Mary Caffrey

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Whether a provider accepts their insurance is still the leading factor for consumers selecting a doctor or hospital, but online reviews are rising in importance, especially among millennials, according to a new study.

Reputation, which this week released its 

, found that insurance acceptance and location ranked first and second in importance among consumers making healthcare choices.

Once consumers have eliminated options that do not accept insurance or are too far away, online reputation and consumer reviews can make or break a decision, the report suggests. And that could be a problem for the 50% of health systems and 65% of physicians who had no online reviews.

Insurers should not assume that consumers generally, and millennials in particular, will blindly accept referrals to certain providers, according to Reputation’s Annie Haarmann, head of strategy and consulting, Healthcare and Life Sciences.

“They’re not really relying just on word of mouth or who their insurance provider tells them to go to,” she said. Even when patients receive a referral, they check out the physician online before making the appointment, Haarmann said.

The report highlights a “digital divide” as some physicians and health systems have become savvy about managing their online reputation and others are asleep at the wheel. The report found those with little or no online review presence are at a disadvantage among millennials, who are the generation most likely to use reviews when selecting a provider. Up to 50% of consumers use reviews when making a healthcare decision, the study found.

Findings were based on 348,000 customer reviews across 113,000 physicians and facilities.

Reputation uses reviews and artificial intelligence, developed over a decade, to drive an algorithm that calculates a reputation score of 0 to 1,000; the best-ranked health system in this year’s report, Universal Health Services, scored 729. According to a statement from the company, the algorithm measures nine elements that include many “stars” patients award a health system to how many reviews it receives. The AI capabilities capture both solicited an unsolicited feedback, from patient ratings to Facebook posts.

The Growing Importance of Reputation Management

How important is online reputation management for health systems?

According to a statement from the company, data scientists found that found that healthcare facilities with strong reputation scores have 1,290% more conversions on Google My Business (GMB) listings, which matters as more consumers turn to Google to search for providers. In this year’s rankings of the 25 largest U.S. health systems, for example, top performing systems had 232% more online, third-party reviews than those at the bottom. A world-class institution such as Cleveland Clinic, for example, landed in 15th place on reputation score largely because of a 3% rating on patient engagement.

"At our UHS Acute Care Hospitals and Behavioral Health Facilities, our reputation as the preferred healthcare provider in our served markets is important to us,” Celine Patterson, Lead, Online Reputation Management, Universal Health Services, said in the statement accompanying the report. “It is a key aspect of our mission statement, 'to provide superior quality healthcare services that patients recommend to their family and friends.' We have an unwavering focus on the consumer—making it easier for them to find us online and select us for their care.”

Haarmann said in an interview the findings highlight not only the digital divide, but generational differences in how consumers make healthcare decisions. Over the past decade, as more attention has been paid to “patient experience,” the ratings that matter most to consumers aren’t the ones collected and disseminated by the providers. Consumers have direct access to unfiltered feedback from current and former patients.

“A millennial is twice as likely to search online for a health care provider than a baby boomer,” she said. What this tells us is with the Triple Aim, the consumer experience piece is driven more by the information that is available online. Consumers are armed with more data than they've ever had before. And that allows them to make more educated decisions.

Also, she said, millennials want information such as online pricing and online scheduling. “They’re providing feedback around the experience itself—the interaction outside of the clinical experience. Whereas [with] baby boomers the feedback they’re providing is more focused on the physician. They’re looking at, ‘What are the factors that make that physician the right person for me—whether it’s the educational background, or the connection to a specific brand. It’s very interesting to see the differences in the two generations.”

The pandemic has changed what consumers look for in online reviews: they want to see options for virtual care. They care about cleanliness, social distancing, and what steps are being taken to protect the staff. Two years ago, Haarmann said, the typical consumer knew little about hospital acquired infections. Now, safety protocols are among the first things consumers look for online.

“There's a lot more understanding around things like the waiting room, disinfection, and wearing protective equipment,” Haarmann said. “I think that will continue in the future, now that people understand that they can get these viruses anywhere.”

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Half the health systems and 65% of doctors had no online reviews, which puts them at a disadvantage when millennials go shopping for healthcare.

Insurance Still Top Factor Driving Healthcare Choices, But Online Reviews Grow in Importance, Study Finds

For years, heart failure was the unsolvable problem of healthcare. Patients with heart failure cannot adequately pump blood through the body, causing fatigue, persistent cough, weakness or other symptoms. They have long hospital stays. When they are discharged, they often return. Most have other health problems, diabetes being among the most common. Half of patients with heart failure will die within five years of showing symptoms.

Heart failure is so costly — the tab reached $30.7 billion in 2012 — that it got special mention in the Patient Protection and Affordable Care Act, which tried to compel the delivery system to stop the revolving hospital door by imposing readmission penalties. Meanwhile, drug manufacturers have been searching for better treatments, partly because any products they come up with will enjoy a growing market. Heart failure is a disease of old age, and tens of millions of baby boomers are now in their 60s and beyond.

Even so, a 2014 heart failure breakthrough received a lukewarm reception. Results from the pivotal PARADIGM-HF trial showed that patients taking Novartis’ Entresto (sacubitril/valsartan) had a 20% lower risk of death from cardiovascular causes than those taking enalapril, an ACE inhibitor. But sales fell short of expectations, and heart failure lost some luster as a therapeutic area. “If a ‘blockbuster’ therapy with demonstrable mortality reduction benefit was seldom prescribed for patients who would benefit, how could future investments be justified?” wrote Tariq Ahmad, M.D., M.P.H., FACC, and Nihar R. Desai, M.D., M.P.H., of the Yale School of Medicine, in 

But in 2020, Novartis’ patience with Entresto paid off. Third- quarter results showed U.S. sales had climbed 45% for the year. Marie-France Tschudin, president of Novartis Pharmaceuticals, told investors that in a pandemic, “Entresto delivers on its value proposition of keeping patients out of the hospital. This, of course, is especially important right now.”

Patients in the PARADIGM-HF trial had heart failure with reduced ejection fraction, also called systolic heart failure, which occurs when the heart’s left ventricle becomes enlarged and fails to push blood out into the circulatory system properly. At the time the Entresto results were reported, other treatments for this type of heart failure were already available. It took time for Entresto to be embraced as a first choice, but Tschudin said this is finally happening.

Keeping patients out of the hospital is the goal of other heart failure treatments under development, including Amgen’s omecamtiv mecarbil, which targets a protein that powers the pumping function. Omecamtiv mecarbil, for reduced ejection fraction, is among a new wave of drugs being studied that addresses cardiac damage without causing adverse events. Another is Merck and Bayer’s vericiguat, which has a different mechansism of action.

Some patients, however, have heart failure with preserved ejection fraction: The left ventricle has enough pumping power but the heart is stiff, so the chamber doesn’t fill up with enough blood. This year, it looks like heart failure with preserved ejection fraction is where the action will be as far as drug development, approval and marketing.

Novartis got a head start by filing an application with the FDA in June 2020 to market Entresto as a treatment for heart failure with preserved ejection fraction. Novartis’ strategy for Entresto seemed to pay off on Dec. 15 when an FDA advisory committee voted 12-1 to be the first drug approved for heart failure with preserved ejection fraction. An FDA staff recommendation, and the positive committee vote, came despite trial results that fell short of reaching statistical significance. The advisory panel debate highlighted some of the problems with dividing heart failure into reduced and preserved ejection fraction. 

By the end of the discussion, Norman Stockbridge, M.D., Ph.D., director of the FDA’s Office of Cardiology, Hematology, Endocrinology and Nephrology, said that coming up with a meaningful label may require a different way of describing “the heart failure spectrum.” Steven Nissen, M.D., of Cleveland Clinic, discussed a label that would include reducing heart failure hospitalization. Cynthia Chauhan, M.S.W., the panel’s consumer representative, called for a new trial that would have greater representation of minorities and patients with common comorbidities. Novartis’ David Soergel, global head of cardiovascular, renal and metabolic drug development, said the need for diversity is recognized within the company and across the industry.

Both the FDA staff and the panel weighed the fact that results from the phase 3 PARAGON-HF trial supporting the preserved ejection fraction indication did not reach statistical significance for reducing morbidity and mortality. But Novartis’ supplemental new drug application included data from PARADIGM-HF and made the case that the “totality of the evidence” supported approval with ejection fraction in the “overlap HFrEF (heart failure with reduced ejection fraction) and the lower end of HFpEF (heart failure with preserved ejection fraction).”

Novartis is studying Entresto for yet another indication in the phase 3 PARAGLIDE-HF trial. This trial looks at whether the drug works in patients with preserved ejection fraction with acute decompensated heart failure — a sudden worsening of heart failure — after stabilization during hospitalization. This indication could have important implications for insurers because of the penalties for hospital readmissions. But results from this trial aren’t expected until early 2022. The next day the committee made a similar recommendation for the blood pressure medication spironoclatone but by a narrower vote of 8-4. Spironoclatone is currently approved to treat heart failure with reduced ejection fraction.

Hot on Novartis’ heels are the SGLT2 inhibitors, which started as diabetes drugs but have crossed over and are fast becoming heart failure drugs too. AstraZeneca’s Farxiga (dapagliflozin) is approved as a treatment for heart failure with reduced ejection fraction, and Eli Lilly and Boehringer Ingelheim’s SGLT2 inhibitor Jardiance (empagliflozin), may join Farxiga based on strong results presented at European Society of Cardiology Congress 2020. Results of trials assessing both of them as treatments for heart failure with preserved ejection fraction are expected to be reported this year.

Most likely, the effective treatment of heart failure — for both reduced and preserved ejection fraction — will not be a single drug but a combination of drugs. Ahmad and Desai endorsed “quad therapy” for heart failure with reduced ejection fraction, arguing that a cocktail of Entresto, Farxiga, a beta blocker and a mineralocorticoid receptor blocker would be greater than the sum of its parts.

Burkert Pieske, M.D., a German heart disease researcher, says the same is true in preserved ejection fraction: “I do believe in the future, a combination therapy of Entresto and an SGLT2 inhibitor and, in addition, a (mineralocorticoid receptor) antagonist — as an anti-fibrotic and blood pressure lowering agent — could be the ideal combination.”

The only thing to do now, he says, is wait for the data.

Attention is turning this year to heart failure with preserved injection fraction.

The race for new heart failure treatments heats up

The Trump administration’s price transparency rule, which requires hospitals to disclose what they charge for basic items and services, will take effect today after getting the green light from a U.S. 

 with just days to spare earlier this week.

Empowering consumers by making hospitals show their cards is one of the healthcare highlights that Trump officials point to as they prepare to leave office this month. Other efforts, such as 

 to put prices in television ads, did not pass muster with the courts.

The American Hospital Association (AHA) had vigorously fought the transparency rule, arguing that requiring disclosure of the closely guarded rates negotiated with payers represented a violation of the First Amendment. The U.S. Circuit Court in the District of Columbia unanimously disagreed; Chief Judge Merrick Garland did not participate in the final disposition, as he is being considered for attorney general by President-elect Joe Biden.

The judges wrote Tuesday that the HHS rule was consistent with the First Amendment and did not seek to expand it, nor did it intend “to otherwise affect traditional or ordinary economic regulation of commercial activity.”

AHA arguments that final prices cannot be known “miss the mark,” the court wrote, because even if the bill depends on many factors, negotiations must start somewhere.

HHS issued instructions December 18, 2020, on the core requirements of the new rule, which require hospitals to report their prices in two ways:

 that contains standard charges for all charges and services at the hospital, including gross charges, discounted cash prices, payer-specific negotiated charges, and de-identified minimum and maximum negotiated charges.

 of at least 300 shoppable services, that can be scheduled in advance, including plain-language descriptions in a searchable format. This section must also provide gross and discounted cash prices, payer specific charges, and de-identified minimum and maximum negotiated charges.

Penalties for violations include fines of $300 per day and publication on the CMS website if the hospital fails to respond to CMS’ demand for correction action. Enforcement may prove tricky, however. According to a 

 by attorneys from the firm Husch Blackwell, hospitals have found the rule does not offer guidance for some situations and does not apply to all facilities.

The law appears to generally apply to state-licensed entities but not those under the Indian Health Service facilities, Veterans Affairs facilities, and Department of Defense Military Treatment Facilities. Also exempt are “ambulatory surgical centers or other nonhospital sites-of-care from which consumers may seek healthcare items and services.”

Enforcement will occur through audits that will start in January and based on complaints, CMS said in its statement. However, the AHA appealed to the incoming Biden-Harris administration 

 December 21, 2020, to “exercise enforcement discretion” with the new rule.

“We, like your Administration, have made it clear that tackling the COVID-19 pandemic should be our nation’s highest priority,” the letter states.

On the day of the appellate ruling the Healthcare Financial Management Association reported that hospital advocates sought to 

 entirely, along with several other Trump-era policies, such as 340B reform.

But going against the judges could be tricky politically for the Biden team, since the judges note that Trump’s HHS acted in the wake of complaints about surprise hospital bills after passage of the Affordable Care Act. The bill’s chief purpose, they wrote, is to “shift to hospitals some of the burden that patients currently bear” in “navigating a non-transparent hospital-care system.”

The rule may represent an about-face from prior policy but that’s not necessarily a bad thing, they wrote. “The Secretary weighed the rule’s costs and benefits and made a reasonable judgment that the benefits of easing the burden for consumers justified the added burdens imposed on hospitals.”

The U.S. Circuit Court of Appeals of the District of Columbia ruled Tuesday that the rule could take effect today.

Ready or Not, the New Year Brings Trump’s Price Transparency Rule

® interested in oncology looked for updates from FDA and news about biosimilars in 2020. The FDA Updates column, appearing on Sundays, became a popular feature during the second half of the year. Here are the most-read oncology news items for 2020:

5. More Action Is Sought to Prevent Continuous Rise of Childhood Cancer in U.S.

 called for scientists, policy makers, health advocates, businesses and parents to put more emphasis on prevention to stop the rise of childhood cancer in the United States. Steps such as reducing toxic chemicals and environmental damage are just as important as finding new treatments, the foundation said a statement. Such an approach would require across-the-board action from government to the consumer level, starting with increased investment in prevention research and an expansion of regulations to reduce known causes of cancer.

4. OneOncology Having Success With Mvasi, Kanjinti

OneOncology, the expanding partnership of community oncology practices based in Tennessee, decided to all-in for biosimilars and to advertise its success. 

, OneOncology CEO Jeffrey F. Patton, MD, spoke with 

® about its use of a pair of Amgen biosmilars, Mvasi ((bevacizumab-awwb), and Kanjinti ((trastuzumab-anns), whose reference products are the widely used cancer therapies Avastin (bevacizumab) and Herceptin (trastuzumab). Patton said the switch from day one of availability of the products resulted in 15% savings, reducing therapeutic costs for patients, the public, and for commercial payers. Patton has been an advocate for giving community practices autonomy over selection of biosimilars so that that practices are not required to carry multiple biosimilar versions of the therapy, which can create administrative and storage issues.

3. Oncology Care Model Spurs Use of Biosimilar Filgrastim

Biosimilar versions of the filgrastim, a recombinant non-pegylated 

 (GCSF), have proliferated in recent years, and their use has taken off since the launch of the 

. Evaluators from Abt Associates who studied the rise of biosimilar filgrastim found that while prescriptions rose in both OCM practices and a comparator group of practices not taking part in the alternative payment model, uptake of biosimilars was greater in the episodes of care delivered by the OCM practices between July 1, 2016, and December 31, 2017.

2. FDA Updates: Blood Cancers, Orphan Drug Designations Get Priority

that lets readers get caught up on the week’s activity covered a busy week in late July as FDA approved the first new chimeric antigen receptor (CAR) T-cell therapy in nearly three years, when it approved Tecartus (brexucabtagene autoleucel) for refractory mantle cell lymphoma (MCL) has relapsed or not responded to treatment. FDA also approved a combination including Monjuvi (tafasitamab-cxix) for adults with diffuse large B-cell lymphoma who are not eligible for an autologous stem cell transplant.

1. FDA Updates: Assays Used in Cancer Care Get Green Light

, Adaptive Biotechnologies’ clonoSEQ received its third approval—to detect minimal residual disease (MRD) in in chronic lymphocytic leukemia (CLL). The assay uses a proprietary immunosequencing platform to detect MRD, in which a small number of cancer cells can remain after treatment. Precise measurement tools are needed to detect MRD, which can lead to cancer recurrence. MRD has received increased attention as an endpoint in clinical trials in blood cancers. That same week, FDA also approved the Guardant360 CDx liquid biopsy for comprehensive genomic profiling, In non-oncology news, regulators approved Genentech’s Evrysdi (risdiplam), an oral treatment given at home for spinal muscular atrophy (SMA).

Drug and diagnostic approvals and biosimilars news were popular with readers.

Mary Caffrey

Articles

Insurance Still Top Factor Driving Healthcare Choices, But Online Reviews Grow in Importance, Study Finds

The race for new heart failure treatments heats up

Ready or Not, the New Year Brings Trump’s Price Transparency Rule

MHE’s Most-Read Oncology News in 2020