GENERAL MEDICAL NEWS 

Written By The Staff of the Reproductive Times

The staff of The Reproductive Times here offers brief referenced notes on interesting general medical and scientific news with broad relevance to reproductive medicine and biology. Some of these news items may become subjects of more detailed reporting in The Reproductive Times on later occasions. The purpose of these short notifications is to give readers the opportunity to get immediately more detailed information by looking up the reference of the note.

Getting fairly covered as patients and fairly paid as providers by insurance companies

The introductory paragraph of a KODIAK RCA benchmarking analysis published in August under the intriguing title “Death by a thousand requests” began with the following:1

“Nothing is more frustrating, perplexing, and needlessly expensive for a provider than an initial request for information claim denial from a payor. Initial RFI (request for information) claim denials are rising and, along with them, providers’ administrative costs at a time when they can least afford it. It’s time for providers to take the fight to payors.”

And initial RFI claim denials are constantly increasing. Between 2022 and 2024 alone, denials increased by 8.8%. These data are in line with increasing unhappiness among medical service providers regarding how they are treated by their payors. Well-known ethicist at NYU, Arthur L. Caplan, PhD, in one of his recent commentaries for Medscape Business of Medicine put it this way: “I don’t think I’ve seen anything screwier from a moral point of view than the system we have that allows preauthorization by third-party payor, or insurers, in order to give care to patients. It’s pretty clear that a third-party payor has a conflict of interest. It’s simple: They don’t want to spend money.”2

 

And it seems that things now may get even worse because insurers are considering the integration of A.I. into the review and approval process. Caplan considers the whole idea to be ethically “nuts,” arguing that only (treating) physicians really can know what a patient needs.

 

We, of course, agree in principle but also have to acknowledge that, just as insurance companies have been squeezing physicians and hospitals more and more, so have at least some physicians abused insurance companies with an onslaught of bills for unnecessary and/or often unindicated medical services. Some bad apples can do considerable damage and insurance companies have clearly overreacted: they for all practical purposes are now actively practicing medicine which, under the law,  they are prohibited from doing.

 

Some of the insurance companies appear to sense the potential (legal) danger. CVS Health’s Aetna, the country’s third-largest insurance company, for example, recently announced that it would widen coverage for fertility services, regardless of sexual orientation or partner status.3 The changes are, however, still inadequate. Practically the company just removed the definition of infertility as one year of unsuccessful exposure to semen, from lesbians and transgender individuals who – up to this point – had to pay for one year of inseminations out of pocket before they became eligible for infertility coverage. The decision, therefore, does not reflect Aetna’s position that it shows the company’s commitment to women’s health across all communities, including LGBTQ+ and unpartnered individuals.

The company made this decision because Blue Cross/Blue Shield of Illinois was legally forced to make this decision.

 

And then – everything goes in circles – after the HMO craze of the 1980s and 1990s which shifted fee-for-service to all-inclusive capitation services under which a certain patient volume was assigned for all-inclusive services to a provider organization. In other word, providers received a certain amount of payment per patient in that sub-insured group. Providers were paid whether that member received services or not. The system, therefore, clearly incentivized less (and poorer-quality) care because the less service the provider had to give, the more profitable the contract.

 

Unsurprisingly, this system collapsed on itself because patients revolted due to too little and too poor medical care.  And now basically an almost identical system is introduced under the new name, Value-Based-Care (VBC) because it allegedly focuses on patient outcomes rather than the volume of services provided, aiming for (i) Improved patient health outcomes; (ii) Reduced costs of healthcare; and (iii) Enhanced patient satisfaction.4

 

Good luck! Exactly the same goals were claimed for the HMO-madness in the 1980s and 1990s. And just like in those HMO days physicians were complaining about too low capitation rates per patient, so have they started lamenting about so-called Relative Value Units which determine provider reimbursements and, of course, are determined by insurance companies.4 Our health care system is going in circles!

California may no longer want private equity-financed health deals

This is for two reasons a potentially important issue for the infertility field: First, because this is happening in California and what happens in California usually is quickly also introduced in most other blue states. Second, private equity in the U.S. already controls more than half of the IVF cycle market and related procedures.

 

Gov. Gavin Newson, according to an article in The Wall Street Journal 1 has not yet announced whether he will sign Assembly Bill 3129 which passed the Senate by a vote of 49 to 14. If we had to guess, we would suspect that he may not sign the bill. Private equity just provides too much money to his fundraising efforts. But who knows; maybe he will surprise us. Such a law would, likely, overnight significantly reduce the value of existing equity investments in medicine because these investments are made with a cash-out horizon of 5-7 years. Who will then be the buyers if private equity is not permitted to invest?

Reference

1.      Cumming C. The Wall Street Journal, September5, 2024. https://www.wsj.com/articles/california-senate-passes-bill-to-clamp-down-on-private-equity-healthcare-deals-118a2134

How private-equity drained finances of a hospital, putting it into bankruptcy

That – because of increasing numbers of reported negative effects of private equity investments in medicine – such investments deserve more scrutiny and, maybe as California’s above noted new law suggests, may not be in the public’s best interest, is further supported by the recent bankruptcy of a for-profit hospital (Steward Health Care System in Dallas, TX) which, according to an article in The Wall Street Journal on September 12, 2024, was (at least to as significant degree) caused by a dividend payment of $790 million by the hospital to its private-equity owner at the time, Cerberus Capital Management. According to the article this payment “drained” the hospital’s finances and it, consequently, never recovered. A spokesperson for Cerberus denied the allegation, commenting that the company at that time “had more than sufficient capital and liquidity.”

 

Whatever the underlying causes may have been for this bankruptcy, what happened to this hospital after accepting a substantial private-equity investment is just one more example demonstrating that such private equity investments for the investor are planned for a very short time frame only, after which the investor – really at all costs – has to exit a deal. And under such circumstances, a profitable exit is, of course, more important for the investor than the well-being and/or survivability of the company the investor leaves behind. Unsurprisingly, therefore, increasing numbers of experts have started to question whether private-equity investments are appropriate for health care.

Reference

1.      Weil J. The Wall Street Journal, September 11, 2024. https://www.wsj.com/finance/how-a-private-equity-payday-drained-a-hospital-chain-of-cash-35a5cb35

 The FDA updates mammography regulations

Women with dense breast on mammography will now have to be told. The reason is that dense breasts to significant degrees increase the risk of false-negative mammography. Once notified, women then have the opportunity to ask for follow up examinations with ultrasound of MRI, with especially the latter often not covered by insurance.

 

This follows a recent announcement by the American Cancer Society noting that women starting at age 40 should be given the option of annual mammograms. It recommended annual screening starting at age 45.2 This stands in contrast to an April 30, 2024, recommendation by the U.S. Preventative Service Task Force which recommended that women be screened after age 40 every two years.

An example of “fake” medical news in The New York Times picked up by many other news outlets

Why Black women in the U.S. would have 25% “unneeded” Cesarean sections in comparison to White women would, indeed, be an important question to find out; that is, if one assumes this information is, indeed, correct.

 

But before we get to addressing this question, a little bit of interesting background: On September 6, 2024, Sarah Kliff reported in The New York Times1 on a study by Janet Curtis, PhD, et al., the Henry Putnam Professor of Economics and International Affairs at the Princeton University School of Public and International Affairs, which – based on a large study of almost 1 million births in 68 New Jersey hospitals – found that Black women demonstrated a 25% excess in Cesarean section deliveries compared to White mothers. In addition – and important to note – the headline of the Kliff article noted that these excessive Cesarean sections were “unneeded.”

 

Within 24 hours her article had become the basis for several reports, including by CBS News,2 even though Kliff referenced no peer-reviewed study in her article and a quick literature search we conducted for such an article under the authorship of Janet Curtis was unsuccessful.

 

In other words, here was The New York Times – based on no source data whatsoever – reaching the conclusion that Black women in the U.S. undergo 25% more “unneeded” Cesarean sections and distributed this information as a fact and, since it was The Times, everybody picked up the message without asking where all of this information was coming from.

 

As we are writing this commentary, we have absolutely no idea what kind of information Curtis apparently offered Kliff for this article. We, however, know one thing for sure: unless we see data or at least are reassured that a written manuscript underwent competent peer review, the information provided by Kliff is not only worthless but also irresponsible. Even if Curtis as an economist is assumed to understand the subtleties of defining what is a “needed” vs. “unneeded” Cesarean section – even competent obstetricians often disagree on this issue – it appears irresponsible to disseminate a not only medically unproven allegation but, in this case also an unproven allegation of racism.

 

Black women have consistently, and globally, worse pregnancy outcomes than White women.3 This fact alone not only explains higher Cesarean section rates in Black women, but mandates them. Shame on The New York Times and every other media outlet that reprinted this – as of this point – totally unsupported allegation of “unneeded” Cesarean sections in Black women!

References

1.      Kliff S. The New York Times. September 11, 2024. 2024. https://www.nytimes.com/2024/09/10/health/cesarean-sections-black-women.html

2.      Stahl S. September 11, 2024, CBS News. https://www.cbsnews.com/philadelphia/news/new-research-black-women-unnecessary-c-sections/Janet Curtis, Cesarean Sections

3.      National Institute for Health Care Research. May 25, 2023. https://evidence.nihr.ac.uk/alert/black-women-around-the-world-have-worse-pregnancy-outcomes/

The Staff of the Reproductive Times
Previous

UNDERSTANDING IN EARLY STAGES OF EMBRYOS CHROMOSOMAL ABNORMALITIES MUCH BETTER
Next

REVIEW AND COMMENTARY ON RECENT LITERATURE IN REPRODUCTIVE MEDICINE