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Sunday, September 2, 2018

Simple tool predicts readmission risk for heart attack patients


To gauge readmission risk for patients with acute myocardial infarction, clinicians can easily assess seven variables during the first day of a hospital admission.

KEY TAKEAWAYS

For heart attack patients, the annual cost of readmission is estimated at $1 billion.
About 1 in 6 of heart attack patients will experience a hospital readmission within a month of discharge.
The new AMI READMITS prediction model helps clinicians target patients who are at high risk of readmission.
A new risk model provides a simple and inexpensive way to determine whether acute myocardial infarction patients are at high risk for hospital readmission.
Research published by the Healthcare Cost and Utilization Project shows that about 1 in 6 AMI patients are readmitted to a hospital within 30 days of discharge, with annual healthcare costs estimated at $1 billion.
Targeting AMI patients who are at high-risk of readmission also helps hospitals avoid financial penalties under the federal Hospital Readmissions Reduction Program and promotes cost-effective interventions, the JAHA researchers wrote.
“Although federal readmission penalties have incentivized readmissions reduction intervention strategies (known as transitional care interventions), these interventions are resource intensive, are most effective when implemented well before discharge, and have been only modestly successful when applied indiscriminately to all inpatients.”
The risk model, which is detailed in a recent study published in the  Journal of the American Heart Association (JAHA), features seven variables that can be scored in as little as five minutes during a patient’s first day of hospital admission.
With a simple calculation at the bedside or in an electronic health record, physicians can determine whether a heart attack patient is at high risk for readmission and order interventions that can help patients avoid a return to the hospital after discharge.
“The acute myocardial infarction READMITS score (renal function, elevated brain natriuretic peptide, age, diabetes mellitus, nonmale sex, intervention with timely percutaneous coronary intervention, and low systolic blood pressure) is the best at identifying patients at high risk for 30‐day hospital readmission; is easy to implement in clinical settings; and provides actionable data in real time,” the researchers wrote.
The AMI READMITS risk model is superior to other models, they wrote. “The few currently available AMI readmission risk prediction models have poor-to-modest predictive ability and are not readily actionable in real time.”

KEY FINDINGS

The JAHA research, which examined health outcomes for 826 AMI patients at six hospitals in North Texas, has several key findings:
  • The AMI READMITS score accurately predicts which heart attack patients are at high risk or low risk of readmission. In the JAHA research, about one third of AMI patients that were deemed at high risk through the AMI READMITS score had a 30-day readmission. Only 2% of patients considered at low risk experienced a readmission.
  • The AMI READMITS score can accurately predict readmission risk during the first 24 hours of a hospital inpatient admission, which gives clinicians the ability to make timely interventions.
  • Clinical severity metrics such as shock, heart strain or failure, and renal dysfunction as well as timely percutaneous coronary intervention were strongly associated with readmission risk.

WHY THIS MODEL MATTERS

Assessing the readmission risk of AMI patients during the first day of hospital admission is crucial, says Oahn Nguyen, MD, MAS, the lead author of the JAHA research and an assistant professor at UT Southwestern Medical Center in Dallas.
“[The model] gives you more time to intervene and try to prevent someone from having to come back to the hospital. It gives you more time to optimize someone’s path to recovery,” she told HealthLeaders.
She said development of the AMI READMITS risk model is the first step toward significantly reducing readmissions for AMI patients. “Studies of interventions to reduce readmissions for other conditions suggest that the earlier you can intervene the better. One caveat is those interventions have yet to be assessed in acute myocardial infarction.”
The current primary strategy to prevent readmissions for heart attack patients is transitional care intervention, and the AMI READMITS score helps physicians target patients for this intervention, she said.
“Transitional care intervention is a bundle of care to promote a safe transition from hospital to home. One way I like to think of it is deploying a medical SWAT team in the hospital to make sure that everything you can do for a patient is being done to ensure the transition from the hospital to the community is as smooth as possible,” Nguyen said.
A “SWAT team” approach to care is often costly, so the capability of the AMI READMITS score to target patients who are at high risk of readmission improves the cost-effectiveness of care.
There are several primary elements to transitional care intervention:
  • Medication counseling to make sure AMI patients know how to take them
  • Making sure patients get their medications when they leave the hospital
  • Connecting patients with the most appropriate outpatient care such as setting up clinic appointments
  • Conducting phone calls to the homes of patients to check on their health status after discharge
Major strengths of the AMI READMITS score include the risk model’s simplicity and low cost, she said.
“Our goal in creating this model was creating something that was simple and pragmatic; so, it’s parsimonious because there are only seven variables that go into it. The seven variables are also information that is commonly and routinely collected during most hospitalizations.”
The AMI READMITS risk model does not require sophisticated support systems, Nguyen said.
“In an age when there is a lot of hype about machine learning and big data, we were able to distill the big data of an electronic health record down to small, simple, parsimonious data that is easily applied at the bedside by clinicians,” she said.
Expense is minimal for the AMI READMITS risk model.
“It’s low cost because a clinician could look at our [research], then see how many of the seven factors a patient has in the hospital. You can literally spend less than five minutes summing up the points in the model scale, add them up, and determine whether a patient is at high risk or not. It does not take a fancy new IT infrastructure to implement,” Nguyen said.
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Trump Court pick signals skepticism over GOP’s latest bid to repeal Obamacare


If Republicans are hoping Supreme Court nominee Brett Kavanaugh will help them knock down Obamacare in the courts, they might be in for a disappointment.
Kavanaugh has signaled in private meetings with Senate Democrats that he is skeptical of some of the legal claims being asserted in the latest GOP-led effort to overturn the Affordable Care Act.
The lawsuit, which has oral arguments next week in Texas, claims that because Congresslast year effectively invalidated a key provision of Obamacare — the requirement that all Americans have health insurance — the entire 2010 law should be struck down.
After repeatedly failing to repeal Obamacare in Congress last year, Republicans are again turning to the courts to strike down the law, despite the fact that the Supreme Court has twice upheld it.
As Kavanaugh made the rounds on Capitol Hill in recent weeks, he suggested that even if one piece of the healthcare law is ruled invalid, the entire law doesn’t necessarily have to come down with it, three Democrats who were in the meetings told the Los Angeles Times.
In response to questions about the lawsuit, he declined to comment on it directly, but repeatedly pointed to the legal idea that one unconstitutional provision shouldn’t eliminate an entire statute.
Kavanaugh’s views on the issue could be important if the Texas case — which the Trumpadministration has partially endorsed — eventually makes its way to the Supreme Court, as some expect it will.
Democrats said they were viewing Kavanaugh’s comments warily, unsure if they indicated his beliefs or were merely an attempt to use legal semantics to alleviate fears that he would support the renewed legal attack on the Affordable Care Act.
Democratic senators are expected to press Kavanaugh on the issue during his confirmation hearing next week, particularly emphasizing the need to preserve Obamacare’s protections that ban insurers from refusing to cover people with preexisting medical conditions.
“I think this becomes the narrative of his nomination, which could bring it down,” said Sen. Sherrod Brown (D-Ohio), who met Kavanaugh earlier this month. “If people realize that their insurance is at risk because of this court nominee, I think there is going to be a lot of pressure put on a lot of people to vote no.”
Brown said it was unclear if Kavanaugh was using “legalese” to try to address Democratic concerns about the future of the healthcare law.
Kavanaugh did not directly indicate how he would rule on this or any other Obamacare case in the closed-door meetings, Brown and the other Democrats said. But when asked about the lawsuit, Kavanaugh repeatedly pointed to the legal concept of severability, or how much of a law needs to be invalidated when one piece is struck down by the courts.
“Asked about the Texas lawsuit, what Kavanaugh brought up was severability,” said another person who attended one of the meetings with a Democratic senator. The person did not want to be identified speaking about the private conversation.
His comments are likely to frustrate some conservatives who had criticized Kavanaugh’s views on an earlier Obamacare case.
In 2011, he wrote in a dissenting opinion that the courts couldn’t decide on the legal challenge to the individual mandate until the mandate and its penalty went into effect in 2014. He cited an obscure tax law that says Americans cannot challenge a tax until it goes into effect. At the time, the decision — which echoed a similar ruling in a different circuit court — was viewed as a way of dodging issuing a high-profile decision on the controversial healthcare law.
In some ways, Kavanaugh’s comments are not surprising. Conservative legal theory suggests that if one piece of a law is struck down, judges should limit how much of the remainder of the law needs to be unwound.
In 2016, he suggested in the Harvard Law Review that the courts develop a default rule that if a piece of a law is ruled invalid, judges should cut “the statute to the narrowest extent possible unless Congress has indicated otherwise in the text of the statute.”
In the same Harvard Review piece, he said deciding how much of the healthcare law could have been cut in the 2012 Supreme Court decision on the individual mandate is an “extraordinarily difficult question.”
Sen. Sheldon Whitehouse (D-R.I.) said the idea of severability did not come up in his meeting with Kavanaugh, but he left the meeting convinced that President Trump’s nominee would not protect the health law.
“I asked him if he could give me any assurance that he would not throw out statutory protections for insurance coverage for people with preexisting conditions, and he would not,” Whitehouse said.
At issue is a lawsuit filed by Texas and other GOP-led states that argues that the individual mandate is a foundation of the law, and without it, the entire law cannot stand.
The Trump administration responded to the suit by saying that Obamacare should not be struck down in its entirety, but that some parts should be invalidated, including protections for preexisting conditions.
Legal experts say the lawsuit is a long shot at best. But the Supreme Court has shown significant interest in cases related to the healthcare law, having heard four of them since 2012.
In the end, Kavanaugh’s position on Obamacare may not determine the law’s fate. The justice he was nominated to replace, Anthony M. Kennedy, voted in 2012 to strike the individual mandate.
It was Chief Justice John G. Roberts Jr. who angered Republicans by twice voting with liberal appointees to allow the law to stand.
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South Dakota-based health system eyes Chicago-area hospital system


A South Dakota-based hospital system is looking to enter the Chicago area — with its eye on at least one local player, according to reports.
Sanford Health, which has 45 hospitals and 289 clinics in nine states, is in talks to merge with a Chicago-area health system, its CEO told digital news organization SiouxFalls.Business earlier this week.
Shawn Neisteadt, a spokesman for Sanford, declined to comment Thursday.
But observers say it’s possible Sanford is looking to acquire west suburban hospital system Edward-Elmhurst Health. Sanford CEO Kelby Krabbenhoft described the system Sanford is in talks with as a $1 billion health care organization on the area’s “west side,” according to SiouxFalls.Business. Krabbenhoft said a Chicago-area merger is on track for a board vote before the end of the year.
Edward-Elmhurst, headquartered in Naperville, had revenue of $1.4 billion for the year ended June 30, according to an unaudited financial statement. Representatives for Rush, Sinai Health System and Loyola Medicine, which have hospitals on the city’s West Side or in the western suburbs, told the Tribune they are not in talks with Sanford.
Edward-Elmhurst has no “immediate plans” to partner with another organization but “we continue to look at options that might benefit our community and strengthen our health system,” said spokesman Keith Hartenberger, in a statement.
“It has always been and continues to be our position that we, like many health care providers, should evaluate strategic opportunities on an ongoing basis,” he said.
Edward-Elmhurst has three hospitals including Edward Hospital in Naperville, Elmhurst Hospital in Elmhurst and Linden Oaks Behavioral Health in Naperville. The system has had a fair share of challenges in recent years. In an accounting misstep, it overestimated by $92 million the revenue it expected to receive from insurance companies and patients for the fiscal year that ended June 30, 2017.
The system also laid off 84 employees last year as part of plans to cut $50 million after falling short of its budget for operating income.
The financial picture has recently started to improve. Edward-Elmhurst recently reported annual operating income of nearly $41 million, compared with a $15 million loss the previous year, according to unaudited financial statements.
Edward-Elmhurst’s recent financial struggles, coupled with increased competition from Northwestern Medicine’s recently acquired Centegra Health System hospitals in the northwest suburbs, may be making the system more open to a merger or acquisition, said Allan Baumgarten, an independent health care financial analyst.
Sanford is a fast-growing system. It has announced plans to acquire The Evangelical Lutheran Good Samaritan Society, a South Dakota-based provider of senior housing and services with more than 200 locations in 24 states, including Illinois.
“They have big ambitions and they have big pockets,” Baumgarten said of Sanford. “I think they still want more acquisitions and want their system to grow and want to have a presence in major metropolitan areas in the United States.”
Hospitals in the Chicago area and across the country have been merging in recent years as they face ongoing competition and financial pressure from insurers, government programs and unpaid medical bills, among other things.
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Patient experience in new realm: Influencing consumer behavior


A Google study released this month finds that customer experience is the primary reason consumers choose to travel with a particular brand. Easy-to-use websites and online reviews are second and third.
What does this have to do with healthcare? Quite a bit, according to experts in customer experience, a field that is becoming increasingly important to health systems. Thanks to new ways to gather and organize data, health systems now have actionable information to improve patient experience, often in real time. These processes are enhanced by technology that uses natural language processing to detect patterns in that data.
I spoke to several representatives in this field attending the Health:Further conference in Nashville this week about the trends behind this burgeoning practice.

BEYOND HCAHPS

“Customer experience is the number one thing driving retention in business today, says Lindsay Neese Burton of Reputation.com, which works with health systems including Ascension, Banner Health, Hackensack Meridian Health, Ochsner Health System and Sutter Health. The Google travel study about building brand loyalty through experience is just as applicable to healthcare, she says. To enhance opportunities, systems need to “move away from traditional ways of thinking and doing things, and move more towards the personalized healthcare experience that I think everybody wants,” she says.

GET THE LATEST ON HEALTHCARE LEADERSHIP IN YOUR INBOX.

Improving the patient experience begins with data. Many start with the HCAHPS hospital survey, but that’s not enough. Organizations often don’t have a mechanism to gather and organize unstructured feedback from those instruments or from social media, which plays a substantial role in influencing consumers—particularly star ratings, according to the experts.

STAR RATINGS BUILD PATIENT VOLUME

Star ratings “definitely impact revenues and volume,” says Aaron Clifford of Binary Fountain, who formerly worked for HCA Healthcare and helped the system, which has 178 hospitals, build its reputation management practice.
“We did a study looking at the star ratings of [HCA] physicians,” Clifford says, which occurred during his tenure with the hospital system. “Those physicians who had a lower star rating on review sites actually had a lower new patient volume. Physicians with four-and-a-half stars or higher had new patient revenues of 17%, compared to 2% for those with three stars. [Boosting star ratings] is a volume-building initiative.”

INFLUENCING CONSUMER BEHAVIOR

Methods to enhance ratings demonstrate the discipline of reputation management has matured into a new realm of influencing behavior.
Today, healthcare systems want to “resolve issues and build loyalty with their existing patient base, but they also can use these experiences to attract new patients at the digital front door,” says Andrew Rainey, also of Binary Fountain, which works with HCA, Intermountain Healthcare, Providence St. Joseph Health, and Tenet Healthcare.
They want to know how to “not only make operational improvements to maximize the patient experience, but also make sure that they’re represented appropriately online,” says Rainey. “[More than] 70% percent of patients are going online to look at the reviews and ratings. It’s one thing to be making process improvements to the patient experience, but how are you driving more patients to share that story online as well, and how can you make sure that those validated patient stories are also represented on your own website, as well, to guide the overall consumer choice?”

ROOM FOR GROWTH

Many healthcare organizations have embraced these practices, but with competing priorities for resources, others have yet to do so.
“I have a background in consumer products, and we see a blind spot in health systems,” says Mary Kay O’Connor, founder and CEO of PatientsVoices. “They haven’t yet learned how much patient feedback can help the system make the transitions that they need to go through over the next few years in a way that improves the experience for patients and for the financial health of the system.”
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Saturday, September 1, 2018

Lab-grown meat is not meat, Missouri state rules


What’s the definition of “meat”? Once upon a time that would have been an easy enough question to answer, but the advent of meat-substitute products such as the Impossible Burger and the arrival of cultured meat — aka lab-grown meat — has given regulators in Missouri pause for thought. On Tuesday, it became the first state in the US to enact a law stating that the word “meat” cannot be used to sell anything that “is not derived from harvested production livestock or poultry.”
The law could see violators hit with a $1,000 fine and up to a year in prison. The driving force behind the ruling, apparently, is shopper confusion. Mike Deering, a spokesperson with The Missouri Cattlemen’s Association, which fought for the law, said, “The big issue was marketing with integrity and … consumers knowing what they’re getting. There’s so much unknown about this.”
While it’s certainly the case that the ruling may help protect the livelihoods of local ranchers, there is some question as to how many consumers really will benefit from the new law. The company that produces meat substitute Tofurky, which is marketed as a “plant-based meat,” filed an injunction to prevent the enforcement of the statute, alleging that it’s seen no evidence of shoppers being confused by the terminology.
There are also concerns about the precedent the ruling could set for the wider food industry (Tofurky says it “prevents the sharing of truthful information and impedes competition”) and for its environmental implications. According to Allied Market Research, the meat-substitute market is expected to reach $7.5 billion globally by 2025, as consumers look to reduce their (traditional) meat intake due to sustainability and animal welfare issues. Cultured meat, or “clean meat,” will play a significant role in that shift, but the way it’s produced still technicallyqualifies it as meat (albeit via a different journey to your plate). So what this law means for the popularity of the Impossible Burger and other meats-but-not-meats remains to be seen.
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The rise of crypto in higher education


Coinbase regularly engages with students and universities across the country as part of recruiting efforts. We partnered with Qriously to ask students directly about their thoughts on crypto and blockchain — and in this report, we outline findings on the growing roster of crypto and blockchain courses amid a steady rise in student interest.

Key Findings

  • 42 percent of the world’s top 50 universities now offer at least one course on crypto or blockchain
  • Students from a range of majors are interested in crypto and blockchain courses — and universities are adding courses across a variety of departments
  • Original Coinbase research includes a Qriously survey of 675 U.S. students, a comprehensive review of courses at 50 international universities, and interviews with professors and students
When David Yermack, the finance department chair at New York University Stern School of Business, first offered his course on blockchain and financial services in 2014, 35 students signed up, eight fewer than the school’s typical elective.
By spring 2018, the number of enrolled students climbed to 230, forcing Stern to move the class to its largest auditorium. This academic year, Yermack will teach the blockchain course both semesters to meet interest from students.
Yermack says he first developed the class because he was interested in bitcoin and how quickly interest in the cryptocurrency was growing. But other reasons soon emerged, notably demand from companies for people who understood cryptocurrency-related issues. Now, he sees his class as a way to give students the skills they’ll need for jobs in the future.
“A process is well underway that will lead to the migration of most financial data to blockchain-based organizations,” he says. “Students will benefit greatly by studying this area.”
Similar scenes are playing out at top universities around the world. Students are flocking to classes on cryptocurrency and blockchain — the “distributed ledger” technology that makes decentralized financial systems work — motivated in part by a hot job market for graduates with training in those fields.
Universities, in turn, are forming research centers and adding more crypto-related courses, in part to meet rising demand and also because they now see cryptocurrency as an area worthy of serious academic study.
Coinbase reviewed course catalogs at the top 50 universities and found cryptocurrency classes across a variety of departments, including anthropology and finance — not only computer science.
In fact, the rise in offerings across disciplines maps to student interest: Students with a diverse set of majors say they’d like to take cryptocurrency classes, according to a Coinbase survey conducted in partnership with Qriously. Nearly half of all social science majors expressed interest in taking a crypto class.
One possible reason for such diverse interest in blockchain is its potential to impact society across many domains. “Blockchain combines theory and practice and can lead to fundamental breakthroughs in many research areas,” says Dawn Song, a computer science professor at University of California, Berkeley. “It can have really profound and broad-scale impacts on society in many different industries.”
To assess the current landscape of cryptocurrency in higher education, Coinbase analyzed the courses at the world’s top 50 universities as ranked by U.S. News and World Report. Our study focused on classes available to undergraduate-level students in the fall 2018 semester or the most recent semester for which information was available online.
The analysis found that 42 percent of the top 50 universities offer at least one class on blockchain or cryptocurrency, and 22 percent offer more than one. Expanding the results to include longstanding foundational classes on cryptography, 70 percent of universities offer at least one crypto-related class.
Blockchain and cryptocurrency courses are most prominent in the U.S. Only five of the 18 international universities on the list, or 27 percent, offer at least one class on blockchain or cryptocurrency. And only two — Swiss Federal Institute of Technology Zurich and National University of Singapore — offer more than one.
Johns Hopkins University offers a business course on blockchain, where students learn about its security features and “the potential benefits and weaknesses of its fundamental structure as applied to businesses and organizations,” according to the school’s course catalog.
At Princeton, students can take an information-security class focused on secure computing systems, cryptocurrencies, blockchain, and related economics, ethics, and legal issues.
Cornell offers the highest number of classes when including cryptography, cryptocurrency, or blockchain. The 28 courses include “Anthropology of Money” and “Introduction to Blockchains, Cryptocurrencies, and Smart Contracts,” which covers the cryptocurrency bitcoin and “the technological landscape it has inspired and catalyzed,” according to the course description.
More than half of the universities analyzed offer at least one class on cryptography, the study of creating and solving coded messages and a key technical foundation for blockchain and cryptocurrencies.
“The techniques used in blockchain aren’t necessarily new,” says Song, as it draws on areas such as cryptography, game theory, and distributed systems. These are areas “where research and even education has been around for a really long time.”
Stanford launched its Center for Blockchain Research this summer to bring together students and faculty from across the school’s departments to work on various aspects of cryptocurrencies and blockchain.
Dan Boneh, a professor of computer science and electrical engineering at Stanford University and co-director of the center, said that every time he talks with a new team in the group he finds himself walking away with three new research ideas. “There are new technical questions being raised by blockchain projects that we would not work on otherwise,” he says.
Other leading universities that are known for strong engineering programs are adding courses and programs centered around blockchain, too. The University of Waterloo, Georgetown University, and the University of Illinois at Urbana-Champaign are among those expanding their research and course offerings.
At Berkeley, Song co-taught a course in the spring semester of 2018 on “Blockchain, Cryptoeconomics, and the Future of Technology, Business and Law.” It was a collaboration between the school’s computer science, business, and law schools and admitted an equal number of students from each school.
Song says the course was “hugely popular,” noting that the instructors had to turn away more than 200 students because their classroom only had a 70-student capacity.
That interdepartmental approach may emerge as a hallmark of cryptocurrency and blockchain education, given the number of departments that are currently offering classes on the subject. Coinbase’s analysis found that of the 172 classes listed by the top 50 universities, 15 percent were offered by business, economics, finance, and law departments, and four percent were in social science departments such as anthropology, history, and political science.
Harvey says students recognize how in-demand this kind of knowledge is now. “If you’re graduating from law school it’s a tough market these days,” Harvey says. “However, the law students that are trained in blockchain, they don’t need to apply anywhere. People are just asking them to join their firms.”
Among students, interest in cryptocurrency and blockchain cuts across fields. In fact, more social science majors — 47 percent — said they were interested in learning about cryptocurrency than computer science and engineering majors — 34 percent — according to a survey of 675 U.S. students commissioned by Coinbase and conducted by Qriously.
The survey found that 17 percent of computer science and engineering majors have already taken a course that focuses on cryptocurrency and blockchain, as have 15 percent of economics and math majors and 11 percent of business majors. Just five percent of social science majors have taken such a course, the survey found.
Among all students surveyed, 17 percent said they consider their knowledge of cryptocurrency and blockchain very good, compared to just nine percent of the general population surveyed at the same time. Similarly, 18 percent of students said they own (or have owned) cryptocurrency, twice the rate of the general population.
A quarter of all students said they would definitely or probably take a course focused on cryptocurrency or blockchain.
“There’s tremendous excitement” among students right now, says Benedikt Bünz, a doctoral student at Stanford focusing on cryptocurrencies.
Bünz was pursuing a master’s degree in artificial intelligence when he took a cryptography class. That sparked his interest in cryptocurrencies, setting the direction for his doctoral degree.
People often approach Bünz asking if he’d be able to recommend someone with knowledge of cryptocurrencies for a job, he says, but the high demand means all the candidates he knows already have positions secured.
These days, he says, “if you’re an expert in cryptocurrencies and cryptography you’ll have a difficult time not finding a job.”
There are also plenty of options for people not currently enrolled at a university to learn more about crypto. Online learning sites like Udemy, Coursera, edX, and Udacity offer hundreds of courses, including general lessons in foundational cryptography and more specialized classes on blockchain and cryptocurrency.
These classes draw on a range of experts, including professors from some of the top 50 global universities and practitioners in the field. For instance, Coinbase Chief Technology Officer Balaji S. Srinivasan is one of several industry experts featured as part of the Udacity nanondegree program called “Become a Blockchain Developer.” The program has two three-month terms and is focused on “mastering job-ready skills with a hands-on approach.”
Academia isn’t known for moving quickly. But professors say that the maturation of blockchain and cryptocurrency and their adoption by businesses and other groups over the last few years has made it clear that it’s a field with the potential for wide-ranging impact. And that’s causing universities to take it seriously. “You need to prepare your students for the future,” Duke’s Harvey says, and “blockchain is not going away.”
A note on methodologyCoinbase analyzed the courses currently offered at the world’s top 50 universities as ranked by U.S. News and World Report: Best Global Universities 2018. Our study focused on classes available to undergraduate-level students in the fall 2018 semester or the most recent semester for which information was available online. The research excluded classes that are graduate-level only. It left in classes that are open to undergraduate and graduate students or classes that were not clearly marked as graduate-level only. Results for the search term “crypto” were excluded from the tallies and course descriptions listing if they were clearly unrelated to cryptocurrency or the foundational math principles underlying the technology.
To assess student sentiments about crypto, Coinbase also commissioned a study conducted by Qriously of 675 U.S. students ages 16 and older. The general population survey included 6,011 respondents over the age of 16.
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How much can M&A cut costs? Lower your expectations


Target hospitals may see a small savings, but not nearly as much as promised. Acquiring hospitals are likely to see none at all.

The flurry of M&A activity has been driven, in large part, by the promise of cost efficiencies, with CEOS and hospital boards holding on to the idea that buying power simply must increase with the hospital system’s size.
But CEOs and boards might want to reconsider that assumption, as new research by the National Bureau of Economic Research suggests the gains are marginal, at best.
With M&A activity continuing at a brisk pace, and standalone hospitals finding it harder to survive on their own, the potential for cost savings might be more hype than reality. The hospital or system being acquired (or target hospital) can expect to save, on average, $176,000, or 1.5%, annually, according to the research.
That is still not a huge savings, but the data suggests that—at least as far as cost efficiencies on supplies—an M&A opportunity should be seen more as a good bet for the target than for the buyer.
The savings for target hospitals were driven by “geographically local efficiencies in price negotiations for high-tech physician preference items [PPI],” explains Ashley Swanson, assistant professor of health care management with The Wharton School at the University of Pennsylvania and coauthor of the paper addressing the marginal cost efficiencies of M&A.
Those efficiencies result in a 2.6% decrease in costs for PPIs, which include expensive implantable devices for which physicians have strong preferences.

ZERO SAVINGS FOR SOME

Swanson and her colleagues studied the effects of horizontal mergers on marginal cost efficiencies, using data containing supply purchase orders from a large sample of U.S. hospitals from 2009 to 2015. The results were not the same as what health leaders often read in M&A proposals.
The data “translate into targets saving 10 percent of the amount that might be claimed in a merger justification, and acquirers saving 0 percent,” the report says.
The savings from PPI efficiencies at the target hospitals did not continue at the acquirer-level, where a 1.1% increase in PPI overwhelmed a 6.4% savings on less expensive commodities.
“We find no significant evidence that savings are mediated by supplier concentration, downstream market power, or standardization,” the report says.

PPI COSTS LOWER LOCALLY

At the target hospital, there is little effect on the cost of many products, but the cost of PPIs go down by about the same rate as within-brand prices on other items that happen at the time of the merger, Swanson says.
The decrease in PPI costs for target organizations is not related to utilization changes, she says, but rather the buying power of the larger entity coming in and shaving a little more off of the price previously negotiated by the target hospital.
Everything changes at the acquirer level.
“We see a very mixed-bag picture for acquirers. Costs at the category level seem to go down for commodity products and seem to go up for physician preference products. That’s a little curious because PPIs are big-ticket items, and you might think facilities or systems are going to go after them the fastest if there is a new opportunity around a merger event,” Swanson says.
She continues, “But when we look at mechanisms, it doesn’t seem to be driven by negotiation. It seems there is a shift in utilization post-merger for acquirers purchasing commodity-like products, rather than prices being negotiated downward.”
The differences in PPI expenditures surrounding a merger make more sense when considering how different the merger participants might be, Swanson says. The within-brand prices for PPIs increase about a half percent for acquirers post-merger, not a huge increase but certainly in the wrong direction.
That may be because the acquirer is already large enough that it doesn’t gain more stature from taking on the new hospital or system, but it does gain a handful of physicians who have strong preferences about what expensive items they use.
“It may be that the acquirers have already leveraged their scale to a great extent. They may already be paying lower prices, the lowest they’re going to be able to negotiate, when they acquire the next hospital,” Swanson says. “They may have already squeezed the orange as much as they can. The fact that they can’t gain any additional economies of scale from acquiring another hospital may not be that surprising, in that light.”

REALISTIC M&A EXPECTATIONS

This reality about supply cost savings may come as a surprise to some healthcare leaders post-merger, Swanson says. The promise of savings from economies of scale is always a big selling point when mergers are proposed, she says, right alongside a commitment to quality improvement.
Realistic portrayals will focus more on the cost savings at the target level, with the acquirer sharing its economy of scale with the smaller entity, she says.
The nature of M&A has changed over time, Swanson notes, with the 1990s seeing more local hospitals and smaller, within-market M&A activity. More recent years have seen more cross-market mergers and large multi-market systems acquiring hospitals, and that is driving these most recent effects on costs, she says.
The results might be different for targets and acquirers on a smaller scale in the same market, she says.
“Even though there is always a lot of focus on cost savings in merger discussions, I don’t think the large multi-market acquirers usually go into it expecting a major cost saving from the acquisition of a hospital. That they see none and even some negative effect might be surprising,” Swanson says. “I think this could be more surprising to policymakers and regulators.”
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