going to be a challenge for lawmakers.

The Wall Street Journal: Google’s ‘Project Nightingale’ Triggers Federal Inquiry

Politico Pro: Google’s New Partnership Might Creep You Out. That Doesn’t Mean It’s Illegal.


It’s been a quiet week health-wise on the campaign trail, but I’m certain they’ll make up for it at next Wednesday’s debate. Meanwhile, Sen. Bernie Sanders (I-Vt.) nabbed a coveted endorsement from a big nurses union that went hard for him in 2016.

The New York Times: Big Nurses Union Backs Bernie Sanders And His Push For ‘Medicare For All’

How do you sort out all the contradictory claims about “Medicare for All”? It’s tricky now that the policy has become so entangled with political rhetoric, but The New York Times offers some guidance.

The New York Times: Examining Conflicting Claims About ‘Medicare For All’


More details are emerging about the communications contracts Seema Verma, the administrator for the Centers for Medicare & Medicaid Services, gave to outside contractors—including a longtime ally of hers who was greenlighted to bill as much as $425,000 for about a year’s worth of work. The decision to pay so much on a communications strategy that in part was meant to burnish her personal brand stands in stark contrast to Verma’s views on Medicaid spending and waste.

Politico: Federal Health Contract Funneled Hundreds Of Thousands Of Dollars To Trump Allies

Elsewhere in the administration, the Environmental Protection Agency is preparing a rule that at first glance might not catch your attention but could have major repercussions. The proposal, which the administration says is meant to increase transparency, would require scientists to disclose all their raw data (including medical records) before research can be considered by the agency while it’s making rules. But what that means is that the EPA doesn’t have to consider older studies that were done under the promise of medical confidentiality.

If that all still seems a little obscure, here are some the topics of those older studies: lead causing behavioral disorders in children; mercury from power plants impairing brain development; and air pollution leading to premature deaths. The proposal would be retroactive.

The New York Times: E.P.A. To Limit Science Used To Write Public Health Rules


There was a breakthrough this week in scientists’ scramble to find the root cause of the mysterious vaping-related lung illness (officially called EVALI, but between you and me I don’t think that’s caught on at all). It appears that Vitamin E oil might be one of the main culprits. Apparently it turns sticky like honey and coats the inside of vapers’ lungs. Why is it in the products at all? Sellers use it to thicken the vaping fluid or dilute the THC used, boosting their overall profits.

The New York Times: Vaping Illnesses Are Linked To Vitamin E Acetate, C.D.C. Says

Meanwhile, a hospital announced that it successfully performed a double-lung transplant on a teenager who was facing “certain death” without it.

The New York Times: Facing ‘Certain Death,’ Teenager With Vaping Injury Gets Double Lung Transplant


The Food and Drug Administration sent a warning letter to the Dollar Tree for selling over-the-counter medications from companies that failed to ensure the drugs were safely manufactured and tested. One such company was found to have had rodent feces throughout its facility.

Stat: FDA Slams Dollar Tree For Purchasing Drugs From Suppliers With Checkered Safety Records


In the miscellaneous file for the week:

• Hate crime murders in the U.S. reached a 27-year high in 2018, according to a new FBI report. “We’re seeing a leaner and meaner type of hate crime going on,” said one expert, referring to the fact that crimes on people themselves had increased while things like vandalism had gone down.

CBS News: FBI Hate Crimes Data Released Today: Hate Crime Murders Hit Record In 2018; Crimes Targeting Transgender People Soar

• Self-harm is prevalent among young people, but there’s little actual research out there on the behavior itself. Often the reaction from loved ones if fear and panic, and an assumption that the teen was attempting suicide. That might not be the case, though.

The New York Times: Getting A Handle On Self-Harm

• This is a fun David and Goliath story about a little pharmacy with only 14 employees that is holding big drug companies’ feet to the fire over the safety of their products.

The Washington Post: A Tiny Pharmacy Is Identifying Big Problems With Common Drugs, Including Zantac

• Kaiser Permanente CEO Bernard Tyson died unexpectedly in his sleep at age 60. Here’s a look at the legacy he left behind.

The Wall Street Journal: Death Of CEO Comes At A Time Of Expansion, Big Bets For Kaiser Permanente


That’s it from me! Have a great weekend.

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Listen: How A Wisconsin Senator Is Trying to Prevent A Vape Flavor Ban

Kaiser Health News Midwest Correspondent Lauren Weber joined host Kealey Bultena on Wisconsin Public Radio’s news magazine “Central Time” to discuss Republican Sen. Ron Johnson’s role in the politics of vaping.

Weber and fellow KHN reporter Rachel Bluth had reported on how the recent crackdowns on vaping amid a surge of mysterious lung injuries are politicizing vapers. Johnson, who in 2016 thanked vapers for helping him win his reelection bid, has publicly urged President Donald Trump to back away from banning flavored e-cigarette products.

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Children Are Having Exposure To Pornography Younger And Younger, But Little Guidance Is Being Offered By Adults In Navigating It

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First Edition: November 15, 2019

Surgeon General’s Marijuana Warning Omits Crucial Context

Speaking about a recent federal advisory on marijuana, Dr. Jerome Adams, the surgeon general, put a new spin on long-standing admonitions about the drug.

“Marijuana has a unique impact on the developing brain. It can prime your brain for addiction to other substances,” Adams said at a Washington, D.C., substance abuse conference held late in August and sponsored by Oxford House, a recovery center network.

This is a reiteration of the old “gateway” argument: the idea that marijuana is frequently an entree to using other, harder drugs. And the surgeon general’s emphasis comes just as many states are loosening restrictions around its medicinal and adult recreational use.

But marijuana research is limited, and this particular hypothesis is fairly controversial. We decided to put Adams’ claim to the test. Is his central thesis ⁠— marijuana has a “unique impact” on developing brains and can “prime your brain for addiction” ⁠— accurate?

We contacted the surgeon general’s office, which directed us to statements from the National Institute on Drug Abuse. NIDA noted that marijuana may have a gateway effect, but that most people who use the drug don’t progress to other, harder substances; and that alcohol and nicotine appear to have a similar impact. But the surgeon general’s office was also unequivocal on a related point: “From a public health perspective, no amount of drug use is safe for the developing brain.”

So how fair is Adams’ statement? When we interviewed experts, the responses were all over the map ⁠— reflecting just how contested this issue is and how difficult it is to speak definitively about marijuana’s impact.

The Gateway Effect?

The idea that marijuana can “prime your brain for addiction” has some basis: namely, the results of some studies conducted with rodents.

There are findings to suggest that early exposure to the drug may “sensitize animals to the effects of other drugs,” noted Joshua Isen, an assistant professor at the University of South Alabama, who researches adolescent marijuana use.

For instance, Adams’ office noted that preclinical studies indicate exposure to THC ⁠— marijuana’s main psychoactive compound ⁠— during a period roughly equivalent to adolescence in rats resulted in greater self-administration of heroin when the animals reach adulthood.

In addition, THC exposure yielded changes in their brains’ reward system ⁠— in other words, yes, priming the brain for the rewarding effects of opioids.

But, Isen said, it’s scientifically problematic to draw a line from the effects seen in rodents to what might happen to a human. Ethical considerations about human research make it more or less impossible to do a randomized controlled trial ⁠— the gold standard of scientific research ⁠— that would measure how marijuana does or doesn’t affect a developing brain.

“We should remain agnostic about the surgeon general’s claim,” Isen argued.

Other experts suggested otherwise, saying that since animal research is the best we can get, it’s worth taking seriously ⁠— and it is fairly conclusive.

Jonathan Caulkins, a professor and drug policy researcher at Carnegie Mellon University in Pittsburgh, took a more optimistic view of that research, arguing that the animal evidence is “very clear” when it comes to marijuana’s neurological impact. He called it a fair basis for the surgeon general’s warning.

“What we know is strong enough to say that exposure during adolescence when the brain is developing is a risk,” said Susan Weiss, a scientific adviser to the NIDA director.

But how meaningful a risk ⁠— and how it compares with other drugs ⁠— is exceptionally tough to say, given the limitations on research. Studies on humans are limited because people who use marijuana at a young age may be exposed to other risk factors, such as peer influencers using harder drugs, or sociodemographic factors that might predispose them to abuse or addiction.

As Dr. Sue Sisley, an Arizona-based psychiatrist who tracks the state of marijuana research, put it: “I don’t see very much good, rigorous data to confirm either way.”

What About Uniqueness?

In the narrowest sense, marijuana indeed has a “unique” effect on the brain. It elicits a response from what are called “endocannabinoid receptors.” Other drugs don’t ⁠— they interact with different brain receptors. So, certainly, marijuana affects development using a different (or “unique”) neurological mechanism from the ones used by, say, nicotine or alcohol.

And, as best as science can tell us, marijuana harms developing brains, both Weiss and Sisley said. From a commonsense public health perspective, young people in particular should be exceptionally cautious when using the drug.

But ⁠— and this is important context ⁠— marijuana is not the only substance that has this potential “priming” for subsequent addiction. The surgeon general’s office acknowledged this finding when we asked follow-up questions. That same context, though, is missing from Adams’ public statement.

“It seems that early exposure to many substances can make it likely someone will be addicted to other substances,” Weiss said. She acknowledged that rodent studies do also suggest nicotine may have a priming effect, albeit via a different neurological route.

On a practical level, Isen said, while one could highlight the distinct scientific effect marijuana has, “there is no evidence that marijuana has a uniquely deleterious effect on the developing brain — certainly not more than other substances such as alcohol.”

Our Ruling

Speaking about the risks associated with marijuana, the surgeon general said it “has a unique impact on the developing brain” and “can prime your brain for addiction to other substances.”

The implications are tricky, and it’s important to note the significant limitations on marijuana research, as well as how it compares with other drugs. It may have its own, unique mechanism of “priming” adult addiction.

Still, other substances have similar effects ⁠— even if they take a different brain path to get there. And since this idea about marijuana’s priming effect is central to Adams’ broader public health campaign, emphasizing that nicotine and alcohol also could function in this manner matters even more.

This statement is partially accurate, but it leaves out important details and context. We rate it Half True.

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KHN’s ‘What The Health’: Spending Bill Slowdown


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The fiscal year started a month and a half ago, but Congress has still not agreed on an annual spending bill for the Department of Health and Human Services – or any of the other annual spending bills that fund the government.

Meanwhile, Congress IS moving on efforts to further restrict tobacco and vaping products, particularly to limit their marketing to underage users. The Trump administration has been vowing to use its own authority to crack down on a youth vaping epidemic, but so far has not acted.

The administration is moving on the drug price front, however, filing a lawsuit against drugmaker Gilead for allegedly infringing a government-owned patent on a drug regimen to prevent HIV.

This week’s panelists are Julie Rovner from Kaiser Health News, Rebecca Adams of CQ Roll Call and Alice Miranda Ollstein of Politico.

Rovner also interviews Dan Weissmann, host of the podcast “An Arm and a Leg,” about why health care costs so much and what patients can do about it. KHN is co-producing the podcast’s new season.

Among the takeaways from this week’s podcast:

  • Among the partisan arguments holding up the HHS funding bill are disagreements on spending for family planning programs and the amount of an increase for HHS as a whole.
  • A House subcommittee this week approved new regulations that would limit flavors for vaping and other tobacco products. But that comes as the administration appears likely to step back from Trump’s earlier vow to outlaw flavored products.
  • Some lawmakers and administration officials suggest that any legislation to prohibit flavored e-cigarette products should include carve-outs for some groups, including small businesses that cater to vapers and to members of the military.
  • The recent revelation that Google is working with a major health care system to analyze patient records is raising concerns about consumers’ privacy. That and other recent issues surround health care tech may signal that the federal privacy law, HIPAA, needs to be updated.
  • The Trump administration’s suit against Gilead seeking to bring down costs of its HIV pre-exposure prophylaxis drug may signal that the government is ready to take on other companies with high price tags on drugs developed with federal support.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: The Philadelphia Inquirer’s “A Philly woman’s broken back and $36,000 bill shows how some health insurance brokers trick consumers into skimpy plans,” by Sarah Gantz.

Rebecca Adams: CQ Roll Call’s “Surprise billing fight highlights hurdles for bolder health care changes,” by Mary Ellen McIntire.

Alice Ollstein: Politico’s “Trump allies received hundreds of thousands of dollars under federal health contract,” by Dan Diamond and Adam Cancryn.


To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

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Nursing Home Safety Violations Put Residents At Risk, Report Finds

As huge swaths of California burned last fall, federal health officials descended on 20 California nursing homes to determine whether they were prepared to protect their vulnerable residents from fires, earthquakes and other disasters.

The results of their surprise inspections, which took place from September to December of 2018, were disturbing: Inspectors found hundreds of potentially life-threatening violations of safety and emergency requirements, including blocked emergency exit doors, unsafe use of power strips and extension cords, and inadequate fuel for emergency generators, according to a report released Thursday by the U.S. Department of Health and Human Services Office of Inspector General.

The nursing home residents “were at increased risk of injury or death during a fire or other emergency,” the report concluded.

The threat is not theoretical in a state that has been ravaged by natural disasters: One of the nursing homes that was inspected burned down in a wildfire afterward, so the report only includes results for the 19 remaining facilities, which it does not identify.

“The fact that one of the nursing homes inspected was later destroyed by a wildfire speaks to the grave danger residents are facing today,” said Mike Connors of the advocacy group California Advocates for Nursing Home Reform. He called the findings alarming but not surprising.

Even though the report didn’t name the nursing home that was destroyed, the California Association of Health Facilities, which represents most of the state’s skilled nursing facilities, identified it as one that burned down in the November 2018 Camp Fire, the deadliest wildfire in the state’s history.

Craig Cornett, CEO and president of the association, said all the residents were evacuated safely from that home — and from two others destroyed in the same fire. Hundreds of other nursing homes also have responded to emergencies in the past three years without loss of life, he said, which shows that “the deficiencies in the report do not reflect true facility readiness.”

The association is concerned about safely violations, he added, but “this is an example of bureaucracy equipped with blinders.”

The federal auditors said the violations occurred because of poor oversight by management and high staff turnover at the homes. But they also criticized the California Department of Public Health, the agency responsible for overseeing nursing homes in the state, for not ensuring the homes complied with federal safety and emergency requirements.

In some cases, the state’s own inspectors had previously cited nursing homes for the same problems, but did not inspect the facilities again to ensure they had been fixed, the report said.

The department “can reduce the risk of resident injury or death by improving its oversight,” the report said. For example, it could “conduct more frequent site surveys at nursing homes to follow up on deficiencies previously cited rather than relying on reviews of documentation submitted by nursing homes.”

The public health department told the auditors it had followed up with the 19 remaining homes to ensure they were addressing the problems auditors identified. But the state disagreed with the auditors’ recommendation to inspect nursing homes more frequently, saying in a letter to the auditors that federal rules don’t require onsite visits to determine whether problems have been fixed — and that the agency simply does not have enough inspectors.

The department declined a California Healthline request for comment.

The Office of Inspector General is auditing nursing homes across the nation that receive payments from the public health insurance programs Medicare or Medicaid to determine whether the facilities meet the stricter federal safety and emergency guidelines that were adopted in 2016. The auditors did not choose the 20 nursing homes randomly out of the approximately 1,200 statewide, but rather selected those in fire- and earthquake-prone regions, as well as ones already on notice for health and safety violations.

The inspectors found a total of 325 violations at the 19 homes. Among them:

  • Two of the homes had pathways leading to emergency exit doors that were blocked, including one exit door blocked by a pallet.
  • 16 had violations related to their fire alarm and sprinkler systems, including two that didn’t have their fire alarm systems routinely tested and maintained.
  • All had violations related to electrical equipment, including using power strips that did not meet requirements or were unsafely connected to appliances or other power strips.
  • Eight had not properly inspected, tested and maintained their emergency generators, which provide electricity for critical medical equipment during a power outage. Two didn’t have enough generator fuel to last 96 hours. Generator power has become critical for nursing homes in recent months amid widespread power shutdowns aimed at preventing wildfires.
  • Three nursing homes’ emergency plans didn’t address evacuations.

“We don’t want reports like this,” said state Sen. John Moorlach (R-Costa Mesa). “It sounds like maybe we need to ask the state auditor to see if the site visits done by the state are being done thoroughly.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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