• Of the 3,606 hospitals reviewed by the Lown Institute, only 66, or less than 2%, earned the organization’s ‘most socially responsible’ distinction.
• Gun violence is a major public health problem in the United States, with an increase of 43% in the number of firearm deaths between 2010 and 2020, according to the National Institute for Health Care Management.
• Some 18%, or 42.3 million, of all in-network claims in 2020 were denied by ACA health insurers, with denial rates varying widely.

Over the last few weeks, I have found these industry news stories that should be of interest to healthcare finance professionals.   

1. Few hospitals earn the Lown Institute’s ‘most socially responsible’ honor

Only 66, or just under 2%, of 3,606 U.S. hospitals earned the distinction of “most socially responsible,” according to findings from the 2022 Lown Institute Hospitals Index for Social Responsibility.

“To achieve this designation, hospitals earned ‘A’ grades across measures of health equity, value, and outcomes,” according to a June 28 news release.  “The Lown Institute used publicly available [2018-20] data from Medicare claims, CMS hospital cost reports, IRS 990 forms, and other sources. COVID burden for March 2020-2021 is reported for each hospital, but does not factor into the hospital social responsibility ranking. “

The top five hospitals to earn the honor are:

• Adventist Health Howard Memorial, Willits, California
• Duke Regional Hospital, Durham, North Carolina
• Tristar Horizon Medical Center, Dickson, Tennessee
• Boston Medical Center Corporation
• Salinas Valley Memorial Hospital, Salinas, California

Fifteen of the straight “A” hospitals earned their grade while also enduring extraordinary challenges during the first year of the pandemic, exceeding the Lown Institute’s COVID-19 burden threshold, which is defined as having 26 or more weeks in which 10% or more of hospital beds were filled by COVID-19 patients  from March 1, 2020, to February 28, 2021.

The index “draws attention to leading and lagging institutions nationwide, and provides benchmarks for hospitals to measure how well they serve their patients and communities,” states the release.

2. NIHCM infographic: Gun violence is a major public health problem

Gun violence is a major public health problem in the United States, with the number of firearm deaths increasing by about 43% between 2010 and 2020, according to an infographic published July 12 by the National Institute for Health Care Management (NIHCM).

Among the data presented in the infographic:

• In 2010, 31,672 deaths were attributed to firearms, while in 2020, “45,222 people died in the U.S. from gun related injuries, more than any other year on record,” wrote the authors. Of those 2020 deaths, homicide accounted for 24,292 and suicide for 19,384. Additional deaths included 611 law enforcement-involved, 535 unintentional and 400 undetermined.
• “Every day, at least 321 people are shot across the U.S., for a total of 117,165 people per year,” wrote the authors. “For every individual who dies by firearm, more than two survive, often with expensive and long-term mental and physical injuries.”
• Between Jan. 1 and July 8, 2022, there were 326 mass shootings, defined by the Gun Violence Archive as “incidents in which four or more people are shot or killed, excluding the shooter.” There were 343 mass shootings during that same period in 2021 and 692 by year’s end.
• “Between 2018 and 2021, there was a yearly average of around 513 mass shooting events,” the authors wrote. “While mass shootings are often the most publicized events, they are not the primary source of gun violence,” accounting for less than 2% of gun-related deaths.

3. KFF report: ACA health insurers denied 18% of in-network claims in 2020

About 18%, or 42.3 million, of all in-network claims in 2020 were denied by ACA health insurers, with insurer denial rates varying widely, “ranging from less than 1% to more than 80%,” according to a July 5 report released by the Kaiser Family Foundation (KFF).

“Of the 213 major medical issuers in HealthCare.gov states that reported for the 2020 plan year, 144 showed complete data on in-network claims received and denied,” wrote the authors. “Together these issuers reported 230.9 million in-network claims received.”

Reasons for denials

Of denials with a reason other than being out-of-network, according to KFF:

• About 16% were denied because the claim was for an excluded service.
• 10% were due to lack of preauthorization or referral.
• Only about 2% were based on medical necessity (among claims identified as medical necessity denials, 1 in 5 were for behavioral health services).
• Most plan-reported denials (72%) were classified as ‘all other reasons’ without a specific reason.

KFF analyzed transparency data released by CMS on claims denials and appeals for non-group qualified health plans (QHPs) offered on HealthCare.gov. Data were reported by insurers for the 2020 plan year, posted in a public use file in 2021 and updated in 2022.

Low number of consumer appeals holds

“As in our previous analysis of claims denials, we find that consumers rarely appeal denied claims and when they do, insurers usually uphold their original decision,” wrote the authors. “In 2020, HealthCare.gov consumers appealed just over one-tenth of 1% of denied in-network claims, and insurers upheld most (63%) of denials on appeal.”

HFMA bonus content

Read this July 8 article, “Even as costs surge, Medicare physician payments are scheduled to decrease in 2023,” by Nick Hut, senior editor.

Listen to this HFMA Voices in Healthcare Finance podcast with host Erika Grotto and Wes Wheeler, president of UPS Healthcare, discussing the importance of a worldwide effort to manufacture, transport and store pharmaceuticals at ultra-cold temperatures. 

Read coverage of several sessions from HFMA’s recent Annual Conference, with topics including hospital-at-home programs, surprise billing dispute resolution and the importance of thoughtful investment strategies.