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Becker's Source Article | Comments Courtesy of Matt Zavadsky

A little lengthy, but a nice consolidation of takeaways from one of the premier healthcare conferences in the country…

The No. 1 takeaway from the 2019 JP Morgan Healthcare Conference: It's the platform, stupid

Written by Dan Michelson, CEO, Strata Decision Technology | January 11, 2019 

If you want to understand the shifting sands of healthcare, you'll find no better place than the nonprofit provider track during the infamous JP Morgan Healthcare Conference that took place this week in San Francisco.

Over 40,000 players were in town from every corner of the healthcare ecosystem. However, if you want to hear the heartbeat of what's happening at ground level, you needed to literally squeeze into the standing room only nonprofit provider track where the CEOs and CFOs of 25 of the most prominent hospitals and healthcare delivery systems in the country shared their perspectives in rapid-fire 25 minute presentations.

This year those presenters represented over $300 billion, or close to 10 percent of the annual healthcare spend in U.S. healthcare. These organizations play a truly unique role in this country as they are integrated into the very fabric of the communities that they serve and are often the single largest employer in their respective regions. In other words, if you work in or care about healthcare, understanding their perspective is a must.

Every year I take a shot at condensing all of these presentations into a set of takeaways so healthcare providers who aren't in the room can share something with their teams to help inform their strategy. So what do you need to know? Glad you asked, here you go.

Shift Happens — Moving from Being a Healthcare Provider to Creating a Platform for Health and Healthcare in Your Community

Trying to synthesize 25 presentations into a single punch line is pretty stressful. I listened to every presentation, debriefed with other healthcare providers in the audience afterwards and then spent the next 48 hours trying to process what I heard. I was stumped.

But then, finally, it hit me. To take a new spin on an old phrase, "It's the platform, stupid." To be clear, even though I've been in healthcare for close to 30 years, "stupid" in that sentence is absolutely referring to me.

So the No. 1 takeaway from the 2019 JP Healthcare Conference is this — for healthcare providers, there is a major shift taking place. They are moving from a traditional strategy of buying and building hospitals and simply providing care into a new and more dynamic strategy that focuses on leveraging the platform they have in place to create more value and growth via new and often more profitable streams of revenue. Simply stated, the healthcare delivery systems of today will increasingly leverage the platform and resources that they have in place to become a hub for both health and healthcare in the future. There is a level of urgency to move quickly. Many feel that if they don't expand the role that they play in both health and healthcare in their community, someone else will step in.

Folks in tech would think of this as the difference between a "product" strategy (old school) and a "platform" strategy (new school). Think of this as the difference from cell phones (Blackberry) to smartphones (iPhone and Android devices). One was a product, the other was a platform. Common platforms that we're all familiar with such as Facebook, Amazon, Google, Apple and even Starbucks have always 1) started with a very small niche, 2) built an audience, 3) built trust and 4) then added other offerings on top of that platform. By now there is no need for a "spoiler alert." We all know that this strategy works and these companies have created a breathtaking amount of value. The comforting news for hospitals and healthcare delivery systems is that many have already completed the first three steps and have many of the building blocks they need to leverage a "platform" as a business strategy. The presentations at the JP Morgan Healthcare Conference made it clear that most are now actually taking that fourth step to separate themselves from the pack.

There is enormous upside to those who understand this pivot and take advantage of this change in the market. Dennis Dahlen, CFO of Mayo Clinic, shared his perspective on this: "Thinking differently in the future is essential. In many ways, at Mayo, we are already operating as a platform today, but we have to continue to leverage this approach to uncover additional ways that we can be a hub for both health and healthcare in our community." Mayo's platform includes leveraging research, big data, expert clinic insights and artificial intelligence to create new value for Mayo's clinical practice as well as new opportunities for Mayo's partners.

To be clear, the mental shift here is massive. It's the difference of being on defense (where most healthcare providers are) to be being on offense (which is where they know they need to be). Executive teams have focused their time, energy and resources on driving and supporting inpatient admissions via a traditional bricks and mortar presence coupled with the acquisition of physician practices. The difficulty of thinking through what it means to truly be "asset light" and taking a different approach shouldn’t be underestimated. The good news is that the recent financial results of many health systems have improved, providing a little breathing room for investments to enable this shift in strategy. Those who don't may fall way behind. 

A New Way of Thinking — What it Means to be a Hub

Being a hub is essentially bringing together people with common interests to spark innovation and facilitate work getting done more efficiently. Examples include Silicon Valley as a "tech hub," Los Angeles as an "entertainment hub," New York as a "financial hub," Washington, D.C. as a "hub for politics" and how essentially every college town is or can become a "research hub."

Given that hospitals and health systems are the largest employers in their community, they are already set up to become a hub. In the past, they leveraged that position to simply care for the sick. Increasingly in the future, these organizations will be health and healthcare hubs for innovation and building new companies, for bringing the community together to tackle issues like hunger and homelessness, for education and training, for research and development partnerships, for coordinated, compassionate and longitudinal care delivery for treatment, for support groups for specific chronic conditions, for digital and virtual care, and for thoughtful and effective support for mental and behavioral health. Changes in the care delivery market over the last 10 years have put the right building blocks in place to make this happen.

Hiding in Plain Sight — The Single Biggest Change in Healthcare We May Ever See Has Already Happened

Taking advantage of becoming a hub and leveraging the strategic concept of being a platform requires new thinking, new structures and new skill sets. The great news for healthcare providers is they have already made the toughest move of all in order to set this in motion.

Over the last decade, there has been a massive level of consolidation with hundreds of hospitals and thousands of physician practices being acquired every year. While more mergers and acquisitions will still happen, this stunning and fundamental restructuring of healthcare delivery has taken place and there is no turning back. This is likely the single biggest shift relative to how healthcare is structured in this country that will take place during our lifetime, and it barely gets mentioned. The strategy many were chasing was primarily being driven by a "heads in beds" pay-off that was both based on offense ("an easier way to grow") and defense ("we better buy them before someone else does"). That said, as this consolidation happened most healthcare delivery systems were really just an amalgamation of stand-alone hospitals set up as a holding company that provided no real leverage other than more top-line revenue.

During the JP Morgan Healthcare Conference, it was clear that most have made the shift from a holding company into a single operating entity. Chicago-based Northwestern Medicine shared a very refined playbook for quickly bringing acquisitions onto their "platform," and the results are pretty stunning as they have transformed from a $1 billion academic medical center into a $5 billion regional healthcare hub in a handful of years.

And over the last few years, these organizations have gotten super serious about making the toughest decisions right away. The mega-merger of Advocate Health and Aurora Health, the largest healthcare delivery systems in Illinois and Wisconsin respectively, was accompanied by a gutsy decision to fast-track the implementation of Epic at Advocate to get the leverage of a single EHR platform across the system. While many focus on the cost of the transition and the shortcomings of some of the applications, what gets missed is the enormous long-term leverage this provides regarding communication, integration, continuity of care and, of course, access to data and the potential to improve clinical and financial performance. This creates a "platform-like" experience for both employees and customers. 

So, the twist in the story is that the pay-off for consolidation will likely be very different and perhaps much better than many had originally intended. They have the building blocks in place to be a health and healthcare platform for their community. But now they need to figure out how to truly take advantage of it.

Your Action Plan — 6 Ideas from 25 Healthcare Delivery Systems on How to Leverage Your "Platform"

During their presentations the 25 non-profit provider organizations opened up their playbooks on how others can leverage their platforms and the idea of becoming the hub for health and healthcare in their respective communities. Here is what they shared.

1. Create the Digital Front Door — or Someone Else Will

The big shift in play right now is the moving away from traditional reliance on transactional face-to-face interactions with individual providers. Building relationships and trust is something that has been a core competency and core strategic asset for hospitals in the past. In the future, this simply won't be possible without leveraging digital platforms as we do in every other aspect of our lives today. As Stephen Klasko, MD, CEO of Philadelphia-based Jefferson Health, shared, the real strategy will be to deliver "health and healthcare with no address."

Many provider organizations are moving aggressively to create digital front doors. Kaiser Permanente delivered 77 million virtual visits last year. Intermountain introduced a virtual hospital that provides over 40 services and has delivered over 500,000 interactions. Nearly every health system leverages MyChart or a similar personal health record platform. There is an enormous amount of risk for hospitals and health systems that don't take action here, as traditional healthcare providers will be competing with more mainstream and polished consumer brands for the relationships and trust of the folks in their community.

As the team from Spectrum Health shared, "87 percent of Americans measure all brands against a select few — think Amazon, Netflix and Starbucks." Google, Apple and Facebook as well as Walgreens or CVS are all going after this "digital handshake," and are big threats to healthcare providers. There is no question that some of these organizations will be "frenemies," where they are both competing and collaborating. Healthcare organizations will need to approach any partnerships mindful of that risk.

2. Drive Affordability and Reduce Cost — or Risk Being the Problem

As the burden of the cost of care increasingly shifts to the patient's wallet, healthcare providers will need to play in driving affordability. Coupled with the recent federal requirement to post prices online, there is a great deal of visibility around the price of care, even if the numbers are way off the mark. Understanding and reducing the total cost of care is now viewed as a requirement. As legacy cost accounting applications relied on charges as a proxy for cost and were limited to the acute care setting, most provider organizations have or are now in the process of deploying advanced cost accounting applications with time-driven and activity-based costing capabilities including a number that presented during the conference, such as Advocate Aurora Health, Bon Secours Mercy, Boston Children's Hospital, Hospital for Special Surgery, Intermountain Healthcare, Northwestern Medicine, Novant Health, Spectrum Health and Wellforce.

This was one of the hottest topics during the conference, and there was significant buzz regarding having a single source of truth for the cost of care across the continuum. Vinny Tammaro, CFO of Yale New Haven Health, commented, "We need to align with the evolution of consumerism and help drive affordability in healthcare. How we leverage data is mission critical to making this concept a reality. Bringing clinical and financial data together provides us with a source of truth to help both reduce the cost of care as well as reallocate our finite resources to high impact initiatives in our community." Organizations like Intermountain Healthcare, which implemented a 2.7 percent price reduction in exchange pricing, are taking the next step in translating cost reduction into lower prices for consumers. And now healthcare systems are starting to work together to create additional leverage via Civica Rx, which now includes 750 hospitals joining forces to help lower the cost of generic drugs.

3. Tackle Social Determinants of Health — or You Won't Be the Hub for Health in Your Community

It is always less expensive to prevent a problem than it is to fix it. The good news is that the economic incentives for hospitals and healthcare delivery systems to both think and act that way are beginning to line up. They are certainly there already for providers that are also health plans such Intermountain, Kaiser Permanente, Providence St. Joseph Health, Spectrum Health and UPMC. They are also in place for providers that have aggressively taken on population-based risk contracts such as Advocate Aurora Health. With that said, it feels like every health system is starting to lean in here — and they should.

Being the central community hub for these issues makes a ton of sense. The way that Kaiser framed it is that while they have 12 million members, there are 68 million people in the communities they serve. Taking that broader lens both allows them to make a bigger impact but also broaden their market. Many organizations, such as Henry Ford Health System, are taking on hunger via fresh food pharmacies. Geisinger shared how a 2.0 reduction in Hemoglobin A1c reduction leads to a $24,000 cost reduction per participant in their fresh food "farmacy." So while hospitals are perfectly positioned, have the resources and know it's the right thing to do, they are now also beginning to understand the business model tied to targeting the social determinants of health. There is also strong strategic rationale associated with taking on a broader role of driving health versus only providing healthcare.

4. Create Partnerships for Healthcare Innovation — or Lose the Upside

Spectrum Health has a $100 million venture fund. Providence St. Joseph's Health announced a second $150 million venture capital and growth equity fund. Mayo Clinic Ventures has returned over $700 million to their organization. Jefferson Health has a 120-person innovation team focused on digital innovation and the consumer experience, partnering with companies to build solutions. These are all variations on a theme as virtually every organization that presented is leveraging their resources to make a bigger impact and drive additional upside from their platform. "We have close to 900 agreements with over 500 partners," stated Sanda Fenwick, CEO of Boston Children's Hospital. "Our strategy is to be a hub for research, innovation and education in order to help evolve how care is delivered. This can only be done by collaborating with others."

5. Become the Hub for Targeted Services and Chronic Conditions — or They Will Go Elsewhere

Perhaps the best example here is the work of Hospital for Special Surgery, the largest orthopedics shop in the world. It has become a destination for good reason — fewer complications, fewer infections, a higher discharge rate to home and fewer readmissions. The most compelling data point is that when patients come to HSS for a second opinion, one-third of the time they receive a non-surgical recommendation. The same type of shopping is increasingly going to happen for chronic conditions.

Healthcare delivery systems that take a more holistic yet targeted approach have significant potential. They will need to think more deeply about the end-to-end experience and become immersed within the community outside of the four walls of the hospital. Other players in the community, such as CVS Health and Walgreens, would say they have a platform — and they would be right. The platform that healthcare providers have built and are building will absolutely be competing against other care delivery platforms.  

6. Leverage Applied Analytics — or You'll Lose Your Way

In order to enable everything listed above, the lifeline for every health and healthcare hub will be actionable data. Applied analytics is a boring term that is actually gaining traction and starting to dislodge buzzwords like big data, machine learning and artificial intelligence relative to its importance to healthcare providers.

Similar to how analytics are being used in a practical way in baseball to determine where to throw a pitch to a batter or position players in the field, healthcare providers are pushing for practical data sets presented in a simple, actionable framework. That may seem obvious, but it is simply not present in many healthcare organizations that have been focused on building data warehouse empires without doors to let anyone in. Many organizations, such as Advocate Aurora Health, Bon Secours Mercy and Spectrum Health, have deployed more dynamic business decision support solutions to access better insight into performance and care variation. This allows them to assess opportunities to reallocate resources to invest in more productive ways to leverage their platform.   

While leveraging a platform as a business strategy is new to healthcare providers, the good news is that building blocks are already in place. It's time to leverage that platform to drive better outcomes and more affordable care in the community. And now is the time to get started.

Dan Michelson is the CEO of Chicago-based Strata Decision Technology. Mr. Michelson has authored recaps of JP Morgan Healthcare conferences for the past several years for Becker's. Read his account of the 2018 event here and the 2017 event here.

Presenting non-profit provider organizations during the 2019 JP Morgan Healthcare Conference included the following: AdventHealth, Advocate Aurora Health, Ascension, Baylor Scott & White Health, Bon Secours Mercy Health, Boston Children's Hospital, CommonSpirit Health, Geisinger, Hartford HealthCare, Henry Ford Health System, Hospital for Special Surgery, Intermountain Healthcare, Jefferson Health, Kaiser Permanente, Mayo Clinic, Memorial Sloan Kettering, Northwell Health, Northwestern Medicine, Novant Health, Oregon Health & Science University, Providence St. Joseph Health, Spectrum Health System, SSM Health, University of California Health, UPMC and Wellforce.

Source Article from Blue Zones | Comments Courtesy of Matt Zavadsky

Interesting article from an organization committed to helping people live healthier lifestyles. 

The findings in the referenced studies is not very dissimilar to those found in the EMS Fatigue study by Daniel Patterson, et. al.; the evidence-based guidelines to reduce fatigue in EMS workers, and the NHTSA guidance on fighting fatigue in EMS.

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Is Not Sleeping the New Smoking?

By Joel Frohlich, science writer and postdoctoral researcher studying consciousness in the laboratory of Martin Monti at the University of California, Los Angeles. He is also editor in chief at Knowing Neurons. 

Down with the larks: on the virtues of sleeping like a sloth

In the sixth century, Pope Gregory I compiled an infamous list of seven deadly sins. Of these seven, sloth is the only sin that shares its name in English with an animal. But are these curious animals truly guilty of vice?

Sloths personify laziness in Western culture through a reputation for sleeping a lot (though they actually sleep for less than 10 hours a night in the wild). Indeed, seen through the value system of medieval Catholicism, this cute, tree-loving mammal must really be a demonic Snorlax hellbent on dragging humanity into a sleepy damnation.

But is slothfulness actually wrong? If slothfulness means avoiding responsibility and failing to accomplish important, meaningful goals, then most likely yes. However, if slothfulness means getting more than seven hours’ sleep a night to improve health and increase productivity, then surely there’s nothing wrong with that.

A Gallup poll in 2013 found that Americans sleep, on average, 6.8 hours a night, with 40 per cent getting less than the recommended minimum of seven hours.

According to Nationwide Children’s Hospital in Ohio, teenagers get a little more than seven hours of sleep a night, while actually needing at least nine. Yet society continues to function … if only like a frail, untuned clock.

According to the sleep neuroscientist Matthew Walker at the University of California at Berkeley: ‘The number of people who can survive on six hours of sleep or less without measurable impairment, rounded to a whole number and expressed as a per cent, is zero.’ In fact, most adults need between seven and nine hours of sleep per night to be healthy.

Sleep Deprivation and its Effect on Cardiovascular Health, Mental Health, Alzheimer’s Disease, Immunity, Cancer

Not convinced? To really appreciate human sensitivity to sleep, consider daylight savings time (DST). Each year, millions of people lose an hour of sleep when clocks ‘spring forward’ on the first Sunday of DST. Like a cruel experiment, we watch the health consequences of this spring forward: heart attacks and even suicides spike the following week as bodies are put under stress by the sudden change.

Though it might feel like we aren’t doing anything when we sleep, nothing could be further from the truth. During sleep, the fluid-filled ventricles of the brain open so that deadly toxins – including the amyloid plaques that cause Alzheimer’s disease – can drain.

Volunteers who were kept awake for 31 hours straight showed huge spikes in the Alzheimer’s causing molecule compared with well-rested participants. The implications are clear – pulling an all-nighter is hardly harmless.

Beyond staving off Alzheimer’s, sleep generally strengthens the immune system and protects us against cancer. Because our daily sleep cycle, or circadian rhythm, appears to regulate many biological functions, a night of light sleep throws a wrench into the gears of health and rejuvenation.

Moreover, we often fail to take sleep deprivation as seriously as alcohol intoxication, even though both immediately impair our behavior and cognition. According to Walker: ‘After 20 hours of being awake, you are as impaired cognitively as you would be if you were legally drunk.’ Driving after being awake for 24 hours straight gives similar levels of impairment as driving with a blood alcohol concentration of 0.1, higher than what is considered over the legal limit in many jurisdictions.

Walker, the author of the book Why We Sleep: Unlocking the Power of Sleep and Dreams (2017), also points to what is perhaps the most appalling irony of all: that doctors – the very people who are supposed to be caring for our health – are often complicit in creating today’s sleep-deprived culture. New medical residents serve 30-hour shifts, and this sleep deprivation affects not only them but also their patients. Indeed, Walker states that: ‘Residents working a 30-hour shift are 460 per cent more likely to make diagnostic errors in the intensive care unit relative to when they’re working 16 hours.’ Doctors’ lack of sleep might literally be killing patients.

We have a cultural problem in the West. From bosses to self-help gurus to school administrators, responsible and otherwise intelligent people who should know better advocate that we sleep less and accomplish more.

Even when we’re not explicitly told to sleep less, advice that often passes for wisdom leaves little space for eight hours of sleep a night. Consider the retired US Navy SEAL, author and podcaster Jocko Willink, who relentlessly encourages his followers to wake up before the crack of dawn. Sure, waking up at 4:30am and hitting the gym can be a healthy habit – if you’re in bed by 9:30pm. Willink himself goes to sleep around 11pm or midnight, but admits that more sleep is healthier.

‘We are with sleep where we were with smoking 50 years ago,’ Walker said on a recent podcast. ‘We had all of the evidence about the … disease issues, but the public had not been aware, no one had adequately communicated the science of, you know, smoking to the public. The same I think is true for sleep right now.’

As we plough recklessly through the night, coffee cup in one hand and smartphone in the other, we curse sleep while slumbering in a deeper, mental sense. True slothfulness isn’t sleeping eight hours a night – it’s ignoring our health and taking on important responsibilities in an underslept state. As we update our values based on empirical evidence, it might be only a matter of time before society appreciates the true wisdom of the sloth.

This is an adaptation of an article originally published by Knowing Neurons and Aeon.

Business Insider / Reuters Source Article | Comments Courtesy of Matt Zavadsky

Interesting study – perhaps a good time to review decontamination processes...

Tip of the hat to healthcare and EMS icon Don Jones for sharing this story!

Ambulance equipment contaminated with drug-resistant superbug

Jan. 4, 2019

By Manas Mishra

(Reuters Health) - Ambulance oxygen tanks are likely to carry the "superbug" MRSA, a small U.S. study suggests, pointing to the need for regular disinfection of medical equipment.

Researchers tested nine oxygen tanks carried by three ambulances based at an emergency medical services (EMS) station in Alabama. They found MRSA, or methicillin-resistant Staphylococcus aureus, on all nine tanks.

They also swabbed oxygen tanks in a storage area, finding MRSA on 96 percent of the stored cylinders.

MRSA infections are difficult to treat because the bacteria are resistant to common antibiotics. Although usually mild, MRSA infections still cause thousands of deaths each year.

Other equipment on the ambulances, such as heart monitors and blood pressure cuffs, tested negative for MRSA contamination. But the floor of all three ambulances and a door handle in one ambulance tested positive.

"Oxygen cylinders are exchanged pretty rapidly between facilities, they (need) to be refilled, they're not like normal pieces of medical equipment or supplies, which are disposable," study author Cody Gibson, who was with Calhoun Community College when the study was conducted, told Reuters Health over the phone.

Because oxygen tanks are exchanged between facilities, the bacteria could spread across large areas, Gibson notes in the Emergency Medicine Journal.

The presence of MRSA on the tanks could be due to a lack of universal disinfection protocols for oxygen equipment, said Gibson, who is now at the University of Alabama at Birmingham.

Most ambulance equipment is disinfected after each patient because of company protocol or as directed by regulatory authorities, but oxygen cylinders could oftentimes be overlooked.

Gibson interviewed EMS personnel and found the staff was not aware of when the oxygen cylinders were last disinfected, while other surfaces that patients contacted were regularly decontaminated with disinfectants.

Dr. David Tan of Washington University in St. Louis, Missouri, who is President-Elect of the National Association of EMS Physicians, told Reuters Health, "While it would be safe to say there is no 'universal' protocol for disinfection of an ambulance, there are a number of guidelines available for agencies to develop their own policy and procedure for ambulance disinfection."

"MRSA exists in firehouses and EMS stations as well," Tan said, "and the challenge is finding universally effective disinfection procedures and techniques that are both effective and efficient, especially in busier EMS services where there is constant system pressure to get back in service to answer the next call for help."

Dr. Michael David, assistant professor of Medicine and Epidemiology at the University of Pennsylvania's Perelman School of Medicine in Philadelphia, said contamination of ambulance oxygen cylinders is not widely discussed.

"This paper raises the problem of these specific objects being contaminated by MRSA and resulting in a previously unaddressed reservoir of MRSA in ambulances," he told Reuters Health. "This observation importantly may result in new standard procedures to clean these objects with an antiseptic between uses."

The study didn't look at actual transmission rates, so it's unclear whether anyone actually became infected from bacteria on these tanks. Also, Gibson points out, the samples only came from a single EMS station, and at only one point in time.

Still, he concludes, "Oxygen cylinders appear (likely to carry) MRSA. The development of universal disinfection protocols for oxygen equipment could help reduce the risk of patient infection due to cross-contamination."

SOURCE: http://bit.ly/2QgqJX5

Emergency Medicine Journal, online December 1, 2018.

FierceHealthcare Source Article | Comments Courtesy of Matt Zavadsky

Interesting summary in Fierce Healthcare about the study published in JAMA.

May highlight the importance of safe care transitions from hospital to home – a role an increasing number of EMS agencies are providing in mobile integrated healthcare partnerships with hospitals and health systems.

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Link between readmission rates, mortality rates back under scrutiny

by Matt Kuhrt | 

Jan 2, 2019 7:20am

A new study shows a statistically significant correlation between lower readmission rates and higher mortality rates for patients with heart failure and pneumonia, renewing questions about the efficacy of the Center for Medicare and Medicaid Services' Hospital Readmissions Reduction Program (HRRP).

The new study, published in JAMA, looked specifically at changes in mortality rates in the 30- and 45-day periods after discharge for patients suffering from heart failure, heart attack or pneumonia. The 30-day data showed accelerated mortality rates for those with heart failure or pneumonia, though the 45-day data did not.

The HRRP has come under previous scrutiny for potentially raising mortality rates by offering hospitals a perverse incentive to reduce admissions in ways that don’t necessarily meet the patient’s best interest, such as discharging them after emergency room treatment or placing them in a temporary observation unit rather than readmitting them. In other studies, however, the program’s success at reducing overall readmissions has been hailed as broadly effective.

While the study’s limitations don’t necessarily indicate a causal relationship between the HRRP and the higher mortality rates, it does raise some potential red flags, according to Rishi Wadhera, M.D., a cardiology fellow at Brigham and Women’s Hospital and the study’s lead author.

Wadhera notes that the increase in mortality rates comes amid troubling context. While post-discharge deaths for heart patients with heart failure had already begun to increase in the years prior to the HRRP, the trend actually accelerated after the program was established. At the same time, the increase in mortality rates for pneumonia patients followed a period of stability in the years prior to the HRRP. Those conditions also saw significant decreases in the number of readmissions after discharge.

Whether hospitals are acting in ways that don’t necessarily benefit patients remains an open question, but Wadhera sees important lessons in the lack of clarity around how the program actually functions.

“I think one of the issues is we really haven’t done a deep dive into how physicians and hospitals have responded to the HRRP,” he said. “All we’ve really observed are the decline in admission rates and we’ve assumed that that was due to improvements in quality of care, but we don’t actually know that.”

Given the potential for unintended harm, Wadhera believes policymakers should slow down and take a more measured approach. “Our takeaway from the findings is that the HRRP should not be expanded to all hospitalized conditions, which is what some policymakers have advocated for recently, and that we should be more cautious before widespread expansion of the program.”

The findings also offer useful lessons for developing nationwide incentive-based quality programs in the future, Wadhera said. 

At the very least, he recommends more limited pilot programs or randomized studies before rolling programs out nationwide. In cases where that’s not possible, he recommends specifying analyses to identify potential unintended consequences before implementation, and monitoring after implementation with well-defined stop-loss thresholds if that analysis uncovers a signal of harm.

“The HRRP teaches us about the importance of evaluating policies rigorously before we implement them nationwide, and I think CMS and specifically the Centers for Medicare and Medicaid Innovation, which have some leeway to test policies, could really take the lead on evaluating policies before they’re implemented nationwide,” Wadhera said.

D Magazine Source Article | Comments Courtesy of Matt Zavadsky

Interesting outcome that may have implications across the country for emergency medical care providers.  Another signal that we should be partnering with payers on payment models that bring enhanced value to the patient, the provider, and the payer.

For our EMS brethren, note the reporter’s use of the term ‘emergency medical services’ to refer to the care received in the ED. 

NHTSA and the Red Flash Group are embarking on a project seeking input on terms that most accurately reflects the services provided by out-of-hospital medical care providers working on ambulances and First Response vehicles. 

NEMSAC and some professional organizations have recommended use of the term “paramedicine” as the services we provide, whereas “EMS” in its purest sense was originally intended to represent a ‘system’ of care, including pre-hospital, inpatient and post-hospital care.

We encourage all who are invited to provide input into this project to do so.

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Judge Dismisses Blue Cross Lawsuit Over Low Reimbursement Rates

12/21/2018| by Will Maddox|

A federal judge has dismissed a lawsuit against Blue Cross Blue Shield of Texas by 49 physician groups that claim the insurer is not paying enough for emergency medical care.

The groups argue  there are 250,000 claims where Blue Cross’ reimbursement rate for out-of-network providers violates Texas insurance laws and regulations.

In an emergency, patients are brought to the nearest hospital, which might not always be in network. “As out-of-network providers, the Provider Entities are not contractually bound to accept discounted rates of payment for the emergency medical services they provide to BCBSTX Members and instead expect to receive their billed charges for these services,” the lawsuit reads.

The 49 complainants, who come from all over the state, say that there have been hundreds of thousands of out-of-network claims where Blue Cross has underpaid. “Rather than pay the true and accurate bill generated by the Provider Entities, BCBSTX has knowingly lowered the reimbursement rate allowed for ‘out-of-network’ care to levels below what member plans and applicable regulatory authority require. BCBSTX paid most of these claims at a net payment rate that is significantly less than what the Provider Entities are entitled to receive as out-of-network providers.”

The lawsuit also highlights past action taken against Blue Cross by the Texas Department of Insurance. “TDI found that Blue Cross set its allowable amounts for out-of-network providers at ‘unreasonably low rates that are less than the amounts billed by facilities and also less than the rates paid to BCBSTX contracted facilities.’ TDI also stated that Blue Cross’s “reimbursement rates are so low as to violate Texas insurance laws and regulations.”

Judge Karen Gren Scholer of the U.S. District Court for the Northern District of Texas dismissed the case without explaining the decision, and the physicians have 60 days to file a new complaint with additional support. Due to the appeals process, Blue Cross Blue Shield of Texas had no comment.

60 Minutes Source Article | Comments Courtesy of Matt Zavadsky

For those of you who may have missed it, 60 Minutes aired a very interesting story about an attorney taking on the opioid manufacturers and distributors.  He’s the same attorney who won the big tobacco settlement and the BP gulf oil spill settlements.

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Opioid Crisis: The lawsuits that could bankrupt manufacturers and distributors

The attorney behind a multibillion-dollar tobacco settlement in 1998 has turned his attention to the opioid epidemic. And he wants drug companies to pay

December 16, 2018

Mike Moore says he's, "just a country lawyer from Mississippi." But this country lawyer has engineered two of the most lucrative legal settlements in American history. As Mississippi's attorney general, he engineered the historic 1998 settlement under which Big Tobacco paid billions to address smoking-related health issues. In 2015, he convinced BP to settle multibillion-dollar lawsuits over its huge oil spill in the Gulf of Mexico.

Now Mike Moore has taken aim at the manufacturers and distributors of opioid painkillers, claiming they should pay for the epidemic of addiction and death that has swept this nation. As you'll hear in a moment, he has powerful new evidence that he says proves that states like Ohio, among the hardest-hit by the opioid epidemic, should collect billions from all the companies he's suing.

Mike Moore: If we try the Ohio case, if we win a verdict against these manufacturers and distributors there, it could bankrupt them. It'd put them outta business.

Bill Whitaker: Truly? These are huge, profitable--

Mike Moore: Huge.

Bill Whitaker: --wealthy companies.

Mike Moore: Well, you know-- they can be as profitable as they want to. But-- Ohio is losing $4 billion or $5 billion a year from the opioid epidemic. And they're losing 5,000 or 6,000 people a year from overdose deaths. So when a jury hears the evidence in this case, they're not gonna award just a couple hundred million dollars. It may be $100 billion. And whoever amongst these companies thinks they can stand up to that? Good luck.

Attorney General Mike DeWine: We are hurting now in Ohio. We need help now in Ohio.

Ohio's Republican attorney general Mike DeWine, who will be sworn in next month as governor, hired Mike Moore as soon as he decided to file suit against opioid manufacturers and distributors.

Attorney General Mike DeWine: They flooded the State of Ohio with these opioid pills that they knew would kill people.

Bill Whitaker: They knew would kill people.

Attorney General Mike DeWine: If they didn't know it the first couple years, they clearly would've seen it after that. You can't miss it. When one year we had close to a billion-- a billion pain meds prescribed in the state of Ohio, you know, 69 per man, woman, and child in the state. And that lies at the feet of the drug companies. They're the ones who did that.

Ohio is one of four states Mike Moore formally represents, but he's coordinating with 30-plus states that have filed suit, and with many of the local governments, nearly 1,500 cities and counties that also are suing. He is the unofficial commanding officer of the army that's attacking the opioid industry.

Bill Whitaker: This is where your war room is located?

Mike Moore: That's right.

The unlikely "command center" for Moore's legal war is the sleepy town of Grayton Beach on Florida's panhandle.

Mike Moore: You know, in a place like this, you're not limited with a bunch of tall buildings, and coats and ties, and that kinda thing. You can think outside the box a little bit. So.

When we were in Grayton Beach, about a dozen lawyers from all around the country, some working on state cases, others on local lawsuits, had gathered for all-day strategy sessions, focused on an audacious goal.

Mike Moore: Success for me would be that we would find funding to provide treatment for all the 2.5 million opioid-dependent people in this country.

That would take many billions of dollars, of course, but remember, Mike Moore has done it before.

Mike Moore: Look, when I filed this tobacco case in 1994 there was nobody that thought that we had a chance to win. We showed up for our first hearing, and in our first hearing, so there was three of us there. On the courtroom on the other side they had 68 lawyers.

Despite that early mismatch, within four years Moore had all 50 states lined up against Big Tobacco. He did it partly by going to court, but mostly by going public.

Mike Moore: A case in court is a case in court, and that's fine. But there's also the court of public opinion. And the court of public opinion is sometime the most powerful court.

60 Minutes played an important and controversial role in the public case against Big Tobacco. Moore was interviewed for a segment that at first, CBS corporate lawyers refused to allow on the air.

Mike Moore: We're thinking to ourself, "Look, if 60 Minutes seems to be afraid of these guys for whatever reason, then what about us?" (LAUGH)

60 Minutes finally aired the segment in early 1996 after The Wall Street Journal ran a story featuring the same tobacco industry whistleblower.

Bill Whitaker: You said this in that 60 Minutes story, "This industry," talking about this-- the tobacco industry, "in my opinion is an industry…

Mike Moore in 1996: …who has perpetrated the biggest fraud on the American public in history. They have lied to the American public for years and years, they've killed millions and millions of people and made a profit on it."

Bill Whitaker: Those are pretty strong words.

Mike Moore: Well, it-- they were true. Those words were true.

Bill Whitaker: And you finally got big tobacco to cry uncle.

Mike Moore: That's right.

Bill Whitaker: They ended up paying, what, over $200 billion?

Mike Moore: $250 billion, yeah.

Bill Whitaker: So when you look back on what you did what has been the impact?

Mike Moore: We reduced smoking rates to a place that nobody ever thought was possible. So the number one cause of death in America has been reduced dramatically. That's pretty powerful.

"The distributors are saying things like, 'We're just truck drivers. We didn't know where the pills went.' Of course, they did"

Now, going after the opioid industry, Mike Moore is using the same playbook he used against tobacco and more recently against BP for the Gulf Oil Spill: build legal and public pressure until the companies see no choice but to settle, and fork over billions.

Mike Moore: Here's the deal. There's a huge pill spill in this country. It's huge.

Bill Whitaker: Pill spill?

Mike Moore: Pill spill. Huge pill spill. It never should've occurred. Everybody's got some fault. But we have 72,000 people dying every year. Let's figure out a way to resolve this thing. You guys made billions of dollars off of this. Take some of that money and apply it to the problem that you helped cause.

He's a long way from convincing the drug industry to do that, of course, that's why all the lawsuits. The first targets are opioid manufacturers like Purdue Pharma, which makes oxycontin, the pill that fueled the opioid epidemic.

Mike Moore: Purdue Pharma created an environment so that opioid use was okay. So if you prescribe your patients this drug, there's less than 1 percent chance they'll get addicted. That was a lie, a big lie.

Bill Whitaker: Can you prove that in court?

Mike Moore: Absolutely.

Purdue Pharma declined our request for an interview, but said in a statement that when the FDA approved oxycontin in 1995 it authorized the company to state on the label that "addiction to opioids legitimately used is very rare." But as evidence of abuse mounted, the company admitted in federal court in 2007 that it had misled doctors and consumers about just how addictive oxycontin can be.

Mike Moore: The Purdue Pharma case is an easy case. I hate to say it, but it's an easy case to prove. You can prove that they told the lies that they told.

It has been considered tougher to build a case against Mike Moore's other targets, the huge drug distributors who've made billions delivering opioids from manufacturers to pharmacies.

Mike Moore: The distributors are saying things like, "We're just truck drivers. We didn't know where the pills went." Of course, they did. There's a Controlled Substance Act. Controlled Substance Act. You're supposed to control these pills. And when you don't, you have a responsibility for it. It-- it's real simple.

"The stories that you've heard from some of the DEA investigative agents concerning the large volumes of pills going into certain parts of our country are absolutely true."

It's also simple why Moore is going after the biggest players in drug distribution: because they have much deeper pockets than the manufacturers. Purdue Pharma, for example, had less than $2 billion in revenue last year. Distributor McKesson, by contrast, had $208 billion in revenue.

Mike Moore: McKesson, you're the sixth largest company in this country. You're telling the American public you didn't have systems in place to adhere to the Controlled Substance Act? Seriously?

Mike Moore and his allies now have what they characterize as devastating evidence proving that distributors knew what they were doing. A huge confidential DEA database called ARCOS tracks all transactions involving controlled substances. This spring, a federal judge in Cleveland who is hearing many of the local lawsuits ordered all that data to be handed over to the plaintiffs' lawyers.

Burton LeBlanc: And I can actually tell you which distributor distributed to which particular pharmacy, by year, by volume, and where the pills came from.

Burton LeBlanc is a Louisiana lawyer who regularly huddles with Mike Moore in Grayton Beach. His firm represents hundreds of cities and counties in their opioid lawsuits, and his team has taken the lead in analyzing the ARCOS data.

Burton LeBlanc: In terms of the wholesale distributor's duty to report suspicious orders, we can immediately look at volume and detect patterns with the data that we currently have.

Bill Whitaker: So, you can see that for every pharmacy in the-- in the country?

Burton LeBlanc: I have it for every transaction in the United States.

Bill Whitaker: What's the most important thing that it has shown you?

Burton LeBlanc: That the stories that you've heard from some of the DEA investigative agents concerning the large volumes of pills going into certain parts of our country are absolutely true.

One of those stories concerned Kermit, West Virginia, a town of just 400 people, where nine million opioid pills were delivered in just two years to a single pharmacy.

Bill Whitaker: Did the companies have access to this information?

Burton LeBlanc: It was their data.

That data has now been shared with state attorneys general, including Ohio's Mike DeWine.

Attorney General Mike DeWine: I'm not allowed to talk about the specifics. But I will simply tell you it's shocking.

Anyone who was looking at those numbers, as those middlemen were, as these distributors were, clearly, clearly should've seen that something was dramatically wrong.

"If they cared enough, maybe we would not have lost 500,000 lives from this problem."

Like Purdue, drug distributors declined our request for an interview, but in a statement from their trade association, said, "it defies common sense to single out distributors for the opioid crisis… distributors deliver medicines prescribed by a licensed physician and ordered by a licensed pharmacy." But Mike Moore insists that does not let the companies off the legal hook.

Mike Moore: If you've got walking around sense and you care, you're gonna check before you send nine million pills to a little, bitty county in West Virginia or Mississippi or Louisiana or Ohio. You're gonna check if you care.

Bill Whitaker: You think they don't care?

Mike Moore: I don't think they cared enough. And if they cared enough, maybe we would not have lost 500,000 lives from this problem. It's-- it just-- it appalls me.

Trial dates have been set for next year in a few of the state and local cases. But rather than go to trial, and just as he did with tobacco, Mike Moore hopes to force a mega-settlement to fund drug treatment, prevention, and education.

Bill Whitaker: You had to have thought about how much money you would need to do the projects that you foresee?

Mike Moore: Oh, I've seen all the models. To be effective, we need at least $100 billion to start off with.

Bill Whitaker:  And I know you've heard the criticism, that with all these lawyers involved, that this is just a bunch of trial lawyers looking for a great, big payday.

Mike Moore: Right. I don't care one whit about any money in this case. Not one whit whatsoever about it.

Bill Whitaker: Nobody's gonna believe that the attorneys are not going to make any money.

Mike Moore: No, no, no. No, no, and I'm not saying that. I was talking about-- all I can speak for is me.

Bill Whitaker: You made money off tobacco.

Mike Moore: Nope, not a penny.

That's because for all the years of the tobacco litigation, and many years after, Moore was working for a modest state salary as Mississippi attorney general.

Bill Whitaker: You made money off of BP spill.

Mike Moore: I made some money on helping resolve the case, yeah.

Moore has made enough money to be comfortable. At age 66, this may be his last big case, and he believes the ARCOS data gives him the ammunition he needs to demolish the opioid industry's argument that it should not be blamed.

Mike Moore: Nobody in the world's gonna believe that. And-- and don't go try to tell that to 12 jurors in Mississippi or Ohio who've lost people from this. You know what-- (LAUGH) you know what those jurors are gonna do? They're gonna go in the back room, they're gonna spend about 30 minutes thinking about it, gonna come back out and bam.

Produced by Rome Hartman. Associate producer, Sara Kuzmarov.

By Wayne C. Harbour, NRP , Matt Zavadsky, MS-HSA, NREMT  

Ask EMS professionals to define “quality in EMS” and you may get a tip of the head and an answer like, “Well, I’m not sure, but I know it when I see it.”

In today’s healthcare environment, demonstrating quality is crucial. Payers are increasingly linking payment to outcome and quality, and becoming less interesting in paying for services that don’t add value or are quality-based.

Read the full article in JEMS>

Modern Healthcare Source Article | Highlights by Matt Zavadsky

Health insurer, employer groups call on Congress to end surprise billing

By Shelby Livingston  

December 10, 2018

Nine groups representing health insurers, employers and consumers on Monday called for federal legislation to protect patients from surprise medical bills from out-of-network providers.

Surprise medical bills may arise when a patient unintentionally visits a doctor or healthcare facility that does not contract with the patient's health insurer. This sometimes occurs when patients are taken to an out-of-network emergency department during a crisis. Surprise billing is common, with 4 in 10 insured adults reporting they received a surprise medical bill in the last year, a Kaiser Family Foundation poll found in September.

The groups—which include powerful lobbyists like the Blue Cross and Blue Shield Association, America's Health Insurance Plans, the National Business Group on Health, and Consumers Union—called on Congress to prohibit providers from billing patients for costs not covered by the health plan when the out-of-network visit isn't the patient's fault. But they also said Congress should ensure any policy enacted doesn't increase premiums or discourage providers from joining a health plan's network.

The other organizations involved include the American Benefits Council, The ERISA Industry Committee, Families USA, the National Association of Health Underwriters and the National Retail Federation.

While the groups committed to keeping patients informed about which doctors and facilities are out of network, they ultimately pinned the blame for surprise billing on providers. 

"When doctors, hospitals or care specialists choose not to participate in networks, or if they do not meet the standards for inclusion in a network, they charge whatever rates they like," the groups wrote. "The consequence is millions of consumers receiving surprise, unexpected medical bills that can often break the bank." 

The CEOs of the American Hospital Association and the Federation of American Hospitals quickly hit back in a joint statement, saying health plans' inadequate provider networks for emergency care are one of the "root causes" of surprise medical bills.

While some states, including California, Connecticut, Florida, Illinois, Maryland and New York, have passed comprehensive consumer protection laws to protect patients from surprise out-of-network medical bills, the federal government has yet to tackle the issue. That may change soon. In August, a bipartisan group of senators introduced the Protecting Patients from Surprise Medical Bills Act, which would protect patients from large out-of-network charges if they were being treated at an in-network facility.

Source Article | Comments courtesy of Matt Zavadsky

Kudos to Chief Lyman and his team at Greeley Fire!

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Colorado Fire Department Reduces 911 Calls By Helping Frequent Callers

By MICHAEL DE YOANNA • DEC 4, 2018

MICHAEL DE YOANNA / KUNC

The Squad 1 crew makes their way to their truck at a downtown Greeley fire station. They're walking, not running, and once their truck is on the road, there are no flashing lights.

"We hardly ever use the siren," says driver Darren Conradson.

This is the Greeley Fire Department's solution to a vexing problem: 911 calls that simply aren't emergencies. 

Instead of sending a big engine with several firefighters -- and possibly police officers and paramedics -- Squad 1 may take the call instead. None of the crew members are firefighters. Conradson is a community paramedic. The other crew members include a crisis intervention counselor and experts at helping people navigate the complex world of social services.

Their truck is red, but it's an ambulance. It comes to a stop at Paul Villa's small house. He's 89 and used to work in the fields and then at the local meat plant.

His goal is to keep living in his home, but he's had to resort to 911 several times for help -- but not always for what the fire department would consider an emergency.

Proactive steps, like this simple check-in, aim to prevent those non-emergency calls, Conradson said.

"So are you still good on your test strips?" Conradson asked Villa.

"Yeah," Villa replied. "I'm OK."

"And glucometer?" Conradson asked.

"M-hmm," Villa said. "Good."

 

Five people, 200 calls to 911

This proactive approach, mixed with Squad 1's triaging of 911 calls as they come in, represents a major shift in culture and thought for the fire department.

"We're very traditional," Chief Dale Lyman said with a laugh. "We like to send lots of people and big trucks to things."

The department is set up to respond to fires, life-or-death medical emergencies, hazardous materials situations and rescues. Yet too many 911 calls, Lyman said, are more along the lines of personal emergencies, like people who couldn't get to a doctor's appointment or can't find a way to pick up their prescription.

"So they get to a point where, 'Well, I'll call 911 and maybe somebody can help me,'" Lyman said.

 

"There is a segment of our population in our community that doesn't -- I'll just say it -- they don't have access to health care like you or I would."

For years, firefighters have exchanged anecdotes about such calls. That inspired Lyman to dive into the department's 911 data to learn more.

First, the obvious: 911 calls to the Greeley Fire Department are up significantly. Since 2001, they have risen by more than 160 percent thanks, in large part, to the city's growing population.

Yet Lyman uncovered another driver of the calls: social ills.

"The data, once we started looking at it, proved it," Lyman said. "There is a segment of our population in our community that doesn't -- I'll just say it -- they don't have access to health care like you or I would."

He also identified what he calls "super utilizers," people who call the department often, posing a big challenge for the

increasingly-stretched department. In 2016, just five people generated more than 200 of the department's 911 calls.

One of them was a homeless person and chronic alcohol abuser who called 86 times, prompting 86 trips to the emergency room.

Another one, with mental health problems, made 26 of the calls and took 20 trips to the ER.

"It was insanity," Lyman said. "We're sending this highly-trained expensive crew -- fire apparatus, equipment -- for legitimate big-scale problems just over and over again to these things that don't need that. (…) It was a vicious cycle that needed to be stopped."

When Squad 1 hit the streets in a pilot last year using one of the station's old Chevy Suburbans, the frequent callers didn't just stop. But once the crew started securing long-term services and/or substance abuse help for the group, the number of 911 calls they made dropped significantly.

 

Squad 1 in action

After saying goodbye to Paul Villa at his house, Squad 1's crew gauge what they can do for him. Team member Meredith Munoz is also a coordinator with the nonprofit North Colorado Health Alliance and the Community Action Collaborative.

"He's afraid if he goes and gets care because they're going to say you need to go to a nursing home or something," she said. "His wish is to die in this house so he's very reluctant to even leaving."

That concerns Jayme Clapp, a mental health therapist with the nonprofit North Range Behavioral Health.

"I'm assessing his loneliness and if he's had contact because that can lead to a lot of physical problems," she said. "We want to make sure he doesn't lose contact with somebody who is checking to see."

Lyman said Squad 1 has the potential to make a positive dent on the homeless community. He told the story of one man who was linked to counseling and services through the crew and has since found a job.

"That's huge," Lyman said. "That's one less person that might be out on the streets or sleeping in the park because of substance abuse or whatever the case may be."

Greeley isn't alone in trying the concept. Departments in Colorado Springs and at least two other states -- New Mexico and Arizona -- have similar units and other departments around the country are studying the idea.

 

A growing need

So far this year, more than 12,700 calls have been made to 911. Squad 1 began operating in Feb. 1, and since then has run more than 350 of those calls.

 

"That's one less person that might be out on the streets or sleeping in the park because of substance abuse or whatever the case may be."

Yet the number of calls the squad is potentially needed for is much higher -- two, maybe even three, times as high. The squad only has funds to run 40 hours a week, not round-the-clock, meaning firefighters are still responding to non-emergency 911 calls.

But before Squad 1 existed, Lyman said, firefighters weren't always able to help people facing a personal crisis. That led to frustrations, he said, because firefighters want to be helpful. Now, firefighters can refer cases to the squad's crew for follow-up.

He said he's seeking additional streams of funding to cover more hours for the unit.

The existing funding is from the nonprofits that participate and, on the department's side, carved out of a savings the squad helped create. Because of Squad 1, the department hasn't had to send out his big engines to respond to as many 911 calls.

"Less miles," Lyman said. "Less wear and tear. Less fuel."

Beckers's Source Article | Highlights Courtesy of Matt Zavadsky

BCBS of Texas beats physician lawsuit alleging ER underpayments

Written by Morgan Haefner

December 05, 2018 

A lawsuit filed by 49 physician groups against Blue Cross Blue Shield of Texas was dismissed Dec. 3, according to Bloomberg Law.

The physicians' lawsuit accused BCBS of Texas of underpaying 250,000-plus claims for emergency medical care. Earlier this year, the health insurer announced a new discretionary ER policy, under which a medical director hired by the insurer reviews claims after the ER visit to determine the reason a patient opted for the ER and if they could have received treatment in a less expensive setting.

In the original lawsuit, the physician groups said BCBS of Texas reimburses out-of-network providers at a rate that violates state law and regulations. The judge's two-page order did not explicitly explain why the case was dismissed, according to Bloomberg Law. The physician groups have 60 days to submit a new complaint with additional supporting facts.

Anthem launched a similar policy in multiple states and has faced harsh criticism as well as numerous lawsuits. A recent report from Sen. Claire McCaskill, D-Mo., found the insurer denied 12,200 claims from members in three states during the second half of 2017 on the grounds the ER visits were "avoidable." However, when patients challenged the denials, Anthem proceeded to reverse itself and pay the claims most of the time.