Welcome to the April 2024 Newsletter for

Santa Monica Primary Care

This month’s newsletter covers the COVID-19 Spring Booster answering the question “Do I Need One?” (spoiler alert: probably not). We also highlight the
expected seasonal lull in COVID cases we see in the Spring months before moving to the Change Healthcare hack and Blue Shield/Providence contract negotiations. By the end of the newsletter, readers will know the meaning of  “ACO”.

On Spring COVID Boosters: Do I Need One?

In late February, the CDC’s Advisory Committee on Immunization Practices (ACIP)  recommended that adults 65 years and older or those with an immunosuppressive condition receive an additional 2023-2024 COVID-19 vaccine dose. This recommendation is intended to “acknowledge” (CDC’s wording) the increased disease burden from COVID infection in this group and the efficacy of the vaccine. In their statement, the CDC references data that ‘show the importance of vaccination to protect those most at risk of severe outcomes of COVID-19. They also note that more than half of COVID-19 hospitalizations from October 2023 to December 2023 occurred amongst those over 65 years. The UK’s Advisory Committee recommended a Spring Booster for those over 75 years. So how do we proceed?

Let’s start with some perspective: the current booster is neither new nor bivalent. It contains only a single target, which last circulated in December of 2022. In discussion with patients, many have referred to the Spring 2024 Booster as a ‘new’ shot. The currently available vaccine targets the Omicron XBB.1.5 subvariant and was originally approved mid-September 2023. The Omicron KBB.1.5 variant itself emerged in late 2022 and rapidly spread in December of that year. So the currently available booster targets a variant that circulated in earnest about 16 months ago. To be fair, many of the subsequent variants share a relationship with KBB.1.5 making the booster still a reasonable choice.

Interestingly, in the UK the Spring 2024 booster is recommended for those aged 75 and older as well as those who may have immune compromise. The UK’s Joint Committee on Vaccination and Immunisation (JCVI) used a quantitative analysis to delineate when “reinforcing” immunization was likely to be most cost effective

A brief analysis from our own data at Santa Monica Primary Care was undertaken to look at the efficacy of Spring Boosters in preventing summer infections based on 2023 data. We had 31 COVID cases from May 1st of 2023 through August 31st. Of these we classified 16 as mild infections (congestion, runny nose, short duration illness) and 13 were moderate (fever/chills, prolonged illness). One was classified as severe (fever/chills, shortness of breath, nausea/vomiting and high heart rate) and one patient was hospitalized. Given that spring boosters are intended to prevent severe illness, we looked at the time between COVID infection and the last vaccine dose. When comparing those with mild illness to those with illness that was moderate, severe or required hospitalization there was essentially no difference in days from last vaccination.

Average Days from last vaccination

Mild Symptoms: = 391 days
Moderate/Severe Symptoms or Illness Requiring Hospitalization: 410 days

Now granted, this analysis is limited by small numbers, broad illness categories and an inability to meaningfully age adjust these results. Nevertheless, there is more information than has been provided by the CDC in terms of booster efficacy. The UK takes a different tack in terms of recommendations by looking at cost effectiveness in reducing hospitalization, ICU admission and death. It is for this reason that I’ve recommended in line with the UK’s advisory group that patient’s older than the age of 75 have the vaccine as well as those with underlying conditions that would predispose them to severe disease.

COVID-19: Spring Data from Santa Monica Primary Care

In the last two newsletters we have discussed the bimodal distribution of COVID cases that corresponds to two distinct seasonal peaks: one in summer and the second in November and December. Inversely, we have relative lulls in the Spring and Fall. So is that holding true for 2024 thus far? Most certainly it is. In 2024 we had 10 cases in January, 9 in February and only 2 in March. Thus far in April we have only had 1 case. This is a similar pattern which we have seen in prior years as well.

Total Cases of COVID-19 by Month: Santa Monica Primary Care

The Change Healthcare Cyber Attack: The Biggest Healthcare Story of 2024 (Which You Haven’t Heard About)

It would surprise me if any of our readers are familiar with Change Healthcare (a subsidiary of the UnitedHealthcare Group, yes the same company that provides insurance) cyberattack that occurred in late February and the massive impact it had on our healthcare infrastructure. There has been very little press on it (other than a Wall Street Journal here: https://www.wsj.com/articles/change-healthcare-hack-what-you-need-to-know-45efc28c) despite the fact that Change Healthcare accesses one third of all medical records in the US. Fortunately, our practice and patients were relatively spared although laboratory reporting and prescribing were impacted. Network outages began on February 21st for Change Healthcare which operates the largest clearinghouse of medical claims processing 15 billion claims a year.

In addition to Change Healthcare itself, the hack also caused disruptions in over 100 affiliate services giving some insight into how the centralization of medical records has led to significant vulnerability and downstream effects. We began to first notice difficulties with electronic prescriptions on February 21st and 22nd, particularly with Costco. Prescriptions needed to be rerouted and, in some cases, we returned to writing paper prescriptions for patients to bring into the pharmacy. We thereafter noted difficulty with our lab provider LabCorp which typically integrates directly into our Electronic Medical Record (EMR). As a workaround, I was able to access results directly through a physician portal and did so for the better part of a month. Patients, however, were not able to access their laboratory records for several weeks. Only this
week has our direct integration largely returned, but even still with some glitches.

Fortunately for our practice, Change Healthcare does not process our claims but other offices, clinics and hospitals were not as fortunate. The Department of Health and Human Services has had to step in and provide advance payments to keep funding available so these healthcare providers could continue to stay open. Change Healthcare completed a $7.8 billion merger (yes billion with a b) in 2022 with UnitedHealthcare. Antitrust experts have pointed to this data breach as an example of the risks of having one conglomerate at the center of healthcare services. While integrated medical records do provide a benefit to the coordination of patient care, they represent an attractive target for hackers.

The American Medical Association (AMA) recently released a survey of 1400 respondents, ranging from solo practitioners to groups of over 1000 physicians. Of these 80% reported lost revenue because of the cyberattack. A total of 55% of respondents used personal funds to cover practice expenses and 31% could not make payroll. This ransomware attack cost UnitedHealth $872 million in revenue during the first quarter of 2024 which presumably includes the $22 million paid to the hackers. Despite such, UnitedHealth exceeded earning expectations, reporting $99.8 billion (yes billion with a b) in the quarter, surpassing the $99.2 billion projected by analysts. Presented without additional comment that while healthcare providers and systems
could not make payroll, UnitedHealth’s valuation improved.

Santa Monica Primary Care: An Accountable Care Organization (ACO) / Open Payments

Healthcare can often be a lot of alphabet soup (HMO, PPO, IPA – not a beer – TQM, and CMS). Amongst those acronyms is ACO which stands for Accountable Care Organization, of which we are one. This is our second year participating in this type of organization, although we have now moved from participating at a regional level into a national level so many of our readers are likely familiar with the contours of such an organization. The goal of an ACO is to work as part of a larger group to improve the quality of healthcare provided. As a solo practitioner, this is an especially important process so that I might have some metrics against which I can evaluate the type of care we provide in the office.

Currently, our focus is on care transitions, such as following up with patients after Emergency Department visits as well as formal in-office visits after a hospitalization. The goal of these evaluations is to decrease admissions or re-admissions to the hospital. Hospital care accounts for about one third of all Medicare expenditures, totaling $1.4 trillion (yes, trillion with a t) so any opportunities to reduce these events could lead to significant cost savings. In some instances a hospital stay may be unavoidable but, in others, there may be steps that can be taken to reduce the chance of such occurring.

Another ACO effort is directed at having patient’s in for their Annual Wellness Examination (AWE). Currently our focus is on our Medicare-age patients but it is something we encourage of all our patients. Interestingly, a systematic review showed that routine health checks increased the number of new diagnoses and medications, but failed to reduce morbidity or mortality overall or from cardiovascular or cancer causes. On the other hand, in a study of over 8000 Medicare beneficiaries, AWEs were associated with a significant improvement in use of preventive care and a reduction in total healthcare costs compared with matched controls. The greatest cost  reductions were driven by decreases in hospital costs (but not hospital utilization implying that hospital stays were of lower severity) and subspecialist costs. Patients receiving and AWE were also more likely to experience improved glucose control and to receive other key preventive services, including breast and colorectal cancer screening.

Because data-sharing is a key component to ACO participation, it is important for patients to know that they can opt out of this program if they are not comfortable with their data being shared (securely). Patients who do not wish to participate can do so by calling 1-800-MEDICARE (1-800-633-4227). A similar notice is posted in our office, if you need additional information.

Lastly, you may have noticed a new link on DrBretsky.com called “Open Payments”
(https://openpaymentsdata.cms.gov/physician/70669). This is a Medicare program which seeks to highlight financial relationships that physicians have with private industry (pharmaceutical and device makers). The magnitude of our financial payments ($54.28) is far below the average US physician ($4195.00). Medicare has sought to make these data more accessible to patients, an effort with which I am in complete agreement.

Blue Shield and Providence Negotiations Reach An Agreemen

In some good news, Providence has ‘rescinded’ its contract termination with Blue Shield of California, having reached a tentative agreement this past Friday the 26th. Before the agreement, over 110,000 members would have been ‘out of network’ (i.e. not covered) for visits to Providence physicians, hospitals, clinics or Emergency Departments. Providence had been negotiating for a rate increase from Blue Shield. Normally these talks go on behind closed doors, but the contentious nature of them spilled over into the press (link:https://www.fiercehealthcare.com/payers/contract-negotiations-between-providence-blue-shield- california-go-publicly-south).

It is important for my patients to know that although I have staff and admission privileges at Providence Saint John’s, I am not an employee of the Providence Health System and, as such, have an independent contract with Blue Shield. So there would have been no effect whatsoever on Blue Shield patients coming to the office as we remain in network with the insurer

This is not the first instance in which a major health network’s relationship with Blue Shield has gone crossways. For over one year beginning in 2011 and extending until September of 2012, UCLA did not have a contract with Blue Shield, forcing patients to seek care elsewhere or pay upfront for their care. This was especially burdensome for our patients who had subspecialty care (such as organ transplant) that is unique to an academic medical center like UCLA. In these instances, I was in the position of trying to manage their care and/or finding new subspecialists with whom they could establish a relationship. UCLA and Blue Shield had talk breakdowns in 2006 and 2008 as well.

Both Blue Shield and Providence are both non-profit corporations. As neither are publicly traded, there is no requirement that either file compensation disclosures so the financial implications behind these disputes are impossible to quantify. But, it is safe to say that patients do not benefit from them.

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