Health Insurers Seek Rate Increase

Despite dramatic decrease in claims costs due to the pandemic, health insurers seek rate increase for 2021

Earlier this month, New York’s insurance plans asked the State Department of Financial Services to consider a weighted average rate hike of 11.7 percent in the individual market and a weighted average increase of 11.4 percent in the small group market for 2021. The 2021 average rate increase request is higher than last year’s average request of 8.4 percent in the individual market.  This request perplexes those of us in the healthcare business.

With fewer claims costs because elective procedures were halted for two months during the peak of the coronavirus crisis and fewer individuals venturing out, even now, to access healthcare, shouldn’t there be a decrease in rates?

What’s the Reason?

Some plans cite increased costs due to COVID-19 as the reason for the rate hikes.  Fidelis Care, which requested the second largest increase at 18.8 percent, says it took into account the increased risk and uncertainty caused by the pandemic when calculating its 2021 rate increase request.  Fidelis does business in nearly all of New York’s 62 counties.

New York State requires health insurers to seek pre-approval for premium rate hikes.  Plans must present reasonable justification for their increase requests.  Typically, plans will look at prior year claims costs and activity, medical cost trends, and the medical inflation rate when determining rates for the upcoming year.   The state’s Medical Loss Ratio regulation also comes into play.  It requires plans to spend  82 percent of premium dollars on direct care and quality improvement activities.  If plans exceed this ratio, money is returned to consumers. The New York State Department of Financial Services ultimately decides the percent increase it will allow.  We will know that in August.

The State Acts

While it is true that health plans did not and still do not collect co-pays for COVID testing when an in-network provider is used, the sheer drop in patient claims for routine care and cancelled elective surgeries more than balanced this. The state issued a Circular Letter on April 22, 2020 directing health plans to take a variety of steps to alleviate the financial burden imposed by COVID-19 on hospitals and help them with their cash flow.  Some of these steps included no retrospective reviews, no medical necessity denials, resolution of appeals within 60 days, and a requirement that plans work directly with hospitals and provide some financial assistance, especially to those hospitals that were severely cash-strapped.  Nevertheless, many hospitals report that plans have not acted in good faith to ease the cash crisis, despite the health plans’ ever-growing reserves.  The letter’s directives expired June 18th but an extension is under negotiation.

Predicting Health Costs

PwC’s Health Research Institute recently issued a report that detailed several economic scenarios that could play out next year.  The report projects that the medical cost trend could range from a high of 10 percent to a low of 4 percent.

The surge in telehealth has also driven down costs for health insurers.  These visits are reimbursed at a lower rate.  In the Northeast, telehealth claims increased by 4300 percent, during the peak of the pandemic, according to nonprofit Fair Health’s monthly telehealth tracker .

We can’t figure out how COVID-19 imposed undue financial burden on health insurers.  Let’s hope the State Department of Financial Services keeps that fact in mind when it reviews the plans’ rate increase requests for 2021.

About the Suburban Hospital Alliance of New York State 

The Suburban Hospital Alliance of New York State advocates on behalf of hospitals in the Hudson Valley and Long Island regions. It engages key lawmakers and regulatory decision-makers in Albany and Washington to ensure reasonable and rational health care policy prevails.

About the Nassau-Suffolk Hospital Council (NSHC)   

The Nassau-Suffolk Hospital Council represents the not-for-profit and public hospitals on Long Island. It works in conjunction with the Suburban Hospital Alliance of New York State to advance legislative and regulatory priorities.  NSHC serves as the local and collective voice of hospitals on Long Island.

About the Northern Metropolitan Hospital Association (NorMet)  

The Northern Metropolitan Hospital Association represents the not-for-profit and public hospitals in the Hudson Valley region. It works in conjunction with the Suburban Hospital Alliance of New York State to advance legislative and regulatory priorities.  NorMet serves as the local and collective voice of hospitals in the Hudson Valley.


Hospital Association Reminds the Public that Hospitals are Responsive, Resilient, Ready

Campaign draws attention to safety, infection control protocols

Delaying care can lead to more acute and complicated health problems

We have come a long way since New York recorded its first coronavirus patient on March 1, 2020.  Thankfully, today, the number of daily coronavirus cases has decreased dramatically.

Now, fears about utilizing hospitals and physician offices for routine, but necessary care could spark another crisis of sorts.  Routine care, screenings, and vaccinations serve to blunt more complex health issues if left unattended.   Delaying care is not the healthiest option.  All hospitals in the suburban regions were recently given the green light to resume elective surgeries and scheduling a procedure sooner rather than later is a wise decision.

NorMet 1NSHC 12







It is understandable that patients are wary of accessing care, and they fear for their safety in such settings.  But throughout this pandemic, hospitals took extraordinary measures with infection control and safety protocols to protect patients and staff.  This continues full force.  Social distancing in waiting areas, temperature checks, and deep sanitization, are some of the measures your healthcare providers are taking to keep you safe during your next visit.

Recent studies and polls show that many consumers are delaying care – some with telltale signs of heart attack or stroke are not going to the emergency department where immediate care and minutes are critical to a positive outcome.  One study shows ischemic stroke patients are arriving at the ER 160 minutes later as compared to a similar timeframe in 2019.

A poll conducted in late April by the American College of Emergency Physicians and Morning Consult found that nearly a third of American adults (29 percent) delayed or avoided care due to fears about contracting the coronavirus.  A Kaiser Health poll conducted several weeks later found that nearly half of the adults surveyed said they or a family member skipped or delayed care due to the coronavirus. But most said they expect to access care within three months.

Responsive, Resilient, Ready – this is the message healthcare providers throughout the Hudson Valley and Long Island regions have for patients.  The world has changed, but their care has not.  Consumers can read about the specific steps that hospitals in their area are taking to keep patients safe during their next in-person visit by visiting the Responsive, Resilient, Ready page maintained by the Suburban Hospital Alliance.

Consumers should also keep in mind that a region’s ability to remain open hinges on a few metrics maintained by hospitals.  Ensuring that timely primary care and other care needs are handled in the community ensures that hospital capacity is not overtaxed with critically patients.  As part of the governor’s New York Forward Plan, hospitals must maintain a 30 percent hospital bed and ICU bed capacity at all times.

About the Suburban Hospital Alliance of New York State

The Suburban Hospital Alliance of New York State advocates on behalf of hospitals in the Hudson Valley and Long Island regions. We engage key lawmakers and regulatory decision makers in Albany and Washington to ensure reasonable and rational health care policy prevails.

About the Nassau-Suffolk Hospital Council (NSHC)   

The Nassau-Suffolk Hospital Council represents the not-for-profit and public hospitals on Long Island. It works in conjunction with the Suburban Hospital Alliance of New York State to advance legislative and regulatory priorities.  NSHC serves as the local and collective voice of hospitals on Long Island.

About the Northern Metropolitan Hospital Association (NorMet)  

The Northern Metropolitan Hospital Association represents the not-for-profit and public hospitals in the Hudson Valley region. It works in conjunction with the Suburban Hospital Alliance of New York State to advance legislative and regulatory priorities.  NorMet serves as the local and collective voice of hospitals in the Hudson Valley.

Coronavirus Impacts Minority Communities Disproportionately

Chronic diseases, a compromising factor for coronavirus, also run higher in these communities as do social determinant of health inequities

While the Covid-19 pandemic is ravaging all of New York State, from Montauk on Long Island to Mahopac in the Hudson Valley, many minority communities are feeling the effects more than others. Underlying chronic conditions such as hypertension, chronic obstructive pulmonary disease (COPD), and asthma are some of the chronic conditions that also disproportionately affect minorities.  Public health researchers also note that most of these communities endure inferior housing, higher unemployment, and less access to affordable healthy foods – factors known as the social determinants of health.

In early April, the state began to see a trend where communities of color were contracting COVID-19 at a higher rate than their white counterparts.  In response, the governor opened five new testing sites in downstate minority communities and requested state staff to investigate this disheartening trend.  The Centers for Disease Control and Prevention (CDC) is also tracking this COVID-19 incidence disparity.

But health disparities among minority communities are nothing new. The coronavirus pandemic just brought them to light in a more profound way rather quickly.  It is a perverse silver lining to a persistent problem that has plagued healthcare providers, public health practitioners, and researchers for years.

The Numbers on Long Island

In Nassau County, 17 percent of residents who died from coronavirus were black, while they only make up 11.7 percent of the population. In Suffolk County, blacks made up 11 percent of deaths and only eight percent of the county’s population.  Percentages were derived from the New York State Department of Health COVID-19 data posted on April 14, 2020, and the U.S. Census Bureau 2018 American Community Survey.

The Numbers in the Hudson Valley

Some regions of the Hudson Valley are seeing their unfair share of minority communities being disproportionately infected by the coronavirus.  According to state data as of the end of April, in Westchester County age-adjusted deaths from COVID-19 per 100,000 of the population revealed the rate for Hispanics was 96.7 per 100,000 and for blacks 104.5 per 100,000.  The rate for whites was half.  It is a similar story in Orange County and Rockland County.  In Orange, the rate was 66.2 per 100,000 of the population for Hispanics, 89.1 for blacks, and only 32.1 for whites.  The rates in Rockland County were 133.5, 176.4, and 73.3, respectively.

The state’s analysis of May data for newly diagnosed COVID-19 patients shows these disparities are continuing in both of these suburban regions.

The NYS-Covid-19 Tracker reports that outside of New York City, blacks make up 17 percent of coronavirus-related fatalities, while Hispanics account for 14 percent of deaths. These are revealing statistics as blacks and Hispanics make up only nine percent and 12 percent of the New York State population, excluding New York City, respectively. The report also shows that 88.5 percent of all fatalities suffered from at least one comorbidity.

Long before the days of coronavirus, communities of color were experiencing disparities related to the social determinants of health (SDOH).  These are the conditions in the environment in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. These conditions include economic stability, education, social and community context, healthcare, and neighborhood and built environment.

Black and Hispanic families are more likely to live in areas with higher rates of poverty and are less likely to have access to resources such as quality health coverage, access to new treatments, and paid time off from work. The lack of a federal paid leave policy forces low-income workers to choose between staying home from work when sick and not losing wages.  Those who go to work ill are potentially spreading the coronavirus. Many minority workers are also essential workers who do not have a work-from-home choice. These historical health inequities that affect communities of color are also why they are more likely to suffer from chronic diseases such as asthma, hypertension, and diabetes – the underlying, chronic conditions that make them more vulnerable to the coronavirus.


The importance of programs combating chronic diseases, especially in high-need communities, is more necessary than ever.  And equally important, are social determinant of health interventions that work in tandem with medical care.  Hospitals offer a variety of programs and services to help patients manage their chronic diseases, including culturally-sensitive outreach programs that connect with minority communities.  There are onsite hospital-based “farmacies” that equip discharged patients, who have a diagnosis tied to a nutritional need, with bags full of vegetables, fruits, and other healthy foods to set them on their way to healing.  Other hospitals provide medical transportation, either fully-covered or subsidized.

Some health plans also fund social determinant of health interventions.  One plan embeds nutritionists in primary care offices.  Another co-locates social workers so patients’ behavioral needs are addressed during a routine visit.

However, we know more needs to be done to eliminate health disparities.  COVID-19 has made that glaringly apparent. The solutions are not easy and they cost money.  Public and private partnerships have made only a small dent in the need.  But if we are to improve mortality and co-morbidities stemming from chronic diseases we have to intensify our efforts now.

Part of those efforts include chronic disease self-care and management – tools to help individuals easily adapt healthier lifestyle changes, which are scientifically proven to improve health.  The Live Better campaign offered by the Long Island Health Collaborative is designed to do just that – raise awareness about better self-care of chronic diseases.  It provides basic education and links to helpful community and hospital-based programs.

If we chip away at the incidence of chronic diseases now then if and when another contagious epidemic strikes we will be more resilient individually and societally.

Learn more about hospital and health policy and regulations at Suburban Hospital Alliance of New York State.






For Your Own Well Being, Use News Correctly

This month we feature guest blogger Jaci Clement, CEO and Executive Director, The Fair Media Council, a nonprofit organization working to improve the public conversation on the hyperlocal, regional, and national levels.  There is a constant barrage of information related to the COVID-19 pandemic, especially for those of us in the health, social, and human services sectors.  It is daunting to say the least, particularly as we are all overwhelmed with our daily jobs whether those jobs are in direct patient care or behind-the-scenes.  Our guest blogger offers expert advice on how to safely consume news during this stressful time.

You’ve heard it said countless times – when it comes to your health, everything in moderation.  Yet, you’ve probably never thought to apply that same rule to your usage of news coverage.

Today, the concept of a balanced approach to using news is ever more vital, as the 24/7 news cycle brings us severe news and information in relation to the COVID-19 pandemic. The good news is it is quite easy to get your news habit in check.

  • First, remember you have total control over how much news you allow into your life. When the news is at its darkest, it’s best to set limits, for your own well being. As a best practice, read newspapers (print or online) in the morning, then use television, radio and the Internet to give you updates on the news throughout the day. The reason is simple. Newspapers provide the most detail and background of a news story, compared to other formats of news, which are designed to sum up a story quickly and provide the latest developments.
  • If you rely heavily on your phone to bring you the news, don’t be alarmed if you are constantly getting updates. That doesn’t mean something horrible has necessarily happened; it just means each news outlet you follow is doing its job. Today’s news is highly repetitive to cater to our shorter attention spans and greater demands on our time. Consider muting some of the voices you follow, even if only temporarily, if you are having difficulty balancing your time and the news.
  • One of the top complaints about news is: Too much opinion, not enough facts. Fair enough. Here’s the answer to that. Prioritize news over commentary, because the commentary is opinion driven.
  • When it comes to television, limit your time watching talk shows. Some people have a hard time distinguishing between a news program and a talk show, so here’s a rule of thumb. If someone is reporting the news, it’s a news program. If someone is talking about what’s in the news, it’s a talk show. You can also check the guide on your television menu to verify a talk show or news program — although not all menus carry this information.
  • Also, keep in mind: the cable news networks don’t report news for 24 hours a day. In fact, a look at the FOX News Channel’s daily lineup showed at least 16 hours of talk shows within a 24-hour span. CNN does news, talk shows and documentaries. Watch whatever you want; just know what you’re watching.
  • Breaking news is what people tend to give too much credence to, and here’s why. On a regular day, breaking news should be taken with a grain of salt, because the speed at which the news is being reported often prevents it from being fact-checked by multiple sources. (To be fair, outlets are slowing things down a bit these days, as credibility comes back into vogue.) Breaking news during a pandemic often changes dramatically from what is originally reported, because the sources — the doctors and authority figures — aren’t sure of the answers. For instance, social distancing started at three feet, then went to six feet, then moved to “at least six feet.” Masks and gloves were not advised for the general public, now they are. Just think of breaking news the way you think of the 1.0 version of any app. You know it will be full of bugs that will be worked out later.
  • One of the biggest changes in news is how it hangs around for a long time, so you shouldn’t have a fear of missing out. The story will be there, if not being repeated during a broadcast then available online. That should give you comfort to know you can tune it out and go about your daily life, then check in to see what’s going on at your convenience. Reach Jaci at:

Go to COVID-19 Information Sources:

New York State Department of Health 

Centers for Disease Control and Prevention

Centers for Medicare and Medicaid Services

Healthcare Association of New York State

Suburban Hospital Alliance of New York State

Medicaid Ensures Access, Especially Vital During Infectious Disease Outbreak

It’s always a good idea to get back to basics when a topic becomes more and more complex as the years move along.  That is the case with New York State’s Medicaid program.  And, during the current coronavirus crisis, it is especially important to understand the necessity of such a public program to ensure everyone has access to healthcare during an infectious disease outbreak.   About one-third of the state’s population of – 19.5 million people – is covered by Medicaid.

The federal government established Medicaid in 1965 to provide health insurance to poor and low income families and individuals and to disabled children and adults.  Each state administers its Medicaid program and receives federal matching dollars.  In New York’s case, that is about 50 percent; many other states receive a higher federal match.

New York has witnessed increasing enrollment in Medicaid, especially since the state expanded its program under provisions of the Affordable Care Act.  According to the United Hospital Fund’s Medicaid Institute, enrollment increased by more than 36 percent between 2009 and 2015, though much of this population was inexpensive to cover.  For example, children account for 37 percent of the Medicaid population, but less than 20 percent of the Medicaid expenditures.  Members who are eligible for both Medicaid and Medicare comprise 13 percent of the total population, but generally represent the most medically complex patients and therefore incur higher costs.   About half of all Medicaid dollars are spent on long-term care, like nursing home and home care services.

Who Are Medicaid Recipients?

The majority of Medicaid recipients are individuals we encounter in our daily lives – grandparents, neighbors, friends, children, and even some co-workers.  Contrary to popular belief, the vast majority of Medicaid enrollees – 87 percent – are children, the elderly, the disabled and working-age adults with jobs. The Kaiser Family Foundation’s website features the stories of Americans who are Medicaid recipients and how this program serves as a lifeline.

New York’s Medicaid program is quite comprehensive compared to other states.  Benefits include regular exams, immunizations, doctor and clinic visits, relevant medical supplies and equipment, lab tests and x-rays, vision, dental, nursing home services, hospital stays, emergencies, and prescriptions.  Costs for long-term care either provided in a nursing home or in a patient’s home are by far a major driver of the program’s escalating price tab in recent years.  Enrollment in and the cost of the state’s managed long-term care program has been growing at about 13 percent per year.

Funding Is Fragile

Governor Cuomo’s 2020 – 2021 state budget proposes cuts and changes to the Medicaid program in order to close a $6.1 billion budget hole.  His office estimates that about $4 billion of the total deficit is attributable to Medicaid expenses.  The governor formed a Medicaid Redesign Team II  (MRT II) as the venue through which the state will find $2.5 billion in Medicaid savings in the upcoming state fiscal year and will ensure that Medicaid spending in future years stays within the global Medicaid cap.  The cap was a recommendation forwarded by the MRT I when it convened in 2011.  At that time, the state was facing a $10 billion deficit.  The cap, which is tied to the Consumer Price Index, restricted Medicaid spending growth to about four percent annually.  For the most part, it has worked, until recently.  The MRT has a very short window of time in which to present its recommendations for savings to the governor and legislature so the recommendations can be incorporated into the 2020-2021 state budget.

It is difficult to predict, at this time, what the MRT will recommend, but hospitals certainly cannot absorb any more cuts to Medicaid reimbursement.  On January 1, 2020, the state health department instituted an across-the-board one-percent reduction in Medicaid payments to providers through the first quarter – March 31, 2020.  It is a total reduction of $124 million.  Those most affected by continuing Medicaid cuts are the most vulnerable New Yorkers among us.  We hope the governor and state legislators keep the “faces of Medicaid” in mind, as they deliberate the budget and make recommendations for changes to the Medicaid program.  About six million New Yorkers’ access to healthcare hinges on their decisions.


Hospitals Ready for Coronavirus

While 2019-nCoV (coronavirus) is new, hospitals have lots of experience handling emerging infectious diseases.  Think of the seasonal flu.  It varies year to year in both its potency and molecular design.  The current flu season officially began September 29, 2019, and was declared prevalent by the New York State Health Commissioner on December 5, 2019.  In terms of reach, this season’s flu is infinitely more widespread in the United States than the coronavirus.  Consider that there are 14 confirmed cases of coronavirus in the U.S. and 121,088 confirmed cases of the flu in New York State this season.  At present, there have been no confirmed cases of coronavirus in New York State.

But that does not mean there is a zero threat from this pathogen.

Hospitals remain vigilant and are prepared to handle any patient who presents with coronavirus.  All facilities follow strict infectious disease protocols that begin with immediately isolating the patient so that staff and the public are kept safe.   Anti-viral drugs and supportive therapies are the best defenses we have to fight this virus.  Once diagnosed with the coronavirus, rest, fluids, and fever reducers are in order.  This is the same treatment plan in place for the seasonal flu.

Hospitals learned many lessons about containing an infectious disease during the Ebola outbreak in 2014.  With one confirmed Ebola case in New York State and only a handful of other cases noted in the United States, the Centers for Disease Control and Prevention (CDC), state health departments, and local county health departments lost no time in preparing for more widespread disease occurrence.  This positioned them well to deal with the current coronavirus and other novel and emerging infectious diseases.  Today, in every hospital emergency department, patients are asked whether they returned from recent travel outside the United States whether or not there is a current pandemic in place.  The New York State Health Department also requires hospitals to hold surprise emergency preparedness drills on a regular basis.

During a pandemic, such as the coronavirus, communication is key.  The World Health Organization  (WHO) deemed the coronavirus outbreak a public health emergency of international concern on January 29, 2020 and the U.S. Department of Health and Human Services (HHS) declared it a public health emergency two days later.  As a result, hospital staff have been in constant communication with the CDC, the state health department, and their local county health departments to ensure they have the most up-to-date information about the spread of the disease and that proper infectious disease control procedures and methods are in place.

At the very local level, hospitals and the broader healthcare community keep in touch.  In the Hudson Valley – MACE – Mutual Aid Coordinating Entity – works cooperatively to keep tabs on regional supplies and personnel resources.  In Suffolk County, that task falls to the Suffolk County ESF 8 Group (Emergency Support Function) and in Nassau County it is the Health and Medical Multi-Agency Coordinating Group (HMMACG).

But back to the coronavirus.  Just what is it, and how do we keep ourselves safe.  Coronaviruses are a large family of viruses that cause illness ranging from the common cold to more severe diseases such as Severe Acute Respiratory Syndrome (SARS), which emerged in 2003.  Common signs of infection include fever, cough, shortness of breath, and breathing difficulties.  In more severe cases, infection can cause pneumonia, SARS, kidney failure, and even death.   As the coronavirus is so new, scientists and epidemiologists are working to pinpoint the virus’ transmission process, which appears to be airborne, and other characteristics of this novel infectious agent.  While they make progress, the best defense right now is to frequently wash one’s hands, cough and sneeze into one’s elbow, stay home if any signs of viral infection emerge, and place a call to one’s physician for further instructions.  The same advice public health officials give for combating the flu.

Hospitals Urge Flu Vaccination

The New York State Health Commissioner declared the influenza prevalent in our state on December 5, 2019.   That set in motion a state regulation that requires healthcare workers who are not vaccinated against the flu to wear surgical masks in areas where patients are typically present.  This is why you may see some hospital employees wearing masks and some not.  Once the commissioner declares the flu no longer prevalent or widespread, masks are not needed. The regulation also requires hospitals to maintain records documenting the influenza vaccination status of all personnel for the current flu season.

But the resounding message of this declaration is that everyone who has not yet received their flu vaccine should do so immediately.

People often think of the flu as a non-threatening viral infection, but for the elderly, pregnant women, children younger than 2 years old, and anyone with a compromised immune system, there can be drastic complications.  These include pneumonia, bronchitis, and sinus infections.  Those who have a chronic illness could experience a worsening of their chronic disease problems.   This is why the Centers for Disease Control and Prevention (CDC) recommend that everyone six months and older get a flu vaccine.

During the 2017 – 2018 flu season, the most recent one for which CDC has statistics, the agency estimates that influenza was associated with 45 million illnesses, 21 million medical visits, 810,000 hospitalizations, and 61,000 deaths.  It says this burden was higher than any other season since the 2009 swine flu pandemic.  It further estimates that the flu vaccine during that season prevented 6.2 million illnesses, 3.2 million medical visits, 91,000 hospitalizations and 5,700 deaths associated with the flu.

There is no question that flu vaccination saves lives, healthcare dollars, and prevents misery among those who contract the flu and suffer its symptomatic consequences throughout the duration of the infection.   Everyone should get vaccinated.  And even though we are well into the 2019 -2020 flu season, vaccination still makes sense.   Although the effectiveness of the vaccine can vary, some protection is better than no protection.

During the week ending December 21, 2019, there were 5,301 laboratory-confirmed influenza reports, a 62 percent increase over the prior week.

Contact your local hospital for information about their flu vaccine clinics and other convenient ways for community members to get their flu shot.  Local pharmacies and your primary care physician also administer the flu vaccine.  Most insurance plans cover the cost of flu vaccine and most providers are willing to work with those who are poor and/or uninsured.

Hospitals’ Number One Goal       

During the flu season, hospitals’ priority is to protect patients, employees, and visitors by adhering to strict infection control practices and prevention guidelines.  As a matter of standard practice, all Long Island and Hudson Valley hospitals enforce universally-recognized precautions to prevent the flu.  These include hand washing, the use of hand sanitizers placed conveniently throughout the hospital, as well as goggles and gowns.  In addition, all hospitals adhere to rigorous infection control guidelines and policies every day to ensure a clean environment for patients, staff, and visitors.  These practices are especially important during flu season.  Antiseptic wipes are located in patient rooms, work stations, hallways, and other treatment areas and are easily accessible to hospital employees responsible for sanitizing medical equipment and surface areas.



Healthcare Shoppers Led by Insurers’ Hands

Centers for Medicare and Medicaid Services (CMS) officials say the hospital transparency rule released by the agency on November 15, 2019 is all about “putting the patient first.”  This is the same goal held by hospitals.  However, there is little in this directive that will clarify price information and a lot that will further confuse patients.  Arming patients with price information about procedures and services charged at various hospitals is a lofty ideal, but the reality is this rule will not achieve that. Patients remain essentially powerless to effectively shop and compare prices because they are beholden, for the most part, to accessing care from their insurers’ in-network providers.  At any hospital, customers of each healthcare insurer pay different rates, including members of different plans from the same insurer.  If there is a bargain on appendectomies at hospital A, but your insurance plan does not include that hospital in its network then your price comparison shopping doesn’t mean much to you.

CMS’ asserts that this rule will foster higher-value healthcare by promoting competition and choice because it requires hospitals to make public privately negotiated payer-specific price information for all items and services in multiple formats.  In our market driven economy, this approach is riddled with legal implications and goes well beyond the level of regulation necessary to promote the stated government interest of “putting the patient first.”  Disclosure of prices negotiated with individual health plans would unduly burden hospitals’ ability to enter into competitive contracts, resulting in less choice and even higher prices for consumers.

Is Healthcare Shoppable?

Specifically, hospitals must post a list of five types of standard charges – now defined by CMS as gross charges, payer-specific negotiated rates, the de-identified minimum and maximum negotiated rates, and discounted cash price – for all items and services in a machine-readable format on their websites.  Hospitals must also post the negotiated rates, minimum and maximum negotiated rates, and discounted cash prices for 300 “shoppable” services in a consumer-friendly, searchable way.  CMS will select 70 of these services and 230 will be chosen by the hospital.

In September 2019, the Suburban Hospital Alliance supported the comments that our state and national hospital associations forwarded to CMS when the rule was in its proposed state.  We argued that the rule was more extensive than needed to advance CMS’ interest of putting consumers first.  CMS’ own research indicates that consumers are more interested in their out-of-pocket costs and not the prices agreed upon between payer and provider.  Hospital leaders hold fast to the fact that the best way for consumers to get information about real-time out-of-pocket costs, charges and in-network status is from their health plans.  Any other mechanism will introduce widespread confusion.

Legal Concerns

Further, such disclosure infringes upon intellectual property rights recognized by Congress and individual states. This rule also stymies competition and restrains efforts to widely adopt and implement value-based care contracts.  The disclosure of hospitals’ private insurance contract rates upends the market-based process, wherein hospitals secure competitive and reasonable rates for services.  Making this private contract information public will compromise market dynamics.  It also raises serious anti-trust concerns.  The Federal Trade Commission holds that price transparency be limited to “predicted out-of-pocket expenses, co-pays and quality and performance comparisons of plans and providers.”  This is the price information patients truly seek.

The rule goes into effect January 1, 2021.  Hospitals that do not comply will be fined $300 per day, or $109,500 per year, says CMS.  The hospital field has vowed to file a legal challenge to this rule on the grounds that it exceeds the Administration’s authority.

Hospitals want consumers to have all the information they need to make informed healthcare decisions.  That begins with timely, accurate insurer estimates of patients’ out-of-pocket costs, including estimates from the insurer that account for complexities that may arise during the course of treatment and/or procedure.

New Insurer Rules

CMS also issued a proposed rule on November 15th that would impose new requirements on private insurers in the individual and group markets to publicly disclose negotiated rates and real-time, personalized access to cost-sharing information.   Comments on this proposed rule are due January 15, 2020.

Learn more about healthcare policy, legislation and regulation at:

All Cost of Care Is Not Equal

The hospital field and the Centers for Medicare and Medicaid Services (CMS) do not see eye-to-eye when it comes to fair reimbursement for basic clinic visits, known in medical terminology as evaluation and management services, when these specific services are provided by a hospital-owned outpatient department located off the hospital’s main campus.  These off-campus clinics are key sources of primary care and other physician services throughout Long Island and the Hudson Valley, as well as the state and the nation.  What makes them unique is that patients served by these clinics are generally of lower income and present with more medically-complex conditions, leading to a higher cost of care than would be experienced by a private physician practice in a local community.

Yet, CMS instituted in a 2018 rule that payment to all outpatient hospital clinics should be reduced by 60 percent to match the rate paid to private physician practices.  This ignores the disparity in cost of care in favor of what is familiarly known as “site neutral” payment.  It also ignores the more stringent regulations and oversight hospitals face as opposed to physician offices, and likewise, the costs associated with compliance.

The issue stems back to 2015 when Congress included specific language in the Bipartisan Budget Act of 2015 to exempt from the “site neutral” cut those hospital-owned clinics that were in operation before November 2, 2015.  The 2018 rule essentially ignores Congress’ intent of the statute, and it is on these grounds that the hospital industry takes issue.  In December of 2018, the American Hospital Association filed suit against CMS stating that the rule is executive overreach and contradicts Congress’ original intent.  The suit also challenged Medicare’s own budget neutrality law that requires any reductions in reimbursement to be offset by reinvestment elsewhere in the program.

A federal judge agreed with the hospital industry’s argument and in mid-September ruled that CMS overreached its authority to implement site neutral cuts for basic clinic visits to all hospital-owned outpatient departments.  The U.S. District judge further tasked CMS to develop remedies and required all parties to the lawsuit to submit a joint status report by October 1, 2019. CMS asked a federal judge to reconsider the September 17, 2019 decision, but that was rejected by a federal judge on October 21, 2019. The judge also denied CMS’ request for a stay to consider whether to appeal the order. CMS is likely to appeal the court’s most recent decision.

Lost in all of this legal wrangling is the patient – more specifically, the patient of lower economic means who suffers from a variety of medical conditions and benefits from the comprehensive services a hospital-based outpatient clinic offers.  Hospitals are there to service these patients regardless of their ability to pay.

Fortunately, an overwhelming number of House and Senate members oppose these site neutral cuts because they realize that such steep reimbursement reductions affect hospitals’ overall financial viability.  In that respect, all patients, all constituents in a community are adversely affected.



Battling Opioid Addiction and Mental Health Issues

Favorable Court Rulings, Regulatory Reforms, New Legislation Offer Hope for Patients and Providers

The $572 million that an Oklahoma judge ordered Johnson and Johnson to pay to the state of Oklahoma for the company’s role in the opioid crisis is the first court ruling among hundreds more to be handed down by state and local courts throughout the country.  Such sizable awards earmarked for prevention and treatment will help health providers and public health officials arrest this soaring epidemic.  And while state and county officials battle the issue out in court, including New York’s own attorney general, regulators and lawmakers grapple with the complex web of rules and regulations that govern the provision of substance use and mental health treatment.  With the majority of substance abusers also suffering from a mental health disorder, it’s critically important these two behavioral health issues are addressed in tandem.

In our state, the Office of Alcoholism and Substance Abuse Services (OASAS)  oversees addiction and chemical dependency treatment, and the Office of Mental Health (OMH) oversees treatment related to emotional and psychiatric disorders.  The two offices have historically operated in silos making it difficult for providers, especially hospitals, to care for patients with a dual diagnosis.  That has led to frustrated patients, family members, and even treatment providers.

The Suburban Hospital Alliance of New York State places behavioral health reform, including regulatory changes, enhanced reimbursement, and workforce needs, at the top of its advocacy agenda each year.  Successful treatment for a substance abuse and/or mental health issue is heavily dependent upon the right services being offered in the right setting at the right time.  This requires coordination among various health and social services providers, insurers, and regulatory agencies.

Rules and Regs

Different programs require different levels and types of certifications from the respective oversight agencies and insurers often impose even more rules and regulations upon patients and providers.  However, there has been some relief in the area of insurance denials.  Providers across the state voiced concerns about the rising number of claims denials for behavioral health services.  The state reviewed claims for a handful of services from December 2017 – May 2018 and found high rates of inappropriate denials among the services.  Psychiatric emergency room visits were one of the services with the highest rate of denials. The state is now holding managed care organizations – insurers – accountable for inappropriately denied claims and requiring the organizations to reach a payment agreement with providers.

Prior authorization for certain types of treatment is another roadblock in the management of behavioral health.   Medication Assisted Treatment (MAT)  is an evidence-based and proven approach to treating opioid addiction.  It combines counseling and behavioral therapies with approved medications.  Yet, until this most recent New York State legislative session, commercial insurers and Medicaid managed care plans could require prior authorization for coverage of these highly successful medications.  We are hopeful the governor will sign the legislation.

Buprenorphine is one of the more successful MATs.  It treats opioid addiction by reducing cravings and blocking painful withdrawal symptoms.  Yet, federal prescribing restrictions on the drug limit who can prescribe and how much they can prescribe.   This is often seen as a barrier to care.  Physicians must complete 8 hours of training and complete a waiver in order to prescribe buprenorphine and can only treat up to 100 patients a year.  Another waiver is needed to exceed this cap.  However, the Support Act (2018) extends the privilege of prescribing buprenorphine in office-based settings to clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives until October 1, 2023.  The behavioral health field continues to experience workforce shortages, especially among psychiatrists, and legislation like this will increase access to MAT.  But longer term solutions are needed.  The Opioid Workforce Act of 2019 is one.  It would incentivize the training of physicians who specialize in treating substance abuse disorders and pain management by supporting additional residency slots.

Tragic Toll

According to the Centers for Disease Control and Prevention, on average, 130 Americans die every day from opioid overdose.  New York State’s 2018 Opioid Annual Report shows that, among New York State residents, the number of overdose deaths involving any opioid increased from 1,074 in 2010 to 3,009 in 2016. The age-adjusted rate of deaths involving all opioids in New York State approximately tripled between 2010 and 2016, from 5.4 to 15.1 deaths per 100,000 population.  The state’s quarterly reports on the opioid crisis provide county-level data.  The most recent report was published April 2019.

Promising Alternative

In Suffolk County on Long Island and in Dutchess County in the Hudson Valley, an innovative treatment model in the form of a triage-type, free-standing facility is showing promise for those suffering from any range of behavioral health issues. Suffolk County’s  Diagnostic and Stabilization Hub (DASH) and Dutchess County’s Stabilization Center are open 24/7 and both offer mobile crisis intervention.  They are an alternative to the hospital emergency room, which is often not the best place of care for someone suffering from a mental illness and/or substance use disorder.  Preliminary data show a dip in behavioral-based emergency room visits since the facilities opened.   The new models of care are embraced by area hospitals because they are so highly specialized and focused on mental health care, and they are easing the strain on overcrowded emergency rooms.  In fact, the MidHudson Regional Hospital of Westchester Medical Center is one of the Dutchess County center’s partners.

Cost to Society

The emotional toll of behavioral health issues on patients, families, and society is incalculable.   However, the financial impact in terms of lost productivity, healthcare costs, and missed opportunity is measurable.  The Fiscal Policy Institute recently released a report that specifically looked at the economic impact of the opioid crisis on Long Island, one of the regions hardest hit by the epidemic.  It found that the opioid crisis caused Long Island $8.2 billion in economic damage in 2017 – 4.5 percent of Long Island’s gross domestic product.  Such a report underscores the fact that mental illness and addiction touches everyone, and we are all responsible in some way for solving this public health crisis.

That is the crux of the 2,000 plus lawsuits advanced by states and local counties who believe drug manufacturers, retailers, and distributors have put profits over people and ignited the opioid epidemic.  While Johnson and Johnson said it will appeal the Oklahoma court ruling and any payout could take years, Purdue Pharma, owned by the Sackler family, was denied the family’s request to dismiss New York State’s lawsuit against the pharmaceutical giant.  The ruling was issued by a state judge at Supreme Court in Suffolk County, Long Island.  Meanwhile Purdue Pharma is in talks with the United States Department of Justice to reach a settlement regarding civil and criminal accusations against the company’s role in the opioid epidemic. The deal is complicated by Purdue Pharma’s many local lawsuits with states and counties.

Treatment of mental illness and substance use disorders is difficult enough without the interference of many of the barriers outlined in this blog.  We are, however, making progress.  Hospitals are pushing on all fronts to ensure that those affected by any behavioral health issue get the right care in the right place and at the right time, despite the complexities of our healthcare and legal systems.