Reimagining Rehabilitation: In-Home Physical Therapy Gets a Boost

 As the aging population grows and telehealth expands in the wake of the COVID-19 pandemic, an emerging trend of in-home care is reshaping how patients access and receive physical therapy services.

Partnerships between hospitals and home health companies are increasing access to rehabilitation services not only for older adults but also for people in rural areas, those without reliable transportation, and patients with injuries that hinder their driving abilities.

"We find more and more that physical therapy at their home, instead of coming to an outpatient facility, is something more and more folks are requesting," said Bill Benoit, MBA, chief operating officer of University Hospitals (UH) in Cleveland, Ohio. "In this post-COVID environment, people are getting all different types of services in their home when they're available, and this is one of them. The pandemic sped up the process of us moving away from the traditional brick and mortar hospital."

UH recently announced a partnership with Luna Physical Therapy, a company founded in 2018 that provides home services. Luna has teamed up with more than two dozen other hospitals in the United States to offer home-based rehabilitation, according to the company.

The process for arranging in-home therapies through hospital-clinic partnerships is like any other inpatient or outpatient rehabilitation, Benoit said: A patient meets with a specialist or primary care practitioner, they discuss options, and eventually the clinician recommends physical therapy. The only difference here, he said, is rather than going to a separate facility or a hospital, the patient logs onto a mobile app that matches them with a physical therapist on the basis of their location, needs, and the times they are available.

The prescribing physician oversees the patient's progress through notes provided by the therapist.

"For the primary care physician or surgeon, they're not going to see much of a difference," Benoit said. "This just adds to that list of options for patients."

Safer, More Productive PT

A 2021 study published in the journal Family Practice found that 76% of patients who are prescribed physical therapy do not initiate the services after it has been recommended.

Aside from the convenience and expanded accessibility for patients, the home therapy option can be more productive, said Denise Wagner, PT, DPT, a physical therapist with Johns Hopkins in Baltimore.

"Home is safer for many patients, but home is also more engaging and motivating," Wagner said. "Home health clinicians are experts in using whatever they find in the home environment as equipment; many people have stairs in their home, so we can use the rail as something to hold. If patient likes to walk their dog, we can use putting a leash on dog as balance activity."

Therapy in the home setting helps physical therapists customize programs to fit each patient's lifestyle, said Gira Shah, PT, a physical therapist with Providence Home Services in Seattle.

For example, patients generally want to know how to function within their own space ― navigate their kitchens to make food, or get in and out of their bathtubs. Staying in that space allows therapists to focus on those specific goals, Shah said.

"It's more of a functional therapy," she said. "The beauty of this, as therapists we're trying to assess what does the patient need to be independent."

The consulting firm McKinsey predicts that as much as $265 billion in healthcare services for Medicare recipients will be provided within the home by 2025.

The obvious question is: Why would hospitals partner with clinics rather than offer in-home services on their own?

The answer, like most things in healthcare, boils down to money.

The billing and documentation system that they use is more efficient than anything hospitals have, said John Brickley, PT, MA, vice president and physical therapist at MedStar Health, a healthcare system in Maryland and the Washington, DC, area. MedStar and Luna announced a partnership last June.

"We would financially fall on our face if we tried to use our own billing systems; it would take too much time," Brickley said. "Do we need them from a quality-of-care standpoint? No. They have the type of technology that's not at our disposal."

Patients should be aware of the difference between home-based PT and other health services for homebound patients, Brickley said. Medicare considers a patient homebound if they need the help of another person or medical equipment to leave their home or if their doctor believes their condition would worsen with greater mobility.

From the perspective of an insurance company, a home therapy session arranged by a hospital-clinic partnership is an ambulatory appointment and uses the same charging mechanism as most other visits. For a home healthcare visit, patients must qualify as homebound.

Home-based PT can be used for conditions including neurologic issues, bone and joint problems, balance, and fall deconditioning and prevention. But if a patient needs heavy equipment that cannot be transported, outpatient services are more practical.

That should be determined by the primary care practitioner or specialist evaluating each patient, said Palak Shah, PT, cofounder and head of clinical services at Luna.

"Primary care physicians play a huge role ― that's where patients express their initial concerns," she said. "It's up to them to make patients aware about all the options."

https://www.medscape.com/viewarticle/998179

Not Enough Evidence for Primary Care to Routinely Conduct Dental Screenings

 Routine screenings for signs of cavities and gum disease by primary care clinicians may not catch patients most at risk of these conditions, according to a statement by the US Preventive Services Task Force (USPSTF) that was published in JAMA on November 7.

Suggesting ways to improve oral health also may fail to engage the patients who most need the message, the group said in its statement.

The task force is not suggesting that primary care providers stop all oral health screening of adults or that they never discuss ways to improve oral health. But the current evidence of the most effective oral health screenings or enhancement strategies in primary care settings received an "I" rating, for "Inconclusive." The highest ranking a screening can receive is an "A" or "B," which indicate that there is strong evidence for conducting a screening, while a "C" would indicate that clinicians could rarely provide a screening, and a "D" would indicate not to, given the current evidence.

Primary care clinicians should immediately refer any patients with apparent caries or gum disease to a dentist, the USPSTF noted. But what clinicians should do for patients who have no obvious oral health problems is up for debate.

"The 'I' is a note about where the evidence is at this point, and then a call for more research to see if we can't get some more clarity for next time," said John Ruiz, PhD, professor of clinical psychology at the University of Arizona in Tucson, who is a member of the task force.

More than 90% of US adults may have caries, including 26% with untreated caries that can cause serious infections or tooth loss. In addition, 42% of adults have some type of gum disease. More than two thirds of Americans aged 65 or older have gum disease, and it is the leading cause of tooth loss in this population. People earning low incomes and those who do not have health insurance or who belong to a marginalized racial or ethnic group are at greater risk of the harms of caries and gum disease.

"Oral health care is important to overall health," and any new research on oral health screening and enhancement efforts should be demographically representative of adults affected by these conditions, Ruiz said.

In an accompanying editorial, oral health researchers from the National Institutes of Health and the University of California, San Francisco, echoed the call for representative research and encouraged closer collaboration between primary care providers and dentists to promote oral health.

"Oral health screening and referral by medical primary care clinicians can help ensure that individuals get to the dental chair to receive needed interventions that can benefit both oral and potentially overall health," the authors wrote. "Likewise, medical challenges and oral mucosal manifestations of chronic health conditions detected at a dental visit should result in medical referral, allowing prompt evaluation and treatment."

Lack of Data

The USPSTF defined oral health screenings for patients older than 18 who have no obvious signs of caries or gum disease as looking at a patient's mouth during physical exams. Additionally, clinicians might use prediction models to identify patients at greater risk of facing these problems.

Strategies to improve oral health include providing encouragement to patients to reduce intake of refined sugar, to floss and brush effectively to reduce bacteria, and to use fluoride gels, fluoride varnishes, or other kinds of sealants to make caries harder to form.

A literature review found that there has been limited analysis of primary care clinicians performing these tasks. Perhaps unsurprisingly, more such studies about dentists existed, leaving an open field for dedicated studies about what primary care clinicians should do to optimize oral health with patients.

"Clinicians, in the absence of clear guidelines, should continue to use their best judgment," Ruiz said.

One dentist who spoke to Medscape Medical News said screening could be as simple as doctors asking patients how often they brush their teeth and giving patients a toothbrush as part of the office visit.

"It all comes down to, Is the person brushing their teeth?" said Jennifer Hartshorn, DDS, who specializes in community and preventive dentistry at the University of Iowa in Iowa City.

"By all means look in their mouth, ask how much they are brushing, and urge them to find a dental home if at all possible," Hartshorn said, especially for patients who smoke or have conditions such as dry mouth, which can increase the risk of oral disease.

Ruiz and Hartshorn report no relevant financial relationships.

https://www.medscape.com/viewarticle/998164

Marijuana use increases risk of heart attacks, new studies suggest

 Two new studies suggest that regular use of marijuana could be linked to a higher risk of heart failure or heart attack, especially among older people. 

The preliminary findings of the studies, which have yet to be published, will be presented next week at the American Heart Association’s (AHA) Scientific Sessions 2023 in Philadelphia.

The first study followed 156,999 people for 45 months, nearly four years. At the start of the study, all participants were free from heart failure and filled out a survey about their marijuana use, which was defined as “using marijuana when not prescribed for a health condition, or, if prescribed for medical purposes, using it beyond that purpose.” 

The study found that those who used marijuana daily had a 34 percent increased risk of developing heart failure, when compared with those who said they never used marijuana. Throughout the study, nearly 2 percent — 2,958 people — developed heart failure.

When accounting for coronary artery disease, however, the risk dropped from 34 percent to 27 percent, which researchers said could reveal that “coronary artery disease is a pathway through which daily marijuana use may lead to heart failure.”

The press release noted that research did not specify whether the marijuana was eaten or inhaled, which “may influence cardiovascular outcomes,” research said.

“Prior research shows links between marijuana use and cardiovascular disease like coronary artery disease, heart failure and atrial fibrillation, which is known to cause heart failure,” lead study author Yakubu Bene-Alhasan, a resident physician at Medstar Health in Baltimore, said in the press release. “Marijuana use isn’t without its health concerns, and our study provides more data linking its use to cardiovascular conditions.”

“Our results should encourage more researchers to study the use of marijuana to better understand its health implications, especially on cardiovascular risk,” Bene-Alhasan added. “We want to provide the population with high-quality information on marijuana use and to help inform policy decisions at the state level, to educate patients and to guide health care professionals.”

A second study analyzed data from the 2019 National Inpatient Sample, which the press release described as the largest database of hospitalizations. The researchers pulled data on adults ages 65 and older with cardiovascular risk factors. They focused on those who reported no tobacco use, and then divided the patient records into two groups: marijuana users and nonusers. 

The study, which looked at 28,535 marijuana users, found that marijuana users had a 20 percent increased chance of “having a major heart or brain event while hospitalized,” compared with the other group. Nearly 14 percent of marijuana users “had a major adverse heart and brain event while hospitalized compared to non-cannabis users.” 

Researchers warned that more data is needed to determine the risk of marijuana usage. They encouraged health professionals to ask about marijuana specifically, not just smoking, when taking a patient’s medical history.  

“We must be mindful about major heart and stroke events in older adults with cannabis use disorder,” lead study author Avilash Mondal, a resident physician at Nazareth Hospital in Philadelphia, said in the press release.

“The main public message is to be more aware of the increased risks and open the lines of communication so that cannabis use is acknowledged and considered,” Mondal added.

https://thehill.com/policy/healthcare/4296308-marijuana-use-heart-attack-risk/

China Is Having a Hard Time Wooing Foreign Investors Back

• Direct investment liabilities book first drop since 1998: data
• Abrupt regulatory changes have been ‘damaging’ for sentiment

 

China is struggling in its attempt to lure foreigners back as data shows more direct investment flowing out of the country than coming in, suggesting companies may be diversifying their supply chains to reduce risks.

Direct investment liabilities in the country’s balance of payments have been declining rapidly in the last two years. After hitting a near-peak value of more than $101 billion in the first quarter of 2022, the gauge has weakened nearly every quarter since. It fell $11.8 billion in the July-to-September period, marking the first contraction since records started in 1998.

https://www.bloomberg.com/news/articles/2023-11-08/china-is-having-a-hard-time-wooing-foreign-investors-back

CMS Proposes Rule to Limit Medicare Advantage Plan Sales Commissions

 To stop Medicare Advantage (MA) and Part D plan marketing agents from steering beneficiaries into plans that pay the agents the highest commissions -- rather than the plans that best suit the patients' needs -- the Centers for Medicare & Medicaid Services (CMS) proposed a rule

opens in a new tab or window Monday that would limit the amount they'd receive on sales to $632 for the 2025 plan year.

Currently, agents can receive far more than the current national commission cap of $601, even as high as $1,300 on one sale for 1 year's enrollment, because of "add-on" or "incentive fees," according to recent Senate committee hearing testimonyopens in a new tab or window. CMS called the practice "anti-competitive steering" since larger plans are usually paying the most, putting smaller, potentially better plans at a disadvantage.

In the 486-page proposed rule, CMS explained that it has received complaints from state partners, consumer advocates, and some MA plans that agents and brokers receive add-on and other financial incentives that "are likely to influence which MA plan an agent encourages a beneficiary to select during enrollment."

For example, the agency said it has seen web-based ads that offer agents and brokers "bonuses and perks (such as golf parties, trips, and extra cash) in exchange for enrollments." The payments are implemented in a way that allows the plan sponsor "to credibly account for these anti-competitive payments as 'administrative' rather than 'compensation,' and these payments are therefore not limited by the regulatory limits on compensation."

That would change if this proposed rule is finalized.

The compensation should reflect "only the legitimate activities required of agents and brokers by broadening the scope of the regulatory definition of 'compensation' so that it is inclusive of all activities associated with the sales to/enrollment of a beneficiary into a Medicare Advantage plan or Part D plan," CMS said in an accompanying fact sheet.

This proposed rule is part of a series of regulatory crackdowns on MA plans' deceptive marketing practices, prior authorization delays and denials of care, and narrow provider network limitations.

In Aprilopens in a new tab or window, the agency finalized a rule that required all television ads for MA plans to undergo prior review, and limited the times and places that agents could approach beneficiaries with sales pitches. Last Octoberopens in a new tab or window, the agency stepped up its efforts in other areas, including its intent to use secret shoppers, and review agents' recorded calls with their clients to make sure that beneficiaries were not being misled.

The new proposed rule estimates that about 2 million new beneficiaries a year enroll in MA plans or stand-alone prescription drug plans, and 50% of those have interaction with an estimated 100,000 agents/brokers selling the plans.

If finalized, the rule would also prohibit MA organizations from contracting with marketing middlemen, such as field marketing organizations, that result in volume-based bonuses that incentivize these sellers to enroll beneficiaries in certain plans that may not best suit their healthcare needs.

The CMS proposal would also set forth requirements for MA plans to meet network adequacy standards for outpatient behavioral health, which will include marriage and family therapists and mental health counselors. In separate rulemaking, addiction or drug and alcohol counselors meeting requirements would be able to enroll in Medicare.

Another provision of the proposed rule addresses the agency's concern that while 99% of MA plans offer one or more supplemental benefits, such as vision, dental, or hearing services, and transportation or food support -- benefits that may seem persuasive enough to lure beneficiaries into these plans -- actual utilization by enrollees has been low.

"To ensure the large federal investment of taxpayer dollars in these benefits is actually making its way to beneficiaries and are not primarily used as a marketing ploy," the proposed rule would require MA plans to send a mid-year notice to enrollees of benefits that weren't accessed during the first 6 months, according to the CMS fact sheet. The notices would include the scope of the benefits not yet accessed, cost-sharing, and instructions on how to get these services, with a customer service number to call.

Another provision in the proposed rule would require MA plans to demonstrate in their bids to Medicare that special supplemental benefits for the chronically ill that are offered have a reasonable expectation of improving health or overall function of enrollees with chronic illness.

Further provisions in the proposed rule would lessen the burden of prior authorization delays and denials affecting underserved populations by requiring MA plans to include in their utilization management committees a committee member with an expertise in health equity. An annual health equity analysis of prior authorization policies and procedures would also be required, with those analyses available publicly on their websites.

The goal of these analyses is to "create additional transparency and identify disproportionate impacts of utilization management policies and procedures on enrollees who receive the Part D low-income subsidy, are dually eligible, or have a disability," CMS said in its fact sheet.

Provisions would also allow Part D plan sponsors to treat formulary substitutions of biosimilar biological products as maintenance changes, thus eliminating the requirement that Part D plan sponsors otherwise would have to obtain CMS approval for each drug change. This would allow beneficiaries to have faster access to equally effective but potentially more affordable options, the agency said.

Premier, Inc., an alliance of hospitals and health systems geared toward improvement strategies and supply chain improvements, quickly applauded the proposed change for biosimilar products.

In a press statement, Soumi Saha, PharmD, JD, senior vice president of government affairs at Premier, said, "It has been known for years that biosimilars can improve patient access to medications while saving the U.S. healthcare system billions of dollars, yet anti-competitive practices by vertically integrated payers have put their own profits ahead of lowering drug costs for patients by favoring the reference biologic and lucrative rebates."

Provisions would also require federal quality improvement organizationsopens in a new tab or window -- instead of representatives of the MA plans -- to review a fast-track appeal when the plan has decided to terminate services in a skilled nursing facility, comprehensive outpatient rehabilitation facility, or a home health agency. Such fast-track review is now available to traditional Medicare beneficiaries in fee-for-service, but not to those in MA plans.

Lastly, a provision would revise the current quarterly special enrollment period for beneficiaries dually eligible for Medicare and Medicaid and other Part D low-income subsidy to once per month, to allow them to enroll in a stand-alone prescription drug plan and a new integrated special enrollment period and to elect an integrated dual-eligible special needs plan on a monthly basis.

https://www.medpagetoday.com/publichealthpolicy/medicare/107203

Why I 'Anti-Trust' Google Search on Healthcare

 After more than 20 years of using Google, why do I now "anti-trust" the search engine?

I've found that Google often spits out results that are, in my opinion, flat out bad for public health. They've also known about the problem for years, and yet, have not effectively solved it, despite some new policies targeted at the issue.

At the same time a major antitrust lawsuitopens in a new tab or window against them unfolds in a U.S. courtroom, Google has another big, very different kind of trust issue. The two problems are linked and build off of one another.

For background, I'm a cancer and stem cell biologist running a research lab, but I also devote time to educational outreach. These latter efforts include running an educational website about stem cells and other innovative technologies called The Nicheopens in a new tab or window, which I started in 2010. I've regularly written on The Niche about a major public health threat emerging in the stem cell arena. There are now estimated to be around 2,000 clinicsopens in a new tab or window marketing unproven stem cell "therapies" in the U.S., with hundreds more internationally.

Many of these clinics' stem cell offerings are both scientifically unproven and unapprovedopens in a new tab or window by the FDA, even though the products often qualify as drugs that require approval by the agency. As a result, what many of these clinics are doing is technically illegal (since 2021) and a growing number of people have been harmedopens in a new tab or window.

Some of the most catastrophic results have included blindness and at least 20 casesopens in a new tab or window of sepsis in the U.S. alone. There also have been infections, such as meningitisopens in a new tab or window, elsewhere in the world, and some patients abroad have gotten tumorsopens in a new tab or window linked to stem cell treatments. Such stem cell clinic-related harms have been documented in papers, such as one by my colleague Gerhard Baueropens in a new tab or window, as well as by the Pew Trustopens in a new tab or window, which documented 20 deaths. Collectively, consumers are likely wasting hundreds of millions of dollars on what often turns out to be snake oil.

While researching the clinics, I've come to believe that Google plays a big role in this public health mess. Many potential customers likely find out about and get recruited to stem cell clinics via Google (the most popularopens in a new tab or window U.S. search engine); this aligns with what patients tell me when they reach out to me for information. For years, Google accepted adsopens in a new tab or window from these clinics, which effectively exposed thousands of patients to risky, unproven medical interventions.

To its credit, Google implemented a new, positive ad policyopens in a new tab or window in 2019. Moving forward, it would no longer accept ads from these clinics. Many of us applauded Google and thought this step could make a significant dent in the problem.

Unfortunately, there is a big loophole. Instead of paying for Google ads, the clinics can just finagle the system via search engine optimization (SEO) to rank their websites at or near the top of Google Search results. It's been a big success for many clinics as they often dominate Google Search results.

How do the clinic websites do so well in internet searches? Google generally won't comment on the specifics of its ranking system, but it appears the SEO strategy of many clinics is to portray their websites as educational resources rather than as strictly marketing efforts. They fill up their pages with loads of stem cell-related text and cool images. It is possible that some of the more recent text may even be AI-generated. Despite this veneer, it's clear to human experts that these websites are just marketing unproven stem cells.

Even so, it appears Google's algorithm eats it up even though the same web pages are often full of heavy-handed marketing buttons and pop-ups to draw in clinic customers. I also found what appears to be evidence of clinics potentially buying backlinks, which is another SEO strategy -- one that Google claims violates its policiesopens in a new tab or window -- which could lead to SEO penalties.

It appears Google has known about its stem cell clinic search problem for years but hasn't effectively addressed the issue. As I wrote in STATopens in a new tab or window in early 2022, I met with Google in 2021 to explain the patient injuries, health risks, and lack of science behind these clinic practices, so Google should be fully aware of situation. Google should also recognize that some of the clinics are breaking the law. Yet, if anything, the stem cell search situation now seems even worse than before based on my own ongoing research with common stem cell-related search phrases on Google.

Google seems to either not care that these clinics are trying to make money from risky offerings or is not taking visible action due to some other unknown reason, perhaps because displaying these search results generates profits. Whatever the motivation, the result is harmful both for the public and the legitimate stem cell research field.

To be clear, there is some very promising stem cell research going on, as shown in dozens of FDA-approved clinical trials. However, in my view, the direct-to-consumer clinics are not part of this legitimate sphere. They are not the real authorities, despite their effortsopens in a new tab or window to seem legitimate and part of the research community. They generally don't conduct real clinical trials or publish data. In looking over various stem cell clinic websites, I also can't easily find expert stem cell researchers or physicians on staff. Often, it is just one or a handful of obscure doctors or even chiropractors.

Despite this reality, Google is now so off-base with its stem cell internet search that it often ranks these clinic websites, and others that promote the clinics, higher than the real authorities doing clinical trials or funding stem cell research: the NIH, universities, and other prestigious entities like the Mayo Clinic.

For example, when someone Google searches "stem cells for neuropathy" (or swap in "COPD," "pain," "knee arthritis," etc. for "neuropathy"), stem cell clinic websites are often listed first or in the top few results, right where clinic ads used to appear. Only further down does one find web pages of the institutions that are the true stem cell experts.

Another particularly concerning example is that Google often ranks stem cell clinics as the authorities on stem cell side effectsopens in a new tab or window, even though the clinics have a clear financial conflict of interest to downplay the risks. I'm not saying that the specific stem cell clinics that tend to rank high up on Google Search have necessarily broken any laws or harmed patient health, but in my view, there is major harm when unproven clinics are so often presented as the topline experts.

Google search for "stem cells for knees"

In a way, the current situation is worse than when Google allowed the unproven clinic ads. At least then the clinic marketing was labeled as such. Now, Google users just see search results and probably assume they can trust them.

What about my site, The Niche? It does not rank in Google Search like it used to and I have no idea why. However, since The Niche is an educational resource, if it gets outperformed by clinic websites, I won't lose anything substantial. But I know that Google's ranking of unproven stem cell clinics so high up in search results can potentially translate to substantial harm. Out of hundreds of patients I've communicated with, many say they have been harmed or feel ripped off.

This Google stem cell problem is an important public health issue on its own, but there's a bigger picture concern here too. Google's ineffective handling of stem cell-related searches may be a canary in the search engine coal mine. Could Google Search be leading people to marketers of dubious information on a host of other healthcare topics?

Whether it's anti-aging supplements, homeopathy for autism, energy healing, or other highly questionable health practices, the search engine may steer consumers the wrong way.

Google relies on an implicit kind of consumer trust when we want to search the web. We should wake up and question that faith in Google Search. While the big antitrust case is unfolding, internet users probably have at least as much power to challenge Google's long-standing alleged monopoly as the government. Especially on healthcare topics, we can simply try other search engines and potentially move on from Google.

Paul Knoepfler, PhD,opens in a new tab or window is a cancer and stem cell biologist, and professor at UC Davis School of Medicine.

Disclosures

Knoepfler receives limited funding from one advertiser (unrelated to clinical use of stem cells) on The Niche, a large fraction of which goes toward expenses of running the site.

https://www.medpagetoday.com/opinion/second-opinions/107201

'Envision Healthcare Bounces Back After Bankruptcy'

 Six months after filing for bankruptcy, the physician staffing firm Envision Healthcare has bounced back after extensive restructuring that cut the company's debt by more than 70%.

The biggest change, according to a press releaseopens in a new tab or window from the company, is that Envision is no longer linked to AMSURG, its ambulatory surgery center, because the health system reorganized by splitting into two separate entities.

An AMSURG press releaseopens in a new tab or window from last month stated that the two "will remain strong partners," despite having separate leadership and new equity owner groups.

"Now that our financial restructuring has been completed successfully, we are driving Envision's future growth from a position of stability and strength," Envision CEO Jim Rechtin said in the press release, noting that the company has "significantly less debt" and a "strong operating model."

Nashville, Tennessee-based Envision is backed by private equity, acquired by Kohlberg Kravis Roberts, or KKR, in 2018. When Envision announced in a May press releaseopens in a new tab or window that it was filing for bankruptcy with a voluntary petition for reorganization, some of the reasons cited included decreasing patient volumes as COVID-19 lessened, reimbursement issues, and what they called "flawed implementation" of the No Surprises Actopens in a new tab or window (NSA), which aims to protect patients from surprise medical bills.

Of the NSA-eligible claims submitted through the independent dispute resolution process, "only a small fraction has been resolved, and of those that were resolved, many remain unpaid by health insurers," Envision said, noting that these delays have caused "hundreds of millions of dollars in underpayments and delayed payments from all health insurance plans."

Adam Brown, MD, MBA, an emergency medicine physician and business leader, told MedPage Today that the recent restructuring relieved Envision of the bulk of its debts, though he cautioned that the company isn't out of the woods yet.

"Significant financial headwinds exist for Envision and most hospital-based healthcare service providers," he said, citing ongoing challenges including "continued wage inflation pressures and legal challenges," as well as "Medicaid disenrollments, reimbursement declines from private payers, CMS rate cuts for physicians next year, and the ever-present drag of the poorly administered, legal-challenged, and backlogged No Surprises Act."

"While Envision may have gained some much-needed breathing room in the short term, these challenges necessitate ongoing strategic realignment," Brown added.

When Envision first announced its bankruptcy, Brown wrote aboutopens in a new tab or window how these issues aren't new -- and aren't unique to Envision. Just a few months after Envision filed for bankruptcy, American Physician Partners (APP), another physician staffing firm, also foldedopens in a new tab or window.

APP is also backed by private equity, being partially owned by Brown Brothers Harriman & Co., along with member physicians and management. When APP announced its closure in July, the American College of Emergency Physicians said it wasopens in a new tab or window "deeply concerned" about the event and the "impact this disruption will have on thousands of emergency physicians, their families, patients, and communities."

https://www.medpagetoday.com/special-reports/features/107213